Abstract
Editor:
Tenckhoff catheter insertion is a standard procedure for patients with end-stage renal failure commencing on peritoneal dialysis. Other reported applications for the Tenckhoff catheter include relief of refractory ascites resulting from cardiomyopathy, end-stage liver disease, or intra-abdominal malignancies (1-5). We report here 2 patients with refractory ascites due to liver cirrhosis and concomitant chronic renal failure in whom Tenckhoff catheters were inserted with successful relief of ascites.
The first patient was a 69-year-old lady with known hypertension and type II diabetes mellitus. She presented with progressive derangement of renal function due to diabetic nephropathy. There was persistent derangement of liver function, suggestive of an underlying liver disease. The exact etiology could not be defined, despite extensive investigations. Liver ultrasonography showed normal liver size with a patent portal vein and normal flow direction. She developed progressive ascites, and diagnostic paracentesis showed sterile ascitic fluid with a normal cell count. The ascites was refractory to repeated therapeutic paracentesis. A Tenckhoff catheter was inserted and the patient started on continuous ambulatory peritoneal dialysis (CAPD), with satisfactory ultrafiltration while on three daily exchanges. Serum albumin was 31 g/L before and 33 g/L 6 months after starting dialysis. Peritoneal equilibration test (PET) showed D4/D0 glucose of 0.51 and a dialysate-to-plasma ratio of creatinine of 0.67; total Kt/V was 1.64. Daily protein loss amounted to 6.36 g, which was not excessive. The patient was subjectively well, had a good appetite, and did not complain of abdominal distension.
The second patient was a 62-year-old lady with a history of left nephrectomy, hypertension, and hepatitis C-related cirrhosis. She presented with gross ascites, and liver ultrasonography showed cirrhotic changes with a patent portal vein and normal flow direction. Diagnostic paracentesis revealed an elevated white cell count, suggestive of peritonitis. Empiric intravenous antibiotics were given, with prompt response. The ascites, however, was refractory to repeated therapeutic paracentesis. Eventually, a Tenckhoff catheter was inserted and CAPD started, with ultrafiltration averaging 800 mL/day while maintaining 300 mL residual urine daily. Serum albumin was 27 g/ L before and 22 g/L 4 months after dialysis. Her PET was compatible with an average transporter status. Total Kt/V was 1.76, while daily protein loss was 8.4 g/day.
There was no postoperative bleeding or complication after commencement of dialysis in either patient.
Conventional treatments of patients with refractory ascites include bed rest, diuretics, therapeutic paracentesis, and insertion of a Le Veen shunt. Paracentesis provides the most straightforward drainage of ascitic fluid. Tenckhoff catheter insertion is also useful for refractory ascites resulting from diverse etiologies, as it provides a form of external drainage. Since the early1980s, peritoneal dialysis has been used successfully for the treatment of ascites associated with end-stage renal disease (6). Our experience is in accord with this observation. In both of our patients, a Tenckhoff catheter was inserted for refractory ascites due to cirrhosis and concomitant renal failure. The catheter provided simultaneous relief of ascites and allowed commencement of peritoneal dialysis. This obviated the need for hemodialysis, which is less well tolerated in this group of patients (7). Kt/V and ultrafiltration were considered adequate in both patients, taking into account their small body size. Serum albumin at the end of our observation period was stable for the first patient and slightly lower for the second patient compared with predialysis values. Overall, this therapeutic modality should be seriously considered for this special group of patients who have concomitant refractory ascites and chronic renal failure.