Use of Peritoneal Catheters for Patients Receiving Palliative Care

Introduction

Ascites is one of the most common complications of chronic liver disease (CLD). Refractory ascites refers to the inability to mobilize ascitic fluid and occurs in 5%–10% of all patients with ascites. ¹ It is a poor prognostic indicator, with associated problems such as spontaneous bacterial peritonitis, electrolyte disturbances, hepatorenal syndrome, and hemodynamic instability. In addition, if presented with other comorbidities, such as hepatocellular carcinoma, the survival is significantly lower and with a clear impact on the patient's quality of life. ²

Management of ascites involves regular paracentesis for volume control; however, serial large-volume paracentesis in ascites besides being an invasive procedure place a great burden on terminal patients. Tunneled indwelling peritoneal catheters (PCs) provide an alternative treatment approach with a low complication rate in patients who fail medical management.

With this case report we hope to highlight the possible role that PC might play in the palliation process.

Case Description

A 71-year-old male patient with stage 4 chronic kidney disease (CKD) and recurrent ascites secondary to hepatocellular carcinoma was referred to a consultation in our nephrology department. His past medical history also included congenital hearing loss and ischemic cardiomyopathy with moderate systolic dysfunction. In view of his overall poor prognosis, the patient was not a candidate for curative treatment.

Physical examination revealed a frail, cachectic, and functionally dependent patient, although he was keenly alert and no cognitive impairment was present. A massive enlargement of the abdominal cavity with an umbilical hernia was evident, which caused him pain and dyspnea in the supine position. Last paracentesis had been performed six days earlier, and a growing need for progressively more frequent paracentesis was obvious. No other peripheral stigmata of CLD were noted besides angiomata and there was no clinical evidence of hepatic failure. Examination of other systems was unremarkable.

Renal dysfunction (creatinine 2.3 mg/dL, urea 100 mg/dL, CKD-EPI eGFR 27.5 mL/min/m²), severe hypoalbuminemia (serum albumin 1.6 g/dL, total protein 5.3g/dL), and asymptomatic hyponatremia (125 mmol/L) were present and liver function tests were expectedly altered. Pleural effusion or pulmonary venous congestion was absent.

Given the patient's present clinical status and the inability to control his ascites without serial paracentesis, after careful multidisciplinary discussion it was decided to place a PC as an integral part of the palliation process. The patient underwent a Tenckhoff double-cuffed pigtail percutaneous catheter insertion into the abdominal cavity using a minimally invasive modified Seldinger technique by a trained nephrologist. The procedure was uncomplicated and allowed for immediate ascites' control.

All the arrangements were made for the patient to return to his home, after his primary caregiver received training from a peritoneal dialysis (PD) nurse on catheter manipulation and instructions on how to periodically remove ascitic fluid and in small amounts (not >2 L at a time) to avoid intravascular volume depletion and worsening of renal function. Medical and nurse staff were available for contact at any time and, if adjustment to care was considered necessary, hospital appointments were scheduled to assure the patient's continued comfort.

Progressive functional decline was observed due to his terminal illness, and the patient was referred to a palliative care unit with the family's consent. Palliative nurses received identical training with a “hands-on” approach as the family caregiver by our PD nurse and the same method for volume control was applied.

Throughout the period since PC insertion (a total of three months), no additional paracentesis was required and no complications were noted, namely hospitalizations, peritonitis, or catheter dysfunction. Owing to natural progression of his underlying disease, the patient eventually died peacefully.

Discussion

The use of indwelling PC, originally developed by Dr. Henry Tenckhoff in 1968, was first described as a palliative option in 2001 for refractory malignant ascites. ³ Since then, growing evidence, mostly from small series and case reports, suggests that PCs are a safe and effective option for these patients, as well as in other nonmalignant ascites, such as heart failure.^4–7

PC in palliative care offers several advantages, including access simplicity, schedule flexibility, and independence from hospitals. The possibility of immediate use for fluid removal is also of convenience in this population. Palliative patients with ascites and CKD association pose a greater challenge as far as hemodynamic stability is concerned, since effective arterial blood volume is reduced. Again, with PC, due to slow solute and volume removal, cardiovascular instability is infrequent. In contrast, PC seems to be more cost-effective than serial paracentesis, even considering the cost of drainage containers plus placement cost. ⁸

The lack of a standardized protocol for palliative treatment of patients with ascites and its unsatisfactory outcome has led, more recently, to a search for new evidence about PC. One area of particular interest is catheter-related infections with this device. In fact, although concerns have been raised due to impaired antibacterial activity, ⁹ results are conflicting. ¹⁰ Macken et al. ¹¹ systematically reviewed 18 studies concerning the use of PC in refractory ascites attributable to end-stage liver disease. Despite the small sample (176 patients), heterogeneity in study design and overall low-quality reporting, data results were favorable considering this was an end-stage liver disease population, with an incidence of bacterial peritonitis of 12.7%. Caldwell et al. ¹² also reviewed PC placement in patients with chronic ascites; in 14 studies with 957 patients (687 with malignancy and 270 with cirrhosis), infection rates for malignant and nonmalignant ascites were 5.4% and 12.2%, respectively, although infection risk was shown to increase with longer catheter duration. Either way, in this group of patients with very short lifespan, it is believed that the benefits exceed the risks.

Catheter malfunction is another possible complication, including occlusion and low drainage volume, but is usually resolved by simply flushing the device, and very few patients require catheter replacement or removal due to device malfunction. ¹³ In the review article by Caldwell et al., only 5.7% of patients exhibited catheter dysfunction. Other complications included minor pain and leakage around the catheter site, which usually resolved spontaneously over time. Peritoneal protein losses, initially high, are described in the literature as decreasing over time, maintaining serum albumin within the low-normal range. ¹²

Several PCs have been used for ascites management. There is no consensus regarding the most suitable one for palliation purposes since no comparative studies have been performed, save for one small retrospective study that used both PD and hemodialysis catheters ¹⁴ and found no difference concerning patency, infection, or complication rates. Coiled Tenckhoff catheters have some theoretical advantages, including better catheter flow, reduced risk of migration and clogging due to their flexible material, larger diameter, pigtail end, and the presence of multiple side holes.

PC percutaneous implantation by nephrologists is a minimally invasive procedure, performable in an outpatient setting, with residual postoperative pain and a fast recovery, all essential factors when considering palliative patients. Relative contraindications include coagulopathy, severe anemia/thrombocytopenia, or uncorrected large abdominal wall hernias. In this particular patient, despite having an umbilical hernia, regular removal of peritoneal fluid helped reducing abdominal distension, so it did not exacerbate the hernia. Contrary to common belief, PC handling has a shallow learning curve and is taught by trained PD nurses to other health care providers not accustomed with the procedure or to family caregivers/patients, although training time can be extended if necessary.

Patient assessment for this particular technique should be tailored to meet individual needs, that is, considering multiple factors such as patient's choice and social context, clinical status, or resistance to medical management. Timely referral is beneficial to both patient and caregivers as a way to offer improved care and support.

The frequency of drainage sessions may vary among patients. Most individuals require drainage daily or every other day; however, in this patient, to reduce the risk of worsening kidney function, small volume removal of ascitic fluid was performed two times a week. An initial intravenous albumin and plasma expander infusion can be given initially to maintain effective plasma volume and serum albumin at adequate levels (i.e., after catheter insertion). In our opinion, initial workup should be restricted to complete blood count and coagulation tests to ensure safe PC implantation. Routine follow-up is unnecessary, unless a large volume is retrieved from the patient, in which case electrolyte imbalance should be excluded.

Conclusion

In conclusion, there is room for PC in palliative care as it seems to be an effective alternative to paracentesis in patients with refractory ascites (malignant or not). Its application should be assessed to optimize quality of life and elevate standards of care.