Questions About PD
One of the major concerns with a patient initiating PD is to try to prevent leakage of dialysate at the PD catheter exit site (peri-catheter leak). Having the patient lie flat (supine position) while starting PD will decrease intra-abdominal pressure, thus decrease the chance of leakage at the PD catheter exit site. Having the patient sitting straight up, or standing up, will increase intra-abdominal pressure and thus, increase chance of leakage. Coughing and straining can also increase intra-abdominal pressure. However, I know of no specific best practice guidelines on how long a patient should lie supine for when starting PD.
If a patient with chronic kidney disease stage 5 becomes quite uremic and/or fluid overloaded and needs to start PD urgently within one to three days of having the PD catheter inserted, then the catheter exit site will not have had a chance to heal well and may be prone to dialysate leakage. With this patient, it is most important to have the patient lie supine for the first several days of PD exchanges, use low PD fluid volumes (e.g. 0.5 – 1 L fill volume), and monitor the PD catheter dressing daily for signs of moisture indicating dialysate leakage. Fill volumes are then increased only slowly over 1 – 2 weeks. If the patient needs to sit up, get up to walk around or use the bathroom, then the PD fluid should be first drained out completely. The patient should also be drained of PD fluid in between the regular dialysis sessions – that is left ‘dry’.
If a patient waits the usual 2 – 3 weeks or longer after PD catheter insertion before starting PD exchanges, giving the PD catheter exit site more time to heal, there is less chance of leakage at the PD catheter exit site. Still starting with low volume exchanges, the patient can lie a more semi-recumbent position in a reclining chair. Of note, patients starting PD who are diabetic, obese, elderly or on steroids are more at risk for PD catheter exit-site leakage and fill volumes should be increased only slowly with more frequent monitoring of the PD catheter exit-site for signs of leakage in those patients.
There is quite a variation in incidence of reported dialysate leakage in patients starting PD. Drs. Crabtree and Burchette in their most recent editorial in Peritoneal Dialysis International recommend that each PD unit conduct periodic audits to ascertain for that specific unit how soon after catheter placement PD can be safely started to ensure a low risk for dialysate leaks (1).
- Crabtree J. H., Burchette, R. J. Peritoneal dialysis access and start practices that affect dialysate leak and technique failure: Acts of commission and omission. Peritoneal Dialysis International 2017; 37: 358-61.