|Year : 2017 | Volume
| Issue : 2 | Page : 70-72
Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases
Ruba Abo Essa1, Abdullah Muzalef2, Saleh Al-Qahtani3
1 Department of Pediatrics, Abha Maternity and Children’s Hospital, King Khalid University, Abha, Kingdom of Saudi Arabia
2 Department of Pediatric Nephrology, Abha Maternity and Children Hospital and Head of Dialysis Centers, King Khalid University, Abha, Kingdom of Saudi Arabia
3 Department of Child Health, College of Medicine, King Khalid University, Abha, Kingdom of Saudi Arabia
|Date of Submission||01-Jul-2017|
|Date of Acceptance||21-Aug-2017|
|Date of Web Publication||21-Sep-2017|
Ruba Abo Essa
Department of Pediatrics, Abha Maternity and Children’s Hospital, Abha, Kingdom of Saudi Arabia Zip code: 61321
Kingdom of Saudi Arabia
Source of Support: None, Conflict of Interest: None
The aim of this study was to know and validate whether the use of ventriculoperitoneal shunt (VPS) and peritoneal dialysis catheter (PDC) is a safe and acceptable option in children requiring PD and VPS. A case of myelomeningocele with accompanied paraplegia and hydrocephalus was treated surgically in the neonatal period with placement of VPS. Later the child developed a neurogenic bladder with recurrent cystitis, which culminated into severe bilateral ureterohydronephrosis and progressive chronic renal disease. In a second case, a boy with an immaculate past history, admitted in a local hospital for meningitis complicated by hydrocephalus, necessitating the insertion of VPS, was treated. During the course of his illness, the child developed acute renal failure, volume overload, and severe hypertension and ended up in our pediatric ICU. We experienced two cases in our artificial kidney unit with concomitant insertion of VPS and PDC with an excellent outcome. On the basis of the outcomes of our patients as well as results from other centers, we conclude that the concurrent use of a VPS and PDC is a safe and acceptable option in child requiring PD and VPS.
Keywords: hydrocephalus, peritoneal dialysis, ventriculoperitoneal shunt
|How to cite this article:|
Essa RA, Muzalef A, Al-Qahtani S. Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases. J Egypt Soc Nephrol Transplant 2017;17:70-2
|How to cite this URL:|
Essa RA, Muzalef A, Al-Qahtani S. Concomitant insertion of peritoneal dialysis catheter and ventriculoperitoneal shunt in children: a report of two cases. J Egypt Soc Nephrol Transplant [serial online] 2017 [cited 2018 Mar 23];17:70-2. Available from: http://www.jesnt.eg.net/text.asp?2017/17/2/70/215229
| Introduction|| |
End-stage renal disease (ESRD) is a rare but significant health problem in children, with a reported incidence of 5–10 children per million each year . Being the most severe form of chronic kidney disease, it is associated with various social, medical, and financial problems. Children with ESRD have a 10-year survival rate of about 80% with an age-specific mortality rate of 30 times compared with children without ESRD. Most of these children succumb to cardiovascular complications and infections . Because of its universal applicability and superior compatibility, peritoneal dialysis (PD) remains the most preferred treatment modality for ESRD .
Hydrocephalus is an abnormal accumulation of cerebrospinal fluid in the brain impairing vision, hearing, cognitive, and cranial nerve function, and, if untreated, can lead to death. It can either be congenital with an incidence of between 0.5 and four per 1000 children  or secondary to infections, bleedings, head trauma, and central nervous system tumors.
Currently, hydrocephalus is treated effectively with the insertion of ventriculoperitoneal shunt (VPS) and a PD; it is considered to be a successful bridge to renal transplantation .
The synergistic use of peritoneal dialysis catheter (PDC) and VPS in a child is very rare and there is a paucity of data with no large case series found in the literature. Here, we report two cases in which patients underwent both dialysis and cerebrospinal fluid shunting.
| Case report 1|| |
An 11-year-old girl, a case of myelomeningocele with accompanied paraplegia and hydrocephalus, was treated surgically in the neonatal period with placement of VPS. Later the child developed a neurogenic bladder with recurrent cystitis, which culminated into severe bilateral ureterohydronephrosis and progressive chronic renal disease. Subsequently, she also suffered from severe hypertension, cerebrovascular accident, and right-sided hemiparesis. Because of various socioeconomic reasons, the family did not go for PD and the follow-up was poor.
Eventually, she was admitted in our hospital as an acute renal failure superimposed on a chronic renal failure. She showed signs of hypertensive encephalopathy and seizures before the scheduled insertion of the PDC and was admitted in the pediatric ICU. The patient underwent a computed tomography scan, which ruled out the obstructed VPS, and was started on urgent hemodialysis. Later the child underwent peritoneal catheter insertion and was started on automated PD program ([Figure 1]). Because of her seizures, the patient was started on antiepileptic drugs and antihypertensive medications.
|Figure 1 Both ventriculoperitoneal shunt tube and peritoneal dialysis tube are in place.|
Click here to view
Her laboratory investigations revealed the baseline blood urea nitrogen of 68 mg/dl and creatinine of 2.4 mg/dl. There was marked increment before dialysis, which showed urea of 187 mg/dl and creatinine of 7.1 mg/dl. She had normocytic normochromic anemia with hemoglobin of 9.5 g/dl, secondary hyperparathyroidism, calcium of 8.7 mg/dl, phosphorus of 7.6 mg/dl, parathyroid hormone of 1252 ng/l, and alkaline phosphatase of 581 IU/l. Echocardiogram showed significant left ventricular and septal hypertrophy.
After placing on the PD and VPS, the clinical course had been significant with an episode of PD-related peritonitis. PD fluid showed a white blood cell count of 1400 cells/ml, of which lymphocytes constitutes 98%, red blood cell of 0–1/high power field, and no growth on culture. She was treated with intraperitoneal antibiotics for 10 days and improved without any complications of VPS or any manifestations of central nervous system infection. After 1 year of follow-up the patient is maintained on automated PD program waiting for renal transplant.
| Case report 2|| |
The second case is that of a 4-year-old boy, with an immaculate past history, admitted in a local hospital for meningitis complicated by hydrocephalus, necessitating the insertion of VPS. During the course of his illness, the child developed acute renal failure, volume overload, and severe hypertension and ended up in our pediatric ICU. A PDC was inserted and he was started on Automated Peritoneal Dialysis (APD) program as a live-saving measure. Unfortunately, his condition progressed to ESRD. The patient had to be on both VPS and PD for almost a couple of years, both remain completely functional during the entire course of treatment and did not result in any significant complication. Eventually, the patient was transplanted successfully.
| Discussion|| |
The primary objective of our case studies was to identify the various complications that may have influenced the outcome in patients with a concomitant use of a VPS and a PDC, as there is a scarcity of data resulting in a lack of evidence-based practice recommendations .
It is not uncommon for patients with VPS to end up with ESRD because of different reasons. The safety and viability of PD in patients with a VPS have been a matter of great concern and have derived a mixed response from different quarters .
Although results from Warady et al.  in early 90s were encouraging, many still are reluctant to adopt this practice. Common reasons cited for this avoidance are infections and nonfunctioning of the shunt. VPS and PD can lead to a damaged peritoneum . Similarly, ascites and sclerosing encapsulating peritonitis secondary to a VPS are also reported ,. Hydrothorax can occur in patients with a VPS  and on PD .
Despite few reports of peritonitis, there has been no episode of meningitis reported in patients with concurrent insertion of a VPS and PDC, which shows that the risk for an ascending ventriculitis or meningitis is very slim .
One study in Poland reveals that patients with myelomeningocele on VPS and PD have a greater risk for complications . Similarly, VPS dysfunction is another caveat in such patients  and needs close monitoring.However, it has been endorsed by various studies in which it was found that the concurrent use of both VPS and PDC in a patient is not a contraindication and can be used successfully with the help of a professional team ,,.
In our patients, VPS was placed initially and subsequent ESRD prompted the insertion of PDC. Except for an episode of peritonitis in the first patient, no other complications were noted, which could be attributed to a good nursing care, appropriate family support, and an experienced multidisciplinary team.
We also suggest that a registry of patients with myelomeningocele and spina bifida on PD should be established, where they are followed up for longer periods, which will provide an objective assessment of their problems and management.
| Conclusion|| |
On the basis of the outcomes of our patients as well as results from other centers, we conclude that concurrent use of a VPS and PDC is a safe and acceptable option in children requiring PD and VPS.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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