Cuff extrusion in peritoneal dialysis: single-centre experience with the cuff-shaving procedure in five patients over a 4-year period

Abstract

Catheter-related infections in peritoneal dialysis (PD) remain a significant complication, and some patients with recurrent exit-site (ESI) and/or tunnel infections may experience external cuff extrusion. In these cases, cuff-shaving has been described as a possible course of treatment. During a 4-year period, there were 44 patients with PD at our department; all received double-cuffed Tenckhoff catheters. Six (13%) never started on PD. Five (13%) of the 38 active PD patients experienced cuff extrusion. Causes of end-stage renal disease (ESRD) were diabetic nephropathy (n = 1), toxic nephropathy (n = 1), hypertensive nephrosclerosis (n = 1), systemic disease (n = 1) and one with unknown cause. PD catheters were inserted by the Department of Surgery and our patients waited a mean of 3.71 weeks (0.57–7.86) from catheter insertion to PD start. Patients were followed up by monthly and even fortnightly during infections. Our cohort experienced two (1–5) ESIs per patient prior to cuff extrusion. Cultures showed growth of Staphylococcus aureus and the patients received dicloxacillin orally 500 mg qid for 3–4 weeks. Of the 38 active PD patients, 5 (13%) developed cuff extrusion with an incidence of 0.20 episodes/patient/year, manifesting on average at 32 weeks (17.3–40.6), due to repeated ESI in four patients and substantial weight loss in one patient. All five underwent cuff-shaving and the ESIs resolved completely in 80% of the cases assisted by supplemental treatment with mupirocin and/or dicloxacillin. There were no complications to the cuff-shaving procedure itself. None of the five patients experienced new ESIs after cuff-shaving had been performed. Cuff-shaving reduces the rate of recurring ESIs. The procedure is safe, if performed correctly, and poses no risk to the patient or the catheter.

Creating and Maintaining Optimal Peritoneal Dialysis Access in the Adult Patient: 2019 Update

“…Depending on the magnitude of these shape memory forces and the proximity of the cuff to the exit site, straightening of the tubing may cause the cuff to extrude through the exit site. If the extruding cuff is not managed, it soon becomes seeded with bacteria and predisposes the patient to exit-site infection (141). A cuff that has completely extruded still remains a reservoir of bacteria in the vicinity of the exit site.…”

Peritoneal Dialysis Cuff-Shaving—A Salvage Therapy for Refractory Exit-Site Infections

“…Debowski et al (7) reported 5 cases of cuff-shaving in patients who had developed cuff-extrusion. Although the reason for the procedure was extrusion of the external cuff, it had developed secondary to repeated ESIs in 4 patients and the cuff was likely to be infected, as none of the 5 patients experienced new ESIs after cuff-shaving had been performed.…”

Exit-Site Relocation: A Novel, Straightforward Technique for Exit-Site Infections

“…For refractory ESIs, current guidelines suggest the timely replacement of the entire catheter, as this can prevent the inward dissemination of the infection, with the added advantage of permitting simultaneous replacement, thus avoiding prolonged periods on hemodialysis (4–7). Alternatively, the replacement of the infected external tubing segment by catheter splicing (8–11), or unroofing of the tunnel tract and shaving/removal of the superficial catheter cuff (12 13 14 15 16 17 18-19) have been proposed. On the contrary, our method is based on the assumption that the removal of the superficial cuff rather than the entire catheter is adequate to eradicate the infection since it is known to be an ongoing reservoir of infection.…”