Peritoneal Dialysis in Children with Spina Bifida and Ventriculoperitoneal Shunt: One Center'S Experience and Review of the Literature

Objective

The goal of this paper was to review the viability of peritoneal dialysis (PD) in patients with spina bifida and/or ventriculoperitoneal shunt (VPS).

Setting

Pediatric dialysis unit in a tertiary-care hospital.

Data Source

The course and outcome in 9 children, 5 from the authors’ experience and 4 from reported experience, are analyzed.

Results

One patient died of a cause unrelated to PD or VPS, 2 were transferred to hemodialysis because of recurrent peritonitis, 1 discontinued PD transiently, 2 were transplanted, and 3 continue on PD. Six of these 9 children had a functioning VPS, and none presented evidence of ventriculitis or VPS dysfunction, even though 4 had PD-related peritonitis. One child presented with a massive PD-related hydrothorax.

Conclusions

( 1 ) Having a VPS is not an absolute contraindication to PD; the available data support the viability of PD in patients with spina bifida and/or a VPS. ( 2 ) If cerebrospinal fluid diversion is needed simultaneously or after starting PD, an extraperitoneal site should be a better choice than VPS. This should avoid the risk of intra- and postoperative infection in the PD catheter secondary to surgical intervention for VPS insertion. ( 3 ) Loss of peritoneal function is a potential late risk related to cerebrospinal fluid and PD. ( 4 ) Spina bifida patients on PD present specific diagnostic challenges due to overlapping symptoms ( e.g., vomiting, abdominal tenderness, fever) secondary to PD- or VPS-related complications ( e.g., peritonitis, visceral injury by devices) or primary disease ( e.g., neurogenic bladder, pyelonephritis), with inherent risks of delaying adequate treatment. Cloudy peritoneal effluent is an early indication of peritonitis, although it is not specific. ( 5 ) Early evaluation by a pediatric surgeon and a neurosurgeon is required for effective management of complications and selection of more efficient individualized therapeutic alternatives. Prompt treatment of complications is crucial. A registry of children with spina bifida on PD and the accumulation of a large population followed up for longer periods will provide an objective assessment of their problems and management.

Post-transplantation encapsulating peritoneal sclerosis in a pediatric patient

BACKGROUND

Encapsulating peritoneal sclerosis (EPS) is a serious complication of long-term peritoneal dialysis (PD), but only a few cases have been described in the pediatric patient population. There is no established medical treatment, and surgery has been reported with variable success. The number of reports of EPS being successfully treated with tamoxifen, based on its anti-fibrotic effects, are increasing. The role of sirolimus, an mTOR inhibitor with immunomodulatory and anti-proliferative properties, has been less well-defined.

CASE-DIAGNOSIS/TREATMENT

A 17-year-old kidney transplant recipient, with a previous cumulative time on PD of 8 years and 3 months, developed severe bowel obstruction 8 months after undergoing a second kidney graft. Her immunosuppressive regimen consisted of tacrolimus, mycophenolate mofetil, and prednisolone. The patient underwent laparotomy, which revealed multiple thick leathery adhesions with an encapsulated small bowel. Enterolysis was performed, and total parenteral nutrition was commenced after surgery to provide an adequate food intake. Treatment with tamoxifen was initiated, but the patient developed significant liver toxicity 2 weeks later, and the drug was withdrawn. The immunosuppressive regimen was changed to an increased dose of prednisolone, and tacrolimus was replaced with sirolimos. At 20 months of follow-up, the patient remains symptom-free, with a functioning kidney transplant.

CONCLUSION

Although EPS is a very rare condition in the pediatric population, it should be considered when a child or adolescent with a long-term history of PD presents with nonspecific gastrointestinal symptoms or with signs of bowel obstruction. There is an urgent need for alternative immunosuppressive protocols. The use of sirolimus in this group of patients remains controversial.

Post-transplantation encapsulating peritoneal sclerosis in a young child

Encapsulating peritoneal sclerosis (EPS) is a very rare condition in children. Nevertheless, EPS should be considered when a child with a history of peritoneal dialysis (PD) presents with signs of bowel obstruction. We describe a child with post-transplantation EPS and discuss risk factors, diagnosis and treatment options. CT scan should be performed promptly to confirm the diagnosis. Treatment consists of cessation of the PD, if applicable, and adequate nutrition, either parenteral or enteral. Further medical therapy remains controversial but may involve steroids and/or interruption of calcineurin inhibitors.

Sclerosing encapsulating peritonitis in a child secondary to peritoneal dialysis

Sclerosing encapsulating peritonitis, or "abdominal cocoon," is a rare but serious complication of continuous ambulatory peritoneal dialysis. It is characterized by the diffuse appearance of marked sclerotic thickening of the peritoneal membrane resulting in intestinal obstruction. A 14-year-old adolescent boy with a history of end-stage renal failure on continuous ambulatory peritoneal dialysis presented with symptoms of acute intestinal obstruction. A computed tomography scan of the abdomen revealed distended small bowel loops clustered and displaced to the right upper quadrant. The overlying peritoneum was markedly thickened and calcified. Laparotomy confirmed the diagnosis of sclerosing encapsulating peritonitis and the patient was treated with excision of the fibrocollagenous membrane. Postoperatively, he had prolonged ileus requiring parenteral nutritional support and peritoneal dialysis was restarted on postoperative day 10. A high degree of cognizance is needed to facilitate diagnosis and treatment of this uncommon and potentially life-threatening condition.