Literature
Clinical Pearls & Morning Reports
Published November 3, 2021
Which cancers are most frequently associated with paraneoplastic pemphigus?
Evaluation of oral ulcers begins with determination of whether the patient has a single lesion or multiple lesions and whether the process is episodic or continuous. Read the NEJM Case Records of the Massachusetts General Hospital here.
How often does peritoneal dialysis-related peritonitis result in hospitalization?
An estimated 3.8 million people worldwide currently rely on some form of dialysis for treatment of end-stage kidney disease (ESKD). Although the prevalence of peritoneal dialysis varies from country to country, it accounts for approximately 11% of patients undergoing dialysis overall. Read the NEJM Review Article here.
Clinical Pearls
Q: Are there many contraindications to peritoneal dialysis?
A: There are only a few absolute contraindications to peritoneal dialysis. These include an insufficiently clean environment in which to perform exchanges, an inadequate cognitive or physical ability on the part of the patient or an assisting partner to learn and perform peritoneal dialysis, and lack of a suitable peritoneal cavity due to extensive scarring or adhesions. The degree of scarring often cannot be assessed until the peritoneal cavity is visualized laparoscopically at the time of attempted catheter placement.
Q: How often does peritoneal dialysis-related peritonitis result in hospitalization?
A: Although many episodes of peritoneal dialysis–related peritonitis can be treated in the outpatient setting, approximately 50% of episodes result in hospitalization. The majority of episodes are successfully treated without removal of the peritoneal dialysis catheter. The catheter should be removed if peritonitis fails to resolve after 5 days of treatment with appropriate antibiotics or in cases of fungal peritonitis. Mortality from peritoneal dialysis–related peritonitis ranges from 3 to 10%. The risk of death after an episode of peritonitis remains elevated for up to 120 days after resolution of the episode itself.
Morning Report Questions
Q: Are there valid concerns about excessive weight gain in patients treated with peritoneal dialysis?
A: Metabolic complications of peritoneal dialysis include development of metabolic syndrome, with concern regarding the attendant weight gain, which may prevent or delay kidney transplantation. It is important to recognize, however, that the average weight gain after 1 year of peritoneal dialysis is reported to be only 1.3 kg or 2.3 kg. Some of this weight gain presumably reflects reversal of uremic anorexia and is therefore physiologically appropriate. Furthermore, in a large, propensity-matched cohort study of weight gain in patients treated with peritoneal dialysis as compared with those receiving hemodialysis, weight gain was lower in the peritoneal dialysis group. In addition, patients in the peritoneal dialysis group were more likely to undergo transplantation than those in the hemodialysis group and had equivalent survival. Thus, the concern about excessive weight gain and delay of transplantation appears to be unfounded.
Q: Does peritoneal dialysis have to be withheld for an extended period of time after abdominal surgery?
A: Many hospitals lack personnel with experience in the performance of peritoneal dialysis. As a result, sometimes a central venous catheter is placed and hemodialysis is performed when it is not actually required. In addition, many surgeons believe that patients treated with peritoneal dialysis who are undergoing surgery must be switched to hemodialysis during the postoperative period, often for many weeks, if not permanently. Concerns cited include leakage of dialysate through an abdominal incision, delayed wound healing, and the risk of peritonitis with possible subsequent infection of foreign materials (e.g., surgical mesh or aortic grafts). However, study data and anecdotal experiences do not support such concerns. In patients undergoing hernia repair or a variety of laparoscopic procedures, peritoneal dialysis can often be resumed within 48 hours after surgery by performing small-volume exchanges with the patient in the supine position, thereby minimizing intraabdominal pressure. The same is true for surgeries associated with relatively small upper abdominal incisions (e.g., cholecystectomy). Patients undergoing bowel procedures that involve large anterior abdominal incisions should probably have a 2-to-3-week hiatus from peritoneal dialysis.