What is the absolute contraindication to peritoneal dialysis (PD) among the given options: prune belly syndrome, typhoid peritonitis, abdominal surgery, obesity, and umbilical hernia?

Absolute Contraindications to Peritoneal Dialysis

Typhoid peritonitis is the absolute contraindication to peritoneal dialysis among the given options. 1

Understanding Contraindications to Peritoneal Dialysis

According to the NKF-K/DOQI Clinical Practice Guidelines, absolute contraindications to peritoneal dialysis include:

1. Documented loss of peritoneal function or extensive abdominal adhesions that limit dialysate flow
2. Physical or mental incapability of performing PD without a suitable assistant
3. Uncorrectable mechanical defects that prevent effective PD or increase infection risk 1

Active peritonitis, such as typhoid peritonitis, would fall under the first category as it would compromise peritoneal function and increase infection risk substantially.

Analysis of Each Option

Typhoid Peritonitis

• Absolute contraindication - Active peritonitis from any cause prevents effective peritoneal dialysis and poses significant risk of systemic infection
• Typhoid peritonitis would cause inflammation of the peritoneal membrane, compromising its function for dialysis
• The presence of active infection in the peritoneal cavity would be exacerbated by introducing dialysate

Abdominal Surgery

• Relative contraindication - Not absolute
• Guidelines recommend waiting 4-6 weeks after abdominal surgery before initiating peritoneal dialysis 1
• Fresh intra-abdominal foreign bodies (e.g., vascular prostheses) require healing time of 6-16 weeks before PD can be initiated

Obesity

• Relative contraindication - Not absolute
• Morbid obesity can pose challenges in catheter placement, healing, and achieving adequate dialysis 1
• However, larger individuals can achieve acceptable clearances with modified regimens (combination of CAPD and nocturnal automated PD)

Umbilical Hernia

• Relative contraindication - Not absolute
• Hernias can be surgically corrected before initiating PD
• Only uncorrectable mechanical defects are considered absolute contraindications 1

Prune Belly Syndrome

• Not a contraindication - Evidence shows successful PD in patients with prune belly syndrome
• Research demonstrates that despite the deficiency of abdominal musculature, PD can be successfully performed in patients with prune belly syndrome 2
• Special techniques like laparoscopic catheter placement may improve outcomes in these patients

Important Clinical Considerations

• For patients with relative contraindications, modifications to PD protocols can often overcome challenges:

  • Smaller, more frequent exchanges for patients with limited abdominal capacity
  • Surgical repair of hernias before initiating PD
  • Gradual increase in fill volumes when starting PD

• Peritonitis remains the most common complication of PD and is responsible for most cases of method failure 3

• When evaluating a patient for PD, careful assessment of all potential contraindications is essential to minimize complications and optimize outcomes

• For patients with active infections like typhoid peritonitis, hemodialysis would be the preferred renal replacement therapy until the infection resolves completely