Peritoneal Dialysis–Related Drain Pain and Patient and Treatment Characteristics: Findings From the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Drain pain, a peritoneal dialysis (PD) complication, impacts patient quality of life. Understanding the prevalence and risk factors associated with drain pain is essential in developing avoidance and management strategies. In the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), we identified 1,630 patients (121 facilities, 5 countries) who completed a patient questionnaire (PQ) reporting drain pain in the preceding week (Table S1). Multivariable logistic regression identified patient and treatment risk factors associated with (1) any drain pain and (2) severe drain pain (≥5/10, Likert scale). Study approval and patient consent were obtained as per ethics committee regulations. Analyses used SAS software, version 9.4 (SAS Institute Inc, Cary, NC). Patient characteristics are presented in Table 1 by drain pain status (by country, Table S2). Drain pain was reported by 461 of 1,626 (28%) patients, of whom 35% rated their pain as severe. Drain pain was most prevalent in the United Kingdom (22/47, 47%) and least prevalent in the United States (77/409, 19%).Table 1Patient and Treatment Characteristics by Reported Drain Pain in the Preceding Week (Yes/No)NoYesTotal (n)1,165461CountryaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. Canada12%13% Japan30%38% Thailand28%27% United Kingdom2%5% United States28%17%Pain Likert scale (0 = minimum, 10 = maximum), median (IQR)aP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain.0 (0,1)5 (3,6)MaleaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain.61%54%Age, yearsaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. <4514%15% 45-5929%36% 60-7441%39% >7516%11%Body mass index, kg/m2 <2013%16% 20-2438%40% 25-2922%22% >3015%13% Missing12%9%PD vintage (months)aP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. <343%62% 3-1225%16% 12-3619%13% >3613%8%Etiology of ESKDaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. Glomerulonephritis17%20% Diabetes mellitus34%23% Renovascular disease / hypertension17%18% Polycystic kidney disease2%7% Other/missing30%32%PD Prescription APD44%46% APD with tidalaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain.24%39%PD catheter insertion techniqueaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. Laparoscopic catheter insertion21%18% Open surgical catheter43%54% Percutaneous catheter insertion6%8% Other/missing30%20%PD catheter tip configurationaP < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain. Coiled-tip PD catheter44%48% Straight-tip PD catheter21%29% Other/missing35%23%Bristol Stool ScorebMissing data, owing to this question not being asked on all questionnaire rounds, omitted. Separate hard lumps or lumpy and sausage-shaped (<3)6%8% Sausage-shaped with or without cracks on surface (3,4)18%25% Soft blobs to liquid (>5)15%18% Missing61%49%Abbreviations: APD, automated peritoneal dialysis; ESKD, end-stage kidney disease; IQR, interquartile range; PD, peritoneal dialysis.a P < 0.05 in terms of the distribution of this variable among patients with drain pain and patients without drain pain.b Missing data, owing to this question not being asked on all questionnaire rounds, omitted. Open table in a new tab Abbreviations: APD, automated peritoneal dialysis; ESKD, end-stage kidney disease; IQR, interquartile range; PD, peritoneal dialysis. Patients aged ≥75 years versus 60-74 years (adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.39-0.85) and males (aOR 0.61, 95% CI 0.48-0.78) had lower odds of drain pain (Fig 1). Incident patients receiving PD had higher drain pain odds (<3 months vs ≥3 years) (aOR 2.64, 95% CI 1.74-4.00), as did those with polycystic kidney disease (PKD) (aOR 3.23, 95% CI 1.72-6.10). There was a trend toward less drain pain with straight-tipped catheters (vs coiled) (aOR 0.76, 95% CI 0.50-1.16) and laparoscopic (vs open surgical or percutaneous) catheter insertion (aOR 0.72, 95% CI 0.50-1.06). Automated PD (APD) compared to continuous ambulatory PD (CAPD) use had higher drain pain odds (aOR 1.61, 95% CI 1.20-2.17) but less severe pain. Only 39% (69/176) of patients receiving APD with drain pain received tidal prescriptions. Constipation and abdominal surgical history did not increase drain pain likelihood. In this large cohort of patients receiving PD, drain pain is common, impacting nearly 1 in 3 PD patients. Prior reports in a single-center survey of 136 patients demonstrated that 13% reported pain during filling or draining.1Juergensen P.H. Murphy A.L. Pherson K.A. Chorney W.S. Kliger A.S. Finkelstein F.O. Tidal peritoneal dialysis to achieve comfort in chronic peritoneal dialysis patients.Adv Perit Dial. 1999; 15: 125-126PubMed Google Scholar In another survey of 293 APD patients, only 25% were on tidal PD, drain pain being the most common indication.2Blake P.G. Sloand J.A. McMurray S. Jain A.K. Matthews S. A multicenter survey of why and how tidal peritoneal dialysis (TPD) is being used.Perit Dial Int. 2014; 34: 458-460Crossref PubMed Scopus (14) Google Scholar Extending beyond North America and including all PD modalities, we found differences in drain pain prevalence by country potentially influenced by differences in sample size, survey response rate, and variable use of tidal PD. The increased drain pain observed in PKD and females may relate to enlarged polycystic kidneys and a uterus "crowding" the peritoneal space, pushing the PD catheter against sensitive tissues, as seen in urinary retention and colonic distension. Incident PD patients have higher drain pain risks, as they need time to acclimatize to PD and PD catheter positions may change over time. The trend toward less drain pain in those with laparoscopically inserted catheters may be the result of direct visual inspection and optimization of PD catheter position. The trend toward less drain pain with straight-tipped versus coiled-tipped catheters adds to their reported lower rates of infusion pain and catheter drainage dysfunction.3Chow K.M. Wong S.S.M. Ng J.K.C. et al.Straight versus coiled peritoneal dialysis catheters: a randomized controlled trial.Am J Kidney Dis. 2020; 75: 39-44Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar Our findings may be confounded by factors such as insertion site, length of intraperitoneal tubing, and side hole drainage location that may differ between coiled and straight catheters and impact drain pain risks. More proximal side holes (closer to the deep cuff) in straight- versus coiled-tip catheters may lessen drain pain risks, particularly important when a catheter has been implanted too deep in the pelvis. Tidal prescriptions as evidence-based drain pain management was used in only 39% of APD patients with drain pain, representing a missed therapeutic intervention.3Chow K.M. Wong S.S.M. Ng J.K.C. et al.Straight versus coiled peritoneal dialysis catheters: a randomized controlled trial.Am J Kidney Dis. 2020; 75: 39-44Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 4Blake P. Drain pain, overfill, and how they are connected.Perit Dial Int. 2014; 34: 342-344Crossref PubMed Google Scholar, 5Chang H. Miller M.A. Bruns F.J. Tidal peritoneal dialysis during pregnancy improves clearance and abdominal symptoms.Perit Dial Int. 2002; 22: 272-274Crossref PubMed Scopus (26) Google Scholar, 6Fernando S.K. Finkelstein F.O. Tidal PD: its role in the current practice of peritoneal dialysis.Kidney Int Suppl. 2006; 70: S91-S95Abstract Full Text Full Text PDF Scopus (10) Google Scholar, 7Agrawal A. Nolph K.D. Advantages of tidal peritoneal dialysis.Perit Dial Int. 2000; 20: S98-S100Crossref PubMed Google Scholar Our results support reduced drain pain with use of CAPD versus APD. Contemporary APD cyclers may use hydraulic suction, applying negative pressure to the sensitive parietal peritoneum, exacerbating drain pain.8Crabtree J.H. Peritoneal dialysis catheter implantation: avoiding problems and optimizing outcomes.Semin Dial. 2015; 28: 12-15Crossref PubMed Scopus (35) Google Scholar In such cases and after a failed trial of tidal PD, CAPD can be considered in those with established drain pain. If lifestyle considerations preclude CAPD use, early drain pain identification and timely PD catheter replacement is a final consideration in remediating drain pain. Reinsertion should carefully consider the technique that facilitates reduction in intraperitoneal length to avoid placement too deep in the pelvis. Use of incremental CAPD and APD prescriptions may also minimize drain pain.9Cheetham M.S. Cho Y. Krishnasamy R. et al.Incremental versus standard (full-dose) peritoneal dialysis.Kidney Int Rep. 2021; 7: 165-176Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Study strengths include the use of robust data from a large, international cohort. Limitations include lack of PD prescription details, operative details (ie, location of incision site and use of stencil-based mapping), reporting bias, and lack of PQ validation. The cross-sectional nature of data capture may have impacted reported drain pain incidence. particularly by dialysis vintage. Those with early intractable/severe drain pain may have been switched to hemodialysis and would not be included in later vintage cohorts. Patient questionnaire completion ranged from 75% of the Japanese patients to only 10% in the United States. PD drain pain is common, particularly early in treatment. Use of CAPD, tidal APD, straight PD catheters, and laparoscopic catheter insertion carefully considering pelvic PD catheter position may reduce drain pain, particularly in those identified at highest risk. Prior to PD initiation, the possibility of drain pain should be discussed with patients, particularly those at high risk, such as females and those with PKD. This work informs the need for a validated drain pain questionnaire to support innovations in PD catheter design, implantation technique, and APD technology. David Johnson (Australia); Hideki Kawanishi (Japan); Yong-Lim Kim (South Korea); Simon Davies (United Kingdom); Angelito Bernardo, Bruce Robinson, Jenny Shen (United States). Research idea and study design: GA, JP, ZA; data acquisition: RLP; data analysis/interpretation: JZ, RLP, KM, GA, SW, ZA; statistical analysis: KM; supervision or mentorship: AEF, TK, NG, MF, JP, KHO. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate. Global support for the ongoing DOPPS Programs is provided without restriction on publications by a variety of funders, as detailed at www.dopps.org/AboutUs/Support.aspx. Funding for PDOPPS has been provided by National Health and Medical Research Council (Australia); National Institute for Health Research (UK); National Institute of Diabetes and Digestive and Kidney Diseases (USA); Patient-Centered Outcomes Research Institute (USA); Japanese Society of Peritoneal Dialysis; Canadian Institutes of Health Research (Canada); Baxter International Inc (USA); The National Research Council of Thailand (2558-113); Rachadaphiseksompot Endorsement Fund (GCURS_59_12_30_03), Chulalongkorn University, Thailand; and the National Science and Technology Development Agency (NSTDA), Thailand. Jennifer McCready-Maynes, an employee of Arbor Research Collaborative for Health, provided editorial support. The funders did not have a role in study design, data collection, analysis, reporting, or the decision to submit for publication. KM, RLP, and JZ are employees of Arbor Research Collaborative for Health, which administers the DOPPS Program. MF reports board membership on the Japanese Society for Dialysis Therapy, Japanese Society for Dialysis Access, Japanese Society of High-Performance Membrane for Blood Purification, Japanese Society of Renal Failure Complications, and Japanese Society for Dialysis Functional Management & Assessment. GA reports employment by Satellite Healthcare and consulting for Akebia therapeutics. NG reports being on the advisory board for Fresenius and UptoDate patents. TK has received consultancy fees from VISTERRA, ELEDON, Otsuka OLE, and Otsuka VISIONARY as a country investigator, is current recipient of the National Research Council of Thailand, and has received speaking honoraria from Astra Zeneca and Baxter Healthcare. AEF reports speaker fees from Baxter and Bayer. JP reports grants from AHRQ during the conduct of the study; personal fees from Baxter Healthcare, Fresenius medical care, DaVita Healthcare Partners, US Renal Care, Astra Zeneca Canada, Otsuka Canada, Bayer Canada, and Amgen Canada, and is on the advisory board for Liberdi, outside of the submitted work. The remaining authors declare that they have no relevant financial interests. Authors RP, TK, and JP are PDOPPS Steering Committee members. Authors SW and MF are PDOPPS Research Group members. We thank the following additional PDOPPS Research Group members for their contributions: Sunil Badve, Neil Boudville, Fiona Brown, Josephine Chow, John Collins, Rachael Morton (Australia); Andreas Vychytil (Austria); Wim Van Biesen (Belgium); Ana Figueiredo, Thyago de Moraes (Brazil); Gillian Brunier, Arsh Jain, Vanita Jassal, Sharon Nessim, Matthew Oliver, Valerie Price, Rob Quinn (Canada); Wei Fang (China); CC Szeto, Angela Wang (Hong Kong); Yasuhiko Ito, Munekazu Ryuzaki, Tadashi Tomo (Japan); Alfonso Cueto Manzano (Mexico); Mark Marshall (New Zealand); Susanne Ljungman (Sweden); Sarinya Boongird, Chanchana Boonyakrai, Areewan Cheawchanwattana, Guttiga Halue, Suchai Sritippayawan, Sajja Tatiyanupanwong, Kriang Tungsanga (Thailand); Elaine Bowes, Edwina Brown, Richard Fluck, Bak Leong Goh, Helen Hurst, Martin Wilkie, Graham Woodrow (United Kingdom); Filitsa Bender, Judith Bernardini, Dinesh Chatoth, John Crabtree, Fred Finkelstein, Arshia Ghaffari, Rajnish Mehrotra, Beth Piraino, Martin Schreiber, Isaac Teitelbaum (United States). Received December 5, 2022. Evaluated by 2 external peer reviewers, with direct editorial input from a Statistics/Methods Editor, an Associate Editor, and the Editor-in-Chief. Accepted in revised form April 11, 2023. Download .pdf (.1 MB) Help with pdf files Supplementary File (PDF)Tables S1-S2.