The anuric preterm newborn infant with a normal renal ultrasound: a diagnostic and ethical challenge

Abstract

Diagnosis and treatment of an anuric premature infant with severe respiratory compromise and a normal renal ultrasound (US), is a difficult task that requires a multidisciplinary approach. A 29-week gestation premature male infant, born after 5 weeks of worsening oligohydramnios, was ventilated for respiratory distress and remained anuric. Intensive clinical investigations and pediatric nephrology consultation that predicted very poor prognosis were followed by progressive renal failure, electrolyte imbalance, respiratory failure, ventricular arrhythmia, and finally cardiac arrest and death on day 5. In view of the predicted poor outcome, and after discussion with the parents, a decision was made not to start peritoneal dialysis (PD), and to offer only palliative therapy, with comfort care alone. Pre and postnatal diagnosis lead, in this case, to an ethical challenge that focuses on the question of futility.

Long Term Peritoneal Dialysis in an Anuric Preterm Infant - a Futile Treatment?

“…Presently the literature consists of only 2 case reports, where long term PD has been discussed as a therapeutic option for a primarily anuric VLBWI. In 1 case, reported by Waisman, PD was withheld and therapy switched to palliative care [ 20 ] . In the second case report from Rainey PD was started with the intention to bridge to transplantation.…”

“…The child's renal function recovered only partially (renal insuffi ciency stage IV) [ 10 ] . Since there is only limited experience in treating primarily anuric preterm infants frequently therapy has been withheld despite the growing success of the long term PD in full term newborn and older infants [ 20 ] . This was supported by the reports of a poor outcome for long term PD in infants below 1 year of age showing a mortality of 42 % and considerable additional morbidity of survivors, including surgical revision of the PD catheter, peritonitis, growth and weight retardation and developmental delay [ 7 , 17 ] .…”

“…In comparison to primarily anuric term neonates treatment of anuric preterm infants is considered futile [ 20 ] . Few cases are reported where peritoneal dialysis (PD) was commenced in chronic renal failure to achieve suffi cient growth for prospective renal transplantation.…”

A survey demonstrates limited palliative care structures in paediatric nephrology from the perspective of a multidisciplinary healthcare team

“…Up to now, there are few case reports on the implementation of palliative care in the field of paediatric nephrology . One retrospective study showed that the main fields of palliative care were complex communication, interdisciplinary support and education regarding palliative care .…”