Milky appearance of peritoneal fluid in a neonate on peritoneal dialysis due to end-stage renal disease: Questions

Excerpt

A 5-week-old Caucasian male infant was born at 37 weeks and 3 days of gestation, with a birth weight of 3.375 kg and a pre-natal diagnosis of lower urinary tract obstruction with normal amniotic fluid. The post-natal ultrasound [day of life (DOL) 1] was consistent with a diagnosis of bilateral cystic renal dysplasia. The initial serum creatinine (Cr) level was 1.34 mg/dL at birth. A voiding cystourethrogram on DOL 3 identified dilated posterior urethra and right vesicoureteral reflux. On DOL 6, the infant underwent diagnostic cystoscopy which showed a congenital bulbar urethra stricture without valves and dilation of the stricture; a peritoneal dialysis (PD) catheter (39 cm single cuff curled) was put in place at this time. Due to the non-oliguric nature of the infant’s renal failure, the PD catheter was allowed to heal prior to use. Continuous manual PD (Gesco AG, Wuppertal, Germany) was started on DOL 12 when the Cr level peaked at 6.69 mg/dL, with hourly cycles and a fill volume of 10 mL/kg (30 ml) using 1.5% Dianeal solution; average ultrafiltration ranged from 90 to 170 mL/day. His neonatal course was further complicated by the development of Escherichia coli urosepsis on DOL 18 with bacteremia and cerebrospinal fluid pleocytosis which was treated with intravenously administered ceftriaxone for a total of 21 days. He received expressed breast milk (380 mL) + Similac PM 60/40 10 kcal/oz. + Duocal 3 kcal/oz. + 1.2 g Beneprotein/100 mL (Diet 1) to limit electrolyte content due to end-stage renal disease while providing adequate nutrition for growth at 100 kcal/kg/day and volume 100 mL/kg/day. He tolerated feeds well while on the Gesco PD system and showed good interval weight gain. The fill volume was adjusted by 5 mL/kg every 1–2 weeks to achieve the eventual target of 40 mL/kg fill volume. On DOL 34, at which time the infant had been receiving PD on the Gesco PD system for approximately 3 weeks, and 48 h after the fill volume had been increased to 60 mL (15 mL/kg), his peritoneal fluid turned milky in appearance (Fig. 1).

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