Complications of peritoneal dialysis

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Complications of peritoneal dialysis

  1. 1. Complications of Peritoneal Dialysis Abhijit Kontamwar,MD Renal Consultants, Inc Clinical Assistant Professor of Internal Medicine at NEOUCOM (Northeastern Ohio Universities Colleges of Medicine and Pharmacy).
  2. 2. Complications <ul><li>Infectious </li></ul><ul><li>Non-infectious </li></ul>
  3. 3. Case <ul><li>65 F h/o chronic GN is on CCPD (APD) for 8 months p/w cloudy dialysate fluid. Also c/o diffuse abdominal pain. Denies fever, nausea, vomiting, constipation. </li></ul><ul><li>Vitals: BP 116/78, P 76 </li></ul><ul><li>P/E: exit site appears ok, no discharge or erythema. Diffuse abdominal tenderness + </li></ul><ul><li>Diagnosis???? </li></ul>
  4. 4. Infectious complications <ul><li>Exit – site infection </li></ul><ul><li>Tunnel infection </li></ul><ul><li>Peritonitis: remains significant cause of </li></ul><ul><ul><li>Hospitalization </li></ul></ul><ul><ul><li>PD failure </li></ul></ul><ul><ul><li>Damage to peritoneal membrane </li></ul></ul><ul><ul><li>Morbidity and mortality </li></ul></ul>
  5. 5. Causes of transfer to HD among PD patients Mujais et al; Kidney Int Suppl 2006; 70: S21-36
  6. 6. Hospitalization rates for access related infections Chavers et al, J Am Soc Nephrol 18: 952 – 959, 2007
  7. 7. Peritonitis <ul><li>Usual presentation is with </li></ul><ul><ul><li>Abdominal pain and </li></ul></ul><ul><ul><li>Cloudy effluent fluid </li></ul></ul><ul><li>History </li></ul><ul><ul><li>Recent break in technique </li></ul></ul><ul><ul><li>h/o peritonitis </li></ul></ul><ul><ul><li>Recent exit site infection </li></ul></ul><ul><ul><li>Diarrhea, constipation </li></ul></ul>
  8. 8. How does bacteria gain entry into peritoneal cavity? <ul><li>During catheter connection </li></ul><ul><li>Tracking around the catheter around the exit site </li></ul><ul><li>Across the bowel wall; diverticulosis </li></ul><ul><li>Transvaginal </li></ul><ul><li>Rarely hematogenous </li></ul><ul><ul><li>Bacteremia can cause peritoneal seeding and peritonitis </li></ul></ul><ul><ul><li>Peritonitis rarely causes bacteremia </li></ul></ul><ul><ul><li>Use antibiotic prophylaxis for anticipated bacteremia during procedures like dental work, colonoscopy, GU instrumentation </li></ul></ul><ul><ul><li>Drain effluent before colonoscopy or colposcopy </li></ul></ul>
  9. 9. Pathophysiology <ul><li>Multiple connection and disconnections from the transfer set </li></ul><ul><li>Presence of non-physiologic fluid in the peritoneal cavity may impair host defenses </li></ul><ul><li>High glucose concentration, low pH and hyperosmolality dilute resident peritoneal macrophage and cytokine levels </li></ul><ul><li>Constant removal of macrophage and cytokines during each exchange </li></ul><ul><li>Alteration of mesothelial cell defense properties over time </li></ul>
  10. 10. Flush before fill <ul><li>Connect bag to tubing </li></ul><ul><li>Drain old effluent </li></ul><ul><li>Flush small amount of dialysate through tubing to drain bag </li></ul><ul><li>Infuse rest of fresh dialysate into peritoneal cavity </li></ul>
  11. 11. Diagnosis <ul><li>At least two of the following three features </li></ul><ul><ul><li>Peritoneal fluid leucocytosis; >100 cells/mm 3 and at least 50% PMNs </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul><ul><ul><li>Positive culture of the dialysis effluent </li></ul></ul>
  12. 12. Specimen collection and processing <ul><li>Effluent fluid sent for cell count with differential, culture and gram stain </li></ul><ul><li>Collection of effluent: 50ml of effluent is centrifuged for 15 min followed by re-suspension of sediment in 3-5 ml of sterile saline and inoculation to media </li></ul><ul><li>Dwell time of at least 2 – 4 hours before effluent collection </li></ul><ul><li>If peritoneal cavity is dry, 1L of dialysate infused to dwell for at least 1 – 2 hours </li></ul><ul><li>Peripheral blood cultures usually not necessary </li></ul>
  13. 13. Microbiology Friedrich et al, Kidney Int, Oct 1992; 42: 967-974
  14. 14. Microbiology Mujais, S. Microbiology and outcomes of peritonitis in North America. Kidney Int 2006; 70:S55
  15. 15. Gram +ive organisms <ul><li>Coag neg Staph: </li></ul><ul><ul><li>most common </li></ul></ul><ul><ul><li>secondary to touch contamination </li></ul></ul><ul><ul><li>Mild peritonitis, rapidly responsive to abx </li></ul></ul><ul><li>Staph aureus </li></ul><ul><ul><li>Frequently associated with catheter infection </li></ul></ul><ul><ul><li>More virulent and resistant to abx </li></ul></ul><ul><ul><li>Anterior nares reservoir of staph aureus </li></ul></ul><ul><ul><li>Nasal carriers possibly at increased risk of exit site infection and peritonitis </li></ul></ul><ul><li>VRE </li></ul><ul><ul><li>Risen dramatically </li></ul></ul><ul><ul><li>Also resistant to penicillin and aminoglycosides </li></ul></ul><ul><li>Group B strep </li></ul><ul><ul><li>Rare cause, case reports </li></ul></ul><ul><ul><li>Can present with severe systemic symptoms including septic shock </li></ul></ul>
  16. 16. Gram –ve organisms <ul><li>Non-pseudomonal gram –ve organisms: aasociated with </li></ul><ul><ul><li>Touch contamination </li></ul></ul><ul><ul><li>Exit-site infection </li></ul></ul><ul><ul><li>Trans mural migration from constipation or colitis </li></ul></ul><ul><ul><li>Polymicrobial or anaerobic: due to diverticulitis or bowel perforation </li></ul></ul><ul><li>Pseudomonal peritonitis </li></ul><ul><ul><li>Common at some centers where reduction in touch contamination peritonitis with techniques like flush before fill and prophylactic topical antibiotic </li></ul></ul><ul><ul><li>Difficult to eradicate </li></ul></ul><ul><ul><li>Severe infection can damage peritoneal membrane </li></ul></ul><ul><ul><li>Can be associated with catheter infection </li></ul></ul>
  17. 17. Treatment <ul><li>Majority of peritonitis resolve with outpatient antibiotics treatment alone </li></ul><ul><li>Antibiotics with or w/o fibrinolytic agents. Few cases need catheter removal </li></ul><ul><li>In 2005 International Society of Peritoneal Dialysis (ISPD) working group established a series of peritonitis treatment guidelines </li></ul><ul><li>In 2007 systematic review of 36 RCT was performed addressing the efficacy of abx and other factors </li></ul><ul><ul><li>No specific antimicrobial regimen was superior </li></ul></ul><ul><ul><li>Intermittent and continuous dosing were largely equivalent </li></ul></ul><ul><ul><li>1 st generation cephalosporins and glycopeptides had equivalent efficacy </li></ul></ul><ul><ul><li>In cases with suspected catheter infection, simultaneous catheter removal resulted in treatment success </li></ul></ul><ul><ul><li>The trials were limited by small patient number and inconsistent outcome definitions </li></ul></ul>
  18. 18. Treatment <ul><li>Non-antimicrobial measures </li></ul><ul><ul><li>Heparin 500 units/L can be used to lyse or prevent fibrin clots when dialysate remains cloudy </li></ul></ul><ul><ul><li>Pain control </li></ul></ul><ul><li>Dwell time </li></ul><ul><ul><li>Long dwell exchanges (4-6 hrs) when compared with short dwells are associated with higher number of functional macrophages </li></ul></ul><ul><li>Membrane properties: changes during peritonitis </li></ul><ul><ul><li>Patients may transiently become rapid transporters, thereby requiring the use of hypertonic glucose or shorter dwells </li></ul></ul><ul><ul><li>Alternatively, icodextrin may be helpful </li></ul></ul>
  19. 19. Empiric Therapy Initiate empiric therapy Simultaneous gram +ve and gram –ve coverage For prevention of fibrin occlusion heparin 500 U/L can be used Gram +ve coverage: 1 st generation cephalosporin or vancomycin Gram –ve coverage: 3 rd generation cephalosporin or aminoglycoside
  20. 20. Empiric therapy <ul><li>1 st generation cephalosporin: cefazolin or cephalothin </li></ul><ul><li>Vancomycin used at centers with high rate of MRSA </li></ul><ul><li>3 rd generation cephalosporin: ceftazidime or cefepime </li></ul><ul><li>Short term use of aminoglycoside is safe and does not diminish residual renal function </li></ul><ul><li>Aztreonam can be used in cephalosporin allergic patients </li></ul><ul><li>Monotherapy with imipenem/cilastatin is possible. One study with 102 patients randomly assigned to either imipenem/cilastatin or cefazolin + ceftazidime showed similar outcomes in both groups </li></ul>
  21. 21. Mode of antibiotic administration <ul><li>Intraperitoneal administration of abx is preferred over IV </li></ul><ul><ul><li>Infection is usually localized to the peritoneum </li></ul></ul><ul><ul><li>Bacteremia is exceedingly rare (<1%) </li></ul></ul><ul><ul><li>Outpatient basis </li></ul></ul><ul><li>IP antibiotics can be given either </li></ul><ul><ul><li>Continuous: abx given with each exchange </li></ul></ul><ul><ul><li>Intermittent: abx given once daily with a dwell of at least 6 hours </li></ul></ul><ul><ul><li>No sufficient data to suggest that one is better than other; usually equivalent </li></ul></ul>
  22. 22. Staph. aureus peritonitis Staph. Aureus on culture D/c gram –ve coverage, cont. gram +ve coverage for 3 weeks If MRSA change to Vancomycin and rifampin can be added (600 mg/day for 1 week) If clinical improvement continue for 3 weeks If no clinical improvement reculture and revaluate for exit-site or tunnel Infection or intra-abd abscess If peritonitis with exit-site or tunnel Infection – remove catheter Allow 2 weeks rest period before reinitiating PD If no improvement in 5 days on appropriate antibiotics, remove catheter
  23. 23. Enterococcus/Streptococcus peritonitis Enterococcus/Strep on culture D/c empiric coverage Start continuous Ampicillin 125 mg/L each bag Consider adding aminoglycoside for enterococcus If ampicillin resistant, start vanco; If VRE consider quinupristin/dalfopristin or linezolid Clinical improvement; treat for 2 weeks – strep 3 weeks - enterococcus No improvement, reculture and evaluate for exit-site or tunnel infection Peritonitis with exit or tunnel infection Consider catheter removal Treat for 3 weeks In no improvement by 5 days, remove catheter
  24. 24. Pseudomonas peritonitis Pseudomonas on culture W/o exit-site/tunnel infection With exit-site/tunnel infection Remove catheter Use 2 abx with different mechanism Oral quinolone, cephalosporin, piperacillin based on sensitivities If clinical improvement Treat for 3 weeks If no improvement reculture and evaluate If no improvement by 5 days on appropriate abx, remove catheter
  25. 25. Gram negative organism peritonitis Single gram –ve organism on culture E. coli, klebsiella or proteus Stenotrophomonas 3 rd generation cephalosporin: ceftazidime or cefepime Two drugs with different mechanisms based on sensitivity pattern Duration of therapy: 3 weeks Duration of therapy: 3-4 weeks If no clinical improvement by 5 days, remove catheter
  26. 26. Polymicrobial peritonitis Polymicrobial peritonitis Multiple gram –ve organisms Multiple gram +ve organisms Change to metronidazole In conjunction with ampicillin, Ceftazidime or aminoglycoside Surgical evaluation Laprotomy for suspected intra-abd pathology/abscess with catheter removal Continue therapy based on sensitivities W/o catheter infection, treat for 3 weeks With catheter infection, remove catheter
  27. 27. Culture negative peritonitis Culture negative peritonitis 24-48 hours Continue initial therapy If culture negative for 72 hours Repeat cell count and diff Infection resolving, pt improving Infection not resolving Cont initial therapy for 2 weeks, But D/c aminoglycoside if used initially Special culture techniques for Mycobacteria or legionella Culture positive Culture negative Adjust therapy as per sensitivity patterns If no improvement in 5 days, Consider catheter removal
  28. 28. Other causes of peritonitis <ul><li>Fungal peritonitis </li></ul><ul><ul><li>Catheter removal </li></ul></ul><ul><ul><li>Flucytosine 1gm/day + Fluconazole 200 mg/day PO for 10 days after catheter removal </li></ul></ul><ul><li>Mycobacterial peritonitis </li></ul><ul><ul><li>M. tuberculosis: Rifampin + INH (for 12 months) + pyrazinamide + ofloxacin (3 months) </li></ul></ul><ul><ul><li>Consider catheter removal </li></ul></ul>
  29. 29. Antibiotic dosing recommendations for CAPD LD: loading dose in mg, MD: maintenance dose in mg Antibiotic Intermittent Continuous Gentamicin 0.6 mg/kg LD 8, MD 4 Amikacin 2 mg/kg LD 25, MD 12 Cefazolin 15 mg/kg LD 500, MD 125 Cefepime 1 gm LD 500, MD 125 Cephalothin 15 mg/kg LD 500, MD 125 Ceftazidime 1 – 1.5 gm LD 500, MD 125 Ciprofloxacin No data LD 50, MD 25 Vancomycin 15-30 mg/kg every 5-7 days LD 1000, MD 25 Aztreonam No data LD 1000, MD 250 Amphotericin NA 1.5 Imipenem/cilistatin 1 gm bid LD 500, MD 200
  30. 30. Intermittent dosing of antibiotics in APD <ul><li>Cefazolin (IP): 20 mg/kg every day, in long dwell </li></ul><ul><li>Cefepime (IP): 1 gm in one exchange per day </li></ul><ul><li>Vancomycin (IP): loading dose 30 mg/kg in long dwell, repeat dosing 15 mg/kg in long dwell every 5-7 days </li></ul><ul><li>Fluconazole (IP): 200 mg in one exchange per day every 24-48 hours </li></ul>
  31. 31. Catheter removal in peritonitis patients <ul><li>2005 ISPD guidelines recommend catheter removal in following </li></ul><ul><ul><li>Relapsing peritonitis: another episode with same species that caused the preceding episode within 4 weeks of completing abx </li></ul></ul><ul><ul><li>Refractory peritonitis: failure to respond to abx in 5 days </li></ul></ul><ul><ul><li>Refractory catheter infection </li></ul></ul><ul><ul><li>Fungal peritonitis </li></ul></ul><ul><ul><li>Fecal peritonitis </li></ul></ul><ul><ul><li>Peritonitis associated with intra-abdominal pathology </li></ul></ul><ul><li>Consideration to catheter removal in mycobacterial and multiple enteric organisms peritonitis </li></ul>
  32. 32. Other causes of cloudy effluent <ul><li>Eosinophilic peritonitis </li></ul><ul><li>Chyloperitoneum </li></ul><ul><li>Fluid that’s been dwelling for a long time </li></ul>
  33. 33. Eosinophilic peritonitis <ul><li>Relatively new PD catheter </li></ul><ul><li>Effluent is cloudy w/o abdominal pain </li></ul><ul><li>PD differential count: eosinophils ++ </li></ul><ul><li>Effluent culture: no growth </li></ul><ul><li>Cause: ?immune reaction to catheter </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Usually self limited, goes away in few days </li></ul></ul><ul><ul><li>Some reports of benefit with IP steroids </li></ul></ul>
  34. 34. PD catheter removal after transplant <ul><li>Optimal time after transplant is unclear </li></ul><ul><li>Some clinicians wait 3 – 4 months after transplant for catheter removal </li></ul><ul><li>Early catheter removal is advised in high-risk patients </li></ul>
  35. 35. Case <ul><li>PD patient presents with abdominal pain </li></ul><ul><ul><li>Diagnosed as peritonitis </li></ul></ul><ul><ul><li>PD effluent is clear </li></ul></ul><ul><ul><li>Pain localized to one spot </li></ul></ul><ul><ul><li>High peritoneal fluid amylase level on further w/up </li></ul></ul>
  36. 36. Other causes of abdominal pain in PD patients <ul><li>Ischemic bowel </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Cholecystitis </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>Nephrolithiasis </li></ul><ul><li>Constipation </li></ul><ul><li>Incarcerated hernia </li></ul><ul><li>Appendicitis </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Ruptured viscous </li></ul>
  37. 37. Exit-site/Tunnel infection <ul><li>Exit-site infection: presence of purulent discharge with or w/o erythema of the skin at catheter-epidermal interface </li></ul><ul><li>Tunnel infection: usually occult but may be present with erythema, edema or tenderness over subcutaneous path </li></ul><ul><li>Rarely occurs alone </li></ul><ul><li>Staph aureus and pseudomonas exit site infections are often associated with concomitant tunnel infection </li></ul>
  38. 39. Treatment of exit-site/tunnel infection Purulent discharge from exit-site Do culture/gram stain Gram +ve organism Gram –ve organism 1 st generation Cephalosporin PO PO Quinolones If slow improvement or severe Cases add Rifampin 600mg/day If Pseudomonas and no improvement add 2 nd anti-pseudomonal; ceftazidime IP Infection resolving; cont treatment for 2 weeks Infection resolving; cont treatment for 2 weeks Infection unresolved in 3-4 weeks; consider catheter revision/removal Infection unresolved in 3-4 weeks; consider catheter revision/removal
  39. 40. <ul><li> Non-infectious complications </li></ul>
  40. 41. Non-infectious complications Non infectious complications Catheter related Catheter unrelated <ul><li>Outflow failure </li></ul><ul><li>Pericatheter leak </li></ul><ul><li>Abdominal wall herniation </li></ul><ul><li>Catheter cuff extrusion </li></ul><ul><li>Intestinal perforation </li></ul>GERD Hemoperitoneum Back/abdominal pain UF failure Abdominal wall herniation Peritoneal sclerosis Pleural effusion Metabolic
  41. 42. Case <ul><li>A patient reports difficulty filling and draining </li></ul><ul><ul><li>There is a positional component </li></ul></ul><ul><ul><li>Catheter was placed several weeks ago. The dwell & drain has never been normal </li></ul></ul><ul><ul><li>Bowel movements are normal and soft </li></ul></ul><ul><ul><li>No fibrin noted in previous drains </li></ul></ul>
  42. 44. Outflow failure <ul><li>Incomplete recovery of instilled dialysate </li></ul><ul><ul><li>Unable to remove dialysate from peritoneal cavity </li></ul></ul><ul><ul><li>Fluid is no longer in peritoneal cavity </li></ul></ul><ul><li>Incidence: 5-20% </li></ul><ul><li>Etiologies </li></ul><ul><ul><li>Constipation (anytime) </li></ul></ul><ul><ul><li>Catheter malposition (days) </li></ul></ul><ul><ul><li>Intraluminal catheter occlusion by thrombus </li></ul></ul><ul><ul><li>Extraluminal catheter occlusion by omentum or adhesions (weeks) </li></ul></ul><ul><ul><li>Kinking (soon after placement, positional) </li></ul></ul><ul><ul><li>Loss of dialysate from peritoneal cavity </li></ul></ul>
  43. 45. Diagnosis <ul><li>History </li></ul><ul><ul><li>Flow disturbance – inflow, outflow or both </li></ul></ul><ul><ul><li>When was the catheter placed </li></ul></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Fibrin in dialysate drain </li></ul></ul><ul><li>Plain film </li></ul><ul><ul><li>Severe constipation </li></ul></ul><ul><ul><li>Catheter malposition </li></ul></ul><ul><li>Lost dialysate: peri-catheter dialysate leakage; either internal or external </li></ul>
  44. 46. Treatment <ul><li>Constipation </li></ul><ul><ul><li>More than half of the cases are cured with releif of constipation </li></ul></ul><ul><ul><li>Laxatives, stool softeners, suppositories or enema </li></ul></ul><ul><li>Fibrin clot </li></ul><ul><ul><li>Heparin 500 units/L of dialysate for lysis </li></ul></ul><ul><ul><li>Urokinase – instilled in catheter for 1 hour and then removed </li></ul></ul><ul><ul><li>Recombinant tPA – used if obstruction is refractory </li></ul></ul>
  45. 47. Treatment <ul><li>Malpositioned catheter </li></ul><ul><ul><li>Fluoroscopy with stiff wire manipulation </li></ul></ul><ul><ul><li>Redirection either laproscopically or surgically </li></ul></ul><ul><ul><li>Replace catheter if not successful </li></ul></ul><ul><li>Catheter kinking </li></ul><ul><ul><li>Usually requires catheter replacement </li></ul></ul><ul><ul><li>Superficial cuff removal if kinking is due to placement of the catheter cuffs too close to each other </li></ul></ul><ul><li>Abdominal exploration may be necessary for catheter redirection, omentectomy or adhesiolysis or catheter replacement </li></ul>
  46. 48. Case <ul><li>A 63 year old female started on CAPD 4 weeks ago is noted to have swelling of abdominal wall on regular visit. On history reports increased activity this week </li></ul>
  47. 49. Pericatheter leakage <ul><li>Early after placement </li></ul><ul><li>Increased intra-abdominal pressure on CAPD 2ry to increased activity </li></ul><ul><li>Weak abdominal wall (pervious surgeries, pregnancies) </li></ul><ul><li>High dialysate volumes </li></ul><ul><li>Catheter placement techniques: poor evidence of technique with incidence </li></ul><ul><ul><li>Peritoneoscopically placed catheters may be better </li></ul></ul><ul><ul><li>Double cuff catheters are considered less likely to leak </li></ul></ul>
  48. 50. Pericatheter leakage <ul><li>Clinical features </li></ul><ul><ul><li>Subcutaneous swelling </li></ul></ul><ul><ul><li>Fluid in area surrounding the catheter </li></ul></ul><ul><ul><li>Genital and abdominal wall edema </li></ul></ul><ul><ul><li>Diminished outflow volumes </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Check glucose concentration of fluid around the catheter to determine if it is dialysate or serous fluid from subcutaneous tissue </li></ul></ul><ul><ul><li>For confirmation – peritoneal scintigraphy, CT scan or MRI after dialysate infusion using dialysate as a contrast </li></ul></ul>
  49. 51. Pericatheter leakage <ul><li>Treatment </li></ul><ul><ul><li>Reduce physical activity </li></ul></ul><ul><ul><li>Reduce dialysate volumes </li></ul></ul><ul><ul><li>Conversion to cycler </li></ul></ul><ul><ul><li>Temporary conversion to HD </li></ul></ul><ul><ul><li>If conservative measures fails then surgical repair of deep cuff or catheter replacement </li></ul></ul>
  50. 52. Case <ul><li>42 year old female with h/o ADPKD started on CAPD 1 month back </li></ul><ul><li>c/o progressive shortness of breath on exertion </li></ul><ul><li>PD flow sheet reveals consistently inadequate UF </li></ul><ul><li>On exam: normal BP, no edema, decreased breath sounds over right lung base </li></ul>
  51. 54. Pleural effusion <ul><li>Possible etiologies: </li></ul><ul><ul><li>Volume overload, CHF </li></ul></ul><ul><ul><li>Local pleural process </li></ul></ul><ul><ul><li>Peritoneal dialysate </li></ul></ul><ul><li>Suspicion of peritoneal dialysate in a non edematous pt with inadequate UF </li></ul><ul><li>Incidence: 1.6%, more common in females </li></ul><ul><li>ADPKD patients prone to have due to decreased abdominal capacity </li></ul>
  52. 55. Pleural effusion <ul><li>Usually occurs early after starting PD </li></ul><ul><li>Unrelated to dialysate volumes </li></ul><ul><li>Hypotheses: </li></ul><ul><ul><li>Congenital communication between pleura and peritoneum. Dissection of fluid through defects around major vessels and the esophagus </li></ul></ul><ul><ul><li>Combination of increased intra-abdominal pressure and negative intra-thoracic pressure may open small defects in the diaphragm </li></ul></ul>
  53. 56. Pleural effusion <ul><li>Clinical features </li></ul><ul><ul><li>Can be asymptomatic </li></ul></ul><ul><ul><li>Dyspnea on exertion </li></ul></ul><ul><ul><li>Inadequate UF </li></ul></ul><ul><ul><li>More common on right side </li></ul></ul><ul><ul><li>Occurs early after PD initiation, 50% of cases within 1 st month </li></ul></ul><ul><li>Diagnosis: high glucose concentration in pleural fluid </li></ul>
  54. 57. Pleural effusion <ul><li>Treatment: depends on acuity and severity </li></ul><ul><ul><li>Thoracentesis </li></ul></ul><ul><ul><li>Drain peritoneal cavity and avoid overnight supine dwells </li></ul></ul><ul><ul><li>If recurrent and unresponsive: chemical pleurodesis using talc, tetracycline or autologous blood </li></ul></ul><ul><ul><li>Surgical correction if diaphragmatic defect is identified </li></ul></ul><ul><ul><li>Temporary conversion to HD </li></ul></ul>
  55. 58. Catheter cuff extrusion <ul><li>Catheter cuff erodes through the skin to the outer abdominal wall </li></ul><ul><li>Can be 2ry to exit-site infection or superficial cuff placement </li></ul><ul><li>Incidence: 3.5 – 7%; no specific association with catheter type and method of placement </li></ul><ul><li>Treatment: depends on presence or absence of infection </li></ul><ul><ul><li>No infection: extruding cuff removed by opening the subcutaneous tissue at exit site and trimming the cuff under sterile conditions </li></ul></ul><ul><ul><li>Infection present: remove the catheter </li></ul></ul>
  56. 59. Intestinal perforation <ul><li>Direct injury during catheter placement </li></ul><ul><li>By erosion – weeks to months after catheter placement </li></ul><ul><li>Requires high index of suspicion </li></ul><ul><li>Incidence: rare (<1%); more common with semi-rigid PD catheters </li></ul><ul><li>Clinical features </li></ul><ul><ul><li>Bloody or feculent dialysate </li></ul></ul><ul><ul><li>Dialysate retention </li></ul></ul><ul><ul><li>Diarrhea after dialysate instillation </li></ul></ul><ul><ul><li>Gram negative peritonitis </li></ul></ul><ul><li>Treatment: surgery </li></ul><ul><ul><li>Bowel repair, catheter removal and antibiotics </li></ul></ul>
  57. 60. Bleeding exit-site <ul><li>Etiology </li></ul><ul><ul><li>Trauma to small blood vessels after catheter placement </li></ul></ul><ul><ul><li>Crust removal before natural separation occurs </li></ul></ul><ul><ul><li>Exit-site infection with secondary hemorrhage </li></ul></ul><ul><li>If possible avoid peri-op anticoagulation for 24 hours </li></ul>
  58. 61. Case <ul><li>A 30 year old female reports pink tinged effluent </li></ul>
  59. 62. Hemoperitoneum <ul><li>Benign causes </li></ul><ul><ul><li>Menstruation </li></ul></ul><ul><ul><li>Ovulation </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Coagulopathy </li></ul></ul><ul><ul><li>Ruptured renal or ovarian cyst </li></ul></ul><ul><li>Serious causes </li></ul><ul><ul><li>Ischemic bowel </li></ul></ul><ul><ul><li>Colon cancer </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Encapsulating peritoneal sclerosis </li></ul></ul><ul><ul><li>Urologic malignancy </li></ul></ul>During training, warn females in advance!
  60. 63. Hemoperitoneum <ul><li>Treatment </li></ul><ul><ul><li>IP heparin to avoid clotting of catheter </li></ul></ul><ul><ul><li>Flushes </li></ul></ul><ul><ul><li>Investigations depend on suspected cause and type of presentation </li></ul></ul>
  61. 64. Case <ul><li>45 year old female PD patient reports of epigastric discomfort </li></ul><ul><li>No relation to food or exertion </li></ul><ul><li>Usually occurs during a dwell period </li></ul>
  62. 65. GERD and delayed gastric emptying <ul><li>GERD: Clinical features </li></ul><ul><ul><li>nausea, vomiting, fullness or discomfort </li></ul></ul><ul><ul><li>24 hours pH monitoring has shown abnormalities after dialysate instillation in symptomatic patients </li></ul></ul><ul><li>Delayed gastric emptying: mechanical or neurogenic mechanism triggered by the presence of intra abdominal fluid </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>GERD: minimize supine intraperitoneal fluid volume </li></ul></ul><ul><ul><li>Delayed gastric emptying: metoclopramide or erythromycin, case report of IP ondansetron in a patient with refractory symptoms </li></ul></ul>
  63. 66. Case <ul><li>A 55 year old male undergoing CAPD for 2 years c/o dull lower back pain. The onset has been gradual over the past 6 months. Pain is 3/10 intensity, non-radiating, aggravated during dwell periods and while standing. Denies fever, wt loss, neurologic symptoms or trauma </li></ul><ul><li>On exam </li></ul><ul><ul><li>Normotensive </li></ul></ul><ul><ul><li>Non-tender abdomen </li></ul></ul><ul><ul><li>Slight lardosis + </li></ul></ul><ul><ul><li>Poor abdominal muscle tone </li></ul></ul><ul><ul><li>Neurologic exam: non focal </li></ul></ul>
  64. 67. Back pain <ul><li>Can be 2ry to increased mechanical stress on lumbar spine (lardotic position) </li></ul><ul><li>May be associated with other musculoskeletal disease </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Decrease dialysate fill volumes </li></ul></ul><ul><ul><li>If inadequate dialysis, may need to change to cycler (APD). Pt may tolerate larger fill volumes while supine </li></ul></ul>
  65. 68. Case <ul><li>48 year old male is on APD for one year </li></ul><ul><li>Reports a new lump in his left groin </li></ul><ul><li>He had been gardening and felt a ‘pop’ and some tenderness in groin </li></ul>
  66. 69. Peritoneal Scintigram
  67. 71. Hernia <ul><li>Treatment </li></ul><ul><ul><li>Surgical repair </li></ul></ul><ul><ul><li>No PD for 2 days after surgery, then back on cycler, day dwell can be re-introduced in 2 months </li></ul></ul><ul><ul><li>No need for interim HD </li></ul></ul><ul><li>Perioperative management of peritoneal dialysis patients undergoing hernia surgery w/o the use of interim HD; Shah et al, Perit Dial Int 2006; 684-687 </li></ul>
  68. 72. Dialysate infusion pain <ul><li>Causes </li></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><ul><li>Patient new to PD. Pain diminishes during dwell </li></ul></ul><ul><ul><li>Acidic ph of conventional lactate dialysate </li></ul></ul><ul><ul><li>Catheter position abutting bowel wall </li></ul></ul><ul><ul><li>Dialysate temperature </li></ul></ul><ul><ul><li>High dialysate glucose concentration </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Slow infusion rate </li></ul></ul><ul><ul><li>Dialysate with higher ph eg bicarb or bicarb/lactate </li></ul></ul><ul><ul><li>Injection of local anesthetic into dialysate before infusion eg 1% lidocaine; 50mg/exchange </li></ul></ul><ul><ul><li>Incompletely drain the fluid after a dwell period </li></ul></ul><ul><ul><li>Rarely catheter replacement or conversion to HD </li></ul></ul>
  69. 73. Metabolic <ul><li>Hypokalemia </li></ul><ul><ul><li>10 – 35% of PD patients require K supplements </li></ul></ul><ul><ul><li>Hypokalemia can be due to increased cellular K uptake secondary to insulin secretion after glucose load </li></ul></ul><ul><ul><li>Liberalize dietary K intake </li></ul></ul><ul><li>Hypermagnesemia </li></ul><ul><ul><li>More common in PD than HD </li></ul></ul><ul><ul><li>Results from high Mg in dialysate (0.75 mmol/L) </li></ul></ul><ul><ul><li>Consider other dialysate conc (with Mg 0.5 or 0.25 mmol/L) </li></ul></ul><ul><ul><li>Avoid Mg containing medications </li></ul></ul>
  70. 74. Encapsulating peritoneal sclerosis <ul><li>Rare </li></ul><ul><li>Inflammatory phase: non-specific symptoms like nausea, vomiting, weight loss, high CRP, hypoalbuminemia </li></ul><ul><li>Sclerosing phase: recurrent bowel obstruction, abdominal pain or hemoperitoneum, progressive malnutrition </li></ul><ul><li>Incidence: 0.5 – 2.8% </li></ul><ul><li>Mortality: 38 – 63% </li></ul><ul><li>Both incidence and mortality increase with increased time on PD </li></ul>
  71. 75. EPS: Diagnosis <ul><li>Markers of inflammation </li></ul><ul><ul><li>Elevated CRP </li></ul></ul><ul><ul><li>Anemia, resistant to ESA’s </li></ul></ul><ul><ul><li>Hypoalbuminemia </li></ul></ul><ul><li>Radiology: CT scan </li></ul><ul><ul><li>Peritoneal thickening </li></ul></ul><ul><ul><li>Peritoneal calcification </li></ul></ul><ul><ul><li>Tethering and cocooning of bowel </li></ul></ul><ul><ul><li>Small or large bowel obstruction </li></ul></ul>
  72. 78. EPS: Treatment <ul><li>Corticosteroids: </li></ul><ul><ul><li>Probably more useful in inflammatory phase </li></ul></ul><ul><ul><li>Both pulse steroids or daily therapy have been used </li></ul></ul><ul><ul><li>Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study: Kawanishi et al; Am J Kidney Dis, 2004; 729-737 </li></ul></ul><ul><ul><li>Reported 38.5% remission rate with corticosteroids </li></ul></ul><ul><li>Tamoxifen: case reports </li></ul><ul><li>Surgical treatment </li></ul><ul><ul><li>Surgical lysis of intestinal adhesions and stripping of fibrous cocoon </li></ul></ul><ul><ul><li>Indications for surgery: recurrent bowel obstruction, failing nutritional status, failure to respond to medical therapy </li></ul></ul>

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