Establishing Learning Curve for Tenckhoff Catheter Insertion by Interventional Nephrologist Using CUSUM Analysis: How Many Procedures and in Which Situation?

A Service Reconfiguration Bundle for Expanding Access to Peritoneal Dialysis Including for Older Frailer Patients

INTRODUCTION

Rates of peritoneal dialysis (PD) have been traditionally low in Northern Ireland. With rising numbers of patients reaching end-stage kidney disease, PD is a more cost-effective treatment than haemodialysis and aligns with international goals to increase home-based dialysis options. The aim of our study was to highlight how a service reconfiguration bundle expanded access to PD in Northern Ireland.

METHODS

The service reconfiguration bundle consisted of the appointment of a surgical lead, a dedicated interventional radiologist for fluoroscopically guided PD catheter insertion, and a nephrology-led ultrasound-guided PD catheter insertion service in an area of particular need. All patients in Northern Ireland who had a PD catheter inserted in the year following service reconfigurations were included and prospectively followed up for one-year. Patient demographics, PD catheter insertion technique, setting of procedure, and outcome data were summarised.

RESULTS

The number of patients receiving PD catheter insertion doubled to 66 in the year following service reconfigurations. The range of approaches to PD catheter insertion (laparoscopic n = 41, percutaneous n = 24 and open n = 1) allowed a wide range of patients to benefit from PD. Six patients had emergency PD catheter insertion, with four receiving urgent or early start PD. Nearly half (48%, 29/60) of the PD catheters inserted electively were in smaller elective hubs rather than the regional unit. A total of 97% of patients successfully started PD. Patients who experienced percutaneous PD catheter insertion were older [median age 76 (range 37-88) vs. 56 (range 18-84), p < 0.0001] and had less previous abdominal surgery than patients who experienced laparoscopic PD catheter insertion (25%, 6/24 vs. 54%, 22/41, p = 0.05).

DISCUSSION

Through a service reconfiguration bundle, we were able to double our annual incident PD population. This study highlights how flexible models of service delivery introduced as a bundle can quickly deliver expanded access to PD and home therapy.

International Variations in Peritoneal Dialysis Utilization and Implications for Practice

In many countries, the use of peritoneal dialysis (PD) remains low despite arguments that support its greater use, including dialysis treatment away from hospital settings, avoidance of central venous catheters, and potential health economic advantages. Training patients to manage aspects of their own care has the potential to enhance health literacy and increase patient involvement, independence, quality of life, and cost-effectiveness of care. Complex reasons underlie the variable use of PD across the world, acting at the level of the patient, the health care team that is responsible for them, and the health care system that they find themselves in. Important among these is the availability of competitively priced dialysis fluid. A number of key interventions can affect the uptake of PD. These include high-quality patient education around dialysis modality choice, timely and successful catheter placement, satisfactory patient training, and continued support that is tailored for specific needs, for example, when people present late requiring dialysis. Several health system changes have been shown to increase PD use, such as targeted funding, PD First initiatives, or physician-inserted PD catheters. This review explores the factors that explain the considerable international variation in the use of PD and presents interventions that can potentially affect them.

Hospital-Volume Effects on Perioperative Outcomes in Peritoneal Dialysis Catheter Implantation: Analysis of 2,505 Cases

BACKGROUND

Evidence regarding volume-outcome effects on peritoneal dialysis (PD) catheter implantation is limited. This study aimed to investigate associations between hospital volume (annual caseload of catheter implantation) and perioperative outcomes.

METHODS

Clinical data for patients who underwent PD catheter implantation from 2007 to 2012 were extracted from the Japanese nationwide Diagnosis Procedure Combination database. Hospital volume was divided into tertiles: low-volume (1 - 6 cases/year), medium-volume (7 - 13 cases/year), and high-volume (≥ 14 cases/year). Multivariate logistic regression analysis for the occurrence of any adverse events and blood transfusion, and gamma-distributed log-linked linear regression analysis for postoperative length of stay were conducted with explanatory variables of hospital volume, age, sex, Charlson comorbidity index, history of hemodialysis, type of anesthesia, and type of hospital.

RESULTS

Among 906, 855, and 744 cases in the low-volume, medium-volume, and high-volume groups, overall adverse events were 10.0%, 7.6%, and 6.0%, transfusion rates were 1.3%, 1.1%, and 0.9%, and median postoperative stays were 12, 10, and 9 days, respectively. In multivariate analyses, compared with the low-volume group, medium-volume and high-volume groups were associated with a lower incidence of overall adverse events (odds ratio [OR] = 0.71, p = 0.058, and OR = 0.59, p = 0.013, respectively) and shorter postoperative stay (% difference = -10.5%, p = 0.023, and % difference = -18.5%, p = 0.001, respectively), while no significant association was detected for transfusion.

CONCLUSIONS

Less frequent adverse events and shorter stays were observed in higher-volume centers. Inverse volume-outcome relationships in PD catheter implantation were confirmed.

Respecting shape memory to optimize peritoneal dialysis catheter outcomes

Disruption of the shape memory of a peritoneal dialysis catheter at the time of insertion may be a factor responsible for tip migration and catheter dysfunction. The use of postimplantation radiology to confirm the preservation of both the swan neck angle and the inclination angle may have a role in standardizing insertion technique with the potential to reduce the impact of operator variation on catheter outcomes.

Novel educational approaches to enhance learning and interest in nephrology

The number of U.S. medical graduates pursuing careers in nephrology has declined over the last several years. Some of the proposed reasons for this declining interest include difficult-to-understand or unstimulating kidney pathophysiology courses in medical school; disheartening inpatient elective experiences; and few opportunities to experience the other aspects of nephrology careers such as outpatient nephrology clinics, outpatient dialysis, and kidney transplantation. Novel and alternative educational approaches should be considered by the nephrology training community to enhance the understanding of nephrology from medical school to fellowship training. Newer teaching methods and styles should also be incorporated to adapt to today's learner. These innovative educational approaches may not only increase interest in nephrology careers, but they may also enhance and maintain interest during nephrology fellowship. In this article, we will review several educational approaches that may enhance teaching and learning in nephrology.

Training of surgeons in peritoneal dialysis catheter placement in the United States: a national survey

BACKGROUND AND OBJECTIVES

Peritoneal dialysis (PD) depends on timely and skilled placement of a PD catheter (PDC). Most PDCs are placed surgically, but little is known about the residency training of surgeons in this procedure. Inadequate residency training could limit surgical expertise in PDCs, resulting in high complication rates that discourage PD use. This study assessed surgical PDC training in the United States to explore this issue.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A survey was sent to program directors of 248 U.S. surgery residency programs regarding the amount of PDC training, attitudes toward PDCs, and barriers to PDC training. Results were compared between academic and private centers.

RESULTS

Ninety-three surgery programs (38%) responded: 82% provided training in PDC and 69% were academic centers. Most surgeons placed 2 to <or=5 catheters during residency. Forty-eight percent of program directors felt that PDC training was important, 61% felt PDC training affected outcomes and increased the likelihood surgeons would place PDCs in practice, and 62% of programs expressed willingness to provide more PDC training. Lack of referrals from nephrology was the most frequently cited barrier to PDC training.

CONCLUSIONS

Although many U.S. surgery residency programs provide PDC training, this training appears inadequate. Low PD use and lack of referrals limits surgical training at most centers. Nephrologists need to develop initiatives with surgeons to improve PDC training and outcomes.