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JANUARY 2009 – VOL. 29, NO. 1
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Another Peritoneal Dialysis Catheter Encapsulated in Peritoneal Tissue
Figure 1 — X ray with contrast medium of the peritoneal dialysis catheter. As indicated by the arrows, contrast medium spilled from the catheter tip into the abdominal cavity only, but no flow is seen from the many side holes of the catheter, as would be expected.
Figure 2 — Operational site at laparoscopic intervention. The whole catheter was encapsulated in an apparently vascularized granulomatous sheath. This sheath had to be cut off, as shown here, after the first incisions at the distal part of the sheath.
seen by Kazory et al. (1) or that in our patient. Both patients have in common the relatively long period between catheter placement and start of PD (1 and 2 months 119
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Editor: We read with interest the short report by Kazory and co-workers on primary malfunction of a peritoneal dialysis (PD) catheter found in a thick encapsulated sheath 1 month after catheter insertion (1). We would like to add our experience with a similar observation in a 60-year-old male with diabetic nephropathy as the cause of end-stage renal disease. Our patient had his first PD catheter implanted using a technique described previously (2) in which the catheter (Quinton swan neck Tenckhoff PD catheter; Tyco Healthcare, Mansfield, MA, USA) was surgically placed below the umbilicus in a typical manner. The outer part of the swan-neck catheter was embedded in the subcutaneous tissue. Prior to suture of the skin, the catheter was filled with heparin solution as in the report by Kazory et al. The period of wound healing was uneventful. After 67 days, when clinical symptoms indicated beginning renal replacement therapy, the outer part of the PD catheter was exteriorized via a small skin incision under local anesthesia. When connecting the catheter to the PD fluid bag, very poor inflow of fluid was recognized and an attempt to drain fluid from the peritoneal cavity exhibited no outflow. Radiological examination with contrast medium showed contrast medium spilling into the peritoneal cavity from the tip of the catheter but not from the side holes, as would be expected (Figure 1). The catheter was in a normal position but with the tip at the entry to the small pelvis. An attempt was made to mobilize the catheter using a guidewire but was unsuccessful. The next day laparoscopy was performed with the expectation of finding omental wrapping. Surprisingly, the catheter was found to be completely surrounded by connective-tissue-like material on the frontal inner abdominal wall (Figure 2). The sheath appeared vascularized, clearly distinguishing the tissue from a simple fibrin sheath. Inspection of the abdominal cavity revealed no other abnormalities, especially no adhesions or inflammation. The catheter was surgically cut out of this sheath. No fibrin clots were seen within the catheter lumen. A specimen was taken from the sheath for histological examination and the operation was finished successfully. Immediate dialysate inflow and drainage was possible without problems. Histological examination of the sheath specimen revealed granulation tissue, as seen in scars, with no signs of inflammation. A recent clinical commentary on noninfectious complications in PD (3) did not mention the complication
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JANUARY 2009 – VOL. 29, NO. 1
ACKNOWLEDGMENTS The authors thank Dr. Wolfgang Fröhler, 1st Department of Radiology, for radiological examination, and Hans Kalchmair and Walter Schauer, 2nd Department of Surgery, all Klinikum Wels-Grieskirchen, for successful laparoscopic intervention.
F.C. Prischl* F. Knoll R. Kramar Nephrology 3rd Department of Medicine Klinikum Wels-Grieskirchen Wels, Austria *e-mail:
[email protected] REFERENCES 1. Kazory A, Cendan JC, Hollen TL, Ross EA. Primary malfunction of a peritoneal dialysis catheter due to encasement in an encapsulating sheath. Perit Dial Int 2007; 27:707–9. 2. Prischl FC, Wallner M, Kalchmair H, Povacz F, Kramar R. Initial subcutaneous embedding of the peritoneal dialysis catheter—a critical appraisal of this new implantation technique. Nephrol Dial Transplant 1997; 12:1661–7. 3. McCormick BB, Bargman JM. Noninfectious complications of peritoneal dialysis: implications for patient and technique survival. J Am Soc Nephrol 2007; 18:3023–5. 4. McCormick BB, Brown PA, Knoll G, Yelle JD, Page D, Biyani 120
M, et al. Use of the embedded peritoneal dialysis catheter: experience and results from a North American center. Kidney Int Suppl 2006; 70:S38–43.
An Unusual Cause of Skin Ulceration in a Very Long-Term Peritoneal Dialysis Patient Editor: A 73-year-old Asian male had been diagnosed in 1987 to have chronic kidney disease secondary to hypertension. He started hemodialysis in early 1991 and subsequently switched to peritoneal dialysis (PD) in April 1991 because of intolerance to hemodialysis. In November 2006, after 15 years of PD, the patient reported a non-healing skin ulcer 5 – 6 cm from the PD catheter exit site on the catheter tunnel, which he had noticed for 5 – 6 months (Figure 1). He also reported exit-site discharge on that day in the clinic. Upon examination of the wound, there was hypertrophied flesh with no discharge. The patient was referred to a dermatologist, who advised excision of the hypertrophied flesh around the ulcer. Silver nitrate was applied as a temporary measure. The culture from the exit-site swab was negative for bacterial and fungal organisms. In late January 2007, he presented to the emergency room with fever, abdominal pain, diarrhea, and hypotension. The peritoneal fluid had a white cell count suggestive of peritonitis and grew coagulase-negative staphylococcus. An abdominal wound swab also grew coagulase-negative staphylococcus. Due to suspicion that the skin ulcer was related to the PD catheter, an abdominal computerized tomography (CT) scan was done (Figure 2). The CT scan revealed a subacute bowel obstruction with peritoneal adhesions. No drainable collection of fluid could be identified. Overlying the PD catheter there was an area of focal thinning, representative of the area of the clinically evident ulceration. There was a small amount of fluid surrounding the PD catheter. In early February 2007, diagnostic laparoscopy showed extensive thickening of all peritoneal surfaces. There were no peritoneal adhesions. The visceral peritoneum was found to be grossly thickened and abnormal. No other intra-abdominal abnormalities were detected. The catheter tunnel tract was found to contain large amounts of pus. The two PD catheter cuffs could be separated from the subcutaneous tissues easily because they were grossly infected. The PD catheter was changed.
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respectively.) In our patient, we thought the observation of a vascularized granulation tissue sheath might be related to our method of catheter implantation (2). However, one of the largest series on subcutaneously embedded PD catheters in recent time (304 embedded catheters in 303 patients) reported an initial rate of 15% having either one- or two-way obstruction to dialysate flow (4). Seven percent of their patients never achieved adequate inflow and drainage function, but an encapsulating sheath was not described in their series as the cause of catheter dysfunction. Therefore, we follow the possible explanations of Kazory et al. that the catheter itself, that is, the mechanical movements of the catheter along the peritoneum, or catheter material, or the saline and/or heparin solution leaking out the catheter side holes may induce a local inflammatory process, followed by mesothelial cell proliferation and growth of a sheath. Finally, with granulation tissue, as documented histologically in our patient, surgical intervention, preferably laparoscopy, is the only method to successfully activate catheter function.
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