Similar Outcomes of Catheters Implanted by Nephrologists and Surgeons: Analysis of the Brazilian Peritoneal Dialysis Multicentric Study

Comparing surgeon- and nephrologist-inserted Tenckhoff catheters: experience from a metropolitan centre in Sydney

BACKGROUND

Peritoneal dialysis (PD) is an effective home-based form of dialysis. Although several factors limit its use, the timely and successful insertion of a PD catheter is essential for increased uptake.

AIMS

This retrospective observational study was performed at a tertiary teaching hospital in Sydney with the aim of comparing outcomes of PD catheter insertion using a percutaneous, modified Seldinger technique utilised by a trained nephrologist to the traditional surgical insertion using a mini-laparotomy.

RESULTS

Over an 8-year period, 194 PD catheters were inserted. Aside from lower body mass indexes in the nephrologist-led interventions (P = 0.02), patient demographics were well matched. Time-to-insertion was significantly shorter with the percutaneous technique (P < 0.001). Univariant logistic regression noted no difference in the complication rate between the nephrologist-inserted and surgically inserted groups (likelihood ratio, 1.59; P = 0.08). There were differences in the type of adverse outcomes with each technique. Surgical procedures were more likely to have exit site leaks (P = 0.009) and peritonitis (P = 0.004), whereas procedure abandonment (P = 0.009) was more common in nephrologist-led procedures.

CONCLUSIONS

The current study highlights that with careful patient selection, trained nephrologists in metropolitan areas can successfully insert PD catheters. Our experience noted fewer delays to catheter insertion, with similar total complication rates.

Peritoneal catheter insertion: combating barriers through policy change

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians—both surgical and medical—to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.

A half-percutaneous technique for peritoneal dialysis catheter implantation using a modified trocar: a report of 84 cases

PURPOSE

Peritoneal dialysis (PD) catheter implantation is necessary for patients with end-stage renal disease (ESRD) to maintain continuous ambulatory PD (CAPD). In this study, we aimed to introduce a half-percutaneous technique based on a modified trocar device for the placement of a PD catheter and to evaluate the safety and efficacy of this technique and its associated short-term postoperative outcomes.

METHODS

Eighty-four ESRD patients who underwent PD catheter implantation with the half-percutaneous technique were recruited retrospectively between September 2016 and October 2017 from the Guangdong Provincial Hospital of Chinese Medicine. All catheter implantation procedures were performed by the same three nephrologists. The surgical protocol was described in detail, and the general intraoperative parameters and short-term complications were evaluated.

RESULTS

All ESRD patients underwent successful PD catheterization with our novel technique. Neither conversion from this method to traditional open surgery nor major intraoperative complications were observed. The mean operative time was 20.8 ± 4.5 min, and the incision length was 2.28 ± 0.53 cm. The operative cost was CN ¥ 1762.45 (US $261), and the length of hospital stay was 7.5 ± 0.58 days. One patient (1.19%) showed leakage, and one patient (1.19%) experienced bleeding 2 weeks after the surgery. Catheter dysfunction due to catheter tip migration occurred in nine patients (10.7%) 2 weeks after the procedure, and the placement of the catheter was corrected with conservative treatment. No visceral injuries or PD-related infections were observed up to 4 weeks after the catheters were implanted.

CONCLUSIONS

This half-percutaneous technique for PD catheter implantation appears to be a safe, effective and feasible procedure. This technique has the advantages of reduced surgical trauma, a shorter operative time and faster postsurgical recovery. In particular, this novel technique is easy for nephrologists to perform and therefore may help to promote and popularize PD treatment.

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.

Peritoneal Dialysis Catheter Insertion

The success of peritoneal dialysis as renal-replacement therapy depends on a well-functioning peritoneal catheter. Knowledge of best practices in catheter insertion can minimize the risk of catheter complications that lead to peritoneal dialysis failure. The catheter placement procedure begins with preoperative assessment of the patient to determine the most appropriate catheter type, insertion site, and exit site location. Preoperative preparation of the patient is an instrumental step in facilitating the performance of the procedure, avoiding untoward events, and promoting the desired outcome. Catheter insertion methods include percutaneous needle-guidewire with or without image guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy. The insertion technique used often depends on the geographic availability of material resources and local provider expertise in placing catheters. Independent of the catheter implantation approach, adherence to a number of universal details is required to ensure the best opportunity for creating a successful long-term peritoneal access. Finally, appropriate postoperative care and catheter break-in enables a smooth transition to dialysis therapy.

Overcoming the Underutilisation of Peritoneal Dialysis

Peritoneal dialysis is troubled with declining utilisation as a form of renal replacement therapy in developed countries. We review key aspects of therapy evidenced to have a potential to increase its utilisation. The best evidence to repopulate PD programmes is provided for the positive impact of timely referral and systematic and motivational predialysis education: average odds ratio for instituting peritoneal dialysis versus haemodialysis was 2.6 across several retrospective studies on the impact of predialysis education. Utilisation of PD for unplanned acute dialysis starts facilitated by implantation of peritoneal catheters by interventional nephrologists may diminish the vast predominance of haemodialysis done by central venous catheters for unplanned dialysis start. Assisted peritoneal dialysis can improve accessibility of home based dialysis to elderly, frail, and dependant patients, whose quality of life on replacement therapy may benefit most from dialysis performed at home. Peritoneal dialysis providers should perform close monitoring, preventing measures, and timely prophylactic therapy in patients judged to be prone to EPS development. Each peritoneal dialysis programme should regularly monitor, report, and act on key quality indicators to manifest its ability of constant quality improvement and elevate the confidence of interested patients and financing bodies in the programme.

The outcomes of percutaneous versus open placement of peritoneal dialysis catheters

BACKGROUND

Peritoneal dialysis catheters (PDCs) can be inserted by a percutaneous, open surgical, or laparoscopic approach. Considerable controversy surrounds the mode of catheter placement and its impact on technical success. We compared the complications and survival characteristics of PDCs that were inserted by the open approach versus those inserted percutaneously.

METHODS

We reviewed the outcomes of 167 patients who received PDCs between September 2009 and February 2012. Of these, 89 were placed percutaneously and 78 were placed by open surgical techniques. The mechanical complication rates, including catheter bleeding, wrapping, migration, leakage, and technical failure of intraperitoneal placement were compared between the two groups. Additionally, peritonitis episodes, exit site infection rates, and tunnel infection rates were compared between groups.

RESULTS

The incidence of one or more previous intra-abdominal surgeries was significantly higher in the open group (4.5 percutaneous vs 21.7 % open; P = 0.001). Although the overall number of complications did not differ between the two groups, the incidence of early mechanical complications (11.2 vs 0 %; P = 0.002) and the number of catheter removals due to mechanical complications (7.9 vs 1.3 %; P = 0.047) were higher in the percutaneous group. Of the 15 mechanical complications in the percutaneous group, one third were due to technical failures compared to none in the open group (5.6 vs 0 %; P = 0.034). The 1 year survival rate of the PDCs for the percutaneous and open groups was 89.9 and 93.3 %, respectively (P = 0.249).

CONCLUSIONS

The placement modality did not affect catheter survival. However, early mechanical complications, including technical failures, were more frequent in the percutaneous group, despite the proportion of patients with a history of one or more previous intra-abdominal surgeries being significantly lower in that group. The direct visualized open method of catheter insertion may provide the most reliable and secure access for a PDC.

Evaluating the benefits of home-based peritoneal dialysis

Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy.

Implantation of peritoneal catheters by laparotomy: nephrologists obtained similar results to general surgeons

Purpose

To analyze the complications and costs of minilaparotomies performed by a nephrologist (group A) compared with conventional laparotomies performed by a surgeon (group B) for peritoneal catheter implantation.

Setting

Two university hospitals (Santa Sofia and Caldas) in Manizales, Caldas, Colombia.

Methods

The study included stage 5 chronic kidney disease patients, with indication of renal replacement therapy, who were candidates for peritoneal dialysis and gave informed consent for a peritoneal catheter implant. Minilaparotomies were performed by a nephrologist in a minor surgery room under local anesthesia. Conventional laparotomies were performed by a surgeon in an operating room under general anesthesia.

Results

Two nephrologists inserted 157 peritoneal catheters, and seven general surgeons inserted 185 peritoneal catheters. The groups had similar characteristics: the mean age was 55 years, 49.5% were men, and the primary diagnoses were diabetic nephropathy, hypertensive nephropathy, and unknown etiology. The implant was successful for 98.09% of group A and 99.46% of group B. There was no procedure-related mortality. The most frequent complications in the first 30 days postsurgery in group A versus group B, respectively, were: peritonitis (6.37% versus 3.78%), exit-site infection (3.82% versus 2.16%), tunnel infection (0% versus 0.54%), catheter entrapment by omentum (1.27% versus 3.24%), peritoneal effluent spillover (1.91% versus 2.16%), draining failure (4.46% versus 6.49%), hematoma (0% versus 1.08%), catheter migration with kinking (3.18% versus 2.70%), hemoperitoneum (1.27% versus 0%), and hollow viscera accidental puncture (1.91% versus 0.54%). There were no statistically significant differences in the number of complications between groups. In 2013, the cost of a surgeon-implanted peritoneal dialysis catheter in Colombia was US $366 (666,000 COP), whereas the cost of a nephrologist-implanted catheter was US $198 (356,725 COP).

Conclusion

Nephrologist-performed minilaparotomies had similar effectiveness to surgeon-performed conventional laparotomies and were cost-effective; however, the nonuse of general anesthesia may be related with hollow viscera puncture during the procedure.

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.