What are the complications of peritoneal dialysis and how are they managed?

Complications of Peritoneal Dialysis

Major Complications

Peritonitis is the most serious and common complication of peritoneal dialysis, causing technique failure in approximately 16% of patients and requiring conversion to hemodialysis, with an overall mortality rate of 3.5% per episode. 1

Infectious Complications

Peritonitis

• Incidence and Impact: Reported rates range from 0.24-1.66 episodes per patient-year, with quality standards demanding rates below 0.67 episodes per patient-year 2. For every 0.5-per-year increase in peritonitis rate, mortality risk increases by 4% 2.

• Causative Organisms:

  • Gram-positive cocci (Staphylococcus epidermidis, coagulase-negative staphylococci, and Staphylococcus aureus) are the most frequent worldwide 2
  • Coagulase-negative Staphylococcus typically indicates touch contamination 3
  • Pseudomonas aeruginosa and Staphylococcus aureus most often indicate catheter infections 3
  • Candida species are the most common fungal cause 1
  • Aspergillus species are less frequent but well-established fungal pathogens 1
  • Other Gram-negative organisms relate to bowel problems, constipation, hypokalemia causing dysmotility, or touch contamination 3

• Management Protocol:

  • Start empirical intraperitoneal antibiotics immediately after obtaining specimens, covering both Gram-positive and Gram-negative organisms including Pseudomonas 4
  • Vancomycin plus ciprofloxacin achieves 77% success rate as first-line therapy 2
  • Add antifungal prophylaxis (preferably oral nystatin) to prevent secondary fungal peritonitis 4
  • Adjust antibiotics once culture results available 4
  • Duration is typically 2-3 weeks depending on organism 4
  • Remove catheter for: refractory peritonitis (no resolution after 5 days of appropriate antibiotics), relapsing peritonitis, or fungal peritonitis 3, 4
  • For fungal peritonitis specifically, catheter removal plus antifungal treatment for minimum 3 weeks is standard, with transfer to hemodialysis 2

Exit-Site and Tunnel Infections

• These infections can lead to peritonitis and catheter loss 5, 6
• Ultrasound inspection of exit site and subcutaneous tunnel is best practice for early diagnosis 6
• Prompt treatment prevents progression to peritonitis 4
• Refractory exit-site or tunnel infections require catheter removal 4

Non-Infectious Complications

Inadequate Dialysis

Consistent failure to achieve target Kt/Vurea and creatinine clearance mandates switching to hemodialysis when maximum PD prescription has been reached or lifestyle complications make the procedure unachievable. 5

• Inadequate Solute Transport:

  • High transporters may have poor ultrafiltration and/or excessive protein losses 5
  • Low transporters in large patients may have inadequate peritoneal creatinine clearance 5
  • Excessive protein losses from active nephrosis, high transporter status, or frequent peritonitis cause malnutrition, increasing mortality and morbidity 1

• Inadequate Ultrafiltration:

  • Usually secondary to high transport characteristics or mechanical catheter defects 5, 1
  • Many high transporters can be managed with short dwell periods and daytime exchanges, but this may become too burdensome 5

Mechanical and Technical Problems

• Catheter-related mechanical problems are a common cause of technique failure 5
• Development of technical/mechanical problems is a formal indication for switching to hemodialysis 5
• Abdominal wall defects are strongly associated with history of previous abdominal surgery 7

Metabolic Complications

• Unmanageably severe hypertriglyceridemia is an indication for switching to hemodialysis 5
• Increased caloric absorption from dialysate can lead to further weight gain in morbidly obese patients 5

Volume-Related Complications

• Patients may experience abdominal pain, discomfort, shortness of breath, or loss of appetite from increased exchange volumes 5
• Intolerance to necessary PD volumes is problematic in patients with advanced lung disease or recurrent hydrothorax 5

Encapsulating Peritoneal Sclerosis (EPS)

• Rare but serious complication with 20% mortality rate 7
• Risk increases with duration of PD treatment 7
• Diagnosis requires high index of suspicion based on clinical symptoms 7
• Treatment is surgical enterolysis of peritoneal adhesions; conservative treatment wastes time 7

Indications for Switching to Hemodialysis

Transfer to hemodialysis is indicated for: 5

• Consistent failure to achieve target Kt/Vurea and creatinine clearance
• Inadequate solute transport or fluid removal
• Unmanageably severe hypertriglyceridemia
• Unacceptably frequent peritonitis or other PD-related complications
• Development of technical/mechanical problems
• Severe malnutrition resistant to aggressive management

Prevention Strategies

• Prophylactic antibiotics before catheter placement 2, 4
• Daily topical antibiotic cream or ointment to catheter exit site (mupirocin reduces exit-site infection risk by 46%) 2, 4
• Adequate patient training 2
• Proper exit-site care 4
• Treatment for Staphylococcus aureus nasal carriage 2
• Prevention of constipation 3
• Continuous quality improvement tracking of each episode with root cause analysis 3