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      Continuous ambulatory peritoneal dialysis—a guide to imaging appearances and complications

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          Abstract

          Objectives

          The aim of this article is to review and illustrate the typical imaging findings for a patient on continuous ambulatory peritoneal dialysis (CAPD) and its complications, examining the uses and limitations of multimodality imaging.

          Background

          CAPD is a commonly and increasingly used method of renal replacement therapy in end-stage renal failure (ESRF). From the set-up and insertion of the peritoneal catheter through to the actual treatment, there are pitfalls and complications that may adversely affect the patient and compromise the success of the dialysis. Complications can be either immediate or delayed, and can also be categorised into infectious and non-infectious aetiologies, including catheter failure, dialysate leaks, hernias and encapsulating sclerosing peritonitis.

          Conclusion

          Early recognition of complications, both clinically and on the different imaging modalities, is essential in the management of CAPD in order to reduce treatment failure and limit patient morbidity and mortality.

          Main messages

          • Complications of peritoneal dialysis cause patient morbidity and treatment failure.

          • Early recognition of complications from normal appearances is essential to limit dialysis failure.

          • Multimodality imaging plays an important role in the diagnosis of these complications.

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          Most cited references 27

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          Sclerosing peritonitis: the experience in Australia.

           R Rigby,  C Hawley (1997)
          Sclerosing peritonitis (SP) is a rare but serious complication of peritoneal dialysis (PD). Small-bowel obstruction (SBO) due to encapsulation, dense adhesions, or mural fibrous is characteristic, often associated with peritonitis. The aim of the study was to determine the incidence, clinical features, effect of duration of dialysis, and other possible aetiological factors in severe SP. All dialysis units in Australia were surveyed for possible cases up to 1994. Patients were included if there was either surgical or radiological evidence of sclerosing encapsulating peritonitis or SBO with tanned or thickened peritoneum in the absence of other causes of SBO. Fifty-four patients were analysed. The duration of continuous PD was mean 52 +/- 30 months, median 48 months and range 8-127 months. Nineteen cases were diagnosed between 1980 and 1989 and 35 between 1990 and 1994, giving mean annual incidences 1.9 and 4.2 per 1000 PD periods respectively. The overall prevalence was 0.7%, which increased progressively with the duration of PD being 1.9, 6.4, 10.8, and 19.4% for patients on dialysis for > 2, 5, 6 and 8 years respectively. Sclerosing encapsulating peritonitis was diagnosed in 87% of cases, SBO in 92%, and haemoperitoneum in 8%. Peritoneal calcification was present in seven cases, all of which had been on PD > 7 years. Peritonitis was associated with 38% of cases with fungal infection in 7%. Treatment with immunosuppression in five patients appeared to result in a favourable outcome in three. The mortality rate was 56%. Severe sclerosing peritonitis is a serious complication of peritoneal dialysis and there is a time dependent increase on CAPD.
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            Dialysate leaks in peritoneal dialysis.

            Dialysate leakage represents a major noninfectious complication of peritoneal dialysis (PD). An exit-site leak refers to the appearance of any moisture around the PD catheter identified as dialysate; however, the spectrum of dialysate leaks also includes any dialysate loss from the peritoneal cavity other than via the lumen of the catheter. The incidence of dialysate leakage is somewhat more than 5% in continuous ambulatory peritoneal dialysis (CAPD) patients, but this percentage probably underestimates the number of early leaks. The incidence of hydrothorax or pleural leak as a complication of PD remains unclear. Factors identified as potentially related to dialysate leakage are those related to the technique of PD catheter insertion, the way PD is initiated, and weakness of the abdominal wall. The pediatric literature tends to favor Tenckhoff catheters over other catheters as being superior with respect to dialysate leakage, but no consensus on catheter choice exists for adults in this regard. An association has been found between early leaks (< or =30 days) and immediate CAPD initiation and perhaps median catheter insertion. Risk factors contributing to abdominal weakness appear to predispose mostly to late leaks; one or more of them can generally be identified in the majority of patients. Early leakage most often manifests as a pericatheter leak. Late leaks may present more subtly with subcutaneous swelling and edema, weight gain, peripheral or genital edema, and apparent ultrafiltration failure. Dyspnea is the first clinical clue to the diagnosis of a pleural leak. Late leaks tend to develop during the first year of CAPD. The most widely used approach to determine the exact site of the leakage is with computed tomography after infusion of 2 L of dialysis fluid containing radiocontrast material. Treatments for dialysate leaks include surgical repair, temporary transfer to hemodialysis, lower dialysate volumes, and PD with a cycler. Recent recommendation propose a standard approach to the treatment of early and late dialysate leaks: 1-2 weeks of rest from CAPD, and surgery if recurrence. Surgical repair has been strongly suggested for leakage causing genital swelling. Delaying CAPD for 14 days after catheter insertion may prevent early leakage. Initiating CAPD with low dialysate volume has also been recommended as a good practice measure. Although peritonitis and exit-site infections are the most frequent causes of technical failure in peritoneal dialysis (PD), dialysate leaks represent one of the major noninfectious complications of PD. In some instances, dialysate leakage may lead to discontinuation of the technique (1). Despite its importance, the incidence, risk factors, management, and outcome of dialysate leakage are poorly characterized in the literature. We will review the limited available information on this topic in the next few sections.
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              Pathogenesis of peritoneal fibrosing syndromes (sclerosing peritonitis) in peritoneal dialysis.

               W Dobbie (1991)
              Drawing from diverse sources including epidemiological and clinical data, surgical observations, histopathology, serosal healing responses to fibrin and fibrinolysis, tissue reaction to chronic exposure, and to exo- and endotoxins, new information on mesothelial stem cells, autocrine and paracrine influences on their proliferation and collagen synthesis, and the effect of glucose on fibroconnective tissue, we have begun to piece together the pathogenetic jigsaw of fibrosis in continuous ambulatory peritoneal dialysis (CAPD). The reaction of peritoneal mesothelium and stroma to the stress of continual dialysis results in a spectrum of alterations ranging from opacification through a tanned peritoneum syndrome to sclerosing encapsulating peritonitis (SEP). Any agent that causes irritation of the mesothelial layer and induces serositis, or single severe or multiple episodes of peritonitis resulting in mesothelial loss, predisposes the peritoneum to fibroneogenesis. An accurate definition of the histopathological changes of peritoneal thickening is a prerequisite for defining pathogenesis. This paper is the first attempt to create such a framework. It is evident from many areas of study that fibrin deposition and fibrinolysis, hyalinization of the superficial stromal collagen possibly tanned through nonenzymatic glycosylation by dialysate glucose and the proliferative potential of mesothelial stem cells play an important and possibly interdependent role in excessive fibroneogenesis in certain patients on CAPD. Many of the pieces of the jigsaw are obviously still missing, and the picture is most surely incomplete. Nevertheless, the outline of the pathologic and etiologic landscape should now be discernible.
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                Author and article information

                Contributors
                +44-1865-741166 , goldsteinmark@yahoo.co.uk
                maclacarrillo@gmail.com
                Sangeet.Ghai@uhn.on.ca
                Journal
                Insights Imaging
                Insights Imaging
                Insights into Imaging
                Springer-Verlag (Berlin/Heidelberg )
                1869-4101
                6 December 2012
                6 December 2012
                February 2013
                : 4
                : 1
                : 85-92
                Affiliations
                [ ]Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals, Headley Way, Oxford, OX3 9DU UK
                [ ]Joint Department of Medical Imaging, University of Toronto, Toronto General Hospital, 200 Elizabeth St., Toronto, ON M5G 2C4 Canada
                Article
                203
                10.1007/s13244-012-0203-y
                3579998
                23225216
                © The Author(s) 2012
                Categories
                Pictorial Review
                Custom metadata
                © The Author(s) 2013

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