Peritoneal dialysis in an ELBW infant after resolution of hemoperitoneum: Challenges with peritonitis and cellulitis

Hemoperitoneum, though rare in neonates, often arises from birth trauma, congenital disorders, or spontaneous intestinal perforation. ¹ , ² This condition can precipitate hypovolemic shock, leading to acute kidney insufficiency and potentially chronic kidney failure. ¹ While peritoneal dialysis (PD) is a recognized solution for managing acute or chronic kidney injury in neonates, it has been successfully used in patients with congenital diaphragmatic hernia and necrotizing enterocolitis‐related gastrointestinal perforation, conditions traditionally considered contraindications for PD. ³ , ⁴ , ⁵ However, the appropriateness of PD in cases of hemoperitoneum remains uncertain. Here, we present a case of an extremely‐low‐birth‐weight (ELBW) infant with hemoperitoneum due to birth injuries to the liver and spleen, in whom PD was initiated after the resolution of active bleeding.

A female infant, born at 26 weeks and 5 days of gestation and weighing 650 grams, was delivered by cesarean delivery to a 31‐year‐old mother with severe preeclampsia and reversed umbilical cord blood flow. The cesarean section was deemed necessary due to fetal distress, following the administration of two doses of betamethasone and magnesium sulfate infusion. After birth, she required endotracheal intubation and positive pressure ventilation due to respiratory distress, with APGAR scores of 2 and 8 at 1 and 5 min, respectively. Shortly after NICU admission, she developed profound hypotension (mean arterial pressure 16 mmHg) that was unresponsive to volume expansion. Initial bedside ultrasound showed significant ascites and heterogeneous echogenicity in the liver and spleen, suggesting intra‐abdominal hemorrhage (Figure 1a,b). Serial ultrasounds demonstrated resolution of echogenic ascitic fluid and stabilization of hepatic and splenic parenchymal changes, supporting birth injury rather than coagulopathy‐related bleeding. To address internal bleeding, she received extensive blood product transfusions, including red blood cells, platelets, fresh frozen plasma, cryoprecipitate, and Factor VII, totaling 90 mL/kg/day. Her blood pressure stabilized within 12 h.

FIGURE 1.

(a) and (b) Ultrasound shows significant ascites and heterogeneous echogenicity (yellow arrow) in the liver and spleen; (c) and (d) The abdominal wall cellulitis and peritonitis emerged during the peritoneal dialysis (PD); (e–g) The trend of blood gas pH level, lactate (mmol/L), base excess (mmol/L), potassium (mmol/L), bicarbonate (mmol/L), urine output (mL/day), creatinine (mg/dL) of the patient. The red box indicates PD administration. During PD, acidosis, bicarbonate, and base excess improved.

Following hemodynamic stabilization, she developed acute kidney injury, oliguria, electrolyte imbalances, fluid overload, and metabolic acidosis. Initial management included fluid restriction and diuretics. Due to concerns of active bleeding, PD was deferred. On day of life (DOL) 10, a diagnostic peritoneal tap was performed by percutaneously inserting a 6‐French pigtail catheter (SKATER™, Argon Medical Device, USA) showing an erythrocyte count of 2,641,624 × 10⁶/L. Subsequent analysis revealed a decrease to 3,423 × 10⁶/L, with stable hemoglobin levels, confirming the absence of active bleeding. PD was initiated on DOL 13 due to worsening oliguria and metabolic acidosis, using 10 mL/kg 2.5% dialysate (DIANEAL PD‐2®, Baxter, USA) per cycle with a 10‐min inflow, 40‐min dwell, and 10‐min outflow, 24 cycles per day.

On DOL 15, peritonitis with abdominal wall cellulitis developed, likely due to umbilical venous catheter extravasation, leading to dialysate retention failure (Figure 1c,d). Despite this challenge, base excess and metabolic acidosis improved with continuous peritoneal lavage (Figure 1e–g). PD was discontinued on DOL 25 following urine output recovery, and the pigtail catheter dislodged on DOL 28. After PD cessation, serum bicarbonate levels dropped, with metabolic acidosis and mild hyperkalemia. PD was not reintroduced because peritoneal access could not be safely re‐established due to severe abdominal wall cellulitis and ongoing peritoneal inflammation. Hemodialysis was also not feasible due to her ELBW and lack of suitable vascular access. On DOL 30, she experienced unexpected cardiac arrest and passed away despite resuscitation.

Although the patient's outcome was unfortunate, our case highlights the importance of timing for PD initiation in ELBW infants after active bleeding resolves. It also demonstrates that abdominal wall cellulitis and peritonitis are not absolute contraindications for PD. Continuous dialysate lavage, even without adequate dwell time, can be effective. This experience provides valuable insights for clinicians managing complex neonatal cases.

AUTHOR CONTRIBUTIONS

S.‐P. S. designed the study; B.‐R. C. collected the data; S.‐P. S., Y‐T. C., and B.‐R. C. wrote the manuscript. All authors read and approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to declare.

Chen B‐R, Chen Y‐T, Shen S‐P. Peritoneal dialysis in an ELBW infant after resolution of hemoperitoneum: Challenges with peritonitis and cellulitis. Pediatr Int. 2025;67:e70128. 10.1111/ped.70128

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.