Literature on the feasibility of gastrostomy tubes in peritoneal dialysis (PD) patients is still sparse. Paudel and Fan’s recent article in AJKD should give nephrologists some confidence when dealing with this situation. The article describes two cases: a 68-year-old man on continuous ambulatory PD (CAPD) for ESRD from IgA nephropathy. He required percutaneous endoscopic gastrostomy (PEG) tube insertion for dysphagia and inability to take adequate oral intake. A second case describes a young girl with a preexisting PEG tube (due to poor nutritional status from congenital chloride diarrhea) who required PD for advanced CKD. The first patient had one episode of peritonitis during one year of follow up, while the girl had none during her 28 month follow up.
Although the two situations might seem similar, note the difference in timing and sequence of PD and PEG tube insertion. The first case actually describes PEG placement in a patient already on PD. “Traditional” teaching and the limited (mostly pediatric) literature is leery of PEG tube insertion in PD patients. This is due to concerns about in exit site infection, peritonitis, and leakage from exit sites. Fungal peritonitis is a major concern given its association with high mortality. Owing to such concerns, some authors even consider placement of PEG while on PD as contraindicated. On the other hand, insertion of PD catheters and initiation of peritoneal dialysis in patients who have PEG tubes appears to be relatively safe. Some might call this “PEG before PD”! In this light, Paudel and Fan’s description of a PEG being placed for enteral feeds in a man already on PD is interesting.
Granted that one case report might not change what’s considered “standard practice”; however given our aging population and chronic disease burden, PEG use might continue to increase. Furthermore, since the patient population that often requires PEG placement overlaps with the population at a higher CKD risk (older patients with high cardiovascular morbidity), many nephrologists are bound to see this situation in clinical practice sooner or later. If a patient on PD requires a PEG placement, antibiotic and antifungal prophylaxis and withholding PD for 2-3 days could reduce the infection risk.
An even larger issue is the use of laparoscopic surgery in patients on PD. Just like PEG tube placement, our PD patients could require any of the multitudes of laparoscopic procedures. How do we manage that? In such situations, temporary cessation of PD until two weeks post laparoscopic procedure while switching the patient to hemodialysis is a strategy that has shown to be effective in reducing peritonitis risk.
Dr. Veeraish Chauhan