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This interactive case study was organised and funded by Vantive. Medical writing support was provided by Jessica Jinks, EMJ, London, UK.
Why Are You Avoiding Peritoneal Dialysis in Patients with Prior Abdominal Surgery?
1/21
Nephrology
Disclosure
This interactive case study was developed with support from Peter Rutherford, Global Medical Affairs VP, Vantive LLC; and Robin Cooper, Global Medical Affairs Manager, Vantive LLC.
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Disclaimer
These are hypothetical patient cases and outcomes may not be reflective of clinical studies or real-life circumstances. This includes reference to agents that may be used off-label or for unlicensed indications. The mention of these agents and their uses is intended solely for educational purposes and should not be considered an endorsement or recommendation for their use outside approved indications. Please always consult guidelines and local prescribing information in your country of practice, as information may vary.
2/21
Introduction to Case
You have been following your patient for 3 years in the outpatient clinic. She is approaching the need for dialysis and wishes to pursue home-based therapy if possible. According to her Kidney Risk Failure Equation (KRFE), she will need to start dialysis within the next few months, and it is now time to begin discussions with the patient about their renal replacement options.
In this interactive case study, you will: Identify the patient’s renal replacement options Evaluate factors that may impact risk to the patient with each option
Patient Background
Keen to pursue home-based therapy if feasible.
58-year-old female with progressive chronic kidney disease (CKD).
Single, no children, lives independently.
Motivated for self-care with strong desire to maintain independence and flexibility.
Concerned about in-centre or hospital-based haemodialysis (HD).
3/21
Current Patient Assessment and Medical History
Medical History: Age: 58 years Sex: Female Height: 168 cm (5' 6") Weight: 68 kg (150 lbs) BMI: 24.2 kg/m2 BSA: 1.77 m2
Click to explore her surgical history
Open appendectomy aged 22 years.
Hysterectomy aged 45 years.
Laparoscopic cholecystectomy aged 50 years.
Now has intermittent abdominal pain, no recent surgeries.
4/21
Diagnoses and Kidney Risk Factor Equation
The patient has been previously diagnosed with glomerulonephritis.
References
Using the patient's urine, sex, age, and glomerular filtration rate, the kidney failure risk equation provides the 2- and 5-year probability of treated kidney failure for a potential patient with CKD Stage 3 to 5.1
You have run the patient's results through the Kidney Risk Factor Equation and found the following: Stage 5 Progressive CKD.
1. Kidney Failure Risk Calculator. Available at: https://www.kidneyfailurerisk.com/. Last accessed: 7 April 2026.
5/21
Understanding Absolute and Relative Contraindications
In clinical practice, contraindications are situations in which a treatment should be avoided due to potential harm and are classified as absolute or relative. Absolute contraindications indicate that the risk of serious harm outweighs any benefit.1 Relative contraindications require caution; treatment may require additional assessment if benefits outweigh risks, based on individual clinical judgement.1 Distinguishing between these supports risk stratification and informed, patient-centred decision-making.
1. National Library of Medicine (US). Contraindications [MeSH]. National Library of Medicine. 2018. Available at: https://www.ncbi.nlm.nih.gov/mesh/2023412. Last Accessed: 07 April 2026.
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A. Multiple prior surgeries may be associated with adhesions and reduced effective peritoneal surface area, but modality choice should prioritise patient preference and quality of life. B. Most patients with prior abdominal surgery retain sufficient peritoneal membrane surface area to achieve adequate PD; treatment decisions should incorporate the impact of the dialysis regimen on quality of life, mental health, and social circumstances. C. Prior abdominal surgeries are an absolute contraindication to PD as they will compromise peritoneal membrane surface area and PD should not be considered; home HD is the preferred option.
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A
B
C
A patient with end-stage kidney disease has a history of multiple prior abdominal surgeries. How should this history influence consideration of peritoneal dialysis (PD)?
Choose the following:
only
Explanation Previous abdominal surgery is not an absolute contraindication to PD. Although adhesions may occur, peritoneal membrane function cannot be reliably predicted from surgical history alone, and PD is often feasible with appropriate surgical technique.1 Most patients can still achieve adequate dialysis. Modality selection should therefore be individualised and patient-centred, rather than excluding PD automatically. This approach is supported by practice recommendations from the International Society for Peritoneal Dialysis (ISPD), which emphasise goal-directed, patient-focused PD prescribing.2 1. Lambie M, Davies S. An update on absolute and relative indications for dialysis treatment modalities. Clin Kidney J. 2023;16(Suppl 1):i39-47. 2. Brown EA et al International Society for Peritoneal Dialysis practice recommendations: prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int. 2020;40(3):244-53.
7/21
Attainability of PD for Patients with Prior Abdominal Surgery
Understanding contraindications1 There are few absolute contraindications to peritoneal dialysis (PD), and PD is feasible for most patients with a history of abdominal surgery. In such cases, successful PD requires an adequately functioning peritoneal membrane that is maximized during PD catheter placement. Nevertheless, prior abdominal surgery should not be regarded as an absolute contraindication. It is often appropriate to consider PD and to assess the patient’s suitability further, weighing the potential risks and benefits. Of note, among patients with multiple prior abdominal surgeries, certain subgroups may particularly benefit from PD, including: Patients awaiting transplantation Patients with a failed transplant Patients initiating or resuming PD following HD
1. Lambie M, Davies S. An update on absolute and relative indications for dialysis treatment modalities. Clin Kidney J. 2023;16(Suppl 1):i39-47. 2. Brown EA et al. International Society for Peritoneal Dialysis practice recommendations: prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int. 2020;40(3):244-53.
Figure 1: Contraindications with clinically defined groups. The double ended arrow represents the spectrum of modality indications according to specific patient-level groups in which there is either a clear contraindication or where specific concerns have been raised. Reproduced with permission from Lambie and Davies 2023.1
Figure 1
Informed patient preference should always be considered1,2 The choice of modality often involves compromises, and a patient's personal preferences and what is considered 'best' by clinicians do not always align. Success of dialysis is not only a function of suitability, but also dependent on the continued support from the dialysis provider. The range of modality choices and their risks should include the optimal patient pathway, provider limitations, and patient factors, such as how the relative contraindication affects clinical outcomes. If the benefits of PD outweigh the risks and informed patient preference has been considered, it should be prioritised.
8/21
Review of Evidence: The Impact of Prior Abdominal Surgeries on PD
Within 6 months of insertion, around one in four patients experience a catheter-related complication requiring emergency care, hospitalisation, treatment interruption, or further procedures. This is a major cause of early loss from PD and places a substantial burden on patients and the healthcare system.1,2 A 2024 study by Khan et al.3 reviewed findings from the North American Peritoneal Dialysis Registry of over 800 patients. The study identified that prior abdominal surgery was not associated with an increase in catheter abandonment of PD before start, interruption of PD, or termination of PD as compared to patients with no prior abdominal surgery.3
1. Fox DE, Quinn RR. A practical guide to understanding and managing non-infectious complications of peritoneal dialysis catheters in clinical Practice. Kidney Dial. 2025;5(3):36. 2. Chow KM et al. ISPD Catheter-related Infection Recommendations: 2023 Update. Perit Dial Int. 2023;43(3):201-19. 3. Khan WA et al. Impact of prior abdominal procedures on peritoneal dialysis catheter outcomes: findings from the North American Peritoneal Dialysis Catheter Registry. Am J Kidney Dis. 2024;84(2):195-204.e1.
Figure 2: Unadjusted, cumulative probability of peritoneal dialysis catheter–related complications by prior abdominal surgery, accounting for competing risks. Competing risks included death, transplant, recovery of kidney function, and termination of therapy for reasons not related to complications of the peritoneal dialysis catheter. Abbreviations: PD, peritoneal dialysis; PDC, peritoneal dialysis catheter. Reproduced with permission from Khan et al.3
9/21
Select the possible implications of prior surgery for patients who are considering PD.
ALL are correct As noted previously, it is virtually impossible to determine peritoneal viability after major surgery.1 1. Lambie M, Davies S. An update on absolute and relative indications for dialysis treatment modalities. Clin Kidney J. 2023;16(Suppl 1):i39-47.
Adhesions that may require adhesiolysis during PD catheter placement
Loss of peritoneal membrane surface area that may require a PD prescription to meet their needs
Compromised peritoneal membrane transport that requires the use of PD prescription tailoring
Extensive adhesions and exceptional loss of peritoneal membrane surface area that identifies the inability to perform adequate PD
D
Lambie and Davies: "In the case of PD, a functioning peritoneal membrane is absolutely necessary, and a history of major abdominal surgery associated with extensive peritoneal membrane adhesions would be the main cause of losing this. Even then, it is reasonable to attempt laparoscopic PD catheter insertion as it is often impossible to predict whether a membrane will function adequately regardless of adhesions."1
10/21
Risks Associated with Prior Surgery and PD
A healthy and functional peritoneal membrane is key to achieving sufficient ultrafiltration and restoring fluid balance, a major component of high-quality prescription in patients treated with PD.1,2
Prior surgeries may cause adhesions that can:4-7 Create loss of viable peritoneal membrane surface area Compromise peritoneal membrane transport. Predispose a catheter to malposition and kinking, resulting in compromised dialysate flow Result in abdominal pain after PD surgery
For how to assess membrane function and optimise therapy, the reader should refer to the recent ISPD guidelines.3
1. Morelle J et al. The peritoneal membrane and its role in peritoneal dialysis. Clin J Am Soc Nephrol. 2024;19(2):244-53. 2. Lambie M, Davies S. An update on absolute and relative indications for dialysis treatment modalities. Clin Kidney J. 2023;16(Suppl 1):i39-47. 3. Morelle J et al. ISPD recommendations for the evaluation of peritoneal membrane dysfunction in adults: classification, measurement, interpretation and rationale for intervention. Perit Dial Int. 2021;41(4):352-72. 4. Cheng BC et al. Impact of intra-abdominal adhesion on dialysis outcome in peritoneal dialysis patients. Biomed Res Int. 2018;2018:1978765. 5. Crabtree JH, Burchette RJ. Effect of prior abdominal surgery, peritonitis, and adhesions on catheter function and long-term outcome on peritoneal dialysis. Am Surg. 2009;75(2):140-7. 6. Eroglu E et al. Peritoneal dialysis patient selection from a comorbidity perspective. Semin Dial. 2022;35(1):25-39. 7. Qureshi MA et al. The association of intra-abdominal adhesions with peritoneal dialysis catheter-related complications. Clin J Am Soc Nephrol. 2024;19(4):472-82.
Impacts of prior surgeries on PD4,5
Scars do not determine suitability for PD.5 Previous abdominal surgical scars do not predict the presence or extent of intra-abdominal adhesions Prior surgeries should not be used alone to determine eligibility for PD
Scars do not determine suitability for PD5
Laparoscopy is currently the only practical and reliable method to assess peritoneal cavity suitability in these patients.5 Appropriate laparoscopic evaluation and technique provides the best tool for evaluating the extent of adhesions and determining whether a PD catheter placement should be attempted, maximising the likelihood of achieving durable, long-term peritoneal access, irrespective of adhesion status.5
Suitability for PD should be determined via laproscopy5
11/21
Role of Laparoscopy in Assessment and Placement
Laparoscopy is a minimally invasive surgical technique that can be used to assess adhesions, facilitate real-time lysis, and provide accurate catheter placement.1 Video-laparoscopic catheter placement can eliminate the differences in PD catheter outcomes that accompany conventional catheter insertion methods when intraperitoneal adhesions are present.2
Adhesiolysis Adhesiolysis refers to the dissection and removal of adhesions, in this case within the abdominal space, during laparoscopic catheter placement.3 Adhesions should be removed if they interfere with catheter placement or produce compartmentalisation that could impede dialysate drainage.3 However, it is neither necessary nor desirable to mobilise every adhesion found during this process.3
1. Tiong HY et al. Surgical complications of Tenckhoff catheters used in continuous ambulatory peritoneal dialysis. Singapore Med J. 2006;47(8):707-11. 2. Keshvari A et al. The effects of previous abdominal operations and intraperitoneal adhesions on the outcome of peritoneal dialysis catheters. Perit Dial Int. 2010;30(1):41-5. 3. Crabtree JH, Burchette RJ. Effect of prior abdominal surgery, peritonitis, and adhesions on catheter function and long-term outcome on peritoneal dialysis. Am Surg. 2009;75(2):140-7.
What is Adhesiolysis?
Risks of Non-Laparoscopic Approaches In patients with a history of major abdominal surgery, blind or fluoroscopically guided Seldinger techniques carry a substantial risk of placement failure and bowel perforation and are therefore relatively contraindicated.2 Beyond these major procedural risks, early complications following Tenckhoff catheter insertion include catheter malposition and poor flow, infection, peritonitis, and pericatheter leakage.1
Risks of Non-Laparoscopic Approaches
Why video-laparoscopy reduces contraindications:1,2 More accurate catheter placement Direct visualisation of peritoneal cavity Allows lysis of adhesions that may block optimal catheter positioning or impede drainage of dialysate Lower risk compared with blind or open techniques
Why video-laparoscopy reduces contraindications
12/21
Review of Evidence: Adhesions are Manageable
Quereshi et al.1 Among individuals with adhesions, 35 (17%) had PD catheter-related complications at 6 months, while among those without adhesions, 58 (10%) had complications Although the presence of adhesions increased the risk of PD catheter-related complications, most individuals with or without adhesions, around 79%, were able to initiate PD successfully and avoid complications resulting in invasive procedures
Clinical studies have investigated the outcomes of patients with and without prior abdominal surgery and/or resulting adhesions:
Clinical studies show that PD can be successful in patients with prior abdominal surgeries, but there are risks.1-4 It is important to identify and communicate these risks so that patients understand the complications that may occur.
Cheng et al.2 Patients who had previous abdominal surgery had higher risks of subsequent adhesions, especially patients with a higher mean age PD adequacy decreased after adhesion formation, but technical failure rates not significantly different at ≥2 years follow-up However, no significant difference was seen in 1- and 2-year catheter survival between patients with and without adhesions
Dias da Silva et al.3 Results showed that patients with a history of prior abdominal surgery, where PD was able to be started, presented similar baseline and evolutionary peritoneal transport characteristics These patients also had comparable PD technique survival rates, when compared to controls without such a background
Muhamad et al.4 142 patients received laparoscopic PD catheter placement, with 82 patients (58%) having had prior abdominal surgery. Adhesiolysis was required in 26 (28%) of patients No differences were found in PD catheter survival between patients with or without prior abdominal surgery Laparoscopic PD catheter placement should be a part of vascular surgery training as it provides an additional option for patients on dialysis
1. Qureshi MA et al. The association of intra-abdominal adhesions with peritoneal dialysis catheter-related complications. Clin J Am Soc Nephrol. 2024;19(4):472-82. 2. Cheng BC et al. Impact of intra-abdominal adhesion on dialysis outcome in peritoneal dialysis patients. Biomed Res Int. 2018;2018:1978765. 3. Dias da Silva A et al. Does prior abdominal surgery influence peritoneal transport characteristics or technique survival of peritoneal dialysis patients? Blood Purif. 2021;50(3):328-35. 4. Mohamed A et al. Laparoscopic peritoneal dialysis surgery is safe and effective in patients with prior abdominal surgery. Ann Vasc Surg. 2018;53:133-8.
13/21
Ensuring Successful Placement Also Includes Exit Site Planning
Practical considerations for exit site planning:1,2 Mark site preoperatively in sitting, standing, bending, and supine positions Marking the exit site helps in preventing mechanical issues Correcting issues inside the peritoneal cavity would be redundant if the exit site creates issues Avoid skin folds, belt line, and previous scars Ensure patient can visualise and access the site Consider low abdominal or paramedian placement if needed
1. Peppelenbosch A et al. Peritoneal dialysis catheter placement technique and complications. NDT Plus. 2008;1(Suppl 4):iv23-8. 2. Crabtree JH. Selected best demonstrated practices in peritoneal dialysis access. Kidney Int Suppl. 2006;(103):S27-37.
Figure 3: Schematic drawing indicating the manner in which the catheter insertion site and deep cuff location are selected in order to achieve proper pelvic position of the coiled catheter tip. Reproduced with permission from Crabtree et al.2
14/21
Surgical Evaluation of the Patient
During surgical appointment, healthcare professional assesses: Scar patterns Position of previous incisions Risks of blind catheter placement Likelihood of adhesions requiring lysis Suitability for laparoscopic PD catheter placement
What is the practical strategy for this patient? Practical strategy for this patient Proceed with planned laparoscopic PD catheter placement Intraoperative assessment of adhesions Lysis performed if feasible Decision to proceed based on real-time findings
15/21
Intraoperative and Postoperative Management
Intraoperative Decision Points Laparoscopic assessment as part of the PD catheter placement procedure is the best tool for evaluating the peritoneal cavity and identifying if PD catheter placement should even be attempted1 If adhesions are not amenable to lysis and are extensive to the extent that either catheter function or peritoneal membrane function is not viable → absolute contraindication1 Treatment decisions should be individualised rather than based solely on surgical history1,2
1. Crabtree JH, Burchette RJ. Effect of prior abdominal surgery, peritonitis, and adhesions on catheter function and long-term outcome on peritoneal dialysis. Am Surg. 2009;75(2):140-7. 2. Son YJ et al. Shared decision-making in choosing dialysis modalities for patients with chronic kidney disease: an evolutionary concept analysis. Nurs Health Sci. 2025;27(2):e70099. 3. Shah H et al. Perioperative management of peritoneal dialysis patients undergoing hernia surgery without the use of interim hemodialysis. Perit Dial Int. 2006;26(6):684-7. 4. Chow KM et al. ISPD Catheter-related Infection Recommendations: 2023 Update. Perit Dial Int. 2023;43(3):201-219. 5. Leong FF et al. Patient education interventions for haemodialysis and peritoneal dialysis catheter care: an integrative review. Int J Nurs Stud Adv. 2023;5:100156. 6. Iorga C et al. Management and outcomes for peritoneal dialysis patients diagnosed with abdominal hernias. Life (Basel). 2024;14(8):1003.
Postoperative Management After Successful Adhesion Lysis and Catheter Placement Early postoperative resumption of PD using modified prescriptions is feasible and recommended3 Patients should be closely monitored for mechanical complications, particularly outflow failure1 Structured patient education should include recognition of catheter dysfunction, dialysate leakage, and symptoms of peritonitis, to facilitate early intervention4-6 Close multidisciplinary follow-up between nephrology, surgical teams, and PD nursing is recommended to optimise catheter performance and adjust prescriptions in the early postoperative period3
16/21
How would you approach discussion about modality choice and decision-making with this patient?
A shared decision approach will improve the patient’s quality of life, reduce decisional conflict, maintain safety in dialysis, and ensure patient- and family-centred care.1 1. Son YJ et al. Shared decision-making in choosing dialysis modalities for patients with chronic kidney disease: an evolutionary concept analysis. Nurs Health Sci. 2025;27(2):e70099.
Don’t tell the patient about the issues with catheter insertion and proceed with catheter insertion if patient wants PD
Encourage the patient to choose HD as the prior surgery is too much of a risk
Follow a shared decision approach, listen to the patient about their wishes and values, and inform them about the surgical issues and then proceed if they wish to have PD
17/21
Important Considerations When Meeting with the Patient
Embed shared decision-making in practice.1
Use prognostic tools, such as the KFRE, to contextualise modality discussions and support informed deliberation Present all modalities, including home therapies, with explicit discussion of risks and practical implications For PD, address individualised catheter placement, peri procedural considerations, and required training and aftercare
1. Son YJ et al. Shared decision-making in choosing dialysis modalities for patients with chronic kidney disease: an evolutionary concept analysis. Nurs Health Sci. 2025;27(2):e70099.
The clinician as the medical expert
Align modality choice with the patient’s goals, quality of life priorities, and overall prognosis Provide transparent, comprehensive information tailored to health literacy
The patient as expert in their values, life context, and preferences
18/21
Case Outcome
Through shared decision-making, the patient and the care team select PD for her initial dialysis modality. Case Outcome Laparoscopic assessment performed Moderate adhesions found → lysis performed Catheter placed successfully Patient initiated PD without early complications Maintained desired autonomy and work routine
19/21
Key Takeaways
Prior abdominal surgery is not an automatic exclusion for PD. Adhesions are common but frequently manageable with appropriate surgical strategy Laparoscopic evaluation, adhesiolysis, and tailored catheter type expand eligibility. Laparoscopic placement significantly increases access to PD Shared decision-making should guide modality choice, barring absolute contraindications. Close surgeon–nephrologist coordination, clear expectation counselling, and early postoperative monitoring are critical to success
20/21
THANK YOU
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