Peritoneal Dialysis catheter complication CAPD Chaken 2017

Peritoneal Dialysis Conference
Maj. Chaken Maniyan M.D.
Division of Nephrology, Department of Medicine
Phramongkutklao Hospital
23.5.2017

Demographic data
§ผู้ป่วยหญิงไทยคู่ อายุ 74 ปี
§ภูมิลำเนา : เขตลาดพร้าว กทม.
§ศาสนาพุทธ
§สิทธิการรักษา : ประกันสุขภาพทั่วหน้า รพ.รร. 6

Case Presentation
§ESRD initiated CAPD since March 2016 (TK insertion since Feb 2016)
§ Initial PD prescription: 1.5 % PD fluid 2 L x 4 cycle/d
dwell time 4 hr/cycle
§ Average UF 200-400 ml/d
§ Residual urine 600-700 ml/d
§Hypertension
§Dyslipidemia
§Gout
§Primary hyperthyroidism
§Vitamin D deficiency

Chief complaint
§ เหนื่อยมากขึ้น 2 สัปดาห์ ก่อนมาโรงพยาบาล (ก.พ.2560)

Present illness
§ 2 สัปดาห์ : มีอาการเหนื่อยมากขึ้น FC IIà III
§อาการเป็นตอนท่านอนมากกว่าท่านั่ง ไม่มีแน่นหน้าอก ไม่มีลุกขึ้นมาเหนื่อยตอนกลางคืน
§อาการเป็นมากขึ้นในช่วงที่ใช้น้ำยาล้างหน้าท้อง ไม่มีอาการปวดท้อง ไม่มีน้ำยาขุ่น ไม่มีไข้ ไม่มีถ่ายเหลว
§อาการเหนื่อย ตะแคงขวาแล้วดีขึ้น
§ไม่มีอาการขาบวม ไม่มีหน้าบวม
§Net UF from PD +100-300 ml (ขาดทุน) , residual urine 400-500 ml/d(เท่าเดิม)
§ดื่มน้ำวันละ 1-1.5 ลิตร
§ไม่มีเบื่ออาหารหรือคันตามตัว ไม่มี ตะคริว
§2 วัน อาการเหนื่อยเป็นมากขึ้น ญาติจึงพามารพ.

Personal history
§Personal history
§ ปฏิเสธยาลูกกลอน/ยาสมุนไพร/ยาต้ม/ยาชุด
§ ปฏิเสธดื่มสุรา สูบบุหรี่
§ ไม่มีสัตว์เลี้ยงที่บ้าน
§ Family history :
§ ปฏิเสธโรคไตในครอบครัว

Current medication
§ Losartan(50) 1x2 o pc
§ Hydralazine (25) 2x4 o pc
§ Metroprolol (100) ½ x1 o pc
§ Furosemide (500) 1x1 o pc เช ้า
§ Aldactone (25) 2x1 o pc
§ Amlodipine(10) 1x1 o pc
§ Ferrous fumarate (200) 1x3 o ac
§ Simvastatin (10) 1 x1 o hs
§ PTU (50) 1x1 o pc
§ CaCO3(1) 1x2 with meal
§ Vitamin D2 (20,000) 1cap o จันทร์ พฤหัส
§ KCl elixir 15 ml o OD
§ Pregabalin (25) 1x1 o hs

Physical examination
§ V/S: BT 36.6 C, RR 22 /min, BP 151/61 mmHg, HR 110 /min BW 66 kg
§GA:An elderly Thai female, alert , follow to command
§HEENT: mildly pale conjunctivae, anicteric sclera, no thyroid gland enlargement
§LN: not palpable
§CVS: JVP 4 cm above sternal angle , normal S1 S2, no murmur
§Lungs: Trachea in midline , Normal chest contour , dullness on percussion over
left lung , decreased breath sound left lower lung, no wheezing
§Abdomen: mild distension, active bowel sound, soft, not tender, no guarding,TK
insertion no erythema, no purulent discharge, not tender along tunnel route
§Extremities : No pitting edema
§ Neuro : good consciousness , follow to command, no facial palsy
§ No weakness , decrease pinprick sensation both lower legs , BBK plantar
flexion

Problem lists
§Progressive dyspnea in ESRD on CAPD patient
§Possible Left pleural effusion
§Hypertension
§Dyslipidemia
§Gout
§Primary hyperthyroidism
§Vitamin D deficiency

What is provision diagnosis
and differential diagnoses ?

Laboratory investigation
Lab Result
CBC Hb 10.9 g/dL, Hct 37.9 % MCV 84 fl. RDW 17 %, WBC 8,100, N 73.8%, L 12% M 14% E 0.1% B
0.2% Platelet 267,000
Blood chemistry BUN 69 Cr 12.9 mg/dL Na 138 K3.29 Cl 93.1 HCO3 20.3 mEq/L Ca 8.6 , P 2.3 mg/dL
Lactate 7.3 mg/dL
ABG pH 7.44, pCO2 24.4, pO2 113.2, HCO3 20
LFT TP 4 Alb 2.8 AST 32 ALT 35 ALP 88

Date Fluid. Color WBC PMN Mono RBC Protein Albumin LDH Lactate Sugar ADA
20/2 Pleural Turbid 230 12 88 205 1.7 1 65 12 143 13
Pertoneal Clear 2 - - - 1.6 1 - 74 139 -
Pleural and peritoneal
fluid analysis
Serum protein = 4 g/dL. Pleural/serum ratio = 0.4
Serum albumin 2.9 g/dL
Serum LDH = 192 U/L Pleural/serum ratio = 0.33
Serum glucose = 109

What is the further investigation
and RRT management in this case

Initial management
§ 1.5 % PDF 1500 ml, dwell time 3 hour for 3 cycle
§ 4.25 % PDF 1500 ml, dwell time 4 hour last cycle
§ Dry abdomen in nighttime
§ Increase furosemide to 1 gm /d
§ Advice patient to dialysis in upright position

Follow up March 2017
§ April 2017:
§ มา F/U หลังจาก ปรับ PD prescription อาการหอบ
เหนื7อยลดลง ไม่ปวดท ้อง ไม่มีไข ้ถ่ายอุจจาระ ทุกวัน
ไม่มีท ้องผูก
§NET UF from PD = 200 ml/d
§Residual urine = 500-600 ml/d

Follow up April 2017
§ มา F/U มีปัญหา PD ขาดทุนตลอด วันละ 1500-2000 ml
ตลอด ปัสสาวะออกวันละ 500-600 ml ต่อวัน
§มีอาการบวม หอบเหนื7อยมากขึGน +orthopnea , + PND
§ไม่มีไข ้ไม่มีท ้องผูก ถ่ายอุจจาระได ้ทุกวัน

Physical examination
§ V/S: BT 36.6 C, RR 22 /min, BP 190/100 mmHg, HR 92 /min BW 69 kg
§GA:An elderly Thai woman, follow to command
§HEENT: mildly pale conjunctivae, anicteric sclera, no thyroid gland enlargement
§LN: not palpable
§CVS: JVP 4 cm above sternal angle , normal S1 S2, no murmur
§Lungs: Trachea in midline , Normal chest contour , equal breath sound
§Abdomen: mild distension, active bowel sound, soft, not tender, no guarding,TK
insertion no erythema, no purulent discharge, not tender along tunnel route
§Extremities : pitting edema 2+
§ Neuro : good consciousness , follow to command, no facial palsy
§ No weakness , decrease pinprick sensation both lower legs , BBK plantar
flexion

Laboratory investigation
Lab Result
CBC Hb 9.4 g/dL, Hct 27.9 % MCV 84 fl. RDW 17 %, WBC 10,100, N 73.8%, L 12% M 14% E 0.1% B
0.2% Platelet 287,000
Blood chemistry BUN 99 Cr 12.9 mg/dL Na 138 K5.29 Cl 93.1 HCO3 16.3 mEq/L Ca 8.6 , P 3.4 mg/dL
ABG pH 7.44, pCO2 24.4, pO2 113.2, HCO3 20

Management
§ Consult surgery forTK catheter revision
§ Temporary acute hemodialysis

Peritoneal Dialysis : Catheter Placement
and Complication Management

Requirement of catheter for dialysis adequacy
§Peritoneal membrane w/o sclerosis/adhesions
§Abdominal wall w/o leaks or hernias
§Subcutaneous tract w/o infection
§Skin exit site w/o infection
§Catheter surface w/o persistent biofilm
5th edition Handbook of Dialysis

Why Is Design or Surgical Technique Important?
§ Reduce risk for catheter-related complications
Mechanical Complications
Inadequate Hydraulic Function
Omental Entrapment
Leaks
Infectious Complications
Exit-Site
Tunnel
Peritonitis

Catheter Material
§ Catheters are made either of polyurethane or silicone
§ Either mupirocin or gentamicin - damage polyurethane
§ Manifestations of Damage:
§Opacification of catheter
§Leaks – leading to peritonitis
§Rarely – rupture of catheter

Common used catheter set:
Double cuff, swan neck, coiled Tenckhoff design.
avoid cuff extrusions.
5-mm external diameter and
internal diameters of 2.6 -3.5 mm.
Decreases pain during PD and less likely to migrate.
Nebel M, et al .Adv Perit Dial 7:208–213, 1991
Prevent infection (ESI,Tunnel infection, peritonitis)

Internal diameters for PD catheters
(outer diameter of 5 mm )
Flex-Neck Tenckhoff catheter (silicone)
Internal diameter 3.5 mm
Cruz Tenckhoff catheter (polyurethane)
standard Tenckhoff (silicone)
T-fluted catheter (Ash Advantage, silicone)
Adapted from Crabtree J. Kidney Int Suppl 2006; 70: S27-37

Proper position of peritoneal cuffs
External Segment
Tunneled Segment
Intra-Peritoneal Segment
Crabtree J. Kidney Int Suppl 2006; 70: S27-37

Intraperitoneal portion
1. Straight Tenckhoff, 8-cm ,1-mm side holes
2. CurledTenckhoff, 16-cm, 1-mm side holes
3. Straight Tenckhoff/ perpendicular silicone
discs (Toronto-Western)
4. T-fluted catheter (Ash Advantage), aT-
shaped catheter with grooved limbs
positioned against the parietal peritoneum
1 2
3
4

Superiority of intraperitoneal catheter design
§No consistent data to support
§2014 meta-analysis : straight segments compare with
coiled
§remain functional at 2 years (79 /55 %)
§faster failure (1.4/2.1 yrs) (inadequate small-solute
clearance
§lower rate of late catheter tip migration (5VS 32 %)
Hagen SM, et al . Kidney Int 2014; 85:920.
Johnson et al,Am J Kidney Dis, 2006

Subcutaneous portion
§1-2 extraperitoneal Dacron
(made from polyester)
§Induce fibrous plug
§fix catheter in position
§prevent fluid leaks
§prevent bacterial migration
§Similar rates of ESI, peritonitis,
migration, leakage, removal, and
dysfunction

Extraperitoneal portion
Selection of swanneck or straight catheters
determined by:
-Belt line
-Placement of exit site

Insertion techniques
§ Percutaneous approach
§ Peritoneoscopic approach
§ Open surgical approach
§ Laparoscopic approach
§ Advanced laparoscopic (rectus sheath tunneling, selective
prophylactic omentopexy and adhesiolysis)
Choice of operator/technique depend on local expertise
Joni H.Hansson et al,AJKD Update on Peritoneal Dialysis:Core Curriculum 2016

Advanced laparoscopic :
Rectus Sheath Tunneling

Advanced laparoscopic : Omentopexy
Guest S. Handbook of Peritoneal Dialysis, 2011

Probability of Free of Mechanical Flow Obstruction
At 24 Months Increased by Newer Techniques
Crabtree JH et al .Am Surg . 2005 ; 71:135-143

Proper position of Catheter
§Intraperitoneal portion - between visceral and parietal
peritoneum, near pouch of Douglas (cal de sac)
§ Hydraulic function of catheter AND
§ Minimize omental entrapment
§Inner cuff should be inserted in rectus muscle to prevent
leaks.
§Outer cuff - subcutaneous tissue (create a dead space in
between cuffs) approximate 2 cm
§Subcutaneous tract and exit site should face downward and
laterally to avoid exit site infection.

Location of deep cuff
Placingde ep cuff in abdominal musculature
- promotes tissue ingrowth
- minimizes pericatheter hernias, leaks
- catheter extrusion, and exit site erosion

Principle of exit site placement
§Away from belt-lines, skin creases, and folds
§Clearly visible to daily exit site care
§About one inch from the superficial cuff

Selection of various catheter
Belt line below umbilicus à swan-neck catheter preferred
if lateral point , a straight catheter is preferable
Selected patients prefer uppper or presternal tips

Presternal Exit-Site is Easily Visualized and
Remote from Urostomy

Indication for presternal catheter
§ Morbid obesity
§ Floppy abdominal skin folds
§ Presence of stoma(colostomy, ileostomy, or urostomy)
§ Incontinence of urine or feces
§Very young children who wear diapers
§ Patients with Hx of recurrent catheter infections

Postoperative catheter care
§Covered with a nonocclusive dressing and should not be
used for 10-14 days.
§Catheter should be flushed at least 1-2 times /wk with
saline or dialysate solution
§Low-volume PD may be attempted within 24 hours in case
of emergency
Song JH, Kim GA, Lee SW, et al:. Perit Dial Int 2:194–199, 2000

ISPD : Implantation protocol
§Preoperative:
§ Check for hernias/ MRSA and nasal carriage of S. aureus;
§ Suitable catheter length
§ Marking exit site with the patient sitting or standing. •
§ Preparing bowel with laxatives; ensuring bladder emptying;
administering prophylactic antibiotics
§ Post-procedure: flushing catheter and cap off using suitable dialysate
§ Covering exit site w/ dressing and, if possible, not disturbing for 5 –
10 days;
§ Immobilizing the catheter
§ Choice of antibiotic should be based upon local guidelines, with
consideration given to efficacy, risks of selection of resistant
organisms, and development of Clostridium difficile colitis
ISPD CLINICAL PRACTICE GUIDELINES FOR PERITONEAL ACCESS , Peritoneal Dialysis International,Vol. 30, pp. 424–429, 2010

Audit standards for catheter-related complications:
§Bowel perforation: < 1%
§Significant hemorrhage: < 1%
§Exit-site infection in 2 weeks of insertion: < 5%
§Peritonitis within 2 weeks of insertion: < 5%
§Functional catheter problem requiring manipulation or
replacement or leading to technique failure: < 20%
§At least every 12 months, a combined meeting between
surgeons (or other healthcare providers inserting PD
catheters) and the nephrology team should be held to
review PD catheter data
ISPD CLINICAL PRACTICE GUIDELINES FOR PERITONEAL ACCESS , Peritoneal Dialysis International,Vol. 30, pp. 424–429, 2010

Complication of chronic catheter
§Peri-catheter leak
§Infusion pain
§Drain pain
§Outflow failure
§Cuff extrusion
§Pleural effusion
§EPS
§Infection

Early pericatheter leak
§3 factors :
§ catheter implantation technique
§ timing of initiation
§ strength of abdominal wall tissues.
§Confirmed by glucose dipstick indicating high glucose
§Discontinue for 1–3 weeks usually spontaneous cessation
§Leakage through exit site tunnel :: ↑ risk infection

Late pericatheter leaks
§Caused by pericannular hernia or occult tunnel
infections, (with separation of the cuffs)
§If abdominal wall is weak : track may dilate , develop true
hernia.
§Most late leaks and pericatheter hernias are best managed
by catheter replacement.

Pericatheter leakage
§Treatment
§Reduce physical activity
§Reduce dialysate volumes
§Conversion to cycler
§Temporary conversion to HD
§If conservative measures fails then surgical repair of deep
cuff or catheter replacement

Infusion pain
§ Usually resolved in several weeks in new patients
§ Persistent pain
§ Acidity (pH 5.2–5.5) of conventional lactate based dialysate
§ Use of bicarbonate/lactate- buffered dialysate (pH 7.0–7.4)
§ 1% or 2% lidocaine solution added to the dialysate (5 mL/L)
§Other causes
§ hypertonic dialysate
§ aged dialysate
§ overdistended abdomen
§ extreme temperature
§ straight-tip cathters (jet effect).
§ catheter malposition with tip against abdominal wall

Drain pain
§Common in early days after initiation of dialysis.
§Tip of catheter against sensitive parietal peritoneum
§ Constipation (bowel around catheter in pelvis)
§ More frequently in APD due to hydraulic suction
§ If persistent pain à avoid complete drainage of effluent

Outflow failure
§Definition: Incomplete recovery of instilled
dialysate
§Incidence: 5-20%
§Etiologies
§Constipation (anytime)
§Catheter malposition (days)
§Intraluminal catheter occlusion by thrombus
§Extraluminal catheter occlusion by omentum or
adhesions (weeks)
§Kinking (soon after placement, positional)
§Loss of dialysate from peritoneal cavity

Diagnosis
§History
§ Flow disturbance – inflow, outflow or both
§ When was the catheter placed
§ Constipation
§ Pain
§ Dyspnea
§ Fibrin in dialysate drain
§Plain film
§ Severe constipation
§ Catheter malposition
§Lost dialysate: pericatheter dialysate leakage; either internal
or external

Treatment
§Constipation
§More than half of the cases are cured with releif of
constipation
§Laxatives, stool softeners, suppositories or enema
§Fibrin clot
§Heparin 500-1000 units/L of dialysate for lysis
§Urokinase – instilled in catheter for 1 hour and then
removed
§Recombinant tPA – used if obstruction is refractory

Treatment
§Malpositioned catheter
§Fluoroscopy with stiff wire manipulation
§Redirection either laproscopically or surgically
§Replace catheter if not successful
§Catheter kinking
§Usually requires catheter replacement
§Abdominal exploration may be necessary for catheter
redirection, omentectomy or adhesiolysis or catheter
replacement

Catheter cuff extrusion
§Catheter cuff erodes through the skin to the outer
abdominal wall
§Can be 2nd from ESI or superficial cuff placement
§Incidence: 3.5 – 7%; no specific association with
catheter type and method of placement
§Treatment: depends on presence or absence of
infection
§ No infection: extruding cuff removed by opening the
subcutaneous tissue at exit site and trimming the cuff under
sterile conditions
§ Infection present: remove the catheter

Pleural effusion associated peritoneal dialysis
§Possible etiologies:
§Volume overload, CHF
§Local pleural process
§Peritoneal dialysate (pleuroperitoneal fistula)
§Suspicion of peritoneal dialysate in a non-edematous pt
with inadequate UF
§Incidence: 1.6%, more common in females
§ADPKD patients prone to have due to decreased
abdominal capacity

Pleural effusion
§Usually occurs early after starting PD
§Unrelated to dialysate volumes
§Hypotheses:
§Congenital communication between pleura and
peritoneum. Dissection of fluid through defects around
major vessels and the esophagus
§Combination of increased intra-abdominal pressure and
negative intra-thoracic pressure may open small defects in
the diaphragm

Pleural effusion
§Clinical features
§Can be asymptomatic
§Dyspnea on exertion
§Inadequate UF
§More common on right side
§Occurs early after PD initiation, 50% of cases within 1st
month
§Diagnosis: glucose level higher than serum (no cut point)
§ Nuclear scintigraphy is the most reliable test

Pleural effusion
§Treatment: depends on acuity and severity
§Thoracentesis
§Drain peritoneal cavity and avoid overnight supine dwells
§If recurrent and unresponsive: chemical pleurodesis using
talc, tetracycline
§Surgical correction if diaphragmatic defect is identified
§Temporary conversion to HD

Hemoperitoneum
§ Benign causes
§Menstruation/Ovulation
§Trauma
§Coagulopathy
§Ruptured renal/ ovarian cyst
§Serious causes
§Ischemic bowel
§Colon cancer
§Pancreatitis
§Encapsulating peritoneal sclerosis
§Urologic malignancy
§Treatment
§IP heparin to avoid clotting of catheter
§Flushes
§Investigations depend on suspected cause

Encapsulating peritoneal sclerosis
§Rare: Incidence: 0.5 – 2.8%
§ Stage 1- Pre-EPS stage:
§ Asymptomatic with mild ascites and no inflammation
§ Stage 2- Inflammatory stage:
§ nausea and diarrhea (partial encapsulation of bowel and intestinal swelling)
§ mild inflammation with fibrin exudation is present.
§ Stage 3- Encapsulation:
§ Symptoms of bowel obstruction due to formation of fibrous cocoon
causing encapsulation.
§ Stage 4- Chronic stage of ileus:
§ Absolute bowel obstruction caused by thickening of encapsulating fibrous
cocoon
§Mortality: 30–63%
§Both incidence and mortality increase with increased time on PD
Nakamoto H Perit Dial Int. 2005 Apr; 25 Suppl 4():S30-8.

Pathogenesis of EPS:
“Two-hit” theory
AugustineT, Nephron Clin Pract. 2009; 111(2):c149-54; discussion c154.

EPS: Diagnosis
§Markers of inflammation
§Elevated CRP
§Anemia, resistant to ESA’s
§Hypoalbuminemia
§Radiology: CT scan
§Peritoneal thickening
§Peritoneal calcification
§Tethering and cocooning of bowel
§Small or large bowel obstruction

Nephrol DialTransplant (2006) 21 [Suppl 2]: ii38–ii41
Gross pathology of EPS

CT Findings of EPS
Cameron et al:American Roentgen Ray Society Annual Meeting, 2010

EPS: Treatment
§Corticosteroids:
§ Useful in inflammatory phase
§ Both pulse steroids or daily therapy can be used
§ Reported 38.5% remission rate with corticosteroids
§Tamoxifen: case reports
§Surgical treatment
§ Surgical lysis of intestinal adhesions and stripping of fibrous cocoon
§ Indications for surgery:
§ recurrent bowel obstruction
§ worsening nutritional status
§ failure medication
Mario R. , et al Nature Reviews Nephrology 7, 528-538 (September 2011)

Absolute contraindication for PD
ที่มา :คู่มือบริหารกองทุนหลักประกันสุขภาพแห่งชาติ ปี
งบประมาณ 2560

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Peritoneal Dialysis catheter complication CAPD Chaken 2017

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