1. Recurrent Outflow Failure and Encapsulation of a PD Catheter in One Patient
ASDIN Blog Entry
2016
Stephen R. Ash, MD, FACP
Nephrology, Indiana University Health Arnett, and Ash Access Technology, Lafayette, Indiana.

2. Patient History and first outflow failure with inflow pain
69 year old patient with hypertensive nephrosclerosis started on hemodialysis in 2010
Failure of several attempts to create AV fistula.
First PD catheter placed surgically 4/11, without difficulty, lateral border of rectus on left side.
By 5/11 had pain with inflow/outflow of PD fluid, limited volume exchange. Encapsulation of catheter was seen with IP dye injection. Attempts at passing guidewire were painful and this procedure was abandoned.
In 7/11 PD cath was repositioned laparoscopically from mid-abd level and fibrous plug removed. Lots of omentum was seen but no omentopexy was done.
PD continued without problems except intermittent nausea and vomiting until 5/12.

3. Pain on inflow and outflow of flushes 5/11, pain with attempted reposition

4. Second outflow failure with inflow pain
5/12 had pain in LUQ with inflow, and greatly diminished fluid tolerance and outflow volume
Reposition planned.
Dye injection indicated again an encapsulation of the PD catheter by omental space, and little communication of encapsulated area to the peritoneum.
New PD catheter placed peritoneoscopically on right with coil in left lower abdomen and old catheter removed.
No adhesions were seen in the peritoneum but a large amount of omental tissue was seen. Catheter in LUQ was not visualized.

5. LUQ pain on inflow and outflow failure 5/12

6. 5/12 some dye progressed to around spleen, none returned

7. Third outflow failure with inflow pain
PD continued uneventfully until 11/12
Day before Thanksgiving, patient had RUQ pain with inflow and limited outflow drainage.
Dye injection indicated again encapsulation of the PD catheter by omentum, this time around the liver.
There was no communication of encapsulated area to the peritoneum.

8. 11/12 RUQ pain on inflow and outflow failure

9. 11/12 all dye was trapped in a space around the liver

10. Questions What is the cause of all three outflow failures?
What is your next step to provide dialysis for this patient?