Acute kidney injury (AKI) is a common complication, affecting almost one-third of critically sick children and also noncritically ill children admitted to wards [1][2]. It is common in pediatric intensive care units (ICUs) and has an incidence of 10% to 35% [3]-[5]. AKI is also common in wards, especially in children receiving aminoglycosides and multiple nephrotoxins during their hospital stay [6][7]. Severity of AKI several classification systems have been proposed and include the RIFLE, AKIN, and KDIGO criteria [8], whereas in children, AKI is staged using broadly similar criteria to adults, modified as pRIFLE [9]. Rates of AKI in hospitalised children across North America and observed were 3.9 episodes of AKI per 1000 admissions [10] with AKI being more common in those admitted to paediatric ICU, and was associated with poor outcome, including increased mortality [11]. In the developing world, especially in rural regions, the etiological factors remain as dehydration, sepsis, and hemolytic uremic syndrome [12]. Whereas in Tanzania, local herbs, nephrotoxic agents and infections have been postulated as one of the causes [13]. We report a case of a child with acute kidney injury who underwent peritoneal dialysis.

We present the case of a 2 years old boy who was admitted on 14^th June 2022 with complains of fever and cough. This is a known patient with global developmental delay who was attending pediatric outpatient clinic regularly and was on Phenobarbitone tabs 45 mg nocte, Carbamazepine 150 mg BD and was on Baclofen 5 mg three times a day. This patient on admission clinically was fair looking, febrile T- 38.6˚C, conscious with a Glasgow Coma Score (GCS) of 15/15. His body weight was 9.7 kgs. On his respiratory system examination he had a respiratory rate of 36 with crackles heard in his lungs. The admitting doctor suspected Aspiration Pneumonia and the patient was started on IV Ampicillin and Metronidazole. On day 2 of admission, mother reported the child had not passed urine for 3 days and was also draining coffee ground material from the orogastric tube (OGT) and had 3 episodes of convulsions. Clinically he was sick looking, dyspneic, tachypneic, cold extremities grade 2, his heart rate was 207 beats per minute, temperature 38.1˚C, respiratory rate 40 breaths per minute, blood pressure of 90/60 mmHg and the oxygen saturation was 83% on CPAP. Bedside tests showed pH 7.2 (7.310 - 7.410), PCO2 39.1 (41.0 - 51.0), HCO3 16.2 (23.0 - 28.0), Creatinine 4.3 mg/dl (0.6 - 1.3), BUN 69 mg/dl (8 - 26). The diagnosis was changed to Septic Shock with Meningitis, Aspiration Pneumonia, Respiratory Acidosis, Acute Kidney Injury secondary to suspected local herb intake, Stress Gastritis. The patient was given a bolus of IV Ringers Lactate 97 mls to run over 1 hour, IV Pantoprazole 10 mg once a day for 7 days,Ampicillin was stopped and Meropenem 194 mg twice daily (given adjusted to the Glomerular Filtration rate) was initiated. After 2 boluses of Ringers Lactate, clinically there was no improvement so packed red blood cells 97 mls was given and his vitals stabilized (HR- 120 - 150 beats per minute). Urine catheter after 24 hours had 5 mls of urine despite maintenance fluid, blood and bolus IV fluids. Renal challenge was done with IV RL and IV Lasix 10 mg stat and produced 20 mls of urine. Despite a slight increase in urine output (from no urine to 5 mls to 20 mls) (Table 1), there was worsening of acidosis and renal function (Table 2).

Table 1. Trends in urine output.

Table2. Trend of electrolytes and gases from admission to during dialysis.

Day 5 after admission, patient still had no improvement in urine output. Peritoneal Dialysis (PD) was initiated. A modified PD catheter was inserted in theatre using a Foley urinary catheter and patient was transferred to ICU afterwards. Whilst in ICU, patient received several cycles of Peritoneal Dialysis (2.5% PD at 290 mls 2 hrly) and was improving clinically from Glasgow Coma Score (from 3 to 9), urea decreased, creatinine decreased and urine output increased to 104 mls per 24 hours.

On day 10, patient sustained respiratory failure and was desaturating to 64%. He was put on Ventilator but 9hours later succumbed due to cardiac arrest.

Peritoneal dialysis is the mainstay of managing acute kidney injuries in the pediatric population in limited resource settings such as Tanzania. However, due to financial constraints many cannot afford the costs for the equipment necessary for peritoneal dialysis [14]. Acute peritoneal dialysis (PD) has been offered in Tanzania since 2009 with the aim of supporting health care providers in Acute PD [15]-[16]. In our region, this was the first attempt of Peritoneal Dialysis which was done and was successful though the patient succumbed to Respiratory failure.

Management of AKI is challenging in critical infants and children [18]. Peritoneal Dialysis is a treatment modality of choice to neonates and children with good treatment outcomes. Unfortunately not many people are conversant with how it is done or how to manage patients on peritoneal dialysis.

We are very grateful to the nurses in the intensive care unit who were very supportive, aggressive and diligent in providing care to this patient.

MEI and DNM conceptualized and prepared the manuscript.MEI and DNM reviewed the patient medical records, and all authors have read and approved the final manuscript.

Data for this work can be requested from the corresponding author on reasonable request.

Our institution does not require ethical approval for reporting individual cases or case series.