Acute peritoneal dialysis following ruptured abdominal aortic aneurysms

Background: Acute renal failure is common after repair of ruptured abdominal aortic aneurysm. Early dialysis has recently been advocated to reduce the mortality associated with multiorgan failure, but hemodialysis (HD) is not well-tolerated in critically ill patients because of hemodynamic instability and risk of bleeding from anticoagulation therapy. Peritoneal dialysis (PD) has the advantage in that it causes minimal cardiopulmonary instability and does not require anticoagulation. The presence of a freshly-closed abdominal wound and an aortic graft, however, have previously been considered to be contraindications to PD. Methods: Peritoneal dialysis catheters were placed in 69 of the 105 patients who underwent grafting for a ruptured abdominal aortic aneurysm between 1982 and 1993. Criteria for placement included shock, perioperative oliguria, and preoperative renal insufficiency. All charts were reviewed retrospectively to evaluate the safety and efficacy of placing PD catheters and initiating early dialysis in patients at risk for developing acute renal failure. Results: Acute tubular necrosis developed in 31 patients, 19 of whom required dialysis. Peritoneal dialysis alone provided effective dialysis in 8 patients, and it was combined with hemofiltration and/or HD in 9 additional patients for an overall efficacy of 58%. The peritoneal catheter also facilitated the early diagnosis of peritonitis due to colon ischemia in 5 patients, and was helpful in diagnosing intra-abdominal hemorrhage in 4 others. Bacterial peritonitis occurred in 3 (17%) patients undergoing PD with no cause noted for the infection other than use of the PD catheter. A single aortic graft infection was diagnosed 4.2 years postoperatively with an enteric organism in a patient with recurrent diverticulitis. Two patients with peritoneal catheters developed abdominal wound dehiscence, but neither had undergone PD ( P >0.2). In a multivariate analysis, placement of a PD catheter did not affect survival. Conclusions: Placement of a PD catheter at the time of resection of a ruptured abdominal aortic aneurysm in patients at risk for development of acute renal failure is without significant complications and can facilitate early and effective dialysis. The peritoneal dialysis catheter may also be useful in making an early diagnosis of intraperitoneal bleeding and infection.