Short Reports
june 2014 – Vol. 34, No. 4
DISCLOSURES
Peter G. Blake and Arsh K. Jain have received research funds fom Baxter. James A. Sloand, Susan McMurray and Sandee Matthews are employees of Baxter. 460
Peter G. Blake1 James A. Sloand2 Susan McMurray2 Arsh K. Jain1 Sandee Matthews2 Division of Nephrology1 London Health Sciences Centre and Western University London, Ontario, Canada Renal Division2 Baxter Healthcare Corporation McGaw Park, Illinois, USA *email: [email protected] REFERENCES 1. Perez RA, Blake PG, McMurray S, Mupas L, Oreopoulos DG. What is the optimal frequency of cycling in automated peritoneal dialysis? Perit Dial Int 2000; 20:548–56. 2. Juergensen PH, Murphy AL, Pherson KA, Kliger AS, F inkelstein FO. Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis. Kidney Int 2000; 57:2603–7. 3. Juergensen PH, Murphy AL, Pherson KA, Chorney WS, Kliger AS, Finkelstein FO. Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients. Adv Perit Dial 1999; 15:125–6. 4. Neri L, Viglino G, Cappelletti A, Gandolfo C. Evaluation of drainage times and alarms with various automated peritoneal dialysis modalities. Adv Perit Dial 2001; 17:72–4. 5. Mujais S, Childers RW. Profiles of automated peritoneal dialysis prescriptions in the US 1997-2003. Kidney Int Suppl 2006; (103):S84–90. 6. Davis DI, Cizman B, Mundt K, Wu L, Childers R, Mell R, et al. Relationship between drain volume/fill volume ratio and clinical outcomes associated with overfill complaints in peritoneal dialysis patients. Perit Dial Int 2011; 31:148–53. 7. Mujais S, Childers RW. Profiles of automated peritoneal dialysis prescriptions in the US 1997-2003. Kidney Int Suppl 2006; 103:S84–90. 8. Fernando SK, Finkelstein FO. Tidal PD: Its role in the current practice of peritoneal dialysis. Kidney Int Suppl 2006; (103):S91–5. doi:10.3747/pdi.2013.00314
Delayed Bowel Perforation in a Peritoneal Dialysis Patient: A Case Report and Literature Review Erosion of the peritoneal dialysis (PD) catheter into the bowel is very rare. Some patients experience serious
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are receiving 75 – 80% tidal, while others are receiving 70% or levels greater than 85%. Some of the variation may result from a process of trial and error, carried out in order to find the amount of tidal required to minimize drain pain. Overall, the impression is that the choice of the tidal volume percent is arbitrary from center to center and is not based on any specific evidence. Similarly, the practice of fully draining a TPD patient every third or fourth cycle is used in the majority of patients in one center, but not at all in the other five, suggesting a similar degree of arbitrariness. The same applies to setting the “Tidal Total Ultrafiltration” volume greater than the default value of zero. This was used universally in two centers and not at all in three others. In only one center were both selections used in the majority of TPD patients. These cycler settings were both designed to prevent a progressive rise in residual volume, as ultrafiltrate accumulates during TPD, potentially resulting in increased intraperitoneal volume and consequent raised intraperitoneal pressure. The potential adverse consequences of this have been highlighted in a recent study looking at the problem of “overfill” in PD patients (8). Adverse events including a number of deaths were associated with overfill. In theory, TPD may increase the risk of overfill (8). The default for both these TPD prescription settings was “off” in the Home Choice 10.2 cycler. Conversely, both of these settings are now programmed “on” by default in the new Home Choice 10.4 software, with full drains every third cycle and minimum “Total UF” of 1,000 mL. The change was implemented specifically to reduce the possibility of overfill. Prescribers now need to actively turn off or alter these settings if they are unwanted or if they desire a different frequency of Tidal Full Drain, or a greater or lesser Tidal Total UF. This change reflects recent concerns about overfill (8). There is clearly a need for greater understanding of how TPD is best used and studies on this issue would be helpful. There is a need to understand better how effective TPD is for drain pain or a poorly draining PD catheter, how real the risks of overfill are, and how much TPD might contribute to them. At present, there is insufficient information in the literature to provide evidencebased guidelines on how to deliver TPD. However, use of the prescription settings to prevent overfill may be particularly important in patients who have substantial ultrafiltration on TPD.
PDI
PDI
june 2014 – Vol. 34, No. 4
consequences such as peritonitis, difficulties in draining, and feculent dialysate effluent with watery diarrhea, but some patients develop no symptoms. Most cases have occurred upon insertion of a stylet-catheter. Perforation by a PD catheter is distinctly unusual. Here, we report a 72-year-old man who presented with a plastic tube protruding from the anus after defecating. We diagnosed the patient with delayed rectal perforation by a PD catheter. We compare our patient with similar patients identified by a search of the English-language literature indexed at PubMed (keywords: “perforation,” “erosion,” “peritoneal dialysis,” “catheter”) and a search for references within articles identified in the primary search.
Short Reports
The patient was admitted to our hospital because of a tunnel infection related to the peritoneal catheter. Abdominal computed tomography (CT) showed that the catheter tip had entered the sigmoid colon (Figure 1), and a subsequent colonoscopy revealed that the catheter tip had invaded the rectal lumen (Figure 2). The patient was given a cleansing enema, and the catheter was then removed by open surgery without bowel resection and without closure of the hole in the rectum within the peritoneal cavity. Some discolored substances were observed in the catheter when it was removed. The patient recovered fully and was well at a 3-month follow-up.
CASE REPORT
The patient was a 72-year-old man who initially presented in February 2001 with proteinuria (1250 mg daily) and elevated serum creatinine (350 μmol/L). He initially took a Chinese herb to treat his symptoms, but started PD in October 2002 when his serum creatinine was 680 μmol/L. A double-cuffed, curled Tenckhoff PD catheter was inserted by open surgery. The patient remained on PD without complications for 27 months and was then converted to hemodialysis because of peritoneal membrane failure in January 2006. The peritoneal catheter was not removed at that time. In August 2010, the patient was admitted to the local hospital complaining that he felt a plastic tube protruding from his anus after defecation. Examination indicated that he was afebrile and had a stable cardiovascular system and a soft, tender abdomen. Rectal examination revealed the tip of the PD catheter protruding through the anus. The local doctor pulled and cut part of the protruding catheter before discharging the patient.
Delayed perforation is an uncommon complication of PD and usually involves a dormant catheter. Our review of the literature indicated 28 cases, including the present case (Table 1). In 15 patients, PD had been suspended;
Figure 2 — Colonoscopy showing the peritoneal dialysis catheter tip inside the rectal lumen.
Figure 1 — Abdominal computed tomography images showing the peritoneal dialysis catheter tip inside the lumen of the rectum. This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
461
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DISCUSSION
Sigmoid NA colon
Catheter removal, bowel segment resection
Rambausek et al., 8 42 Male GN 48 1.6 NA Peritonitis EL Small bowel 1989 (7)
Immunosuppression
6 44 Male MPG 28 4 NA Appendicitis EL Appendix, Catheter ileum, removal, ascending appendix colon and segment small bowel resection Catheter removal only
Immunosuppression
Catheter removal only
Brady et al., 1988 (5) 5 66 Female MN 2.25 1.75a NA Peritonitis Postmortem Sigmoid examination colon
Jamison et al., 1988 (6) 7 46 Male PKD NA 4 NA Asymptomatic Sonogram Rectum
Immunosuppression
Catheter removal, suture repair of perforation
Risk factor
Parvin and Beaman, 4 53 Female DN NA 8 NA Watery CF Ileum 1985 (4) diarrhea
Sigmoid NA colon
Peritonitis Methylene Transverse Catheter with blue colon removal, watery blue injection suture repair diarrhea of perforation
Volpe et al., 1984 (3) 3 66 Female CPN 7 6 NA Asymptomatic CF
Valles et al., 1982 (2) 2 62 Female PKD 0.5 0 NA
Watson and Thompson, 1 71 Male GN 9 0 NA Peritonitis EL 1980 (1)
Site of perforation Treatment
june 2014 – Vol. 34, No. 4
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462
Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 Literature Reports of Delayed Bowel Perforation Caused by a Peritoneal Dialysis Catheter
Short Reports PDI
NA
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Catheter removal, bowel segment resection
NA
Paraumbilical hernia repair 10 days earlier
Immunosuppression
6 with diverticulitis
Risk factor
june 2014 – Vol. 34, No. 4
Shrestha et al., 2003 (13) 20 74 Male NA 10 8 Straight Watery CF Sigmoid diarrhea colon
Foul smell Colonoscopy (feces-like)
Catheter removal, limited right hemicolectomy
Balaji et al., 1996 (11) 18 46 Male GN 21 0 Coiled Rectal Colonoscopy Cecum hemorrhage
Borazan et al., 2003 (12) 19 36 Male NA 54 6 NA
Catheter removal; abdominal part extracted via the regular exit site; the rest, via the anus
Jansen et al., 1994 (10) 17 43 Male MPG 5 26 Coiled Catheter Clinical NA protrusion manifestation (anus)
Rotellar et al., 1992 (9) 9 22 Male PSG NA NA Peritonitis EL Sigmoid Surgery Left 10 69 Female PKD NA NA Peritonitis EL Sigmoid hemicolectomy 5 11 36 Male IgAN NA NA Peritonitis EL Right colon Surgery straight, 12 80 Male HN NA NA Peritonitis CF Sigmoid Surgery 2 13 54 Male RT+HP NA NA Peritonitis EL Sigmoid Surgery coiled 14 54 Female DN NA NA Peritonitis EL Ileum/cecum Surgery 15 53 Female IN NA NA Peritonitis EL Sigmoid Surgery
Catheter removal, jejunal loop resection
Site of perforation Treatment
Korzets et al., 1992 (8) 16 78 Male HN 24 0 Straight Peritonitis Contrast Proximal enema jejunum
Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 (cont’d)
PDI Short Reports
Catheter removal, colostomy
25
54
Male
DN
6.5
0
Straight Watery diarrhea
CT
Appendix
NA
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Catheter CT and Rectum protrusion colonoscopy (anus)
Catheter removal only
Immunosuppression
Immunosuppression
Colonic amyloidosis
Risk factor
PD = peritoneal dialysis; GN = glomerulonephritis; NA = not available; EL = exploratory laparotomy; PKD = polycystic kidney disease; CPN = chronic pyelonephritis; DN = diabetic nephropathy; CF = contrast fluoroscopy; MN = membranous nephropathy; MPG = membranoproliferative glomerulonephritis; HN = hypertensive nephrosclerosis; PSG = post-streptococcal glomerulonephritis; IgAN = immunoglobulin A nephropathy; RT = renal tuberculosis; HP = hypertension; IN = interstitial nephritis; MGUS = monoclonal gammopathy of uncertain significance; CT = computed tomography; PN = polyarteritis nodosa. a Catheter was flushed every week by a trained peritoneal dialysis nurse. b Two 24-hour dialysis sessions per week with hour dwell time for 3 months.
Present case 28 72 Male GN 27 48 Coiled
Baek et al., 2011 (20) 27 50 Male DN NA 6 Straight Watery CT and Rectum Endoscopic diarrhea colonoscopy closure, catheter removal
Trivedi et al., 2010 (19) 26 31 Male PN 24 8 Coiled Catheter CT Sigmoid Catheter protrusion colon removal, (anus) bowel segment resection
George et al., 2008 (18)
Askenazi et al., 2007 (17) 24 2 Male PKD 1.5 1.5 Coiled Fluid instilled, CF Small Catheter infant not draining intestine removal, bowel segment resection
Saweirs and Casey, 22 4 Male MN 10 4 Coiled Catheter Clinical Rectosigmoid Catheter 2005 (16) protrusion manifestation junction removal, (anus) suture repair of perforation
Finkle, 2005 (15) 23 73 Male MGUS, NA NA Coiled Watery diarrhea CF Rectum HN
Grzegorzewska, 2004 (14) 21 62 Female NA 3 3b Straight Abdominal CF Transverse Catheter distension, colon removal diarrhea, only feculent effluent
Site of perforation Treatment
june 2014 – Vol. 34, No. 4
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464
Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 (cont’d)
Short Reports PDI
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june 2014 – Vol. 34, No. 4
an acute problem arising from bowel perforation. Our review also indicates that bowel perforation might not be diagnosed even after death (5). Indeed, some patients remain asymptomatic (3,6). We therefore suggest routine abdominal CT imaging if a patient with peritonitis is treated with antibiotics for more than 3 days without resolution of symptoms. The low incidence of bowel perforation makes establishing a standard management plan difficult, but surgery is the usual treatment. Successful endoscopic repair using clips (20) or endoscopic closure of the colonic perforation (23,24) after colonoscopy has also been reported. In addition, perforations could be self-curing, and so a conservative approach, with removal of the catheter, might be tried before consideration of surgical exploration. Favorable outcomes were reported in patients without signs of peritonitis or sepsis (6,14) or after conservative management with only catheter removal. In our view, if a patient presents with no signs of peritonitis or sepsis, but has formation of a sinus around the catheter, then simple catheter removal might be feasible if the patient can be carefully followed over time. CONCLUSIONS
We want to emphasize several points with respect to the diagnosis and treatment of bowel perforation by a catheter in PD patients. First, the signs and symptoms of perforation are extremely variable. A high index of suspicion is required when the patient has watery diarrhea or peritonitis, and routine abdominal CT imaging should be performed if the patient has peritonitis and if antibiotic treatment for more than 3 days has not resulted in significant amelioration of symptoms. Second, patients discontinuing PD for more than 1 month could potentially benefit from catheter removal. Third, PD patients undergoing renal transplantation should have their catheters withdrawn or regularly flushed after the transplantation procedure. Finally, for a patient with no signs of peritonitis or sepsis, but with the formation of a sinus around the catheter, removal might be feasible if the patient can be followed over time. DISCLOSURES
The authors have no financial conflicts of interest to declare.
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Rending Wang1 Zhimin Chen1 Jiaxin Wang1 Xiaohui Zhang1 465
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the other 13 patients were on intermittent PD. Of the 28 patients affected, 10 had a straight PD catheter and 9 had a coiled catheter. The clinical course of the perforations was heterogeneous and included peritonitis, watery diarrhea, and catheter protrusion from the anus, among other manifestations. The diagnoses were confirmed by CT, contrast fluoroscopy, colonoscopy, or exploratory laparotomy. The risk factors in the 28 patients included use of immunosuppressants and the presence of diverticulitis or colonic amyloidosis. In our patient, bowel perforation occurred more than 4 years after cessation of PD. Review of the other cases in the literature indicated that half were attributable to an unused PD catheter, typically 1.6 – 48 months after use had ceased. Lack of fluid in the peritoneal cavity after cessation of continuous ambulatory PD increases the risk for pressure-induced necrosis by the immobile catheter. Apparently, the peritoneal fluid that bathes the bowel loops acts as a barrier that prevents adhesion of the catheter to the bowel wall. However, in the Moncrief–Popovich technique, catheters are routinely implanted for several months without use, and regular flushing is not performed (21,22). For patients who suspend PD for more than 1 month, catheter removal might be the better choice to avoid severe complications such as bowel perforation. If the patient or doctor decides not to remove the catheter, then the catheter could be flushed regularly. The continuous presence of fluid in the peritoneum of patients actively engaged in a continuous ambulatory PD program does not totally preclude the possibility of catheter adhesion. In fact, PD patients with diverticulitis might have an increased risk of catheter perforation (8,9). A patient with a history of diverticulitis should therefore be more carefully observed upon cessation of PD. Gastrointestinal pathology, including amyloidosis, might also increase the risk of catheter perforation (15). Although no general guidelines have been formulated concerning the timing of PD catheter removal after renal transplantation, the presence of a normally functioning allograft is the main indication for catheter removal. It might therefore be necessary to remove the catheter much sooner after transplantation or to flush the catheter regularly after cessation of PD. The diagnosis of bowel perforation is definite when the catheter protrudes through the anus. Based on our literature review, we suggest that watery diarrhea during fluid instillation into the cavity, with or without peritonitis, could indicate bowel perforation. When clinical examination indicates peritonitis, it might be difficult to determine whether the cause is related to PD or is
Short Reports
Short Reports
june 2014 – Vol. 34, No. 4
Zhangfei Shou1 Jianghua Chen1,2 Kidney Disease Center1 The First Affiliated Hospital College of Medicine Zhejiang University Key Laboratory of Zhejiang Province2 Hangzhou, PR China *email: [email protected] REFERENCES
466
caused by a permanent peritoneal dialysis catheter. Perit Dial Int 2004; 24:298. 15. Finkle SN. Peritoneal dialysis catheter erosion into bowel: amyloidosis may be a risk factor. Perit Dial Int 2005; 25:296–7. 16. Saweirs WW, Casey J. Asymptomatic bowel perforation by a Tenckhoff catheter. Perit Dial Int 2005; 25:195–6. 17. Askenazi D, Katz A, Tenney F, Benfield M, Barnhart D. An unusual case of peritoneal dialysis malfunction. Kidney Int 2007; 72:524. 18. George J, Varma S, Gopi SP, Ramachandran S, Thampi M, Kunjukunju M, et al. Quiz page. Perforation of a functioning Tenckhoff catheter through the appendix. Am J Kidney Dis 2008; 52:A47–8. 19. Trivedi H, Tan HP, Morgan C, Shapiro R, Basu A. Colonic perforation by a dormant peritoneal dialysis catheter post renal transplantation. Am Surg 2010; 76:908–9. 20. Baek SK, Bae OS, Jang K. Endoscopic management of delayed perforation of the rectum caused by a peritoneal dialysis catheter. Surg Laparosc Endosc Percutan Tech 2011; 21:e44–7. 21. Elhassan E, McNair B, Quinn M, Teitelbaum I. Prolonged duration of peritoneal dialysis catheter embedment does not lower the catheter success rate. Perit Dial Int 2011; 31:558–64. 22. Brown PA, McCormick BB, Knoll G, Su Y, Doucette S, Fergusson D, et al. Complications and catheter survival with prolonged embedding of peritoneal dialysis catheters. Nephrol Dial Transplant 2008; 23:2299–303. 23. Magdeburg R, Collet P, Post S, Kaehler G. Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2008; 22:1500–4. 24. Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc 2001; 54:258–9. doi:10.3747/pdi.2012.00345
Pet-Related Peritonitis and Its Prevention in Peritoneal Dialysis: A Case Study Infectious peritonitis is a major complication of peritoneal dialysis (PD), accounting for considerable mortality and morbidity of PD patients. Although the usual organisms associated with peritonitis are Staphylococci aureus, Staphylococci epidermidis, Pseudomonas species and other gram-negatives, peritonitis due to zoonotic organisms in the context of close contact with companion animals has been reported in literatures (1–12). On a literature review, 124 cases of peritonitis caused by 12 different zoonotic agents have been reported in PD patients. Thirty of them were following documented contacts with an animal with overall mortality of
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1. Watson LC, Thompson JC. Erosion of the colon by a long-dwelling peritoneal dialysis catheter. JAMA 1980; 243:2156–7. 2. Valles M, Cantarell C, Vila J, Tovar JL. Delayed perforation of the colon by a Tenckhoff catheter. Perit Dial Bull 1982; 2:190. 3. Volpe MD, Iberti M, Ortensia A, Vernonesi GV. Erosion of the sigmoid by a permanent peritoneal catheter. Perit Dial Int 1984; 4:108. 4. Parvin SD, Beaman M. Ileal erosion by the Tenckhoff catheter. Perit Dial Int 1985; 5:82–3. 5. Brady HR, Abraham G, Oreopoulos DG, Cardella CJ. Bowel erosion due to a dormant peritoneal catheter in immunosuppressed renal transplant recipients. Perit Dial Int 1988; 8:163–5. 6. Jamison MH, Fleming SJ, Ackrill P, Schofield PF. Erosion of rectum by Tenckhoff catheter. Br J Surg 1988; 75:360. 7. Rambausek M, Zeier M, Weinreich T, Ritz E, Rau J, Pomer S. Bowel perforation with unused Tenckhoff catheters. Perit Dial Int 1989; 9:82. 8. Korzets Z, Golan E, Ben-Dahan J, Neufeld D, Bernheim J. Decubitus small-bowel perforation in ongoing continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1992; 7:79–81. 9. Rotellar C, Sivarajan S, Mazzoni MJ, Aminrazavi M, Mosher WF, Rakowski TA, et al. Bowel perforation in CAPD patients. Perit Dial Int 1992; 12:396–8. 10. Jansen GP, Gerlag PG, Bruyninckx BC. Unusual presentation of bowel perforation by a CAPD catheter. Perit Dial Int 1994; 14:180–2. 11. Balaji V, Digard N, Wise MH. Delayed bowel erosion due to functioning chronic ambulatory peritoneal dialysis catheter. Nephrol Dial Transplant 1996; 11:368–9. 12. Borazan A, Ustün H, Akkas¸ M, Ozbay O, Yilmaz A. Bowel perforation during catheter removal after the sixth month of peritoneal dialysis termination. Acta Medica (Hradec Kralove) 2003; 46:77–8. 13. Shrestha BM, Wilkie M, Raftery AT. Delayed colonic perforation caused by an unused CAPD catheter in a patient presenting with diarrhea. Perit Dial Int 2003; 23:610–11. 14. Grzegorzewska AE. Perforation of the transverse colon
PDI
june 2014 – Vol. 34, No. 4
DISCLOSURES
Peter G. Blake and Arsh K. Jain have received research funds fom Baxter. James A. Sloand, Susan McMurray and Sandee Matthews are employees of Baxter. 460
Peter G. Blake1 James A. Sloand2 Susan McMurray2 Arsh K. Jain1 Sandee Matthews2 Division of Nephrology1 London Health Sciences Centre and Western University London, Ontario, Canada Renal Division2 Baxter Healthcare Corporation McGaw Park, Illinois, USA *email: [email protected] REFERENCES 1. Perez RA, Blake PG, McMurray S, Mupas L, Oreopoulos DG. What is the optimal frequency of cycling in automated peritoneal dialysis? Perit Dial Int 2000; 20:548–56. 2. Juergensen PH, Murphy AL, Pherson KA, Kliger AS, F inkelstein FO. Tidal peritoneal dialysis: comparison of different tidal regimens and automated peritoneal dialysis. Kidney Int 2000; 57:2603–7. 3. Juergensen PH, Murphy AL, Pherson KA, Chorney WS, Kliger AS, Finkelstein FO. Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients. Adv Perit Dial 1999; 15:125–6. 4. Neri L, Viglino G, Cappelletti A, Gandolfo C. Evaluation of drainage times and alarms with various automated peritoneal dialysis modalities. Adv Perit Dial 2001; 17:72–4. 5. Mujais S, Childers RW. Profiles of automated peritoneal dialysis prescriptions in the US 1997-2003. Kidney Int Suppl 2006; (103):S84–90. 6. Davis DI, Cizman B, Mundt K, Wu L, Childers R, Mell R, et al. Relationship between drain volume/fill volume ratio and clinical outcomes associated with overfill complaints in peritoneal dialysis patients. Perit Dial Int 2011; 31:148–53. 7. Mujais S, Childers RW. Profiles of automated peritoneal dialysis prescriptions in the US 1997-2003. Kidney Int Suppl 2006; 103:S84–90. 8. Fernando SK, Finkelstein FO. Tidal PD: Its role in the current practice of peritoneal dialysis. Kidney Int Suppl 2006; (103):S91–5. doi:10.3747/pdi.2013.00314
Delayed Bowel Perforation in a Peritoneal Dialysis Patient: A Case Report and Literature Review Erosion of the peritoneal dialysis (PD) catheter into the bowel is very rare. Some patients experience serious
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at WASHINGTON UNIVERSITY on November 18, 2015
are receiving 75 – 80% tidal, while others are receiving 70% or levels greater than 85%. Some of the variation may result from a process of trial and error, carried out in order to find the amount of tidal required to minimize drain pain. Overall, the impression is that the choice of the tidal volume percent is arbitrary from center to center and is not based on any specific evidence. Similarly, the practice of fully draining a TPD patient every third or fourth cycle is used in the majority of patients in one center, but not at all in the other five, suggesting a similar degree of arbitrariness. The same applies to setting the “Tidal Total Ultrafiltration” volume greater than the default value of zero. This was used universally in two centers and not at all in three others. In only one center were both selections used in the majority of TPD patients. These cycler settings were both designed to prevent a progressive rise in residual volume, as ultrafiltrate accumulates during TPD, potentially resulting in increased intraperitoneal volume and consequent raised intraperitoneal pressure. The potential adverse consequences of this have been highlighted in a recent study looking at the problem of “overfill” in PD patients (8). Adverse events including a number of deaths were associated with overfill. In theory, TPD may increase the risk of overfill (8). The default for both these TPD prescription settings was “off” in the Home Choice 10.2 cycler. Conversely, both of these settings are now programmed “on” by default in the new Home Choice 10.4 software, with full drains every third cycle and minimum “Total UF” of 1,000 mL. The change was implemented specifically to reduce the possibility of overfill. Prescribers now need to actively turn off or alter these settings if they are unwanted or if they desire a different frequency of Tidal Full Drain, or a greater or lesser Tidal Total UF. This change reflects recent concerns about overfill (8). There is clearly a need for greater understanding of how TPD is best used and studies on this issue would be helpful. There is a need to understand better how effective TPD is for drain pain or a poorly draining PD catheter, how real the risks of overfill are, and how much TPD might contribute to them. At present, there is insufficient information in the literature to provide evidencebased guidelines on how to deliver TPD. However, use of the prescription settings to prevent overfill may be particularly important in patients who have substantial ultrafiltration on TPD.
PDI
PDI
june 2014 – Vol. 34, No. 4
consequences such as peritonitis, difficulties in draining, and feculent dialysate effluent with watery diarrhea, but some patients develop no symptoms. Most cases have occurred upon insertion of a stylet-catheter. Perforation by a PD catheter is distinctly unusual. Here, we report a 72-year-old man who presented with a plastic tube protruding from the anus after defecating. We diagnosed the patient with delayed rectal perforation by a PD catheter. We compare our patient with similar patients identified by a search of the English-language literature indexed at PubMed (keywords: “perforation,” “erosion,” “peritoneal dialysis,” “catheter”) and a search for references within articles identified in the primary search.
Short Reports
The patient was admitted to our hospital because of a tunnel infection related to the peritoneal catheter. Abdominal computed tomography (CT) showed that the catheter tip had entered the sigmoid colon (Figure 1), and a subsequent colonoscopy revealed that the catheter tip had invaded the rectal lumen (Figure 2). The patient was given a cleansing enema, and the catheter was then removed by open surgery without bowel resection and without closure of the hole in the rectum within the peritoneal cavity. Some discolored substances were observed in the catheter when it was removed. The patient recovered fully and was well at a 3-month follow-up.
CASE REPORT
The patient was a 72-year-old man who initially presented in February 2001 with proteinuria (1250 mg daily) and elevated serum creatinine (350 μmol/L). He initially took a Chinese herb to treat his symptoms, but started PD in October 2002 when his serum creatinine was 680 μmol/L. A double-cuffed, curled Tenckhoff PD catheter was inserted by open surgery. The patient remained on PD without complications for 27 months and was then converted to hemodialysis because of peritoneal membrane failure in January 2006. The peritoneal catheter was not removed at that time. In August 2010, the patient was admitted to the local hospital complaining that he felt a plastic tube protruding from his anus after defecation. Examination indicated that he was afebrile and had a stable cardiovascular system and a soft, tender abdomen. Rectal examination revealed the tip of the PD catheter protruding through the anus. The local doctor pulled and cut part of the protruding catheter before discharging the patient.
Delayed perforation is an uncommon complication of PD and usually involves a dormant catheter. Our review of the literature indicated 28 cases, including the present case (Table 1). In 15 patients, PD had been suspended;
Figure 2 — Colonoscopy showing the peritoneal dialysis catheter tip inside the rectal lumen.
Figure 1 — Abdominal computed tomography images showing the peritoneal dialysis catheter tip inside the lumen of the rectum. This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
461
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DISCUSSION
Sigmoid NA colon
Catheter removal, bowel segment resection
Rambausek et al., 8 42 Male GN 48 1.6 NA Peritonitis EL Small bowel 1989 (7)
Immunosuppression
6 44 Male MPG 28 4 NA Appendicitis EL Appendix, Catheter ileum, removal, ascending appendix colon and segment small bowel resection Catheter removal only
Immunosuppression
Catheter removal only
Brady et al., 1988 (5) 5 66 Female MN 2.25 1.75a NA Peritonitis Postmortem Sigmoid examination colon
Jamison et al., 1988 (6) 7 46 Male PKD NA 4 NA Asymptomatic Sonogram Rectum
Immunosuppression
Catheter removal, suture repair of perforation
Risk factor
Parvin and Beaman, 4 53 Female DN NA 8 NA Watery CF Ileum 1985 (4) diarrhea
Sigmoid NA colon
Peritonitis Methylene Transverse Catheter with blue colon removal, watery blue injection suture repair diarrhea of perforation
Volpe et al., 1984 (3) 3 66 Female CPN 7 6 NA Asymptomatic CF
Valles et al., 1982 (2) 2 62 Female PKD 0.5 0 NA
Watson and Thompson, 1 71 Male GN 9 0 NA Peritonitis EL 1980 (1)
Site of perforation Treatment
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Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 Literature Reports of Delayed Bowel Perforation Caused by a Peritoneal Dialysis Catheter
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NA
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Catheter removal, bowel segment resection
NA
Paraumbilical hernia repair 10 days earlier
Immunosuppression
6 with diverticulitis
Risk factor
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Shrestha et al., 2003 (13) 20 74 Male NA 10 8 Straight Watery CF Sigmoid diarrhea colon
Foul smell Colonoscopy (feces-like)
Catheter removal, limited right hemicolectomy
Balaji et al., 1996 (11) 18 46 Male GN 21 0 Coiled Rectal Colonoscopy Cecum hemorrhage
Borazan et al., 2003 (12) 19 36 Male NA 54 6 NA
Catheter removal; abdominal part extracted via the regular exit site; the rest, via the anus
Jansen et al., 1994 (10) 17 43 Male MPG 5 26 Coiled Catheter Clinical NA protrusion manifestation (anus)
Rotellar et al., 1992 (9) 9 22 Male PSG NA NA Peritonitis EL Sigmoid Surgery Left 10 69 Female PKD NA NA Peritonitis EL Sigmoid hemicolectomy 5 11 36 Male IgAN NA NA Peritonitis EL Right colon Surgery straight, 12 80 Male HN NA NA Peritonitis CF Sigmoid Surgery 2 13 54 Male RT+HP NA NA Peritonitis EL Sigmoid Surgery coiled 14 54 Female DN NA NA Peritonitis EL Ileum/cecum Surgery 15 53 Female IN NA NA Peritonitis EL Sigmoid Surgery
Catheter removal, jejunal loop resection
Site of perforation Treatment
Korzets et al., 1992 (8) 16 78 Male HN 24 0 Straight Peritonitis Contrast Proximal enema jejunum
Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 (cont’d)
PDI Short Reports
Catheter removal, colostomy
25
54
Male
DN
6.5
0
Straight Watery diarrhea
CT
Appendix
NA
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Catheter CT and Rectum protrusion colonoscopy (anus)
Catheter removal only
Immunosuppression
Immunosuppression
Colonic amyloidosis
Risk factor
PD = peritoneal dialysis; GN = glomerulonephritis; NA = not available; EL = exploratory laparotomy; PKD = polycystic kidney disease; CPN = chronic pyelonephritis; DN = diabetic nephropathy; CF = contrast fluoroscopy; MN = membranous nephropathy; MPG = membranoproliferative glomerulonephritis; HN = hypertensive nephrosclerosis; PSG = post-streptococcal glomerulonephritis; IgAN = immunoglobulin A nephropathy; RT = renal tuberculosis; HP = hypertension; IN = interstitial nephritis; MGUS = monoclonal gammopathy of uncertain significance; CT = computed tomography; PN = polyarteritis nodosa. a Catheter was flushed every week by a trained peritoneal dialysis nurse. b Two 24-hour dialysis sessions per week with hour dwell time for 3 months.
Present case 28 72 Male GN 27 48 Coiled
Baek et al., 2011 (20) 27 50 Male DN NA 6 Straight Watery CT and Rectum Endoscopic diarrhea colonoscopy closure, catheter removal
Trivedi et al., 2010 (19) 26 31 Male PN 24 8 Coiled Catheter CT Sigmoid Catheter protrusion colon removal, (anus) bowel segment resection
George et al., 2008 (18)
Askenazi et al., 2007 (17) 24 2 Male PKD 1.5 1.5 Coiled Fluid instilled, CF Small Catheter infant not draining intestine removal, bowel segment resection
Saweirs and Casey, 22 4 Male MN 10 4 Coiled Catheter Clinical Rectosigmoid Catheter 2005 (16) protrusion manifestation junction removal, (anus) suture repair of perforation
Finkle, 2005 (15) 23 73 Male MGUS, NA NA Coiled Watery diarrhea CF Rectum HN
Grzegorzewska, 2004 (14) 21 62 Female NA 3 3b Straight Abdominal CF Transverse Catheter distension, colon removal diarrhea, only feculent effluent
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Patient Age Renal Time Inactive Catheter Clinical Methods Reference ID (years) Sex disease on PD use time type presentation of diagnosis
TABLE 1 (cont’d)
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PDI
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an acute problem arising from bowel perforation. Our review also indicates that bowel perforation might not be diagnosed even after death (5). Indeed, some patients remain asymptomatic (3,6). We therefore suggest routine abdominal CT imaging if a patient with peritonitis is treated with antibiotics for more than 3 days without resolution of symptoms. The low incidence of bowel perforation makes establishing a standard management plan difficult, but surgery is the usual treatment. Successful endoscopic repair using clips (20) or endoscopic closure of the colonic perforation (23,24) after colonoscopy has also been reported. In addition, perforations could be self-curing, and so a conservative approach, with removal of the catheter, might be tried before consideration of surgical exploration. Favorable outcomes were reported in patients without signs of peritonitis or sepsis (6,14) or after conservative management with only catheter removal. In our view, if a patient presents with no signs of peritonitis or sepsis, but has formation of a sinus around the catheter, then simple catheter removal might be feasible if the patient can be carefully followed over time. CONCLUSIONS
We want to emphasize several points with respect to the diagnosis and treatment of bowel perforation by a catheter in PD patients. First, the signs and symptoms of perforation are extremely variable. A high index of suspicion is required when the patient has watery diarrhea or peritonitis, and routine abdominal CT imaging should be performed if the patient has peritonitis and if antibiotic treatment for more than 3 days has not resulted in significant amelioration of symptoms. Second, patients discontinuing PD for more than 1 month could potentially benefit from catheter removal. Third, PD patients undergoing renal transplantation should have their catheters withdrawn or regularly flushed after the transplantation procedure. Finally, for a patient with no signs of peritonitis or sepsis, but with the formation of a sinus around the catheter, removal might be feasible if the patient can be followed over time. DISCLOSURES
The authors have no financial conflicts of interest to declare.
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Rending Wang1 Zhimin Chen1 Jiaxin Wang1 Xiaohui Zhang1 465
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the other 13 patients were on intermittent PD. Of the 28 patients affected, 10 had a straight PD catheter and 9 had a coiled catheter. The clinical course of the perforations was heterogeneous and included peritonitis, watery diarrhea, and catheter protrusion from the anus, among other manifestations. The diagnoses were confirmed by CT, contrast fluoroscopy, colonoscopy, or exploratory laparotomy. The risk factors in the 28 patients included use of immunosuppressants and the presence of diverticulitis or colonic amyloidosis. In our patient, bowel perforation occurred more than 4 years after cessation of PD. Review of the other cases in the literature indicated that half were attributable to an unused PD catheter, typically 1.6 – 48 months after use had ceased. Lack of fluid in the peritoneal cavity after cessation of continuous ambulatory PD increases the risk for pressure-induced necrosis by the immobile catheter. Apparently, the peritoneal fluid that bathes the bowel loops acts as a barrier that prevents adhesion of the catheter to the bowel wall. However, in the Moncrief–Popovich technique, catheters are routinely implanted for several months without use, and regular flushing is not performed (21,22). For patients who suspend PD for more than 1 month, catheter removal might be the better choice to avoid severe complications such as bowel perforation. If the patient or doctor decides not to remove the catheter, then the catheter could be flushed regularly. The continuous presence of fluid in the peritoneum of patients actively engaged in a continuous ambulatory PD program does not totally preclude the possibility of catheter adhesion. In fact, PD patients with diverticulitis might have an increased risk of catheter perforation (8,9). A patient with a history of diverticulitis should therefore be more carefully observed upon cessation of PD. Gastrointestinal pathology, including amyloidosis, might also increase the risk of catheter perforation (15). Although no general guidelines have been formulated concerning the timing of PD catheter removal after renal transplantation, the presence of a normally functioning allograft is the main indication for catheter removal. It might therefore be necessary to remove the catheter much sooner after transplantation or to flush the catheter regularly after cessation of PD. The diagnosis of bowel perforation is definite when the catheter protrudes through the anus. Based on our literature review, we suggest that watery diarrhea during fluid instillation into the cavity, with or without peritonitis, could indicate bowel perforation. When clinical examination indicates peritonitis, it might be difficult to determine whether the cause is related to PD or is
Short Reports
Short Reports
june 2014 – Vol. 34, No. 4
Zhangfei Shou1 Jianghua Chen1,2 Kidney Disease Center1 The First Affiliated Hospital College of Medicine Zhejiang University Key Laboratory of Zhejiang Province2 Hangzhou, PR China *email: [email protected] REFERENCES
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caused by a permanent peritoneal dialysis catheter. Perit Dial Int 2004; 24:298. 15. Finkle SN. Peritoneal dialysis catheter erosion into bowel: amyloidosis may be a risk factor. Perit Dial Int 2005; 25:296–7. 16. Saweirs WW, Casey J. Asymptomatic bowel perforation by a Tenckhoff catheter. Perit Dial Int 2005; 25:195–6. 17. Askenazi D, Katz A, Tenney F, Benfield M, Barnhart D. An unusual case of peritoneal dialysis malfunction. Kidney Int 2007; 72:524. 18. George J, Varma S, Gopi SP, Ramachandran S, Thampi M, Kunjukunju M, et al. Quiz page. Perforation of a functioning Tenckhoff catheter through the appendix. Am J Kidney Dis 2008; 52:A47–8. 19. Trivedi H, Tan HP, Morgan C, Shapiro R, Basu A. Colonic perforation by a dormant peritoneal dialysis catheter post renal transplantation. Am Surg 2010; 76:908–9. 20. Baek SK, Bae OS, Jang K. Endoscopic management of delayed perforation of the rectum caused by a peritoneal dialysis catheter. Surg Laparosc Endosc Percutan Tech 2011; 21:e44–7. 21. Elhassan E, McNair B, Quinn M, Teitelbaum I. Prolonged duration of peritoneal dialysis catheter embedment does not lower the catheter success rate. Perit Dial Int 2011; 31:558–64. 22. Brown PA, McCormick BB, Knoll G, Su Y, Doucette S, Fergusson D, et al. Complications and catheter survival with prolonged embedding of peritoneal dialysis catheters. Nephrol Dial Transplant 2008; 23:2299–303. 23. Magdeburg R, Collet P, Post S, Kaehler G. Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2008; 22:1500–4. 24. Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc 2001; 54:258–9. doi:10.3747/pdi.2012.00345
Pet-Related Peritonitis and Its Prevention in Peritoneal Dialysis: A Case Study Infectious peritonitis is a major complication of peritoneal dialysis (PD), accounting for considerable mortality and morbidity of PD patients. Although the usual organisms associated with peritonitis are Staphylococci aureus, Staphylococci epidermidis, Pseudomonas species and other gram-negatives, peritonitis due to zoonotic organisms in the context of close contact with companion animals has been reported in literatures (1–12). On a literature review, 124 cases of peritonitis caused by 12 different zoonotic agents have been reported in PD patients. Thirty of them were following documented contacts with an animal with overall mortality of
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1. Watson LC, Thompson JC. Erosion of the colon by a long-dwelling peritoneal dialysis catheter. JAMA 1980; 243:2156–7. 2. Valles M, Cantarell C, Vila J, Tovar JL. Delayed perforation of the colon by a Tenckhoff catheter. Perit Dial Bull 1982; 2:190. 3. Volpe MD, Iberti M, Ortensia A, Vernonesi GV. Erosion of the sigmoid by a permanent peritoneal catheter. Perit Dial Int 1984; 4:108. 4. Parvin SD, Beaman M. Ileal erosion by the Tenckhoff catheter. Perit Dial Int 1985; 5:82–3. 5. Brady HR, Abraham G, Oreopoulos DG, Cardella CJ. Bowel erosion due to a dormant peritoneal catheter in immunosuppressed renal transplant recipients. Perit Dial Int 1988; 8:163–5. 6. Jamison MH, Fleming SJ, Ackrill P, Schofield PF. Erosion of rectum by Tenckhoff catheter. Br J Surg 1988; 75:360. 7. Rambausek M, Zeier M, Weinreich T, Ritz E, Rau J, Pomer S. Bowel perforation with unused Tenckhoff catheters. Perit Dial Int 1989; 9:82. 8. Korzets Z, Golan E, Ben-Dahan J, Neufeld D, Bernheim J. Decubitus small-bowel perforation in ongoing continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 1992; 7:79–81. 9. Rotellar C, Sivarajan S, Mazzoni MJ, Aminrazavi M, Mosher WF, Rakowski TA, et al. Bowel perforation in CAPD patients. Perit Dial Int 1992; 12:396–8. 10. Jansen GP, Gerlag PG, Bruyninckx BC. Unusual presentation of bowel perforation by a CAPD catheter. Perit Dial Int 1994; 14:180–2. 11. Balaji V, Digard N, Wise MH. Delayed bowel erosion due to functioning chronic ambulatory peritoneal dialysis catheter. Nephrol Dial Transplant 1996; 11:368–9. 12. Borazan A, Ustün H, Akkas¸ M, Ozbay O, Yilmaz A. Bowel perforation during catheter removal after the sixth month of peritoneal dialysis termination. Acta Medica (Hradec Kralove) 2003; 46:77–8. 13. Shrestha BM, Wilkie M, Raftery AT. Delayed colonic perforation caused by an unused CAPD catheter in a patient presenting with diarrhea. Perit Dial Int 2003; 23:610–11. 14. Grzegorzewska AE. Perforation of the transverse colon
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