Issues in patients on peritoneal dialysis undergoing surgery

INTRODUCTION — Patients on peritoneal dialysis (PD) who undergo surgery face a variety of unique issues related to their dialysis modality.

This topic reviews perioperative strategies that are specific to PD. Medical and anesthetic management issues common to all patients on dialysis (PD or hemodialysis [HD]) undergoing surgery are presented elsewhere.

●(See "Medical management of the dialysis patient undergoing surgery".)

●(See "Anesthesia for dialysis patients".)

PREOPERATIVE CONSIDERATIONS

Medical evaluation — The preoperative medical evaluation of patients on dialysis, whether peritoneal dialysis (PD) or hemodialysis (HD), includes baseline laboratory testing, determining the adequacy of dialysis access, and assessing comorbidities. This is discussed in detail elsewhere. (See "Medical management of the dialysis patient undergoing surgery", section on 'Preoperative evaluation'.)

Indications for preemptive hemodialysis — With proper planning and preparation, most patients on PD will not have to switch, even temporarily, to HD due to surgery. Staying on peritoneal dialysis is ideal, both for patient satisfaction and to avoid short- and long-term complications of HD central venous catheter placement. In addition, the transition to temporary HD from PD may accelerate loss of residual kidney function (RKF) to the detriment of the patient. (See "Residual kidney function in kidney failure", section on 'Effects of dialysis on residual kidney function'.)

PD can often be maintained even after many abdominal and cardiothoracic surgeries, settings where concerns about continuing PD traditionally arise. Violation of the integrity of the peritoneal cavity (intentionally in abdominal surgery or unintentionally in cardiothoracic or urologic surgery) and the potential for postoperative ileus or constipation to cause PD catheter dysfunction are sometimes raised as reasons to switch patients from PD to HD before surgery. However, with foresight and modification to the PD regimen, these issues often can be addressed successfully. (See 'Preoperative management' below and 'Postoperative management' below.)

Unfortunately, there are types of surgeries, or anticipated situations arising from surgery, that should prompt a preemptive, if temporary, switch to HD from PD. Continuing PD after these surgeries may be associated with peritonitis and/or poor wound healing or may be logistically impossible. Specific circumstances that require at least a temporary interruption in PD with subsequent HD initiation include the following:

●Surgeries or procedures that open the gastrointestinal (GI) tract or have a high risk of GI tract disruption. These include gastrostomy, jejunostomy, ileostomy, colostomy, and transabdominal urologic surgery. Other surgeries that violate the visceral peritoneum should be considered on a case-by-case basis.

●Abdominal surgeries with anticipated delayed closure of the surgical wound.

●Abdominal surgery with planned placement of intraperitoneal mesh. Tension-free hernia repairs with extraperitoneal mesh usually do not require transition to temporary HD.

●Admission to facilities (whether hospital or posthospital) unable to perform or support PD.

●Surgeries expected to compromise manual dexterity, visual acuity, or cognitive decision making in patients who do not have a partner to assist with their PD.

Some patients with autosomal dominant polycystic kidney disease (ADPKD), especially those with very large kidneys, may not be able to undergo abdominal surgery without transition to temporary HD. Due to reduced peritoneal cavity volume, patients with ADPKD may have elevated intraabdominal pressures with PD that do not permit adequate wound healing after abdominal surgery.

Steps necessary to preserve the ability to perform PD in patients switched to temporary HD are discussed below. (See 'Patients who need temporary hemodialysis' below.)

The ability to maintain PD successfully without the temporary use of HD after abdominal and cardiothoracic surgery is illustrated by observational data. As an example, a retrospective study reported the outcomes of 50 patients on PD undergoing hernia repair who stayed on PD with the use of a modified dialysis prescription [1]. Over a 33-month average follow-up, there were no immediate or late peritoneal dialysate leaks and no early hernia recurrences. Another study comparing 36 patients on PD and 72 matched controls on HD undergoing cardiothoracic surgery reported similar rates of perioperative mortality and complications between the groups; only two patients on PD required postoperative conversion to HD [2].

Timing of elective surgery — If possible, elective surgery for a patient on PD should be performed early in the dialysis course before the loss of RKF, which often occurs within 18 months after starting PD. By preserving electrolyte homeostasis and mitigating potential volume overload, RKF increases the likelihood of successfully avoiding temporary HD if PD is disrupted postoperatively for a short period (eg, several days).

PREOPERATIVE MANAGEMENT — Several preoperative dialysis issues are unique to patients on peritoneal dialysis (PD). Issues common to the preoperative management of all patients on dialysis, whether PD or hemodialysis (HD), including indications for urgent preoperative dialysis and medication management, are discussed in detail elsewhere. (See "Medical management of the dialysis patient undergoing surgery", section on 'Preoperative management'.)

Communication with surgery and anesthesiology — Communication and preoperative planning with surgery and anesthesiology are important elements of a successful surgery for patients on PD. Specific issues to be discussed preoperatively include individual patient characteristics such as peritonitis history and baseline blood pressure, management of the PD catheter, and the approach to planned or unplanned violations of the peritoneal cavity.

●Individual patient characteristics – Before abdominal surgery, the nephrology team should inform the surgeon about the patient's history of peritonitis; repeated peritonitis episodes can lead to intraabdominal adhesions that may require lysis during the planned surgery.

The anesthesiology team should be aware of the baseline blood pressure of the patient on PD. Avoidance of relative hypotension is important to protect residual kidney function (RKF) from hypoperfusion injury.

●Management of the PD catheter – The approach to the PD catheter should be planned preoperatively. Specific measures taken to protect the PD catheter and catheter tunnel during abdominal surgery, as well as the approach to PD catheter removal during kidney transplant surgery, are discussed below. (See 'Intraoperative management' below.)

●Violations of the peritoneal cavity – The surgical team should be aware of the major consequences of violation of peritoneal cavity integrity during any procedure in the proximity of the chest or abdomen. Unanticipated surgical compromise of the peritoneal cavity, including diaphragmatic rents that may lead to hydrothorax during PD, should be communicated promptly to the nephrology team so that the postoperative PD strategy can be modified accordingly. (See 'Modified peritoneal dialysis regimens' below.)

Surgical techniques to lessen the risk of dialysate leak after abdominal surgery are discussed below. (See 'Intraoperative management' below.)

Intensification of peritoneal dialysis before surgery — The authors and editors of this topic do not fully agree on the role of intensified peritoneal dialysis (PD) before elective surgery. Some UpToDate contributors to this topic increase the amount of PD before surgery to prevent underdialysis postoperatively in the event that resumption of PD is delayed. Other UpToDate contributors do not increase the amount of PD in well-dialyzed patients before surgery.

If preoperative PD intensification (ie, hyperdialysis) is performed, the amount of PD is increased approximately a week before surgery (table 1). Hyperdialysis is used preoperatively even for surgeries in which postoperative delays in PD are not expected, since unanticipated delays (eg, due to an ileus or constipation) are relatively common [3]. Typically, for patients who are on continuous ambulatory PD, an extra exchange is added each day for approximately one week before surgery. For patients on automated PD, an extra nighttime cycler exchange may be added and the duration of cycler time increased by at least one hour for a week before surgery. A combination of the strategies can be used according to patient preference, the presence or absence of RKF, and individual peritoneal membrane transport characteristics.

For patients on PD with a history of hypokalemia, initiation or escalation of oral potassium supplementation may be required during hyperdialysis to avoid the development or worsening of hypokalemia. (See "Noninfectious complications of continuous peritoneal dialysis", section on 'Hypokalemia'.)

Although associations between specific preoperative PD regimens and postsurgical outcomes have been inadequately studied, there are no convincing data to support routine preprocedure intensification of PD in well-dialyzed patients, and many nephrologists do not adhere to this practice. However, in the experience of some UpToDate contributors, the use of preoperative hyperdialysis has a proven ancillary benefit: increasing the appropriate use of postoperative PD by providing reassurance to surgical teams accustomed to HD.

Bowel preparation — For patients on PD who are scheduled for elective surgery, we suggest bowel preparation with laxatives prior to surgery. We prefer bulk-forming laxatives or lactulose for this purpose since stimulant laxatives may be associated with a higher risk of peritonitis [4]. We generally administer laxatives for two to three days before surgery. Decreasing the amount of stool in the intestines preoperatively may minimize the effect of postoperative ileus (should it develop) on the resumption of PD. Anesthesia, the surgical procedure itself, or analgesia may contribute to postoperative ileus or constipation, which can impair PD catheter function and thereby limit the ability to perform PD. Distended loops of bowel due to ileus or constipation typically cause one-way PD catheter dysfunction, where inflow is normal but drainage is compromised.

Prophylactic antimicrobials — To prevent peritonitis, antimicrobial agents should be administered to patients on PD prior to selected procedures, including colonoscopy, upper endoscopy, and dental and gynecologic procedures. Good communication between treatment teams is required to ensure the appropriate administration of antimicrobials before such procedures. (See "Risk factors and prevention of peritonitis in peritoneal dialysis", section on 'Prophylactic treatment with procedures'.)

For surgeries that will definitely or possibly violate the peritoneum (eg, abdominal or cardiothoracic surgery), perioperative systemic antibiotics routinely administered by the surgeon generally suffice for prevention of peritonitis.

Intravenous access — Because it is not uncommon for patients on PD to transition their dialysis modality to HD at some point in the future, protecting future or existing arm arteriovenous access sites is important. Strategies to ensure the integrity of these access sites in the perioperative setting are detailed elsewhere. (See "Medical management of the dialysis patient undergoing surgery", section on 'Intravenous access' and "Anesthesia for dialysis patients", section on 'Intravenous access'.)

Draining the abdomen before surgery — Patients on PD should have their peritoneal cavity completely drained before going to surgery. Peritoneal dialysate in the abdomen during a surgical procedure can have several adverse effects. By increasing intraabdominal pressure and diaphragmatic elevation, a full peritoneum can aggravate hypoventilation associated with surgery, postsurgical pain, or analgesic agents. In addition, the presence of intraperitoneal fluid may increase the risk of peritonitis and can compromise cardiopulmonary resuscitation (by impairing diaphragmatic excursion) in the event of a catastrophic intraoperative complication.

INTRAOPERATIVE MANAGEMENT — The general intraoperative and anesthetic management of patients on dialysis, whether peritoneal dialysis (PD) or hemodialysis (HD), is discussed elsewhere. (See "Anesthesia for dialysis patients", section on 'Intraoperative anesthetic management'.)

Specific intraoperative considerations for patients on PD undergoing abdominal surgery and kidney transplantation are discussed below:

●Measures to preserve PD during abdominal surgery – The PD catheter and the catheter tunnel should be protected during abdominal surgery. Incisions should not be made near the catheter insertion site. During packing or manipulation of abdominal contents, the catheter should be clearly identified to ensure that it is not displaced. Care should also be taken in closing the abdomen to avoid trapping the catheter in sutures. At the completion of surgery, the catheter should be checked to ensure it has not been dislodged.

A multiple-layer closure approach that tightly approximates the abdominal layers may mitigate postoperative dialysate leakage.

●Indications for intraoperative catheter removal – Indications for intraoperative PD catheter removal include the presence of necrotic bowel and/or soiling of the peritoneal cavity; in such cases, the PD catheter may serve as a nidus of infection.

●Kidney transplant surgery – The approach to the PD catheter at the time of kidney transplantation varies by transplant center and is discussed elsewhere. (See "Kidney transplantation in adults: Timing of transplantation and issues related to dialysis", section on 'Removal of peritoneal dialysis catheter'.)

POSTOPERATIVE MANAGEMENT — Issues common to the postoperative management of all patients on dialysis, including monitoring and anemia management, are discussed in detail elsewhere (see "Medical management of the dialysis patient undergoing surgery", section on 'Postoperative management'). Several postoperative dialysis issues unique to PD are discussed below.

Indications for unanticipated hemodialysis — Despite adequate planning and preparation, some patients on peritoneal dialysis (PD) experience surgical or other postoperative complications that necessitate an unexpected switch to a different kidney replacement therapy (KRT) modality. Clinical scenarios resulting in unplanned interruptions to PD in the postoperative period include the following:

●Postoperative dialytic emergencies (eg, volume overload, hyperkalemia, metabolic acidosis) requiring immediate KRT after abdominal or cardiothoracic surgeries that violate the peritoneum. Such patients are unable to pause PD for the recommended two to three days after the peritoneal cavity is compromised.

●The need for accelerated drug removal. The clearance of most dialyzable drugs is greater with hemodialysis (HD) compared with PD.

●PD dialysate fluid leakage or wound dehiscence after abdominal surgery.

●Strangulated or incarcerated bowel encountered during abdominal surgery. The injured bowel is a potential source of enteric peritonitis.

●Unexpected intraperitoneal mesh placement during abdominal surgery.

●Pleural effusion due to pleuroperitoneal leak after cardiothoracic surgery.

●Prolonged difficulty with mechanical ventilation thought aggravated by increased intraabdominal pressure.

●Unexpected transfer to another facility that is unable to perform or support PD.

●Unexpected complications that compromise manual dexterity, visual acuity, or cognitive decision-making in patients who do not have a partner to assist with PD.

Postoperative volume overload in patients on PD who have RKF sometimes can be managed with high-dose diuretic therapy. (See "Management of hypervolemia in patients on peritoneal dialysis", section on 'Loop diuretics'.)

Steps necessary to preserve the ability to perform PD in patients switched to temporary HD are discussed below. (See 'Patients who need temporary hemodialysis' below.)

Modified peritoneal dialysis regimens — The general approach to resuming dialysis postoperatively is discussed elsewhere. (See "Medical management of the dialysis patient undergoing surgery", section on 'Resuming dialysis'.)

Our approach to resuming PD in patients who do not require a temporary switch to HD after selected abdominal surgeries and cardiothoracic surgery (see 'Indications for preemptive hemodialysis' above and 'Indications for unanticipated hemodialysis' above) is detailed here. If the modified PD regimens below cannot address postoperative hyperkalemia, acidosis, or volume overload, the patient may require HD or continuous KRT.

Abdominal surgery — PD should be held for two to three days after abdominal surgery to optimize wound healing and prevent dialysate leaks. If dialysis is needed sooner than two days postoperatively, temporary HD is generally necessary.

When PD is resumed two to three days after abdominal surgery, we use recumbent low-volume PD (table 2). Performing PD in the supine position with low fill volumes minimizes intraabdominal pressure, which facilitates abdominal wound healing and reduces the risk of dialysate leakage. We gradually intensify postoperative PD with the goal of resuming the presurgical PD prescription two weeks after surgery, as wound healing and abdominal wall integrity permit.

After resumption of a modified PD regimen, the patient's serum electrolytes as well as volume and acid-base status should continue to be closely monitored (at least daily) for at least one week after surgery.

Cardiothoracic surgery — Resumption of PD after cardiothoracic surgery can be problematic because of leakage of peritoneal fluid into the pleural space, wound dehiscence caused by increased intraabdominal pressure, and difficulty with mechanical ventilation due to reduced vital capacity. However, PD can often be maintained successfully after cardiothoracic surgery, even in settings where concerns about continuing PD traditionally arise (eg, postoperative volume overload).

Our approach to resuming PD after cardiothoracic surgery depends on whether the patient has a known or suspected violation of the peritoneal cavity:

●For patients with confirmed or suspected disruption of the peritoneum, we use the same approach as that for patients undergoing abdominal surgery (ie, delayed recumbent low-volume PD) unless a pleuroperitoneal dialysate leak is present (table 2). Patients with a pleuroperitoneal dialysate leak require at least a temporary switch from PD to a different KRT modality. (See 'Abdominal surgery' above and 'Indications for unanticipated hemodialysis' above.)

●For patients without confirmed or suspected disruption of the peritoneum, we initiate low-volume PD as soon as needed. Such patients do not need to hold PD for two to three days postoperatively, nor do they need to perform PD in the supine position. Fill volumes are gradually increased to preoperative fill volumes over a two-week period.

Pain management — The approach to postoperative pain management for patients on dialysis, including the selection of analgesic agents, is discussed in detail elsewhere. (See "Medical management of the dialysis patient undergoing surgery", section on 'Pain management' and "Anesthesia for dialysis patients", section on 'Postoperative analgesia'.)

Pain management issues that may complicate PD include the following:

●Constipation – Analgesic agents may cause constipation and associated PD catheter dysfunction. For patients taking opioids, we administer lactulose to prevent constipation.

●Cognition – Sedating analgesics such as opioids, gabapentinoids, and muscle relaxants like cyclobenzaprine can impair cognition, which in turn may compromise the patient's ability to perform PD. The dose of such analgesic agents should be titrated to avoid levels of sedation that preclude the safe administration of PD.

Physical therapy — With foresight and planning, PD does not need to interfere with postoperative physical therapy. In some patients on PD, the abdomen may need to be emptied before intensive physical therapy to avoid discomfort. If automated PD can be performed at the rehabilitation facility, almost all PD can be performed at night, freeing the days for physical therapy.

Special populations

Patients who need long-term antibiotics — Some patients on PD may require long-term antibiotics following surgery. The following two issues arise in such patients:

●Antifungal prophylaxis – Patients receiving a prolonged course of antibiotics should receive antifungal prophylaxis to prevent the development of fungal peritonitis. Exposure to long-term antibiotics is associated with fungal peritonitis in patients on PD. This is discussed in detail elsewhere. (See "Fungal peritonitis in peritoneal dialysis".)

●Intraperitoneal antibiotic administration – For patients on PD who require a prolonged course of antibiotics after surgery, administration of select antibiotics via the intraperitoneal (IP) route rather than the intravenous (IV) route may be an option. IP antibiotic delivery can prevent the need for long-term vascular access (eg, a peripherally inserted central catheter), thereby preserving blood vessels that may be needed for future arteriovenous access and eliminating the risk of intravascular catheter-related infections. However, this strategy requires monitoring the serum concentration of IP-administered antibiotics to demonstrate therapeutic levels.

Patients who need temporary hemodialysis — Patients on PD may be switched to HD in the perioperative period, whether preemptively or unexpectedly (see 'Indications for preemptive hemodialysis' above and 'Indications for unanticipated hemodialysis' above). The following issues are important elements of caring for a patient on PD who is undergoing temporary HD.

Peritoneal dialysis catheter care — For patients who need to be temporarily switched to HD after surgery, daily care of the PD catheter exit site should continue. (See "Peritoneal catheter exit-site and tunnel infections in peritoneal dialysis in adults", section on 'Maintenance preventive care'.)

Although practice patterns vary, the PD catheter can be flushed weekly with one liter of dialysate to maintain patency.

Other issues

●Discharge planning for HD – Once it is clear that temporary HD will be needed after surgery, the process for arranging outpatient HD should be initiated. Hospital or rehabilitation staff may be unaware that the home dialysis unit overseeing maintenance PD may not have room to accommodate another patient on HD after hospital discharge.

●PD retraining – If a patient is off PD for even several weeks, retraining should occur before home PD is resumed. Retraining after PD interruption may be brief for experienced patients, but it should occur [5].

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topic (see "Patient education: Peritoneal dialysis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Maintaining peritoneal dialysis – With proper planning and preparation, most patients on peritoneal dialysis (PD) will not have to switch, even temporarily, to hemodialysis (HD) due to surgery. PD can often be maintained even after many abdominal and cardiothoracic surgeries, settings where concerns about continuing PD traditionally arise. However, there are types of surgeries, or anticipated situations arising from surgery, that should prompt a preemptive, if temporary, switch to HD from PD. (See 'Indications for preemptive hemodialysis' above.)

●Preoperative management

•Intensification of PD before surgery – The authors and editors of this topic do not fully agree on the role of intensified PD before elective surgery. Some, but not all, UpToDate contributors increase the amount of PD approximately a week before surgery to prevent underdialysis postoperatively in the event that resumption of PD is delayed (table 1). (See 'Intensification of peritoneal dialysis before surgery' above.)

•Bowel preparation – For patients on PD who are scheduled for elective surgery, we suggest bowel preparation with laxatives prior to surgery (Grade 2C). We prefer bulk-forming laxatives or lactulose for this purpose since stimulant laxatives may be associated with a higher risk of peritonitis. We generally administer laxatives for two to three days before surgery. Decreasing the amount of stool in the intestines preoperatively may minimize the effect of postoperative ileus (should it develop) on the resumption of PD. (See 'Bowel preparation' above.)

•Intravenous access – Because it is not uncommon for patients on PD to transition their dialysis modality to HD at some point in the future, future or existing arm arteriovenous access sites should be protected. Intravenous (IV) lines should not be placed at or near these sites. (See 'Intravenous access' above.)

•Prevention of peritonitis – To prevent peritonitis, antimicrobial agents should be administered to patients on PD prior to selected procedures. In addition, patients on PD should have their peritoneal cavity completely drained before going to surgery. (See 'Prophylactic antimicrobials' above and 'Draining the abdomen before surgery' above.)

●Intraoperative management – Specific intraoperative surgical considerations for patients on PD include the use of abdominal closure techniques to minimize dialysate leakage and measures to protect the PD catheter. (See 'Communication with surgery and anesthesiology' above and 'Intraoperative management' above.)

●Postoperative management

•Switching dialysis modalities – Despite adequate planning and preparation, some patients on PD experience surgical or other postoperative complications that necessitate an unexpected switch to a different kidney replacement therapy (KRT) modality, such as HD or continuous KRT. (See 'Indications for unanticipated hemodialysis' above.)

•Abdominal or cardiothoracic surgery – PD should be held for two to three days after abdominal surgery to optimize wound healing and prevent dialysate leaks. When PD is resumed after abdominal surgery, we use recumbent low-volume PD (table 2). Our approach to PD after cardiothoracic surgery depends on whether the patient has a known or suspected violation of the peritoneal cavity during surgery. (See 'Modified peritoneal dialysis regimens' above.)

•Pain management and physical therapy – Postoperative analgesia may interfere with PD by causing constipation or sedation. With foresight and planning, appropriate postoperative rehabilitation, including pain management strategies and physical therapy, can be pursued in conjunction with successful PD. (See 'Pain management' above and 'Physical therapy' above.)

•Patients on temporary HD – For patients who need to be temporarily switched to HD after surgery, daily care of the PD catheter exit site should continue. If a patient is off PD for even several weeks, retraining should occur before home PD is resumed. (See 'Patients who need temporary hemodialysis' above.)