Peritoneal dialysis in the setting of acute brain injury: an underappreciated modality

ABSTRACT

Introduction

Dialysis is complicated in the setting of acute brain injury (ABI) due to several factors including acute solute shifts, acid base changes, need for anticoagulation, and changes in intracranial pressure. For these reasons, continuous renal replacement therapy (CRRT) is often the chosen modality for renal replacement needs in these patients. Peritoneal dialysis (PD) is less discussed but shares many of the benefits often attributed to CRRT. We describe, from both nephrology and neurosurgical perspectives, a case successfully managed with PD.

Case

A 25-year-old male with history of end-stage kidney disease (ESKD) secondary to focal segmental glomerulosclerosis on continuous cycling PD for 5 years presented to the hospital with headache and altered mental status. Initial imaging revealed a large intraventricular hemorrhage extending to the fourth ventricle. He underwent an emergent right depressive hemicraniectomy and clot evacuation. Post-operative imaging revealed worsening cerebral edema, intraventricular hemorrhage, and hydrocephalus. The decision was made to continue PD, noting that it retains many of the benefits of CRRT (which it is in fact, a form of) which he tolerated well until the need for a percutaneous gastrostomy tube arose. He was transiently transitioned to hemodialysis but returned to PD once his gastrostomy healed. He continued PD for 1 year without complication and eventually received a kidney transplant.

Discussion

In managing patients with ABI undergoing dialysis, a number of considerations must be undertaken including avoidance of hypotension to maintain cerebral perfusion pressure and minimize ischemia reperfusion injury, avoidance of anticoagulants that can precipitate or worsen bleeding, the potential for cerebral edema due to rapid solute clearance and osmotic dissipation of therapeutic hypernatremia, and the mitigation of intracellular acidosis from bicarbonate delivery. Although underutilized, PD may potentially serve as a viable option for dialysis in the setting of ABI as demonstrated by the case presented.

KEYWORDS:

• renal replacement therapy
• end-stage kidney disease
• traumatic brain injury
• dialysis
• peritoneal
• hemodialysis

Declaration of financial/other relationships

A Shah reports consulting with Otsuka and CareDx and honoraria from the Japanese Society of Obstetric Medicine, USC Greenville, CTC-RI, ARA/IRC, and NKF-CRNNE. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. A reviewer on this manuscript has disclosed honorarium from Baxter SPA. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Author contributions

A Shah identified the case, conceived of the topic, and provided oversight. E Wang, S Kim, A Wang and W Jiang identified relevant literature and wrote the manuscript.

Additional information

Funding

This paper was not funded.