Abstract
Background
A refractory catheter-related infection in patients receiving peritoneal dialysis (PD) represents a major challenge that may require catheter removal and reinsertion. We assessed the effect of a tunnel reconstruction operation on refractory infection in a single center.
Methods
We retrospectively collected data from 10 PD patients who, after inadequate responses to treatment with culture-based antibiotic therapy, underwent a tunnel reconstruction operation designed to resolve a refractory catheter-related infection without requiring transition to hemodialysis. The patients were followed for 3–41 months, and outcomes at months 3 and 12 were analyzed.
Results
Tunnel reconstruction surgery was performed in 10 patients, including 7 with exit-site infection and 3 with tunnel infection. No patients developed catheter-related infection, catheter dysfunction, or postoperative complications after 3 months of postoperative follow-up. During the 12-month postoperative follow-up period, there were no catheter-related infections among 7 patients (3 patients were not followed for 12 months). However, 2 patients developed an exit-site infection episode at 33 and 41 months after tunnel reconstruction surgery, respectively. No incidents of PD connector hypersensitivity or catheter leakage occurred during the follow-up period.
Conclusion
Tunnel reconstruction operation may be a promising salvage option that requires prospective validation in PD patients with refractory catheter-related infections.
Keywords: Peritoneal dialysis, refractory catheter-related infection, exit-site infection, tunnel infection, tunnel reconstruction
KEY MESSAGES
In PD patients with refractory catheter-related infections, catheter removal and reinsertion of the PD catheter may lead to bleeding, organ injury, catheter dysfunction, and transfer to hemodialysis. This study shows that a salvage tunnel reconstruction in PD patients with refractory catheter-related infections may resolve the infection without catheter removal and reinsertion. Tunnel reconstruction may be a promising salvage option for treating refractory catheter-related infections in PD patients, potentially avoiding the harm caused by catheter removal and reinsertion.
Introduction
Refractory catheter-related infections in peritoneal dialysis (PD) patients, including exit site infections (ESI) and tunnel infections (TI), could lead to PD-associated peritonitis, hospitalization, transition to hemodialysis, or even death [1]. The treatment of refractory catheter-related infections may be challenging, particularly when the superficial cuff is involved, which may require catheter removal and reinsertion, as recommended by the International Society for Peritoneal Dialysis (ISPD) guidelines [2]. However, catheter removal may lead to discontinuation of PD and a temporary transition to hemodialysis. In addition, manipulation of the peritoneum may lead to complications such as hemorrhage, peritoneal leakage, catheter malposition, and omental trapping [3]. Salvage methods that allow prompt resumption of PD without peritoneal manipulations have been investigated for the treatment of refractory ESI and TI, including curettage [4], cuff shaving [5], partial reimplantation of the catheter [6], and cuff removal [7].
Nevertheless, the infection often relapses after salvage treatment because the tunnel or exit was not thoroughly debrided and disinfected due to the remaining subcutaneous catheter. Microorganisms may transmigrate along the subcutaneous catheter and the superficial cuff, forming a biofilm that facilitates their proliferation and renders these infections unresponsive to medical therapy [8]. Here, we successfully treated ten patients with catheter-related infections, seven with ESI and three with TI, using a new surgical approach (tunnel reconstruction) without removing the original catheter; all ten patients recovered and remained relapse-free during follow-up.
Methods
We retrospectively collected data from the hospital electronic medical record system at our PD center on 10 patients with refractory catheter-related infection, which was defined as the absence of clinical improvement after 2 weeks of effective antibiotic therapy and appropriately intensified exit-site care, or after 3 weeks for infection due to Pseudomonas species, according to the ISPD 2023 guidelines [2]. Patients were included if they had a diagnosis of refractory catheter-related infection and no evidence of peritonitis. Patients were excluded if they had peritonitis concurrent with catheter-related infection or infection involving the deep cuff (confirmed by ultrasonography). Inadequate response was defined as failure to respond after at least 2 weeks of effective antibiotic therapy (based on culture results) and appropriately intensified exit site care. Ultrasonography was performed before and after antibiotic treatment to confirm the area of infection, including the deep cuff. All 10 patients who underwent tunnel reconstruction due to an inadequate response were followed up to assess treatment efficacy after surgery. The initial resolution success (no infection occurrence at 3 months after surgery) and sustained infection-free success (at the end of follow-up) were observed in all patients. The study was conducted in compliance with the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of the First Affiliated Hospital of Dalian Medical University (approval No. PJ-KS-KY-2026-878). Written informed consent was obtained from all PD patients.
The tunnel reconstruction procedure was performed under local anesthesia with 1% lidocaine in the operating room, and the sterile field was the abdomen and the PD catheter. First, aseptic disinfection of the abdomen (including the PD catheter) was performed. Then a horizontal incision was made along the superficial cuff, followed by dissection to expose the superficial cuff and the infected exit or tunnel tract (Figures 1A and 2A). Subsequently, the superficial cuff, the infected tunnel, and the exit site were thoroughly debrided and disinfected in the operating area with hydrogen peroxide, normal saline, and iodophor, respectively. Next, a longitudinal incision was made near the original incision, and a new tunnel was created on the contralateral side. The catheter, including the superficial cuff, was transected proximally to the area of infection (Figure 2A and B). Another PD catheter was used and cut from the distal end of the deep cuff. The left catheter with a superficial cuff was connected to the remaining original catheter via a bidirectional titanium connector (Figures 1B and 2C). Catheter function was confirmed by saline flushing and observing for possible leakage. The wound was then closed in layers. The patients were asked to remain supine after the operation to facilitate recovery. Thorough debridement was performed intraoperatively, particularly in the tunnel tract and superficial cuff area. Since the operation was performed subcutaneously, the deep cuff and the intraperitoneal portion of the original PD catheter were not manipulated in the procedure. Postoperatively, the wound was managed with regular dressing changes and drainage. All patients received antibiotic therapy (based on culture results) for about one week. The surgical sites were monitored for changes, with particular attention to signs of infection at the new exit site, and daily follow-up was provided in the outpatient clinic for several days.
Figure 1.
Design of tunnel reconstruction operation. (A) The original position of the tunnel and the exit site. (B) A new tunnel and a new exit site were created on the contralateral side.
Figure 2.
Procedures for removal of the infected part of the catheter and creation of a new tunnel and exit site: (A) The catheter, including the superficial cuff, was transected proximally to the area of infection. (B) Using the bidirectional titanium connector to connect the original catheter to a new one. (C) A new subcutaneous tunnel and exit were created.
Results
There were 17 cases of refractory PD catheter-related infections at our center from 05 January 2023 to 28 August 2025; 3 patients underwent catheter removal and reinsertion, 4 patients were cured after 2 weeks of treatment, and 10 patients underwent tunnel reconstruction. The latter group of 10 patients included 6 men and 4 women, with ages ranging from 24 to 70 years and a median (IQR) age of 59.5 (49.75, 62.50) years. The duration of PD treatment ranged from 8 to 74 months, with a median (IQR) of 42.5 (25.0, 54.0) months (Table 1). There were 7 patients with ESI and 3 with TI (Table 1). The identified infectious microorganisms included Enterococcus avium, Staphylococcus hominis, Klebsiella pneumoniae, Staphylococcus aureus, Escherichia coli, and Corynebacterium striatum (Table 1). Ultrasonography was performed in 3 patients with TI before and after antibiotic treatment, and both long-axis and short-axis views were acquired in the same lesion area along the subcutaneous catheter tunnel. The maximal diameters of hypo-/anechoic collections were measured: 4.37 vs 4.91 mm, 6.13 vs 7.26 mm, and 9.74 vs 11.07 mm. No hypo/anechoic collections around the superficial cuff were observed in those with ESI. Sensitive antibiotic therapy was administered based on bacterial culture results, and tunnel reconstruction was performed after medical management failed (Table 1).
Table 1.
Treatment and outcomes of tunnel reconstruction in ten cases of refractory catheter-related infections in patients undergoing PD.
| No | ESI/TI | Age | Gender | Etiology | PD vintage (months) | Microorganism | Sensitive antibiotics used, duration | Cause of infection | Follow-up (months)/outcome |
|---|---|---|---|---|---|---|---|---|---|
| 1 | TI | 65 | M | MN | 54 | Enterococcus avium | Ampicillin, 16 days | Catheter traction injury | 33a/cured |
| 2 | ESI | 63 | F | CIN | 8 | Staphylococcus hominis | Levofloxacin, 15 days | Catheter traction injury | 41a/cured |
| 3 | TI | 30 | F | FSGS | 54 | Klebsiella pneumoniae | Cefazolin sodium, 18 days | Bathing | 39b/cured |
| 4 | ESI | 51 | M | ADPKD | 35 | Staphylococcus aureus | Mezlocillin sodium, 16 days | Unknown | 3c/cured |
| 5 | ESI | 58 | F | CGN | 15 | Staphylococcus aureus | Gentamicin, 17 days | Unknown | 31b/cured |
| 6 | ESI | 60 | M | CGN | 74 | Staphylococcus aureus | Gentamicin, 16 days | Catheter traction injury | 18b/cured |
| 7 | TI | 70 | M | CGN | 42 | Staphylococcus aureus | Moxifloxacin 2 weeks, Gentamicin 1 week | Catheter traction injury | 22b/cured |
| 8 | ESI | 24 | F | CGN | 25 | Escherichia coli | Moxifloxacin 2 weeks, Meropenem 1 week | Unknown | 12b/cured |
| 9 | ESI | 61 | M | DN | 43 | Corynebacterium striatum | Vancomycin, 22 days | Catheter traction injury | 11b/cured |
| 10 | ESI | 59 | M | CGN | 47 | Staphylococcus aureus | Linezolid, 21 days | Catheter traction injury | 9b/cured |
Abbreviations: ESI: Exit site infection; TI: Tunnel infection; PD: Peritoneal dialysis; M: Male; F: Female; MN, Membranous Nephropathy; CIN: Chronic Interstitial Nephritis; FSGS, Focal Segmental Glomerular Sclerosis; ADPKD, Autosomal Dominant Polycystic Kidney Disease; CGN: Chronic Glomerulonephritis; DN, Diabetic Nephropathy.
Recurrent exit site infection.
No recurrent infection.
Renal transplantation.
Following tunnel reconstruction surgery, all refractory catheter-related infections were resolved, without PD-associated peritonitis. Because of the subcutaneous approach, the intraperitoneal portion of the PD catheter was not manipulated, and no operation was performed in the abdominal cavity. PD treatment was not suspended in any patient, and the dialysate fill volume was not changed. More importantly, peritoneal dialysis treatment was not interrupted, thereby maintaining continuity of PD. During the 3-month postoperative follow-up period, no patients developed catheter-related infections (Table 1), indicating that tunnel reconstruction surgery achieved initial resolution in all patients. During the 12-month postoperative follow-up period, there were no catheter-related infections among 7 patients (3 patients were not followed for 12 months).
No catheter dysfunction or postoperative complications were observed in any patient after the operation, including catheter tip migration, leakage, or disconnection between the two catheters. One patient, who had no recurrence of catheter-related infection within 3 months after the procedure, subsequently underwent kidney transplantation. In addition, no incidents of PD connector hypersensitivity or catheter leakage occurred during follow-up. Two patients developed an episode of ESI at 33 months and 41 months after surgery, respectively. Both infections were caused by accidental catheter pulling and were cured with mupirocin ointment. Eight patients had no catheter-related infections at the end of follow-up, and thus sustained infection-free success was established in all except two patients with ESI. The infection-free survival and the number of cases at risk at each time point in the study are shown in a Kaplan-Meier curve (Supplementary Figure 1).
Discussion
Refractory catheter-related infection, ESI or TI, in patients undergoing peritoneal dialysis is a significant predisposing factor for PD-related peritonitis, often leading to poor outcomes. Therefore, prompt and appropriate treatment is necessary to resolve the problem, if possible, without discontinuation of PD [6]. Compared with catheter removal and reinsertion, tunnel reconstruction surgery offers significant advantages: ⅰ. The procedure does not involve the peritoneum, allowing patients to undergo peritoneal dialysis immediately after surgery. It also avoids complications associated with peritoneal manipulation, facilitating a quicker return to regular dialysis. ⅱ. The procedure is minimally invasive and does not require peritoneal surgery; therefore, patients may recover soon after the operation. In the present study, there were no relapses of catheter-related infections after the operation, indicating that tunnel reconstruction had successfully resolved the problem.
In our study, a bidirectional titanium connector was used to connect the original and the new catheters. The main issues with connection during the operation are the risk of disconnection between the two catheters, leakage at the splice, and long-term durability; therefore, a bidirectional connector was designed to connect two PD catheters, significantly reducing the risks of disconnection and leakage after the operation. The follow-up data showed that no patient experienced disconnection or leakage, indicating that the bidirectional connector was well designed. In addition, titanium offers superior biocompatibility, which minimizes the inflammatory response and promotes better tissue integration without degradation or hypersensitivity [9–11]; therefore, a titanium connector may have a lower risk of chemical reactions than medical adhesives or specific intraluminal connectors [12–14].
In the present study, the cause of initial catheter-related infection was catheter traction injury in 6 patients. In addition, 2 patients developed an episode of ESI after surgery, and both infections were caused by accidental pulling of the catheter. This shows that catheter fixation/immobilization is of great importance for preventing catheter-related infections, and this should be emphasized in patient training after PD treatment; this is also the main training content in our center to avoid catheter-related infections.
Our study has several limitations. First, no standardized scoring system was used to evaluate the exit site, and the study is retrospective. Second, the study included only 10 patients. A larger sample size is required to validate the efficacy of tunnel reconstruction surgery. Furthermore, the follow-up period was relatively short in some cases (ranging from 3 to 41 months). A longer follow-up is necessary to better evaluate long-term treatment outcomes. Since the findings are currently limited to PD patients without deep-cuff involvement, tunnel reconstruction is available only for those with refractory PD catheter-related subcutaneous infections, not for those with infections around the deep cuff or with peritonitis.
In summary, tunnel reconstruction surgery may be an effective alternative to conventional techniques for the clinical management of refractory catheter-related infection. However, larger-scale prospective studies are warranted to validate the method.
Supplementary Material
Acknowledgments
We gratefully acknowledge all the patients who participated in this study and all the colleagues who contributed to it. Part of the abstract was presented as a poster at the ISN Frontiers Meeting (September 5-7, 2026) and will be published in the Kidney International Reports supplement.
Funding Statement
The study was supported by the grant from the Educational Department of Liaoning Province, China (No. JYTZD2023044).
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The data from the present study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data from the present study are available from the corresponding author on reasonable request.