A two-person collaborative repositioning approach for high peritoneal dialysis catheter migration: case reports and literature review

Abstract

Background

Peritoneal dialysis catheter migration, a common complication in patients undergoing peritoneal dialysis, often leads to poor dialysate drainage, infection, and abdominal pain. Timely and effective treatment of catheter migration is essential to ensure uninterrupted dialysis.

Case presentation

This study presents three cases of peritoneal dialysis (PD) catheter displacement in patients with end-stage renal disease (ESRD), involving three elderly individuals aged 80, 81, and 76 years. All instances of catheter displacement were primarily localized to the upper abdominal region. Following unsuccessful attempts with traditional repositioning methods (such as positional adjustments, ambulation, and saline infusion), a two-person collaborative repositioning technique was employed, combining external manual pressure with rapid saline injection. Consequently, all catheters were successfully repositioned to the pelvic area and remained stable throughout the follow-up period.

Conclusions

This re-port preliminarily demonstrated the feasibility and effectiveness of two-person collaborative repositioning approach in elderly patients with PD catheter displacement. Although the results have potential application value, further studies are needed to verify their generality and long-term efficacy in larger samples.

Background

Peritoneal dialysis (PD) is a home-based treatment modality whose success relies on maintaining the normal function of the PD catheter [1]. Ensuring proper drainage of the PD catheter is crucial for effective dialysis treatment. However, catheter migration is one of the most common complications in patients undergoing PD with an incidence of approximately 60% and represents a significant cause of PD technique failure [11].

The management of PD catheter migration primarily includes conservative repositioning techniques and surgical intervention. Although widely used in clinical practice, conservative methods such as adjustment of position, abdominal massage, and increasing abdominal pressure are associated with relatively low success rates [14]. While surgical intervention is generally effective, it carries a higher risk of infection, greater financial burden, and increased physical and psychological stress on patients, especially the elderly [6, 7, 22].

This article presents a detailed description of a novel two-person collaborative conservative repositioning approach for addressing PD catheter migration, as demonstrated in three elderly patients.

Case presentation

Case report 1

An 80-year-old female patient with end-stage renal disease (ESRD, chronic kidney disease (CKD) stage 5) underwent PD catheterization using a Tenckhoff straight catheter on October 10, 2023. Three daily 1.5% glucose PD exchanges were initiated on October 24. By October 29, her ultrafiltration volume had dropped to 600 Ml, accompanied by abdominal distension but no abdominal pain or stool abnormalities. A digital radiography (DR) abdominal X-ray revealed significant up-ward migration of the PD catheter, with its tip positioned in the upper abdomen, accompanied by increased intestinal gas and contents (Fig. 1A). Laboratory tests showed C-reactive protein (CRP) levels of 3.37 mg/L, serum creatinine of 929 µmol/L, and an estimated glomerular filtration rate (eGFR) of 2.98 mL/min/1.73 m².

After traditional position adjustments and walking techniques failed, the two-person collaborative conservative repositioning method described in this report was implemented. Based on DR imaging, the catheter tip was found to be tilted towards the right upper abdomen, and the patient was positioned in a 30-degree left lateral position to optimize gravitational effects.

Then, one operator (Y. Li) placed her palm approximately 3 to 5 cm above the displaced catheter and applied inward and downward pressure toward the perineum, following the direction of the catheter. This not only provided stable fixation and repositioning force but also increased resistance when the other operator rapidly injected saline into the catheter, facilitating its return to the pelvic cavity. Simultaneously, with the other hand, the first operator (Y. Li) lifted the abdomen on the opposite side of the displaced catheter and applied inward and downward pressure toward the perineum. This manoeuvre helped straighten the catheter’s path back to the pelvic floor, reducing obstruction and providing favourable return force to prevent dislocation or drifting of the catheter under external force.

Once the catheter was stabilized and fixed, the second operator (L. Zhai) injected 50 to 60 ml of normal saline in one or more rapid injections (total volume not exceeding 500 ml) to temporarily increase internal pressure and the weight of the catheter. This action allowed the catheter tip to move quickly along the “reconstructed” path and return to the pelvic floor, achieving successful repositioning. It is essential to maintain a sterile environment during the procedure, and the patient’s reaction should be closely monitored. If the patient experiences perineal, anal, or lower abdominal discomfort, drainage should be promptly initiated, and the drainage volume assessed to determine if the repositioning was successful. Figure 2 illustrates the repositioning process, while Fig. 1B shows the DR abdominal X-ray after the conservative repositioning approach was carried out. Figure 1C shows the results of a DR abdominal X-ray review four months after conservative repositioning. The results showed that the position of the PD catheter was significantly improved and the repositioning effect was good.

Fig. 1

Abdominal X-ray-1

Fig. 2

Two-person catheter repositioning

Case report 2

An 81-year-old male patient diagnosed with obstructive kidney disease and end-stage renal disease (stage 5 CKD) underwent PD catheterization with a Tenckhoff straight catheter on June 7, 2022. On February 16, 2023, the patient’s ultrafiltration volume suddenly dropped to 400 ml, accompanied by mild tenderness in the right abdomen—but no rebound pain or mass—and normal stool. The DR abdominal X-ray showed that the end of the PD catheter was significantly shifted to the left upper abdominal region from the normal pelvic position (see Fig. 3A). Laboratory test results were as follows: CRP, 4.8 mg/L; serum creatinine, 705 µmol/L; and eGFR, 5.67 mL/min/1.73 m². The routine examination of ascitic fluid revealed a clear to pale yellow appearance, with a nucleated cell count of 5 × 106/L and a neutrophil proportion of 40%. The ascitic fluid culture was negative.

After following failed attempts with traditional methods—including walking, enema, and pulsed saline infusion—the patient’s catheter migration was addressed using the two-person collaborative repositioning technique. The collaborative method was performed as described in Case 1. Post-procedure imaging confirmed that the catheter had successfully returned to the pelvic region (Fig. 3B). The patient’s abdominal tenderness resolved, and follow-up imaging after 43 days confirmed catheter stability and effective dialysis (Fig. 3C).

Fig. 3

Abdominal X-ray-2

Case report 3

A 76-year-old female patient with end-stage renal disease (stage 5 CKD) underwent PD catheterization with a Tenckhoff straight catheter on June 20, 2024. On August 21, 2024, the patient experienced a significant drop in ultrafiltration volume to 700 ml. Although she did not report abdominal pain or rebound tenderness, her bowel movements had increased to three times per day, and her daily urine output was approximately 300 ml. A DR abdominal X-ray revealed that the PD catheter had migrated significantly to the right upper abdomen, deviating from its normal pelvic position (Fig. 4A). Laboratory tests showed a serum creatinine level of 173 µmol/L and an eGFR of 5.67 ml/min/1.73 m². Owing to prolonged bedridden status and significant physical frailty, the patient was unable to perform traditional position adjustments or walking-based repositioning techniques.

The two-person collaborative conservative repositioning technique was performed success- fully. Post-procedure imaging confirmed successful repositioning to the pelvic region (Fig. 4B), and follow-up imaging after 74 days showed stable catheter placement with effective dialysis (Fig. 4C).

Fig. 4

Abdominal X-ray-3

Discussion

PD catheter displacement is a common complication in patients undergoing PD, especially in older patients with end-stage renal failure and is often associated with gastrointestinal dysfunction, such as rapid bowel movements or constipation, accompanied by reduced activity and prolonged bed rest. In addition, older patients often have a relaxed abdominal wall and larger abdominal volume, which further increases the likelihood of catheter displacement [15, 17]. Therefore, how to effectively and quickly resolve the problem of catheter displacement is crucial for successful PD treatment of elderly patients.

At present, the main management strategies for catheter displacement include surgical intervention and traditional conservative repositioning methods [2]. Over the past 20 years, several approaches have been developed for the management of displaced and nonfunctional PD catheters, including Fogarty catheter manipulation [5], double wire guide [12], modified Malecot catheter technique [18], laparoscopy [22, 23], gastroscopic brush correction displacement, microincision techniques [13], and catheter repositioning under local anaesthesia [19]. Although all of these methods have had some success in catheter repositioning, they are invasive procedures that carry risks of infection; additionally, they are expensive and can be more physically and mentally taxing on patients, especially older patients.

Traditional conservative treatments include manual repositioning, sitting and standing with pulsed peritoneal fluid infusion, and having the patient perform calf raises and heel thrusts or walk down stairs after an elevator ride to a high floor, and enema to increase intestinal pressure [21]. These methods are simple and safe, and, to an extent, effective for simple functional catheter displacement; as a result, they are often preferred in clinical practice.

Traditional manual repositioning is usually conducted by one operator. The procedure is as follows: First, 1000 ml of 1.5% peritoneal dialysate is injected into the abdominal cavity. The patient is placed in a supine kneeling position to relax the abdominal muscles. If the catheter tip is in the left lower abdomen, the operator stands on the left side, places both hands on the lower abdomen, aligns with the patient’s breathing, and gradually pushes firmly toward the right lower abdomen during deep breaths. For thicker abdominal walls, the right hand is placed with fingers together at a 45-degree angle on the left abdominal wall, an intermittent shock technique is used and the operator pushes down with the left hand. If the catheter tip is in the right lower abdomen, the direction is reversed. Each session lasts 10 min and is performed 3–5 times daily [20].

Traditional manual repositioning and other conservative strategies are important treatment methods for PD catheter displacement [8]. These have the advantages of high safety, economic benefits, simple operation and little discomfort for patients, and are therefore valuable and popularly used in clinical practice.

Although a previous study reports that the catheter displacement reduction rate for conservative treatment is about 96% (n = 96), the mean age of patients in that study is 40.9 years, and the catheter displacement location is not mentioned [11]. In cases where the catheter is wrapped by the greater omentum and displaced, as well as in elderly patients, who have difficulty walking, surgical intervention is often required to ensure the correct position and function of the catheter [10, 16].

Furthermore, increasing exercise as an auxiliary repositioning measure places higher physical requirements on elderly patients and the infirm, and may be difficult for them to achieve [9]. In addition, although enema can improve abdominal cavity condition in some cases, for patients, especially the elderly and the infirm, it often causes abdominal discomfort, abdominal pain, and other symptoms, and carries a risk of infection [3]. These factors limit the application of traditional manual repositioning in specific groups of patients.

In the case of PD catheter migration, clinical guidelines generally recommend that a conservative repositioning approach be attempted first [4]. While traditional single-operator re-positioning techniques are considered simple and safe, they may lack sufficient force or precision in complex cases, particularly in elderly or frail patients and those with severe catheter displacement. In such situations, the two-person collaborative technique offers a more effective alternative.

The two-person collaborative conservative repositioning method proposed in this study demonstrates clear advantages. By dividing tasks between two operators, this approach enhances precision and efficiency. One operator applies a steady downward force through the palm of the hand, providing the necessary pressure to facilitate catheter repositioning. Simultaneously, the second operator administers saline quickly, leveraging the fluid’s pressure to help guide the catheter smoothly back into the abdominal cavity. This dual-force approach not only improves the stability and success rate of the repositioning but also addresses challenges associated with single-operator techniques, particularly in elderly patients with thickened abdominal walls or increased abdominal volume. Additionally, this method significantly reduces operation time and minimizes patient discomfort.

Another key benefit of this technique is its non-invasive nature. By eliminating the need for surgical equipment, it lowers the risks associated with invasive procedures while also reducing the financial burden on patients. This may make it a practical, cost-effective solution for managing catheter migration, particularly in resource-limited settings or among vulnerable patient populations. To further validate the clinical efficacy of the two-person collaborative conservative repositioning approach, future multicentre, large-scale clinical studies should be conducted to assess its applicability and long-term outcomes across diverse patient populations. Additionally, potential improvements to application of the method in managing complex cases should be explored in order to enhance its overall effectiveness and broaden its clinical utility.

Advantages and limitations

This method offers several advantages. First, it eliminates the need for pharmacological assistance, thereby reducing both the side effects and costs associated with medications. Second, by customizing the repositioning route based on the specific catheter migration position and employing different patient positions, this technique is particularly suitable for elderly, frail patients, those with mobility issues, or those who should remain bedridden. Third, the rapid conservative repositioning approach through two-person collaboration significantly enhances the success rate of repositioning, markedly shortens the repositioning time, and reduces the likelihood of re-operation. The procedure is further characterized by its safety, painlessness, simplicity, and speed, leading to high patient acceptance, good compliance, and minimal psychological burden, as well as a substantially lower economic burden. However, there are limitations to this approach. Effective operator cooperation is essential, and in certain cases, such as when greater omental wrap occurs, catheter migration may not be fully resolved, necessitating surgical intervention. Additionally, the three reported cases involve only Tenckhoff straight catheter transposition; therefore, further research is needed to evaluate the efficacy of this method for Tenckhoff coil catheters and swan-neck PD catheters.

Conclusion

The two-person cooperative conservative repositioning technique proposed in this paper demonstrated promising outcomes in addressing catheter displacement in three elderly patients undergoing PD. Although the approach yielded positive results in these initial cases, the reported findings are preliminary. Further research, including studies with larger patient cohorts and multi-centre trials, is essential to establish its efficacy and safety comprehensively. Until such evidence is avail- able, this technique may serve as a viable alternative in specific clinical scenarios, particularly for elderly and frail patients.