Peritoneal Dialysis in an Infant with Severe Acute Kidney Injury: Dialysis Performed In-Flight During a Medical Evacuation in French Guiana – A Case Report

Abstract

We report the case of a 7-month-old infant presenting with severe acute kidney injury in the context of respiratory infection and dehydration who was managed in French Guiana, an isolated territory with limited medical resources. Automated peritoneal dialysis was initiated early, leading to rapid clinical improvement. Due to the necessity of medical evacuation to a referral center, continuity of treatment was maintained aboard a commercial flight from Cayenne to Paris (duration 8 hours 30 minutes) through the performance of three manual exchanges of ambulatory continuous peritoneal dialysis. These exchanges were conducted by a multidisciplinary team (pediatrician, adult nephrologist, nurse) with the assistance of the infant’s mother using an improvised setup that adhered strictly to aseptic protocols. This case highlights the feasibility, safety, and strategic importance of peritoneal dialysis in extreme pediatric settings and constrained environments.

INTRODUCTION

Acute kidney injury (AKI) is a common complication in hospitalized children, with a prevalence ranging from 5% to 25% depending on the severity of the episode and the level of care[1]It is associated with a significant increase in morbidity and mortality across all age groups[1][2][3][4]. In regions where renal replacement therapy is not readily available, mortality associated with AKI is significantly higher[5].

Peritoneal dialysis (PD) has long been the first-line renal replacement therapy in pediatrics. Although it has been gradually replaced in high-income countries by hemodialysis (HD) and continuous renal replacement therapy (CRRT), PD remains the most common technique in infants and in resource-limited countries[6][7]. It has several advantages over other techniques: moderate cost, technical feasibility, the lack of need for heavy equipment, and adaptability to small volumes, including in premature infants[8][9][10]. Thus, recent recommendations from the International Society for Peritoneal Dialysis (ISPD) emphasize its value as the minimum standard of care for pediatric AKI, particularly in resource-limited regions[11][12].

In this context, French Guiana presents a profile of a location with increased vulnerability for the pediatric population. Access to pediatric nephrology is limited, geographical distances require frequent medical evacuations, and infrastructure remains fragile[13][14]. PD is, therefore, an essential adaptive tool in this territory, ensuring accessible and safe emergency renal replacement therapy.

The ISPD’s international recommendations emphasize the relevance of PD in AKI in children, particularly in resource-limited areas. They reiterate that PD, including manual PD, can be performed safely even in infants and newborns and is often the treatment of choice in the absence of extracorporeal technologies such as CRRT or HD[9][10][11][12]. These guidelines emphasize the need to adapt standards to the realities on the ground, setting a minimum safety standard for pediatric PD while recommending that an optimal standard be sought whenever possible.

In this context, the case presented here is particularly noteworthy. It involves a 7-month-old infant with severe AKI in a context of metabolic decompensation in French Guiana who was successfully treated with automated peritoneal dialysis (APD) and then manual continuous ambulatory peritoneal dialysis (CAPD) during an intercontinental medical evacuation flight. This extremely rare experience demonstrates the feasibility, safety, and efficacy of continuous PD treatment even outside a hospital setting and in a very young child. It highlights the strategic value of PD for the pediatric population in isolated areas and argues for the strengthening of this modality in public health policies in French Guiana.

PATIENT AND OBSERVATION

Patient presentation

A 7-month-old infant weighing 8.3 kg and measuring 72 cm (estimated body surface area 0.41 m²), with no significant medical history, was transferred from the Centre Hospitalier de l'Ouest Guyanais (CHOG) to the Centre Hospitalier Andrée Rosemon (CHAR) for acute respiratory distress, severe anemia, and marked renal impairment occurring in the context of an upper respiratory tract infection and diarrhea that had been progressing for four days.

Clinical and paraclinical assessment

On admission, the child presented with Kussmaul breathing and without signs of respiratory distress, indicating profound metabolic acidosis. The extremities were cold, and peripheral pulses were well palpable, with stable systolic blood pressure around 120 mmHg. There was rapidly progressive oligoanuria. The child was conscious and alert, with a Glasgow Coma Scale score of 15, without meningeal syndrome or focal neurological signs. He was afebrile, breathing ambient air, with oxygen saturation at 100% and a respiratory rate ranging between 30 and 40 cycles per minute. No signs of shock were observed.

The initial biological assessment, including arterial blood gas analysis, revealed severe metabolic acidosis (pH: 6.99; pCO2: 26 mmHg; bicarbonate: 5.6 mmol/L), associated with a high anion gap (21.4 mmol/L). Acute renal failure was evident from creatinine levels of 396 µmol/L and urea levels of 30 mmol/L, accompanied by hyperkalemia of 6.7 mmol/L. Serum chloride and sodium concentrations were 108 and 135 mmol/L, respectively, with a lactate level of 3.5 mmol/L. Severe anemia (hemoglobin 6.9 g/dL) was associated with predominantly neutrophilic leukocytosis (26.8 G/L), a normal platelet count, CRP 11.7 mg/L, and moderately elevated procalcitonin (0.79 ng/mL).

Ultrasound of the urinary tract showed kidneys with regular contours, no focal or diffuse lesions, but with increased cortical echogenicity compared to the liver and spleen, as well as bilateral hypotonia consistent with parenchymal involvement. Parenchymal-sinus differentiation was preserved, and no obstructions were visible in the excretory tract. A moderate amount of intra-abdominal fluid effusion was also observed between the intestinal loops. The bladder, gallbladder, and hepatobiliary structures were unremarkable.

Chronology and treatment

•Day 0 (D0): Initial management was implemented to stabilize the patient. This included a 160 mL blood transfusion administered over 4 hours to correct anemia, appropriate rehydration at a rate of 100 mL/kg/day with a 5% glucose solution enriched with 4 g/L sodium chloride, and correction of metabolic acidosis by infusion of sodium bicarbonate at a dose of 2 mL/kg (i.e., 16 mL), administered over 4 hours.

•Day 1 (D1): Given the persistence of anuria and acidosis, a collegial decision was made, after consulting the referring pediatric nephrologist, to resort to emergency peritoneal dialysis (PD). The peritoneal catheter was surgically inserted by the pediatric surgery team.

•Day 2 (D2): Automated peritoneal dialysis (APD) was started according to a protocol of five cycles of 350 mL each, with a dwell time of 30

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