Noninfectious complications of peritoneal dialysis catheters

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]:

●Intestinal and bladder perforation

●Bleeding

●Impaired flow

●Pericatheter leak

●Catheter cuff extrusion

Some of these complications can be managed conservatively; others require intervention by surgery or interventional radiology/nephrology.

This topic will review the causes, presentation, and management of catheter-associated bowel or bladder perforation, bleeding due to catheter placement, outflow failure, pericatheter leaks, and catheter cuff extrusion. The placement of PD catheters and noninfectious complications of PD, such as gastroesophageal reflux disease, pain in the back and abdomen, abdominal wall herniation, and pleural effusion, are discussed separately.

●(See "Placement of the peritoneal dialysis catheter".)

●(See "Noninfectious complications of continuous peritoneal dialysis".)

●(See "Abdominal wall hernia and dialysate leak in peritoneal dialysis patients".)

COMPLICATIONS OF INSERTION

Intestinal perforation — Intestinal perforation is an uncommon complication of PD catheter insertion, occurring in 1 percent or fewer procedures [5-11]. This incidence is largely independent of the type of placement but may be more common with the placement of semirigid, acute PD catheters.

Intestinal perforation generally occurs at the time of catheter implantation because of direct injury, though it can happen weeks to months after placement because of erosion of the catheter into the bowel. This complication can be life threatening and therefore requires a high index of suspicion and urgent attention.

Intestinal perforation should be suspected in any patient on PD who presents with acute abdominal pain shortly after PD catheter implantation (see "Overview of gastrointestinal tract perforation", section on 'Presentations'). Other clues to the presence of bowel perforation in patients on PD are as follows:

●Feculent or bloody dialysate

●Dialysate retention

●Diarrhea occurring after dialysate instillation

●High stool glucose concentration, consistent with stool/dialysate admixture

●Gram-negative peritonitis (see "Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis", section on 'When to suspect secondary peritonitis')

In patients on PD with suspected intestinal perforation, the initial diagnostic evaluation generally includes imaging with computed tomography (CT). The utility of plain radiography in assessing bowel perforation in this setting is limited, in part because free air is commonly observed on imaging of patients on PD in the absence of perforation. The diagnostic approach to intestinal perforation in patients on PD is similar to that for the general population and is discussed in detail elsewhere. (See "Overview of gastrointestinal tract perforation", section on 'Diagnosis'.)

Patients with intestinal perforation should be evaluated by a surgeon. Treatment includes catheter removal and intravenous antibiotics. Details of management are discussed elsewhere. (See "Antimicrobial approach to intra-abdominal infections in adults", section on 'Approach to empiric antibiotic selection' and "Overview of gastrointestinal tract perforation", section on 'Initial management'.)

Bladder perforation — Bladder puncture is a rare complication of PD catheter insertion, usually described in case reports [12]. The risk is increased in patients who are unable to completely empty their bladder (eg, patients with chronic bladder outlet obstruction or neurogenic bladder) before PD catheter placement.

Bladder perforation generally happens at the time of catheter placement. The diagnosis should be suspected in patients on PD who present during or shortly after PD catheter implantation with any of the following clinical features:

●Urgency to void during catheter placement

●Sudden increase in urine volume

●Urinary incontinence with PD fills

●Bladder discomfort with PD filling or draining

●High urine glucose concentration, consistent with urine/dialysate admixture

In patients with suspected bladder perforation, the diagnosis can be confirmed with cystoscopy, cystography, or other imaging. Although surgical intervention may not be required, a urologist should be involved in the management of bladder perforation. The diagnosis and management of suspected bladder perforation are presented in greater detail separately. (See "Traumatic and iatrogenic bladder injury", section on 'Diagnosis' and "Traumatic and iatrogenic bladder injury", section on 'Intraperitoneal bladder injury'.)

Bleeding — Major bleeding due to PD catheter placement is uncommon. The rate of serious bleeding complications was reported in a retrospective review of 292 catheters placed in 263 patients between the years 1992 and 2003 [13]. Six patients had major bleeding (2 percent), which occurred in association with perioperative anticoagulation (three patients) and thrombocytopenia (two patients).

Bleeding that occurs soon after catheter placement is most often due to trauma of small blood vessels located in the abdominal wall and presents as bloody peritoneal dialysate (hemoperitoneum). Most bleeding is mild and can be managed conservatively. The evaluation and management of hemoperitoneum is discussed in detail elsewhere. (See "Bloody peritoneal dialysate (hemoperitoneum)", section on 'Evaluation and diagnosis' and "Bloody peritoneal dialysate (hemoperitoneum)", section on 'Treatment'.)

COMPLICATIONS AFTER INSERTION

Impaired catheter flow — Catheter flow may be impaired during dialysate infusion (ie, inflow impairment) and/or during drainage of the peritoneal cavity (ie, outflow impairment). The reported incidence of catheter flow problems varies widely, ranging from approximately 1 to 20 percent [14-17]. The use of laparoscopic techniques to place peritoneal dialysis catheters is associated with the lowest rate of catheter dysfunction [18-23]. (See "Placement of the peritoneal dialysis catheter", section on 'Catheter insertion'.)

Common causes of impaired flow include the following:

●Extraluminal catheter occlusion (usually due to dilated bowel from constipation)

●Intraluminal catheter occlusion (often by fibrin clot)

●Catheter kinking

●Catheter malposition

●Catheter entrapment (usually by omentum or adhesions)

Clinical presentation — The cause of obstruction affects the timing of flow impairment in relation to catheter insertion and whether outflow impairment is accompanied by inflow impairment.

●Timing in relation to catheter insertion – Although flow problems usually occur within the first month of catheter use, the timing of onset varies by cause (table 1) [9,24]. Impaired flow due to catheter kinking, malposition, or entrapment (usually by omentum or adhesions) typically occurs soon after PD catheter insertion [5,25]. Catheter kinking usually occurs during catheter placement, in which case flow problems are immediately apparent. Flow problems due to catheter malposition or entrapment generally occur days to several weeks after catheter insertion. By contrast, impaired flow due to extraluminal catheter occlusion (usually from constipation) or intraluminal catheter occlusion (often by fibrin clot) can occur at any period after the initiation of PD, even in patients who have undergone PD for an extended duration without problems.

●Outflow and inflow problems – Flow problems can be characterized as one-way outflow impairment or as bidirectional obstruction, where both inflow and outflow of dialysate are impaired (table 1). One-way outflow obstruction is the most common and generally occurs due to extraluminal catheter occlusion (usually from constipation), catheter malposition, or catheter entrapment (usually by omentum or adhesions). Bidirectional obstruction is commonly observed with catheter kinking (where the degree of flow impairment often varies with patient position) and intraluminal catheter occlusion.

●Pain with drainage – Pain with dialysate drainage ("drain pain") occurs occasionally in the setting of outflow obstruction and does not reliably indicate cause. In the absence of peritonitis, outflow obstruction in association with pain suggests catheter abutment against the bowel wall or other peritoneal cavity surfaces; as dialysate drains, the entrapped, malpositioned, or displaced catheter contacts and irritates the parietal peritoneum, causing pain. The approach to pain during dialysate drainage is discussed elsewhere. (See "Noninfectious complications of continuous peritoneal dialysis".)

Evaluation — In patients on peritoneal dialysis who present with flow problems, we take the following approach to evaluation (algorithm 1):

●Exclude mimics of impaired flow – Dialysate leakage can cause incomplete recovery of infused dialysate, as can occur with partial outflow impairment. Patients with a dialysate leak do not require further evaluation for flow problems; rather, efforts should focus on identifying and managing the leak. The detection of dialysate leaking at the pericatheter site (manifest by fluid at the catheter site or by subcutaneous edema) and management of such leaks are discussed below (see 'Pericatheter leakage' below); detection of dialysate leak from the peritoneal cavity into abdominal hernias or the pleural space is discussed elsewhere. (See "Noninfectious complications of continuous peritoneal dialysis", section on 'Clinical characteristics' and "Abdominal wall hernia and dialysate leak in peritoneal dialysis patients".)

●Empirically treat constipation – For patients on PD with impaired catheter flow, we suggest administering laxatives to empirically treat constipation. Constipation is the most common cause of flow failure [26] and may be associated with minimal symptoms. If catheter function normalizes after the successful treatment of constipation, no additional work-up is necessary. (See 'Constipation' below.)

●Empirically treat suspected intraluminal catheter occlusion – Impaired flow due to intraluminal catheter obstruction by fibrin clot is suggested by partial or complete bidirectional obstruction to flow, preceded or accompanied by the appearance of plugs or strands of fibrin in drained dialysate. For patients on PD with impaired catheter flow and suspected intraluminal catheter occlusion, we suggest empiric treatment of fibrin clot. If such treatment resolves the catheter flow problem, no additional work-up is necessary. (See 'Fibrin clot' below.)

●Obtain abdominal imaging – For patients with unexplained flow problems despite the measures above, we obtain an abdominal radiograph (KUB). Most catheters now have a radiopaque stripe, which may identify malpositioned or kinked catheters. Our subsequent approach depends on the results of the KUB as follows:

•KUB showing catheter malposition or kink – If KUB shows catheter malposition or kink, the patient generally requires referral to surgery or interventional nephrology/radiology. However, for malpositioned catheters, some experts repeat empiric treatment for constipation since a second round of laxative administration can sometimes reposition the catheter and resolve flow obstruction. (See 'Constipation' below.)

A catheter kink is much less common than malposition and may be difficult to demonstrate with a plain abdominal radiograph. If a kink does not appear on KUB but clinical suspicion is high (ie, bidirectional flow problems with initial catheter use that vary with patient position), a noncontrast computed tomography (CT) of the abdomen and pelvis should be obtained to evaluate the catheter [26].

•KUB not showing catheter malposition or kink – If KUB does not show catheter malposition or kink, and if not already attempted, we empirically treat fibrin clot (see 'Fibrin clot' below). Persistent flow failure despite this treatment requires referral to surgery or interventional nephrology/radiology for further evaluation and management.

Rarely, bladder distention from urinary retention may lead to extraluminal catheter occlusion, causing outflow problems. For patients who still make urine and have a history of neurogenic bladder or bladder outlet obstruction, a postvoid residual volume should be checked with a bladder scan or ultrasound to assess for urinary retention. In such patients, flow failure may resolve after the successful treatment of urinary retention.

Treatment — The treatment of flow problems depends upon the cause of the obstruction. Some causes can be treated conservatively, while others require surgical intervention and/or catheter 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 successful treatment of constipation resolves nearly one-half of all cases of flow failure [27].

Fibrin clot — For patients with a suspected fibrin clot, we use a large syringe to manually irrigate the catheter. This is done in a sterile fashion by infusing the catheter with heparinized saline or dialysate, partially withdrawing the solution, and rapidly repeating the push/pull cycle. If catheter irrigation resolves the catheter flow problem, no further treatment is necessary.

Our subsequent approach depends on whether obstruction to dialysate flow is partial or complete:

●Heparin for partial occlusion – When drain speed is slowed and plugs or strands of fibrin are visible in the drained fluid, we add heparin (at a dose of 2000 units per 2 L bag for manual exchanges and 4000 units per 5 L bag for cyclers). If heparin administration resolves partial obstruction, we subsequently titrate the frequency of use (daily versus intermittently) to the recurrence of slow drain and/or visible fibrin.

●Thrombolysis for complete occlusion – If heparin is ineffective or if flow is completely obstructed, we use a thrombolytic agent. Alteplase is now more commonly used than urokinase for clot lysis, and urokinase is no longer available in North America. The doses of alteplase and urokinase are usually 4 mg and 5000 units, respectively, with the volume of instilled thrombolytic solution varying according to the size of the PD catheter and its respective transfer set [28,29]. The catheter dwell time is generally between one and two hours. If successful, lysis is followed by the instillation of heparin in the dialysate for several exchanges [25].

Evidence supporting the efficacy of alteplase is anecdotal:

•Using alteplase, fibrin clot dissolution was achieved in four patients on PD with both inflow and outflow intracatheter obstruction refractory to saline flushes [30]. 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 [31].

Malpositioned or entrapped catheters — Patients who have malpositioned or entrapped catheters should be referred to interventional radiology/nephrology or surgery. The most common causes of catheter entrapment are omentum and adhesions, but entrapment by the fallopian tubes has also been reported [32]. Therapeutic options for malpositioned or entrapped catheters include fluoroscopic manipulation, surgical catheter salvage, or catheter replacement.

Fluoroscopic stiff wire manipulation of malpositioned or entrapped catheters can be performed by most interventional radiologists but has variable results. With this technique, initial success with restoration of drain capability is observed in 55 to 80 percent of cases [33-39]. Long-term salvage is less reliable (33 percent).

Traditional surgical or, more commonly, laparoscopic exploration also may be used to manage malpositioned or entrapped catheters. These techniques permit the operator to directly visualize the peritoneal cavity [40] and, if necessary, to perform the following:

●Catheter redirection

●Omentopexy, epiploectomy, adhesiolysis, colopexy, or salpingectomy

●Catheter replacement

An advantage of the laparoscopic 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 [41-45]. The effectiveness of laparoscopic surgery to salvage dysfunctional catheters was evaluated in one study of 16 patients who underwent 19 laparoscopic procedures [46]. Adhesions were the cause of obstruction in 12 cases, omental wrapping in seven, and both adhesions and omental wrapping in one. All 19 salvage procedures were successful.

Catheter kinking — Patients with a kinked catheter should be referred to a surgeon. Kinking usually requires catheter replacement. However, the catheter sometimes may be salvaged if the area of the kink is identified and a surgeon is able to dissect down and around the catheter to release it [47].

Pericatheter leakage — The frequency of pericatheter leakage is difficult to determine since many reports of dialysate leak do not distinguish between leaks associated with the catheter and other dialysate leaks (eg, leaks due to non-catheter-related hernias or pleuroperitoneal leaks). The incidence of exit-site leaks after catheter insertion in the modern era is between 2 and 6 percent [48,49].

Factors that may lead to a pericatheter dialysate leak include the following:

●Initiation of PD less than two weeks after catheter insertion (as employed in urgent start PD)

●Technical problems related to catheter insertion (eg, suture failure, inadequate surgical wound closure, improper catheter placement)

●Development of a pericatheter hernia

●Tunnel infections

●Midline versus paramedian PD catheter insertion

Strategies to minimize dialysate leaks associated with urgent start PD are discussed elsewhere. (See "Urgent-start peritoneal dialysis".)

Clinical manifestations — Pericatheter 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 elevated intra-abdominal pressures.

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, may precede frank leakage. Infrequently, abdominal wall and/or genital edema may occur without obvious external leakage around the catheter due to peritoneal membrane defects associated with the catheter tract.

Diagnosis — The diagnosis of pericatheter leak is made by observing the presence of fluid around the exit site of the peritoneal catheter. In patients with external fluid leaking from nearby subcutaneous tissue, the origin of the fluid may be unclear. In these cases, a dialysate leak can be confirmed by assessing the glucose concentration of the extravasated fluid. Glucose strip testing will yield an extremely high glucose concentration if the fluid is dextrose-containing dialysate. By comparison, serosanguineous fluid leaking from subcutaneous tissue will not be strongly positive for glucose.

If a pericatheter leak is not apparent on physical examination but is suspected as a possible cause of unexplained outflow failure and edema in the abdominal wall and/or genitalia, imaging should be obtained. CT after infusion of dialysate containing contrast material (ie, CT peritoneography) is an effective imaging modality to diagnose dialysate leaks, pericatheter or otherwise. This and other imaging techniques used to identify dialysate leaks are discussed in detail elsewhere. (See "Modalities for the diagnosis of abdominal and thoracic cavity defects in patients on peritoneal dialysis".)

Management — The approach to a pericatheter leak depends on whether it occurs early (≤30 days) or late (>30 days) after catheter insertion.

●Early leaks – Most early leaks can be managed conservatively. Our approach to early leaks is described below.

•Initial approach – Pericatheter leaks occurring within 30 days from catheter insertion usually can be managed by temporarily decreasing dwell volume, ensuring supine position during exchanges, and avoiding activities that increase intra-abdominal pressure, such as heavy lifting. After one to two weeks, one can slowly increase the dwell volume.

For patients with peritoneal catheter exit-site leaks, we use antibiotics for the duration of the leak to prevent the development of peritonitis. Our approach to prophylactic antibiotics is discussed elsewhere. (See "Risk factors and prevention of peritonitis in peritoneal dialysis".)

•Subsequent approach – If the pericatheter leak does not respond to low volume/supine PD, the patient should stop PD entirely for two to four weeks to allow for further healing of the peritoneum around the catheter. This may mean a short-term transition to hemodialysis if the patient does not have sufficient residual kidney function.

Leaks that persist after a period of stopping PD generally require catheter replacement.

●Late leaks – The management of pericatheter leaks occurring after 30 days from catheter insertion depends on the cause. Most late pericatheter leaks are a result of tunnel infection or pericatheter hernia. Treatment of tunnel infection and surgical hernia repair are discussed elsewhere. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults", section on 'Treatment'.)

Superficial catheter cuff extrusion

●Incidence and etiology – The incidence of cuff extrusion ranges from approximately 4 to 17 percent and is unrelated to catheter type or method of catheter placement [9,43,50-53]. Extrusion of the catheter cuff through the exit site may result from exit-site infection or from the catheter returning to its original shape after excessive bending during placement. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)

●Treatment – Superficial catheter cuff extrusion requires evaluation by interventional nephrology/radiology or surgery. 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 [26]. 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. The catheter should be removed if the area heals poorly or exhibits signs of ongoing inflammation and/or infection. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults".)

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 5^th to 6^th 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 10^th to 12^th 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

●Overview – Although less frequent than infection, noninfectious complications of peritoneal dialysis (PD) catheters also occur. Some of these complications can be managed conservatively; others require intervention by surgery or interventional radiology/nephrology. (See 'Introduction' above.)

●Complications of catheter insertion – Complications related to catheter placement are uncommon and include the following:

•Intestinal perforation – Intestinal perforation should be suspected in any patient who presents with acute abdominal pain shortly after PD catheter implantation. Other clues include feculent or bloody dialysate, dialysate retention, diarrhea occurring after dialysate instillation, and gram-negative peritonitis. Treatment of intestinal perforation includes catheter removal, intravenous antibiotics, and timely evaluation by a surgeon. (See 'Intestinal perforation' above.)

•Bladder perforation – Bladder perforation should be suspected in patients who present during or shortly after PD catheter implantation with urgency to void during catheter placement, sudden increase in urine volume, urinary incontinence with PD fills, bladder discomfort with PD filling or draining, and/or high urine glucose concentration, consistent with urine/dialysate admixture. A urologist should be involved in the management of bladder perforation. (See 'Bladder perforation' above.)

•Bleeding – Bleeding that occurs soon after catheter placement is most often due to trauma of small blood vessels located in the abdominal wall and presents as bloody peritoneal dialysate (hemoperitoneum). Most bleeding is mild and can be managed conservatively. (See 'Bleeding' above.)

●Complications after catheter insertion – Catheter-associated complications that occur after insertion include the following:

•Impaired catheter flow – Catheter flow may be impaired during dialysate infusion (ie, inflow impairment) and/or during drainage of the peritoneal cavity (ie, outflow impairment).

-Causes – The most common cause of impaired flow is extraluminal catheter occlusion due to dilated bowel from constipation. Other causes include intraluminal catheter occlusion (often by fibrin clot), catheter kinking or malposition, or catheter entrapment by omentum or adhesions. Flow problems may be characterized by timing in relation to catheter insertion and whether outflow impairment is accompanied by inflow impairment (table 1). (See 'Clinical presentation' above.)

-Evaluation – Our approach to the evaluation of patients with catheter flow problems involves a combination of diagnostic and empiric treatment measures to exclude common causes. For patients on PD with impaired catheter flow, we suggest administering laxatives to empirically treat constipation (Grade 2C). Physical examination and radiography are useful for elucidating other causes of flow impairment (algorithm 1). For patients on PD with impaired catheter flow and suspected intraluminal catheter occlusion, we suggest empiric treatment of fibrin clot (Grade 2C). (See 'Evaluation' above.)

-Treatment – The treatment of flow problems depends upon the cause. Some causes can be treated conservatively, while others require surgical intervention and/or catheter replacement. (See 'Treatment' above.)

•Pericatheter leakage – Pericatheter leaks frequently occur only after a patient becomes physically active on a standard ambulatory PD regimen, a schedule in which dwells occur in association with elevated intra-abdominal pressures.

-Clinical manifestations – Pericatheter leakage is usually recognized by the presence of fluid in the area surrounding the catheter. However, subcutaneous swelling may precede frank leakage, and abdominal wall and/or genital edema may occur due to peritoneal membrane defects associated with the catheter tract. (See 'Clinical manifestations' above.)

-Diagnosis – Pericatheter leaks are usually diagnosed by observing the presence of fluid around the exit site of the peritoneal catheter. In cases where a pericatheter leak is suspected but not apparent on physical examination, imaging should be obtained. (See 'Diagnosis' above.)

-Management – The approach to a pericatheter leak depends on whether it occurs early (≤30 days) or late (>30 days) after catheter insertion. Most early leaks can be managed conservatively. (See 'Management' above.)

•Superficial catheter cuff extrusion – Extrusion of the catheter cuff through the exit site may result from exit-site infection or from the catheter returning to its original shape after excessive bending during placement. 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. (See 'Superficial catheter cuff extrusion' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jean L Holley, MD, FACP, who contributed to earlier versions of this topic review.