Management of refractory peritonitis to maintain the peritoneum for subsequent dialysis

Peritonitis and its sequelae remain major clinical problems in treating peritoneal dialysis (PD) patients. One of these sequelae is the formation of intra-abdominal adhesions, preventing a patient from returning to peritoneal dialysis after a Tenckhoff catheter is removed for refractory peritonitis. We have recently applied a technique that appears to reduce the incidence of this severe complication. When it is determined that a catheter will be removed for refractory peritonitis, hourly peritoneal dialysis exchanges are performed for 12 hr prior to surgery. Postoperatively, the abdomen is rested for 48 hr, after which a temporary peritoneal dialysis catheter is placed at the bedside and hourly exchanges (with antibiotics) are performed for 2-3 days or until the dialysis fluid white blood cell count improves. Then the temporary catheter is removed and the abdomen is rested until the Tenckhoff catheter is replaced in 10-14 days. We treated 5 consecutive patients with refractory peritonitis (2 Pseudomonas, 1 Proteus, 1 Candida, 1 S. aureus) with this technique. All 5 patients were able to return successfully to peritoneal dialysis. At our institution over the past five years, 9 patients with refractory peritonitis due to the same organisms have had their catheters removed. Only 5 (56%) were able to return to PD. Although preliminary, our technique holds promise for those patients wishing to return to peritoneal dialysis after having a catheter removed for refractory peritonitis.