INTRODUCTION — The most frequent and important complication of peritoneal dialysis (PD) catheters is infection, which may result in catheter loss and discontinuation of PD [1,2]. However, some evidence suggests that the transfer to hemodialysis for these reasons may be decreasing. (See "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis".)
There are also significant noninfectious complications of PD catheters. These include [3,4]:
●Outflow failure
●Pericatheter leak
●Abdominal wall herniation
●Catheter cuff extrusion
●Intestinal perforation
Some of these complications can be managed conservatively; others require laparoscopic, peritoneoscopic, or traditional surgical intervention.
This topic will review the causes, presentation, and management of outflow failure, pericatheter and pleuroperitoneal leaks, cuff extrusion, and visceral perforation. Other noninfectious complications of continuous PD, such as gastroesophageal reflux disease, pain in the back and abdomen, abdominal wall herniation, and pleural effusion, are discussed separately. (See "Noninfectious complications of continuous peritoneal dialysis" and "Abdominal hernias in continuous peritoneal dialysis".)
OUTFLOW FAILURE — Outflow failure, which is defined as incomplete recovery of instilled dialysate, most commonly occurs because of one of the following conditions:
●Constipation/obstipation
●Catheter malposition
●Intraluminal catheter occlusion (often by thrombus)
●Extraluminal catheter occlusion (usually by omentum or adhesions)
●Catheter kinking
Incidence — The incidence of outflow failure ranges from 5 to 20 percent. Although the frequency is largely independent of the particular technique used for catheter insertion, peritoneoscopic placement may be associated with the fewest outflow complications [5-12]. In one study, for example, only 10 outflow problems occurred among 136 peritoneoscopically placed catheters (8 percent) followed for 1183 patient-months [12]. One catheter had been placed in the preperitoneal space, and nine had migrated because of misalignment of the radiopaque stripe (a feature that guides placement and maintains a clear view of catheter orientation).
Another technique of catheter placement involves subcutaneous embedding of the peritoneal catheter for weeks to months in patients in whom the need for dialysis is not urgent and/or maximal chances for healing are desired [13]. Since the wound surrounding the catheter site is allowed to heal, subcutaneous embedding may lower the frequency of catheter-related problems. The incidence of drainage failure, as well as other possible complications, was evaluated in one study of 26 such catheters [14]. Outflow failure occurred in five (20 percent). There was no correlation between omental obstruction and the duration of catheter embedding. (See "Placement of the peritoneal dialysis catheter".)
Clinical manifestations — Outflow obstruction is frequently heralded by irregular outflow, fibrin in the dialysate outflow, and/or constipation. Outflow obstruction in association with pain suggests catheter abutment; these patients have been found to have catheters positioned near discrete abdominal sites, such as the subdiaphragm [15].
Outflow failure usually occurs within the first month of catheter use, with the time of onset varying by cause [8,16]:
●Kinking of the catheter, which may cause inflow and outflow problems, usually becomes obvious soon after catheter placement. The degree of dysfunction may vary with patient position.
●Malpositioning causes of outflow failure are usually obvious within days of placement [6].
●Omental occlusion is commonly observed within several weeks of catheter implantation [15].
By comparison, constipation/obstipation is very common and may cause outflow obstruction at any period after the initiation of PD and may occur in those who have undergone continuous therapy for an extended duration without outflow problems.
Radiography — An abdominal radiograph can elucidate the cause of outflow failure, particularly in those with severe constipation and/or catheter malposition. Recently implanted catheters have a radiopaque stripe, which permits radiographic visualization of the catheter tip; the tip should not migrate significantly over time [5].
Diagnosis — Constipation is the commonest cause of outflow failure and should be eliminated as a cause before performing further evaluation [17]. A distended feces-filled rectosigmoid colon can be identified by flat abdominal radiograph.
A bladder scan or ultrasound for estimation of postvoid residual volume should be performed among patients who continue to have urine production and who do not have constipation.
Since outflow failure is defined by the incomplete recovery of instilled fluid, it is important to exclude pericatheter or dialysate leakage as the underlying cause of the lost dialysate. The detection of dialysate leaking out of the abdominal cavity, whether internally or externally, is discussed below. (See 'Pericatheter leakage' below.)
If leakage has been excluded, the etiology of outflow failure can be ascertained by the history, physical examination, and/or radiography. As an example, a decrease in dialysate flow occurring days after catheter placement, in combination with a radiograph showing an abnormally placed catheter, strongly suggests that malpositioning is the underlying cause.
Catheter kinks are another important cause of outflow failure. Kinking of the catheter can be difficult to demonstrate, and it may not always be apparent on a plain abdominal radiograph. Lateral radiographs of the abdomen with the patient supine and sitting (or a lateral chest radiograph for presternal catheters) with arms down by the side, or a computed tomography (CT) scan may be helpful to demonstrate a kink [17].
Prevention — Prevention is optimized by proper positioning of the catheter upon implantation and avoiding constipation.
Treatment — The treatment of outflow failure depends upon the cause of the obstruction. Some can be treated conservatively, while others require surgical intervention and/or replacement.
Constipation — Laxatives, suppositories, or saline enemas can be used to treat constipation. Appropriate agents include sorbitol, polyethylene glycol, lactulose, and other non-magnesium, non-phosphorus-containing stool softener/laxative combinations. The resumption of bowel movements cures nearly one-half of all cases of outflow failure [5].
Fibrin clot — Heparin (at a dose of 2000 units per 2 L bag for manual exchanges and 4000 units per 5 L bag for cyclers) is usually added when plugs or strands of fibrin are visible in the drained fluid or empirically if drain speed is slowed. We titrate the frequency of use (daily versus intermittently) to the presence of visible fibrin and/or slow drain. Occlusions due to fibrin clot were traditionally managed with urokinase-induced lysis, a procedure in which urokinase (5000 units) was instilled into the catheter for one hour and then removed. The effectiveness of this procedure varied between individuals and with the size and viscosity of the clot. If successful, lysis was followed by the instillation of heparin in the dialysate for several exchanges [15].
Given its effectiveness in occluded central venous dialysis catheters, alteplase (recombinant tissue-type plasminogen activator [tPA]), a recombinant protease specific for fibrin, has been utilized in clotted PD catheters with some anecdotal success:
●Using alteplase, fibrin clot dissolution was achieved in four PD patients, with both inflow and outflow intracatheter obstruction refractory to saline flushes [18]. Alteplase was instilled and allowed to dwell for an hour, after which relief of obstruction was obtained.
●In another study, intracatheter thrombolysis was effective in four of seven attempts after instillation and a one-hour dwell in catheters of six pediatric patients [19].
The dose of alteplase will vary according to volume of the PD catheter and its respective transfer set.
Malpositioned catheters — Although malpositioned catheters frequently require replacement (particularly for long-term patency), they can sometimes be managed with fluoroscopy. Stiff wire manipulation can be performed by most interventional radiologists. With this technique, initial success with restoration of drain capability is observed in 55 to 80 percent of cases [20-25]. However, long-term salvage is less reliable (33 percent) as repeated malpositioning is common. In addition, redirection can be performed surgically, including laparoscopically [26].
Urgent-start PD may be associated with catheter complications, often due to malposition, but the incidence is low [27-29]. (See "Urgent-start peritoneal dialysis", section on 'Rapid catheter placement'.)
It is not known whether the catheter design influences the risk of malposition. One randomized, controlled trial that compared coiled versus straight-end swan-neck catheters found no significant differences in catheter malposition or noninfectious complications. However, in this study and in an accompanying meta-analysis that included the results of this study, there was a trend for an increased risk of catheter-tip malposition with coiled-end catheters [30]. Additional study of this is needed before a recommendation for a specific catheter can be made.
Catheter kinking — Kinking usually requires catheter replacement. However, since kinking may be due to the placement of the two catheter cuffs too near each other, removal of the superficial cuff may cure outflow problems [5].
Abdominal exploration — If initial management attempts fail and/or additional catheter manipulation or replacement is required, traditional surgical or laparoscopic exploration may be useful since they allow direct visualization of the peritoneal cavity. These techniques permit the operator, if necessary, to perform the following:
●Catheter redirection
●Omentectomy or adhesiolysis
●Catheter replacement
An advantage of the less invasive surgical techniques is that catheter function can be tested immediately after an attempt at correction but prior to scope removal, thereby permitting additional corrective manipulations, if necessary [31-35]. The effectiveness of laparoscopic surgery to salvage dysfunctional catheters was evaluated in one study of 16 patients who underwent 19 laparoscopic procedures [7]. Adhesions were the cause of obstruction in 12 cases, omental wrapping in 7, and both adhesions and omental wrapping in 1. All 19 salvage procedures were successful.
PERICATHETER LEAKAGE — Leakage of dialysate at the pericatheter site tends to occur early after catheter placement in association with high-dialysate volumes and in those with a weak abdominal wall (such as those with a history of multiple surgeries or pregnancies) [15,36,37]. In addition, leaks frequently occur only after a patient becomes physically active on a standard ambulatory PD regimen, a schedule in which dwells and/or exchanges occur in association with maximum intra-abdominal pressures. They are therefore less common in those who undergo dialysate exchanges when supine.
Incidence — The reported incidence of pericatheter leak is widely variable (1 to 40 percent) due in part to varying outcomes with the three principal methods of catheter placement: surgical, peritoneoscopic, and percutaneous without peritoneoscopy [8-12,37-41]. In one study, a higher incidence of leak was associated with the percutaneous approach compared with conventional surgical placement (20 versus 9 percent), although this difference was not statistically significant [10]. By comparison, earlier studies reported higher incidences of leak with surgical placement (12 to 39 percent) [6,33,42,43]. Leakage appears to be less likely with peritoneoscopically placed catheters and presternal catheters [31,44-46]. Subcutaneous embedding of the implanted peritoneal catheter may be associated with a very low incidence of pericatheter leakage. In one study, 26 catheters were embedded subcutaneously for 28 to 675 days, and 21 were ultimately activated [14]. No leaks occurred.
The incidence of leakage for subcutaneous, embedded catheters may be associated with the length of time the catheters are buried. One report found that no catheter buried for four or more weeks leaked, while 16 percent of catheters activated less than four weeks after placement leaked, as did 14 percent of conventionally placed catheters [47].
Overall, it is not clear that one type of catheter is superior to another with regard to the potential for leakage; however, the double-cuff catheter is generally considered least likely to be associated with leak.
Clinical manifestations — Pericatheter leakage is recognized by the presence of fluid in the area surrounding the catheter. However, the initial manifestations of pericatheter leakage may be subtle. Subcutaneous swelling, which may be overlooked, and diminished outflow volumes may precede frank leakage. Genital and abdominal wall edema may also indicate the presence of a subcutaneous leak. (See "Abdominal hernias in continuous peritoneal dialysis".)
Early leaks, defined as those that occur within 30 days of catheter placement, are usually attributed to the technique of catheter implantation, timing of dialysis initiation (earlier than optimal), high dialysate volumes, and weak abdominal wall tissue strength. Late leaks, defined as those that occur greater than 30 days after catheter placement, usually occur because of hernias, pseudohernias, or occult tunnel infections associated with cuff separation.
Prevention — Prevention of pericatheter leak starts with avoidance of a midline implantation of the PD catheter. Paramedian implantation is ideal. (See "Placement of the peritoneal dialysis catheter".)
We also delay initiation of PD by at least two weeks following catheter placement to minimize the risk of leaks. For patients who require urgent initiation of PD within two weeks of surgery, we perform low-volume exchanges in the recumbent position to minimize the risk of leaks. This practice is consistent with the 2019 update of the International Society of Peritoneal Dialysis (ISPD) recommendations regarding creating and maintaining PD access [17].
We generally delay implantation among patients with a chronic persistent cough. Lifting limitations of 7 to 10 kg are applied for prevention, but weight and activity level are flexible based upon previous physical condition. The risk of a leak can be minimized by performing sports and exercise activities with a dry abdomen.
Diagnosis — The presence of fluid around a peritoneal catheter may be due to leakage of dialysate or to serosanguineous fluid extruding from the subcutaneous tissue. If the etiology of the fluid is unclear, a dialysate leak can be confirmed by checking the glucose concentration of the leaking fluid. Dextrostix testing will yield an extremely high glucose concentration if the fluid is dialysate. By comparison, serosanguineous fluid leaking from subcutaneous tissue will not be strongly positive for glucose.
To help confirm the diagnosis and delineate the anatomy of the leak, peritoneal scintigraphy or, in particular, computed tomography (CT) scanning after infusion of dialysate containing contrast material (ie, CT peritoneography) can be performed [37,48]. In one retrospective study, one-third of leaks occurring late after catheter placement required imaging for diagnosis [49].
Management — Successful management of pericatheter leaks can usually be accomplished by decreasing exertional activity and/or the dialysate volume. Occasionally, converting the patient to continuous peritoneal modalities, in which exchanges occur when supine, or to temporary hemodialysis may resolve dialysate leakage [50]. Leaks that do not respond to conservative management may require minor surgical repair of the deep cuff or, rarely, catheter replacement.
CATHETER CUFF EXTRUSION — Erosion of the catheter cuff through the skin to the outer abdominal wall may be a sequela of exit-site infection or excessive superficial cuff placement. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)
Incidence — The incidence of cuff extrusion ranges from 3.5 to 17 percent [16,33,42,43,47]. Neither the method of catheter placement, surgical or percutaneous, nor the specific catheter used influences the likelihood of extrusion [16,33,42,47,51].
Treatment — The need for cuff shaving or catheter removal depends in part upon the presence or absence of infection and the degree to which the catheter is extruded. When the catheter is not completely extruded and there is no evidence of infection, conservative measures (ie, cuff shaving) should be chosen in order to prevent bacterial seeding and development of an exit-site infection [17]. An eroding, extruding cuff may require removal by opening the subcutaneous tissue surrounding the exit site and trimming or removing the cuff under sterile conditions and local anesthesia. Poor healing of the area or signs of persistent inflammation or infection are indications for catheter removal. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)
INTESTINAL PERFORATION — Intestinal perforation can occur at the time of catheter implantation because of direct injury or weeks to months after placement because of bowel erosion. This complication can be life threatening and therefore requires a high index of suspicion and urgent attention.
Incidence — Intestinal perforation by PD catheters is uncommon (1 percent or less) [6,9-11,16,41,52]. This incidence is largely independent of the type of placement but may be more common with the placement of semirigid acute PD catheters.
Clinical presentation — Clues to the presence of perforation are feculent or bloody dialysate, dialysate retention, diarrhea occurring after dialysate instillation, or gram-negative peritonitis. Diarrhea resulting from perforation may be diagnosed by noting a very high glucose concentration in the stool.
Treatment — Therapy consists of the cessation of PD treatments, catheter removal, intravenous antibiotics, and bowel repair. (See "Placement of the peritoneal dialysis catheter".)
BLEEDING — Bleeding that occurs soon after catheter placement is most often due to trauma of small blood vessels located in the abdominal wall. The incidence of this complication was reported in a retrospective review of 292 catheters placed in 263 patients between the years 1992 and 2003 [53]. Six patients had major bleeding (2 percent), which occurred in association with perioperative anticoagulation (three patients), intraoperative bleeding (one), thrombocytopenia and uremia (one), and thrombocytopenia and aspirin use (one). Based on these observations, preventive measures should include holding anticoagulation therapy for a minimum of 24 hours after the procedure and obtaining and (if necessary) correcting coagulation parameters prior to surgery.
Unless the effluent hematocrit is greater than 2 percent, conservative management with ongoing observation is safe and effective [15]. In this setting, heparinization of the dialysate can be used to prevent catheter occlusion.
Hemoperitoneum not temporally related to catheter placement can also occur and is reviewed separately. (See "Noninfectious complications of continuous peritoneal dialysis" and "Bloody peritoneal dialysate (hemoperitoneum)".)
ABDOMINAL SURGERY — Major abdominal surgery that is unrelated to the catheter is sometimes required in patients with an indwelling PD catheter. In this setting, surgery may be complicated by the presence of dense intra-abdominal adhesions (due in part to repeated peritonitis episodes) and the presence of the catheter in the upper or lower abdomen or pelvis.
Given that many patients have minimal adhesions, the presence of an intraperitoneal catheter is not a contraindication to laparoscopy; the surgeon should be prudent and employ an open insertion of the trocar. With planned open procedures, the possible need for extensive adhesiolysis should be anticipated.
The abdominal incision should not be near the catheter insertion site. In addition, the catheter should be identified to ensure that it is not displaced during packing or manipulation of abdominal contents.
At completion of surgery, the catheter is checked to ensure it has not been dislodged; care should also be taken in closing the abdomen to avoid trapping the catheter in sutures.
Hemodialysis may be required in the immediate postoperative period, depending upon the patient's clinical status, degree of residual kidney function, and ability to perform supine only, low-volume PD exchanges. If interim hemodialysis is required, resumption of PD after a week delay is reasonable, although the time on hemodialysis, time on low-volume supine PD, or time without dialysis is variable based upon patient characteristics and the clinical situation.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topic (see "Patient education: Peritoneal dialysis (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Although less frequent than infection, noninfectious complications of peritoneal dialysis (PD) catheters also occur. These include outflow failure, pericatheter leak, abdominal wall herniation, catheter-cuff extrusion, and intestinal perforation. Some of these complications can be managed conservatively, while others require laparoscopic, peritoneoscopic, or traditional surgical intervention. (See 'Introduction' above.)
●Outflow failure is commonly caused by constipation or obstipation. Radiography is useful for elucidating the cause of outflow failure, especially if related to constipation or catheter malposition. It is important to exclude pericatheter or dialysate leakage as the underlying cause of incomplete recovery of instilled dialysate. Once leakage has been excluded, the underlying cause of outflow failure is usually ascertained by history, physical exam, and/or radiography. Prevention is optimized by proper positioning of the catheter upon implantation and avoidance of constipation. Treatment of outflow failure depends on the cause of obstruction. (See 'Outflow failure' above.)
●Pericatheter leakage tends to occur early after catheter placement in association with high-dialysate volumes and in those with weak abdominal walls. The incidence is widely variable and may relate to the practice of subcutaneous embedding of the implanted catheter upon implantation. Pericatheter leakage is recognized by the presence of fluid surrounding the catheter and may be initially subtle. Subcutaneous swelling and diminished outflow volumes may precede frank leakage. The diagnosis of pericatheter leakage may be made by a high glucose concentration of the leaking fluid. Confirmatory diagnosis and delineation of the anatomy of the leak may be demonstrated more definitively by computed tomography (CT) scanning. Management is usually accomplished successfully by decreasing either dialysate volume and/or exertional activity. Temporary transfer to continuous PD or temporary hemodialysis may be necessary in some patients. (See 'Pericatheter leakage' above.)
●Erosion of the catheter cuff through the skin may be a sequela of exit-site infection or excessive superficial cuff placement. Conservative measures may be attempted in those without evidence of an infectious process. Cuff shaving or catheter removal may be required in the presence of infection. (See 'Catheter cuff extrusion' above.)
●Intestinal perforation can occur at the time of catheter implantation because of direct injury or weeks to months after placement because of bowel erosion. This complication can be life threatening and therefore requires a high index of suspicion and urgent attention. Clues to the presence of perforation are feculent or bloody dialysate, dialysate retention, diarrhea occurring after dialysate instillation, or gram-negative peritonitis. Therapy consists of the cessation of PD treatments, catheter removal, intravenous antibiotics, and bowel repair. (See 'Intestinal perforation' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jean L Holley, MD, FACP, who contributed to an earlier version of this topic review.
