Peritoneal Dialysis Catheter Removal Research Articles

Causative organisms and outcomes of peritoneal dialysis-related peritonitis in Sarawak General Hospital, Kuching, Malaysia: a 3-year analysis

BackgroundPeritoneal dialysis peritonitis remains a significant cause of morbidity for peritoneal dialysis patients and the main reason for conversion from peritoneal dialysis to hemodialysis. As the characteristics of patients and microbial susceptibility vary from center to center, the aim of this study is to evaluate the microbiology and the clinical outcomes among continuous ambulatory peritoneal dialysis patients in Kuching, Malaysia.MethodsThis is a retrospective record review of 82 continuous ambulatory peritoneal dialysis patients who developed peritonitis during 2013 to 2015. Data examined included patients’ demographic data, causative organisms, and outcomes.ResultsA total of 124 episodes of peritonitis were recorded, and the overall peritonitis rate was 0.40 episodes per patient-year. There was an increasing incidence in continuous ambulatory peritoneal dialysis peritonitis over the 3-year study period (0.35 to 0.47 episodes per patient-year). The gram-negative peritonitis rate increased over the period until towards the end of the study period, when gram-positive and gram-negative organisms accounted for almost equal proportions of peritonitis. Streptococcus sp. was the most common organism among the gram-positive peritonitis while Pseudomonas sp. was the most common organism in gram-negative peritonitis. The culture-negative peritonitis rate was 25.8%. The peritoneal dialysis catheter was removed in 32 episodes (26.6%). The catheter loss rate was significantly higher in gram-negative peritonitis, as compared to gram-positive peritonitis (38.9 vs 16.7%, p = 0.027).ConclusionsThe increasing trend of peritonitis and high rates of culture negativity and peritoneal dialysis catheter removal are areas that need further evaluation and improvement in the future. Study on risk factors of continuous ambulatory peritoneal dialysis peritonitis, detailed microbiology, and antimicrobial treatment and response are warranted to further improve the outcomes of continuous ambulatory peritoneal dialysis patients.

Peritoneal dialysis-associated catheter infection caused by Mycobacterium abscessus in an elderly patient who was successfully treated with catheter removal.

An 89-year-old Japanese man on peritoneal dialysis (PD) was suspected of having a PD-associated catheter infection. He visited the hospital because of the discharge of pus from the exit site of his catheter. Gram staining of the pus showed Gram-positive bacilli, but these were acid-fast bacilli. The rapidly growing nontuberculous mycobacteria, Mycobacterium abscessus, was isolated. PD catheter removal and debridement were immediately performed. The patient received combination antibiotic therapy. His clinical course was good, but he required hemodialysis due to the discontinuation of PD. However, the patient and his family chose not to continue hemodialysis even when the symptoms of uremia appeared. Best supportive care was arranged by his primary care physician. M. abscessus is a rare causative organism for PD-associated catheter infections and is difficult to treat. In our case, a rapid and precise diagnosis was made using acid-fast staining and Mycobacterium culture. The risk of nontuberculous mycobacterial infections should be considered in patients on PD.

Urine producing peritoneal dialysis catheter

Insertion of a peritoneal dialysis (PD) catheter into the bladder is a rare complication of PD. Herein, we describe a case of an adult patient undergoing PD tube insertion who...

Peritoneal Dialysis Catheter Surgery Using Transversus Abdominis Plane Block

Peritoneal dialysis (PD) catheter surgery can be performed using regional anesthesia. We present our PD catheter placement and extraction experience using ultrasound-guided transversus abdominis plane (TAP) block. In the present study, we analyzed 74 patients from our center with end-stage renal disease (ESRD) who underwent PD catheter placement (60 patients) and removal (14 patients) using a TAP block between June 2011 and December 2015. The TAP block was successful for 55/60 (91.7%) patients (insertion) and 13/14 (92.9%) patients (extraction). Other patients had pain at the incision site and required general anesthesia. There were no anesthesia-, surgery- or PD catheter-related complications. The TAP block is a safe and effective technique not only for high-risk ESRD patients but for all patients undergoing PD catheter placement or extraction.

Enterobacter cloacae–Related Necrotizing Fasciitis After Peritoneal Dialysis in Delayed Graft Function: A Case Report

IntroductionNecrotizing fasciitis is an uncommon soft-tissue infection that involves the superficial fascia, subcutaneous fat, and deep fascia. Herein, we report the first case of Enterobacter cloacae–related necrotizing fasciitis after peritoneal dialysis in delayed graft function. CaseA 58-year-old man, who was a hepatitis B-viral carrier and had atrial fibrillation, received cadaveric renal transplantation with peritoneal dialysis and encountered delayed graft function. On postoperative day 5, we tried hemodialysis via the right jugular dialysis catheter. However, he was unable to endure the hemodynamic changes during hemodialysis, showing rapid ventricular rhythm on electrocardiography. On postoperative day 7, we changed to peritoneal dialysis. However, he presented with fever and pain on his left flank and lower extremity. His white blood cell count and C-reactive protein levels were suddenly elevated. According to the abdomen computed tomography scan, there were subcutaneous fluid and air in the left flank and anterolateral pelvic wall. We performed peritoneal dialysis catheter removal, debridement, and drainage of the left external oblique muscle fascia. In a culture, Enterobacter cloacae was identified. After receiving meropenem for 2 months, his wound healed and delayed graft function was recovered. ConclusionPeritoneal dialysis of delayed graft function seems to be effective in reducing the incidence and severity of delayed recovery of renal function after renal transplantation in some reports. However, it is necessary to be cautious when dealing with a rapidly developing and life-threatening soft-tissue infection, such as necrotizing fasciitis. To reduce mortality rates, early diagnosis, recurrent surgical debridement, and aggressive therapy are mandatory.

The 'Pull' Technique for Removal of Peritoneal Dialysis Catheters: A Call for Re-Evaluation of Practice Standards.

♦ BACKGROUND: The most commonly used peritoneal dialysis (PD) catheters have silicon tubing with attached Dacron cuffs. The current standard of care for PD catheter removal is by complete surgical dissection, withdrawing both the tubing and the cuffs. The intention is to avoid infection of any residual part of the catheter. We retrospectively analyzed our results with the alternative 'pull' technique, by which the silicon tube is pulled out, leaving the Dacron cuffs within the abdominal wall. This technique never gained popularity due to concern that the retained cuffs would get infected. ♦ METHODS: We reviewed our experience from an 18-month period, between January 2014 and June 2015. There were 46 catheter removals in 40 patients. All the catheters were of the double-cuffed coiled Tenckhoff type (Covidien, Dublin, Ireland). ♦ RESULTS: Of the 46 catheter removals by the 'pull' technique, there was only 1 case of retained cuff infection. ♦ CONCLUSIONS: The 'pull' technique is a safe method for Tenckhoff catheter removal with low risk of infection. We strongly recommend it as the procedure of choice.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a complication of peritoneal dialysis (PD) with a low prevalence but high mortality. It is characterized by peritoneal inflammation and fibrosis with subsequent development of intestinal encapsulation. It is associated with a long lapse on PD, frequent episodes of peritonitis, high glucose solution use, and high peritoneal transport status. To report the clinical features of patients on PD, who developed EPS. Review of medical records of 12 patients aged 43 ± 10 years (eight women) who developed EPS. The mean time spent on PD was 98 months. The main clinical manifestations were abdominal pain in 82% and ultrafiltration failure in 63%. In 92%, there was a history of peritonitis and 75% had high peritoneal transport at the time of diagnosis. The main findings in computed tomography were peritoneal calcification and thickening. There was a biopsy compatible with the diagnosis in 10 cases. Treatment consisted in withdrawal from PD, removal of PD catheter and the use of corticoids and tamoxifen. After withdrawal from PD 50% of patients became asymptomatic. The rest had intermittent abdominal pain and altered bowel movements. Two patients died (17%). EPS is a serious complication of PD, which should be suspected in any patient with compatible clinical symptoms, long time on PD, multiple episodes of peritonitis and high peritoneal transport profile.

A rare bacterial and fungal peritoneal dialysis related peritonitis, a case report and review of literature

Peritoneal dialysis (PD) related peritonitis due to atypical organisms commonly occur following prolonged antibiotic exposure in an immune-compromised hosts. Fungal PD peritonitis is a rare cause of PD related peritonitis and is associated with significant morbidity and mortality with poor response to conservative management. Early PD catheter removal is contemplated in fungal PD peritonitis in view of discouraging response to prolonged medical management and high risk of complications including death.

Transversus abdominis plane block as the primary anesthetic for peritoneal dialysis catheter surgery

Study objectiveThe primary goal of this study was to determine whether transversus abdominis plane (TAP) blocks were effective as the primary anesthetic technique for insertion and/or removal of peritoneal dialysis catheters. DesignThis study is a descriptive case series investigation. SettingOperating rooms at a tertiary care academic medical center. PatientsTwenty-four patients, American Society of Anesthesiologists (ASA) physical status 3 and 4, were included in this study. InterventionsPatients who had received a TAP block preoperatively for open surgical insertion or removal of a peritoneal dialysis catheter over a 26-month period with the intent of the block to serve as the primary anesthetic were included in this study. MeasurementsPreoperative and intraoperative sedative medications and local anesthetic medications were analyzed. The primary outcome of the study was the ability of the TAP block to provide surgical anesthesia as determined by a lack of need to convert to general anesthesia (defined by placement of an airway device, use of volatile anesthetics, intraoperative propofol infusion dose equal to or greater than 100 μg kg−1 min−1). Secondary outcomes included analysis of any complications from the higher concentrations of local anesthetics required for surgical block. Mani resultsOf 24 patients, 21 underwent the procedure without conversion to general anesthesia as defined above. No complications related to local anesthetics were found. ConclusionTransversus abdominis plane blockade can be successful at serving as the primary anesthetic modality for the insertion and/or removal of a peritoneal dialysis catheter by open-surgical approach. There were no systemic toxic effects or other complications recorded.

A Simple Sustained Traction Method for Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Removal.

A Simple Sustained Traction Method for Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Removal.

Peritoneal dialysis exit-site leak complicated by peritoneal dialysis-related peritonitis due to Actinomyces neuii

Introduction: Actinomyces neuii is a rare cause of peritoneal dialysis-related peritonitis. Case presentation: A 66-year-old male had end-stage renal disease on peritoneal dialysis treatment for 30 months. He developed exit-site leak with infection. Diphtheroids were isolated and considered initially as skin commensals. Dialysis treatment was suspended and on reinstitution he developed peritoneal dialysis-related peritonitis. The organism isolated from the peritoneal dialysis fluid was A. neuii. Conclusion: This case was treated successfully with peritoneal dialysis catheter removal and oral amoxicillin.

Sphingomonas paucimobilis peritonitis: A case report and review of the literature.

Sphingomonas paucimobilis, a yellow-pigmented, aerobic, glucose non-fermenting, Gram-negative bacillus, is a rare cause of human infection normally associated with immunocompromised hosts. It has been associated with a few cases of continuous ambulatory peritoneal dialysis (PD) and is notorious for its resistance to the commonly used antibiotics. In half of the cases reported so far, the peritonitis was refractory to treatment, necessitating PD catheter removal. We report a case of Sphingomonas paucimobilis peritonitis in a 50-year-old patient who had been on PD for two years. The patient was successfully treated with intraperitoneal and intravenous antibiotics and the PD catheter was salvaged.

Pasteurella species peritoneal dialysis-associated peritonitis: Household pets as a risk factor.

Pasteurella species are Gram-negative coccobacilli that are a part of the normal oropharyngeal flora of numerous domestic animals. They have been recognized as a rare but significant cause of peritonitis in patients undergoing peritoneal dialysis (PD). A consensus about management strategies for PD-associated peritonitis caused by Pasteurella species currently does not exist. The microbiological database serving the Manitoba Renal Program was searched from 1997 to 2013 for cases of Pasteurella species PD-associated peritonitis, and charts were reviewed. PubMed was searched for case reports and data were abstracted. Seven new local cases and 30 previously reported cases were analyzed. This infection is clinically similar to other forms of PD peritonitis, with household pet exposure appearing to be the strongest risk factor. Cats are the most commonly implicated pet. Direct contact between the pet and the equipment was commonly reported (25 of 37 patients) but was not necessary for infection to develop. The mean duration of treatment was 15 days. Complication rates were low, with only 11% of patients requiring PD catheter removal. There was no mortality reported. Pasteurella species are a rare cause of PD-associated peritonitis that can be successfully treated with a two-week course of intraperitoneal antibiotics with a high likelihood of catheter salvage.

Treatment for peritoneal dialysis-associated peritonitis.

Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008. To evaluate the benefits and harms of treatments for PD-associated peritonitis. For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings. We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal. Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent. Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Mycobacterium fortuitum and Polymicrobial Peritoneal Dialysis-Related Peritonitis: A Case Report and Review of the Literature.

Mycobacterium fortuitum is a ubiquitous, rapidly growing nontuberculous mycobacterium (NTM). It is the most commonly reported NTM in peritoneal dialysis (PD) associated peritonitis. We report a case of a 52-year-old man on PD, who developed refractory polymicrobial peritonitis necessitating PD catheter removal and shift to hemodialysis. Thereafter, M. fortuitum was identified in the PD catheter culture and in successive cultures of initial peritoneal effluent and patient was treated with amikacin and ciprofloxacin for six months with a good and sustained clinical response. Months after completion of the course of antibiotics, the patient successfully returned to PD. To our knowledge, this is the first reported case of M. fortuitum peritonitis in the field of polymicrobial PD peritonitis. It demonstrates the diagnostic yield of pursuing further investigations in cases of refractory PD peritonitis. In a systematic review of the literature, only 20 reports of M. fortuitum PD peritonitis were identified. Similar to our case, a delay in microbiological diagnosis was frequently noted and the Tenckhoff catheter was commonly removed. However, the type and duration of antibiotic therapy varied widely making the optimal treatment unclear.

Recurrent peritoneal dialysis–related peritonitis caused by Microbacterium resistens

We report a case of a recurrent peritonitis due to Microbacterium resistens in a 71-year-old male patient undergoing peritoneal dialysis (PD). Importantly, this Gram-positive rod was intrinsically resistant to cephalosporins and vancomycin, classically used in PD-related peritonitis treatment. His infection resolved after several weeks of appropriate therapy (amoxicillin plus gentamicin) and PD catheter removal.

Peritoneal dialysis versus hemodialysis in patients with delayed graft function

Delayed graft function (DGF) in kidney transplantation affects adverse outcomes. It remains unclear whether the post-transplant dialysis modality alters perioperative or long-term graft outcomes. We performed a retrospective observational quality initiative at two Canadian renal transplant centers, in which DGF occurred in the recipient, necessitating one of peritoneal dialysis (PD) or hemodialysis (HD). There was no difference in baseline factors between patients with post-transplant PD (n = 14) or HD (n = 63). The use of PD was associated with an increased risk of wound infection/leakage (PD 5/14 vs. HD 6/63, p = 0.024), shorter length of hospitalization (13.7 vs. 18.7 d, p = 0.009) and time requiring dialysis post-operatively (6.5 vs 11.0 d, p = 0.043). There were no differences in readmission to hospital within 6 months (4/14 vs. 23/63, p = 0.759), graft loss (0/14 vs. 2/63, p = 1.000) or acute rejection episodes (1/14 vs. 4/63, p = 1.000) at one yr, and GFR did not differ between the PD or HD groups at 30 d (35.7 vs. 33.8 mL/min/m(2), p = 0.731), six months (46.9 vs. 45.5 mL/min/m(2), p = 0.835) or one yr (46.6 vs. 44.5 mL/min/m(2), p = 0.746). Further research is needed to determine which transplant patients are most appropriate to undergo PD catheter removal at the time of transplantation.

Outcomes of peritoneal dialysis catheter reinsertion: does the cause of initial removal matter?

In this study, we aimed to compare patient and technique survival between the patients, in whom peritoneal dialysis (PD) catheter was removed due to severe peritonitis and then it was reinserted, and those, in whom PD catheter was removed due to non-peritonitis causes and then it was reinserted. Sixty-two patients, in whom PD catheter was reinserted surgically, were retrospectively analyzed in this cohort study. Group 1 consisted of 27 patients in whom PD catheter was removed due to severe peritonitis, whereas Group 2 consisted of 35 patients in whom PD catheter was removed due to non-peritonitis causes. There was no significant difference between Group 1 and Group 2 in terms of the estimation of overall patient survival [43 months (95 % CI 43.6-83.7) versus 80 months (95 % CI 52.8-107.3, p 0.362]. Similarly, there was no significant difference between Group 1 and Group 2 in terms of the estimation of overall technique survival [82 months (95 % CI 0-166.0) versus 31 months (95 % CI 9.7-52.3), p 0.346]. Our results suggest that there was no significant effect of causes of PD catheter removal (peritonitis vs. non-peritonitis) on the outcomes of PD treatment.

Should peritoneal dialysis catheters be removed at the time of kidney transplantation?

: Delayed graft function (DGF) following transplantation necessitates support in the form of hemodialyis (HD) or peritoneal dialysis (PD). However, post-transplant PD-related complication and failure rates are unknown. : We studies patients who were on PD at the time of kidney transplantation over a 4-year period at two separate institutions. : Of the 137 PD patients, 19 had their catheters removed at the time of transplant. Of the remaining 118 patients, 89% had immediate graft function. PD-related complications in this group included peritonitis (n=5), catheter-related infections (n=2) and emergency laparotomy (n=1). Of the 15 patients requiring post-transplant PD, 33% developed peritonitis and 20% had fluid-leaks necessitating HD. Overall, leaving a PD catheter in situ post- transplantation is associated with 7% rate of peritonitis versus 0% if removed (p < 0.05). : PD catheter removal should be considered at the time of renal transplantation, as postoperative PD-related failure/complication rates are high.

The PD catheter dilemma

This study helps to shed light on a long-standing dilemma in renal transplant surgery: whether to remove the peritoneal dialysis (PD) catheter at the time of transplant surgery or to leave it in place until established renal allograft function down the road.1 The potential benefits to removing the PD catheter at the time of surgery are that you eliminate the need for a second procedure, as well as avoid the potential complications fraught with having a PD catheter (e.g., infection, peritonitis) as highlighted in this study.1 On the other hand, in the face of delayed graft function (DGF) having PD catheter in place postoperatively leaves the potential to use that catheter for temporizing peritoneal dialysis while waiting for the allograft to recover function.2 However, as pointed out in several studies including this one, peritoneal dialysis in the post-transplant setting is also fraught with a high risk of potential complications, including fluid leakage from the incision if the peritoneum is violated during the transplant surgery.3–5 Therefore, the overall benefit to leaving a PD catheter in place seems to be minimal, especially in the live-donor population of transplants where the DGF rate is exceedingly low. In Winnipeg, we have had a very similar experience with our perioperative PD catheter situations; our new policy is to remove PD catheters on all transplant patients. As pointed out by the authors in this study,1 in the setting of DGF temporary dialysis can be facilitated by a central catheter which is very easy to place and remove and is associated with a low complication rate. In fact, most transplant recipients already have a central line in place at the time of surgery for central venous pressure monitoring and drug administration, so utilizing this line or switching it over to a dialysis line is very convenient. Despite the need for future prospective studies, the evidence points to an overall benefit of PD catheter removal at the time of kidney transplantation. This seems to outweigh the benefits of leaving in the PD catheter. Obviously, every patient and clinical scenario is different and there may be situations were this rule does not apply. Warren and colleagues make a strong case for PD catheter removal at the time of surgery.1