Direct Re-Insertion of a Catheter: CON: Practice patterns in bowel program prior to PD catheter insertion in the Netherlands and Belgium

Peritoneal dialysis (PD)-associated infections are an important cause of PD technique failure. Timely PD catheter removal is mandatory in case of severe peritonitis in order to preserve the peritoneum for future peritoneal dialysis and to prevent morbidity and mortality. Refractory peritonitis, fungal peritonitis and relapsing or repeat peritonitis therefore require catheter removal. Besides, PD catheter removal is warranted in clinical situations associated with severe catheter-related infection, i.e. refractory exit site or tunnel infection, or exit site or tunnel infection with concomitant peritonitis with the same organism.Return to PD is possible in most patients requiring removal of the PD catheter because of PD-associated infections. Although only limited data are available on the optimal time between catheter removal and reinsertion, a two-step approach with a PD catheter-free period of 2 to 3 weeks between removal and reinsertion is generally adopted.Observational data showed feasibility of simultaneous PD catheter removal and reinsertion in case of refractory tunnel infection and in the setting of relapsing or repeat peritonitis whenever the procedure was done under antibiotic coverage and after bacterial effluent cultures became negative, the PD effluent cell count was lower than 100/mcL and in the absence of concomitant exit site or tunnel infection. While the effectiveness of simultaneous PD catheter removal and reinsertion is demonstrated in cases of Gram-positive infections, feasibility of a 1-step approach remains unclear for Pseudomonas, fungal, mycobacterial and severe enteric peritonitis episodes.Treatment of PD-associated infections should always consider long-term PD technique success. Adequate treatment of PD infections, including a PD catheter-free period if necessary to ensure that the source of infection is controlled, will increase the cure rate and reduce long-term problems with ultrafiltration and technique failure.In situations of unresolved peritonitis or uncontrolled source of infection, e.g. refractory peritonitis, fungal peritonitis, peritonitis with concomitant exit-site or tunnel infection or severe tunnel infection with deep cuff involvement, simultaneous PD catheter removal and reinsertion will hinder infection control and peritoneal membrane integrity. In these situations, a 2-step approach for PD catheter removal and reinsertion should be set-up without direct reinsertion of a new PD catheter after PD catheter removal.In patients with some degree of residual kidney function, a dialysis pause may be considered after PD catheter removal instead of temporary hemodialysis. Diuretics, dietary measures, and potassium binders may help in postponing dialysis need. Urgent-start PD after 2nd step PD catheter reinsertion may help to avoid temporary hemodialysis. When temporary dialysis rest is not possible after PD catheter removal in patients with severe and/or uncontrolled peritonitis or PD catheter infection, only temporary hemodialysis and adequate source control of infection - including a PD catheter-free period - will support future viability of PD