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Peritoneal dialysis catheter

A soft tube into the abdomen for peritoneal dialysis. A cloudy bag is PD peritonitis until proven otherwise - send the effluent, call renal, and don't delay antibiotics.

Adult & paediatricVascular access & dialysisGuideline

Also called: PD catheter, peritoneal dialysis catheter, Tenckhoff, Tenckhoff catheter, CAPD catheter, PD line

What it is

A peritoneal dialysis (PD) catheter is a soft silicone tube (a Tenckhoff) that enters the abdomen so that dialysis fluid can be run into and out of the peritoneal cavity, which acts as the dialysis membrane. The patient or carer does exchanges at home, draining used ('spent') fluid - the effluent - and instilling fresh.

The entry that justifies this whole band is PD peritonitis: infection of the peritoneal cavity, which presents as a cloudy drainage bag with or without abdominal pain. It is common, time-critical and eminently treatable if recognised fast. The other problems are exit-site/tunnel infection and mechanical (drainage failure, leak, hernia). PD is used in adults and children, and a child on PD presents the same way (the cloudy bag). But the diagnostic thresholds and antibiotic regimens quoted here are from the adult ISPD guideline, which directs that paediatric PD patients should refer to the latest consensus guidelines; paediatric criteria, dosing and management follow the separate paediatric ISPD guideline, directed by the paediatric nephrology team.

How to recognise it

What goes wrong

PD peritonitis

A cloudy effluent bag and/or abdominal pain, sometimes with fever or nausea. It can be surprisingly non-toxic early, which is why the cloudy bag matters so much.

Red flag
Treat a cloudy bag as peritonitis until proven otherwise. The ISPD guideline: We recommend that PD patients presenting with cloudy effluent be presumed to have peritonitis and treated as such until the diagnosis can be confirmed or excluded. Send effluent for cell count and culture and start treatment urgently - delay worsens outcomes and threatens the catheter and the membrane.

Exit-site or tunnel infection

Redness, discharge, crusting or tenderness at the catheter exit, or along the tunnel. May coexist with or precede peritonitis.

Red flag
Swab the exit site, start antibiotics per renal-unit policy, and refer - tunnel infection or an exit-site infection with peritonitis more often needs catheter removal.

Drainage failure, leak or hernia

Fluid will not drain or instil (constipation, kink, catheter malposition, fibrin), fluid leaking around the exit, or an abdominal/genital hernia or swelling from raised intra-abdominal pressure.

Red flag
If drainage has failed and the abdomen is distended or the patient is breathless, drain the dwelling fluid if you can and call renal. Mechanical failure is a renal/surgical problem, not usually an emergency unless there is compromise.

The first ten minutes

  1. Cloudy bag = presume peritonitis. Diagnose on the ISPD criteria - the guideline recommends peritonitis be diagnosed when at least two of the following are present: clinical features (abdominal pain and/or cloudy effluent), a raised effluent white cell count with predominant neutrophils, and a positive effluent culture. The white-cell criterion assumes a dwell of at least 2 hours, so a just-drained, dry abdomen cannot be judged on cell count - treat on the cloudy bag.
  2. Send the effluent for cell count, Gram stain and culture (inoculate blood-culture bottles) - do this before antibiotics where possible, but do not let it delay treatment.
  3. Start empirical antibiotics promptly, guided by the renal unit. ISPD: empirical antibiotic therapy be initiated as soon as possible and regimens should be centre-specific and cover both gram-positive and gram-negative organisms. The preferred route is usually intraperitoneal - We recommend that IP antibiotics be the preferred route of administration as long as the compatibility and stability of the IP antibiotics allow, unless the patient has features of systemic sepsis - so involve the renal unit immediately, as they give the IP antibiotics and the exact regimen is local.
  4. Treat systemic sepsis with IV antibiotics and resuscitation if the patient is unwell - do not rely on the IP route alone in a septic patient - and take peripheral blood cultures, which ISPD says can be omitted unless the patient is clinically septic or on immunosuppression.
  5. For drainage failure with distension or breathlessness, drain the dwelling fluid and call renal.
  6. Call the renal/PD unit early for every PD peritonitis - they direct the IP antibiotics, the catheter decision and admission.

Do not

Do not dismiss a cloudy bag or wait for culture results to act.
A cloudy effluent is presumed peritonitis and treated as such until excluded. Waiting for cultures before starting treatment loses time that costs the membrane and the catheter.
Do not start antibiotics without sending the effluent first where possible.
The effluent cell count and culture are what confirm the diagnosis and guide treatment. Send it before or alongside the first dose - but never let sampling delay treatment in a septic patient.
Do not improvise an intraperitoneal antibiotic regimen alone.
IP antibiotic choice, dosing and compatibility are centre-specific and the renal unit administers them. Your job is to recognise, sample, start systemic treatment if septic, and call renal immediately.
Do not forget the non-peritonitis abdomen.
A PD patient gets appendicitis, cholecystitis, bowel perforation and ischaemia like anyone else; a surgical abdomen can also present with cloudy fluid (enteric peritonitis). Assess the abdomen, and involve surgery if the picture is not simple PD peritonitis.

Who owns it

The renal / PD unit owns the catheter and directs peritonitis treatment (they give the IP antibiotics); general surgery for a surgical abdomen or catheter problems. Tell them the bag appearance, the effluent cell count and culture status, whether the patient is systemically septic, and the abdominal findings.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first
Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established
Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours
Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought
Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud
The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it
Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways
The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

What the patient will be carrying

PD patients and carers are trained to spot a cloudy bag and usually carry their renal unit's contact and their exchange details. The spent bag they bring in is itself the key specimen.

Scope of this page

This page covers recognising PD peritonitis and the first ED steps: presume peritonitis on a cloudy bag, send the effluent, start treatment and involve the renal unit, who give the intraperitoneal antibiotics. It does not set the IP antibiotic regimen (centre-specific), nor cover catheter insertion, removal or the detailed management of refractory peritonitis, which are the renal unit's. PD is used in adults and children; paediatric dosing is directed by paediatric nephrology.

Sources