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problems

The occurrence of problems on PD and their severity can vary greatly between individuals. The 4 main areas in which problems can occur are listed below:

  1. Psychological Problems: Anxiety and Depression, Body image problems.
  2. Infections: Peritonitis, Exit Site Infection.
  3. Catheter/Drain Problems: Leak of PD fluid, Difficulty draining, blood in PD fluid.
  4. Physical Problems: Fluid overload, Constipation, Hernia, Itching, Pain, Cramps and Restless legs at night.

1. Psychological Problems

Anxiety and Depression: As well as all the anxieties felt by most people at some time in their lives, kidney patients also have additional anxieties relating to their condition and their treatment. You will need to understand the reasons for your anxieties and any medical causes that can be treated. Having a better understanding often helps people to cope.

It sometimes helps to share anxieties, and identify ways of coping. Many Units have a Renal Social Worker, a psychologist, or members of the Kidney Patient Association as well as doctors and nurses who will have experience of helping people to cope with their anxieties. People on dialysis are as prone to depression as anyone else. Occasionally people will need medical treatment for depression, but quite often, after a period of feeling low, people find ways of coping and adjusting to life on PD.

Body image: Some people on PD do not like the way PD affects their appearance. The abdomen tends to get stretched by PD, giving it a rounded appearance. Young people in particular may be very conscious of their body shape, especially if they are slim. Keeping fit and doing exercises to strengthen the abdominal muscles will help.

The PD catheter can also cause body image problems. People on PD have to come to terms with the fact that they now have a plastic tube permanently protruding from their abdomen. Some people find this very difficult to cope with, feeling that they have been mutilated. They may also worry that the catheter might put off a sexual partner. Some people make a joke or tell a funny story about why the catheter is there when showing it to someone for the first time (the website editor asked me to remove the story about the catheter, the leprechaun, and the broken fan belt!). It is important to talk about your feelings with your partner, PD nurse or doctor who can refer you to someone who may be able to help you come to terms with your changed body image. People on PD may need to remind themselves, that people who really love them, will continue to do so, regardless of how they look.

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2. Infections

Peritonitis: This is an infection inside the tummy. The most common reason why people on PD get peritonitis is that they touch the connection between the bag of fluid and the catheter. However, even if PD exchanges are scrupulously clean, infection can still enter the abdomen from the outside world through the catheter. People can expect to get on average less than one attack of peritonitis every year. So it is not that common. Indeed, some people never get it. On APD peritonitis is less likely to occur than on CAPD, probably because fewer catheter connections are required.

A person will know when they have peritonitis because the dialysis fluid that drains out will be cloudy. This fluid is normally ‘see-through’. The signs and symptoms are usually one or more of the following:

  • Cloudy bag
  • Tummy pain
  • Vomiting
  • A raised temperature

Peritonitis is treated by adding one or more antibiotics to the fresh dialysis fluid, and by antibiotic tablets. Patients are not usually admitted to hospital when they have peritonitis.

Occasionally, a person may get several attacks of peritonitis in a row. The doctor may then decide that an operation to remove the old PD catheter, and put in a new one is needed straight away. Alternatively, the doctor may decide that it is better to delay replacing the catheter and to 'rest' the abdomen by not using it for PD for a period of 4 to 6 weeks. If this happens, the person will usually need to have haemodialysis until PD is resumed.

Peritonitis is usually caused by one of two types of bacteria:

  • Staphylococcus epidermidis
  • Staphylococcus aureus

Both of the above infections are often known as “staph” infections. In rare but serious cases, peritonitis is caused by a fungus (usually a type called candida albicans). If peritonitis is caused by a fungus, it will be treated straight away by an operation to remove the PD catheter. Drugs are not very effective against fungi, but the problem soon goes away if the catheter is removed. The catheter can still be replaced at a later date. If a person has many bad attacks of peritonitis, PD may no longer be suitable for them. They will then have to change to haemodialysis as their long-term treatment.

Exit Site and Tunnel Infections: This is an infection at the point where the PD catheter comes out through the skin. This causes a red tender area around the exit site, and when someone has this type of infection, squeezing around the exit site may produce some pus.

Some people get exit site infections regularly, whereas others may never get them. Keeping the catheter taped down to the skin will help reduce the likelihood of an exit site infection, especially when the catheter is new. Most Units advise people to put a clean dressing over their exit site each day, after they have showered.

Exit site infections respond well to antibiotics, usually given either as tablets or creams. Sometimes, a single intravenous injection of an antibiotic called vancomycin is needed. There is usually no need to remove the PD catheter. Occasionally, an exit site infection spreads down the catheter “tunnel” (the route taken by the catheter through the tummy wall). This type of infection is called a tunnel infection. Antibiotics are not always effective when someone has a tunnel infection. An operation to remove the catheter will then be necessary. It may be possible to insert a new catheter at the same operation, but this will depend on how extensive the infection is (there is a risk that the new catheter could also get infected).

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3. Catheter/Drain Problems

Leak of PD fluid: In most people, the ‘seal’ around the catheter exit site (where the catheter leaves the abdomen) works properly. PD fluid drains in and out of the abdomen through the tube without any leakage. However, in some people, the PD fluid leaks out around the catheter, wetting the dressing over the exit site.

If a leaking catheter is ‘rested’ (not used for dialysis) for 2 to 4 weeks, it will usually ‘seal up’ again, and become watertight. Occasionally, however, a leak may recur even if the catheter is rested. It may then be necessary to have an operation to take out the leaking catheter. A new catheter, at a different site, is usually put in during the same operation.

In some men on PD, fluid leaks into the scrotum, or into the vagina in women and causes swelling. If this type of leak occurs, PD must be stopped temporarily until the leak has healed. A test can be carried out to check the location and size of a leak, and whether surgery is needed to repair it. A special dye is put down the catheter and x-rays show where the dye goes – known as a peritonealogram.

Drainage Problems: One of the most common problems with PD – especially when people first start PD is poor drainage of the dialysis fluid. The most common reason for poor drainage is constipation. If a person becomes constipated, the bowels press against the catheter and make the dialysis fluid drain very slowly. The fluid may also get trapped in pockets of bowel, preventing it from draining properly. So it is very important to avoid constipation, perhaps by taking regular laxatives.

The PD catheter may become blocked with a substance called fibrin, which is a form of protein. It looks like tiny strands of cotton wool and is completely harmless. A patient may be able to clear the catheter simply by squeezing the tubing to dislodge the fibrin. Alternatively, a nurse will be able to clear the catheter by injecting water, saline (a salt solution) or a de-clotting agent called heparin, down the catheter. This is a simple procedure and will not need an operation. Some patients have to inject a small quantity of heparin into a single bag each day (usually the overnight bag) to dissolve any fibrin that accumulates in the peritoneum and hence keep the catheter clear.

Another reason for poor drainage is that the catheter is in the wrong position. Sometimes a displaced catheter will ‘float’ back into the right position naturally. If this does not happen, then an operation may be required to correct the position of the catheter.

Blood in PD fluid: Sometimes when PD fluid is drained out at the end of an exchange it may look slightly red or pinkish in colour. This happens if any of the small blood vessels in the peritoneum are broken. This can be caused by lifting something heavy or can happen while playing sport. In females, red or pink bags can occur during their period (menstruation). People are advised to contact their Unit if the bags don’t clear up in a few days, or if the fluid in the bags look very bloody, and not just stained red or pink.

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4. Physical Problems

Fluid overload: The amount of ‘used’ fluid that is drained out of the body after PD is about 1 to 1.5 litres per day more than the amount of fresh dialysis fluid that is put in. This extra fluid is in effect, the PD person’s urine. It does not increase in quantity however much the patient drinks. This means that people on PD have to restrict their drinking to avoid problems due to fluid overload, particularly when they stop passing urine. Fluid overload leads to an increase in body weight, high blood pressure, swollen ankles and shortness of breath.

Constipation: Many people on PD are prone to constipation. There are several reasons for this. People on PD (like many other who are not on dialysis!) do not have enough fibre (roughage) in their diet. Wholemeal or brown bread, fresh fruit and vegetables are good sources of fibre. Restrictions on fluid intake, certain fruit (patients on a potassium restriction), and decreased level of activity can all contribute to constipation. Constipation can cause problems with poor drainage of PD fluid. It is therefore important to avoid constipation, by taking regular laxatives, such as lactulose and senokot (senna) (more detail).

Hernia: A hernia occurs when a wall of muscle weakens and lets an organ or tissue out from inside. Hernias can cause difficulties for people on PD. If a person has a hernia before the PD catheter is put in, it can become more of a problem afterwards. The daily draining of PD fluid into and out of the abdomen can cause the hernia to become bigger (and more painful). If nothing is done, the bowel can become ‘stuck’ inside the hernia, thereby blocking the bowel. This will require an emergency operation. If an existing hernia is noticed by the surgeon during an operation to insert a PD catheter, it will be repaired during the same operation to prevent it causing problems in the future. If a hernia develops months or years after the catheter insertion, an operation is needed to repair it.

Itching: The normal level of phosphate in the blood is 0.8 to 1.4 mmol/L. On PD, people sometimes have a raised blood phosphate level. It is thought that a high phosphate level causes itching. Blood phosphate levels can be controlled by taking phosphate binders, and reducing phosphate intake in the diet. Sometimes medications such as hydroxyzine or chlorpheniramine (piriton) are used to relieve itching until the blood phosphate level is reduced. Iron deficiency and anaemia can also cause itching.

Pain and discomfort: Some people find PD is uncomfortable, or even painful, particularly when they first start treatment. Most people will get used to having fluid in their abdomen, but sometimes small people will be unable to tolerate more than 1.5-2 litres of fluid. A feeling of ‘fullness’ or of being ‘bloated’ after eating is quite common. People with back problems may be unable to tolerate CAPD and switch to APD (using smaller volumes of fluid by day, and larger volumes when lying down at night) or haemodialysis.

Cramp or Restless legs at night: Cramps and restless legs at night affect some people on PD. An imbalance in the levels of water and salt in the blood may be a factor in cramp. Stretching and massaging the limb can help. Quinine sulphate taken at bedtime helps prevent cramp. Restless leg syndrome (an irresistible urge to move the legs at night) can occur in kidney failure. It can be very stressful as it disrupts sleep, leading to tiredness during the day. A tablet called Clonazepam is sometimes used to treat this problem. It may also help the person to sleep.

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The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.

NKF Controlled Document No. 242: problems written: 26/01/2001 last reviewed: 20/10/2017