An Unusual Cause of Peritoneal Dialysis Catheter Dysfunction

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Case Description

The patient is a 71-year-old man with diabetes mellitus, hypertension, heart disease, peripheral vascular disease requiring bilateral below-knee amputation, prostate cancer treated with prostatectomy, and CKD stage 5 due to diabetic kidney disease. Diabetes mellitus was complicated by neurogenic bladder. After prostatectomy, the patient had significant postvoid residual urinary volumes of around 600 ml, as measured by ultrasound, and he was started on tamsulosin.

As the patient approached ESKD, he chose peritoneal dialysis (PD) as his dialysis modality and had a PD catheter placed by interventional radiology (IR). After placement of the PD catheter, while still in the IR suite, the catheter had normal PD fluid inflow but outflow was very low. Abdominal roentgenogram revealed displacement of the PD catheter by a distended bladder (Figure 1A). The bladder was decompressed by Foley catheter placement and 850 ml of urine was drained. After decompression, the wire was advanced into the pelvis (Figure 1B). PD fluid drainage failure resolved, and the PD catheter was repositioned so that the coiled loop was in the lower pelvis (Figure 1C). The Foley catheter was then removed, and the patient was instructed to perform intermittent self-catheterization by the urology department (1,2).

Figure 1.

Bladder distension leading to inability to position PD catheter. (A) Peritoneal dialysis catheter with wire that could not be passed into the pelvis and is observed to traverse the dome of the bladder (blue arrows). (B) After bladder decompression, wire was able to be advanced into the pelvis (blue arrow), as noted by contrast injection demonstrating free spill in the pelvis. (C) The final position of the peritoneal dialysis catheter with coiled tip and free spill of contrast is noted within the pelvis (blue arrow).

Over the following 2 months, the patient’s PD catheter drainage issues continued. Imaging studies showed that the PD catheter was in the upper central pelvis and the patient’s PD catheter was replaced by IR. A new PD catheter was placed more inferiorly, with the loop in the lower pelvis. Despite replacement of the PD catheter, his outflow and ultrafiltration did not improve. The urology department recommended continuing intermittent self-catheterization or the placement of a suprapubic urinary catheter, but the patient was reluctant to consider either option and remained on PD. However, PD therapy remained suboptimal and the patient was subsequently transitioned to home hemodialysis after placement of a tunneled hemodialysis catheter.

This case illustrates the importance of ruling out urinary retention from neurogenic bladder or prostatic enlargement as a cause of PD catheter outflow failure or inflow-outflow dysfunction (due to extrinsic compression of the PD catheter by a distended bladder) (1,2). This is a particular concern if the postvoidal urine volume in the bladder is >300 ml.

This case also demonstrates that, although outflow failure due to urinary retention from neurogenic bladder can be resolved by bladder decompression by regular self-urinary catheter drainage, some patients might eventually prefer to be on another dialysis modality, such as hemodialysis, to avoid ongoing self-catheterization.

Teaching Points

• In cases of PD fluid outflow failure or inflow-outflow dysfunction after PD catheter placement, urinary retention from neurogenic bladder or prostatic enlargement as a cause must be ruled out.

• Peritoneal fluid outflow failure in PD due to urinary retention can be resolved by bladder decompression using a urinary catheter.

• For patients with neurogenic bladder required to perform frequent straight urinary catheterization, PD might not be the optimal modality of choice.

Disclosures

All authors have nothing to disclose.

Funding

None.

Author Contributions

N.K. Dahl provided supervision, was responsible for validation, and reviewed and edited the manuscript; I. Latich was responsible for investigation; I. Latich and A. Sundararajan were responsible for data curation; and A. Sundararajan wrote the original draft.