Can patients with a ventriculoperitoneal (VP) shunt undergo peritoneal dialysis?

Ventriculoperitoneal Shunt and Peritoneal Dialysis

Patients with ventriculoperitoneal (VP) shunts can undergo peritoneal dialysis, but it is considered a relative contraindication that requires careful management to reduce the risk of infectious complications, particularly peritonitis that could spread to the central nervous system.

Risk Assessment and Considerations

• A VP shunt is considered a "fresh intra-abdominal foreign body" and is listed as a relative contraindication for peritoneal dialysis in kidney disease guidelines 1
• The presence of VP shunts presents challenges during peritoneal dialysis due to the risk of bacterial translocation and increased infectious complications 1
• The primary concern is the potential spread of peritonitis to the shunt system, which could lead to ventriculitis or meningitis 2, 3
• Despite these concerns, peritoneal dialysis is not absolutely contraindicated in patients with VP shunts, as successful cases have been reported in the literature 2, 3

Management Recommendations

Timing Considerations

• If peritoneal dialysis is planned for a patient who already has a VP shunt:

  • Consider converting to or maintaining the patient on hemodialysis for at least 6 weeks to reduce (but not eliminate) the risk of peritonitis 1
  • This waiting period allows for better healing and reduced risk of infection transmission 1

• If a patient on peritoneal dialysis requires CSF diversion:

  • Consider alternative shunt placement sites rather than peritoneal placement 3
  • Extraperitoneal CSF diversion options may be preferable to avoid the risk of infection related to surgical intervention 3

Monitoring and Infection Prevention

• Implement rigorous peritoneal dialysis protocols with strict aseptic technique to minimize infection risk 2
• Monitor closely for signs of peritonitis, including cloudy peritoneal effluent, abdominal pain, or fever 3
• If peritonitis occurs:
  • Obtain cultures of both peritoneal fluid and CSF to evaluate for potential spread 2
  • Consider early removal of the peritoneal dialysis catheter in cases of fungal peritonitis 2
  • Administer appropriate antimicrobial therapy based on culture results 2

Special Considerations

• Patients with VP shunts on peritoneal dialysis may present diagnostic challenges due to overlapping symptoms that could be attributed to either shunt malfunction or dialysis complications 3
• Early evaluation by both neurosurgery and nephrology is essential for effective management of complications 3
• Loss of peritoneal function is a potential late risk related to the combination of cerebrospinal fluid and peritoneal dialysis 3

Common Pitfalls and Caveats

• Do not assume that peritonitis in a patient with a VP shunt has spread to the CNS without appropriate evaluation 2
• Recognize that VP shunt malfunction can present with atypical symptoms that may be confused with dialysis complications 4, 5
• Be aware that increased intra-abdominal pressure from peritoneal dialysate may exacerbate structural defects or lead to peritoneal leaks 1
• Consider that patients with VP shunts who develop peritonitis may require more aggressive management, including early catheter removal and systemic antimicrobials 2

While peritoneal dialysis in patients with VP shunts carries risks, with proper patient selection, timing, monitoring, and management protocols, it can be successfully implemented when necessary.