Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program

Impact of renality-CASE training on knowledge, skills, and practices in peritoneal dialysis catheter placement among nephrologists

INTRODUCTION

Despite being an effective home-based kidney replacement therapy, peritoneal dialysis (PD) remains underutilized. The aim of the Renality-CASE training program was to assess its impact on nephrologists by expanding their knowledge of PD therapy and enhancing their catheter placement skills to better offer the PD option.

METHODS

The Renality-CASE program provided two days of training, including theoretical lectures, virtual reality sessions, and hands-on practice of PD catheter placement on live pigs. Eighty-eight participants attended four sessions. An anonymized online questionnaire collected demographic data, self-assessments of knowledge and skills, and feedback. Pre- and post-training comparisons were analyzed using paired samples t-tests and the Wilcoxon signed-rank test, with significance at p < 0.05.

RESULTS

Fifty-seven out of 88 participants responded to the survey one-year post-training. Post-training, 94.7% felt at least moderately knowledgeable compared to 61.4% pre-training (p < 0.001). Confidence in skills increased to 73.6% post-training from 26% pre-training (p < 0.001). The number of PD catheters placed by participants also rose significantly (p = 0.012). The program received positive feedback and high satisfaction rates.

CONCLUSIONS

The Renality-CASE program significantly improved nephrologists' PD catheter placement skills through comprehensive training. Despite limitations such as sample size and response bias, the study highlights the need for standardized PD training to enhance clinical practice and increase PD utilization in CKD management.

Minimally invasive peritoneal access: A new approach of catheter placement for peritoneal dialysis

BACKGROUND

Catheter implantation techniques for peritoneal dialysis (PD) have advanced significantly in recent years. We aimed to analyze the survival and associated complications of catheters inserted using a new technique that is guided by ultrasound and fluoroscopy and requires minimal tissue dissection. The procedure was performed by nephrologists in the outpatient basis, we compared these results of the minimally invasive insertion with traditional implantation using trocars.

METHODS

A total of 152 PD catheters were placed in 152 patients with stage 5 chronic kidney disease; 62.5% of the patients were men, with a mean age of 56.6 ± 18.5 years. The following two methods were used: minimally invasive insertion (MI group, n = 73) and trocar insertion (T group, n = 79). Patients in both the groups were followed prospectively for 26 months from the date of the first implantation.

RESULTS

Gender, age, and prevalence of diabetes mellitus were not significantly different between the groups, while the body mass index, presence of obesity, and abdominal scars from previous surgeries were higher in the MI group (p = 0.021). The incidence of catheter dysfunction was lower in the MI group compared to group T (6.8% vs 20.3%; p = 0.019). Exit site infection was also lower with the new technique (4.1% vs. 18.9%; p = 0.005). Further, the cumulative incidence of peritonitis also reduced with MI (p = 0.034). Finally, the overall catheter survival at 1 year was 89%, which has been shown as higher in group MI (95% vs 82% in group T; p = 0.025).

CONCLUSION

The MI technique for catheter insertion showed low complication rates and excellent catheter survival as compared to traditional implantation methods; thus, it may be an alternative method for PD catheter placement.

Peritoneal dialysis catheter salvage performed by nephrologists in tunnel exposure management

Background

Tunnel exposure, a non-infectious complication, is a rare finding in peritoneal dialysis (PD) patients, which has been described in some case reports. Our study aimed to present catheter salvage therapy using a revision procedure of tunnel exposure by nephrologists.

Methods

Our retrospective study was conducted between July 1998 and October 2021. We identified all PD patients with tunnel exposure from a database of a tertiary medical center. Tunnel exposure was diagnosed following gross inspection by clinicians during outpatient consultations. We attempted revision with partial external cuff shaving and creating a new tunnel without catheter change.

Results

Fourteen cases in 12 patients were diagnosed as tunnel exposure. The median age at presentation of tunnel exposure was 51 years. Eleven patients underwent revision, and the PD catheter was removed in one patient. The patients who underwent revision were followed up for 6 months. The catheter salvage rate was 72.7%.

Conclusions

The present study demonstrated that catheter revision performed by nephrologists could be a valuable alternative for original catheter salvage before considering catheter removal in tunnel exposure management.

Changing the peritoneal dialysis access algorithm with a precise technique of percutaneous Seldinger PD catheter placement

Background:

In 1953, Swedish radiologist Sven Seldinger introduced a technique for blood vessel or hollow organ access using a needle, guide wire and catheter. Over the last two decades, this technique has been used for Peritoneal Dialysis (PD) catheter placement, “Seldinger PD” (SPD). To improve the safety and accuracy of SPD, ultrasound, X-ray guidance, contrast imaging and micropuncture techniques have been incorporated to a greater or lesser extent.

Methods:

This manuscript describes a new and rigorous technique of SPD developed at our unit and results in the first 64 cases. One of our goals was to replace emergency Central Vein Catheter Hemodialysis with “Urgent-Start” PD. We therefore sought to develop a procedure that was ultra-safe, minimally invasive and readily done on the sickest patients under Local Anesthetic. As the technique was new to our unit, and because of progressive modifications of the technique, some of the results reflect our “learning curve.” In addition, 55% of the patients referred to our program had “crashed” into renal failure, 32% were deemed “unfit for General Anaesthesia” by the Anaesthetists and 53% were moderately to severely obese, resulting in a very morbid and vulnerable cohort.

Results:

Despite this, we had no procedure related mortality, no organ injury and no significant bleeding. Technical success was 97% (intention-to-treat). Urgent Start PD was used in 36%; overall, 3/61 catheters placed experienced PD fluid leak. Correct catheter tip placement – in the Pelvic Pouch – was documented in all cases; significant catheter migration was seen in 18% of those with imaging follow-up, only two requiring revision. Most catheter migrations occurred early in our series before our low peritoneal puncture technique became standard.

Conclusions:

We believe this SPD technique is safe, precise, clinically and financially cost-effective and can replace other forms of PD placement in most situations.

Neobladder creation is still a conduit to peritoneal dialysis - Successful use of peritoneal dialysis after invasive bladder cancer

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.

From "feeling" to "seeing": modification of the percutaneous peritoneal dialysis catheter insertion with an optical puncture system

PURPOSE

Blind insertion limits the application of percutaneous peritoneal dialysis (PD) catheter placement. In this study, we first described the use of an optical puncture system in the PD catheter insertion, and investigated the feasibility and advantages of this modified technique.

METHODS

This retrospective study included 65 patients with chronic kidney disease stage 5 (CKD5) who received ultrasound-guided percutaneous PD catheter insertion with or without optical puncture system assistance between June 2018 and July 2019. The patients' characteristics as well as the surgical outcomes and complications were compared between the modified group and the routine percutaneous insertion group.

RESULTS

Twenty-five patients underwent optical puncture system assistant insertion, whereas 40 patients received routine percutaneous insertion. More patients had previous abdominal surgical histories in the modified group than those in the routine group (24.0% vs. 5.0%, p = 0.047). The time of accessing to the abdominal cavity was significantly shorter in the modified group (median [IQR]; 1.1 min [0.8-1.3] vs. 5.0 min [4.0-6.0]; p < 0.001). Meanwhile, the time of the whole procedure was also significantly shorter in the modified group (median [IQR]; 26.0 min [25.0-29.0] vs. 33.0 min [29.0-35.0]; p < 0.001). None of the patient in the modified group, while two patients (5.0%) in the routine group converted to open procedure. There were no significant differences in the short and long postoperative complications between the two groups.

CONCLUSIONS

The operation of ultrasound-guided PD catheter placement with the optical puncture system is easy, safe, fast and accurate, whereby the PD catheter can be implanted percutaneously and visually under local anesthesia with minimal procedure-related complications. The visible puncture of the optical puncture system may facilitate ultrasound-guided percutaneous PD catheter insertion in patients with obesity and previous abdominal surgeries.

Percutaneous insertion of peritoneal dialysis catheter is a safe and effective technique irrespective of BMI

BACKGROUND

A large body mass index (BMI) has been considered as a relative contraindication for percutaneous catheter insertion, although this technique has many advantages. Up to now, there are few studies on peritoneal catheter placement and obesity. The aim of this study was to determine whether patients with large BMI can also choose the percutaneous technique for peritoneal dialysis catheter insertion.

METHODS

One hundred eighty seven consecutive patients underwent peritoneal catheter insertions in the Chinese PLA General Hospital between January 1, 2015 and December 31, 2016, with 178 eligible cases being included in the analysis. Two groups were created based on the catheter insertion techniques, the percutaneous group (group P) and the surgical group (group S). Subgroups were created according to BMI > 28 or ≤ 28. The outcomes included catheter related complications and catheter survival.

RESULTS

Total infectious complication rates were significantly lower in group P than in group S. There were no significant differences in peritonitis rate between group P and group S (1.20% vs. 3.16% with P = 0.71 in early stage, and 4.82% vs. 11.58% with P = 0.11 in late stage). All other measured complications were similar between the two groups. Though the one-year infection-free catheter survival in group P was 7.5% higher than group S, the difference was not significant. The one-year dysfunction-free catheter survival, one-year dysfunction-and-infection-free catheter survival, and overall catheter survival were similar between the two groups. Subgroup analyses showed a superior one-year infection-free catheter survival of percutaneous technique in patients with BMI > 28, which was confirmed by Kaplan-Meier analysis.

CONCLUSIONS

Despite the challenges that may be encountered with patients who have a large BMI, the percutaneous technique seems to be a safe and effective approach to placing a peritoneal dialysis catheter.

Dialysis Access: At the Intersection of Policy, Innovation, and Clinical Care

The Advancing American Kidney Health executive order aims to reduce the incidence of end-stage kidney disease, promote home dialysis therapies, increase the number of kidney transplants, and encourage innovation in new technologies, evidence-based practice, and early detection of kidney disease. Improvements in dialysis access care are essential to the success and expansion of this program, and to being able to provide high-quality, cost-efficient care to this patient population. Specifically, the need for expanded access to home dialysis will require surgeons and interventionalists to become proficient and trained in peritoneal dialysis catheter placement and for the referral process to be streamlined to accommodate the increased interest in this modality. In addition, new technologies, namely percutaneous fistula creation, bioengineered vessels, and a variety of interventions to reduce arteriovenous stenosis, will hopefully allow for timely and durable vascular access options that will support implementation of the executive order.

Setting Up and Expanding a Home Dialysis Program: Is There a Recipe for Success?

Home dialysis modalities remain significantly underused in the United States despite similar overall survival in the modalities, and recent incentives to expand these modalities. Although the absolute number of patients using home modalities has grown, the proportion compared to in-center hemodialysis (ICHD) continues to remain quite low. Well known barriers to home dialysis utilization exist, and an organized and team-based approach is required to overcome these barriers. Herein, we describe our efforts at growing our home dialysis program at a large academic medical center, with the proportion of home dialysis patients growing from 12% to 21% over the past 9 years. We prioritized individualized education for patients and better training for physicians, with the help of existing resources, aimed at better utilization of home modalities; an example includes dedicated dialysis education classes taught twice monthly by an experienced nurse practitioner, as well as the utilization of the dialysis educator from a dialysis provider for inpatient education of patients with CKD. The nephrology fellowship curriculum was restructured with emphasis on home modalities, and participation in annual home dialysis conferences has been encouraged. For timely placement and troubleshooting of access for dialysis, we followed a complementary team approach using surgeons and interventional radiologists and nephrologists, driven by a standardized protocol developed at UAB, and comanaged by our access coordinators. A team-based approach, with emphasis on staff engagement and leadership opportunities for dialysis nurses as well as collaborative efforts from a team of clinical nephrologists and the dialysis provider helped maintain efficiency, kindle growth, and provide consistently high-quality clinical care in the home program. Lastly, efforts at reducing burden of disease such as decreased number of monthly visits as well as using innovative strategies, such as telenephrology and assisted PD and HHD, were instrumental in reducing attrition.

Tenckhoff Catheter Insertion by Nephrologists: Open Dissection Technique

Background

The practice of Tenckhoff catheter insertion by nephrologists remains uncommon in most countries.

Methods

We report our single-center experience of Tenckhoff catheter insertion by nephrologists using the open dissection surgical technique in a dedicated ward-based procedure room.

Results

Between November 2005 and September 2008, 250 peritoneal catheters were inserted by 6 nephrologists with varying levels of experience. Surgical dissection followed by exposure of the peritoneum under direct vision was performed under local anesthesia. Primary catheter failure, as defined by catheters that failed to function within 1 month after insertion, occurred in 2.8% of cases. Within 1 month of catheter insertion, 20 patients developed infectious complications: 9 (3.6%) peritonitis, and 11 (4.4%) exit-site infections; none of these complications led to catheter removal. Mean technique survival for the catheters was 41.2 months (95% confidence interval: 39.5 months to 42.9 months). Catheter survival rates at 1 and 2 years were 92.7% and 87.2% respectively.

Conclusions

We reported an encouraging outcome for Tenckhoff catheters inserted by nephrologists in an open surgical manner, with a 2-year catheter survival of 87.2% and a good safety profile.

The Utility of Sonographic Assessment in Selecting Patients for Percutaneous Insertion of Peritoneal Dialysis Catheter

Background

Percutaneous insertion of peritoneal dialysis (PD) catheters by nephrologists is a safe and effective alternative to open surgical techniques. These patients are usually carefully selected due to anatomical considerations and medical comorbidities, with the current literature suggesting exclusion of patients with prior abdominal surgery.

Method

We conducted a retrospective cohort study of pre-dialysis patients who attended a preprocedural clinic in a tertiary center over 6 years. Procedural complications and catheter survival were assessed. Chi-squared test and Kaplan-Meier survival analysis were undertaken. Inpatient assessments were excluded.

Results

A total of 217 patients were assessed, of whom 171 (78.8%) were accepted for percutaneous PD catheter insertion by a nephrologist. The key exclusion criteria were: ( 1 ) the clinical presence of abdominal hernia ( p < 0.001), ( 2 ) ultrasound findings of skin to peritoneum depth of > 5.5 cm ( p < 0.001) and ( 3 ) ultrasound findings of impaired visceral slide test ( p < 0.001). Prior abdominal surgery was not a default exclusion criterion ( p = 0.1), as 63 patients (37%) with prior abdominal surgery, average of 1.3 prior surgeries per patient, were assessed as appropriate for the percutaneous procedure. There was no difference in the procedural complication rate and catheter survival between patients with and without prior abdominal surgery.

Conclusion

A comprehensive preprocedural assessment utilizing ultrasound permits an objective selection of patients for percutaneous insertion of PD catheters by nephrologists. This allowed for successful and safe percutaneous insertion of PD catheters in patients who may have otherwise been excluded, e.g., prior abdominal surgery, patients with large bilateral poly-cystic kidneys, and central obesity.

Diagnostic and Interventional Nephrology in Spain: A snapshot of current situation

BACKGROUND:

Diagnostic and Interventional Nephrology has been a rising field in recent years worldwide. Catheter insertion, renal biopsy, renal ultrasound, and peritoneal dialysis catheter or permanent dialysis catheter insertion are vital to our specialty. At present, many of these procedures are delegated to other specialties, generating long waiting lists and limiting diagnosis and treatment.

METHODS:

An online survey was emailed to all Nephrology departments in Spain. One survey response was allowed per center.

RESULTS:

Of 195 Nephrology departments, 70 responded (35.8%). Of them, 72.3% (52) had ultrasound equipment, 77.1% insert temporary jugular catheters, and 92.8% femoral. Up to 75.7% (53 centers) perform native renal biopsies, of which 35.8% (19) are real-time ultrasound guided by nephrologists. Transplant kidney biopsies are done in 26 centers, of which 46.1% (12) by nephrologists. Tunneled hemodialysis catheters are inserted in 27 centers (38.5%), peritoneal catheter insertion in 18 (31.6%), and only 2 centers (2.8%) perform arteriovenous fistulae angioplasty. In terms of ultrasound imaging, 20 centers (28.5%) do native renal ultrasound and 16 (22.8%) transplanted kidneys. Of all units 71.4% offer carotid ultrasound to evaluate cardiovascular risk, only in 15 centers (21%) by nephrologists. AVF ultrasound scanning is done in 55.7% (39).

CONCLUSION:

Diagnostic and Interventional Nephrology is slowly spreading in Spain. It includes basic techniques to our specialty, allowing nephrologists to be more independent, efficient, and reducing waiting times and costs, overall improving patient care. Nowadays, more nephrologists aim to perform them. Therefore, appropriate training on different techniques should be warranted, implementing an official certification and teaching programs.

Modified Peritoneal Dialysis Catheter Insertion: Comparison with a Conventional Method

PURPOSE

The conventional trocar and cannula method in peritoneal dialysis (PD) catheter insertion has its limitation in clinical setting. The aim of this study was to compare a modified method for percutaneous PD catheter insertion with the conventional method, and demonstrate advantages of the modified method.

MATERIALS AND METHODS

Patients at a single center who had percutaneous PD catheters inserted by nephrologists from January 2006 until September 2012, using either a modified method (group M) or the conventional trocar and cannula method (group C), were retrospectively analyzed, in terms of baseline characteristics, complications experienced up to 3 months after the procedure, and the suitability of the procedure for patients.

RESULTS

Group M included 82 subjects, while group C included 66 cases. The overall early complication rate in group M (1.2%) was significantly lower than that in group C (19.7%) (p<0.001). The catheter revision rate during timeframe for early complications was significantly lower in group M (0%) than in group C (6.1%) (p=0.024). When comparing Procedure time (1 h 3 min±16 min vs. 1 h 36 min±19 min, p<0.01), immediate post-procedural pain (2.43±1.80 vs. 3.14±2.07, p<0.05), and post-procedure days until ambulation (3.95±1.13 days vs. 6.17±1.34 days, p<0.01), group M was significantly lower than group C. There was no significant difference in total hospitalization period (14.71±7.05 days vs. 13.86±3.7 days).

CONCLUSION

Our modified PD catheter insertion method shows its advantages in early complication rate, early complications revision rate, and the patients' conveniences.

Percutaneous versus Surgical Insertion of PD Catheters in Dialysis Patients: A Meta-Analysis

Purpose

Several small studies have suggested that the percutaneous method of peritoneal dialysis (PD) catheter insertion is effective and has a lower complication rate than surgical techniques (open, laparoscopic or peritoneoscopic), although no randomized, controlled study has compared these methods. Our objective was to compare percutaneous PD catheter insertion vs surgical placement in terms of 1-year catheter survival, catheter dysfunction, fluid leak and incidence of peritonitis.

Methods

We searched Medline for English-language literature from 1966 through June 2014, along with national conference proceedings and reference lists of all included publications to identify relevant studies. Inclusion criteria were having a measure of catheter survival at 1 year, catheter dysfunction, peritonitis rate per patient-month or fluid leak as outcomes. Studies were excluded if they were not in English or if they included pediatric patients. Random effects models were used to derive the pooled risk ratios, differences in patency and their variations.

Results

Thirteen studies with a total of 2,681 subjects met the inclusion criteria. There was no significant difference in 1-year catheter survival in percutaneous vs surgical PD catheter placement (relative risk [RR] = 0.81; 95% confidence interval [CI]: 0.59-1.11, p = 0.19). Catheter dysfunction also did not differ significantly between the groups (pooled odds ratio [OR] = 0.86; 95% CI: 0.57-1.29, p = 0.46). The prevalence of peritoneal fluid leak also was similar for percutaneous and surgical groups (OR = 1.10; 95% CI: 0.58-2.09, p = 0.77). However, there was a significant lower incidence of peritonitis among those with percutaneous placement (incidence rate ratio [IRR] = 0.77; 95% CI: 0.62-0.96, p = 0.02). Significant heterogeneity was detected across studies ( I2 = 78.4%, p<0.0001).

Conclusions

Our results suggest that there is no significant difference in catheter survival between percutaneous and surgical placement of PD catheters. Whether there are significant benefits from percutaneous placement in terms of peritonitis rates requires further robust studies. These findings have significant implications for future design of clinical trials in the placement of PD catheters and the delivery of dialysis-related services.

Comparison of Percutaneous and Open Surgical Techniques for First-Time Peritoneal Dialysis Catheter Placement in the Unbreached Peritoneum

BACKGROUND

The percutaneous Seldinger method of peritoneal dialysis catheter (PDC) insertion has gained favor over recent years whereas traditionally it was reserved for patients considered not fit for general anesthesia. This blind technique is believed to be less safe, and is hence avoided in patients with previous laparotomy incisions. Reports on the success of this method may therefore be criticized for selection bias. In those with no prior abdominal surgery the optimal method of insertion has not been established.

METHODS

We retrospectively reviewed the outcomes of first-time PDC placements comparing the percutaneous (group P) and surgical (group S) insertion techniques in patients without a history of previous abdominal surgery in a single center between January 2003 and June 2010. We assessed catheter survival at 3 and 12 months post-insertion and compared complication rates between the two groups.

RESULTS

A total of 63 percutaneous and 64 surgical catheter insertions were analyzed. No significant difference was noted in catheter survival rates between group P and group S (86.2% vs 80% at 3 months, p = 0.37; and 78.3% vs 71.2% at 12 months, p = 0.42 respectively). Early and overall peritonitis rates were similar (5% vs 5.3%; p = 1, and 3.5 vs 4.9 episodes per 100 patient-months; p = 0.13 for group P and group S respectively). There were also no significant differences between the two groups in exit site leaks (15.9% in group P vs 6.3% in group S; p = 0.15), poor initial drainage (9.5% in group P vs 10.9% in group S, p = 0.34) or secondary drainage failure (7.9% in group P vs 18.8% in group S, p = 0.09).

CONCLUSION

This study illustrates the success and safety of percutaneous PDC insertion compared with the open surgical technique in PD naive patients without a history of prior abdominal surgery. Catheter survival was favorable with percutaneous insertion in this low-risk patient population but larger prospective studies may help to determine whether either method is superior. The percutaneous technique can be recommended as a minimally invasive, cost-effective procedure that facilitates implementing an integrated care model in nephrology practice.

Different outcomes of peritoneal catheter percutaneous placement by nephrologists using a trocar versus the Seldinger technique: the experience of two Brazilian centers

A good catheter implantation technique is important to allow effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with different techniques have been limited. The aim of this study was to investigate the rate of early catheter-related complications and catheter survival in two Brazilian centers, according to two different percutaneous methods of catheter implantation performed by nephrologist team. Adult incident patients recruited from January 2006 to July 2013 having undergone first peritoneal dialysis (PD) catheter implantation were included in the analysis. Mechanical and infectious early complication rates were defined as time to the first event occurring up to 3 months. Four hundred and forty-five consecutive Tenckhoff catheters were implanted by nephrologist team percutaneously after antibiotic prophylaxis in an operating room: trocar was used in 349 (78.4 %) and Seldinger technique (ST) in 99 (21.6 %). The ST was significantly associated with a lower rate of leak (16.3 vs 3 %, p = 0.03) and outflow failure due to tip catheter migration (22.6 vs 10.1 %, p = 0.04), while early infectious complication rates were similar between the two groups (p = 0.59). Long-term catheter survival was higher in Seldinger group (log-rank, p = 0.031). By Cox multivariate analysis, adjusted for age, sex, and diabetes, the ST remained independently associated with better catheter survival [HR 0.681 (0.462-0.910), p = 0.04]. As conclusion, our experience showed better PD outcomes with the ST than trocar method of catheter implantation by nephrologist.

Geographic and facility-level variation in the use of peritoneal dialysis in Canada: a cohort study

BACKGROUND

Peritoneal dialysis is associated with similar survival and similar improvement in quality of life and is less costly compared with in-centre hemodialysis. We examined facility and geographic variation in the use of peritoneal dialysis in Canada.

METHODS

We analyzed data from the Canadian Organ Replacement Register for the period January 2001 to December 2010. We identified patients for whom peritoneal dialysis was the primary modality at 90 days after initiation of dialysis. We used multilevel models to evaluate variation in use of peritoneal dialysis by facility and geographic region.

RESULTS

We analyzed data for 31 778 incident dialysis patients at 56 facilities in 13 geographic regions across Canada. Use of peritoneal dialysis at 90 days varied considerably across geographic regions (range 19.8%-36.1%) and declined over time, from 28.8% in 2001 to 22.5% in 2010. After adjustment for case mix and facility-level quality indicators, 9.3% and 3.4% of the variability was attributable to facility and geographic factors, respectively. In adjusted models, there was a substantial difference between geographic regions with the lowest and highest peritoneal dialysis use (odds ratio for high use 1.51, 95% confidence interval [CI] 1.33-1.73 v. odds ratio for low use 0.69, 95% CI 0.60-0.79).

INTERPRETATION

In Canada, substantial variability in the use of peritoneal dialysis attributable to facility and geographic region was not explained by differences in patient case mix. An opportunity exists to optimize use of this cost-effective therapy through changes in policy and standardization of criteria for initiation of peritoneal dialysis.

Comparison between the fixation of peritoneal dialysis catheters to the peritoneal wall and the conventional placement technique: clinical experience and follow-up of a new implant technique for peritoneal dialysis catheters

Peritoneal dialysis (PD) catheters often become severely dislocated, which may lead to malfunction. With the aim of preventing this complication, we have developed a simple method of fixing the catheter downwards in the peritoneal cavity (fixation technique), a technique that does not require a laparoscope. Sixteen patients were implanted using the conventional placement technique and 25 patients were implanted using the fixation technique. The location of the catheter tip was classified from grade 1 (downward, normal) to 5 (dislocated). The frequency of dislocation (defined as the extended time and/or decrease in volume when draining the PD solution) was measured for both the fixation technique and conventional placement technique. There was a significant difference in grade between the fixation technique (2.72 ± 1.01) and conventional technique (3.92 ± 1.31). The time until first dislocation was significantly different between the fixation technique (59.3 ± 48.1 days) and conventional technique (8.8 ± 14.6 days). The time until any dislocation was significantly different between the fixation technique (69.2 ± 41.9 days) and conventional technique (12.9 ± 13.7 days). Complications were not significantly different between the fixation technique and conventional technique. The fixation technique appears to be simple, safe, and useful for preventing severe dislocation and for lengthening the time until dislocation in PD patients.

Peritoneal dialysis catheter placement with peritoneoscopic technique and successful initiation of peritoneal dialysis in a patient with diastasis recti

Preserved anatomical integrity of the anterior abdominal wall is considered important in the presurgical evaluation of a patient who is being considered for placement of a peritoneal dialysis (PD) catheter. Diastasis recti abdominis (DRA) is the excessive widening or separation between the two bellies of the rectus abdominis muscle. The separation can occur anywhere along the linea alba and at times has been found to span the entire length from the xiphosternal angle to the pubic bone. Presence of DRA can pose a surgical challenge in the peritoneoscopic placement of peritoneal dialysis catheter. In this report, we discuss a case of successful placement of peritoneal dialysis catheter with peritoneoscope technique and successful initiation of peritoneal dialysis in a chronic kidney disease patient with DRA.

The choice of peritoneal dialysis catheter implantation technique by nephrologists

Peritoneal dialysis catheter (PDC) is the lifeline of peritoneal dialysis (PD) patients. One of the critical issues for successful PD is a well-functioning PDC which is timely inserted. It is the implantation technique rather than the catheter design that determines the outcome of the catheter. Dedication in acquiring the appropriate technique is vital to the success of a PD program. In this paper, we discuss the pros and cons of various techniques used for PDC implantation. A detailed description of PDC implantation by using the minilaparotomy method is presented. We strongly recommend mini-laparotomy as the method of choice for PDC implantation by nephrologists.

A comparative analysis of percutaneous and open surgical techniques for peritoneal catheter placement

BACKGROUND

Peritoneal dialysis (PD) is the preferred available option of renal replacement therapy for a significant number of end-stage kidney disease patients. A major limiting factor to the successful continuation of PD is the long-term viability of the PD catheter (PDC). Bedside percutaneous placement of the PDC is not commonly practiced despite published data encouraging use of this technique. Its advantages include faster recovery and avoidance of general anesthesia.

METHODS

We carried out a retrospective analysis of the outcomes of 313 PDC insertions at our center, comparing all percutaneous PDC insertions between July 1998 and April 2010 (group P, n = 151) with all surgical PDC insertions between January 2003 and April 2010 (group S, n = 162).

RESULTS

Compared with group P patients, significantly more group S patients had undergone previous abdominal surgery or PDC insertion (41.8% vs 9.3% and 33.3% vs 3.3% respectively, p = 0.00). More exit-site leaks occurred in group P than in group S (20.5% vs 6.8%, p = 0.002). The overall incidence of peritonitis was higher in group S than in group P (1 episode in 19 catheter-months vs 1 episode in 26 catheter-months, p = 0.017), but the groups showed no significant difference in the peritonitis rate within 1 month of catheter insertion (5% in group P vs 7.4% in group S, p = 0.4) or in poor initial drainage or secondary drainage failure (9.9% vs 11.7%, p = 0.1, and 7.9% vs 12.3%, p = 0.38, for groups P and S respectively).Technical survival at 3 months was significantly better for group P than for group S (86.6% vs 77%, p = 0.037); at 12 months, it was 77.7% and 68.7% respectively (p = 0.126). No life-threatening complications attributable to the insertion of the PDC occurred in either group.

CONCLUSIONS

Our analysis demonstrates further encouraging outcomes of percutaneous PDC placement compared with open surgical placement. However, the members of the percutaneous insertion group were primarily a selected subset of patients without prior abdominal surgery or PDC insertion, therefore limiting the comparability of the groups. Studies addressing such confounding factors are required. Local expertise in catheter placement techniques may affect the generalizability of results.

Who should place peritoneal dialysis catheters?

BACKGROUND

Nephrologists are often thwarted in their attempts to grow their peritoneal dialysis programs because of suboptimal surgeon performance in placing catheters. A rallying call is heard among nephrologists to step up to the role of dialysis access providers.

OBJECTIVE

What factors influence the practicability of nephrologists becoming primary dialysis access providers? Why have surgeons failed their task and can anything motivate them to change their performance and improve outcomes?

METHODS

While the issues are universal, this analysis focuses on current practice data from the United States. Evidence reviewed includes dialysis center size and annual new starts, profile of specialties performing catheter placement, nephrology workforce capacity, catheter implantation methodology, resource utilization for peritoneal access, and surgeon performance.

RESULTS

The current nephrology workforce is running at maximum capacity and fellowship training programs will struggle to meet additional demands. Nephrology training programs are often deficient in providing adequate experience in peritoneal dialysis management. Only 2.3% of peritoneal catheters are placed by nephrologists. The best catheter outcomes are produced by laparoscopic methods used by surgeons. Compared to other catheter placement techniques, laparoscopy enables a larger candidate pool of patients. Nonetheless, suboptimal surgical performances are related to inadequate training, low procedure volume, and poor reimbursement.

CONCLUSIONS

It is improbable that nephrologists can expand the scope of their practice to assume the additional role of dialysis access providers. The performance of the existing surgical workforce can be enhanced through medical society-sponsored educational activities, channeling access procedures to designated surgeons, and improved remuneration through outcomes-based incentive programs.

Salvage of accidentally sectioned peritoneal catheter: report of three cases

Peritoneal dialysis (PD) accounts for 6% of patients on maintenance dialysis. There are several factors responsible for this low prevalence. Transfer of patients to hemodialysis when any problem in the technique is present is probably one of the most frequent reasons. Thus, when a problem in the PD catheter appears they are routinely removed instead of subjecting to salvage procedures. We report three cases of accidental cutting of the peritoneal catheter and present the steps taken to salvage the catheter without discontinuing the technique and avoiding withdrawal of the catheter.

Emergence of interventional nephrology at the international level

The development of nephrology has been greatly influenced by the performance of procedures. For example, kidney biopsies have elicited substantial knowledge, thereby linking kidney afflictions with their respective histopathologies, which consequently governed the course of therapy. Further, the growth of nephrology has been marked by the implementations of advanced forms of renal replacement therapy. Moreover, there is now the acute acknowledgement that the success of any modality of renal replacement therapy is contingent upon the integrity of its associated peritoneal or vascular access. Consequently, the concept of nephrologist as interventionalist has garnered broad appeal. In fact, the American Society of Diagnostic and Interventional Nephrology and the International Society of Nephrology promote this concept. Notably, these groups have already demonstrated successful outreach programs that have been replicated at local, regional, and national levels throughout the globe.

Peritoneal dialysis catheter insertion by interventional nephrologists

Peritoneal dialysis (PD) catheter placement is performed by surgeons, interventional radiologists, and interventional nephrologists. Catheter insertion is accomplished through various methods including open surgical technique and laparoscopic, peritoneoscopic, and fluoroscopic guidance. Complication rates and catheter survival can vary based on the insertion technique used. Recently, nephrologists have made significant advances in the area of peritoneal dialysis catheter design and placement. Current data suggest that nephrologists are increasingly placing PD catheters using peritoneoscopic and fluoroscopic technique. This review focuses on peritoneoscopic and fluoroscopic insertion and highlights the advantages of catheter insertion by nephrologists.

American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: Does Catheter Insertion by Nephrologists Improve Peritoneal Dialysis Utilization? A Multicenter Analysis

In contrast to hemodialysis (HD), peritoneal dialysis (PD) remains an underutilized form of renal replacement therapy in the United States. Although a variety of factors have been deemed responsible, timely insertion of a PD catheter may also be a contributory factor. We conducted a multicenter analysis to examine whether the establishment of a program for PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD. Data for catheter insertion performed by nephrologists were collected from three centers. Any change in the prevalent PD population at each respective center was compared to the number of PD patients during the period having the traditional surgical approach. Nephrologists at the three centers used the peritoneoscopic technique and performed catheter insertion under local anesthesia. In center 1, the PD population remained stable at between 38 and 45 patients (approximately 16% of the total end-stage renal disease [ESRD] population) from 1993 to 2001. Nephrologists initiated a program for PD catheter insertion in 2001. The number of PD patients has increased to 101 (32% of the ESRD population). In center 2, the PD population remained stable at between 70 and 78 patients (approximately 17%) between 1988 and 1990. Catheter insertion by interventional nephrologists began in 1991. The number of PD patients has increased to 125 (22%). In center 3, the PD population remained at 20-30 patients (approximately 18%) between 1988 and 1991. Catheter placement by nephrologists was initiated in 1991. The number of PD patients increased to 97 (27%). Catheter insertion by interventional nephrologists was suspended in 2001. The number of PD patients has gradually declined to 25 (6%). This study suggests that catheter insertion by the nephrologist can have a positive impact on the utilization of PD.

Shorter break-in period is a viable option with tighter PD catheter securing during the insertion

BACKGROUND

Recent single-arm studies reported good catheter outcome despite shorter break-in periods after peritoneal dialysis (PD) catheter insertions. These results were attributed to tight catheter securing during the insertions.

OBJECTIVE

To compare catheter-related outcomes after different break-in periods in the tightly secured PD catheters.

PATIENTS AND METHODS

The study cohort comprised 48 patients, who underwent catheter insertions with the modified insertion technique. Based on the duration of break-in period, the patients were grouped into a shorter break-in period arm, with break-in period of 7 days or less and a standard break-in period arm, with break-in period of about 2 weeks. Mean patient follow up was 9.68 +/- 4.35 months, with a similar follow-up duration between the two break-in period arms (P = 0.94).

RESULTS

In the study cohort, the incidence of pericatheter leaks, pericatheter haemorrhage, catheter malfunction and peritonitis was 2/48 (4%), 1/48 (2%), 1/48 (2%) and 3/48 (6%), respectively. There was no other-site leak, bowel perforation, hernia formation or wound dehiscence. Of these complications, two pericatheter leaks, one catheter malfunction and three peritonitis episodes followed standard break-in periods, whereas, one pericatheter haemorrhage occurred in the shorter break-in period arm.

CONCLUSION

After a tight catheter securing during the insertions, overall pericatheter leak incidence remained low in the whole study cohort, and it did not worsen despite a shorter break-in period. Future studies with larger patient numbers are needed to validate the role of shorter break-in period in PD practice.

Does peritoneal dialysis catheter insertion by interventional nephrologists enhance peritoneal dialysis penetration?

Traditionally peritoneal dialysis (PD) catheter was implanted by surgeons using mini-laparotomy or open technique in Malaysia. We introduced peritoneoscopic Tenckhoff catheter insertion technique since the beginning of our PD program. Data were collected from the start of our PD program in February 2006 until April 2008. All Tenckhoff catheters were inserted by nephrologists using the peritoneoscope technique. We also compare the penetration rate of PD versus hemodialysis (HD) in our center, as well as comparing to national PD penetration rate. There were 83 patients who underwent 91 peritoneoscope Tenckhoff catheter insertion procedures from March 2006 until April 2008. The patients were mostly female (66%) with the mean age of 51.99 +/- 1.78 years and the majority (67%) of them were diabetics. All together there were 749.7 patient-months at risk and the overall peritonitis rate was 1 in 93.7 patient-months. The 1-year catheter survival was 86.5%. Primary catheter failure (defined as failure of the catheter within 1 month of insertion) occurred in 16 procedures (17.6%). The main cause of catheter malfunction was catheter tip migration and omentum wrap. The penetration ratio of PD when compared with HD in our center is 44.8%, which is about 4.5 times the national average. With our integrated care approach where nephrologist was heavily involved from the outset of renal replacement therapy discussion, PD access implantation to the assistance of spoke person to whom new patient can identify with, we were able to achieve PD penetration rate which far exceeds that of the national average.

Performance of procedures by nephrologists and nephrology fellows at U.S. nephrology training programs

BACKGROUND AND OBJECTIVES

Some procedures (e.g., placement of temporary hemodialysis catheters and kidney biopsies) are required in nephrology fellowship training. Others (e.g., placement of tunneled hemodialysis catheters, ultrasonography, and hemodialysis access interventions) are not required but are performed at some centers. To assess the procedures performed by nephrologists and nephrology fellows at U.S. adult nephrology training programs and the number of procedures required for fellow competency, a survey was conducted of all such training programs.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

An on-line survey was e-mailed to the directors of all U.S. adult nephrology fellowship programs in October to November 2007.

RESULTS

Responses were received from 93 of 136 programs. Nephrologists and nephrology trainees perform native and transplant kidney biopsies in 98% to 99% of programs and, in about half of programs, also perform the ultrasound guidance. Diagnostic ultrasounds are performed at fewer programs. Temporary dialysis catheters are inserted at nearly all programs. Tunneled hemodialysis catheters and peritoneal dialysis catheters are placed at < or =20% of programs. Interventional procedures on hemodialysis access are performed at 13% to 21% of programs. Continuous renal replacement therapy is performed at 99% of programs, plasmapheresis at 40%. Many programs either do not specify a minimum number of supervised procedures that need to be performed to demonstrate competence or require a very limited number.

CONCLUSIONS

Core procedures are performed at almost all programs. Experience and training in other procedures are variable. Many programs have limited requirements for the number of procedures trainees need to perform to demonstrate competence.

Interventional nephrology in Brazil: current and future status

The care of chronic kidney disease patients frequently involves many diagnostic and interventional procedures. Most of these procedures are currently performed by radiologists, vascular surgeons, and general surgeons. This has caused fragmented medical care, which has led many nephrologists to introduce a new paradigm, often referred as interventional nephrology (IN). The aim of this study was to establish the extent of involvement of the Brazilian nephrology community with regard to specific IN procedures. From October 2004 to February 2005, questionnaires were sent by e-mail to all 2500 nephrologists throughout Brazil. The enrollment questionnaire was composed of five sections, with questions about renal biopsy, specific training in ultrasonography, peritoneal dialysis access (insertion of peritoneal catheters guided or not by peritoneoscopy), hemodialysis vascular access (ability to place tunneled catheters, construction of arteriovenous fistulas, and other vascular access procedures), and the nephrologist's interest in being trained in IN. A total of 239 nephrologists answered the questionnaire. Only 18% of Brazilian nephrologists perform kidney biopsy guided by ultrasonography assisted by a radiologist. On the other hand, 42% of them reported that this procedure was done without any image support. Most of the respondents (85%) indicated that they were not formally trained to perform renal ultrasonography. When asked about peritoneal dialysis catheter placement, 66% of the respondents reported that they referred their patients to a surgeon for this procedure. The insertion of peritoneal dialysis catheters guided by peritoneoscopy was reported by 3% of the respondents. Similar to the results for peritoneal dialysis catheter placement, the majority of the respondents (77%) indicated no training in the insertion of tunneled catheters for temporary hemodialysis. Regarding the interest of nephrologists to participate in an IN program, the great majority (87%) responded that they would like to be trained in these procedures. Most nephrologists are not trained in IN procedures. Therefore, in Brazil, it will be necessary to develop training centers for IN that will allow nephrologists to optimize nephrology care.

Salvage of problematic peritoneal dialysis catheters

Peritoneal dialysis (PD) is a markedly underutilized modality for permanent renal replacement therapy in the United States owing to a low rate of patient referral and high rate of patient dropout or transfer to hemodialysis. One cause for patient loss from PD is problematic PD catheters that often are removed rather than being subjected to simple surgical salvage procedures. We report three patients with problematic catheters and our approach to their management. The first patient developed erosion of the skin overlying the portion of the catheter between the deep and superficial cuffs after 6 months of PD. The second patient developed extrusion of the superficial cuff after 4 years of PD. The third patient demonstrated a localized abscess at the incision site for catheter insertion after 3 years of PD. Other than a mild superficial exit site infection and localized abscess in the second and third patient, respectively, there were no associated infections of the catheter tunnel and cuff or of the peritoneal cavity as determined by either clinical examination, ultrasound evidence of fluid collection, or cultures and white blood cell counts. All three cases were managed successfully by interventional nephrology on an outpatient basis and under local anesthesia without either catheter removal or placement of a new PD catheter. It was possible to continue uninterrupted PD in the first and third patients, while the second patient had temporary hemodialysis to allow for complete healing of the surgical wound. We conclude that in selected cases simple interventions can salvage problematic PD catheters and maintain patients on PD.

Strategies to Minimize Tunneled Hemodialysis Catheter Use

While the use of arteriovenous grafts has recently declined, there has been an astronomical increase in hemodialysis patients dialyzing with tunneled dialysis catheters (TDCs). Recent data have indicated that over 70% of the patients with end-stage renal disease initiate dialysis with a catheter. Additionally, up to 27% of the end-stage renal disease patients in the US are using TDCs as their permanent access, with placement rates having doubled since 1996. Although most modern catheters claim to provide adequate blood flow for dialysis, they are associated with the highest incidence of complications, morbidity and mortality when compared with other types of vascular access. It is for these reasons that the National Kidney Foundation Dialysis Outcomes Quality Initiative guideline 30 as well as the Fistula First Change Concept 7 emphasize limiting the use of catheters and fostering the creation of arteriovenous fistulae. Early referral has clearly been shown to minimize the use of TDCs and maximize fistulae. This report focuses on the role of additional measures that minimize TDC use, such as dialysis modality presentation and peritoneal dialysis, vascular access education, preoperative vascular mapping and salvage of early failure and thrombosed fistulae.

Peritoneal dialysis access-related procedures by nephrologists

Traditionally the placement of a peritoneal dialysis (PD) catheter in a patient with end-stage renal disease (ESRD) has been accomplished by a surgeon and using general anesthesia. This approach often introduces delays in starting PD, incurs additional costs in utilizing an operating room as well as anesthesia services, and introduces the mortality risk associated with general anesthesia. Recent data have emphasized that interventional nephrologists can safely and successfully perform PD access procedures. In this context, operating room facilities and staff and anesthesia services are not required and catheter insertion can be performed in a procedure room using local anesthesia, thereby reducing costs and completely bypassing the mortality risk associated with general anesthesia. When performed by a nephrologist, the catheter insertion can be accomplished swiftly and dialysis therapy initiated in a timely manner. Once begun, the success of PD hinges on reliable and long-term access to the peritoneal cavity. Prospective randomized and nonrandomized studies have shown that PD catheters peritoneoscopically placed by nephrologists have fewer complications (infection, exit site leak) and longer catheter survival rates than those inserted surgically. Although PD offers a variety of advantages, it remains an underutilized form of renal replacement therapy. To counteract PD underutilization, at least two separate centers have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists. This article presents PD access-related procedures currently performed by interventional nephrologists. Furthermore, some of the complicating issues (bowel perforation, catheter migration, prior abdominal surgery) related to PD catheter insertion and management are also discussed.