Advances in Peritoneal Dialysis, Vol. 33, 2017 Peritoneal Dialysis in Patients with Abdominal Surgeries and Abdominal Fahad Aziz,1 Kunal Chaudhary2,3 Complications Peritoneal dialysis (PD) is an excellent treatment adjusted mortality rate was the same or higher for option for the patients with end-stage renal disease, hemodialysis (HD) compared with PD in most patient having been shown to yield improved patient satis- groups, excepting only older patients with diabetes. faction and economic benefit. Many surgeons and Similarly, Heaf and colleagues (2) found a significant physicians believe that patients with prior abdominal mortality benefit for PD compared with HD during the surgeries or other abdominal complications are not first 2 years after dialysis initiation. In a similar study, viable candidates for PD and that prevalent PD pa- Weinhandl et al. (3) paired 6337 HD and PD patients, tients needing abdominal surgery should be switched matching them by propensity score, and found that the to hemodialysis. The purpose of the present review is death risk was 8% lower for patients who, on day 0 of to address those misconceptions. end-stage renal disease, were started on PD compared Our review of literature shows that, when appro- with those who were started on HD. In 2011, Mehrotra priately planned, PD can still be an acceptable option et al. (4) also demonstrated a reduction in the adjusted for patients with end-stage renal disease and certain relative risk of death in patients starting PD treatment abdominal complications, including abdominal compared with those starting HD. surgery, provided that the peritoneum is not compro- Many studies have also shown that psychological mised. Anticipating complications—and changing the satisfaction is improved for PD compared with HD. PD prescription accordingly—can allow many such The CORETH study looked into dialysis modalities patients to continue PD without any interruption, thus and treatment satisfaction. It showed that, compared maintaining their lifestyle and avoiding an increase with HD patients, PD patients were more satisfied with in medical expense. their treatment and had a more autonomy-seeking per- sonality (5). Similarly, Fadem et al. (6) demonstrated Key words that, compared with patients receiving in-center HD, Abdominal surgery, abdominal complications patients on any kind of home dialysis, including home HD or PD, report better satisfaction. The many Introduction advantages of PD over HD include an opportunity for Peritoneal dialysis (PD) is a common form of renal home dialysis, with a flexible schedule that provides replacement therapy for end-stage renal disease pa- the opportunity to travel; better preservation of re- tients. Many studies have shown improved mortality sidual renal function; lower health care costs; greater and better patient satisfaction among patients undergo- patient satisfaction; and fewer episodes of sepsis and ing PD. Vonesh et al. (1) observed 398,940 dialysis bacteremia (7,8). Based on the foregoing studies and patients between 1995 and 2000. They found that the observations, Chaudhary et al. (9) in 2011 recom- mended that, when feasible, PD should be offered as the first-line dialysis modality. From: 1Division of Nephrology, University of Wisconsin, The success of PD depends on patient selection. Madison, Wisconsin, 2Division of Nephrology, University Many physicians believe that patients with prior of Missouri Health Science Center, Columbia, Missouri, and abdominal surgeries and other abdominal complica- 3Nephrology Section, Harry S. Truman Veterans’ Hospital, tions are not suitable candidates for PD. Similarly, Columbia, Missouri, U.S.A. it is also a common belief that patients on PD who Aziz and Chaudhary 41 require abdominal surgery also require temporary a G-tube was placed by Nissen fundoplication and or permanent transition to HD. In 2016, Lee et al. gastrostomy or by open gastrostomy after the start of (10) described many of the misconceptions that lead PD, and in 5 children, a PEG was placed after the start to early termination of PD, with increased expenses of PD. The authors documented multiple episodes of for HD and compromised quality of life for the af- peritonitis in children whose G-tube was placed after fected patients. dialysis initiation. They therefore recommended G- The purpose of the present review article is therefore tube placement before PD initiation. to discuss the impact of various abdominal complica- Recently, in 2015, Prestidge et al. (15) observed tions, including abdominal surgeries, in the PD popula- 17 children who had a G-tube placed either while tion and to clarify the related misconceptions. Peritoneal on PD or before PD start, which occurred within 72 dialysis is a very effective, inexpensive, and safe form hours of G-tube placement. The incidence of perito- of renal replacement therapy. Whenever possible, nitis (episodes/patient–year at risk) in patients who interruption or early termination should be avoided. started PD before G-tube placement was 0.6; in those who started PD after G-tube placement, it was 0.121. Discussion Given the small number of patients in the study, the p value was nonsignificant. However, considering the PD in patients with feeding tubes almost doubled incidence of peritonitis in patients Protein malnutrition is common in patients on PD whose G-tube was placed after PD initiation, the for two reasons: low dietary protein-calorie intake, study result accords with earlier observations of an and protein loss through PD. Low serum albumin in increased incidence of infections in PD patients who PD patients is the single most important predictor of had a G-tube placed after PD initiation. increased mortality (11). The placement of a feeding Dahlan et al. (16) reported the case of a 79-year- tube to provide nutrition, when appropriate, benefits old woman on PD who had a feeding G-tube placed certain patients. and was switched to HD. She received prophylactic In 1999, Ramage et al. (12) assessed the efficacy oral fluconazole and intravenous piperacillin– of placing feeding gastrostomy tubes (G-tubes) in in- tazobactam. Unfortunately, she developed a leak at the fants and children. A G-tube was placed in 15 patients G-tube site. Later, her peritoneal fluid grew multiple receiving PD. Tube feeds facilitated weight gain in bacterial and fungal species, including Klebsiella infants and children without any adverse effect on oxytoca, Pseudomonas aeruginosa, Enterococcus PD treatment. An increase in serum total protein and species, and Candida albicans. albumin was also noted. None of the patients experi- These limited case series and the case report indi- enced an episode of peritonitis. cate that placement of a PD catheter in patients with Later, in 2001, Fein et al. (13) assessed the out- a pre-existing G-tube is usually safe, but insertion of come of percutaneous endoscopic G-tube (PEG) a G-tube in patients already on PD can be associated placement in 10 adult patients on PD. Of those 10 with major adverse outcomes, including leaks and patients, 2 had a functioning PEG at the start of di- episodes of peritonitis (Tables I and II). Residual alysis, and no complications were reported after the peritoneal fluid might prevent effective healing of start of the PD. The other 8 patients were already on the G-tube site, with subsequent spillage of gastric PD when the PEG was inserted. Of those 8 patients, contents into the peritoneal space, inducing peritonitis 6 were switched to HD. The other 2 continued on PD, (16). Withholding PD, switching to HD, and using pro- but both developed peritonitis. The authors concluded phylactic antimicrobials might lower the incidence of that placement of a feeding G-tube before PD initia- peritonitis associated with G-tube insertion in patients tion is safe, but that placement after PD initiation is on PD. It is not clear whether surgical (as opposed associated with multiple complications. to endoscopic) placement of a G-tube provides any Similarly, in 2002, Ledermann et al. (14) observed benefit in preventing leaks or episodes of peritonitis. 29 children on PD with a G-tube. In 15 children, a G-tube was placed by percutaneous gastrostomy, by PD in patients with diverticular disease of the colon Nissen fundoplication and gastrostomy, or by open Clinicians might be reluctant to offer PD to patients gastrostomy before PD start. In another 9 children, with colon diverticulosis, because of a theoretical 42 PD in Patients with Abdominal Surgeries and Abdominal Complications increase in the risk of peritonitis (17,18). In diver- the abdominal cavity makes any diverticula in them ticulosis, loss of intestinal wall integrity because of potential sources for peritonitis. Similarly, being that the absence of a muscular layer in the diverticula the transverse colon is both an intraperitoneal and increases the chances of enteric peritonitis stemming an abdominal structure, diverticular disease in that from inflammation or obstruction of the diverticula. portion is associated with a greater risk of peritonitis. In 1990, Tranæus et al. (19) used barium enema Even if affected by diverticular disease, the sigmoid to assess 129 patients at start of PD. Of those patients, colon, being located in the pelvis and being retro- 42% were found to have more than 1 diverticulum, peritoneal, is not associated with an increased risk with 23% of that group experiencing peritonitis with of peritonitis. enteric flora. The authors suggested that peritonitis Yip et al. (20) evaluated 604 PD patients for diver- episodes in PD patients can be assigned to one of ticulosis by colonoscopy or barium enema. Of those three categories: patients, 24% were found to have diverticulosis, with the most common site being the ascending colon, and • Peritonitis from external contamination (mainly the organism most frequently associated with peritoni- gram-positive organisms) tis being Escherichia coli. The investigators concluded • Peritonitis from diverticular perforation (multiple that the presence of diverticulosis is an independent gram-negative organisms) risk factor for the development of enteric peritonitis.