Indian Journal of Peritoneal Dialysis
41
Relocation Of Exit-Site In A Chronic Pseudomonas Aeruginosa
Exit-Site And Tunnel Infection In A 7 Years Old Boy On CAPD
Albin Serugendo\ Sylvain Kwiratuwe\ Laksbmi Revatbi', Sanjeev Nair', Anand Yuvaraj', Nagarajan pl. Heal Africa
hospital, Goma.DRCongo'.Madras Medical Mission hospital, Chennai.India'
Abstract :
A 7 years old boy wiili end stage renal disease (ESRD) secondary to posterior ureilieral valve (PUV) fulguration presented wiili
repeat Pseudomonas aeruginosa exit-site and tunnel infections (ESTIs) on continuous ambulatory peritoneal dialysis (CAPD).
He developed malnutrition which led to ilie migration of ilie exterua1 cuff of cailieter towards ilie exit-site. He underwent
derooling along wiili external cuff shaving wiili relocation ofilie exit-site.
Keywords: Pseudomonas aeruginosa, ESTI, Derooling, Relocation.
Introduction:
CaseReport:
In patients on chronic peritoneal dialysis (CPD), exit-site and
A 7 years old hoy who had congenital abnormality of ilie
tunnel infection (ESTI) is associated wiili significant
kidney and urinary tract (CAKUT) had fulguration ofilie PUV
morbidity. Cailieter-related infection is a major cause of
and wiili bilateral hydronephrosis at ilie 3'" day of age, in June
cailieter loss in CPD. Inappropriate management of ESTI
may lead to aggravation of infection and peritonitis, which is
ilie major cause of drop-out from peritoneal dialysis [1].
2005 ,underwent
bilateral ureterostomy on the 1O~
subsequently. In September 2008, ilie right ureterostomy was
closed and ilie left inMarch 20 I O.
Therefore it is imperative to provide exit-site care,
In February 2009, a swan neck dnuble cuffTenckhoffpediatric
antimicrobial ilierapy and in refractory cases cailieter
PD cailieter was implanted after omentectomy and CAPD was
replacement [2].
initiated 2 weeks later wiili Glucose 1.5% x 500 ml x 3
exchanges per day wiili 5 hours dwell time. His weight was
We describe a 7 years old boy on continuous ambulatory
peritoneal dialysis (CAPD) wiili ESRD secondary to
posterior ure1hral
valves (PUV) fulguration, wiili repeat
Pseudomonas aeruginosa ESTJ.
10.60 kg, and height 90 cm. The cardiovascular system noted a
blood pressure of ll0/70 mmHg and a regular pulse rate of
66/minute; heart sounds S, S, were normal. Lungs were clear.
He was taken care of by his young moilier being ilie only child
in ilie family. He was attending school and his nutrition state
Address for Correspondence
Albin Serugendo MMED
Heal Africa Hospital
Goma DRCongo
Email: [email protected]
improved and he gained weight and engaged in limited sports
and games. The PD exit-site was clean. Hemogram showed
Hb 8.2 g/dl, wbc 9300/cmm, platelets 454000/cmm,
polymorph 23.6%, lymphocytes 26.7%, monocytes 3.1%,
Indian Journal of Peritoneal Dialysis
42
Figure 2:
Relocated catheter 1 week later with
Figure 1: Deroofed tunnel and shaved cuff
shaved cuff portion outside
Indian Journal of Peritoneal Dialysis
Data from the U.S. National Continuous Ambulatory
43
3.
Suh H, Wadhwa NK, Cabralda T, Bonanno I,
Peritoneal Dialysis Registry indicate that up to 39% of
Wasiluk A, Sorrento I. Persistent exit-site/tonnel
catheter removals are related to persistent ESTIs
infection and subcutaneous cuff removal in PD
unresponsive to antibiotic therapy [I]. Malnutrition is one of
patients. Adv PeritDiall997; 13:233-6.
the predisposing factors accounting for relapsing or recurrent
4.
Tan SY, Thiruventhiran T. Catheter cuff shaving
or repeat infection [5]. ln our patient, three months prior to the
using a novel technique: a rescue treatment for
second episode of Ps Ag
persistent exit-site infections. Perit Dial Int 2000;
ESI, he developed significant
20:471-2.
malnutrition with loss of abdominal fat and muscle tissue
thereby pushing the external cuff towards the exit-site
5.
predisposing to recurrent ESTI. This should be kept in mind
Evans AS, Brachman PS. Bacterial Infection of
Humans: Epidemiology and Control. 3'" ed. New
while implanting permanent PD catheter in children as the
York: Plenum; 1998.
external cuff should be well away at least 3 em from the exitsite preventing migration in case ofma!nutrition.
6.
Crabtree
m,
Burchette RI. Surgical salvage of
peritoneal dialysis catheters from chronic exit-site
Recently, some reports have discussed the efficacy of partial
re-implantation of the catheter in intractable ESTIs cases.
Partial re-implantation is a simple and effective method to
cure intractable ESTIs and to maintain the patient on PD [I].
Surgical salvage procedure by unroofing/cuff shaving is an
effective long-term solution for chronic ESTIs [6].
Conclusion:
Derooting along with cuff shaving with or without relocation
of the tonnel and exit-site prevented catheter loss in our
malnourished child. lntensive nutritional therapy with
frequent monitoring is mandatory in children to promote
growth and to reduce infective episodes.
References:
I.
Kazuhiko M, oshitaka I, Iunna Y, Hiroo K, Haruni K,
Toshiro F. Early Partial Re-implantation of
Tenckhoff catheter to treat intractable exit-site or
tonnel infection. PeritDiallnt2011; 350-353.
2.
ISPD Gnidelines, 2010.
and tonnel infections. AmI Surg 2005: 190(1): 4-8.