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	Indications		Contraindications
	Complications		Catheterisation
	Antibiotic Cover		Dwell Details

The main cause of renal failure in a neonate is the vulnerability of the newborn kidney to injury, essentially caused by renal hypoperfusion (1).

After conservative management has failed, the modality of choice for renal replacement therapy in our 11-bed acute Neonatal Intensive Care Unit in Melbourne, Australia, is Peritoneal Dialysis.

Most of our neonates are premature and therefore of low birth weight. This makes it too difficult to provide renal replacement therapy by haemodialysis or haemofiltration owing to problems with vascular access and coagulation.

Indications for Peritoneal Dialysis are based on a diagnosis of acidosis and/or hyperkalaemia which fail to respond to conservative management and worsening uraemia or hypervolaemia caused by congestive cardiac failure. Peritoneal Dialysis has a “theoretical advantage in the premature neonate secondary to the large peritoneal surface area to body ratio that provides improved dialysis efficiency” (2).

Contraindications to Peritoneal Dialysis include necrotising enterocolitis or recent abdominal surgery in the neonate.

Complications in the neonate often include:

		peritonitis;
		exit-site infections;
		leaks around the exit site;
		catheter obstruction;
		abdominal-wall hernias; and
		respiratory embarrassment, whereby during dwell time the abdomen is so full it places pressure upon the lungs. Often ventilatory support needs to be increased to reverse this.

Peritoneal Dialysis procedure

Catheterisation for Peritoneal Dialysis is performed at the bedside by the nephrologist who inserts a Tenchkoff paediatric peritoneal catheter under local anaesthetic.

Our Tenchkoff catheters generally do not have a Dacron cuff, as there is not enough subcutaneous tissue in a neonate for tunnelling the catheter. Also, the catheter is generally not needed long term.

The catheter is used immediately, dressed with Mefix tape over a large area of abdomen, and well secured to the neonate and the bedside to avoid it being dislodged. This dressing is left intact for 10-14 days unless there is a large leak from the exit site.

We do not use pre-packaged, in-line, peritoneal dialysis sets in our unit. Nor do we use automated cyclers. We assemble our own fluid-exchange system, using differing strengths of Dianeal, IV lines, Burettes and a blood warmer to heat the dialysis solution.

Antibiotic cover is provided by vancomycin and cephazolin being instilled into the dialysis solution. If the neonate’s serum potassium levels are normal, we also instill potassium chloride to prevent hypokalaemia.

We instill heparin into the dialysis solution if bleeding or ooze at the insertion site could cause a fibrinogen blockage of the catheter.

Daily effluent samples are sent for culture.

No general rule of thumb appears to exist for dwell volumes. They appear to be estimated based on the degree of renal failure and the presenting symptoms. I have seen 50mls/kg used, therefore giving, based on a 1.8kg baby, a 90ml fill volume.

Short dwell times are used -- from 30 minutes to 2 hours -- based on the degree of renal failure and the goal of treatment: ie, fluid removal over removal of uraemic toxins.