A Practical Guide to Understanding and Managing Non-Infectious Complications of Peritoneal Dialysis Catheters in Clinical Practice

Abstract

The prevalence of early non-infectious peritoneal dialysis (PD) catheter complications makes performing PD challenging for patients and difficult for the healthcare team to manage. Three common patient scenarios are presented: catheter flow dysfunction, peri-catheter leaks, and catheter-related abdominal pain. Practice recommendations are integrated into each scenario and tailored to clinical presentation, patient need, and resource availability. The importance of including patients in the decision-making process is emphasized, and examples of how contextual factors modify the proposed approach to complications are given.

1. Introduction

Kidney care programs aim to maximize the safe and effective use of peritoneal dialysis (PD) as a treatment for kidney failure. It is cost-effective compared to hemodialysis (HD) in many jurisdictions and provides similar health outcomes [1]. Establishing reliable access to the peritoneal cavity is required to safely perform PD, but this is challenging. Nearly one in four people experience a PD catheter-related complication that results in an emergency room visit, hospitalization, interruption in therapy, or catheter procedure in the first 6 months after insertion, and overall catheter failure rates are up to 35% in prior studies [2,3,4].

PD catheter complications are broadly classified as infectious and non-infectious. Infectious complications are common and include PD exit-site infections, tunnel infections, and PD-associated peritonitis. Much has been written about the prevention, identification, and management of infectious complications, and readers are referred to the International Society for Peritoneal Dialysis (ISPD) guidelines for a comprehensive summary [5]. Non-infectious PD catheter complications are common in the first six months following PD catheter insertion, making them an important cause of early loss from PD that has a significant impact on patients, caregivers, and the health system [3].

Practice recommendations to support clinical decision making for non-infectious PD catheter complications also exist, and readers are again referred to these resources for a comprehensive summary [6,7,8,9]. However, as the quality of evidence to support these recommendations is relatively low, a pragmatic approach to these problems is suggested wherein conservative measures are explored first, followed by more interventional approaches, as required [8]. In our experience, this nuanced approach can be challenging for a novice PD clinician. As such, we present three hypothetical patient scenarios that have been drawn from clinical experience to provide an example of how nuanced clinical decision making happens and the inter-related nature of catheter complications.

A multidisciplinary perspective on the approach to the prevention, assessment, diagnosis, and management of non-infectious complications is presented that draws on the recent literature and is focused on the most common issues likely to be encountered in clinical practice—PD catheter flow dysfunction, peri-catheter leaks, and catheter-related pain. The discussion of strategies to address complications highlights the need to consider the patient experience, their preferences, the unique challenges they face, and the context in which they access care (Figure 1). The intent is not to present a comprehensive discussion of all possible non-infectious complications and their solutions, but rather to highlight the complex and multi-faceted nature of the complications encountered in clinical practice.

2. Patient Scenarios

2.1. A Case of PD Catheter Flow Dysfunction

Jenna had been on PD for a month when her PD catheter suddenly stopped draining. She had left a message with the PD clinic, but she had poor cell service, and when the clinic returned her calls, they went straight to voicemail. She kept trying to complete her exchanges, but her edema and blood pressure progressively worsened, prompting her to call emergency services. She was air-lifted from her remote location to the emergency department.

PD catheter flow dysfunction can present as the inability to fill and/or drain adequately. This may trigger frequent drain alarms or be characterized by flow rates below the expected ~350 mL/min with APD or prolonged drains with continuous ambulatory PD [10,11,12]. There are several scenarios that create catheter dysfunction. The most common is related to constipation, wherein the distended rectosigmoid colon blocks the catheter or displaces the catheter tip such that it is in a suboptimal position for drainage [8]. Additional causes are related to mechanical complications; obstruction from intraluminal debris, largely as the result of a fibrin blockage or clot; and concerns related to adherent intraperitoneal tissues [8]. It is important to differentiate between one-way and two-way obstructions, with two-way obstructions often being attributed to an internal luminal obstruction [10].

An attempt at flushing the PD catheter with 1000 mL of dialysate was made, but only 200 mL was infused over 30 min. Jenna did not initially drain, but there was a very slow trickle of effluent when she was positioned lying down on her left side. Her two-view abdominal flat plate radiograph (X-ray) showed that the catheter tip was no longer in the pelvis, and she had a high fecal load. Jenna had not been taking her laxatives because they were not covered by her drug plan. She was started on polyethylene glycol (PEG) solution in the hospital.

Saline syringes were connected to the PD catheter, and attempts were made to gently pulse the saline through, to check flow and attempt to dislodge the catheter from the bowel loop [9]. There was resistance while flushing and Jenna informed you that she had been menstruating and had blood in her effluent prior to stopping draining. You administered plasminogen activator (tPA) for suspected intraluminal debris, which was successful in restoring inflow, and improved the rate of outflow [8,9]. Aside from a small amount of fibrin and blood, her effluent was clear, and she had no other signs or symptoms of infection. In and out exchanges with 1000 mL of dialysate were performed until her drain bags were clear and she was advised to add 500–1000 units of heparin per litre of dialysate if she noticed fibrin or blood in her effluent in the future, and to continue it until it was clear [9].

Jenna was able to drain, but the flow rate remained sluggish, and she could still only drain fully on her left side. The clinic discussed staying at the hospital with Jenna until her drainage issues had resolved, just in case surgical intervention was required. However, she only had childcare for one night, so Jenna was sent home with laxatives, trialled on an increased dose of her diuretics, and referred to the PD dietician and pharmacist to explore dietary and pharmacological interventions to prevent constipation. The social work team was involved in arranging over-the-counter medication coverage for her laxatives and setting up a landline at no cost. A health clinic was identified near her community where her kids could join her for appointments, and follow-up was arranged via telehealth three days later with the PD clinic, Jenna, and the community health nurse to perform further remote troubleshooting if required.

Additional Considerations When Dealing with Flow Dysfunction

Mechanical considerations: Mechanical concerns with the catheter can also impede inflow/outflow. A first step is to ensure that there are no external kinks in the catheter or issues with the external catheter components (e.g., transfer set, titanium adapter). The equipment height should also be used based on the manufacturer guidelines, typically aiming to have the cycler within 15–20 cm of the height of the bed or chair the patient is dialyzing in or having the CAPD fill bag higher than the catheter (the higher the bag, the faster the flow), while ensuring both the APD and CAPD drain bags are unobstructed and placed below the catheter height, typically on or near the floor [9,13]. Internal kinks may also occur and are often due to technical errors on insertion, with their location determining whether a revision or replacement will be required [8,9]. Internal kinks may or may not be apparent on the X-ray [8].

Surgical considerations: There are various surgical options to attempt to rescue or revise PD catheters, including radiologically guided manipulation, laparoscopic intervention, and/or catheter replacement [8]. Although immediate function is often restored, longer-term success is more variable. In one study, immediate flow restoration occurred in 70 to 90% of catheter manipulations for obstruction, but less than 45% were functioning well at 30 days [14]. An attempt to salvage the existing catheter should be tried first, with catheter replacement only considered after revision has been unsuccessful or not possible [8]. Laparoscopic intervention is preferred as it provides the operator multiple options to address catheter dysfunction, including omentectomy and omentopexy, adhesiolysis, and the ability to remove fibrin casts by stripping the catheter [8,14].

2.2. A Case of Peri-Catheter Exit Site Leak

Rae had a large and distended abdomen due to polycystic kidney disease and obesity. She had chosen PD as her preferred dialysis modality, and at Rae’s center, PD catheters were typically inserted at the bedside by a nephrologist. After assessing Rae, the interventional nephrologist did not feel that they had the expertise to safely perform the procedure, and she was sent to the nearest surgical center for evaluation. Rae had her PD catheter inserted by a surgeon using advanced laparoscopic techniques, and an extended catheter with an upper abdominal exit site was established. This made it easier for Rae to access her catheter and mitigated her risk of catheter complications in the context of her obesity [8].

A few weeks later, Rae came into the PD clinic to test her PD catheter function, as she was nearing the start of dialysis. Upon assessing the exit site, the sinus was not yet tight to the catheter, and the midline incision site was not fully approximated. PD was held another week to enable further healing. On day two of training, Rae’s PD dressing was wet. Although not formally indicated for PD use, the fluid at Rae’s exit site was tested for glucose using a urine dipstick and was positive [9]. She was diagnosed with an exit-site leak.

The risk of peri-catheter leaks has been reported as 5.7% of cases within six months of PD catheter insertion [3]. A peri-catheter leak manifests with the appearance of dialysate fluid at the incision or exit site, or subcutaneous edema [8]. Early peri-catheter leaks are often related to catheter implantation techniques, early dialysis initiation, weak abdominal wall tissues, and increased intra-abdominal pressure [15,16]. Individuals who are obese and at risk of poor wound healing are thought to be at higher risk of leaks [9].

Rae’s effluent was drained, and prophylactic antibiotics were administered due to the risk of developing a tunnel infection or peritonitis [8]. Rae’s clinical condition and volume status were stable, so weekly bloodwork was ordered, and she was taught to perform sterile dressing changes and instructed to call the clinic for symptoms or signs of infection. After three weeks, Rae’s exit site had improved and automated PD (APD) was started with four exchanges of 1000 mL of Dianeal at night and a dry day, with plans to increase the PD prescription every two weeks until Rae was at her optimal PD prescription. Rae performed a significant amount of lifting at work, so the dry day was continued; her fill volumes were increased at night, and a manual fill after work was planned in the event that she required increased dialysis. The social worker suggested Rae speak to her employer about the potential need for future work restrictions should she require 24 h dialysis in the future.

Additional Considerations When Dealing with Peri-Catheter Leaks

Prevention: Leak prevention strategies are aimed at reducing intra-abdominal pressure and should be tailored to the individual. Common strategies include preventing constipation, gradually increasing fill volumes (if not medically required to start at full dose), individualizing fill volumes based on patient size, and recognition of the potential for increased intraperitoneal volume if fluid retention occurs due to drain issues [9].

The use of embedded PD catheters is prominent in some jurisdictions as they enable a longer healing time before use, reducing the risk of early peri-catheter leaks [17]. Embedded PD catheters can be used immediately once exteriorized, reducing the need for urgent PD starts [17]. That said, their use should be balanced with the potential of other complications, including futile placement and risk of flow dysfunction for increased time of embedment duration [3,18]. In circumstances where a PD catheter needs to be used before 2 weeks, urgent PD starts wherein conservatively lower dwell volumes are used with the patient supine, has been shown to be both feasible and safe in inpatient and outpatient settings [19]. PD prescriptions in these circumstances are primarily influenced by patient status, including residual kidney function and metabolic and fluid status. This is also true when determining whether to hold PD and how quickly to resume PD, should a leak occur.

Lifting Restrictions to reduce the risk of intra-abdominal pressure: It is recommended that patients restrict lifting to less than 5 to 10 kg for 2 to 3 weeks after buried and laparoscopic insertions and for 4 to 6 weeks after open surgery or in circumstances where the catheter has been used prior to being healed (i.e., early starts) [20]. Ideally, PD fluid should always be drained prior to activities that are at higher risk of intra-abdominal pressure (e.g., weightlifting, jumping) [20]. The risk of intra-abdominal pressure and subsequent restrictions should be weighed against the need to support and encourage exercise and for patients to maintain employment [20]. Exercise specialists (e.g., physiotherapists and kinesiologists) can play an important role in individualizing strategies to patients’ conditions and circumstances, when available.

Late peri-catheter leaks: Late peri-catheter leaks are less common and typically due to the deep cuff separating from the surrounding tissues secondary to another process, such as a tunnel infection or peri-cannular hernia [15,16]. The clinical approach to managing late peri-catheter leaks is similar to early leaks and can include putting PD on hold for 1 to 2 weeks, gradually restarting PD, further diagnostic imaging (such as CT peritoneography), and surgical consultation in the event of a recurrence [21]. Patients with late leaks are less likely to heal with cessation of PD and often require PD catheter replacement [15,16].

2.3. A Case of Catheter-Related Pain

A message has been left at the PD clinic from Jim, an 84-year-old man who had recently had a PD catheter inserted. He had called at 2:00 a.m. and was frustrated as he had been experiencing pain in his lower abdomen that had been disrupting his sleep for days. He had finally reached his breaking point.

Catheter-related pain is broadly classified as either drain pain or infusion pain. Catheter-related pain has a significant impact on patient quality of life and is more prevalent than is generally appreciated [22,23]. Prior studies suggest that up to one-third of people experience drain pain and 35% report it as severe [23]. Drain pain is thought to be caused by contact and suction of the catheter tip against visceral structures [16,24]. Infusion pain may also be attributed to the tip of the catheter contacting visceral structures. However, it is often observed transiently in new patients and may be attributed to the acidity of the dialysate and the temperature of the solution [25]. Both drain pain and infusion pain appear to become less frequent as time goes on, affecting approximately 20% of patients three months after catheter insertion [26].

Jim’s PD catheter had been inserted one week ago. A few days after insertion, he had called the PD clinic and described a sudden pinching sensation under his ribs that caused severe, lingering cramps. He had been taking the prescribed polyethylene glycol solution since his surgery, but had also been taking acetaminophen with codeine for the pain, which had made him constipated. There was concern that the pain was likely from malposition of the tip of his catheter and that he was feeling the catheter against the sensitive bowel wall [8]. He was provided a more aggressive laxative regimen, and breathing strategies to help him cope with the pain were reviewed.

A few days later and despite frequent bowel movements, the pain was worse. However, the nature of the pain had changed, and Jim now described severe pain low in his pelvis, shooting down his genitals, and aggravating his bladder, making him feel like he must void. He was asked to come into the clinic for evaluation, but Jim lives 4 h away from the clinic and does not drive, so he needed to arrange a ride with his daughter. The option of starting PD training when he arrived was discussed to avoid multiple trips.

When Jim arrived at the clinic, he was sent for an abdominal X-ray that confirmed his catheter was in the appropriate position and suggested that he had minimal fecal load. His exit site was healing well. Normally, patients are advised to wait at least two weeks from catheter insertion to start PD in order to prevent peri-catheter leaks [8,27]. Jim communicated that he was unable to tolerate the abdominal pain, and the decision was made that initiating PD immediately was the best option.

For patients who need to start PD prior to two weeks, it is recommended that they dialyze in a recumbent position with low volumes and have a dry peritoneal cavity when not supine, frequently assessing for leaks, and gradually increasing fill volumes [8,9]. In the case of concurrent hernia repairs or more extensive surgeries, including surgical colleagues in these discussions is advised. Jim’s case was challenging because he had to start earlier than anticipated, but for catheter-related pain, which requires additional considerations when planning his prescription. In his situation, we would like to keep the tip of his PD catheter floating away from his abdominal viscera to prevent pain. As a result, he would have ideally had dialysate in his peritoneal cavity for the full 24 h period, and it was obviously not possible to have him supine the entire time. Dialysate was infused into his abdomen until his pain resolved, which occurred at around 300 mL. Jim had a residual urine output of 1000 mL per day, and his prescription was set at four exchanges of 1.5% glucose-based dialysate, which are 1000 mL each, with a 70% tidal prescription, and a last fill of 500 mL of icodextrin. Icodextrin is used during the day at a low volume because it can dwell for up to 16 h without substantial reabsorption, limiting the number of exchanges required and ensuring that Jim has residual fluid in his peritoneal cavity at all times [28]. Jim was counselled to be vigilant for the presence of a leak at his exit site or into his abdominal wall. He was also reminded to take measures to reduce intraperitoneal pressure (e.g., limited lifting and maintaining his bowel regimen to prevent constipation). Jim experienced the resolution of his drain pain immediately. He was subsequently transitioned to larger fill volumes during the night at approximately 2 weeks after catheter insertion, and his tidal volume was adjusted accordingly to ensure at least 300 mL would remain in the abdomen during the night.

Additional Considerations When Dealing with Catheter-Related Pain

Infusion pain: Appropriately determining the timing of catheter-related pain (e.g., on drain, infusion, or combined) will help guide management. Reasons for infusion-related pain can be multifactorial, including dialysate temperature, patient position, dialysate pH, increased intra-abdominal pressure, and/or due to a high flow rate [9,26]. Resolution strategies include ensuring the solutions are being warmed to body temperature (assessing for technical and user error), trialling biocompatible solutions, and lowering the height of the CAPD fill bag to slow the fill rate or to teach the patient to slow their flow by adjusting their roller clamp [9].

Surgical considerations: Drain pain may also be the result of excessively deep catheter placement in the pelvis, where pain results from the compression of the catheter side holes against internal structures [8]. To prevent this, Crabtree et al. (2019) discuss the importance of proper landmarking and surgical strategies at the time of catheter insertion [8]. Unfortunately, most surgical guidelines do not discuss catheter salvage strategies in the context of pain.

PD therapy considerations: Tidal therapy, where a portion of the dialysate is left in the peritoneal cavity to keep the catheter floating during each exchange, is often successful at reducing drain and infusion pain [9,29]. It may also reduce drain alarms [29]. Accurate assessment of the drain and flow phases is helpful when determining and adjusting tidal therapy [29]. With remote monitoring, it is increasingly possible to review the drain and fill phases to determine where slow flow and pain begin to guide prescription management. Most APD machines require the user to set an ultrafiltration volume. The ultrafiltration volume is typically divided by the number of cycles during the night, and an incremental volume is then added to each drain cycle to account for the estimated amount of ultrafiltration that occurs during that cycle. It is critical to set an appropriate ultrafiltration volume to prevent pain and reduce the risk of increased intraperitoneal pressure. If the ultrafiltration volume is set too high, not enough residual volume may be left, leading to drain pain. If the volume is set too low, there is a risk of overfill. Typically, a complete drain is programmed every three to four cycles to avoid complications related to overfill. It is often during this complete drain that pain occurs in affected patients, and the need for this should be balanced with the risk of increased intraperitoneal pressure. Finally, continuous ambulatory PD may offer improved pain management over APD due to the gentler, gravity-induced drains that do not involve the application of negative pressure, and for the ability to stop or slow fill or drain phases at the onset of pain [24].

3. Conclusions

Non-infectious PD catheter complications are difficult for patients and their families to manage and can be a burden to the health care team. Clinical guidelines are limited by poor evidence, and front-line clinicians need to address catheter malfunction using a multi-faceted and interdisciplinary approach. We presented examples of common clinical scenarios: flow dysfunction, peri-catheter leaks, and catheter-related pain and highlighted the importance of including patients in decision making and how the approach to these problems often requires modification due to contextual factors.