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Non-Infectious Complications. Non-infectious Catheter Complications. Inflow/outflow obstruction Hernia Leakage. Increased Intra-Abdominal Pressure. Instillation of dialysate into the peritoneal cavity leads to increased intra-abdominal pressure The magnitude of the increase depends upon: - PowerPoint PPT Presentation
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Peritoneal Dialysis
Non-Infectious Complications
Peritoneal Dialysis
Non-infectious Catheter Complications
Inflow/outflow obstructionHerniaLeakage
Peritoneal Dialysis
Increased Intra-Abdominal Pressure
Instillation of dialysate into the peritoneal cavity leads to increased intra-abdominal pressure
The magnitude of the increase depends upon:- Volume dialysate filled- Patient age, body mass index- Coughing, lifting straining at stool- Position of the patient (sitting>standing>supine)
Peritoneal Dialysis
Inflow/Outflow ObstructionCauses:- Mechanical (e.g. tip migration, kink in tubing)- Constipation- Catheter blockage
Outflow obstruction is most frequent:
- Intraluminal (clot, fibrin)
- Extraluminal
(constipation, occlusion, omental
wrapping, tip migration, incorrect
catheter placement)
Peritoneal Dialysis
Inflow/Outflow Obstruction - Recommendations Establish type of obstruction Conservative or non-invasive approaches
- body position change
- laxatives
- heparinised saline
- fibrinolytic agents Aggressive therapies
-a) blind - fluoroscopically guided wires, stylet, whiplash
-b) direct - peritoneoscopy, surgical catheter revision
or replacement
Peritoneal Dialysis
Early (within 30 days)
- Manifest externally
- Do not require imaging
- Managed by temporary discontinuation of PD (75%) or surgery
Late (beyond 30 days)
- Manifest by poor outflow, localised oedema, subcutaneous fluid
- 30% require imaging
- Hernia cause 40% of late leaks
- Most late leaks require surgery (70%)
- Frequently lead to change of treatment
Tzamaloukas Adv PD 1990
Dialysate Leaks
Peritoneal Dialysis
Fluid Leak - CT Cannulogram
Peritoneal Dialysis
Abdominal Wall or Pericatheter Leak
Presentation
Abdominal swelling or bogginess Reduced drain (effluent) output Weight gain and abdominal wall oedema,
without peripheral oedema Pericatheter leak: wetness or swelling at exit-
site
Peritoneal Dialysis
Abdominal Wall or Pericatheter Leak
Management
Reintroduce low pressure PD (APD)
or Temporary transfer to HD to allow healing, or Catheter replacement if pericatheter leak,
Peritoneal Dialysis
Hernias and Genital Oedema
Caused by continuous elevation of intra-abdominal pressure and abdominal wall tension
Acquired or congenital defects in the abdominal wall
Inguinal > Catheter insertion site Epigastric > Richters Umbilical > Enterocoele Incisional > Spigelion Ventral > Obturator
Peritoneal Dialysis
Hernias – risk factors
Raised intra-abdominal pressure Female sex and multiparity (no. of pregnancies) Older age Previous hernia Polycystic kidney disease
Peritoneal Dialysis
Hernias – clinical presentation
Painless or tender lump or swelling Bowel incarceration or strangulation
Peritonitis (transmural leakage of bacteria)
Treatment:
1) Surgical repair 2) Reintroduce PD with low volumes, supine posture,
increase volume over 2 weeks
Peritoneal Dialysis
Genital Oedema
Occurs in up to 10% of patients Mechanism:
- fluid tracks through soft tissue plane in a hernia,
catheter insertion site, peritoneal fascial defect,
genital oedema associated with abdo wall oedema
- patent processus vaginalis
- males affected more than females
Diagnosis:
- can be difficult
- CT scan with contrast (100-150mls Omnipaque)
Peritoneal Dialysis
continued…Genital Oedema
Treatment:
- bed rest
- scrotal elevation if symptomatic
- low volume exchange/NIPD
- stop PD temporarily
- surgical repair if cause is hernia or patent processus vaginalis
Peritoneal Dialysis
Infusion or Drainage Pain
CAUSES
- constipation
- jet effect
- fluid pH related
MANAGEMENT
- laxatives - slow infusion rate
- incomplete drainage - Bicarbonate buffer
- 1% lignocaine IP - catheter replacement