What is pericatheter leakage?
Pericatheter leakage describes a complication of PD where administered dialysis fluid and ultrafiltrate is not confined to the peritoneal cavity, but rather escapes or leaks around the entrance site or across the abdominal wall tissue planes crossed by the PD catheter. Leakage around the PD catheter exit site commonly presents as moisture or drainage of clear fluid. Alternatively, leakage can occur around the rectus muscle sheath or Scarpa’s fascia, resulting in pericatheter edema. The technique of PD catheter placement (median as opposed to paramedian location), factors related to initiation of PD (excessive volume of PD fluid relative to timing of the PD catheter placement), or intrinsic abdominal wall weakness (children, excessive physical straining, obesity, or long-term therapy with steroids) are the causative factors associated with peri-catheter leak.
PD fluid can also leak into fluid spaces outside of the peritoneum related to intrinsic peritoneal, abdominal wall, or diaphragmatic defects. A patent processes vaginalis; inguinal or periumbilical hernias can result in edema in genital and other respective areas. Conversely, tendinous defects in the diaphragm can result in collection of fluid within the thoracic cavity. Positive abdominal and negative intrathoracic pressure contributes to the collection of fluid in the chest cavity in the setting of a diaphragmatic defect. Leak or extravasation of fluid outside the peritoneum can present with decreased UF, increased weight, localized swelling, or shortness of breath. The latter is particularly true in the case of transthoracic infiltration of fluid, which, if sizeable, can result in a unilateral decrease in breath sounds, dullness to percussion on the involved side, and a pleural effusion on chest imaging. An increased glucose content of fluid leaking from the area around the PD catheter or obtained by thoracentesis (in the case of a presumed diaphragmatic defect) relative to the blood glucose level provides a helpful diagnostic clue. Suspicion of internal leakage of PD fluid into tissue planes can be confirmed with imaging studies. If magnetic resonance imaging (MRI) is used, it should be done without gadolinium. The PD fluid itself can serve as the “contrast” for MRI diagnosis of internal leaks.
PD should usually be interrupted, if possible, for 1 to 2 weeks when early external or subcutaneous leaks develop to allow more time for healing around the catheter. An alternative is to reduce the dwell volume coupled with use of supine dialysis, leaving the abdomen dry when the patient is sitting, upright, or ambulatory. Antibiotics should be strongly considered in the presence of an external leak to reduce the risk of a tunnel infection or peritonitis. Recurrence of a leak after a several week period of peritoneal rest or modified, supine PD should prompt strong consideration of surgical intervention. Temporary transfer to HD to allow for primary healing or after correction of an abdominal wall defect may be necessary depending on the presence and the amount of RKF in addition to the clinical scenario. Late leaks, defined as those occurring more than 30 days after catheter insertion, are more likely to require surgical correction of the defect to achieve resolution. It is notable that successful continuation of PD using a regimen of supine-attenuated PD has been described.
Discontinuation of PD is appropriate in the case of PD-related hydrothorax. Successful surgical correction of the diaphragmatic defect after surgical repair or pleurodesis may allow the patient to return to PD after a judicious interval to allow for complete healing.