Peritoneal dialysis catheter leakage following intermittent vacuum therapy

Peritoneal dialysis catheter leakage following intermittent vacuum therapy Peripheral arterial disease and diabetic foot syndrome are common comorbidities in dialysis patients. These conditions are treated with intermittent vacuum therapy in order to increase angiogenesis and perfusion. Some devices encase the lower extremities up to the abdomen. Here we report the case of a patient who had performed peritoneal dialysis for 2 years without complications. Following postoperative intermittent vacuum therapy, he presented with extensive catheter leakage. Ultimately the patient had to be switched to haemodialysis and the catheter had to be removed. This case exemplifies that peritoneal dialysis patients have a substantial risk for noninfectious catheter-related complications using vacuum therapy. Key words: continuous ambulatory peritoneal dialysis (CAPD), end-stage renal disease (ESRD), intermittent negative-pressure therapy (INPT), noninfectious PD complications, wound healing and 5 s of atmospheric pressure phases] is recommended. The Background intervals and intensity of negative-pressure phases are variable Negative pressure therapy is a widely accepted therapeutic and little is known about the effects of interchangeable thera- approach and has traditionally been applied in vascular peutic parameters. We here in report the case of a 61-year- and orthopaedic surgery to improve healing of chronic wounds old male dialysis patient who presented with leakage of his [1, 2]. Recently, new intermittent negative-pressure devices peritoneal dialysis (PD) catheter as a complication of post- have been introduced to the market [intermittent vacuum ther- operative IVT. apy (IVT)]. Applications range from treatment of diabetic foot syndrome and peripheral arterial occlusive diseases to lymph- oedema [3–5]. Moreover, it has been used in orthopaedic reha- Case presentation bilitation in order to accelerate subsiding of postoperative swel- A 61-year-old dialysis patient with end-stage renal disease due ling and wound healing. For post-traumatic oedema, daily IVT to IgA nephropathy was admitted to our hospital with leakage treatment with a duration of 30 min [implying alternating 20 s of negative-pressure phases (varying from 20 to 70 mbar) of his PD catheter. Until that time he had performed PD for Received: July 1, 2017. Editorial decision: November 7, 2017 V C The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ckj/advance-article-abstract/doi/10.1093/ckj/sfx142/4772285 by Ed 'DeepDyve' Gillespie user on 12 July 2018 2| E. Leenen et al. at the exit during dwelling with volumes exceeding 750 mL, a computed tomography scan with instillation of contrast media via catheter was performed. It revealed diffuse contrast media accumulation around the catheter. Moreover, a substantial amount of contrast media was detected in the subcutaneous and intermuscular layers on the right side, unrelated to the catheter and the tunnel. This enhancement correlated to former puncture sites of the laparoscopic trocars (Figure 1). Continuous ambulatory peritoneal dialysis (CAPD) had to be stopped and placement of a tunnelled central venous catheter became nec- essary for a transient switch to haemodialysis. After 6 weeks, a renewed attempt to resume CAPD failed, again due to leakage. Another CT scan after 3 months showed no contrast media accumulation in the right rectus abdominis, indicating that leaking ceased with termination of IVT. However, due to contin- uous leakage, the PD catheter had to be explanted. According to the surgical report, catheter material was found to be intact at the time of explantation. Discussion In this report we present a case of PD malfunction following IVT in a patient who was stably performing PD. We hypothesize that IVT not only caused tunnel leakage but also led to diffuse leakage into the abdominal muscles through the former trocar puncture sites. To support the hypothesis, we argue that shear forces in cutaneous and subcutaneous tissue layers caused by alternating pressures led to a reopening of scarred tissue around the old trocar puncture sites. This case report highlights the importance of carefully choosing patients eligible for IVT. The fact that our patient had to be switched to haemodialysis due to the catheter complica- tion caused by IVT emphasizes the need to critically review usual practices with regard to special patient groups, such as CAPD patients. Devices that encompass the abdomen have to be avoided in these patients. In light of the increased utilization of IVT, our case, which demonstrates a severe complication, is intended to alert physicians to potential detrimental effects and Fig. 1. (A and B) Computed tomography with contrast media intraperitoneally demonstrates leakage of contrast media outside the PD catheter (C) into the tis- important contraindications of this new method. sue (arrowhead). Moreover, contrast media is detected in the tissue at the old trocar puncture sites (arrows). Conflict of interest statement None declared. 2 years without any complications. In 2015, the present catheter was implanted using a laparoscopic technique after one episode of peritoneal infection. References The patient had recently been treated with IVT in a rehabili- 1. Gregor S, Maegele M, Sauerland S et al. Negative pressure tation clinic following knee surgery. In this context, not only his wound therapy. Arch Surg 2008; 143: 189–196 lower extremities but also his lower abdomen, including the 2. Tevanov I, Enescu DM, Bal  anescu  R et al. Negative pressure catheter exit, were inserted into the negative pressure device. wound therapy (NPWT) to treat complex defect of the leg after Subsequently, alternating negative pressure up to 70 mbar electrical burn. Chirurgia (Bucur) 2016; 111: 175–179 and atmospheric pressure was applied. Following the second 3. Sundby ØH, Høiseth LØ, Mathiesen I et al. The effects of inter- IVT treatment session, the patient recognized leaking of clear mittent negative pressure on the lower extremities’ periph- dialysis fluids at the exit site while dwelling. Nevertheless, ther- eral circulation and wound healing in four patients with apy was continued for two more sessions and leaking increased. lower limb ischemia and hard to heal leg ulcers: a case report. The patient was not undressed for IVT and reliably reported no event of manual traction of the catheter during or after treat- Physiol Rep 2016; 4: e12998 4. Campisi CC, Ryn M, Campisi CS et al. Intermittent negative ment. On arrival at our hospital his vital signs were normal and the abdomen was found to be tender, not painful and without pressure therapy in the combined treatment of peripheral lymphedema. Lymphology 2015; 48: 197–204 clinical signs of inflammation. The dressing of the catheter was wet. Blood examinations showed no signs of inflammation. 5. Ubbink DT, van der Oord BM, Sobotka MR, Jacobs MJ. Effekte Assuming that IVT led to a reversible leakage of the tunnel, PD der Vakuum-Kompressions-Behandlung auf die Hautmikro- was paused for 4 days. After resuming dialysis, volumes were zirkulation von Patienten mit peripherer arterieller Vers- slowly titrated up from 500 to 1000 mL. When leakage recurred chlußkrankheit. Vasa 2000; 29: 53–57 Downloaded from https://academic.oup.com/ckj/advance-article-abstract/doi/10.1093/ckj/sfx142/4772285 by Ed 'DeepDyve' Gillespie user on 12 July 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Kidney Journal Oxford University Press

Peritoneal dialysis catheter leakage following intermittent vacuum therapy

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Publisher
European Renal Association - European Dialysis and Transplant Association
Copyright
© The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA.
ISSN
2048-8505
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2048-8513
D.O.I.
10.1093/ckj/sfx142
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Abstract

Peripheral arterial disease and diabetic foot syndrome are common comorbidities in dialysis patients. These conditions are treated with intermittent vacuum therapy in order to increase angiogenesis and perfusion. Some devices encase the lower extremities up to the abdomen. Here we report the case of a patient who had performed peritoneal dialysis for 2 years without complications. Following postoperative intermittent vacuum therapy, he presented with extensive catheter leakage. Ultimately the patient had to be switched to haemodialysis and the catheter had to be removed. This case exemplifies that peritoneal dialysis patients have a substantial risk for noninfectious catheter-related complications using vacuum therapy. Key words: continuous ambulatory peritoneal dialysis (CAPD), end-stage renal disease (ESRD), intermittent negative-pressure therapy (INPT), noninfectious PD complications, wound healing and 5 s of atmospheric pressure phases] is recommended. The Background intervals and intensity of negative-pressure phases are variable Negative pressure therapy is a widely accepted therapeutic and little is known about the effects of interchangeable thera- approach and has traditionally been applied in vascular peutic parameters. We here in report the case of a 61-year- and orthopaedic surgery to improve healing of chronic wounds old male dialysis patient who presented with leakage of his [1, 2]. Recently, new intermittent negative-pressure devices peritoneal dialysis (PD) catheter as a complication of post- have been introduced to the market [intermittent vacuum ther- operative IVT. apy (IVT)]. Applications range from treatment of diabetic foot syndrome and peripheral arterial occlusive diseases to lymph- oedema [3–5]. Moreover, it has been used in orthopaedic reha- Case presentation bilitation in order to accelerate subsiding of postoperative swel- A 61-year-old dialysis patient with end-stage renal disease due ling and wound healing. For post-traumatic oedema, daily IVT to IgA nephropathy was admitted to our hospital with leakage treatment with a duration of 30 min [implying alternating 20 s of negative-pressure phases (varying from 20 to 70 mbar) of his PD catheter. Until that time he had performed PD for Received: July 1, 2017. Editorial decision: November 7, 2017 V C The Author 2017. Published by Oxford University Press on behalf of ERA-EDTA. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ckj/advance-article-abstract/doi/10.1093/ckj/sfx142/4772285 by Ed 'DeepDyve' Gillespie user on 12 July 2018 2| E. Leenen et al. at the exit during dwelling with volumes exceeding 750 mL, a computed tomography scan with instillation of contrast media via catheter was performed. It revealed diffuse contrast media accumulation around the catheter. Moreover, a substantial amount of contrast media was detected in the subcutaneous and intermuscular layers on the right side, unrelated to the catheter and the tunnel. This enhancement correlated to former puncture sites of the laparoscopic trocars (Figure 1). Continuous ambulatory peritoneal dialysis (CAPD) had to be stopped and placement of a tunnelled central venous catheter became nec- essary for a transient switch to haemodialysis. After 6 weeks, a renewed attempt to resume CAPD failed, again due to leakage. Another CT scan after 3 months showed no contrast media accumulation in the right rectus abdominis, indicating that leaking ceased with termination of IVT. However, due to contin- uous leakage, the PD catheter had to be explanted. According to the surgical report, catheter material was found to be intact at the time of explantation. Discussion In this report we present a case of PD malfunction following IVT in a patient who was stably performing PD. We hypothesize that IVT not only caused tunnel leakage but also led to diffuse leakage into the abdominal muscles through the former trocar puncture sites. To support the hypothesis, we argue that shear forces in cutaneous and subcutaneous tissue layers caused by alternating pressures led to a reopening of scarred tissue around the old trocar puncture sites. This case report highlights the importance of carefully choosing patients eligible for IVT. The fact that our patient had to be switched to haemodialysis due to the catheter complica- tion caused by IVT emphasizes the need to critically review usual practices with regard to special patient groups, such as CAPD patients. Devices that encompass the abdomen have to be avoided in these patients. In light of the increased utilization of IVT, our case, which demonstrates a severe complication, is intended to alert physicians to potential detrimental effects and Fig. 1. (A and B) Computed tomography with contrast media intraperitoneally demonstrates leakage of contrast media outside the PD catheter (C) into the tis- important contraindications of this new method. sue (arrowhead). Moreover, contrast media is detected in the tissue at the old trocar puncture sites (arrows). Conflict of interest statement None declared. 2 years without any complications. In 2015, the present catheter was implanted using a laparoscopic technique after one episode of peritoneal infection. References The patient had recently been treated with IVT in a rehabili- 1. Gregor S, Maegele M, Sauerland S et al. Negative pressure tation clinic following knee surgery. In this context, not only his wound therapy. Arch Surg 2008; 143: 189–196 lower extremities but also his lower abdomen, including the 2. Tevanov I, Enescu DM, Bal  anescu  R et al. Negative pressure catheter exit, were inserted into the negative pressure device. wound therapy (NPWT) to treat complex defect of the leg after Subsequently, alternating negative pressure up to 70 mbar electrical burn. Chirurgia (Bucur) 2016; 111: 175–179 and atmospheric pressure was applied. Following the second 3. Sundby ØH, Høiseth LØ, Mathiesen I et al. The effects of inter- IVT treatment session, the patient recognized leaking of clear mittent negative pressure on the lower extremities’ periph- dialysis fluids at the exit site while dwelling. Nevertheless, ther- eral circulation and wound healing in four patients with apy was continued for two more sessions and leaking increased. lower limb ischemia and hard to heal leg ulcers: a case report. The patient was not undressed for IVT and reliably reported no event of manual traction of the catheter during or after treat- Physiol Rep 2016; 4: e12998 4. Campisi CC, Ryn M, Campisi CS et al. Intermittent negative ment. On arrival at our hospital his vital signs were normal and the abdomen was found to be tender, not painful and without pressure therapy in the combined treatment of peripheral lymphedema. Lymphology 2015; 48: 197–204 clinical signs of inflammation. The dressing of the catheter was wet. Blood examinations showed no signs of inflammation. 5. Ubbink DT, van der Oord BM, Sobotka MR, Jacobs MJ. Effekte Assuming that IVT led to a reversible leakage of the tunnel, PD der Vakuum-Kompressions-Behandlung auf die Hautmikro- was paused for 4 days. After resuming dialysis, volumes were zirkulation von Patienten mit peripherer arterieller Vers- slowly titrated up from 500 to 1000 mL. When leakage recurred chlußkrankheit. Vasa 2000; 29: 53–57 Downloaded from https://academic.oup.com/ckj/advance-article-abstract/doi/10.1093/ckj/sfx142/4772285 by Ed 'DeepDyve' Gillespie user on 12 July 2018

Journal

Clinical Kidney JournalOxford University Press

Published: Dec 21, 2017

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