J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

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Case Report

Volume 15, Number 10, October 2024, pages 287-296

Role of Continuous Drainage of Tense Ascites in Peritoneal Dialysis: Mehandru/Masud Technique

Figure 2. Potential advantages and disadvantages of PD in patients with kidney failure and ascites. PD: peritoneal dialysis.

**Table 1.** Age, Gender, Etiology of Liver and Kidney Disease, Frequency of Paracentesis, and Systolic Blood Pressure Before and After Initiation of PD
Case	Age	Gender	Etiology of liver disease	Etiology of renal disease	Frequency of paracentesis/weekly volume	Systolic blood pressure on ICHD	Systolic blood pressure on PD 3 months after initiation
ICHD: in-center hemodialysis; PD: peritoneal dialysis.
1	35	F	Alcoholic cirrhosis	Hepatic	2 × weekly/13,000 - 15,000 cc	80 - 120, symptomatic	130
2	52	M	Alcoholic cirrhosis	Diabetes mellitus	2 × weekly/11,000 -13,000 cc	90 - 116, symptomatic	136
3	49	F	Alcoholic cirrhosis	Hypertensive nephrosclerosis	2 × weekly/9,000 - 14,000 cc	93 - 109, symptomatic	128

Table 1. Age, Gender, Etiology of Liver and Kidney Disease, Frequency of Paracentesis, and Systolic Blood Pressure Before and After Initiation of PD

Case

Age

Gender

Etiology of liver disease

Etiology of renal disease

Frequency of paracentesis/weekly volume

Systolic blood pressure on ICHD

Systolic blood pressure on PD 3 months after initiation

ICHD: in-center hemodialysis; PD: peritoneal dialysis.

Alcoholic cirrhosis

Hepatic

2 × weekly/13,000 - 15,000 cc

80 - 120, symptomatic

130

Alcoholic cirrhosis

Diabetes mellitus

2 × weekly/11,000 -13,000 cc

90 - 116, symptomatic

136

Alcoholic cirrhosis

Hypertensive nephrosclerosis

2 × weekly/9,000 - 14,000 cc

93 - 109, symptomatic

128

**Table 2.** Conditions of the Patients in This Study With ESRD and Cirrhosis Before and After PD
Case	Other conditions	Overall conditions on HD	Overall conditions on PD 6 months after initiation	Ascites	Residual renal function, urine output/day	Kt/V on PD
ESRD: end-stage renal disease; HD: hemodialysis; PD: peritoneal dialysis.
1	Alcoholism, anemia, hypoalbuminemia	Wheelchair bound, hospice referral	Ambulatory, able to hold employment, weight gain of 40 lb	2,050 cc	350 cc/cycle, three cycles/day with icodextrin	1,260 cc	3.5
2	Alcoholism, anemia, diabetes mellitus, hypoalbuminemia	Wheelchair bound	Ambulatory, resumed work, stable weight	1,800 cc	290 cc/cycle, three cycles/day with 1.5% dextrose	1,105 cc	2.9
3	Alcoholism, anemia, hypertension, hypoalbuminemia	Wheelchair bound, palliative care consult	Ambulatory, resumed work, gained 15 lb weight	1,250 cc	210 cc/cycle, three cycles/day with icodextrin	1,305 cc	4.2

Table 2. Conditions of the Patients in This Study With ESRD and Cirrhosis Before and After PD

Case

Other conditions

Overall conditions on HD

Overall conditions on PD 6 months after initiation

Ascites

Residual renal function, urine output/day

Kt/V on PD

Initial daily drainage/day

Drainage after 2 years on PD

ESRD: end-stage renal disease; HD: hemodialysis; PD: peritoneal dialysis.

Alcoholism, anemia, hypoalbuminemia

Wheelchair bound, hospice referral

Ambulatory, able to hold employment, weight gain of 40 lb

2,050 cc

350 cc/cycle, three cycles/day with icodextrin

1,260 cc

3.5

Alcoholism, anemia, diabetes mellitus, hypoalbuminemia

Wheelchair bound

Ambulatory, resumed work, stable weight

1,800 cc

290 cc/cycle, three cycles/day with 1.5% dextrose

1,105 cc

2.9

Alcoholism, anemia, hypertension, hypoalbuminemia

Wheelchair bound, palliative care consult

Ambulatory, resumed work, gained 15 lb weight

1,250 cc

210 cc/cycle, three cycles/day with icodextrin

1,305 cc

4.2

**Table 3.** Treatment Timeline for the Patients on Peritoneal Dialysis
Case	Sex (age)	Treatment timeline
CKD: chronic kidney disease; HD: hemodialysis; ICHD: in-center hemodialysis; PD: peritoneal dialysis.
1	Female (35 years)	(February 2020) • Admitted to hospital with progressive renal disease requiring dialysis. • HD was initiated. • Patient was hemodynamically unstable, paracentesis and hypoalbuminemia. • Switch to PD was recommended.	(March - April 2020) • Educated on PD and consented for PD. • Decision to initiate PD was made.	(April 2020) • PD catheter was inserted, and continuous drainage initiated. • Transfer set attached to inserted PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.	(May 2020) • PD training initiated. • Subsequently improvement in hemodynamics, serum albumin and overall health status was observed.	(June 2020) • Stable and independent life style on PD.
2	Male (52 years)	(June 2020) • Admitted to hospital with CKD (stage 5) and uremia, accompanied with weight loss, nausea, poor appetite and shortness of breath for several weeks. • Abdomen was distended with tense ascites. • Underwent paracentesis and started in ICHD, twice weekly. • Paracentesis to remove ascites fluid continued along with symptomatic hypertension on HD leading to normal saline infusions and worsening fluid overload.	(August 2020) • Counseled on PD modality and consented for PD. • PD catheter was inserted, and continuous drainage initiated. • Transfer set attached to PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.	(September 2020) • PD training initiated. • Continued successfully with PD modality with stable hemodynamics and overall improvement to health.	(October 2020) • Continued stable and independent lifestyle on PD.
3	Female (49 years)	(September 2020) • Admitted to hospital with history of CKD, alcoholism, hypotension, and anemia presented with shortness of breath and abdominal distention. • Was on HD, 3 × weekly along with twice weekly paracentesis, 2 months prior to arrival at hospital.	(October 2020) • Was educated on PD modality. • PD catheter was inserted. • Transfer set attached to PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.	(November 2020) • Initiated on PD training. • Continued successfully with PD with stable hemodynamics and overall improvement to health.	(December 2020) • Continued stable and independent lifestyle on PD.

Table 3. Treatment Timeline for the Patients on Peritoneal Dialysis

Case

Sex (age)

Treatment timeline

CKD: chronic kidney disease; HD: hemodialysis; ICHD: in-center hemodialysis; PD: peritoneal dialysis.

Female (35 years)

(February 2020)
• Admitted to hospital with progressive renal disease requiring dialysis.
• HD was initiated.
• Patient was hemodynamically unstable, paracentesis and hypoalbuminemia.
• Switch to PD was recommended.

(March - April 2020)
• Educated on PD and consented for PD.
• Decision to initiate PD was made.

(April 2020)
• PD catheter was inserted, and continuous drainage initiated.
• Transfer set attached to inserted PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.

(May 2020)
• PD training initiated.
• Subsequently improvement in hemodynamics, serum albumin and overall health status was observed.

(June 2020)
• Stable and independent life style on PD.

Male (52 years)

(June 2020)
• Admitted to hospital with CKD (stage 5) and uremia, accompanied with weight loss, nausea, poor appetite and shortness of breath for several weeks.
• Abdomen was distended with tense ascites.
• Underwent paracentesis and started in ICHD, twice weekly.
• Paracentesis to remove ascites fluid continued along with symptomatic hypertension on HD leading to normal saline infusions and worsening fluid overload.

(August 2020)
• Counseled on PD modality and consented for PD.
• PD catheter was inserted, and continuous drainage initiated.
• Transfer set attached to PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.

(September 2020)
• PD training initiated. • Continued successfully with PD modality with stable hemodynamics and overall improvement to health.

(October 2020) • Continued stable and independent lifestyle on PD.

Female (49 years)

(September 2020)
• Admitted to hospital with history of CKD, alcoholism, hypotension, and anemia presented with shortness of breath and abdominal distention.
• Was on HD, 3 × weekly along with twice weekly paracentesis, 2 months prior to arrival at hospital.

(October 2020)
• Was educated on PD modality.
• PD catheter was inserted.
• Transfer set attached to PD catheter helped in controlling leak of ascitic fluid and adequate healing at the site of PD catheter.

(November 2020)
• Initiated on PD training.
• Continued successfully with PD with stable hemodynamics and overall improvement to health.

(December 2020)
• Continued stable and independent lifestyle on PD.

**Table 4.** Peritoneal Leak After PD Catheter Insertion (Immediately, During PD Training and 2 Years After PD Initiation)
Case	Complications after inserting PD catheter	Leaks after attachment of transfer set and drainage bag	Peritonitis for 2-year period	Paracentesis after PD training	Albumin infusion
PD: peritoneal dialysis.
1	Leak (++++)	0	None	None	None
2	Leak (++++)	0	None	None	None
3	Leak (++++)	0	None	None	None

Table 4. Peritoneal Leak After PD Catheter Insertion (Immediately, During PD Training and 2 Years After PD Initiation)

Case

Complications after inserting PD catheter

Leaks after attachment of transfer set and drainage bag

Peritonitis for 2-year period

Paracentesis after PD training

Albumin infusion

PD: peritoneal dialysis.

Leak (++++)

None

Leak (++++)

None

Leak (++++)

None

**Table 5.** Serum and Ascitic Fluid Albumin Before and After Peritoneal Dialysis
Case	Serum albumin	Albumin in ascitic fluid on PD
PD: peritoneal dialysis.
	Before PD	1 month on PD	1 year on PD	2 years on PD	2 weeks on PD	1 month on PD	1 year on PD	2 years on PD
1	1.3	1.8	3.8	4.0	21 g	9.9	200 mg	< 100 mg/day
2	1.4	1.9	3.7	3.8	23 g	11.2	221 mg	< 100 mg/day
3	1.5	2.1	4.0	4.2	19 g	11.5	190 mg	< 100 mg/day

Table 5. Serum and Ascitic Fluid Albumin Before and After Peritoneal Dialysis

Case

Serum albumin

Albumin in ascitic fluid on PD

PD: peritoneal dialysis.

Before PD

1 month on PD

1 year on PD

2 years on PD

2 weeks on PD

1 month on PD

1 year on PD

2 years on PD

1.3

1.8

3.8

4.0

21 g

9.9

200 mg

< 100 mg/day

1.4

1.9

3.7

3.8

23 g

11.2

221 mg

< 100 mg/day

1.5

2.1

4.0

4.2

19 g

11.5

190 mg

< 100 mg/day