Journal of Pediatric Surgery xxx (2015) xxx–xxx

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Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Surgical complications after peritoneal dialysis catheter implantation

depend on children's weight☆
Josephine Radtke a, Anja Lemke b, Markus J. Kemper b, Bjoern Nashan a, Martina Koch a,⁎
a
Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
b
Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: Surgical complications are estimated to be as high as 30%–40% during the first 8 weeks after implan-
Received 9 October 2015 tation of peritoneal dialysis (PD) catheters.
Received in revised form 30 November 2015 Methods: 70 PD catheters which were implanted by transplant surgeons in 61 children (median age 3.3 years,
Accepted 5 December 2015 range 0.01–15.5 years, 31 boys and 30 girls) in 2009–2014 were retrospectively reviewed. The incidence of com-
Available online xxxx
plications and revisions during the first 6 months after implantation was analyzed depending on children's
weight and diagnosis.
Key words:
Kidney insufficiency
Results: 17 out of 70 catheters needed a surgical revision within 6 months after implantation (24.3%). Peritonitis
Peritoneal dialysis was the most common complication affecting 18.6% of peritoneal dialysis catheters followed by obstruction and
Surgical complication dislocation, which it occurred in 9 (12.9%) and 7 (10%) catheters, respectively. Leakage (n = 5) only occurred in
Kidney transplantation children with a weight of less than 10 kg. The total proportion of complications was higher in children with less
than 10 kg of weight (P b 0.001).
Conclusion: PD is safe in children with acute renal failure and older children with chronic renal failure; however
children with a weight of less than 10 kg are more likely to develop complications.
© 2015 Elsevier Inc. All rights reserved.

Peritoneal dialysis is a preferred dialyzing method in children with
acute or chronic renal insufficiency [1–3]. Advantages of this method
are that it does not require vascular access and can be used in hemody-
namically instable patients [4]. Frequent causes of primary peritoneal
dialysis catheter failure, defined as catheter failure within the first
60 days, are obstruction, dislocation, leakage, or infection. Complica-
tions within the first two months of catheter insertion are estimated
to be as high as 30%–40% [5–7]. Catheter dysfunction or catheter infec-
tion is a common cause of peritoneal catheter revision or removal [1].
In children with a weight of less than 15 kg, peritoneal dialysis is the
preferred modality of renal replacement. Maintaining vascular access
often limits long-term use of hemodialysis [3] and renal transplantation
with intraperitoneal or extraperitoneal engraftment is feasible for in-
fants starting at a weight of 10–15 kg [8–11]. Although peritoneal dial-
ysis is the method of choice in infants, an elevated risk of primary
catheter failure has been demonstrated in children with a weight of
less than 10 kg [5,12].
Abbreviations: ARF, acute renal failure; CRF, chronic renal failure; HUS, hemolytic uremic
syndrome; PD, peritoneal dialysis.
☆ Funding: None.
⁎ Corresponding author at: University Medical Center Hamburg-Eppendorf, Depart-
ment of Hepatobiliary and Transplant Surgery, Martinistraße 52, 20246, Hamburg,
Germany. Tel.: +49 7410 56137; fax: +49 7410 40051.
E-mail address: martina.koch@uke.de (M. Koch).
The aim of this study was to evaluate peritoneal catheter complica-
tions and revisions in children with acute or chronic renal failure during
the first six months after placement. All children on chronic dialysis
were also evaluated for kidney transplantation; therefore operations
were done by transplant surgeons at the University Medical Center
Hamburg-Eppendorf, Germany.
1. Patients and methods
This is a single-center retrospective study of all peritoneal dialysis
catheters that were implanted in patients younger than 18 years at
the department of hepatobiliary and transplant surgery at the Universi-
ty Hospital of Hamburg-Eppendorf between March 2009 and July 2014.
During this period 9 general surgeons, who were all members of the
board, implanted 70 catheters in 61 children. One catheter was never
used for peritoneal dialysis because of the child's death and was there-
fore excluded from analysis. Only three children with CRF did not
reach a 6-month follow up because of kidney transplantation and ex-
plantation of catheter. Acute renal failure (ARF) was defined as dialysis
less than three months because of kidney recovery. Chronic renal failure
(CRF) was defined as either dialysis longer than three months or receiv-
ing kidney transplantation [7].
The surgery report was analyzed regarding the duration of the oper-
ation, type of catheter, and performance of a subtotal omentectomy. All
implantations were performed through an open approach; a

http://dx.doi.org/10.1016/j.jpedsurg.2015.12.005
0022-3468/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Radtke J, et al, Surgical complications after peritoneal dialysis catheter implantation depend on children's weight, J
Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.005
2 J. Radtke et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx

laparoscopic technique was not used. Catheters were one-cuffed, either Table 2
31 cm (Covidien Neonatal, Covidien) or 39 cm long (Argyle™ Curl Complications depending on acute or chronic renal failure.

Cath Peritoneal Catheter or Kendall Quinton™ Curl Cath™, Covidien). ARF (n = 37) CRF (n = 33) P-value
The surgeon decided on catheter length depending on children's Total amount of catheters with 6 (16.2%) 21 (63.6%) b0.001
weight. Medical charts were analyzed for sex, diagnosis, weight at complications (n)
operation, time to the start of dialysis (in days), catheter life span, Peritonitis (n) 4 (10.8%) 9 (27.3%)
and complications during the first 6 months after implantation. Compli- Obstruction (n) 1 (2.7%) 8 (24.2%)
Dislocation (n) 2 (5.4%) 5 (15.2%)
cations after peritoneal dialysis catheter implantation included perito-
Leakage (n) 2 (5.4%) 3 (9.1%)
nitis, wound infection, leakage, obstruction, dislocation, and revision. Wound infection (n) 1 (2.7%) 3 (9.1%)
Peritonitis was defined as a positive peritoneal culture or a high leuko- Clavien–Dindo type II (n) 3 (8.1%) 6 (18.2%)
cyte count in the dialysate (N100/μl). Wound infection and leakage Clavien–Dindo type IIIb = revision (n) 3 (8.1%) 15 (45.5%)
were determined by physician examination. The surgeon diagnosed ob-
struction and dislocation during revision. Some dislocations were also
detected by x-ray examination before revision. Revision was defined
as any reoperation performed under general anesthesia. Complications dialysis catheter was explanted after 32 ± 65 days in ARF patients. In
were graded according to Clavien–Dindo classification of surgical com- patients affected by chronic renal failure the catheter had a life span of
plications [13]. 228 ± 311 days (Table 2).

1.1. Statistical analysis
Categorical variables are presented as frequencies and percentages.
Continuous variables are reported as mean ± standard deviation (SD)
values and age is given as median and range. Discrete variables were
compared using a chi-square test. Metric variables were analyzed
using an unpaired t-test. A Bonferroni correction was used for multiple
comparisons. Data were statistically analyzed with SPSS (IBM) version
22. Differences were considered significant at a corrected error proba-
bility of P b 0.05.
2. Results
2.2. Peritoneal dialysis catheter complications depending on acute or
chronic renal failure
The proportion of catheter complications was significantly higher in
the CRF group with 21 (63.6%) peritoneal catheters presenting any kind
of complication, compared to 6 (16.2%) catheters in ARF (Table 1). Com-
plications in children with CRF were more severe. Of those, 6 catheters
had a Clavien–Dindo type II and 15 catheters had a Clavien–Dindo
type IIIb complication that needed revision under general anesthesia.
Only 6 catheters that had been implanted because of ARF had a compli-
cation (P b 0.001 in comparison to CRF) of which 3 could be graded
Clavien–Dindo types II and IIIb, respectively.

2.1. Patient characteristics
70 peritoneal dialysis catheters were implanted in 61 children;
the mean age was 3.3 years (range 0.01–15.5 years) with a similar
proportion of boys (n = 31) and girls (n = 30). 39 cm catheters
were implanted in 70.3% (n = 52) of the children and 14.9% (n = 11)
of children had 31 cm catheters. 37 catheters were implanted for
treatment of acute renal failure and 33 catheters were implanted
because of chronic renal failure. Children with ARF were older
(4.0 years, range 0.01–15.5 years) than children with CRF (1.0 years,
range 0.01–13.8 years) (P b 0.004).
A simultaneous catheter explantation was done in 13 cases of perito-
neal dialysis implantation because of CRF, whereas children with ARF
never needed an exchange of peritoneal dialysis catheter. Partial
omentectomy was performed in 6 patients with chronic renal failure
on a first (n = 2) or subsequent catheter (n = 4).
CRF patients had a longer operation compared to ARF children
(Table 1). Incidence of peritonitis, wound infection, dislocation, and re-
vision did not differ in varying diagnosis. Obstruction occurred more
often in children with chronic renal failure (Table 2). The peritoneal
Table 1
Patient characteristics depending on acute or chronic renal failure.
ARF (n = 37) CRF (n = 33)
2.3. Peritoneal dialysis catheter complications depending on children's
weight
A total of 26 children had a weight of less than 10 kg at the time of
implantation of the peritoneal dialysis catheter. The median age of the
children with a weight of less than 10 kg was 0.2 years (range
0.01–1.4 years). Children with a weight of more than 10 kg (n = 44)
had a median age of 5.4 years (range 0.95–14.5 years). Eight children
(30.8%) with less than 10 kg of weight had an acute renal failure, where-
as 18 children (69.2%) were affected by chronic renal failure. In children
with more than 10 kg of weight, 29 children (65.9%) had an acute renal
failure and 15 children (34.1%) were treated because of chronic renal
failure. Duration of operation and the catheter's life span did not differ
between weight groups (Table 3).
Complications occurred significantly more often in patients with less
than 10 kg of weight with 45.9% developing a complication, whereas
only 22.7% of catheters in children with more than 10 kg of weight de-
veloped a complication (P b 0.001). Of the 26 catheters in children
with a weight of less than 10 kg, 13 catheters needed revision (50%)
(Table 4).
Multivariate analysis of CRF vs. ARF and weight less than 10 kg vs.
more than 10 kg revealed that CRF and weight less than 10 kg at the
time of PD catheter implantation were independent risk factors
P-value
(Table 5).

Median age (years)
Weight (kg)
First catheter (n)
Second catheter (n)
Third catheter (n)
Fourth catheter (n)
Explantation of a catheter at
the time of implantation (n)
Duration of operation (min)
Lifetime of catheter (days)
P values ≤0.01 were considered as statistically significant after applying a Bonferroni ad-
justment for multiple comparisons.
4.0 (range 0.01–15.5) 1.0 (range 0.01–13.8) 0.004
3. Discussion
24.65 ± 18.34 13.14 ± 11.46 0.002
37 (100%) 18 (54.5%)
0 13 (39.4%) Our study demonstrates that implantation of peritoneal dialysis
0 1 (3.0%) catheters is a safe method because of the low complication rate in chil-
0 1 (3.0%)
dren with ARF. Because of the hemolytic uremic syndrome (HUS) epi-
0 13 (39.4%) b0.001
demic in north Germany in 2011, this study also involves many
43 ± 11 57 ± 29 0.017 children with acute renal insufficiency.
32 ± 65 228 ± 311 b0.001 In children with ARF only 3 catheters (8.1%) needed revision where-
as 15 catheters (45.5%) in children with CRF needed revision within the
first six months. This difference is likely caused by the ongoing

Please cite this article as: Radtke J, et al, Surgical complications after peritoneal dialysis catheter implantation depend on children's weight, J
Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.005
 J. Radtke et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx 3

Table 3 Table 5
Patient characteristics depending on children's weight. Multivariate analysis of risk factors for PD catheter complications.

Weight b10 kg Weight N10 kg P-value P-value CI OR

(n = 26) (n = 44)
Chronic vs. acute renal failure 0.002 2.1–22.2 10.1
Median age (years) 0.2 (range 0.01–1.4) 5.4 (range 0.95–14.5) Weight less vs. more than 10 kg 0.013 1.4–14.4 6.2
Acute renal failure (n) 8 (30.8%) 29 (65.9%) 0.004
Chronic renal failure (n) 18 (69.2%) 15 (34.1%)
Male (n) 18 (69.2%) 21 (47.7%) 0.080
Female (n) 8 (30.8%) 23 (52.3%)
Explantation at time of 8 (30.8%) 5 (11.4%) 0.044 by omental plugging or unspecified obstruction. As they had performed
implantation (n) partial omentectomy in 37.5% of failed catheters with diagnosed omen-
Duration of operation (min) 57 ± 30 45 ± 14 0.034 tal plugging they argued that further studies regarding omentectomy
Lifetime of catheter (days) 131 ± 228 97 ± 218 0.107
are needed. As we did not routinely perform omentectomy we are not
P values ≤0.01 were considered as statistically significant after applying a Bonferroni ad- able to comment on this finding. Nevertheless we have a low rate of ob-
justment for multiple comparisons. struction despite not performing omentectomy routinely.
We found that children who weighted less than 10 kg and children
on chronic dialysis had an elevated risk of developing complications
requirement of peritoneal dialysis in children with CRF that results in an after peritoneal dialysis catheter implantation. An elevated catheter fail-
elongated lifetime of catheter in children with CRF (228 ± 311 days) ure rate without a more detailed analysis has been shown in the litera-
compared to children with ARF (32 ± 65 days). The overall incidence ture [5,12]. In the present study, infection was the most frequent
of revision during the first six months was 24.3%. It has to be kept in complication. Although none of the children included in the study had
mind that we defined revision as any operation despite possible salvage a stoma, most children with a weight of less than 10 kg were not
of catheter. The number of revisions in our study was lower than the toilet-trained yet. Therefore, the elevated incidence of peritonitis in chil-
24.6%–30% of primary catheter failure within the first 60 days after im- dren with a weight of less than 10 kg is likely to be caused by a higher
plantation reported in the literature [5,7] and even lower than the over- contamination in this group. Laakkonen et al. [17] showed that the peri-
all catheter failure rate of 39% reported by Ladd et al. [6]. tonitis rate (incidence per patient-month) was comparable in children
We found the most common complication to be peritonitis affecting younger than 2 years compared to older children. As we did not evalu-
18.6% of peritoneal dialysis catheters. This is in accordance with recent ate the total amount of month on peritoneal dialysis we are not able to
studies stating peritonitis rates of 9.1%–25% [6,7]. The question whether directly compare our data to the study of Laakkonen et al. We could
or not the type of implanted catheter influences the rate of complica- speculate that in our study the higher incidence of CRF and therefore a
tions is highly controversial. The types of catheters used and the surgical longer time on peritoneal dialysis in children with a weight of less
techniques described in the literature are diverse [14]. We solely im- than 10 kg lead to a comparable rate of peritonitis per patient-month
planted single-cuffed catheters in contrast to other authors. Lewis as in children with more than 10 kg of weight as those having a higher
et al. [15] demonstrated a lower risk of tunnel infections and peritonitis incidence of ARF with less time to develop peritonitis. The same argu-
in catheters with two cuffs. On the other hand Macchini et al. [16] ment applies when comparing our study to Vidal et al. [18] who demon-
showed that single-cuffed catheters offer no disadvantage when analyz- strated no elevation of episodes of catheter-related complications per
ing the incidence of tunnel infections and exit site infections. Catheters month on peritoneal dialysis in infants compared to older children.
implanted at our department were either straight (31 cm, neonatal More interestingly, we were able to show that obstruction and dislo-
catheters) or curled (39 cm). Cribbs et al. [5] demonstrated no advan- cation, which are better indicators for an elevated complication rate,
tage of curled catheters against occlusion compared to straight cathe- were elevated in children with a weight of less than 10 kg. Leakage
ters. We did not analyze our data concerning the incidence of only occurred in children with less than 10 kg of weight, which might
complications depending on straight or curled shape because of possible be caused by a thinner abdominal wall not enabling a closure of the
confounding bias, e.g., children's weight. catheter tunnel. One can argue that a higher leakage rate may also
Obstruction was the second most common complication with 12.9% cause a higher infection rate.
of implanted catheters showing obstruction with omentum or blood In conclusion, renal replacement therapy is a demanding treatment
clots. We did not routinely perform (partial) omentectomy during the in pediatric nephrology. Peritoneal dialysis is the preferred modality of
initial implantation of a peritoneal dialysis catheter. Omentectomy renal replacement therapy in infants with chronic kidney disease, as
was predominantly performed in case of occlusion with omentum diag- problems with maintaining vascular access limit long term use of hemo-
nosed during revision. Two studies demonstrated a lower incidence of dialysis [3]. Peritoneal dialysis is also preferred in infants as catch-up
catheter dysfunction after omentectomy [5,6]. Stone et al. [7] found growth is reported to occur in 49% of infants younger than 1 year and
that 22 catheters out of 134 implanted catheters (16.4%) were affected 64% in children younger than 2 years [17,18]. Even though we were
able to demonstrate an elevated risk of complications in smaller chil-
dren, peritoneal dialysis was possible within the study period of
6 months in most infants.
Table 4 Our study had some limitations. Firstly, it suffers from the limitations
Complications depending on children's weight.
of a retrospective study, not enabling a detailed analysis of clinical
Weight b10 kg Weight N10 kg P-value course. Although follow-up data might be insufficient it is unlikely
(n = 26) (n = 44) that severe complications have been missed.
Total amount of catheters with 17 (45.9%) 10 (22.7%) b0.001
complications (n)
Peritonitis (n) 8 (30.8%) 5 (11.4%) 4. Conclusion
Obstruction (n) 6 (23.0%) 3 (6.8%)
Dislocation (n) 5 (19.2%) 2 (4.5%)
Leakage (n) 5 (19.2%) 0 We conclude that peritoneal dialysis catheter implantation is a safe
Wound infection (n) 3 (11.5%) 1 (2.3%) method in children with acute renal failure and children with a weight
Clavien–Dindo type II (n) 4 (15.4%) 5 (11.4%) of more than 10 kg. Children with chronic renal failure or children with
Clavien–Dindo type 13 (50%) 5 (11.4%) a weight of less than 10 kg were more often affected by complications
IIIb = revision (n)
but peritoneal dialysis was feasible in most of these children.

Please cite this article as: Radtke J, et al, Surgical complications after peritoneal dialysis catheter implantation depend on children's weight, J
Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.12.005
4 J. Radtke et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
Acknowledgments
The authors want to thank Sandra Hischke from the Department of
Medical Biometry and Epidemiology for her support with statistics.
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