Editing Peritoneal dialysis (section)

==Complications==

=== PD-related peritonitis ===
A common cause of [[peritonitis]] is touch contamination, e.g. insertion of catheter by un-sanitized hands, which potentially introduces bacteria to the abdomen; other causes include catheter complication, transplantation of bowel bacteria, and systemic infections.<ref name=Himmelfarb18 /> Most common type of PD-peritonitis infection (80%) are from bacterial sources.<ref name=Himmelfarb18>{{Cite book| vauthors = Himmelfarb J, Ikizler TA |title=Chronic kidney disease, dialysis, and transplantation : companion to Brenner & Rector's the kidney|isbn=978-0-323-53172-6|chapter=32. Peritoneal Dialysis-Related Infections|oclc=1076544294 |date=2018|publisher=Elsevier Health Sciences }}</ref> Infection rates are highly variable by region and within centers with estimated rates between 0.06–1.66 episodes per patient year.<ref>{{cite journal | vauthors = Cho Y, Johnson DW | title = Peritoneal dialysis-related peritonitis: towards improving evidence, practices, and outcomes | language = English | journal = American Journal of Kidney Diseases | volume = 64 | issue = 2 | pages = 278–289 | date = August 2014 | pmid = 24751170 | doi = 10.1053/j.ajkd.2014.02.025 }}</ref> With recent technical advances peritonitis incidence has decreased over time.<ref name=Himmelfarb20 />

Antibiotics are needed if the source of infection is bacterial; there is no clear advantage for other frequently used treatments such as routine peritoneal lavage or use of [[urokinase]].<ref name="Bal2014">{{cite journal | vauthors = Ballinger AE, Palmer SC, Wiggins KJ, Craig JC, Johnson DW, Cross NB, Strippoli GF | title = Treatment for peritoneal dialysis-associated peritonitis | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005284 | date = April 2014 | pmid = 24771351 | doi = 10.1002/14651858.CD005284.pub3 | pmc = 11231986 }}</ref> The use of preventative nasal [[mupirocin]] is of unclear effect with respect to peritonitis.<ref>{{cite journal | vauthors = Campbell D, Mudge DW, Craig JC, Johnson DW, Tong A, Strippoli GF | title = Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients | journal = The Cochrane Database of Systematic Reviews | volume = 4 | pages = CD004679 | date = April 2017 | issue = 6 | pmid = 28390069 | pmc = 6478113 | doi = 10.1002/14651858.CD004679.pub3 }}</ref> Of the three types of connection and fluid exchange systems (standard, twin-bag and y-set; the latter two involving two bags and only one connection to the catheter, the y-set uses a single y-shaped connection between the bags involving emptying, flushing out then filling the peritoneum through the same connection) the twin-bag and y-set systems were found superior to conventional systems at preventing peritonitis.<ref>{{cite journal | vauthors = Daly C, Cody JD, Khan I, Rabindranath KS, Vale L, Wallace SA | title = Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage kidney disease | journal = The Cochrane Database of Systematic Reviews | issue = 8 | pages = CD003078 | date = August 2014 | volume = 2014 | pmid = 25117423 | pmc = 6457793 | doi = 10.1002/14651858.CD003078.pub2 }}</ref>

The fluid used for dialysis uses [[glucose]] as a primary osmotic agent. According to a 2020 review published in the ''American Journal of Nephrology'', some studies suggest that the use of glucose increases the risk of [[peritonitis]], possibly as a result of impaired host defenses, vascular disease, or damage to the peritoneal membrane.<ref>{{cite journal | last1=Uiterwijk | first1=Herma | last2=Franssen | first2=Casper F.M. | last3=Kuipers | first3=Johanna | last4=Westerhuis | first4=Ralf | last5=Nauta | first5=Ferdau L. | title=Glucose Exposure in Peritoneal Dialysis Is a Significant Factor Predicting Peritonitis | journal=American Journal of Nephrology | publisher=S. Karger AG | volume=51 | issue=3 | year=2020 | doi=10.1159/000506324 | pages=237–243| pmid=32069459 | pmc=7158228 }} "Other studies suggest that a high peritoneal glucose load increases the risk of peritonitis, perhaps as the effect of impaired host defenses, vascular disease, and damage to the peritoneal membrane [9, 10, 11]."</ref> The [[acid]]ity, high concentration and presence of [[Lactic acid|lactate]] and products of the degradation of glucose in the solution (particularly the latter) may contribute to these health issues{{Ambiguous|date=December 2021|reason=which health issues?}}.  Solutions that are [[neutral solution|neutral]], use [[bicarbonate]] instead of lactate and have few glucose degradation products may offer more health benefits though this has not yet been studied.<ref>{{cite journal | vauthors = Perl J, Nessim SJ, Bargman JM | title = The biocompatibility of neutral pH, low-GDP peritoneal dialysis solutions: benefit at bench, bedside, or both? | journal = Kidney International | volume = 79 | issue = 8 | pages = 814–824 | date = April 2011 | pmid = 21248712 | doi = 10.1038/ki.2010.515 | doi-access = free }}</ref>

The mortality rate of peritoneal dialysis related peritonitis is estimated to be 3-10%, with approximately 50% of cases resulting in hospitalization.<ref name="Teitelbaum 2021">{{cite journal |last1=Teitelbaum |first1=Isaac |title=Peritoneal Dialysis |journal=New England Journal of Medicine |date=4 November 2021 |volume=385 |issue=19 |pages=1786–95 |doi=10.1056/NEJMra2100152|pmid=34731538 |s2cid=242938564 }}</ref> Peritoneal fluid studies with a white blood cell count greater than 100 per μL and greater than 50% neutrophils strongly suggest peritonitis, with a definitive diagnosis based on culture of microorganisms from the peritoneal fluid.<ref name="Teitelbaum 2021" /> In order to avoid delaying treatment, a cloudy fluid in the dialysate fluid can be assumed to be due to peritonitis unless an alternative cause is identified.<ref name="Teitelbaum 2021" /> Peritonitis in those undergoing PD is usually due to [[gram positive bacteria]].<ref name="Teitelbaum 2021" /> Intraperitoneal antibiotics are preferred to [[intravenous]] as they have a greater effect at the area of infection, unless [[sepsis]] is present, in which case intravenous antibiotics are indicated.<ref name="Teitelbaum 2021" /> The peritoneal dialysis catheter may have to be removed if the infection does not resolve with antibiotics, and it is recommended that the PD catheter be removed in all cases of fungal peritonitis.<ref name="Teitelbaum 2021" />

=== Volume shifts ===
The volume of dialysate removed as well as patient's weight are monitored. If more than 500ml of fluid are retained or a liter of fluid is lost across three consecutive treatments, the patient's physician is generally notified.{{Citation needed|date=December 2021|reason=No reference for physicians being notified.}}  Excessive loss of fluid can result in [[Hypovolemia|hypovolemic shock]] or [[hypotension]] while excessive fluid retention can result in [[hypertension]] and [[edema]].  Also monitored is the color of the fluid removed:  normally it is pink-tinged for the initial four cycles and clear or pale yellow afterward.  The presence of pink or bloody effluent suggests bleeding inside the abdomen while feces indicates a [[Gastrointestinal perforation|perforated bowel]] and cloudy fluid suggests infection.  The patient may also experience pain or discomfort if the dialysate is too acidic, too cold or introduced too quickly, while diffuse pain with cloudy discharge may indicate an infection.  Severe pain in the [[rectum]] or [[perineum]] can be the result of an improperly placed catheter.  The dwell can also increase pressure on the [[thoracic diaphragm|diaphragm]] causing impaired breathing, and [[constipation]] can interfere with the ability of fluid to flow through the catheter.<ref name="Nursing" />

=== Chronic complications ===
Long term use of PD is rarely associated with fibrosis of the peritoneum.<ref name=Himmelfarb20 /> A potentially fatal complication estimated to occur in roughly 2.5% of patients is [[encapsulating peritoneal sclerosis]], in which the bowels become obstructed due to the growth of a thick layer of [[fibrin]] within the peritoneum.<ref>{{cite journal | vauthors = Kawanishi H, Moriishi M | title = Encapsulating peritoneal sclerosis: prevention and treatment | journal = Peritoneal Dialysis International | volume = 27 | issue = Suppl 2 | pages = S289–S292 | date = June 2007 | doi = 10.1177/089686080702702s49 | pmid = 17556321 | s2cid = 1050358 }}</ref>

=== Other ===
Other complications include [[low back pain]] and [[hernia]] or leaking fluid due to high pressure within the abdomen.<ref>{{cite book | vauthors = Himmelfarb J, Ikizler TA |url=http://worldcat.org/oclc/1076544294|title=Chronic kidney disease, dialysis, and transplantation : companion to Brenner & Rector's the kidney|isbn=978-0-323-53172-6|chapter=33. Noninfectious Complications of Peritoneal Dialysis |oclc=1076544294 |date=6 November 2018|publisher=Elsevier Health Sciences }}</ref> [[Hypertriglyceridemia]] and [[obesity]] are also concerns due to the large volume of glucose in the fluid, which can add 500-1200 [[calorie]]s to the diet per day.<ref>{{cite book| vauthors = Ehrman JK, Gordon P, Visich PS, Keteyian SJ |chapter=15. End-Stage Renal Disease §Peritoneal Dialysis |chapter-url= https://books.google.com/books?id=ZKC3_YPMU84C&pg=PA268|title=Clinical Exercise Physiology|publisher=Human Kinetics|year=2008|isbn=978-0-7360-6565-8|pages=268–9}}</ref>