In a research letter submitted to the editor of the American Journal of Kidney Diseases (AJKD), investigators including lead Zeenia Aga and corresponding author Jeffrey Perl (both St Michael’s Hospital, Toronto, Canada) argue that drain pain is a complication of peritoneal dialysis (PD) that demands more attention from clinicians. Writing as part of the team behind the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), Aga et al sought to establish both the prevalence and the causes of the problem.
The authors of the research letter outline that drain pain’s impact on patients’ quality of life demands the development of “avoidance and management strategies”. This, they suggest, will be made easier by understanding the risk factors with which it is associated.
For their study, they identified 1,630 PD patients across 121 centres in five countries who had filled out a questionnaire on drain pain. Patients were asked if they experienced drain pain in the preceding week, and if so, were then asked to rate their pain on a Likert scale. Severe pain was defined as a score of >5/10 on the scale. Using multivariable logistic regression, the authors then specified patient and treatment risk factors associated with the complication.
In total, 461 (28%) of the 1,626 patients whose answers to the questionnaire were used reported experiencing drain pain, while 35% of these described the pain as severe. There was geographical variation in reported rates, with the complication most prevalent in the UK (22/47 UK responses; 47%) and least so in the USA (77/409 US responses; 19%).
Patients aged 75 or over were found to have lower rates of drain pain than those aged 60–74 years (adjusted odds ratio [AOR] 0.58; 95% confidence interval [CI] 0.39–0.85), as were males compared with females (AOR 0.61; 95% CI 0.48–0.78). Aga et al also detail that incident patients who received PD (<3 months vs. >3 years) had higher odds of experiencing drain pain (AOR 2.64; 95% CI 1.74–4.00), as did those who had polycystic kidney disease (PKD; AOR 3.23; 95% CI 1.72–6.10).
The authors note a trend towards less drain pain with straight-tipped catheters vs. coiled (AOR 0.76; 95% CI 0.50–1.16), as well as with laparoscopic compared with open surgical or percutaneous catheter insertion (AOR 0.72, 95% CI 0.50–1.06).
They also found that automated PD was more strongly associated with drain pain than continuous ambulatory PD (AOR 1.61, 95% CI 1.20–2.17), but also with “less severe pain”—though only 39% of automated PD patients with PD received tidal prescriptions. Neither a history of abdominal surgery nor constipation were associated with any increased rate of drain pain, the authors add.
“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,” the authors speculate towards the end of the letter.
On incident PD patients’ higher risk of drain pain, they suggest that they “they need time to acclimatise to PD and PD catheter positions may change over time”. The lower rates of drain pain seen with laparoscopic insertion may be down to “direct visual inspection” and the “optimisation of PD catheter position”, they add.
Offering suggestions to clinicians, Aga et al suggest finally that “use of continuous ambulatory PD, tidal automated PD, straight PD catheters, and laparoscopic catheter insertion carefully considering pelvic PD catheter position” may all serve to mitigate drain pain.
More broadly, they say that “the possibility of drain pain should be discussed with patients” before initiation of PD—particularly those in more at-risk groups such as women and PKD patients. “This work,” the authors conclude, “informs the need for a validated drain pain questionnaire to support innovations in PD catheter design, implantation technique, and automated PD technology.”
Speaking to Renal Interventions, Aga said: “We hope that our research helps kidney care practitioners identify patients who have a high risk of drain pain to ensure these patients are appropriately counselled prior to initiation of peritoneal dialysis, and to consider implementation of protective strategies such as ambulatory PD prescriptions or tidal automated PD prescriptions to limit their risk of discomfort.
“In the future, with more practitioners adopting the approach of incremental peritoneal dialysis—which often lends itself to ambulatory PD prescriptions—it will be interesting to see if there is an associated reduction in drain pain frequency in incident PD patients. Further research on variations in drain pain by PD technology may help to further guide novel strategies to reduce the incidence of drain pain.”
