WCN23-0594 PERITONEOVAGINAL FISTULA IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS IN A CHILD: A CASE REPORT

S.i. Mada, H.a. Puspitasari, M.y. Amal, G.r. Situmorang, E.l. Hidayati

Research output: Chapter in Book/Report/Conference proceedingConference contributionpeer-review

Abstract

Introduction
Peritoneal dialysis (PD) is the most preferred kidney replacement therapy (KRT) for children with end stage kidney disease (ESKD). In 2017, ESKD children in Indonesia who underwent peritoneal dialysis was 0.6 per million age related population (pmarp). Continuous ambulatory peritoneal dialysis (CAPD) is preferable because it is cost effective, accessible, and convenient for the patient. Complications such as, peritonitis, leakage, and obstruction are common. However, late complication presenting as peritoneovaginal fistula is rare in children.

Methods
A 15 year old girl with ESKD caused by bilateral polycystic kidney disease underwent CAPD for 5 years. She was noncompliant with PD therapy. She had repeated peritonitis caused by various pathogens such as, Acinetobacter baumanii, Staphylococcus aureus, Streptococcus alphahemolyticus, Staphylococcus epidermidis, Escherichia coli, and Candida parapsilosis. Intraperitoneal antibiotic was given according to the susceptibility result of the pathogens. The PD catheter was removed due to candida infection 10 months prior to admission. After 4 months, new catheter was reinstalled, and she had relapsing peritonitis due to Staphylococcus epidermidis. However, the family refused to remove the PD catheter.

Since two weeks before admission, she had intermittent abdominal pain, urinary incontinence with decrease of ultrafiltration volume, and lung edema. She had elevated blood pressure of 140/110 mmHg (P95+15-P95+30), tachycardia, and tachypnea. There was rales in bilateral lungs. Heart sound was normal. Abdominal examination showed no sign of inflammation around PD catheter and no pain. Her laboratory examination showed high ureum (171.2 mg/dL) and creatinine (10.3 mg/dL) with normal procalcitonine (0.57 ng/mL), and moderate elevation of CRP (29.6 mg/L). Emergency hemodialysis was commenced. Third space leakage of PD fluid was suspected due to ineffective dialysis despite good dialysate flow.

Results
Magnetic resonance imaging (MRI) was performed using dialysate which was infused into peritoneal cavity via PD catheter. The MRI showed peritoneum dialysis tube was in peritoneum cavum with distal tip on the edge of anterior rectum wall. There was loculated complex ascites with septa along anterior cavum peritoneum to Douglas cavum that was connected with vagina canal through fornix defect of posterior proximal vagina suggesting peritoneovagina fistula. Peritoneal dialysis was discontinued, and catheter was removed. The patient was planned for hemodialysis until peritoneovagina fistula was closed. She was given intravenous antibiotics of ceftazidime and cefoperazon sulbactam for 28 days. Tuberculosis work up was conducted.

Conclusions
Vaginal leakage of dialysate is one of the late and rare complications of PD. Risk factors contributing to vaginal leaks in this patient is recurrent peritonitis and polycystic kidney disease. MRI using dialysate infused into peritoneal cavity via PD catheter can be used to directly visualize distribution of the PD fluid. Treatment for dialysate leaks are surgical repair and hemodialysis, either temporary or permanent.
Original languageEnglish
Title of host publicationISN World Congress of Nephrology (WCN) 2023 Abstracts
PagesS351
Volume8
Edition3
DOIs
Publication statusPublished - 1 Mar 2023

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