AAP Section on Nephrology Newsletter • Spring 2022 published an article from Dr. Tej Mattoo.

Perspective: Necessity is the Mother of Invention

Tej K. Mattoo, MD, DCH, FRCP, FAAP

Professor of Pediatrics (Nephrology) and Urology, Wayne State University School of Medicine Detroit, Michigan

After spending the most formative years of my life in Kashmir, India, I had the good fortune of working in the United Kingdom and Saudi Arabia before settling down in the United States. Each place provided me with great opportunities I remember with gratitude. The main reason I moved from London to Saudi Arabia with my family in 1985 was my exhilaration over starting the first pediatric nephrology program in the Kingdom. This possibility came up through the Saudi Health Attaché in London, who acted as a liaison for treatment of Saudi Children with renal problems referred to Guy’s Hospital in London, where I was training to be a pediatric nephrologist.

On reaching Riyadh, I woke up to the fact that there was nothing in place to start the program and that my role was going to be even bigger than what I had anticipated. However, the enthusiasm and support of the Ministry of Health and other local administrators was exceptional, and the process started with their decision to build the program as a new department at the children’s hospital in Riyadh, the largest in the country, with about 400 beds. I was asked to finalize the space requirement for inpatient beds and dialysis unit, help select machines and supplies for hemodialysis and peritoneal dialysis, and select nurses for inpatient/outpatient care and the dialysis unit. I was lucky enough to find many enthusiastic nurses in the adult hemodialysis program in the sister hospital whom I could train quickly on the intricacies of dialysis in children. About a year later and with the help of a few young, dedicated pediatricians interested in nephrology (including one with some experience in adult nephrology) we had a fully functioning ~24-bed inpatient floor exclusively for nephrology, and a dialysis unit with hemo-and peritoneal dialysis facilities.

While in Riyadh, my wife and I witnessed the incredible economic transformation of the Kingdom. Most of Riyadh had been rebuilt with a modern infrastructure as well as new housing and shopping malls. A few remaining remnants of old Riyadh that we could visit revealed what the place must have been like a decade or so earlier. Tremendous improvements in the health care sector attracted doctors and nurses from all over the world and the upcoming generation of Saudi doctors were keen participants in rapidly emerging world-class health care. The money was good, and shopping was fun; nothing had prepared me and my wife for the breathtaking sight of shops dripping with gold at the souks.

With all the excitement about starting the new program there were some challenges too, especially in the beginning. One such challenge came up long before the nephrology unit started coming together. A female baby was born at the Prince Salman Hospital who suffered from birth asphyxia due to face presentation. She was born full-term, weighed 2.6 kg, and had significant bruises on her face. Active resuscitation was needed at birth and her subsequent clinical course was complicated by seizures, sepsis, disseminated intravascular coagulation, severe anemia, pulmonary edema and renal failure. She became anuric after birth and the administration of aminoglycosides for sepsis wasn’t helpful for her kidneys either. She received supportive care, including mechanical ventilation, intravenous (IV) antibiotics, fluid restriction, and packed red blood cell transfusions for very low hemoglobin, which could not be avoided.

Over the next couple of days, she showed overall clinical improvement with no apparent motor deficit, and everything seemed to be working well except for her kidneys. She did not have any more seizures and sepsis responded to antibiotic administration. However, she remained anuric and repeated fluid challenges with and without a diuretic were not helpful. As a result, she became edematous with bilateral pitting edema of lower limbs and severe ascites. She needed increasing ventilatory support because of worsening pulmonary edema. She also developed hyperkalemia and it became obvious that she wouldn’t survive without dialysis. Unfortunately, dialysis seemed impossible because we did not have the necessary supplies and the hospital director’s efforts to get the supplies or transfer the baby to another facility were expectedly futile. My thoughts repeatedly wandered back to Guy’s Hospital, where peritoneal dialysis of infants seemed so routine, particularly in those with cardiac surgery, which was a newly emerging medical breakthrough for life-threatening congenital heart disease.

Standing by the incubator and watching this baby, feeling helpless, I had a Eureka moment when my eyes caught the IV fluid bottle hanging over the incubator. In those days, IV fluid came in glass bottles with a plastic tube inside to allow air entry for uninterrupted flow of the fluid. This plastic tube became my peritoneal dialysis (PD) catheter. One end of the tube was beveled with a blade to create a sharp pointed edge. Holes were made for a couple of centimeters with the help of a safety pin, turned red-hot by a cigarette lighter, forgetting that it could be a fire hazard in the NICU. With this “dialysis catheter” ready, the next thing to do was to prepare the dialysis fluid, which was easy because we had everything that we needed. We mixed normal saline (0.9%) 649 mL, dextrose (5%) 300 mL, sodium bicarbonate (8.4%) 30 mL, and distilled water 21 mL, which gave a PD fluid concentration of Na+ 130 mEq/L, Cl- 100 mEq/L, HCO3 30mEq/L, and Dextrose 1.5%. Also added were MgSo4 1.5mEq/L and heparin 300 units/L. Potassium 4 mEq/L was added later, after the resolution of hyperkalemia.

Under aseptic precautions and after local anesthesia, a small incision was made in the midline about 1.5 cm below the umbilicus. The catheter insertion was easy because of severe ascites, as many pediatric nephrologists who have inserted hard PD catheters would know. IV tubing was used to connect catheter with PD fluid and manual PD was started as per the established protocol (Figures 1 and 2). The dialysis went very well. Urine output started on day three after birth, which was followed by a rapid improvement in blood chemistry and baby’s general condition. We dialyzed her for six days with the same catheter and there were no complications. By the time dialysis finished, she had shown a remarkable overall improvement (Figure 3) and was feeding well on her own. The baby stayed in the NICU for another week or so before she was discharged home with resolving bruises and a big smile on her face (Figure 4).

This survival of this baby seemed like a miracle, and I was wonderstruck by the extraordinary effort by the nursing staff. None of them had seen anyone on dialysis, let alone done one, and that too, in a newborn baby. A year later, once the program was established, dialysis in children, including babies, rapidly become a routine process. However, the excitement for me and my team only grew as we got busier running at full service and taking care of renal patients referred from all over country ... and life moved on.

Note: Photos of the patient during and after treatment could not be published because of the unavailability of needed permissions.