Peritoneal Dialysis

Non-Infectious Complications

Peritoneal Dialysis

Non-infectious Catheter Complications

Inflow/outflow obstructionHerniaLeakage

Peritoneal Dialysis

Increased Intra-Abdominal Pressure

Instillation of dialysate into the peritoneal cavity leads to increased intra-abdominal pressure

The magnitude of the increase depends upon:- Volume dialysate filled- Patient age, body mass index- Coughing, lifting straining at stool- Position of the patient (sitting>standing>supine)

Peritoneal Dialysis

Inflow/Outflow ObstructionCauses:- Mechanical (e.g. tip migration, kink in tubing)- Constipation- Catheter blockage

Outflow obstruction is most frequent:

- Intraluminal (clot, fibrin)

- Extraluminal

(constipation, occlusion, omental

wrapping, tip migration, incorrect

catheter placement)

Peritoneal Dialysis

Inflow/Outflow Obstruction - Recommendations Establish type of obstruction Conservative or non-invasive approaches

- body position change

- laxatives

- heparinised saline

- fibrinolytic agents Aggressive therapies

-a) blind - fluoroscopically guided wires, stylet, whiplash

-b) direct - peritoneoscopy, surgical catheter revision

or replacement

Peritoneal Dialysis

Early (within 30 days)

- Manifest externally

- Do not require imaging

- Managed by temporary discontinuation of PD (75%) or surgery

Late (beyond 30 days)

- Manifest by poor outflow, localised oedema, subcutaneous fluid

- 30% require imaging

- Hernia cause 40% of late leaks

- Most late leaks require surgery (70%)

- Frequently lead to change of treatment

Tzamaloukas Adv PD 1990

Dialysate Leaks

Peritoneal Dialysis

Fluid Leak - CT Cannulogram

Peritoneal Dialysis

Abdominal Wall or Pericatheter Leak

Presentation

Abdominal swelling or bogginess Reduced drain (effluent) output Weight gain and abdominal wall oedema,

without peripheral oedema Pericatheter leak: wetness or swelling at exit-

site

Peritoneal Dialysis

Abdominal Wall or Pericatheter Leak

Management

Reintroduce low pressure PD (APD)

or Temporary transfer to HD to allow healing, or Catheter replacement if pericatheter leak,

Peritoneal Dialysis

Hernias and Genital Oedema

Caused by continuous elevation of intra-abdominal pressure and abdominal wall tension

Acquired or congenital defects in the abdominal wall

Inguinal > Catheter insertion site Epigastric > Richters Umbilical > Enterocoele Incisional > Spigelion Ventral > Obturator

Peritoneal Dialysis

Hernias – risk factors

Raised intra-abdominal pressure Female sex and multiparity (no. of pregnancies) Older age Previous hernia Polycystic kidney disease

Peritoneal Dialysis

Hernias – clinical presentation

Painless or tender lump or swelling Bowel incarceration or strangulation

Peritonitis (transmural leakage of bacteria)

Treatment:

1) Surgical repair 2) Reintroduce PD with low volumes, supine posture,

increase volume over 2 weeks

Peritoneal Dialysis

Genital Oedema

Occurs in up to 10% of patients Mechanism:

- fluid tracks through soft tissue plane in a hernia,

catheter insertion site, peritoneal fascial defect,

genital oedema associated with abdo wall oedema

- patent processus vaginalis

- males affected more than females

Diagnosis:

- can be difficult

- CT scan with contrast (100-150mls Omnipaque)

Peritoneal Dialysis

continued…Genital Oedema

Treatment:

- bed rest

- scrotal elevation if symptomatic

- low volume exchange/NIPD

- stop PD temporarily

- surgical repair if cause is hernia or patent processus vaginalis

Peritoneal Dialysis

Infusion or Drainage Pain

CAUSES

- constipation

- jet effect

- fluid pH related

MANAGEMENT

- laxatives - slow infusion rate

- incomplete drainage - Bicarbonate buffer

- 1% lignocaine IP - catheter replacement