Laparoscopic versus open peritoneal dialysis catheter insertion for the management of pediatric acute kidney injury

SAGES peritoneal dialysis access guideline update 2023

BACKGROUND

Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed.

RESULTS

After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction.

CONCLUSIONS

In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

Stratification of Risk Factors of Complications Associated with Peritoneal Dialysis Catheter Placement

Background: Peritoneal dialysis (PD) is a frequent method for renal replacement therapy in pediatric population. However, PD is associated with a high incidence of early and late complications. Thus, this study aims to evaluate the perioperative factors associated with these complications. Methods: Clinical records of patients who had peritoneal dialysis catheter (PDC) placement between January 2013 and June 2016 were retrospectively analyzed. Sociodemographic and perioperative variables were recorded and analyzed. Results: A total of 92 patients required PDC insertion. Primary PDC failure occurred in 21.74% of cases, and 17.39% required reoperation. The most common complication was occlusion (13.04%), followed by leak (8.7%). Age younger than 1 year and weight less than 10 kg were significant risk factors for catheter dysfunction, reoperation, leak, PDC occlusion, hernia, and death. The open technique was associated with higher risks of operation, leak, and peritonitis than the laparoscopic technique. Placement of the catheter by the laparoscopic technique reduced the odds of occlusion by 38%. Conclusions: Patients younger than 1 year and weighing less than 10 kg have an increased risk of complications and death, regardless of the technique used. The most frequent complication is catheter failure; however, the laparoscopic technique appears to reduce this complication.

Peritoneal Dialysis Catheter Placement in Children: Initial Experience with a "2+1"-Port Laparoscopic-Assisted Technique

The placement of a peritoneal dialysis catheter (PDC) is currently a common procedure in pediatric surgeon practice, and the search for the ultimate technique never stops. The purpose of this study is to evaluate our experience with the laparoscopic PDC placement approach, performing a "2+1" ("two plus one") technique, where the "+1" trocar is placed in an oblique manner, pointing toward the Douglas pouch when passing through the abdominal wall. This tunnel is further used to place and maintain the proper position of the PDC.

MATERIALS AND METHODS

We assessed a cohort of five children who underwent laparoscopic-assisted PDC placement between 2018 and 2022.

RESULTS

This procedure is a simple, relatively quick, and safe technique for PDC placement. Furthermore, in our experience, concomitant omentectomy is necessary to reduce the risk of catheter obstruction and migration due to omental wrapping.

CONCLUSIONS

The laparoscopic approach allows for improved visualization and more accurate placement of a catheter inside the abdominal cavity. Concomitant omental excision is necessary to prevent PDC malfunction and migration.

An overview of pediatric peritoneal dialysis and renal replacement therapy in infants: A review for the general pediatric surgeon

Currently, there are about 10,000 pediatric patients in the United States who rely on dialysis for renal replacement therapy. Dialysis allows children with chronic kidney disease a means of support until renal transplant is feasible. All forms of renal replacement therapy require a surgical intervention, whether the modality is hemodialysis or peritoneal dialysis. Despite peritoneal dialysis being the most common modality of dialysis in children, there is not prospectively collected much evidence in the literature which can guide the pediatric surgeon about best practices on access placement, management of complications, and timing of removal. Most available studies are small, single-center retrospective reviews. This limits the power of the data collected to help guide decision-making in the management of peritoneal dialysis catheters. The purpose of this review is to provide a consolidated source of best available evidence and identify important areas for future study. Furthermore, this is an area of pediatric surgical care that lacks up to date outcomes research with robust surgeon participation. Lack of coordinated, evidence-based best practices likely results in heterogenous surgical practices and uneven strategies for managing complications. Furthermore, with improvements in neonatal critical care and fetal interventions available for obstructive uropathies and other congenital kidney disorders, there is increased likelihood of the need for dialysis access in more infants, who represent a particularly vulnerable patient population. Importantly, peritoneal dialysis access should be instituted into the national PEDScore curriculum for pediatric surgical fellows, as this procedure is common enough that any pediatric surgeon could be consulted for catheter placement and management. Surgeon awareness of, and participation in the formulation, of guidelines and prospective studies is of paramount importance to ensure optimal care of this vulnerable population of children.

Acute peritoneal dialysis, complications and outcomes in 389 children with STEC-HUS: a multicenter experience

BACKGROUND

Management of acute kidney injury (AKI) in children with hemolytic uremic syndrome induced by a Shiga toxin-producing Escherichia coli infection (STEC-HUS) is supportive; however, 40 to 60% of cases need kidney replacement therapy (KRT). The aim of this study was to analyze procedure complications, especially peritonitis, and clinical outcomes in children with AKI secondary to STEC-HUS treated with acute PD.

METHODS

This is a multicenter retrospective study conducted among thirty-seven Argentinian centers. We reviewed medical records of 389 children with STEC-HUS hospitalized between January 2015 and February 2019 that required PD.

RESULTS

Complications associated with PD were catheter malfunction (n = 93, 24%), peritonitis (n = 75, 19%), fluid leaks (n = 45, 11.5%), bleeding events (n = 23, 6%), and hyperglycemia (n = 8, 2%). In the multivariate analysis, the use of antibiotic prophylaxis was independently associated with a decreased risk of peritonitis (hazard ratio 0.49, IC 95% 0.29-0.81; p = 0.001), and open-surgery catheter insertion was independently associated with a higher risk (hazard ratio 2.8, IC 95% 1.21-6.82; p = 0.001). Discontinuation of PD due to peritonitis, severe leak, or mechanical complications occurred in 3.8% of patients. No patient needed to be transitioned to other modality of KRT due to inefficacy of the technique. Mortality during the acute phase occurred in 2.8% patients due to extrarenal complications (neurological and cardiac involvement), not related to PD.

CONCLUSIONS

Acute PD was a safe and effective method to manage AKI in children with STEC-HUS. Prophylactic antibiotics prior to insertion of the PD catheter should be considered to decrease the incidence of peritonitis.

ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics)

SUMMARY OF RECOMMENDATIONS

1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)2. Access and fluid delivery for acute PD in children.2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)3. Peritoneal dialysis solutions for acute PD in children3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)3.2  Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3-4 mmol/l. (practice point) (minimum standard)3.3  Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)3.4  In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)3.5  Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)4. Prescription of acute PD in paediatric patients4.1 The initial fill volume should be limited to 10-20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30-40 ml/kg (800-1100 ml/m²) may occur as tolerated by the patient. (practice point)4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60-90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1-3 days of therapy. (1C)4.5  Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)5. Continuous flow peritoneal dialysis (CFPD)5.1   Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point) 5.2  Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point).

Advances in Kidney Replacement Therapy in Infants

Acute kidney injury continues to be a highly occurring disease in the intensive care unit, specifically affecting up to a third of critically ill neonates as per various studies. Although first-line treatments of acute kidney injury are noninvasive, kidney replacement therapy (KRT) is indicated when conservative management modes fail. There are various modalities of KRT which can be used for neonatal populations, including peritoneal dialysis, hemodialysis, and continuous KRT. However, these KRT modalities present their own challenges in this specific patient population Thus, it is the aim of this review to introduce each of these KRT modalities in terms of their challenges, advances, and future directions, with specific emphasis on new technology including the Cardio-Renal Pediatric Emergency Dialysis Machine, Newcastle infant dialysis and ultrafiltration system, and the Aquadex system for ultrafiltration.

Factors associated with early peritoneal dialysis catheter malfunction

BACKGROUND

Peritoneal dialysis (PD) catheter obstruction often leads to surgical revision and may require transition to hemodialysis. The purpose of this study was to evaluate risk factors (including omentectomy) associated with early PD catheter obstruction (<6 months from insertion).

METHODS

A retrospective review of all PD catheters inserted at a single high-volume referral center (2005-2018) was performed. 185 PD catheters were placed in 123 patients (45 female). Potential risk factors for early catheter obstruction were analyzed using Chi-square analysis (p < 0.05 considered statistically significant).

RESULTS

Median age at catheter insertion was 3.42 years (3 days-39 years). Early catheter obstruction occurred in 42 cases (22.7%). Median time to early obstruction was 24 days (3-118 days). Previous PD catheter placement (p = 0.9) or prior abdominal surgery (p = 0.89) was not associated with obstruction. Weight ≥ 10 kg (p = 0.011) and age ≥ 1 year (p = 0.048) were associated with a significantly higher incidence of obstruction. Overall, omentectomy was associated with a trend in reduction of early obstruction in patients with weight ≥ 10 kg (p = 0.08) and significantly in patients ≥1 year (p = 0.028).

CONCLUSION

Early PD catheter obstruction appears to occur more often in older patients with a higher weight. Concomitant omentectomy seems beneficial at reducing early catheter obstruction events in those patients.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.