Peritoneal dialysis complications

Patients who progress to ESRD require renal replacement therapy (RRT). The modalities that are used for RRT are dialysis, including HD and peritoneal dialysis (PD), and kidney transplantation. The United States Renal Data Service (USRDS) reported that the number of patients with ESRD was 452,957, with 102,567 new cases being diagnosed in 2003.2 The most common form of RRT is dialysis, accounting for 72% of all patients with ESRD. The principles and complications associated with dialysis are discussed below. Chapter 52 discusses the principles of kidney transplantation. 

TABLE 23-10. Common Complications during Peritoneal Dialysis... 

Peritoneal dialysis has the potential to affect drug disposition however, drug therapy individualization is often less complicated because of the continuous nature of chronic ambulatory peritoneal dialysis. 

Baillie GR, Eisele G. Continuous ambulatory peritoneal dialysis A review of its mechanics, advantages, complications, and areas of controversy. Ann Pharmacother 1992 26 1409-20. 

Lo WK, Chan KT, Leung AC, Pang SW, Tse CY. Sclerosing peritonitis complicating prolonged use of chlorhexidine in alcohol in the connection procedure for continuous ambulatory peritoneal dialysis. Peril Dial Int 1991 ll(2) 166-72. 

Piraino B. Infectious complications of peritoneal dialysis. Perit Dial Int I997 I7(Suppl 3) SI5-I8. 

An 84-year-old man with diabetic nephropathy and end-stage renal disease began continuous ambulatory peritoneal dialysis and over the next year had four episodes of exit-site infection and peritonitis and used mupirocin ointment. The exit-site catheter became dilated and during an episode of infection for which he used mupirocin on 6 successive days, a longitudinal rupture developed in the peritoneal catheter, which was removed. The peritoneal liquid contained Escherichia coli and Proteus mirabilis and the catheter tip contained E. coli and Enterobacter cloacae. He was treated with ciprofloxacin, without complications, and after 1 month a new peritoneal catheter was inserted. 

Peritonitis is a common complication of peritoneal dialysis. Initial empiric therapy for peritonitis should include in-traperitoneal administration of agents effective against both gram-positive and gram-negative organisms. 

Mechanical, medical, and infectious problems complicate peritoneal dialysis therapy. Mechanical comphcations include kinking of the catheter and inflow and outflow obstruction excessive catheter motion at the exit site, leading to induration and possible infection and aggravation of tissues pain from impingement of the catheter tip on the viscera or inflow pain resulting from a jet effect of too rapid dialysate inflow. 

Although the majority of patients with ESKD receive treatment with hemodialysis, approximately 15% of dialysis patients receive one of the multiple variants of continuous peritoneal dialysis. Peritoneal dialysis, like other dialysis modalities, has the potential to affect drug disposition however, drug therapy individualization is often less complicated in these patients owing to the continuous nature of the procedure (see Chap. 45). 

Acutely, the use of saline infusion accompanied by administration of loop diuretics enhances urinary calcium excretion. Calcitonin, mithramycin and corticosteroids decrease calcium movement from bone. Reduced intake of calcium and corticosteroids decrease intestinal absorption of calcium. Short-term hemodialysis or peritoneal dialysis is effective for the rapid removal of calcium from the blood in crisis situations, especially in patients with renal failure or congestive heart failure. Prolonged hemodialysis, however, is not a therapeutic solution because of its impracticality and high complication rate. 

Sharad G, Saran R Nolph KW. (1998). Indications, contraindications and complications of peritoneal dialysis in the critically ill. In Critical Care Nephrology, Ronco C Bellomo R, pp. 1373-1382. Kluwer, Hingham, MA. 

Taylor PM (2002) Image-guided peritoneal access and management of complications in peritoneal dialysis. Semin Dial 15 250-258... 

Evaluate the patient for complications associated with dialysis. Does the patient develop hypotension or cramps during hemodialysis Does the patient have symptoms consistent with peritonitis or a catheter infection ... 

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