Dr alaa saleh complications of peritoneal dialysis (2)

1. Complications of peritoneal
dialysis
D R . A L A A S A L E H , M D ,
S E N I O R C O N S U L T A N T N E P H R O L O G I S T
K I N G A B D U L A Z I Z S P E C I A S T H O S P I T A L
T A I F - K S A

2. Catheter related complications
 1- Pain
 2- Poor flow
 3 – Cuff erosion

3. Pattern of pain
 Pain occuring during inflow:
burning : acidic PH of dialysate(5.5).
sharp : position of catheter tip
(adjacent to bladder or bowel)
 Treatment : - repositioning - replacement
Saxena AB et al . , 2015 PMC

4. Pain during outflow of dialysate
• Occur at the end of drainage by omental
trapping in the catheter as drainage
proceeds.
• Gentle irrigation of the catheter.
• Catheter Reposition or omentectomy.
Cho Y et al. , Cochrane Database Syst. Rev. 2014

5. Pain occur at the end of inflow
 Generally related to overdistention of the abdomen.
 Minimized by:
 least hypertonic dialysate.
 lowest dialysate volume

6. Poor flow of dialysate
Inflow obstruction related to :
= catheter kink
=occlusion by fibrin
Management:
- repaired surgically
- irrigation with saline
or streptokinase
Szeto cc and Johnson DW, Semin Nephrol 2017

7. Outflow obstruction
 Constipation
 Malposition of catheter
 Obstruction by omentum or fibrin

8. Erosion of the distal cuff
 In some patients this leads to persistent exit–site
infection with tunnel infection or peritonitis

9. Increased intra-abdominal pressure
 Increased intraperitoneal volume:
 Hernia
 Dialysate leak
 Back pain
 Abnormal pulmonary function

10. Hernias
 10-20 % of peritoneal dialysis patients
 Most common site is the midline incision from
catheter placement
 Minimize by use paramedian catheter insertion
Chandhary et al. , Clinical J Am Soc Nephrol 2010

11. Hernias
 All patients should be carefully examined for hernias
prior to starting peritoneal dialysis
 Hernias minimized by waiting 2 weeks before
starting dialysis

13. Dialysate leaks
 Leaks most commonly occur through the exit site ,
around the catheter and into the layers of the
abdominal wall.
 Leaks into scrotum , penis, and vulva have also been
described.
Haag-Weber et al. , Suppl 6:89 – 97 Review German 2005

14. Dialysate leaks
 Early leaks related to inadequate catheter placement
with premature use of high intraperitoneal volume
 The use of paramedian catheter insertion minimize
the leaks.

15. Dialysate leaks
 Dialysate leaks suspected when patients reports
prolonged drainage time or progressive weight gain.
 Diagnosis: CT scan with contrast infused in the
dialysate

19. Massive hydrothorax
 Mostly right side
 Actual tears in the diaphragm have been found
 Diagnosis : analysis of pleural fluid --- high glucose
concentration.
 Use of isotope 99 T. injected intraperitoneal with
scanning over the lung
Saxena AB et al. , PMC 2015

21. Back pain
 Caused by underlying muscloskeletal disease
 Aggravated by postural changes induced by the
intraperitoneal fluid load
 Minimized by:
 Decreasing intraperitoneal volume.
 Proper exercise.
 CCPD
Chandhary et al. , Clinic j Am Nephrol 2010

22. Metabolic Complications
 Glucose load + calorie intake Weight gain
 Minimized by:
• Hypertonic dialysate
• Decrease oral calorie intake
• Exercise

23. Metabolic complications
 Hypertriglycerdemia due to continuous large glucose
load (1st 3 months).
 Cholesterol levels may rise slightly
 Corrected by:
• Use of lipid lowering agents.
• Exercise
Feriani M et al., G ital Nefrol 2012

24. Metabolic complications
 Loss of amino acids and protein into effluent
dialysate is a serious complication
 2 to 3 gm of amino acid lost per day
 9 to 12 gm expected in some cases
 40 gm or more lost in peritonitis per day

25. Metabolic complication
 Anorexia and nausea
 Inadequate nutrient intake
 Dialysate nitrogen loss
 Malnutrition

26. Miscellaneous complications
 Pseudomembranous colitis (use of antibiotics)
 Pancreatitis (recent episodes of peritonitis)
 Chyloperitoneum (trauma to lymphatics by catheter)
 Hypertension
Ahmad M et al., int urol nephrol 2012

27. Miscellaneous complications
 Loss of peritoneal ultrafiltration capacity when
increased peritoneal membrane permeability
 Treatment : shorter exchange cycles or dialysate
solutions with higher dextrose concentration

28.  Severe thickening and sclerosis of the peritoneum 
UF failure , asthenia , weight loss , abdominal mass
& pain and small bowel obstruction.
 Etiology : beta blocker , IP antibiotics , disinfectants ,
and response to siliconized rubber tubing of the
catheter
Howard K et al., Am j kidney Dis , 2015
Sclerosing Obstructive
Encapsulating Peritonitis

36. Peritoneal bleeding
 Peritoneal bleeding can be caused by the pressure
from the tip of the catheter
 Usually the hemorrhage is relatively mild and self-
limited and is due to erosion of small blood vessels.
 Massive bleeding due to catheter perforating intra-
abdominal organs.

39. Conclusion
1) Peritoneal Dialysis complications can be managed
easily if diagnosed correctly.
2) Patient should be evaluated thoroughly to be
managed adequately.
3) Limit the use of hypertonic dialysate solution to
avoid complications.