The diagnosis is confirmed by finding more than 100 white blood cells/mm3 (1 × 107 cells/l). The diagnosis of peritonitis should be suspected in any patient who develops a cloudy bag when PD fluid is drained or abdominal pain. The biggest difference in hemodialysis vs peritoneal dialysis is that hemodialysis requires an artificial kidney machine to filter blood while peritoneal dialysis does not. Immediately on drainage the bag may appear cloudy, but on standing the fibrin will aggregate and the fluid becomes clear. Peritoneal dialysis (PD) is an alternative procedure to chemodialysis for patients with severe chronic kidney disease. Peritonitis. Understanding their etiology, presentation, and management frequently enables their prevention, correction, or amelioration. It is unusual for the blood-stained dialysate to be associated with infection, although it is wise to have the fluid cultured. The dialysate contains sugar (dextrose). Fluid leaks occur whereby dialysate leaks out of the peritoneal cavity—which can be either visible externally or not. Patients should be advised to contact their dialysis unit immediately if they observe a cloudy bag or develop persistent abdominal pain. Complications of peritoneal dialysis can include: 1. (iii) This increases the risk of hernia. IVC Filter Placement and Removal Procedure, Angioplasty, Stent and Atherectomy Procedure, Paracentesis and Thoracentesis Procedures, contact your nephrologist to obtain a referral to avascular access center. It is technically simple and, when necessary, can be performed continuously in On occasion, both can be present. Samples of the dialysate should be taken for cell count and microbiologic examination. Some of the noninfectious complications that occur in patients on continuous peritoneal dialysis (eg, continuous ambulatory peritoneal dialysis [CAPD] and continuous cycler peritoneal dialysis [CCPD]) are due to increased intra-abdominal pressure resulting from instillation of dialysate into the peritoneal cavity. Peritonitis. If inflow is restored, heparin should be added to the dialysate for the next few cycles. This occurs more commonly on the right side. A range of rare conditions are associated with this complication8; a few female patients relate the episode to their time of ovulation or menstruation. An infection can also develop at the site where the catheter is inserted to carry the cleansing fluid (dialysate) into and out of your abdomen. (iv) The leaking of dialysis fluid is one of the more common PD catheter complications. 97-1). The dialysis fluid used in PD tends to be highly concentrated in dextrose to help move a higher amount of fluid and waste into the abdominal cavity. There are also other complications which incorrect treated may lead to failure of the method: mechanical complications, abdominal wall defects, exit site and tunnel infections. Infections of different hues may occur depending on the site. Bowel perforation by a peritoneal dialysis catheter: Report of two cases. (iii) If you have a PD catheter and are gaining excess weight, talk to your nephrologist about changes you can make to your diet that can fight weight gain without compromising dialysis treatment. The present report summarizes the mechanical and infectious complications attributable to the devices and procedures used for chronic peritoneal dialysis (PD), comparing the type and frequency of such complications in contemporaneous groups of patients undergoing continuous ambulatory PD (CAPD) or intermittent PD (IPD). These complications … If this shows that the catheter is in a satisfactory position in the pelvis, an attempt to restore patency should be made with a thrombolytic agent (urokinase, 100,000 U or tissue plasminogen activator [tPA], 2 mg in 40 ml of normal saline, either instilled for at least 1 hour)5 diluted in normal saline, which can be instilled into the PD catheter for approximately 1 hour before being withdrawn. This is can be managed by switching to tidal APD and using a relatively large residual volume, for example 25% to 50% of the fill volume. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. The most common reason for outflow failure is constipation, although causes of inflow failure discussed previously should also be considered. A doctor who specializes in access care and maintenance can perform an evaluation, discuss your symptoms, and arrange for you to receive immediate treatment, to fix and reposition your PD catheter. Isolated edema of the abdominal wall suggests an internal leak from the peritoneal cavity, either spontaneously or in association with a surgical hernia. Peritonitis is a common and serious complication of peritoneal dialysis (PD). Introduction. Complications of peritoneal dialysis 1. Loading of the bowel with fecal material is often obvious on a plain radiograph, but treatment for constipation should be initiated without recourse to this investigation because it is so common. A leak of dialysate, which is confirmed by measuring glucose concentration in the leaking fluid, is a risk factor for infection. There is sometimes a clear history of trauma to the abdomen or of unexpected strain. Guideline 5.1.1 – PD Infectious Complications : Prevention Strategies APD patients are now given large loading doses in dialysis fluid with a minimum 6-hour dwell (e.g., vancomycin 30 mg/kg) and then are given additional doses every 3 to 5 days according to checked blood levels. Peritonitis is the inflammation of a thin layer of tissue inside the abdomen. From a therapeutic point of view, it is important to differentiate between infections at the e… PD patients affected by this complication may notice that their clothing or dressing around theÂ dialysis accessÂ is wet following a PD exchange. Simon J. Davies, Martin E. Wilkie. Dextrose is sugarâmost of which may be absorbed by your body during each dialysis session. (ii) Over time, this can lead to weight gain as a result of your taking in several hundred extra calories per day from the dialysis fluid. Catheter tunnel exit-site infection. If inflow is significantly slowed or even stopped completely, mechanical causes should be suspected. Causes include perforation of the intestinal tract, pancreatitis, pelvic inflammatory disease, stomach ulcer, cirrhosis, or a ruptured appendix. Following are the complications resulting from peritoneal dialysis. If you or a loved one is experiencing abdominal pain or any other symptoms you think may be related to your dialysis access,Â contact your nephrologist to obtain a referral to avascular access centerÂ immediately to discuss your treatment options. The procedure is performed at home and primarily works to remove excess fluid and waste products from the blood. If the results of this testing prove negative, the patient can be reassured. Peritoneal Dialysis Presentations Home Dialysis Lecture Series Session 3: PD Prescriptions & Complications Home Dialysis Lecture Series Session 2: PD Catheters 101 (v). Encapsulating Peritoneal Sclerosis and Renal Transplantation, 537 Although peritonitis is regarded as the Achilles heel of peritoneal dialysis (PD), a number of serious noninfectious complications can develop in patients on PD. A surgical repair will be required if a major leak is visualized and should always be considered when there is a hernia. Introduction PD is generally well tolerated and serves as an effective form of RRT. Slow outflow can be a problem in patients using automated peritoneal dialysis (APD), resulting in excessive machine alarms. 121 Peritoneal Dialysis 1081 † The adequacy of dialysis and assessment of the patient ’ s residual renal function should be evaluated on a periodic basis. Complications of Peritoneal Dialysis It may be necessary for the patient to stand or to perform other maneuvers to increase intra-abdominal pressure before the leak is demonstrated (Fig. Infusion pain can be caused by hypersensitivity to the dialysis solution, which can be addressed by adding more bicarbonate as a buffer to the fluid to balance its pH level. Non-Infectious Complications of PD. Suggested antibiotic regimens when dialysate fluid culture is available. This process is disrupted during peritonitis when the appearance of fibrin in the dialysate is common. Whatâs the Difference Between a CVC and a PICC? All rights reserved. PD dialysis can also spike your blood sugar level to put you at higher risk for type 2 diabetes. It is normally caused by contamination of the dialysis tubing or extension of catheter exit site or tunnel infections. (iv) IncorrectÂ PD catheter placementÂ can also cause infusion pain, especially when the tip of the catheter touches the bladder, pelvic wall, or rectum. Mechanical or catheter-related problems are more likely to occur at the start or early in the treatment course, or when there is an increase made to the volume of the dialysate; infectious complications can occur at any stage during the course of treatment, whereas membrane and metabolic problems are more prominent after the patient has been on treatment for months or years. Knowing more about these complications and their symptoms can empower you or a loved one to contact a vascular specialist at the right time to receive immediate treatment. The dialysate leukocyte count will be affected by dwell length, and this needs to be taken into account in APD patients. Some patients have discomfort or even pain when the fluid is drained out, which can be experienced in the genital area or rectum, and is commonly a result of pelvic irritation related to the catheter tip. Inguinal hernia during peritoneal dialysis. If the catheter has to be used early, then low volumes should be used (start with 1 liter) in the supine position (e.g., APD with a dry day), with the patient instructed not to mobilize while dialysate is in the peritoneal cavity during the first 2 weeks after catheter insertion. Published literature does not give a strong indication that one insertion technique is better than another, although a recent meta-analysis suggested an advantage of the laparoscopic compared with the open surgical insertion technique1 (techniques of catheter insertion are further discussed in Chapters 92 and 96). World Journal of Nephrology 1 (4):106-122. A. It is the most common complication of peritoneal dialysis. Peritoneal dialysis has better outcomes than hemodialysis during the first couple of years. Obstruction occurs when the PD catheter is placed too close to the intestine or when the catheter migrates to cause poor outflow of the dialysis solution. Retrieved February 24, 2019, from https://www.advancedrenaleducation.com/content/complications-pd-catheters. The mesothelial cells of the peritoneal membrane have a range of physiologic functions including the production of fibrinolytic agents such as tPA. In PD, the process of dialysis takes place inside the body. Although PD catheters can be used as the primary approach to manage late-presenting patients or for acute kidney injury, the incidence of leaks is higher under these conditions.6. PD catheter complications can be safely and effectively treated by a vascular specialist at aÂ vascular access center. Although there are reports that repairing pleural leaks allows subsequent PD, the best advice is to transfer the patient to HD unless there are very strong reasons not to. Alternatively, the catheter can be repositioned at laparotomy or with the laparoscope. Peritoneal dialysis. A hernia can occur shortly after PD catheter placement but more commonly occurs as a late complication one year followingÂ PD initiation. Adequacy of dialysis can be measured with urea kinetic modeling (Kt/V) or urea clearance. However, these individuals may be able to avoid the leaking of dialysis fluid by strengthening their abdominal walls with exercise and physical activity. (iv) Signs you may have a hernia include the sudden appearance of bumps or bulges in your belly, feeling a bulge in the groin area, and the leaking of PD fluid from the catheter exit site. Around 18% of the infection-related mortality in PD patients is the result of peritonitis. Although it was customary to transfer APD patients to CAPD for the purpose of treating peritonitis, this is no longer necessary. These complications can be separated into mechanical aspects relating to the PD technique and the catheter itself, infections either at the exit site of the catheter or peritonitis, changes affecting the peritoneal membrane, and metabolic consequences that arise from components of the dialysis solutions—predominantly the glucose content. A small number of patients have fibrin formation in the absence of peritonitis. (2010, September). If one can be confident that the pleural effusion is not caused by the PD, then PD can be continued while the effusion is investigated and managed. It is important that PD catheters be adequately immobilized if used for early start PD to reduce the risk of tugging and leak. The dialysis catheter that is inserted into the belly of a patient who opts for peritoneal dialysis, called the PD catheter, is often the Achilles' heel of the PD patient. Sources: (i) Akoh, J. Â© 2017, 2020 Fresenius Medical Care. For optimized catheter function it is necessary that each center audit its success with catheter placement against internationally agreed-on standards as part of local quality improvement cycles.2,3. This will clear within one or two cycles, and the majority of the cells found will be mononuclear leukocytes. Peritonitis is one of the few complications associated with peritoneal dialysis.Â The peritoneum is the thin membrane that lines your... Beginning dialysis can be stressful and overwhelming. Excess pressure and weight in the abdomen can put undue pressure on spinal nerves to cause back pain. The first time this happens, a sample must be sent to the microbiology laboratory to exclude infection. 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