Sustained dialysis with misplaced peritoneal dialysis catheter outside peritoneum: A case report

BACKGROUND: In patients undergoing peritoneal dialysis (PD), catheter dysfunction is a common complication. A misplaced catheter is one of the reasons contributing to its dysfunction. The present study aimed to describe a case of misplaced PD catheter with an unusual location of the catheter tip. CASE SUMMARY: A 61-year-old man undergoing PD for 4 years was investigated for progressive nausea and fatigue of 3 mo. Dialysis adequacy studies indicated inefficient dialysis. Imaging discovered that the PD catheter tip was mispositioned in the pelvic cavity with its tip outside the peritoneal cavity. Despite the dialysate accumulating outside the peritoneal cavity, the patient had not developed perineal or scrotal edema. The patient had experienced a sustainable prolonged dialysis efficacy in this case until the renal function deteriorated further in view of the poor dialysis outcome and worsening health condition. The patient was subsequently transitioned to hemodialysis. CONCLUSION: Proper placement of the catheter in the peritoneal cavity should always be confirmed and re-checked when necessary in patients undergoing PD to ensure dialytic adequacy.