Managing peritoneal dialysis catheter after kidney transplant

Abstract

Introduction: Peritoneal dialysis is a kidney replacement therapy with outcomes comparable to hemodialysis, although kidney transplantation remains the optimal treatment. The appropriate timing for removing the peritoneal dialysis catheter after transplantation is uncertain, as it may affect patient recovery and graft performance. This study aimed to evaluate infectious complications associated with retained peritoneal dialysis catheters after transplantation and to identify a suitable moment for their removal.

Methods: A retrospective review of all patients who underwent kidney transplantation between January 2013 and June 2023 was performed. Descriptive and inferential analyses were used to assess the timing of catheter removal, catheter-related infections, and post-transplant dialysis needs. Continuous variables were analyzed with the Mann-Whitney U test, while nominal variables were evaluated using Chi-square or Fisher’s exact tests.

Results: The median time to catheter removal was 4.5 months. Infectious complications occurred in 21 patients, representing 17.2% of the cohort, with exit-site infections being the most frequent event. Donor type and prior infections did not significantly influence infection rates. In living-donor transplantations, only 4.5% of catheters were removed during the transplant surgery.

Discussion: These findings support individualized decisions regarding peritoneal dialysis catheter removal, particularly for patients with a low risk of delayed graft function. A risk-based decision algorithm is proposed to assist clinicians. Although current practice aligns with existing guidance, the infectious risks linked to maintaining the catheter suggest that earlier removal should be considered. A tailored approach may improve clinical outcomes and facilitate a safer transition from peritoneal dialysis to kidney transplantation.

INTRODUCTION

Peritoneal dialysis (PD) is an effective kidney replacement therapy (KRT) with outcomes comparable to those of hemodialysis; however, it remains underutilized worldwide ¹. Kidney transplantation (KT), when achievable, is considered the optimal KRT. An important aspect of the KT process is the management of the PD catheter, as it may influence patient and graft outcomes ². Currently, no consensus has been reached regarding the optimal timing for PD catheter removal after transplantation. Although some authors report a lower incidence of delayed graft function (DGF) in patients previously treated with PD, European guidelines suggest that the catheter may be left in situ for 3–4 months despite a functioning graft ³⁴. The main advantage of this approach is the possibility of performing KRT in the event of graft non-function due to post-transplant complications, thereby avoiding the need for additional devices such as a hemodialysis central venous catheter ⁵.

With regard to PD, infectious complications are the most frequent adverse events and may involve the exit site or tunnel and, in more severe cases, progress to peritonitis. Moreover, kidney transplant recipients are at particularly high risk of infectious complications because of immunosuppressive induction regimens ⁶. This study aimed to evaluate outcomes related to PD catheter management after KT by analyzing data from our center on PD catheter-associated infectious complications and catheter use after KT and to propose a tailored algorithm for PD catheter removal following KT.

METHODS

We conducted a retrospective single-center study that included all adult patients previously treated with PD who underwent KT at our center between January 1, 2013, and June 30, 2023. The study was conducted in accordance with the Declaration of Helsinki, and informed consent was obtained according to institutional requirements.

The primary outcome was the occurrence of clinically significant PD catheter-related infectious complications leading to PD catheter removal after KT. Infectious complications were defined as exit-site infection, intraoperative evidence of purulent discharge, tunnel infection, or peritonitis when these events resulted in the clinical decision to remove the PD catheter.

Less severe infectious events that were treated conservatively and did not result in catheter removal were not included in the primary outcome, and this approach was chosen to focus on events with direct clinical and logistical impact.

Secondary outcomes included the occurrence of delayed graft function (DGF), the need for KRT after transplantation, and the dialysis modality used.

Patients whose PD catheters were removed during KT surgery were excluded from the primary outcome analysis but were included in the analysis of secondary outcomes.

PD catheter management and follow-up

PD Catheter management and follow-up extended from the time of KT until PD catheter removal. Before hospital discharge, catheter extensions were removed by the PD nursing team to reduce the risk of contamination. Exit-site care consisted exclusively of cleansing using soap and water.

PD catheters were removed according to institutional practice once graft function was considered stable, typically after the first post-transplant month. Catheter removal was performed by mini-laparotomy by a dedicated surgical team. Direct measures of graft function or graft survival were not evaluated.

Descriptive statistics were used to characterize the study population. Continuous variables were expressed as medians with interquartile ranges (IQRs) and categorical variables as absolute numbers and percentages. Normality was assessed using the Kolmogorov–Smirnov test.

Comparisons between patients with and without PD catheter-related infections were performed using the Mann–Whitney U test for continuous variables and the chi-square or Fisher’s exact test for categorical variables, as appropriate.

Given the limited number of infectious events, multivariable analysis was not performed as this would have resulted in an unfavorable events-per-variable ratio and an increased risk of model overfitting and unstable estimates. Therefore, results are presented as univariable comparisons. Time-to-event analyses accounting for competing risks were not performed, given the retrospective design and the limited number of events. Statistical analyses were conducted using IBM SPSS Statistics, version 29 (IBM Corp., Armonk, NY). A two-sided p-value <0.05 was considered statistically significant.

On the basis of our institutional experience and clinical practice, we developed a pragmatic, hypothesis-generating decision-making algorithm to guide the timing of PD catheter removal after KT. The algorithm considers infection risk and postoperative dialysis needs and aims to provide a standardized approach to catheter management in the post-transplant setting.

RESULTS

Population Characteristics

A total of 132 patients undergoing PD were admitted for KT surgery during the study period. The demographic and clinical characteristics of these patients are summarized in Table I. Among the cohort, 69 patients (52.3%) were male, with a median age at transplantation of 48.4 years (IQR 41–57). Eleven patients (8.3%) had a functioning vascular access at the time of KT.

Table I.Characteristics of PD patients admitted for kidney transplant.

Characteristics
Median age at transplantation (IQR), years	48.4 (41–57)
Median PD time (IQR), months	44.0 (21–71)
Gender Male, n (%) Female, n (%)	69 (52.3) 63 (47.7)
Type of donor Deceased Living	88 (66.7) 44 (33.3)
Number of patients who removed PD catheter during KT surgery, n (%)	10 (7.6)
Mortality rate, %	2.5%
Infections related to PD in the 3 months before KT, n (%)	19 (14.4)
Documented infections in the pre-KT period, n (%) Exit-site infection Tunnel infection Peritonitis	11 (57,9) 4(21.1) 4(21.1)
Diabetes mellitus pre or por KT n (%) Yes No Missing	11 (8.3) 103 (780) 19 (14.4)
Functioning vascular access at the time of KT, n (%)	11 (8.3)
Immunosuppressant treatment before KT, n (%)	15 (11.4)
Renal residual function, n (%)	115 (87.1)

Table II.Chronic kidney disease etiology

Chronic kidney disease etiology	N (%)
Unknown/indeterminate	50 (37.9)
Glomerular diseases	36 (27.3)
Cystic diseases	15 (11.4)
Urologic/obstructive diseases	11 (8.3)
Tubulointerstitial diseases	6 (4.5)
Diabetic nephropathy	6 (4.5)
Vascular nephropathies	4 (3.0)
Hereditary diseases	3 (2.3)
Thrombotic microangiopathy	1 (0.8)

Table II summarizes the distribution of chronic kidney disease etiologies in the study cohort, with unknown/indeterminate causes being the most frequent (n = 50; 37.9%), followed by glomerular and cystic diseases.

With regard to prior KRT, 30 (22.7%) patients had undergone a previous period of hemodialysis. Donor characteristics included 88 (66.7%) deceased donors, 44 (33.3%) living donors, and 21 (15.9%) donors classified as expanded-criteria donors. Nineteen patients (14.4%) had a history of PD-related infectious complications in the three months preceding transplantation. Of these, 10 patients underwent PD catheter removal during KT surgery based on risk assessment, with eight cases attributed to ongoing or recent PD-associated infections requiring antibiotic treatment.

During the study period, three patients died with the PD catheter still in situ. None of these deaths were related to PD catheter complications. The causes of death were lung carcinoma, acute myocardial infarction, and septic shock secondary to pneumonia.

Primary Outcomes – PD Catheter-Related Infections

The median time to PD catheter removal after KT was four and a half months (IQR 0–41). One patient retained the catheter for an extended duration due to personal preference and graft dysfunction.

Of the 122 patients who retained their PD catheter post-KT, 21 (17.2%) developed PD catheter-related infectious complications that led to catheter removal. These included 16 cases (76.2%) of exit-site infections, two cases (9.5%) of tunnel infections, and three cases (14.3%) of peritonitis (two occurring in the same patient). Among these, only two patients had a prior history of PD catheter infections within the three months before transplantation.

More than half (52.3%) of the patients with PD-related infections required hospitalization as our center requires hospitalization for PD catheter removal due to logistical reasons; however, no deaths were attributable to these infections. Microbiological findings are detailed in Table III. The mean catheter removal time in this subgroup was three months (range 0–23), with only 25% of catheters removed within four months post-transplantation. Among all patients who developed any PD-related infection, three (14.3%) were on previous immunosuppressant therapy for another cause prior to KT.

Table III.Isolated microorganisms in PD infectious complications after kidney transplant

Isolated microorganisms	n
Exit site infection	16
Pseudomonas aeruginosa	6
Pseudomonas aeruginosa and Serratia species	1
Pseudomonas aeruginosa and Corynebacterium species	1
Corynebacterium species	1
Staphylococcus epidermidis	1
Polymicrobial infection of gram-positive microorganisms	1
Non-identified	5
Tunnel infection	2
Pseudomonas aeruginosa	1
Non-identified	1
Peritonitis	3
Pseudomonas aeruginosa and Enterococcus faecium	1
Pseudomonas aeruginosa	2
Total	21

Sixteen patients (12.1%) required KRT due to delayed graft function (Figure 1).

Figure 1.Characteristics of the population, infectious complications, and need for KRT.

Of these, 10 patients (62.5%) utilized PD, while six (37.5%) required hemodialysis (four via central venous catheter and two via arteriovenous fistula [AVF]).

In one case, the PD catheter was removed during KT surgery, and an AVF was used as an alternative dialysis access. In two cases, attempted PD was unsuccessful due to peritoneal laceration during surgery, necessitating hemodialysis. In the remaining cases, the dialysis modality was determined by the medical team.

Among patients who underwent living donor KT (n = 44), two (4.5%) had their PD catheter removed during KT surgery. Of those who retained their catheters, six patients (13.6%) experienced infectious complications, all of which were exit-site infections, including two cases with pre-existing PD infections. Three patients (6%) in this subgroup required KRT, with one utilizing the PD catheter due to graft failure and two requiring hemodialysis.

Risk Factors for PD-Related Infections

Potential risk factors for PD-related infections were analyzed. No statistically significant associations were observed with sex (p = 0.803), donor type (p = 0.801), prior PD infections within three months (p = 0.523), diabetes mellitus (p = 1.000), or delayed graft function (p = 0.720).

Similarly, no significant differences were found between patients with and without infections regarding recipient age (p = 0.398), donor age (p = 0.911), or the timing of catheter removal (p = 0.877).

Discussion

There is currently no established global consensus on the optimal timing for PD catheter removal in KT recipients. Most existing literature that addresses this topic is limited and largely focuses on pediatric transplant populations ⁷. In this population, patients often receive living-donor kidney transplants with high-quality grafts. Considering this situation and the fact that subjecting children to two surgical procedures would not be ideal, removing the PD catheter is the best option. Our findings indicate that clinically significant PD catheter-related infectious complications requiring catheter removal are not negligible in the post-transplant period, affecting 17% of cases. Notably, most infections in our cohort occurred despite adherence to the European Best Practice Guidelines for PD catheter removal timing. This result aligns with prior studies that reported similar infection rates ⁸. Importantly, most infections were exit-site infections, and no deaths were attributed to PD catheter complications. However, logistical challenges in hospital settings led to approximately half of the affected patients requiring hospitalization, inherently increasing morbidity and mortality risks.

One potential explanation for the high post-transplant infection risk, apart from the use of high-dose immunosuppressants ⁸, is a shift in patient focus. After transplantation, patients may pay less attention to PD catheter exit-site care, which previously was a daily priority. This issue underscores the need to address exit-site care in post-transplant consultations for patients retaining their PD catheters ⁹. Such care includes always washing hands before catheter manipulation, regular cleaning of the exit site with water and appropriate soap, and securing the catheter in place ¹⁰.

Our findings also revealed that 12% of patients required KRT due to DGF, a figure that rose to nearly 40% in recipients of kidneys from expanded criteria donors. Most patients who required KRT resumed PD without complications, demonstrating the feasibility of continuing PD after KT ¹. However, two patients experienced challenges, such as peritoneal laceration or ultrafiltration failure, necessitating a transition to hemodialysis. These cases highlight the complexities associated with resuming PD in the post-transplant period.

In recipients of living donor transplants, only 4.5% underwent PD catheter removal during surgery, while 13.6% of those retaining their catheters developed infectious complications. Two of these patients had a history of PD-related infections within the preceding three months, suggesting that earlier catheter removal may be warranted in selected cases. Notably, the rate of DGF was lower in living donor transplants than in expanded criteria donor transplants, supporting the safety of earlier catheter removal in this group ¹¹.

In patients with PD-related infections, the median time to catheter removal was four months, raising the possibility that earlier removal could have mitigated infections. Our findings suggest that patients at low risk for DGF, such as living donor recipients or those with alternative dialysis access (e.g., AVF), may benefit from catheter removal during KT surgery. Conversely, the higher rate of infectious complications compared with cases of DGF supports the need to adopt a cautious approach that favors early removal in selected patients.

Limitations: This study has several limitations. First, due to the relatively small number of infectious events, we were unable to perform multivariable analyses to adjust for potential confounders. Performing such analyses under these conditions could have led to model overfitting and unreliable effect estimates. In addition, a time-to-event analysis with competing risks would have been a more appropriate methodological approach to address catheter retention and removal; however, this was not feasible given the limited number of events. Additionally, the extended study period may have introduced heterogeneity in clinical practices, including immunosuppressive regimens, surgical techniques, exit-site care protocols, and donor selection criteria, which represents a potential source of bias.

Proposed Algorithm

On the basis of our findings, we propose an algorithm to guide decision-making regarding PD catheter removal in KT recipients (Figure 2 and Figure 3). This algorithm reflects our single-center experience and should be interpreted in light of the observational nature of the study. It is not intended to be prescriptive but rather to provide a pragmatic framework to support individualized clinical decision-making. External validation in larger, multicenter cohorts is required before broader clinical application.

Figure 2.Proposed flowchart regarding timing of removal of PD catheter in KT patients

Figure 3.Proposed flowchart regarding the timing of catheter removal in patients who maintained it after KT

Living Donor Transplants

Living donor KT is typically a planned procedure with a lower risk of DGF. As such, the threshold for removing the PD catheter during surgery should be low, particularly in patients with no history of recent PD-related infections or those with alternative dialysis access.

If prior infections are present or intraoperative complications (e.g., vascular issues) increase the risk of DGF, then the catheter can be retained, with an earlier planned removal once graft function stabilizes.

Deceased Donor Transplants

In deceased donor transplants, the risk of DGF is influenced by donor and recipient factors, including expanded criteria donor status, ischemia time, and surgical complications [^12131415]. For patients with a high risk of DGF, retaining the PD catheter may be prudent.

Conversely, patients with a history of aggressive infections (e.g., Pseudomonas, Acinetobacter, Stenotrophomonas, or fungi) within the preceding three months ¹⁶ should have their PD catheters removed during surgery. Removal is also advisable if an alternative dialysis access is available, minimizing the need for external device placement in the event of KRT requirements.

Our algorithm aims to balance the risks of infection and the potential need for PD catheter use after KT, supporting a tailored approach to this critical aspect of KRT transition.

Conclusions

Clinically significant PD catheter-related infections requiring catheter removal in the post-transplant period represent a significant concern, particularly given the daily care burden imposed on newly transplanted patients. Our results suggest that earlier PD catheter removal is advantageous in patients at low risk for DGF, such as living donor recipients, or those at high risk of infection.

We propose a pragmatic, risk-based algorithm intended to support individualized decision-making regarding PD catheter management after KT, prioritizing a patient-specific approach that considers donor type, prior infection history, and alternative dialysis access. While further research is needed to validate this approach, we hope this algorithm provides a valuable framework for optimizing outcomes during the transition from PD to KT.

Authors’ Contributions

Beatriz Gil Braga: draft of the article

Sofia Leitão e Sousa: draft and critical review of the article

Ana Cunha: draft and critical review of the article

Isabel Fonseca: statistical analysis

Maria João Carvalho: critical review of the article

Anabela Rodrigues: critical review of the article

Joana Tavares: concept, draft, and critical review of the article

Ethical Considerations and patient consent

In accordance with the recommendations of the ICMJE and COPE, no consent was required because the cases were completely anonymized and analyzed using the institution’s records, which guaranteed their anonymity.

Data Availability Statement

The data used are available from the author upon reasonable request.

Funding

The authors received no funding for this study.

Conflicts of Interest

The authors have no conflicts of interest to declare and have received no financial support.

ORCID iDs

Béatriz Gil Braga : https://orcid.org/0009-0006-8924-0810

Sofia Leitão e Sousa : https://orcid.org/0009-0004-9923-5973

Ana Cunha : https://orcid.org/0000-0001-7755-128X

Isabel Fonseca : https://orcid.org/0000-0001-8984-1751

Maria João Carvalho : https://orcid.org/0000-0003-4374-2867

Joana Manuel Tavares : https://orcid.org/0000-0002-3776-4923

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