Direct Peritoneal Resuscitation: A Surgical Intervention with Renal Implications

Introduction: Direct Peritoneal Resuscitation (DPR), a continuous lavage of the peritoneal cavity using dialysate, has been studied as an adjunct to conventional IV fluid resuscitation for management of hemorrhagic shock (Fig.1). It is used in patients requiring damage control surgery for abdominal trauma due to its studied effects on improving microvascular perfusion and reducing systemic inflammation, organ edema, and time to fascial closure. The effects of DPR on serum electrolytes, renal perfusion and acute kidney injury (AKI) are not known. Case Description: A 76-year-old male with no medical history presented after a boating accident with severe penetrating abdominal trauma, hemorrhagic shock, and AKI (creatinine 2.4 mg/dL) attributed to ATN. He underwent emergent damage control laparotomy and was left with an open abdomen. DPR was initiated with 2.5% dextrose peritoneal dialysate at 800 cc/hr x1hr followed by 400 cc/hr hospital day 1 to 9. He tolerated successful facial closure on postoperative day 9. His course while on DPR was notable for development of hypernatremia and hypokalemia requiring free water and potassium repletion (Fig.2). He maintained a creatinine ~1.9-2.8 mg/dL and robust urine output without need for renal replacement therapy (Fig.2). By discharge, his AKI fully resolved. Discussion: This case presents a successful use of DPR in a patient with abdominal trauma and hemorrhagic shock, resulting in a favorable surgical and renal outcome. It underscores the need for study of renal implications of DPR, including impact on clearance and electrolyte balance, and even possible effects on renal perfusion and AKI outcome. DPR is a valuable tool for surgeons and warrants further study; nephrologists should seek a good understanding of its mechanisms and renal impacts.