Dialysate Leaks with Peritoneal Dialysis

Introduction

Dialysis fluid leakage is a noninfectious complication of peritoneal dialysis, with reported incidence rates varying from 1% to 40%. Leaks are the result of egress of peritoneal dialysis fluid from the peritoneal cavity through defects created either during the catheter insertion process itself or through congenital or acquired defects in the peritoneal dialysis space. Peritoneal dialysis fluid leaks can result in patients needing corrective surgical procedures, changes in peritoneal dialysis therapy, or possibly necessitating temporary or permanent transition to hemodialysis. Therefore, identification of patients at risk of complications, optimization of catheter break-in, and prompt identification and management of complications are necessary for patients on peritoneal dialysis.

Generally, peritoneal dialysis leaks are classified into early leaks, those occurring within the first 4 weeks of peritoneal dialysis, and late leaks, those occurring after the first 4 weeks following peritoneal dialysis initiation. The most common type of early leak is a pericatheter leak, whereas late leaks tend to consist more of abdominal wall leaks, retroperitoneal leaks, genital edema, or hydrothorax, the latter being discussed more fully in Chapter 30 . This temporal classification is not exclusive, however, and any type of leak may present at any given time. Several risk factors exist that may predispose a patient to leaks and are listed in Table 29.1 .

Pericatheter Leaks

Pericatheter leaks are one of the most prevalent types of leaks presenting in the early setting after peritoneal dialysis catheter insertion. These leaks commonly present clinically with persistent nonsanguineous drainage around the exit site, soaking through the surrounding dressing. Confirmation of the fluid as being dialysate can be done by having the fluid tested with a standard urine dipstick, which should come back highly positive for glucose, given the composition of most frequently used dialysates. Should this initial test be uncertain, a computed tomography (CT) peritoneogram can be performed to confirm the etiology of the fluid.

The etiology of pericatheter leaks stems from the dialysis fluid tracking along the surgical tunnel used to insert the peritoneal dialysis catheter. Therefore, optimal methods of catheter placement ( Chapter 25 ) can play an important role in mitigating this risk. In particular, studies have noted that a midline incision through the linea alba, rather than the preferred paramedian approach through the rectus abdominus, is associated with a higher risk for pericatheter leak, as does not using a purse-string suture around the deep cuff embedded in the rectus muscle. Likewise, early use of the catheter, defined as within 2 weeks of insertion, is associated with a higher risk of leak, particularly if larger volumes of dialysate are used.

The general management of pericatheter leaks is conservative. Temporarily holding peritoneal dialysis for a week or more, if possible, allows time for the defect to heal. If necessary, temporary transition to hemodialysis may be necessary, depending on the patient’s clinical status. Should the leak persist despite conservative measures, the catheter should be removed and a new catheter inserted at a different surgical site. It may be necessary to discuss the details of the catheter placement procedure with whoever is performing this in order to obviate subsequent leaks.

Should urgent-start peritoneal dialysis be necessary, the risk of pericatheter leak can be reduced by dialyzing the patient in the supine position only, as well as using decreased volumes of dialysate. This strategy allows for appropriate healing of the surgical site by minimizing the increase in intra-abdominal pressure by the dialysis fluid.