A six-year-old girl with end stage renal disease has had a peritoneal dialysis catheter in place for nine months. She was treated with antibiotics for bacterial peritonitis three months ago and did well until last week when her catheter stopped working well. The effluent cultures reveal a fungal species. What is the next best next step in her management?

 

[size=20px]A Catheter removal and placement of temporary hemodialysis catheter

 

B Catheter removal and placement of new catheter on opposite side

 

C Antifungal therapy administered through the catheter

 

D Laparoscopic omentectomy and catheter reposition

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A

A

A

A.

 

Fungal peritonitis is associated with poor outcomes if the catheter remains in place, even with antifungal therapy.

A

A

A

Correct answer

A Catheter removal and placement of temporary hemodialysis catheter

 

Peritoneal dialysis (PD) is an attractive choice for renal replacement therapy in children. PD has the advantages of ease of use at home, allows for children to attend school, has less dietary restrictions, and there is no need for vascular access. Infection is considered the most common etiology for catheter failure. Most instances of PD catheter-related peritonitis can be managed with antibiotics. Relapsing bacterial infections may be treated with catheter removal and replacement in the same setting, but fungal infections require catheter removal and clearance of infection prior to reinsertion. Patients may require temporary hemodialysis access in those cases.

 

Expert panels have agreed on suggestions for PD catheter placement to prevent dysfunction: (1) Use of a double cuff catheter. (2) Placement of the deep cuff in the anterior abdominal musculature, and the subcutaneous cuff near the skin surface not less than 2 cm from the exit site. (3) Placement of the catheter exit laterally with the exit site directed downward or lateral. (4) Place the intra-abdominal portion of the catheter between the visceral and parietal peritoneum not in the middle of loops of bowel. (5) Performing a routine omentectomy. (6) Use of a straight rather than a coiled catheter. Recently, a randomized controlled trial was performed in adults that supported the use of straight catheter vs coiled catheter in terms of having lower malfunction rates.

Edited October 29, 20242 yr by Admin