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Removal of the Peritoneal Dialysis Catheter Because of Gastrointestinal Disease in Patients on Continuous Ambulatory Peritoneal

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Removal of the Peritoneal Dialysis Catheter Because of Gastrointestinal Disease in Patients on Continuous Ambulatory Peritoneal Advances in Peritoneal Dialysis, Vol. 27, 2011 Removal of the Peritoneal Dialysis Catheter Because of Gastrointestinal Disease in Patients on Continuous Ambulatory Peritoneal Eriko Kojima, Tsutomu Inoue, Keita Sueyoshi, Takahiko Dialysis: A Single-Center Sato, Masahiro Tsuda, Tomohiro Kikuta, Yusuke Watanabe, Hiroshi Takane, Tsuneo Takenaka, Hiromichi Suzuki Case Series We previously reported that peritoneal dialysis Key words (PD)–associated peritonitis is a major cause of PD Catheter removal, gastrointestinal disease, encapsulating catheter removal. Another major cause is disease of peritoneal sclerosis, contrast-enhanced computed the gastrointestinal tract, including neoplasm and tomography perforation. In the present study, we reviewed the records of patients who underwent catheter removal Introduction at our hospital for reasons other than peritoneal Catheter removal is one of the major factors in the infection—and for gastrointestinal disease in par- technical failure of peritoneal dialysis (PD), even ticular. Data were collected from the records of when adequate dialysis is performed. Previously, our patients who received continuous ambulatory PD group reported that the main cause of PD catheter (CAPD) therapy between 2004 and 2010 at the removal is PD peritonitis (1), and electron microscopy Department of Nephrology, Saitama Medical Uni- revealed biofilm formation on catheters removed be- versity. Mean duration of CAPD was 6.2 ± 4.7 years, cause of antibiotic-resistant infection (2). In our center, and mean age at onset was 64.5 ± 9.6 years. During another major cause of catheter removal is urgent or the investigation period, catheters were removed elective surgery for disease of the gastrointestinal tract, from 13 patients (4 men, 9 women) because of including neoplasm and perforation. Identification of gastrointestinal disease: gastric cancer in 3 cases, a gastrointestinal disease requiring laparotomy often colon cancer in 3 cases, perforation of the lower means conversion to hemodialysis and (long-term) gastrointestinal tract in 3 cases, and other reasons cessation of PD, because the PD catheter is removed. in 4 cases. Examination of pathology specimens The idea behind this strategy is that foreign bodies obtained from 6 patients—including 1 in whom should always be removed from infected areas except contrast-enhanced computed tomography indicated under exceptional circumstances (3). the presence of encapsulating peritoneal sclerosis After surgery, patients in these cases generally (EPS)—revealed mild fibrosis in the subserous face two unusual problems specifically related to PD: layer. No patient died of infection after a surgical complications associated with PD, and development procedure. Moreover, throughout the observation of encapsulating peritoneal sclerosis (EPS) over a period, no patient developed new EPS or postop- period of years. erative ileus. The present study suggests that CAPD One concern associated with PD is the possibility of itself seems to be free of untoward effects during the infection after a surgical procedure. To the best of our postoperative course in these patients. knowledge, only one report has presented a case series of PD patients who underwent a surgical procedure for From: Department of Nephrology, Saitama Medical Uni- gastrointestinal disease. That report summarized the versity, Saitama, Japan. data for 15 PD patients who underwent laparotomy for 78 Kojima et al. viscus perforation (4). The report noted that multiple All operations were performed in the Department organisms were found in PD fluid cultures from 12 of of Surgery at our hospital. Preoperative abdominal the 15 patients with perforation. CT imaging with or without contrast was routinely Bioincompatible glucose-containing dialysis fluid performed for all patients. No surgical deaths may also negatively affect the environment of the peri- occurred during the study period, and all patients toneal cavity. It is not known whether PD, performed recovered in the intensive care unit after surgery. until surgery, influences the postoperative course. For patients showing hypotension (systolic arterial However, it seems highly unlikely that PD could have pressure < 100 mmHg), marked tachycardia (120 bpm, a positive impact on an infection that occurs after a including atrial fibrillation), severe acidemia (pH surgical procedure. < 7.100 in arterial blood gas analysis), hyperkalemia In regard to EPS, even if there is no evidential (>7.0 mEq/L), and hypoxemia with excess fluid benefit in screening for a “pre-EPS” state using clinical with or without pulmonary edema, we usually indicators or computed tomography (CT) imaging (5), used a temporary vascular catheter to introduce we nevertheless usually evaluate changes in peritoneal continuous hemodialysis immediately after the membrane transport characteristics or other factors, operation. Otherwise, patients underwent intermittent and we sometimes ask patients, especially long-term hemodialysis within 2 days after surgery, also using a PD patients, to wash the peritoneal cavity for a certain temporary vascular catheter. When patients were able to period to prevent EPS. Even after PD is discontinued, take nourishment by mouth, they were admitted to the EPS may progress, particularly in patients whose CT kidney center for conversion to hemodialysis using an findings demonstrate abdominal signs or some of the arteriovenous fistula. We collected data on prognosis at features of EPS. In cases of antibiotic-resistant infec- 1 October 2010. Informed consent was obtained from tion, catheter removal is probably the best method to each patient. The mean period of observation was 3.7 prevent EPS progression. By contrast, it is uncertain ± 2.3 years (range: 7.1 – 0.5 years). whether accidental cessation of PD will subsequently lead to an undesirable clinical course. Results In the present study, we summarize data from During the study period, catheters were removed 13 patients who simultaneously underwent laparo- from a total of 13 patients (4 men, 9 women) because tomy and PD catheter removal, not for antibiotic- of gastrointestinal disease. Table I shows the clinical resistant peritonitis, but for gastrointestinal disease, characteristics of these patients. The mean age at dis- including neoplasm. ease onset was 64.5 ± 9.6 years. The underlying cause of end-stage renal disease was nephrosclerosis in 7 Methods patients. Mean duration of PD was 6.2 ± 4.7 years. The From January 2004 to September 2010, all patients gastrointestinal diseases were gastric cancer (n = 3), undergoing continuous ambulatory PD (CAPD) at colon cancer (n = 3), perforation of the lower gastro- our kidney center whose PD catheters were removed intestinal tract (n = 3), and others (n = 4). In patient 7, because of gastrointestinal disease were eligible for peritoneal calcification and very mild, but not incon- the study. All patients received outpatient treatment at siderable, adhesion of the intestine was revealed by least once monthly at our outpatient clinic throughout the preoperative contrast-enhanced CT imaging, the period during which they were on PD. The PD and thus EPS was diagnosed. In all cases, excised dose (fluid volume and exchange frequency) was specimens underwent pathology examination. Vari- adjusted to maintain a weekly creatinine clearance of ous degrees of subserous fibrosis accompanied by approximately 60 L. If the weekly creatinine clearance chronic inflammatory changes and occasionally fibrin fell below 45 L despite a full dose of PD, once-weekly deposition were observed in peritoneum in 6 patients, hemodialysis was introduced (6), and those patients including patient 7. were excluded from the study. Daily dietary protein During the study period, 2 of the 13 patients intake was approximately 1 g per kilogram body died. Patient 1, a 63-year-old woman, died from weight, and daily energy intake was more than 30 kcal severe acute necrotizing pancreatitis not associated to 35 kcal per kilogram body weight. Daily salt intake with PD. Patient 2, an 80-year-old woman, already was restricted to between 7 g and 9 g (6). had advanced cancer when PD was initiated because Removal ofPDCatheterforGIDisease TABLE I Clinical characteristics of the patients Pt Agea Sex Renal PD duration Diagnosis Type of Pathology Outcome ID (years) diagnosis (years) surgery findings of peritoneum 1 63 Female Diabetic 4 Necrotizing Cholecystectomy Almost normal Death nephropathy pancreatitis 2 80 Female Nephrosclerosis 0.5 Gastric cancer Distal gastrectomy Almost normal Death 3 59 Female Lupus nephritis 4.5 Rectal perforation Hartmann procedure Subserous fibrosis Aliveb 4 62 Female IgA nephropathy 4 Intra-abdominal Abscess drainage Almost normal Aliveb abscess 5 78 Female Nephrosclerosis 6 Sigmoid Laparoscopic Almost normal Aliveb colon cancer sigmoidectomy 6 67 Male Nephrosclerosis 5 Rectal cancer Low anterior resection Almost normal Aliveb 7 61 Female Nephrosclerosis 12 Renal pelvic cancer Total Subserous fibrosis, Aliveb nephroureterectomy fibrin deposition 8 72 Male Diabetic 6.5 Rectal cancer Low anterior resection Subserous fibrosis Aliveb nephropathy 9 62 Male Polycystic 4.5 Inguinal hernia Hernioplasty Almost normal Aliveb kidney disease 10 66 Female Nephrosclerosis 19 Sigmoid diverticulum Sigmoidectomy Subserous fibrosis Aliveb perforation 11 56 Male Nephrosclerosis 5.5 Gastric cancer Distal gastrectomy Subserous fibrosis Aliveb 12 69 Female Nephrosclerosis 2 Gastric cancer Distal gastrectomy, Subserous fibrosis Aliveb cholecystectomy
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