Peritoneal dialysis (PD) is an effective treatment for patients with end-stage renal disease, based on the peritoneal membrane as a semi-permeable exchange surface ¹. In Tunisia, PD has been known since the early 1960s, when it was introduced as the first method of extrarenal purification, highlighting a long-standing but evolving experience with this technique ².

Compared with hemodialysis, PD offers several advantages, including greater patient autonomy, flexibility in treatment schedules, and better preservation of residual renal function ³. Nevertheless, its success depends on multiple factors, including patient training, prevention of infectious complications, and the proper function of the peritoneal dialysis catheter, with mechanical complications remaining a major source of morbidity, technique failure, and occasional conversion to hemodialysis ⁴.

Mechanical complications may also result from increased intra-abdominal pressure—leading to conditions such as hernias, hemoperitoneum, or hydrothorax—or from catheter-related issues, including dialysate leakage, migration, obstruction, or drainage failure. The incidence and types of these complications vary according to catheter insertion technique, center experience, patient characteristics, and the level of training of healthcare teams ⁴⁵.

The aim of this study was to describe the frequency, types, and management of mechanical complications in patients treated with peritoneal dialysis in a newly established Tunisian center, with particular emphasis on technique survival during the early phase of program implementation.

The success of PD relies on the placement of a functional and long-lasting peritoneal catheter. Mechanical complications remain a major cause of catheter loss and technique failure ⁶. In this retrospective study conducted in a newly established Tunisian PD center, mechanical complications occurred in 37% of patients, with catheter dysfunction being the most frequent event. Despite this relatively high incidence, PD technique survival was preserved, as no patient required permanent transfer to hemodialysis.

The overall rate of mechanical complications in our cohort is consistent with previously reported data, with frequencies generally ranging between 20% and 40% ⁷⁸. Catheter dysfunction, particularly migration and obstruction, represents the leading cause of early and late technical failure in PD ⁹. In this study, the overall incidence of catheter replacement or reinsertion was 2.16 per 100 patient-months. This incidence appears comparable to previously reported data, although variations exist depending on center experience and catheter insertion techniques ⁷. Intraluminal obstruction caused by fibrin, clots, or epiploic adhesions was less frequent, while functional obstruction due to constipation was successfully managed with conservative treatment. For this reason, routine prevention and early treatment of constipation are recommended in PD patients, as bowel distension may displace the catheter tip and impair dialysate flow ³. In our practice, preventive measures include systematic patient education, dietary advice to prevent constipation, and regular clinical monitoring of catheter function. Imaging is performed when dysfunction is suspected.

Catheter placement technique plays a critical role in preventing mechanical complications. In our center, initial catheter insertions were performed via mini-laparotomy, while laparoscopic techniques were reserved for reinsertion or repositioning, allowing direct visualization of the peritoneal cavity. This combined approach may have contributed to effective management of catheter-related complications. Published meta-analyses support laparoscopic insertion as associated with a lower risk of catheter migration and improved catheter survival at 12 and 24 months, compared with open surgery. Percutaneous insertion, often performed by nephrologists, has also shown comparable outcomes with fewer early peritonitis episodes and periprocedural complications ¹⁰.

Other mechanical complications were less frequent in our cohort. Dialysate leakage, hernia, and hemoperitoneum were rare and successfully managed with conservative or surgical treatment when required. Hernia formation is influenced by intra-abdominal pressure, which is affected by dialysate volume, exchange frequency, patient positioning, and individual anatomical factors ¹¹¹². This highlights the need for patient-specific preventive measures, particularly in individuals with prior abdominal surgery, weakened abdominal wall, or central obesity.

The implementation of peritoneal dialysis programs in resource-limited settings, particularly in African countries, is often challenged by limited infrastructure, variability in training, and restricted access to surgical expertise. In this context, the early phase of PD program development is considered critical, with a potentially higher risk of complications and technique failure ¹³. Although data specifically focusing on mechanical complications in such settings remain scarce, several reports have highlighted the feasibility of establishing PD programs with acceptable outcomes when appropriate training, organization, and multidisciplinary collaboration are ensured ¹⁴.

This study has several limitations, including its retrospective design, small sample size, and relatively short follow-up period, which limit the generalizability of the results and preclude the identification of risk factors for mechanical complications. In addition, the single-center nature of the study and the absence of a comparative group further limit the external validity of our findings. Nevertheless, this work represents one of the first single-center Tunisian experiences focusing specifically on mechanical complications of PD in a newly established program.

Our findings emphasize that, even in resource-limited settings, PD can be successfully implemented with acceptable complication rates and preserved technique survival when appropriate surgical expertise, close monitoring, and multidisciplinary collaboration between nephrologists, surgeons, and PD nurses are ensured.

Mechanical complications remain an important challenge in peritoneal dialysis, particularly during the early phase of newly established programs. Ensuring meticulous catheter insertion, early recognition of complications, and structured multidisciplinary follow-up is essential to maintain catheter function and preserve technique survival. Our experience supports the feasibility of developing peritoneal dialysis programs in emerging centers when appropriate surgical expertise and standardized management strategies are implemented.