Dialysate leakage into pericardium in an infant on long-term peritoneal dialysis

A case of a peritoneal dialysis patient with left pleuroperitoneal communication caused by a pericardial defect after coronary artery bypass surgery

A 74-year-old woman with reduced kidney and cardiac function and a history of coronary artery bypass surgery involving the gastroepiploic artery to the right coronary artery and posterior descending artery #4 presented with dyspnea on exertion. Shortly after the induction of peritoneal dialysis (PD), an increase in the left pleural effusion was observed, and a diagnosis of left pleuroperitoneal communication was made by puncture drainage. The pleuroperitoneal communication hole was not detected under thoracoscopic observation; however, a 10 mm-sized hole in the pericardium was found, confirming leakage of ICG-loaded peritoneal dialysate fluid (PDF). CT peritoneography using PDF mixed with iodine contrast medium revealed that the gastroepiploic artery-to-right coronary artery pathway was defective on the abdominal side. We concluded that the left pleuroperitoneal communication was caused by a two-stage fistulous pathway between the abdominal and pleural cavities through the pericardial cavity after coronary artery bypass graft surgery. Although closure of the diaphragmatic hole around the gastroepiploic artery graft should have been performed to restart PD, the patient did not wish to undergo further invasive procedures. Identification of the fistulous pathway is extremely important for prompt diagnosis and treatment of pleuroperitoneal communication.

Tidal continuous cycling peritoneal dialysis in children

About 10% of all home peritoneal dialysis regimens in children with chronic kidney disease stage 5 are reported to involve some form of a tidal peritoneal dialysis (TPD) prescription. Despite this, there remain several gaps in how pediatric nephrologists approach the use of TPD. This stems from a combination of factors such as the confusing technical terminology pertaining to TPD, seemingly conflicting data on the risks, benefits, and indications for TPD, and lastly, limited published guidelines on the practical aspects of how to write a TPD prescription, based on the indication, in children. Our educational review, using evidence-based data, attempts to bridge this gap and provide an easy-to-use guide on the key practical aspects of TPD in children.

A case of peritoneal-pericardial leak in a 19-year-old patient on peritoneal dialysis

We report a case of a peritoneal-pericardial leak in peritoneal dialysis.A 19-year-old patient, with no history of heart disease, with unkown chronic kidney disease, treated with continuous ambulatory peritoneal dialysis (CAPD) for 10 months. complained of chest pain and tachycardia, revealing pericardial effusion of great abundance. Pericardial drainage was necessary. The fluid analysis was a transudate with glucose levels 5 times higher than glucose plasma levels. A peritoneal scintigraphy was performed and showed a distribution of the radio-tracer in the peritoneal cavity without any image of a leak. With clinical and especillay biological arguments, the patient was diagnosed with a peritoneal-pericardial leak.After pericardial drainage and temporary switch to hemodialysis, automated peritoneal dialysis was resumed with progressive increase in volumes, without recurrence of the leak after a 6 months follow-up.

Non-infectious complications of peritoneal dialysis and peritoneal scintigraphy

Peritoneal dialysis (PD) is an alternative to hemodialysis that is indicated in patients with chronic end-stage disease. It has many advantages, but also complications such as dialysate leaks around the catheter insertion site, in the abdominal wall or in the pleural cavity, inguinoscrotal hernia and even intra-abdominal fluid collection. Peritoneal scintigraphy is a simple, non-invasive, low-irradiation examination, without the risk of allergy, that allows both diagnosing and locating these complications because it allows acquiring images at the time of infusion, as well as remotely and after drainage of the dialysate. Tomoscintigraphy coupled with scanner SPECT / CT (Single Photon Emission Computed Tomography / Computed Tomography) can also help narrow the diagnosis. The objective of this article is to clarify the value of peritoneal scintigraphy in the diagnosis of non-infectious complications of peritoneal dialysis, the conditions for performing the examination and the potential indications, as illustrated by a few cases.

The Occurrence of Increased Intraperitoneal Volume Events in Automated Peritoneal Dialysis in the US: Role of Programming, Patient/User Actions and Ultrafiltration

Background, objectives and methods

Increased intraperitoneal volume (IIPV) can occur during automated peritoneal dialysis (APD). The contribution of factors such as cycler programming and patient/user actions to IIPV has not been previously explored. The relationship between IIPV and cycler programming, patient/user actions, and ultra-filtration over a two-year period was investigated using US data from Baxter cyclers. Drain/fill volume ratios of > 1.6 to ≤ 2.0 and > 2.0 were defined as Level I and Level II IIPV events, respectively.

Results

Level I IIPV events occurred in 2.39% of standard and 4.73% of small fill volume therapies, while Level II IIPV events occurred in 0.26% and 1.33% of therapies, respectively. IIPV events occurred significantly more often in association with tidal peritoneal dialysis (PD) compared to non-tidal PD therapies. In tidal therapies, IIPV events were primarily related to suboptimal programming of total ultrafiltration volume. Factors that increased the odds of IIPV events during standard therapies included programming the initial drain volume target to < 70% of the last fill, and setting minimum drain volumes to < 85% of the fill volume. Bypass of initial drain by patients/users was also associated with a significant increase in the odds of IIPV events in non-tidal, but not tidal PD. An increase in the odds for IIPV was also seen for standard therapies within the highest (> 1,245 mL) versus the lowest (< 427 mL) quartile of ultrafiltration. Similar trends were seen in small fill volume therapies. Clinical presentations associated with IIPV events were not assessed.

Conclusions

IIPV events are more frequent in tidal and small fill volume therapies. The greatest potential for IIPV occurred when the total ultrafiltration was set too low for the patient's UF requirements during tidal therapy. Patient/user bypass of drains without reaching the target drain volume contributes significantly to IIPV events in non-tidal PD therapies. Poorly functioning PD catheters may be central to the cycler programming and patient/user actions that lead to IIPV.

Utility of Scintigraphy in Assessment of Noninfectious Complications of Peritoneal Dialysis

Dialysis is an artificial process to remove waste products and excess water from the body in patients with kidney failure. Two main types of dialysis are available. Hemodialysis, which uses an artificial filtration apparatus, is usually done at specialized centers but can be done in a patient's home. Peritoneal dialysis functions by placing dialysis fluid, also called dialysate, into the peritoneal cavity, allowing for solute to be removed from the peritoneal capillaries through diffusion across a chemical gradient into the dialysate and removal of water through an osmotic gradient created by hypertonic dextrose. Peritoneal dialysis can be either automated, which is done with the help of a machine called a cycler, or continuous ambulatory, which is a process involving multiple exchanges a day and is performed using only gravity to infuse and drain the solution from the peritoneal cavity. For many reasons, the number of people using home dialysis has recently started to rise, with the largest increase in the United States occurring after the implementation of the prospective bundled payment system for end-stage renal disease. With the increased use of home dialysis, potential complications will increase as well. It is imperative that our health-care system be poised not only to increase the number of home dialysis patients but also to diagnose and manage any complications. Nuclear imaging is a commonly available modality to detect various complications related to peritoneal dialysis. In this review article, we discuss the role of peritoneal scintigraphy in detecting some noninfectious peritoneal dialysis complications, with emphasis on scintigraphy technique; imaging time points; the role of planar, SPECT, and SPECT/CT imaging; and the clinical indications, with illustrative case examples.

Peritoneal-pericardial communication in an adolescent on peritoneal dialysis

BACKGROUND

Dialysate leakage into the pericardium is a rare but potentially life-threatening complication of peritoneal dialysis (PD). There has been one reported pediatric case of spontaneous peritoneo-pericardial fistula in a 2-year-old boy with tissue fragility due to malnutrition and two reported adult cases in PD patients with a history of previous cardiac surgery and/or pericardiocentesis.

CASE-DIAGNOSIS/TREATMENT

We describe a 15-year-old girl with end-stage renal disease secondary to granulomatosis with polyangiitis, with recurrent pericardial effusions secondary to a peritoneo-pericardial fistula while on continuous cycling peritoneal dialysis (CCPD). She had previously presented with chylous pericardial effusion that required pericardiocentesis and subsequently developed recurrent pericardial effusions when she was commenced on CCPD 9 months later. Pericardial fluid chemistry revealed a sterile, serous fluid containing 15.1 mmol/L of glucose and <0.11 mmol/L of triglycerides. Peritoneal scintigraphy with Tc-99m labeled sulfur colloid injected intra-peritoneally confirmed the presence of a peritoneo-pericardial fistula. The pericardial effusions resolved upon switching the patient to hemodialysis (HD).

CONCLUSIONS

Our case of recurrent pericardial effusions in a child on PD secondary to a peritoneo-pericardial fistula highlights the need for close follow-up in patients with a history of previous pericardiocentesis who are commenced on PD.

Pleuro-peritoneal or pericardio-peritoneal leak in children on chronic peritoneal dialysis-A survey from the European Paediatric Dialysis Working Group

BACKGROUND

Pleural or pericardial effusions secondary to pleuro-peritoneal fistula (PPF) and pericardio-peritoneal fistula (PcPF) are rare but serious complications of peritoneal dialysis (PD).

METHODS

We conducted a 10-year survey across all participating centres in the European Paediatric Dialysis Working Group to review the incidence, diagnostic techniques, therapeutic options and outcome of children on chronic PD with PPF and/or PcPF.

RESULTS

Of 1506 children on PD there were ten cases (8 of PPF, 1 each of PcPF and PPF + PcPF), with a prevalence of 0.66%. The median age at presentation was 1.5 [inter-quartile range (IQR) 0.4-2.4] years, and nine children were <3 years. The time on PD before onset of symptoms was 4.3 (IQR 1.3-19.8) months. Eight children had herniae and seven had abdominal surgery in the preceding 4 weeks. Symptoms at presentation were respiratory distress, reduced ultrafiltration and tachycardia. PD was stopped in all children; three were managed conservatively and thoracocentesis was performed in seven (with pleurodesis in 3). PD was restarted in only three children, in two of them with success.

CONCLUSION

In conclusion, PPF and PcPF are rare in children on chronic PD, but are associated with significant morbidity, requiring a change of dialysis modality in all cases. Risk factors for PPF development include age of <3 years, herniae and recent abdominal surgery.

Chronic peritoneal dialysis in children

The incidence of end-stage renal disease in children is increasing. Peritoneal dialysis (PD) is the modality of choice in many European countries and is increasingly applied worldwide. PD enables children of all ages to be successfully treated while awaiting the ultimate goal of renal transplantation. The advantages of PD over other forms of renal replacement therapy are numerous, in particular the potential for the child to lead a relatively normal life. Indications for commencing PD, the rationale, preparation of family, technical aspects, and management of complications are discussed.

Optimizing peritoneal dialysis prescription for volume control: the importance of varying dwell time and dwell volume

Not only adequate uremic toxin removal but also volume control is essential in peritoneal dialysis (PD) to improve patient outcome. Modification of dwell time impacts on both ultrafiltration (UF) and purification. A short dwell favors UF but preferentially removes small solutes such as urea. A long dwell favors uremic toxin removal but also peritoneal fluid reabsorption due to the time-dependent loss of the crystalloid osmotic gradient. In particular, the long daytime dwell in automated PD may result in significant water and sodium reabsorption, and in such cases icodextrin should be considered. Increasing dwell volume favors the removal of solutes such as sodium due to the increased volume of diffusion and the recruitment of peritoneal surface area. A very large fill volume with too high an intraperitoneal pressure (IPP) may, however, result in back-filtration and thus reduced UF and sodium clearance. Based on these principles and the individual transport and pressure kinetics obtained from peritoneal equilibration tests and IPP measurements, we suggest combining short dwells with a low fill volume to favor UF with long dwells and a large fill volume to favor solute removal. Results from a recent randomized cross-over trial and earlier observational data in children support this concept: the absolute UF and UF relative to the administered glucose increased and solute removal and blood pressure improved.

Relationship between drain volume/fill volume ratio and clinical outcomes associated with overfill complaints in peritoneal dialysis patients

BACKGROUND

To better understand the spectrum of overfill reports and their corresponding clinical severity and etiology, we conducted a review of overfill reports from the Manufacturer and User Facility Device Experience (MAUDE) database, which is within the Food and Drug Administration (FDA) Web site (www.fda.gov).

METHOD

We searched the MAUDE database for events related to overfill reports between 1 January 1995 and 31 December 2008 and recorded drain volume (DV)/fill volume (FV), or DV/FV, and clinical symptoms and signs associated with the overfill report.

RESULTS

Among 462 MAUDE reports with a possible overfill event, 440 reports (95.2%) with a confirmed overfill event contained sufficient information to ascertain the clinical severity of the event. The number of reports with a clinical severity rating of minor, moderate, major, or death was 331, 71, 28, and 10, respectively. The median (range) DV/FV for a subgroup of 292 reports with a clinical severity rating of minor, moderate, major, or death was 1.63 (1.06 - 4.29), 1.71 (1.08 - 5.87), 2.14(1.64 - 2.61), and 2.50 (2.28 - 3.33), respectively. Insufficient drain accounted for a majority of overfill reports.

CONCLUSION

Our analysis of reports from the MAUDE database suggests an association between DV/FV and clinical severity of the reported overfill event, as well as significant patient-to-patient variability with respect to intraperitoneal volume tolerance.