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: Volume dialysate filled Patient age, body mass index Coughing, lifting straining at stool Position of the patient (sitting>standing>supine)

Inflow/Outflow Obstruction Causes: 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)

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

Dialysate Leaks Tzamaloukas Adv PD 1990 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

Fluid Leak - CT Cannulogram

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

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,

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

Hernias – risk factors Raised intra-abdominal pressure Female sex and multiparity (no. of pregnancies) Older age Previous hernia Polycystic kidney disease

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

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)

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

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