Peritoneal dialysis (PD) is as safe and more cost-effective than haemodialysis (HD). It also allows patients to undergo renal replacement therapy (RRT) from home. However, PD remains underutilised in many parts of the world. This is true in part because of many perceived relative contraindications to PD, including a history of prior major abdominal surgery. Prior major abdominal surgery is a concern for standard bedside or surgical catheter placement since these patients are at risk of having adhesions, which can complicate catheter placement. However, with laparoscopic advancements, prior major abdominal surgery is no longer even a relative contraindication to PD for skilled and experienced surgeons. We report the case of a male in his 70s with a history of cystoprostatectomy which was curative for a muscle invasive bladder carcinoma 5 years prior to his RRT. The patient had longstanding chronic kidney disease which worsened gradually. After receiving RRT education, the patient favoured PD. The catheter was placed despite the surgeon noting abdominal adhesions and the patient successfully underwent 12 months of PD which had a positive impact on his quality of life. He transferred to HD after contracting a complex PD-associated peritonitis. Thus, new research should be conducted to better understand the real impact of prior abdominal surgeries as a contraindication to PD, especially in centres where the surgeons have experience with advanced laparoscopy.

Rationale: Clear guidelines currently exist regarding antibiotic prophylaxis for patients on peritoneal dialysis (PD) prior to common diagnostic procedures. However, these guidelines do not include patients with subcutaneously embedded PD catheters who are awaiting PD initiation although both these populations share a great deal of risk factors for infections. Issues regarding antibiotic prophylaxis and avoidable infections are bound to keep occurring if physicians are not conscious of the risks of infections shared by all patients suffering from renal failure. Presenting concerns: Two weeks after a saline infusion sonohysterography (SIS), a 48-year-old woman with chronic kidney disease (CKD) G5 ND, type 2 diabetes, a subcutaneously embedded PD catheter, and prior abnormal uterine bleeding presented to the emergency department complaining of nausea, vomiting, diarrhea, weakness, and abdominal pain. The patient received no antibiotic prophylaxis prior to her SIS. Diagnoses: The final diagnosis of peritonitis was established after acute kidney injury, gastroenteritis, and small bowel obstruction were considered and ruled out. A delay in the final diagnosis occurred because of the complex presentation, the fact that the patient had not yet initiated PD, and the presence of concomitant anion gap metabolic acidosis and an acute elevation of the patient’s creatinine. Interventions: The patient was started on broad-spectrum intravenous antibiotics when the diagnosis of peritonitis was established. Insulin and intravenous bicarbonate infusions were used to correct the patient’s anion gap metabolic acidosis. Surgical debridement of the necrotic subcutaneous tissue and removal of the embedded PD catheter were necessary. Outcomes: The patient’s infection resolved completely as did her anion gap metabolic acidosis. The patient had to transfer permanently from PD to hemodialysis for her renal replacement therapy. Teaching points: This case report serves as a good reminder that physicians should keep in mind the possibility of peritonitis in patients with embedded PD catheters. As these patients are also at risk of infections, antibiotic prophylaxis should be used in patients with embedded catheters in the same way it is used for PD patients prior to obstetrical, gynecological, or gastrointestinal procedures.