Journal Information
Vol. 36. Issue. 5.September - October 2016
Pages 465-582
Vol. 36. Issue. 5.September - October 2016
Pages 465-582
Letter to the Editor
DOI: 10.1016/j.nefroe.2016.11.009
Open Access
Risk factors associated with hernias on peritoneal dialysis
Factores de riesgo asociados a hernias en diálisis peritoneal
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Aránzazu Sastre
Corresponding author
aranchasastre@hotmail.com

Corresponding author.
, Jose González-Arregoces, Igor Romainoik, Santiago Mariño, Cristina Lucas, Elena Monfá, Ana Aguilera, Benjamin de León, George Stefan, Mario A. Prieto
Servicio de Nefrología, Complejo Asistencial Universitario de León, León, Spain
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Tables (1)
Table 1. Comparison between patients with and without hernias.
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Dear Editor,

Dialysis fluid in the peritoneal cavity increases intraperitoneal pressure (IPP).1 This increase in pressure may lead to complications in the abdominal wall, particularly hernias. It may also contribute to the failure of ultrafiltration, and it may be cause of abandonment of the technique.

The aim of the study was to assess the frequency of hernias, identify the risk factors for the development of hernia and to determine whether or not they lead to failure of the dialysis technique.

We studied prevalent patients on peritoneal dialysis at day 01 August 2015 in the Complejo Asistencial Universitario de Leon, in Leon, Spain. We analysed the variables: age; gender; type; time on dialysis; presence of polycystic kidney disease; history of abdominal surgery; diagnosis and repair of hernia before starting dialysis; anthropometric parameters (body mass index (BMI), fat tissue index (FTI) and lean tissue index (LTI) measured by bioimpedance); daytime/sc volume; nocturnal/sc volume; residual volume; and IPP and ultrafiltration measured by a peritoneal equilibration test. We compared the group of patient with hernias with the group without hernias. Continuous variables were expressed as mean and standard deviation; in the case of discrete variables, absolute frequencies and percentages are provided. The association between qualitative variables was evaluated with the chi-square test and quantitative variables using Student's 2-tailed t-test. For the comparisons, the tests were considered to be significant when p<0.05. SPSS® statistical software for Windows was used.

We analysed 44 patients, 27 males (61.4%), 17 females (38.6%), 28 on continuous ambulatory peritoneal dialysis (CAPD) (63.6%), the average time on dialysis 27.63±19.1 months, 3 PKD (6.8%), 22 had a history of abdominal surgery (50%) and 8 (18.8%) had a hernia repair prior to starting dialysis.

There were 8 hernias (18.8%), 3 umbilical and 5 inguinal, 7 in males (87.5%), 50% on CAPD. In 6 patients, the prescription was changed to automated peritoneal dialysis (APD) with a dry day, one patient remained on CAPD with reduction of volume/sc; with these prescription changes, 6 (75%) patients remained asymptomatic and without complications such as incarceration or strangulation. One hernia (12.5%) was repaired surgically with mesh implant, and the patient was switched temporarily to haemodialysis due to the presence of persistent pain.

There were no differences between patients with hernias or without hernias in the variables age, dialysis modality, BMI, FTI, LTI, time on dialysis, volume/sc, ultrafiltration and IPP. In contrast, there was greater residual volume in the patients with hernias: 467±61.8 compared to 360.9±116ml (p 0.017). There were more subjects with PKD and more with hernias and previous abdominal surgery in the group with hernias (p<0.05) (Table 1). 100% of the group with hernias had IPP>13cm/H2O.

Table 1.

Comparison between patients with and without hernias.

  Hernia  No hernia  p Value 
Treatment with dialysis  25.9 (13.3)  28.01 (20.4)  0.7 
Age  57 (19.8)  63.6 (17.6)  0.3 
BMI  26.6 (2.5)  26.2 (5.8)  0.8 
FTI  11.6 (4.7)  12.4 (5.7)  0.7 
LTI  14.7 (3.9)  13.14 (3)  0.2 
Daytime/sc infusion volume  1048.3 (58.2)  1051.9 (242.3)  0.9 
Nocturnal/sc infusion volume  1068.6 (56)  1146.3 (142.6)  0.8 
IPP  15.37 (1.8)  15.83 (4.5)  0.7 
Residual volume  467 (61)  360.9 (116)  0.02 
Ultrafiltration  619 (239)  458.5 (250)  0.1 
Gender, female/male  12.5/87.5%  44.4/55.6%  0.01 
PLKD  25%  2.7%  0.01 
Previous surgery  62.5%  47.2%  0.04 
Previous hernia  37.5%  13.8%  0.02 

FTI: fat tissue index; BMI: body mass index; LTI: lean tissue index; IPP: intraperitoneal pressure; PLKD: polycystic liver and kidney disease.

Data are expressed as mean plus standard deviation.

We analysed the 34 patients who had IPP>13cm/H2O and compared them to those with lower IPP. Time on dialysis was 31.47±18 vs 14.55±15 months (p 0.012), BMI 27.68±4 vs 21.62±46kg/m2 (p 0.001), FTI 13.6±5 vs 7.6±4 (p 0.02), daytime/sc infusion volume 1103.12±132 vs 875±349ml/m2 (p 0.003) and residual volume 411.11±94 vs 275.14±125ml (p 0.001). We found no significant differences in the rest of the variables, including ultrafiltration.

Frequency of hernias vary in the range of 12–37% in different studies,2 similar to that found in our series, and there is no reason why a hernia should influence the continuing success or failure of the technique.3 No patient in our series has had to abandon the technique so far, although it has been needed to increase the use of cycler with dry day.

As in other studies, neither IPP or infusion volume appear to predict the development of abdominal hernias.1,4 A positive association has however been described with being elderly, polycystic kidney disease, BMI,5 prolonged time on peritoneal dialysis6 and previous hernias.7 There is a negative association with being female.6

We were unable to demonstrate any association with age or a lower LTI, perhaps because of the small sample size.

We can conclude that 18.8% of our patients developed an abdominal hernia as a complication; nevertheless 100% were able to continue with their dialysis technique.

The risk factors in our series were: being male; polycystic kidney disease; having had previous hernias; previous abdominal surgery; and greater residual volume.

IPP>13cm/H2O was associated with more time on dialysis, higher BMI, FTI and daytime volume/sc and greater residual volume.

Since 100% of these complications occur with IPP>13cm/H2O, we recommend adjusting the dialysis prescription to not exceed these limits, especially in patients with the risk factors described.

We believe that our finding of residual volume being a risk factor for hernias is a new observation; the tolerated pressure limit could be reduced to 13cm/H2O in patients at high risk of developing mechanical problems affecting the abdominal wall.

References
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A. Dejardin, A. Robert, E. Goffin.
Intraperitoneal pressure in PD patients: relationship to intraperitoneal volume, body size and PD-related complications.
Nephrol Dial Transplant, 22 (2007), pp. 1437-1444
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Prevalence and management of hernias in peritoneal dialysis patients.
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Impact of hernias on peritoneal dialysis technique survival and residual renal function.
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Risk factors for abdominal wall complications in peritoneal dialysis patients.
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S.F. Yang, C.J. Liu, W.C. Yang, C.F. Chang, C.Y. Yang, S.Y. Li, et al.
The risk factors and the impact of hernia development on technique survival in peritoneal dialysis patients: a population-based cohort study.
Perit Dial Int, 35 (2015), pp. 351-359

Please cite this article as: Sastre A, González-Arregoces J, Romainoik I, Mariño S, Lucas C, Monfá E, et al. Factores de riesgo asociados a hernias en diálisis peritoneal. Nefrologia. 2016;36:567–568.

Copyright © 2016. Sociedad Española de Nefrología
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