1

PD-related

Complications

Pr Max Dratwa

Honorary Consultant, Nephrology-Dialysis

CHU Brugmann

Brussels

Hemodialysis Vascular Access Modifies the

Association between Dialysis Modality and Survival Jeffrey Perl, Ron Wald, Philip McFarlane, Joanne M. Bargman,

Edward Vonesh,Yingbo Na, S. Vanita Jassal and Louise Moist

J Am Soc Nephrol 22: ●●●–●●●, 2011. doi: 10.1681/ASN.2010111155

Figure 1. Survival curves for HD-CVC (short-dashed line), HD-

AVF/AVG (long-dashed line), and PD (solid line) demonstrate higher

1-year mortality in HD-CVC patients.

(A) Unadjusted. (B) Adjusted on the basis of a stratified Cox

proportional Hazards model stratified by HD-CVC, PD, and HD-

AVF/AVG and adjusted for age, race, gender, era of dialysis initiation,

end-stage renal disease comorbidity index, primary renal diagnosis,

serum albumin, eGFR, province of treatment, and late referral.

Hemodialysis Vascular Access Modifies

the Association between Dialysis Modality and Survival

Figure 2. Hemodialysis vascular access affects the association between modality

and survival in selected subgroups. *P value for interaction (int).

The models were adjusted for age, race, gender, era of dialysis initiation, ESRD

comorbidity index, primary renal diagnosis, serum albumin, estimated

GFR, province of treatment and late referral.

Perl J et al J Am Soc Nephrol 22: ●●●–●●●, 2011. doi: 10.1681/ASN.2010111155

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Objective

• Explain the different PD-related complications and their

implications

• Broadly classified by their origin : infectious and non-infectious

Non-infectious complications of PD

• Catheter-related

• Related to elevated abdominal pressure (IPP)

• Degradation of peritoneal membrane

• Related to the presence of PD fluid

Catheter-related complications

• Pain

• Bleeding

• Perforation of bowel

• Leakage

• Malposition and/or obstruction

• Cuff extrusion

• Exit-site and tunnel infections

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Pain during dialysate inflow or drainage

• usually improvement within few days after start of PD

• reduce speed of the outflow, incomplete dialysate outflow

• biocompatible dialysate (pH-neutral, low GDP concentration)

• intraperitoneal lidocain 2% (3-5 ml/L dialysate)

• Tidal peritoneal dialysis

• only in rare cases: catheter removal required (in this

situation exploration of the peritoneal cavity recommended)

• use curled catheters if restart of PD is planned

Catheter-related

• Difficult inflow or outflow

• Catheter migration

• Catheter obstruction (clot - omental wrapping)

• Action

• First, plain X Ray

• Laxatives

• Inject dialysate under pressure (never aspire!)

• X Ray after injection of contrast

• If no clue, laparoscopic exploration

Catheter-related

Cause Mechanism Early/Late Infusion/Drain

Constipation KT adheres to bowel both Mostly drain

Adhesions <Op Wrapping of

extremity

early both

Adhesions >Op Wrapping of

extremity

late both

Migration Diaphragm constipation both drain

Kinks both Mostly drain

Blood clots early both

Fibrin - Peritonitis Fibrin clots or

purulent fluid

late both

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Cuff extrusion

with infection

Catheter-related

Catheter migration

Laxatives

Catheter dislocation and drainage problems

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Uncorrect position of a peritoneal dialysis

catheter with mechanical drainage problems

Catheter

coil IUD

Treatment of catheter dislocation

• Treat meteorism, give laxatives in case of obstipation

• Instillation of 2-2.5 L dialysis fluid

• Gymnastics in order to mobilise the catheter

• If partial dialysate inflow/outflow possible:

try tidal peritoneal dialysis (high fill volume, low tidal volume)

• if conservative therapy unsuccessful:

- catheter manipulation (e.g. with semi-flexible guide wire)

- laparoscopic reposition

- catheter replacement – self locating catheter!

Catheter-related

• Catheter obstruction:

blood clot

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Catheter-related

Catheter obstruction: fibrin clot

Vanderperren et al; Nephrol Dial Transplant 2002;17:2265-7

Catheter obstruction

• Rinsing/irrigation of the catheter with 50 ml 0.9% sodium

chloride and 5000 IE heparine

• If no improvement: instillation of 50000 IE urokinase

in 5 ml saline for at least 3 hours, 1x/day (can be

repeated twice or three times)

• Avoid streptokinase (chemical peritonitis!)

• If no improvement: catheter removal and

implantation of a new catheter (same session)

Catheter-related

Catheter obstruction: omental wrapping

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Catheter-related

Drainage problems: Abdominal obesity

Catheter-related

« Personal shortening» of the catheter

Non-infectious complications of PD

•Catheter-related

•Related to elevated abdominal pressure

•Degradation of peritoneal membrane

•Related to the presence of PD fluid

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Related to increased abdominal pressure

Leaks

Hydrothorax

G-oes. reflux

Appetite

Hernia

Prolapsus

Lumbar pain

Increased IPP

Normal IPP < 16 cm H2O

• Depends of:

• Volume infused + UF

• Position (sitting > standing > lying)

• Age

• Body mass index

• Certain activities : great effort,coughing, defecation (constipation!)

Related to high IPP

Respiratory:

• Alteration of respiratory function

Digestive:

• pancreatitis

• constipation

• gastro-oesophageal reflux

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Hernia : risk factors

• IPP too high

• Multiparity

• Age?

• Previous surgery

• Previous hernia

• Polycystic kidney disease

Umbilical hernia

Inguino-scrotal hernia

Tintillier M et al; Lancet 2003;362:1893

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Hernia : attitude

• Assess and treat before starting PD

• Make sure reduction is possible

• Surgical repair always necessary

• Stop PD

• Reintroduce PD with low volumes, supine posture (APD),

increase volume over 2 weeks

Leakage

• Pericatheter : most frequent, early, when early initiation;

easy diagnosis thanks to the presence of glucose (Dextrostix)

• Genital

• Parietal looks like ‘orange skin’ (sometimes in pt’s back!)

• Peritoneo-pleural : dyspnea, clinic and xRay

External dialysate leaks (exit site)

Mostly "early leaks" immediately after catheter implantation

"Late leaks" often associated with sudden increase of intraperitoneal

pressure and/or trauma

Symptoms:

• clear drainage from the exit site (glucose concentration exsudate > blood)

• sometimes edemateous swelling around the catheter (late leaks)

• in unclear cases: CT-peritoneography

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Pericatheter leak

MRI picture Courtesy A. Vychytyl

Pericatheter leak

MRI picture Courtesy A. Vychytyl

Pericatheter leaks

Therapy:

• Stop PD as long as possible (at least 3-5 days)

• Start APD or CAPD with reduced fill volume

• in case of relapse: stop PD again, continuous drainage of the

peritoneal cavity (continuous connection of an outflow bag)

• Start APD or CAPD with reduced fill volume again after 1 week

• in case of relapse: surgical intervention/implantation of a new

catheter

Prophylaxis:

• exact implantation (paramedian, purse-string suture at the deep cuff)

• "break in" – period for 2 weeks before start of PD

• avoid heavy lifting/physical strain during the first 6-8 weeks

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Leakage

• Signs : weight & expected drain volume (# UF failure )

• Associated with age and high BMI (Del Peso G et al PDI 2003; 23:249-54)

• Attitude :

• IPP (small volumes, APD)

• Catheter replacement

• Surgery

Peritoneo-pleural leak

Kanaan N et al; Nephrol Dial Transplant 1999;14:1590-2

Symptoms and signs:

•Those of pleural effusion (mostly on the right side)

Peritoneo-pleural leak

Kanaan N et al; Nephrol Dial Transplant 1999;14:1590-2

diagnostic

Thorax XRay

Pleurocentesis (comparison glucose levels pleural/blood) and drainage

Add Methylene Blue in dialysate before : NO! (painful)

Peritoneography (! Request Late Images)

- isotopic albumin*

- CT with contrast

causes

Direct communication (congenital holes)

Indirect communication via lymphatics

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Peritoneo-pleural leak:management

Kanaan N et al; Nephrol Dial Transplant 1999;14:1590-2

temporary transfer to HD

small infusion volumes

transfer to APD

pleurodesis

• tetracycline

• blood (autologous)

• glue

• talc

Peritoneo-pleural and peritoneo-

mediastinal leak

Coche E et al Eur Radiol 2005; 15:1667-70

Other localisations of leaks

• Scars, open processus vaginalis, retroperitoneal,

pleuroperitoneal, pleuropericardial

• Diagnosis

• Physical examination

• Scintigraphy (Tc99 i.p.)

• CT-peritoneography

• Magnetic resonance imaging

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Retroperitoneal dialysate leak

CT peritoneography

Non-infectious complications of PD

•Catheter-related

•Related to elevated abdominal pressure

•Degradation of peritoneal membrane

•Related to the presence of PD fluid

Changes in morphology of the peritoneal

membrane

The Peritoneal Biopsy Registry®

Mem

bra

ne T

hic

kness

(µ)

1000

16 15 11 24 54 37 23 8 n =

97 + months 73-96 months

49-72 months 25-48 months

0-24 months HD Uremic Donor

0

1500

500

Williams et al. J Am Soc Nephrol, 13: 470-479, 2002

Normal membrane Long-term PD membrane

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Spearman Rank Correlation p < 0.01

(n=70)

Grade of vasculopathy

100000

80000

60000

40000

20000

0

0 1 2 3 4

Tota

l glu

cose

exposu

re (

g)

Exposure to Glucose & peritoneal histology

100000 80000 60000 40000 20000 0

5000

4000

3000

2000

1000

0

Pearson correlation p<0.01

(n=70)

Thic

kness

of

com

pact

zone (µ

)

Total Glucose exposure (g)

The Peritoneal Biopsy Registry®

Encapsulating Peritoneal Sclerosis

(EPS)

• Causes a picture of recurrent intestinal obstruction even after

stopping PD in a patient treated since several years with PD

(5 years) + severe peritoneal infections + catheter removal

EPS

Church C & Junor B N Engl J Med 2002;347:737

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EPS

EPS

Attitude

• TPN during several months

• Adhesiolysis under coelioscopy

• Steroids

• ? Immunosuppression (role of transplantation)

• Tamoxifen (Nolvadex® : breast cancer) 200 mg bid

• ? Maybe keep the PD catheter in place and perform daily short dwell

Bad Prognosis : 50% mortality within 1 year of diagnosis

Non-infectious complications of PD

•Catheter related

•Related to elevated abdominal pressure

•Degradation of peritoneal membrane (increased permeability)

•Related to the presence of PD fluid

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Dialysate as a diagnostic tool

Dialysate as a diagnostic tool

Causes of bloody dialysate:

- retrograde menstruation - ovulation (back thanks to PD) - peritoneal endometriosis - ectopic pregnancy - ruptured cyst (ADPKD, ovary) - cancer (ovary, colon, kidney) - peritoneal carcinomatosis - pancreatitis - splenic laceration or rupture - EPS - intra-abdominal « catastrophy »

Dialysate as a diagnostic tool

Approach to hemoperitoneum :

-cytologic analysis; Hct:0.3 %

-heparin IP 500-1000 U/2L dwell to prevent clot formation and catheter obstruction

-fast lavages using unwarmed, room t° dialysate (vasoconstriction)

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Causes of chyloperitoneum -Non-lymphoma abdominal malignancy -Lymphoma -S/p - PD catheter insertion - cholecystectomy -AAA repair -Cirrhosis -Pancreatitis -Amyloidosis -Superior vena cava syndrome -Calcium channel blocker medication

Dialysate as a diagnostic tool

The same with UV light After fluorography

Dialysate as a diagnostic tool

Courtesy E. Goffin