Renal Infarction Due to Umbilical Artery Catheters

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gestive of persistent fetal circulation clini- Non bacterial endocardial thrombosis in cally or histopathologically neonates Relationship to persistent fetal circulation J Pediatr 1982;100: 117-122. Acknowledgements 2 Menahem S, Robbie MJ, Rajaduran VS The authors are grateful to the Dean, Valvar vegetations in the neonate due to Seth G. S. Medical College and K.E.M Hos- fetal endocarditis Int J Cardiology 1991; pital for permission to publish the article. 32: 103-105. REFERENCES 3 Krous HF Neonatal nonbactenal thrombotic endocarditis Arch Pathol Lab 1 Morrow WR, Haas JE, Benjamin DR Med 1979;103: 73-78.

Renal Infarction Due to Umbilical From the Department of Pediatric Nephrology, Artery Catheters Royal Victoria Infirmary, Newcastle upon Tyne NE14LP R. Kishore Kumar Reprint requests: Dr. Malcolm G. Coulthard, Department of Pediatric Nephrology, Royal Vic- Malcolm G. Coulthard toria, Infirmary, Newcastle upon Tyne NE1 4LP. Manuscript Received: July 24, 1997; Umbilical artery catheters allow reliable Initial review completed: August 6,1997; blood sampling and blood pressure moni- Revision Accepted: August 27,1997

63 CASE REPORTS toring with minimal handling in critically secrion because his mother developed ful- ill infants, but carry a moderate risk of minating pre-eclampsia at 26 weeks gesta- infarction of the distal extremities and tion. Despite surfactant therapy he re- necrotising enterocolitis from thromboem- quired ventilation from birth for eight days bolism(1,2). There is evidence that almost because of hyaline membrane disease, and all umbilical artery catheters develop a umbilical artery catheter was placed with thrombi, but only a minority cause clinical its tip at T8 on day one. His plasma sodium problems(3). Many neonatologists feel their concentration and daily blood pressure advantages outweigh their risks, and favor measurements were normal until day the tip being placed in the 'high' thoracic eight. Thereafter, the plasma sodium fell, (T412) rather than 'low' lumbar (L3.5) and the systolic blood pressure rose; by position, because there is a lower rate of tip day twelve they had reached 122 mmol/1, thrombi affecting the legs, though the and 108 mm Hg. The hyponatremia was risk of necrotising enterocolitis is un- secondary to a high renal salt loss (urinary altered(l,2). sodium, 182 mmol/1), necessitating a daily sodium supplement of 18 mmol/kg until Clearly, a thrombus dislodged into the the hypertension was controlled. Plasma renal arteries could cause renal ischemia or creatinine concentration, urine microscopy infarction, whereas this could not happen and stick testing for blood, glucose and with a 'low' catheter unless there was gross protein, and urinary vanillyl mandelic acid retrograde flow during a rapid fluid excretion were all normal, but the plasma infusion. Thus, authors considering hyper- renin activity and aldosterone concentra- tension secondary to renal artery tion were both elevated at 100 pmol/ml/h, thromboembolism argue in favor of low and 4,000 pmol/1. Renal tract ultrasono- placed umbilical artery catheters because graphy was normal, but dimercapto- most reported cases have occurred with succinic acid scanning showed an irregular thoracic catheters(4,5). This advice was right kidney that contributed only 43% of formulated twenty years ago when the overall function. He still requires antihypertensive drugs were limited and regular propranolol at 3.5 years to maintain the majority of babies with neonatal hyper- normal blood pressure. tension died (4). Considering that hypertension occurs in less than 2% of cases, where- Case 2: A 3425 g boy was born vaginally at as lower limb compliations are common, 34 weeks gestation to a 25 year old and considering medical management of primigravida with insulin-dependent ges- neonatal blood pressure has improved tational diabetes, 36 hours after she had a greatly in the last two decades, this may no laparotomy for abdominal pain which re- longer be the best advice. vealed a fibroid. Despite surfactant therapy he required ventilation from birth for eight We describe two infants observed on days because of hyaline membrane disease, routine examination to develop hyperten- and an umbilical artery catheter was placed sion during the second week of life with its tip at T9 on day one. Daily blood due to renal infarction, both of whom had pressure monitoring was normal until day umbilical artery catheters placed in the ten when it rose to 104 mm Hg systolic, high position. and thereafter he required treatment for Case Reports hypertension. Plasma creatinine and sodium concentrations were normal, as were Case 1: An 880 g boy was born by caesarean

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urine microscopy and stick testing for case by propranolol for 3.5 years so far. In blood, glucose and protein, and urinary the other, drug side effects could not be jus- vanillyl mandelic acid excretion. Subse- tified in a child whose kidney had only quent renal imaging by ultrasonography, minimal residual function, and he under- dimercapto-succinic acid scan and went nephrectomy at fourteen months. The aortogram revealed a small, irregular, high placement of umbilical artery cathe- poorly functioning and minimally perfused ters carries a risk of renal artery embolism, left kidney. The hypertension remained dif- but a reduced risk of harming the legs com- ficult to control, and subsequent scans pared to low placed catheters(l,2). Because demonstrated relative decline in left kidney the management of neonatal hypertension function; he has been normotensive since a has become easier, and because leg left nephrectomy at fourteen months. His- ischemia is a more frequent complication, tology showed patches of normal kidney catheters should be placed routinely in the scattered among large areas of infarction. high position. Discussion REFERENCES These two babies had a similar clinical 1. Mokrohisky ST, Levine RL, Blumhagen course; normal blood pressure was ob- JD, Wesenberg RL, Simmons MA. Low served throughout the first week, and hy- positioning of umbilical-artery catheters pertension detected in the second week, increases associated complications in when they had come off ventilatory sup- newborn infants. New Eng J Med 1978; port. Both had thoracic umbilical artery 299: 561-564. catheters, and imaging evidence of unilat- 2. Kempley ST, Bennett S, Loftus BG, Coo- eral kidney damage. We did not perform per D, Gamsu HR. Randomized trial of immediate aortograms, but its seems al- umbilical arterial catheter position: Clini- most certain that they each had a thrombus cal outcome. Acta Paediatrica 1993; 82: that embolised from the catheter tip into 173-176. one renal artery; spontaneous renal artery 3. Neal WA, Reynolds JW, Jarvis CW, Will- emboli are excessively rare, presumably iams HJ. Umbilical artery catheterisation: traversing the arterial duct. Also, one case Demonstration of arterial thrombosis by had evidence of renin-driven hypertension, aortography. Pediatrics 1972; 50: 6-13. and secondary hyperaldosteronism causing 4. Plumer LB, Kaplan GW, Mendoza SA. an uncontrolled natriuresis and hypo- Hypertension in infants-A complication natremia(6), and the other had reduced of umbilical arterial catheterisation. J renal perfusion and patchy ischemia on Pediatr 1976; 89: 802-805. histology. 5. Adelman RD. Neonatal hypertension. Early control of blood pressure was Pediatr Clin North Am 1978; 25: 99-110. achieved without difficulty using 6. Blanc F, Bensman A, Baudon JJ. Renovas- antihypertensive drugs, many of which cular hypertension: A rare cause of neo- were not available twenty years ago. Both natal salt loss. Pediatr Nephrology 1991; had persistent hypertension, treated in one 5: 304-306.