Applied Nephrology Master Series

Chapter 12 Mechanical Complications

CHAPTER MISSION Turn poor drain, swelling, a new bulge, breathlessness, pain or unexpected free air into a mechanism-based diagnosis: decide whether the catheter-flow system or the pressure/boundary system has failed; correct reversible causes in the least invasive order; localise structural defects; preserve PD with pressure-sparing treatment when safe; and escalate to radiologic or surgical rescue before a correctable mechanical problem becomes technique failure.

Figure 12.1 — Mechanical complications are two systems. Flow failure asks what blocks or mispositions the catheter; pressure/boundary failure asks where dialysate or mechanical force has escaped. Naming the failed system prevents indiscriminate prescription changes.

MASTER PRINCIPLE Mechanical complications are not one list of unrelated events. Think FLOW and PRESSURE. Flow failure asks whether dialysate can move through the catheter. Pressure/boundary failure asks whether dialysate remains within the intended compartment and whether the patient tolerates the intraperitoneal volume. Name the failed system before changing the prescription or abandoning PD.

0. One-page chapter map

Table 12.1 — The eight decisions that govern mechanical-complication care.

Decision	Core question	Bedside output
1. Threat	Is there bowel compromise, a strangulated hernia, severe respiratory compromise or another emergency?	Urgent surgical / hospital pathway when needed
2. Phenotype	Is this primarily flow failure, a leak, a hernia, pleural transfer, pain or free air?	Named mechanical syndrome
3. Catheter	Is dysfunction outflow-predominant or two-way?	Mechanism shortlist
4. Pressure	Is fill volume, posture, straining or a fresh access track increasing mechanical stress?	Pressure-driver assessment
5. Localise	Which bedside test or image will identify the site of failure?	X-ray / ultrasound / CT peritoneography / pleural studies as appropriate
6. Correct	Is there a reversible bowel, bladder, fibrin, connector or prescription problem?	Least-invasive correction
7. Rescue	Does the patient need radiologic manipulation, laparoscopy, hernia repair or thoracic intervention?	Definitive structural plan
8. Verify	Is PD now reliable, comfortable and sustainable?	Function + symptom + delivery reassessment

Learning outcomes

Distinguish catheter-flow dysfunction from pressure/boundary complications at the first bedside assessment.
Use the direction of flow failure—outflow-predominant versus two-way—to narrow the mechanism.
Recognise constipation as the most common reversible cause of PD catheter outflow dysfunction and assess urinary retention when clinically relevant.
Distinguish intraluminal fibrin/blood-clot obstruction from catheter kink, tip migration, omental wrapping and adhesions.
Apply a stepwise catheter-rescue strategy that progresses from reversible and non-invasive causes to radiologic or laparoscopic intervention.
Recognise early and late dialysate leaks and select imaging according to the suspected anatomical pathway.
Assess hernias for reducibility and emergency features, and use pressure-conscious PD around repair.
Diagnose PD hydrothorax without relying on an invented universal pleural-fluid glucose cutoff.
Distinguish volume overload from diaphragmatic splinting and pleuroperitoneal leak in a breathless PD patient.
Troubleshoot infusion pain, drain pain and pneumoperitoneum without masking surgical or infectious disease.
Use current ISPD/GREX activity guidance rather than advising every patient to exercise with an empty abdomen.
Preserve PD when a mechanical complication is correctable, while recognising when definitive repair or modality transition is safer.

EVIDENCE POSTURE The current adult ISPD access guideline listed by ISPD remains the 2019 update, which recommends a two-week break-in when possible, low-volume recumbent PD for urgent starts, and a conservative-to-invasive sequence for catheter dysfunction. The 2023 SAGES update adds contemporary GRADE surgical guidance but repeatedly rates certainty as very low. The 2024 CJASN mechanical-complications review and 2023 AJKD Core Curriculum provide current clinical synthesis. Therefore this chapter states firm guideline thresholds only where they exist and deliberately avoids universal pressure cutoffs, fixed post-repair restart intervals, or a single diagnostic pleural-glucose threshold unsupported by evidence. [1–7]

1. Core concept: mechanical complications are flow failure or boundary failure

Mechanical complications interrupt PD because either dialysate cannot move reliably through the access system or because intraperitoneal fluid and pressure act outside their intended space. These mechanisms overlap: a hernia can alter drainage, constipation can displace a catheter, and a prescription that is technically adequate for clearance can be mechanically intolerable. The first bedside task is therefore classification, not intensification. [1,3,4]

Table 12.2 — The two-system model.

System	Typical failures	First clinical question
Flow	Constipation, urinary retention, fibrin/blood clot, kink, migration, omental wrap, adhesions	Can dialysate enter and leave through the catheter normally?
Pressure / boundary	Pericatheter leak, abdominal-wall/genital leak, hernia, hydrothorax, splinting, pressure-related pain	Is dialysate staying in the intended compartment and is the volume mechanically tolerated?

BEDSIDE TRANSLATION “Low drain volume” is not a diagnosis. Before adding exchanges or hypertonic solution, decide whether the missing volume is trapped behind a flow problem, has escaped through a leak, or reflects true ultrafiltration physiology. Cross-reference Chapter 8 when the question is membrane UF rather than mechanical loss.

2. Intra-abdominal pressure: fill volume is also a mechanical dose

Instilled dialysate increases intra-abdominal pressure (IAP). Pressure varies with fill volume, body habitus, abdominal-wall compliance, posture, cough/strain and individual anatomy. Upright posture generally raises pressure relative to supine treatment. A fresh catheter tract or pre-existing weak point may fail under a pressure that another patient tolerates easily. No single universally validated “safe IAP” threshold should therefore be used as a bedside mandate. [1,3,4]

Table 12.3 — Pressure drivers and bedside consequences.

Driver	Mechanical effect	Prescription consequence
Higher fill volume	Greater abdominal-wall and diaphragmatic load	Reduce volume when pressure symptoms/leak risk outweigh clearance gain
Upright dwell	Often higher IAP than supine dwell	Supine APD can be a pressure-sparing architecture
Fresh catheter tract	Incomplete tissue sealing	Traditional break-in preferred when possible; urgent start requires low-volume recumbent strategy
Constipation / straining	Transiently increases pressure and can compress/displace catheter	Treat bowel dysfunction as both flow and pressure prevention
Cough / heavy lifting	Brief high-pressure spikes	Individualise activity and address persistent cough/strain
Hernia / congenital communication	Provides a low-resistance escape pathway	Pressure reduction alone may palliate; structural repair treats the defect

PRESSURE DISCIPLINE Do not chase a clearance number with progressively larger fills when the patient develops reflux, pain, a leak, hernia symptoms or respiratory compromise. The mechanically tolerated prescription is part of adequate PD.

3. First assessment: classify the phenotype before ordering a rescue procedure

Mechanical presentations are usually recognisable from a small number of patterns: poor drain, poor fill plus poor drain, new swelling/bulge, new pleural effusion, pain during a specific phase of exchange, or free intraperitoneal air. Threat assessment comes first because strangulated hernia, bowel perforation and severe respiratory compromise do not belong in an outpatient troubleshooting loop.

Table 12.4 — Presentation to first hypothesis.

Presentation	Think first	Immediate discriminator
Fills normally, drains slowly/incompletely	Constipation, tip migration, omental/adhesion entrapment	Bowel history + plain abdominal radiograph
Poor inflow and poor outflow	Kink, intraluminal fibrin/blood clot, connector/tubing problem	Inspect system; image catheter; consider irrigation
Abdominal-wall/genital oedema or exit-site fluid	Dialysate leak	Timing after insertion + exam + localising imaging if needed
New reducible bulge	Hernia	Standing/strain examination; reducibility
Tender irreducible bulge +/- vomiting/obstruction	Incarceration/strangulation	Urgent surgical assessment
New unilateral pleural effusion	Pleuroperitoneal communication	Pleural studies + simultaneous serum glucose; imaging if uncertain
Pain only during inflow/drain	Flow mechanics / position / solution factors	Phase-specific history + catheter/bowel assessment
Free subdiaphragmatic air	Technique-related air versus perforation	Symptoms/peritoneal signs + effluent studies + imaging

THREAT GATE Mechanical explanations must never delay emergency assessment of a rigid/focal abdomen, bowel obstruction, tender irreducible hernia, sepsis, haemodynamic instability or severe respiratory compromise.

4. Catheter flow dysfunction: use the direction of failure

Figure 12.2 — Catheter flow failure is directional. Outflow-predominant dysfunction points first toward constipation, migration or tissue entrapment; two-way obstruction raises the probability of kink or intraluminal material. The distinction is not absolute, but it makes the first investigation more efficient.

ISPD recommends approaching catheter dysfunction in a logical sequence from conservative/non-invasive causes toward more invasive rescue. Most flow dysfunction presents as outflow failure. The most common cause is constipation; urinary retention is less common but can similarly compress the catheter. Kink and intraluminal fibrin or blood clot more often produce two-way obstruction. A plain abdominal radiograph is a high-yield early test because it can show faecal loading, tip migration and obvious kink. [1]

Table 12.5 — Flow phenotype to mechanism.

Flow pattern	Mechanisms to prioritise	First actions
Outflow-predominant	Constipation, bladder distension, tip migration, omental/adhesion entrapment	Bowel/bladder assessment; plain radiograph; correct reversible cause
Two-way poor flow	Kink, fibrin/blood clot, severe compression, connector/tubing problem	Inspect line; radiograph; saline irrigation when appropriate
Intermittent positional failure	Tip position, omental contact, constipation, posture-dependent kink	Compare positions; radiograph; bowel correction
Sudden failure after previously normal function	Constipation, fibrin/clot, migration	Treat reversible cause before invasive rescue
Recurrent failure after manipulation	Persistent anatomic cause	Avoid endless temporary manipulation; definitive access review

5. Constipation and bladder distension: the reversible causes to find first

Constipation is the most common cause of PD catheter outflow dysfunction in the ISPD access guideline. A distended colon can compress the drainage holes or displace the catheter tip. The clinical clue is often a change from previously reliable drainage accompanied by reduced bowel frequency, hard stools or radiographic faecal loading. Treat constipation deliberately before assuming catheter failure. [1,3,4]

Table 12.6 — Bowel and bladder troubleshooting.

Finding	Mechanism	Direction
New constipation + poor drain	Colonic distension compresses/displaces catheter	Use an effective bowel regimen and reassess drainage
Radiograph shows faecal loading	Supports mechanical bowel contribution	Treat bowel burden before invasive access procedure
Suprapubic fullness / urinary symptoms	Bladder distension can compress catheter	Assess retention and relieve according to clinical pathway
Flow normalises after bowel treatment	Reversible extrinsic cause confirmed	Build prevention into routine PD care
Flow remains poor despite correction	Another catheter mechanism exists	Proceed to position/kink/intraluminal/tissue-entrapment pathway

CLINICAL PEARL A bowel regimen is part of PD access maintenance. It is not merely symptom treatment. Constipation can simultaneously impair drainage, raise IAP and worsen pain.

6. Intraluminal obstruction: fibrin and blood are a catheter problem, not a membrane problem

When constipation, bladder distension and obvious catheter malposition are excluded, intraluminal fibrin or blood clot becomes important—particularly with two-way flow impairment or visible fibrin. ISPD describes brisk saline irrigation first; if obstruction remains and clot is suspected, a fibrinolytic such as tissue plasminogen activator can be used according to centre protocol. Exact dose, dwell and compatibility should not be improvised from memory. [1]

Table 12.7 — Intraluminal obstruction reasoning.

Clue	Interpretation	Action direction
Visible fibrin + two-way poor flow	Intraluminal obstruction likely	Check for peritonitis/bleeding context; saline irrigation
Recent bloody effluent + abrupt blockage	Blood clot possible	Irrigation; centre-protocol fibrinolytic if appropriate
No response to irrigation/fibrinolytic	Structural problem or organised obstruction	Image and escalate
Repeated fibrin formation	Underlying inflammatory driver possible	Assess for peritonitis/other cause rather than repeated rescue alone

SAFETY BOUNDARY Do not place an exact fibrinolytic dose in a teaching algorithm unless it is verified against the current local PD access/pharmacy protocol. Catheter material, concentration, dwell, contraindications and bleeding risk matter.

7. Migration, kink, omental wrap and adhesions: know when anatomy must be rescued

After reversible extrinsic causes and intraluminal obstruction are addressed, persistent dysfunction usually reflects catheter position or tissue interaction. Cephalad migration can impair drainage; a kink may be intramural or intraperitoneal; omentum or adhesions can trap the tip or side holes. Plain radiography identifies many position problems, while CT or contrast studies can clarify selected cases. [1,3]

Radiologic guidewire manipulation can restore position without general anaesthesia but success is variable and recurrence is common when the underlying anatomic problem remains. Laparoscopy provides direct diagnosis and allows cause-specific treatment such as adhesiolysis, omental management or catheter repositioning. SAGES 2023 makes a conditional recommendation for either operative or non-operative salvage, reflecting very low-certainty comparative evidence; local expertise, patient preference, procedural burden and previous failure should determine the route. [2]

Table 12.8 — Access rescue: match the procedure to the problem.

Problem	Potential rescue	Why it may fail
Simple migration without fixed entrapment	Radiologic manipulation or laparoscopic repositioning	Catheter memory / recurrence
Omental wrap	Laparoscopic release +/- omental procedure	Repeated manipulation does not remove tissue cause
Adhesion entrapment	Laparoscopic adhesiolysis	Extensive adhesions may limit durable function
Kink	Revision or replacement depending location	Manipulation may not correct fixed geometry
Repeated failed salvage	Definitive replacement may be more patient-centred	Procedural burden can exceed benefit

DO NOT AUTOMATE A malfunctioning catheter does not automatically need replacement—and repeated radiologic manipulations are not automatically “less invasive” from the patient’s perspective. Choose the rescue that is most likely to correct the named anatomical cause durably.

8. Early pericatheter leak and urgent-start PD

Dialysate leak is escape of dialysis solution from the peritoneal cavity. ISPD commonly classifies early versus late leaks around 30 days after catheter insertion. Early leaks arise before tissue ingrowth and wound healing have formed a secure boundary. Risk is influenced by insertion technique, timing of PD start, fill volume and abdominal-wall stress. [1,3,4]

ISPD recommends delaying PD initiation for approximately 2 weeks after catheter placement when possible (1B). When urgent start is clinically necessary within that interval, low-volume intermittent exchanges in the recumbent position with the abdomen dry during ambulatory periods are recommended (1C). The Cochrane review found that urgent-start PD may increase dialysate leak compared with conventional start, but the evidence is low/very low certainty. [1,8]

Table 12.9 — Early leak phenotype.

Finding	Interpretation	Management direction
Fluid around exit/wound soon after start	Pericatheter track leak	Reduce IAP; consider PD rest or low-volume recumbent strategy
Abdominal-wall oedema after fresh catheter	Occult tissue-plane leak	Stop pressure escalation; localise if persistent/uncertain
Leak during urgent start	Fresh tract + treatment pressure	Use protected urgent-start protocol; cross-reference Chapter 6
Persistent or dramatic early leak	Structural/wound failure possible	Access-team/surgical review rather than repeated pressure challenge

CROSS-REFERENCE Chapter 6 covers urgent-start prescription architecture. This chapter covers what to do when the pressure barrier fails.

9. Late leaks: localise the pathway rather than assuming ultrafiltration failure

Figure 12.3 — Dialysate can escape through several pathways. Abdominal-wall or genital oedema, new weight gain and unexpectedly low drain volume can represent extraperitoneal dialysate rather than loss of membrane ultrafiltration. Localisation changes treatment.

Late leaks may occur through an abdominal-wall defect, hernia, persistent catheter track, retroperitoneal pathway, patent processus vaginalis or an occult infected tunnel. Presentations include abdominal-wall oedema, genital swelling, an apparent new “mass,” unexpected weight gain or reduced net ultrafiltration. [1,3,4]

ISPD recommends CT peritoneography or peritoneal scintigraphy when a boundary leak is suspected and requires localisation (1A). Ultrasound can help with superficial pericatheter collections or pseudohernia. If the leak is associated with tunnel infection, it is an infectious source-control problem and Chapter 11 applies. [1]

Table 12.10 — Late leak patterns.

Pattern	Likely pathway	Best next question
Scrotal/labial oedema	Patent processus vaginalis / inguinal communication	Is there an inguinal defect requiring repair?
Focal abdominal-wall swelling	Wall defect / pericatheter pseudohernia	Does imaging show dialysate outside the cavity?
Generalised wall oedema + low apparent UF	Occult extraperitoneal leak	Is “lost UF” actually dialysate tracking?
Leak + tunnel inflammation	Catheter-related infection	Enter Chapter 11 source-control pathway
Recurrent leak after rest alone	Uncorrected structural communication	Localise and repair rather than repeat rest indefinitely

10. Hernias: distinguish reducible anatomy from surgical emergency

PD increases mechanical load on the abdominal wall and can make pre-existing defects clinically evident. Umbilical, inguinal, incisional and other ventral hernias may present as a bulge that enlarges with standing or straining. A new reducible hernia is usually a repair-planning problem; a tender irreducible hernia, particularly with vomiting, bowel obstruction or peritonism, requires urgent surgical assessment for incarceration or strangulation.

The 2023 SAGES guideline conditionally favours staged hernia repair followed by PD catheter insertion over simultaneous repair and catheter insertion in adults when medically possible, but the certainty is very low. For established PD patients needing hernia repair, no universal evidence-based number of “days off PD” applies to every repair. Postoperative dialysis should be individualised with the surgeon and PD team, commonly using lower-volume supine therapy when the repair and clinical state permit. [2,9]

Table 12.11 — Hernia decision matrix.

Phenotype	Priority	PD direction
Small reducible, asymptomatic/mild symptoms	Elective surgical review	Pressure-conscious prescription while awaiting plan
Enlarging or symptomatic reducible hernia	Timely repair	Avoid unnecessary high upright fills
Tender irreducible hernia	Emergency surgical assessment	Do not continue routine exchanges while delaying evaluation
Post-repair, stable and surgeon permits PD	Protect repair	Low-volume supine restart with gradual titration
Recurrent hernia	Reassess anatomy + pressure drivers	Definitive surgical/access plan rather than repeated temporary reductions

NO INVENTED RESTART CLOCK Evidence does not support one fixed restart interval for every hernia repair. Type of repair, tissue quality, urgency, wound status, residual kidney function and dialysis need all modify the plan.

11. Hydrothorax: a pleural effusion can be dialysate

Figure 12.4 — PD hydrothorax is a pleuroperitoneal communication. A new unilateral—classically right-sided—pleural effusion with dyspnoea or reduced apparent UF should trigger simultaneous pleural and serum testing and, when needed, imaging to demonstrate the communication. There is no single universal diagnostic pleural-glucose cutoff.

Pleuroperitoneal communication allows dialysate to cross a diaphragmatic defect into the pleural space. Hydrothorax is usually unilateral and predominantly right-sided. Patients may have dyspnoea, reduced net drain volume or may occasionally be minimally symptomatic. Chest imaging often shows a unilateral effusion without the bilateral pulmonary congestion pattern expected from simple fluid overload. [1,3,10,11]

Thoracentesis commonly shows a transudative effusion with pleural glucose higher than simultaneous serum glucose. In a review of verified cases, pleural-fluid-to-serum glucose ratios were >1, but the absolute gradient varied widely; therefore a low gradient does not exclude the diagnosis and no single universal cutoff should be treated as definitive. When biochemical findings are equivocal or anatomical confirmation is needed, CT peritoneography or radionuclide scintigraphy can demonstrate the communication. [10]

Confirmed symptomatic hydrothorax usually requires PD interruption/rest and drainage of the pleural space when clinically indicated, with temporary haemodialysis if required. Persistent or recurrent communication should prompt thoracic surgical assessment; video-assisted thoracoscopic repair and/or pleurodesis can allow many patients to return to PD. [1,11]

Table 12.12 — Hydrothorax versus ordinary volume overload.

Feature	PD hydrothorax	Volume overload / cardiac effusion
Distribution	Often unilateral, usually right	Often bilateral but variable
Pulmonary congestion	May be absent despite large effusion	May accompany systemic/pulmonary congestion
Apparent PD UF	May fall as dialysate enters pleura	May be genuinely insufficient relative to intake
Pleural glucose	Often exceeds simultaneous serum	Usually not dialysate-like
Definitive question	Is there pleuroperitoneal communication?	Is sodium/water balance positive?

DIAGNOSTIC DISCIPLINE Do not label every pleural effusion “PD hydrothorax,” and do not dismiss hydrothorax because the pleural glucose gradient is not dramatically high. The diagnosis is a pattern plus confirmation of communication.

12. Respiratory mechanics and back pain: a full abdomen changes biomechanics

Intraperitoneal dialysate elevates the diaphragm and alters trunk mechanics. Some patients develop breathlessness from diaphragmatic splinting without pleural transfer; others experience reflux, early satiety or back discomfort from increased abdominal load and lumbar postural change. Symptoms that improve promptly after drainage suggest a mechanical volume effect, but cardiopulmonary disease and true volume overload must still be excluded. [3,4]

Table 12.13 — Mechanical symptom versus competing diagnosis.

Symptom	Mechanical clue	Do not miss
Breathlessness with full abdomen, improves after drain	Diaphragmatic splinting / fill intolerance	Pulmonary oedema, hydrothorax, infection, cardiac disease
Back pain worse during larger fills	Postural/mechanical load	Independent spinal/neurologic disease
Reflux/fullness	High intraperitoneal volume/pressure	GI pathology if persistent or atypical
Poor sleep on APD	Fill/drain discomfort or alarms	Chapter 9 delivery/prescription mismatch

PRESCRIPTION LEVER For pressure-related symptoms, smaller ambulatory fills, greater use of supine treatment and a prescription that preserves the required dialysis goal with lower mechanical burden may be more effective than simply “tolerating” discomfort.

13. Infusion pain and drain pain: the phase of the exchange is diagnostic

Pain that occurs only during inflow has a different differential from pain that appears as the abdomen empties. Inflow pain can reflect cold solution, rapid jet/position effects, solution characteristics or catheter contact. Drain pain is classically related to negative pressure and catheter tip contact with pelvic structures, and it may be worsened by constipation or malposition. Persistent pain deserves an anatomical diagnosis rather than chronic analgesia alone. [3,4]

Table 12.14 — Phase-specific PD pain.

Pain timing	Think first	Corrective direction
During inflow	Solution temperature, flow jet, catheter position, irritant solution	Check warming/process, inflow mechanics and position; exclude peritonitis if symptoms are not phase-limited
Near end of drain	Negative pressure / pelvic catheter contact	Check constipation and catheter position; adjust drain strategy
Repeated cycler drain alarms + pain	Drain mechanics or malposition	Treat cause; consider tidal PD only after correctable causes excluded
Pain throughout dwell	Not typical isolated mechanical drain pain	Evaluate peritonitis, leak, pressure intolerance, visceral pathology

CROSS-REFERENCE Chapter 9 covers tidal PD as a prescription tool. Tidal therapy should not be used to hide a kink, migration, severe constipation or another treatable mechanical lesion.

14. Pneumoperitoneum: free air is commoner in PD, but perforation still comes first

Small amounts of intraperitoneal air can be introduced during PD connections, incomplete bag priming or exchanges and may be detected incidentally. Contemporary reviews report wide prevalence estimates. However, the presence of a PD catheter does not neutralise the usual danger of free air: bowel perforation must be considered first when there is abdominal pain, peritoneal irritation, systemic illness or an atypical clinical course. [3]

Table 12.15 — Pneumoperitoneum reasoning.

Context	Interpretation	Action
Asymptomatic, small incidental free air	Technique-related air possible	Review connection/priming technique and observe clinically
Free air + abdominal pain	Perforation or peritonitis must be excluded	Urgent clinical assessment; effluent studies; imaging/surgical review as indicated
Recurrent benign free air	Repeated air entry during exchanges	Observe technique and retrain
Shoulder-tip discomfort after exchanges	Intraperitoneal air can irritate diaphragm	Remove technique source; do not dismiss if abdominal findings concerning

BOARD TRAP “PD patients often have free air” is not permission to ignore a surgical abdomen. The safe sequence is perforation first, technique second.

15. External catheter damage and connector failure

External catheter cracks, cuts or connector damage create two simultaneous problems: loss of mechanical integrity and potential contamination. If a break is identified, the system should be clamped proximal to the defect where feasible and the patient should contact the PD programme immediately. Whether a damaged segment can be repaired/spliced or requires catheter replacement depends on the location and remaining usable tubing. [1]

If the system was open or contaminated, manage the event using the wet-contamination/peritonitis-prevention pathway in Chapter 10. If the damage involves the tunnel/exit site or infection, Chapter 11 applies. Mechanical repair never replaces contamination assessment.

Table 12.16 — Catheter damage: two parallel decisions.

Decision	Question	Output
Mechanical	Can the external segment be safely repaired without compromising catheter integrity?	Repair/splice versus replacement
Contamination	Was the closed system breached or contaminated fluid able to enter?	Dry/wet contamination pathway
Infection	Is the exit/tunnel inflamed or draining?	Chapter 11 evaluation
Delivery	Can PD be performed reliably after repair?	Functional verification before routine use

16. Prevention: pressure management without unnecessary restriction

Mechanical-complication prevention begins before dialysis starts: appropriate catheter placement, inspection and repair planning for abdominal-wall defects, constipation prevention, a protected break-in when possible, and a prescription that respects pressure tolerance. SAGES 2023 conditionally favours traditional over urgent start where medically possible; ISPD recommends a two-week break-in where circumstances allow. [1,2]

Exercise advice should be specific rather than restrictive. ISPD/GREX practice recommendations state that the abdomen does not need to be drained for activities that do not substantially raise IAP, such as walking, hiking or jogging, unless fullness is uncomfortable. For higher-IAP activities such as weightlifting or jumping, draining the abdomen before exercise is advised. Evidence quality is limited, so activity is individualised. [7]

Table 12.17 — Mechanical prevention bundle.

Intervention	Why it matters	Practice translation
Break-in when possible	Allows tract/wound healing	Traditional start preferred where clinically feasible
Protected urgent start	Reduces pressure on fresh access	Low-volume recumbent exchanges; dry ambulatory periods
Bowel regularity	Prevents compression, displacement and straining	Routine constipation prevention/treatment
Hernia awareness	Identifies weak points before emergency	Examine new bulges; repair appropriately
Pressure-conscious fills	Reduces leak/hernia/symptom burden	Do not increase fill beyond mechanical tolerance
Exercise-specific abdomen strategy	Avoids unnecessary sedentary restriction	Drain before high-IAP activity; not required for routine low-IAP activity
Technique competence	Reduces introduced air and line damage	Observe exchanges when recurrent air/mechanical events occur

ACTIVITY RULE Do not tell every PD patient to remain inactive or exercise only with an empty abdomen. Preserve life participation while identifying activities that materially raise IAP and modifying the prescription around them.

17. Keeping PD going: correct the cause, then rebuild a sustainable prescription

Many mechanical complications are correctable and do not require permanent conversion to haemodialysis. The goal is not to preserve PD at any cost; it is to preserve a preferred and effective modality when the mechanical problem can be corrected safely. A successful rescue restores reliable flow, contains dialysate within the intended cavity, avoids recurrent pain or respiratory compromise, and permits the prescribed treatment to be delivered consistently. [1–4]

Table 12.18 — Mechanical rescue hierarchy.

Level	Examples	Decision principle
1. Reversible bedside cause	Constipation, bladder distension, connector issue, air-entry technique	Fix before invasive procedure
2. Intraluminal rescue	Saline irrigation; protocol-based fibrinolytic	Use when clot/fibrin is plausible
3. Diagnostic localisation	X-ray, ultrasound, CT peritoneography, pleural studies	Choose the test that answers the anatomical question
4. Minimally invasive salvage	Radiologic manipulation	Useful when anatomy is amenable and durable success plausible
5. Operative repair	Laparoscopic catheter rescue, hernia repair, VATS diaphragmatic repair	Treat structural cause directly
6. Planned modality transition	Irreparable/recurrent mechanical failure or patient preference	Shared decision, not reflex failure

VERIFY After every mechanical intervention, document: inflow, outflow, net UF interpretation, symptoms, leaks/bulges, prescription delivery and patient burden. A technically “patent” catheter that repeatedly interrupts therapy is not fully rescued.

18. Major clinical algorithms

Flowchart 12.1 — Poorly draining PD catheter. Start with the direction of flow failure and correct bowel/bladder/line causes before advancing to intraluminal or anatomical rescue.

Flowchart 12.2 — Suspected dialysate leak. Timing helps distinguish a fresh-track pressure failure from a late structural communication; persistent or recurrent leaks require localisation and definitive repair.

Flowchart 12.3 — Hernia and hydrothorax source control. Emergency hernia features bypass routine PD troubleshooting; pleural disease requires biochemical/anatomical confirmation rather than assumption.

Flowchart 12.4 — Pain, breathlessness and pneumoperitoneum. The symptom phenotype determines whether to pursue catheter mechanics, pressure/volume physiology, pleural transfer or a surgical abdomen.

19. Retention tables: pattern recognition

Table 12.19 — If you see this, think this first.

Finding	First hypothesis	Immediate action
Fills well, drains poorly + constipation	Colonic compression/displacement	Treat constipation; radiograph if needed
Poor inflow + poor outflow	Kink or intraluminal obstruction	Inspect tubing; image; consider irrigation
Sudden low UF + abdominal-wall oedema	Dialysate leak	Stop pressure escalation; localise if needed
New scrotal/labial oedema	Inguinal communication / patent processus	Surgical/anatomical assessment
Tender irreducible hernia	Incarceration/strangulation	Urgent surgery
Right pleural effusion + no pulmonary congestion	PD hydrothorax	Pleural/serum glucose + confirm communication
Breathlessness only with full abdomen	Splinting / pressure intolerance	Drain/reduce volume; still exclude cardiac/pulmonary disease
End-drain pelvic pain	Negative-pressure tip contact	Check constipation/position; adjust drain strategy
Free air + benign exam	Technique air possible	Review priming/connection
Free air + focal abdominal pain	Perforation/peritonitis	Emergency evaluation

Table 12.20 — What not to confuse.

Do not confuse	With	Correction
Low drain volume	Intrinsic UF failure	Check flow and leak before membrane diagnosis
Constipation	Minor unrelated symptom	It is the commonest reversible outflow cause
Radiographic migration	Automatic need for replacement	Choose radiologic vs laparoscopic rescue based on cause/context
Early leak	Automatic permanent HD transfer	Pressure-sparing rest/modified PD may permit recovery
Reducible hernia	Strangulated hernia	Tender irreducible/obstructive phenotype is emergency
Unilateral effusion	Automatic heart failure	Consider pleuroperitoneal communication
Pleural glucose gradient <50 mg/dL	Hydrothorax excluded	No universal exclusion threshold
Drain pain	Reason for analgesics only	Find catheter/bowel/negative-pressure cause
Pneumoperitoneum in PD	Automatically benign	Perforation must be excluded when clinically concerning
Exercise on PD	Always requires empty abdomen	Drain mainly for higher-IAP activity; individualise

20. Clinical pearls

1. Poor drain + constipation is a bowel problem until proved otherwise.

2. Outflow-only versus two-way failure is a rapid mechanism filter.

3. A plain abdominal radiograph can answer three early questions at once: faecal load, catheter position and kink.

4. Do not use fibrinolytic therapy to treat a catheter that is visibly kinked or displaced.

5. When repeated manipulation fails, ask what fixed anatomical cause has not been corrected.

6. A leak can masquerade as ultrafiltration failure because dialysate is lost into tissue rather than the drain bag.

7. Supine low-volume PD is a pressure-sparing tool, not a universal substitute for definitive repair.

8. A tender irreducible hernia is a surgical problem before it is a dialysis-prescription problem.

9. Right-sided pleural effusion without pulmonary congestion should trigger the hydrothorax question.

10. Pleural glucose greater than simultaneous serum supports hydrothorax; a modest gradient does not exclude it.

11. Breathlessness relieved by draining can reflect mechanical splinting rather than total-body fluid overload.

12. Infusion pain and drain pain have different mechanisms—ask exactly when the pain occurs.

13. Tidal PD may reduce drain pain, but only after constipation and catheter malposition have been addressed.

14. Free air can be technique-related; a surgical abdomen cannot.

15. The best mechanical rescue is the least burdensome intervention likely to correct the named cause durably.

21. Common pitfalls — and the correction

Table 12.21 — High-frequency errors in mechanical PD care.

Pitfall	Why it fails	Correction
Increasing glucose concentration for low drain volume	Treats presumed UF when flow/leak may be cause	Verify mechanics first
Skipping bowel history	Misses commonest reversible outflow problem	Ask and treat constipation early
Repeated tPA without imaging	Cannot correct migration/kink/omentum	Match rescue to mechanism
Repeated radiologic manipulation after recurrent failure	May create procedural burden without durability	Escalate to definitive anatomical review
Calling early leak “technique failure”	Many heal with pressure protection	Use protected rest/low-volume recumbent strategy when safe
Managing recurrent leak with rest alone	Structural defect remains	Localise and repair
Waiting on a tender irreducible hernia	Risks bowel compromise	Urgent surgical pathway
Using one pleural-glucose cutoff as absolute	Diagnostic gradients vary	Interpret ratio/context and image if uncertain
Calling all PD breathlessness overload	Misses splinting/hydrothorax	Examine volume state + pleural/pressure phenotype
Treating recurrent drain pain only with tidal settings	Masks constipation or malposition	Correct cause before prescription workaround
Assuming free air is from PD	Can miss perforation	Threat assessment first
Blanket advice to avoid exercise	Reduces life participation without evidence	Use activity-specific IAP guidance

22. Mini-cases: decisions, not trivia

Case 1 — The constipated catheter

A stable CAPD patient who previously drained normally develops slow, incomplete outflow over 3 days. Inflow is normal. He has not opened his bowels for 4 days.

BEST NEXT STEP The phenotype is outflow-predominant and constipation is the leading reversible cause. Treat bowel dysfunction and reassess catheter drainage before arranging invasive catheter salvage.

Case 2 — Two-way obstruction after bloody effluent

A patient develops poor inflow and poor outflow after an episode of blood-stained dialysate. The catheter position is unchanged on radiograph and there is no major faecal loading.

BEST NEXT STEP Intraluminal blood/fibrin is plausible. Use the centre access protocol: saline irrigation first, then a verified fibrinolytic strategy if appropriate. Do not invent the dose or skip bleeding/peritonitis assessment.

Case 3 — The catheter that keeps migrating

A catheter is successfully repositioned radiologically twice but again migrates and drains intermittently.

BEST NEXT STEP Temporary repositioning has not corrected the durable anatomical problem. Discuss laparoscopic diagnosis/rescue or replacement rather than an indefinite cycle of manipulations.

Case 4 — Urgent-start wall oedema

Five days after catheter insertion, a patient on low-volume urgent-start PD develops new oedema around the lower abdominal wall and unexpectedly poor net drain volume.

BEST NEXT STEP Treat this as a suspected early dialysate leak. Reduce/stop intraperitoneal pressure according to clinical dialysis need, keep the patient recumbent for any protected exchanges, and involve the access team if the leak is significant or persistent.

Case 5 — A new groin bulge

A patient notices a reducible groin bulge that enlarges when standing. There is no pain, vomiting or obstruction.

BEST NEXT STEP This is an elective hernia phenotype, not an emergency. Arrange surgical repair planning and use a pressure-conscious PD prescription while avoiding unnecessary interruption.

Case 6 — The “heart-failure” effusion

A euvolaemic PD patient develops progressive dyspnoea and a large right pleural effusion without pulmonary congestion. Net PD UF appears to have fallen.

BEST NEXT STEP Suspect pleuroperitoneal communication. Sample pleural fluid with simultaneous serum glucose and use CT peritoneography/scintigraphy if confirmation remains uncertain. Do not assume a low absolute glucose gradient excludes hydrothorax.

Case 7 — Cycler pain at every final drain

APD is complete except for severe pelvic pain during the final part of each drain. There is no abdominal pain during the dwell and effluent is clear.

BEST NEXT STEP Think negative-pressure catheter contact, constipation or malposition. Correct reversible causes first; a tidal strategy can then be considered if anatomy is acceptable and pain persists.

Case 8 — Free air and abdominal pain

A PD patient has subdiaphragmatic free air on chest radiograph and new focal abdominal tenderness.

BEST NEXT STEP Do not label this technique-related pneumoperitoneum. Treat it as possible perforation/surgical disease: urgent examination, effluent studies and imaging/surgical assessment as appropriate.

23. Active recall

MUST MEMORIZE

Table 12.22 — Core facts.

Prompt	Answer
Two mechanical systems?	Flow failure and pressure/boundary failure
Most common cause of outflow dysfunction?	Constipation
Outflow-only failure suggests?	Constipation, migration, omental/adhesion entrapment
Two-way failure suggests?	Kink or intraluminal fibrin/blood clot, among other causes
Early high-yield image for poor flow?	Plain abdominal radiograph
Break-in when possible?	Approximately 2 weeks after catheter insertion
Urgent-start pressure strategy?	Low-volume recumbent exchanges; dry when ambulatory
Imaging for occult leak?	CT peritoneography or peritoneal scintigraphy
Emergency hernia phenotype?	Tender irreducible +/- bowel obstruction/peritonism
Typical hydrothorax side?	Usually right-sided
Does low pleural glucose gradient exclude hydrothorax?	No
Pleural/serum glucose pattern supporting hydrothorax?	Pleural glucose greater than simultaneous serum supports communication in context
Persistent hydrothorax after rest?	Thoracic surgical repair/pleurodesis pathway
Drain pain: first correctable causes?	Constipation and catheter position/mechanics
Pneumoperitoneum with pain?	Exclude perforation/peritonitis before benign technique explanation
Exercise: empty abdomen for walking/jogging?	Not routinely required unless uncomfortable
Exercise: empty abdomen for high-IAP weightlifting/jumping?	Recommended by ISPD/GREX practice points
Mechanical success after rescue?	Reliable flow, no leak, tolerable symptoms and complete delivered PD

USE AS REFERENCE

Exact fibrinolytic agent/dose/dwell and contraindications.
Contrast agent and local CT-peritoneography protocol.
Perioperative antibiotic and anticoagulation protocols for access surgery.
Exact postoperative PD restart plan after individual hernia/abdominal/thoracic surgery.
Radiologic manipulation technique and sedation requirements.
Pleurodesis agent selection and VATS procedural approach.

24. Flashcards: spaced repetition

1. Q: Poor outflow + constipation? A: Treat constipation before declaring catheter failure.

2. Q: Poor inflow + outflow? A: Think kink or intraluminal obstruction; inspect/image.

3. Q: First image for catheter dysfunction? A: Plain abdominal radiograph.

4. Q: Visible fibrin + poor flow? A: Irrigation, then protocol-based fibrinolytic if appropriate.

5. Q: Migration after repeated manipulation? A: Consider definitive laparoscopic rescue/replacement.

6. Q: Early leak mechanism? A: Fresh tract + intraperitoneal pressure before full healing.

7. Q: Preferred break-in when possible? A: About 2 weeks.

8. Q: Urgent-start posture? A: Recumbent, low-volume; dry ambulatory period.

9. Q: Genital oedema? A: Think inguinal communication/patent processus vaginalis.

10. Q: Occult leak imaging? A: CT peritoneography or peritoneal scintigraphy.

11. Q: Tender irreducible hernia? A: Emergency surgical assessment.

12. Q: Hydrothorax classic pattern? A: New usually right-sided pleural effusion, dyspnoea, reduced apparent UF.

13. Q: Pleural glucose rule? A: Higher than simultaneous serum supports; no universal cutoff excludes.

14. Q: Uncertain hydrothorax? A: Demonstrate communication with CT peritoneography/scintigraphy.

15. Q: Persistent/recurrent hydrothorax? A: VATS repair and/or pleurodesis assessment.

16. Q: Breathlessness relieved by drain? A: Think diaphragmatic splinting/fill intolerance; still exclude overload/pleural disease.

17. Q: Drain pain? A: Negative-pressure tip contact, constipation or malposition.

18. Q: Tidal PD role? A: Symptom strategy after correctable mechanical causes excluded.

19. Q: Free air without symptoms? A: Technique-related air possible; review priming/connections.

20. Q: Free air with focal pain? A: Exclude perforation urgently.

21. Q: Exercise walking? A: Abdomen need not routinely be empty.

22. Q: High-IAP lifting/jumping? A: Drain abdomen before activity.

23. Q: Mechanical prevention bowel principle? A: Maintain regular bowel function.

24. Q: End point of rescue? A: Reliable, comfortable, sustainable delivered PD.

25. Rapid differential / troubleshooting

Table 12.23 — Mechanical troubleshooting from problem to action.

Problem	Differential	First actions
Slow drain only	Constipation, migration, omentum/adhesions	Bowel review/treatment; plain radiograph
Poor fill and drain	Kink, fibrin/clot, connector problem	Inspect system; radiograph; irrigation if appropriate
Intermittent positional drain	Migration/omentum/constipation	Position test; bowel correction; image
New wall swelling + low UF	Leak	Reduce pressure; localise if persistent
Genital oedema	Patent processus/inguinal leak	CT peritoneography/surgical review
New reducible hernia	Abdominal-wall defect	Surgical plan + pressure-conscious PD
Tender irreducible hernia	Incarceration/strangulation	Emergency surgery
Dyspnoea + right effusion	Hydrothorax	Pleural studies + simultaneous serum glucose; confirm communication
Dyspnoea only when full	Splinting, high fill, overload	Drain response + volume/cardiopulmonary assessment
Pain during inflow	Solution/flow/position	Review warming, flow and catheter position
Pain at final drain	Negative pressure, constipation, malposition	Treat constipation; assess position; consider tidal if appropriate
Incidental free air	Technique air	Observe exchange/priming; retrain
Free air + abdominal signs	Perforation/peritonitis	Urgent diagnostic/surgical pathway
External catheter crack	Mechanical breach + contamination	Clamp proximal; contact unit; contamination pathway
Repeated mechanical events	Persistent anatomy/process problem	Multidisciplinary access CQI review

26. Final revision sheet

CORE CONCEPT Mechanical PD failure is solved fastest by naming the system first. FLOW failure requires a sequence from bowel/bladder and intraluminal causes to position/tissue rescue. PRESSURE/BOUNDARY failure requires reduction of mechanical stress, localisation of the escape pathway and repair of the anatomical weak point when it persists.

Table 12.24 — One-minute revision.

Domain	Must remember
Flow	Outflow-only versus two-way narrows mechanism
Constipation	Commonest reversible outflow cause
Imaging	Plain radiograph early for flow; CT peritoneography/scintigraphy for leaks
Intraluminal obstruction	Irrigation -> verified local fibrinolytic protocol when appropriate
Migration/omentum/adhesions	Radiologic or laparoscopic rescue based on anatomy/context
Break-in	~2 weeks when possible
Urgent start	Low-volume recumbent; dry when ambulatory
Leak	Think pressure + anatomical pathway; do not call it UF failure
Hernia	Tender irreducible = emergency
Hydrothorax	Usually right; pleural glucose > serum supports, but no absolute cutoff
Pain	Phase of exchange is diagnostic
Free air	Perforation first when symptomatic
Exercise	No blanket empty-abdomen rule; drain for high-IAP activity
Goal	Correct cause and preserve sustainable PD where safe

TEN TAKE-HOME RULES 1) Start with FLOW versus PRESSURE. 2) Constipation is the commonest reversible outflow cause. 3) Use flow direction to narrow the differential. 4) Do not use fibrinolytic therapy for an anatomical kink/migration. 5) Protect a fresh catheter with a break-in when possible and low-volume recumbent urgent start when not. 6) A leak can masquerade as UF failure. 7) Tender irreducible hernia is an emergency. 8) Right pleural effusion without congestion is hydrothorax until assessed; no single glucose cutoff is absolute. 9) Pain and free air require mechanism-specific threat assessment. 10) Preserve PD when the defect is correctable, not when repeated rescue only prolongs failure.

Table 12.25 — One-minute bedside synthesis.

If you see...	Think...	Do now...
Poor drain + constipation	Extrinsic outflow obstruction	Treat bowel cause
Poor inflow + outflow	Kink/fibrin/clot	Inspect + image +/- irrigation
Wall oedema + low UF	Leak	Pressure control + localise
Tender irreducible bulge	Strangulated/incarcerated hernia	Urgent surgery
Right effusion + dyspnoea	Pleuroperitoneal communication	Pleural/serum glucose + confirmation
Pain only at drain	Negative-pressure mechanics	Bowel/position assessment
Free air + focal pain	Possible perforation	Urgent evaluation
Recurrent failure after temporary rescue	Uncorrected anatomy	Definitive access review

FINAL MENTAL MODEL Threat -> FLOW or PRESSURE -> reversible cause -> localise anatomy -> least-burdensome durable rescue -> pressure-conscious PD restart -> verify reliable delivery.

Rapid oral viva

Explain the difference between outflow-predominant and two-way catheter dysfunction.
Why is constipation the first reversible cause to address?
When is a fibrinolytic reasonable and when is it the wrong intervention?
Compare radiologic manipulation with laparoscopic catheter rescue.
Define the protected urgent-start strategy and explain why it reduces leak risk.
How do you recognise an occult late dialysate leak?
What makes a hernia an emergency?
Diagnose hydrothorax without relying on a single glucose threshold.
Distinguish diaphragmatic splinting, hydrothorax and volume overload.
Differentiate infusion pain, drain pain and pain that should trigger peritonitis/surgical evaluation.
How should pneumoperitoneum be approached in a PD patient?
Give current ISPD/GREX advice about exercise with a full or empty abdomen.

SAFETY BOUNDARY This chapter teaches clinical reasoning and guideline architecture. Exact fibrinolytic dosing, contrast-peritoneography technique, procedural sedation, perioperative antibiotic/anticoagulation management, timing of PD reintroduction after a specific operation and details of thoracic or abdominal surgery require the current local access, radiology, surgical and pharmacy protocols. Surgical abdomen, bowel compromise and respiratory instability supersede routine PD troubleshooting.

27. Selected authoritative references

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2. Haggerty SP, Kumar SS, Collings AT, et al. SAGES peritoneal dialysis access guideline update 2023. Surg Endosc. 2024;38(1):1–23. https://doi.org/10.1007/s00464-023-10550-8. PMID: 37989887.

3. Cheng XBJ, Bargman J. Complications of Peritoneal Dialysis Part I: Mechanical Complications. Clin J Am Soc Nephrol. 2024;19(6):784–790. https://doi.org/10.2215/CJN.0000000000000417. PMID: 38190178.

4. Khan SF. Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023. Am J Kidney Dis. 2023;82(4):481–490. https://doi.org/10.1053/j.ajkd.2023.03.011. PMID: 37436349.

5. Brown EA, Blake PG, Boudville N, et al. International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int. 2020;40(3):244–253. https://doi.org/10.1177/0896860819895364. PMID: 32063219.

6. Briggs VR, Jacques RM, Fotheringham J, Maheswaran R, Campbell M, Wilkie ME. Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients. Cochrane Database Syst Rev. 2023;2(2):CD012478. https://doi.org/10.1002/14651858.CD012478.pub2. PMID: 36810986.

7. Bennett PN, Bohm C, Harasemiw O, et al. Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations. Perit Dial Int. 2022;42(1):8–24. https://doi.org/10.1177/08968608211055290. PMID: 34743628.

8. Htay H, Johnson DW, Craig JC, Teixeira-Pinto A, Hawley CM, Cho Y. Urgent-start peritoneal dialysis versus conventional-start peritoneal dialysis for people with chronic kidney disease. Cochrane Database Syst Rev. 2020;12(12):CD012913. https://doi.org/10.1002/14651858.CD012913.pub2. PMID: 33320346.

9. Lew SQ, Collins A. When end-stage kidney disease complicates abdominal surgery. Semin Dial. 2020;33(3):270–278. https://doi.org/10.1111/sdi.12872. PMID: 32277515.

10. Momenin N, Colletti PM, Kaptein EM. Low pleural fluid-to-serum glucose gradient indicates pleuroperitoneal communication in peritoneal dialysis patients: presentation of two cases and a review of the literature. Nephrol Dial Transplant. 2012;27(3):1212–1219. https://doi.org/10.1093/ndt/gfr393. PMID: 21771760.

11. Chow KM, Szeto CC, Li PKT. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial. 2003;16(5):389–394. https://doi.org/10.1046/j.1525-139x.2003.16080.x. PMID: 12969393.

12. Kim JK, Lolas M, Keefe DT, et al. Omental Procedures During Peritoneal Dialysis Insertion: A Systematic Review and Meta-Analysis. World J Surg. 2022;46(5):1183–1195. https://doi.org/10.1007/s00268-021-06413-9. PMID: 35076821.

13. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial. 2001;14(1):50–54. https://doi.org/10.1046/j.1525-139x.2001.00014.x.

14. Prischl FC, Muhr T, Seiringer EM, et al. Magnetic resonance imaging of the peritoneal cavity among peritoneal dialysis patients, using the dialysate as contrast medium. J Am Soc Nephrol. 2002;13(1):197–203. https://doi.org/10.1681/ASN.V131197.

15. Prasad N, Agarwal V, Mishra P, et al. Modalities of Diagnosis and Management of Peritoneal Dialysis-related Hydrothorax Including Videothoracoscopy-assisted Repair: A Single-center Experience. Indian J Nephrol. 2021;31(6):562–567. https://doi.org/10.4103/ijn.IJN_101_20. PMID: 35068768.

16. Auguste BL, Bargman JM. Peritoneal Dialysis Prescription and Adequacy in Clinical Practice: Core Curriculum 2023. Am J Kidney Dis. 2023;81(1):100–109. https://doi.org/10.1053/j.ajkd.2022.07.004. PMID: 36208963.