Safety and utility of the alpha-replacer for treatment of intraluminal obstruction of peritoneal catheters by fibrin clots

BACKGROUND

The Moncrief-Popovich technique of peritoneal catheter implantation has beneficial effects for peritoneal dialysis (PD) initiation. However, it might increase the risk of peritoneal catheter obstruction by fibrin clots, because the catheter is buried under the skin for several weeks to months. Effects of treatment of intraluminal occlusion of PD catheters with tissue plasminogen activator, recommended by the International Society for Peritoneal Dialysis guidelines/recommendations are reportedly limited. We investigated the effectiveness of the 'alpha-replacer' (JMS, Tokyo, Japan) for PD catheter obstruction.

METHODS

We retrospectively analyzed a total of 193 patients in whom PD was initiated. PD catheters were embedded using the Moncrief-Popovich technique in 130 of these patients. We assessed the occurrence rates of peritoneal catheter obstruction and the utility of the alpha-replacer for treating intraluminal catheter occlusion by fibrin clots.

RESULTS

Catheter obstruction occurred in eight cases with embedded catheters, one due to omental wrapping and the others due to fibrin clots, in which median catheter burial durations were 477 (interquartile range [IQR], 226-510) days. All catheter obstructions due to fibrin clots were successfully treated with the alpha-replacer, leading to improved catheter drainage. The median amount of contrast agent used in catheterography was 10 (IQR 9-10) mL, which did not adversely affect residual renal function. There were no complications. No recurrence occurred during the observation period (median 111, IQR 55.5-141 months).

CONCLUSION

Our results suggest that treatment with the alpha-replacer is a safe and effective treatment option for intraluminal obstruction of PD catheters by fibrin clots.

Use of the embedded peritoneal dialysis catheter

Introduction The use of embedded peritoneal dialysis (PD) catheters is purported to offer numerous benefits over standard placement. However, the optimum period of embedment and the effect of prolonged embedment on subsequent catheter function remain unclear. Methods This retrospective observational study looked at adult patients undergoing embedded PD catheter insertion in a large tertiary referral centre in the UK. Possible predictors for catheter non-function at externalisation were investigated. These included patient factors (age, sex, diabetic status, body mass index, ethnicity, smoking status, previous surgery, estimated glomerular filtration rate), procedural factors (modality of surgery, concurrent surgical procedure), duration of catheter embedment and catheter damage at externalisation. Outcomes examined were proportion of catheters functioning after externalisation, futile placement rate, surgical reintervention rate, infectious complication rate and proportion of externalised catheters lost owing to malfunction. Results Sixty-six catheters were embedded and two-thirds (n=47, 63.6%) were externalised after a median embedment period of 39.4 weeks. Of these, 25 (53.2%) functioned on externalisation. Fourteen (63.6%) of the 22 non-functioning catheters were salvaged. The overall utilisation of PD was 34/47 (72.3%) and the futile placement rate was 12.1%. Over half of the externalised catheters (n=27, 57.4%) were lost directly as a result of catheter related complications, with a median survival time of 39.4 weeks. In adjusted analysis, increasing embedment duration was significantly predictive of catheter non-function at externalisation (adjusted odds ratio: 0.957, 95% confidence interval [CI]: 0.929-0.985, p=0.003) while subsequent catheter loss was highly dependent on catheter function at externalisation (hazard ratio: 0.258, 95% CI: 0.112-0.594, p=0.001). Conclusions Prolonged embedment of PD catheters is associated with a significantly higher likelihood of catheter dysfunction following externalisation, which is in turn associated with subsequent catheter loss. We have discontinued the use of this technique in our unit.

Embedded Catheters: Minimizing Excessive Embedment Time and Futile Placement while Maintaining Procedure Benefits

BACKGROUND

Embedding peritoneal catheters far in advance of anticipated need may successfully commit patients to their modality choice and reduce central venous catheter use but can be complicated by excessive embedment periods and futile catheter placement.

OBJECTIVE

Embedded catheter outcomes were studied to identify factors that minimize inordinate embedment time and futile placement while maintaining procedure benefits.

METHODS

Clinical and laboratory data were examined in 107 patients with embedded catheters that were either externalized, remained embedded, or were futilely placed.

RESULTS

Externalization of 84 catheters was performed after a median embedment period of 9.4 months. Flow dysfunction occurred in 14.3% of externalized catheters. Overall function rate was 98.8% after laparoscopic revision. One patient changed their mind about modality choice. Except for 1 patient hospitalized acutely in a facility unfamiliar with embedded catheters, none remaining on a peritoneal dialysis pathway initiated dialysis with a central venous catheter. Including catheters with extremely long embedment periods, the incidence of futile placement was 13.1%. Multiple regression analysis identified estimated glomerular filtration rate (eGFR) and serum albumin as the 2 variables best associated with catheter embedment duration (r(2) = 0.44, p < 0.0001). Diabetic nephropathy was statistically more likely to be associated with lower serum albumin values (p < 0.0001); however, no association was noted between diabetic status and embedment duration (p = 0.62).

CONCLUSIONS

Timing of the embedment procedure should include appraisal of both eGFR and serum albumin. Appropriate consideration of these values together may help minimize excessive embedment periods and decrease futile placements while preserving procedure benefits.

Peritoneal dialysis catheter implantation by nephrologists is associated with higher rates of peritoneal dialysis utilization: a population-based study

BACKGROUND

The likelihood of peritoneal dialysis (PD) utilization following a PD catheter insertion attempt is poorly described. We explored the risk factors for PD nonuse, focusing on the method of PD catheter implantation.

METHODS

This population-based retrospective cohort study employed Ontario administrative health data to identify 3886 predialysis adults who had an incident PD catheter implantation between 2002 and 2010. The impact of the method of catheter implantation including open-surgical (open, n = 1884), surgical-laparoscopic (laparoscopic, n = 1154), nephrology-percutaneous (nephrology, n = 498) and radiology-percutaneous (radiology, n = 350) on rates of PD utilization (defined as four consecutive weeks of PD) was examined.

RESULTS

Eighty-three percent of study patients received PD. After adjustment, relative to patients with openly inserted catheters, PD utilization was greater for those with nephrology-inserted catheters [adjusted hazard ratio (aHR) 1.59, 95% confidence interval (CI) 1.29-1.95] and similar for radiology-inserted catheters [aHR 1.16, 95% CI 0.94-1.43] or laparoscopic-inserted catheters [aHR 0.97 (95% CI 0.86-1.09)]. Among PD nonusers, death occurred in 10% of the open group, 6% of the laparoscopic group, 27% of the radiology group and in fewer than 3% of the nephrology group. Sixty-nine percent received hemodialysis in the open group, 63% in the laparoscopic group, 61% in the radiology group and 88% in the nephrology group. Those remaining predialysis comprised 12% of the open group, 22% of the laparoscopic group, 11% of the radiology group and <3% of the nephrology group.

CONCLUSIONS

Nephrology insertion resulted in lower overall rates of PD nonuse, particularly due to death or remaining predialysis. Greater use may be related to insertion timing, technique or greater commitment on the part of nephrologists to the success of PD.

PD First: peritoneal dialysis as the default transition to dialysis therapy

Peritoneal dialysis (PD) and in-center hemodialysis (HD) are accepted as clinically equivalent dialysis modalities, yet in-center HD is the predominant renal replacement therapy (RRT) modality offered to new end-stage renal disease (ESRD) patients in the United States and most other industrialized nations. This predominance has little to do with clinical outcomes, patient choice, cost, or quality of life. It has been driven by ease of HD initiation, physician experience and training, inadequate pre-ESRD patient education, ample in-center HD capacity, and lack of adequate infrastructure for PD-related care. As compared with in-center HD, PD is a widely applicable, yet underutilized modality of RRT that provides comparable clinical outcomes, superior quality of life measures, significant cost savings, and many other unmeasured advantages. A "PD First" approach not only has advantages for patients but also physicians, healthcare systems, and society. In this review, we will summarize evidence demonstrating that PD should be the default modality when new ESRD patients are transitioning to dialysis therapy when preemptive transplantation is not an option and highlight the essential infrastructural requirements to allow for a "PD First" model.

The role of peritoneal dialysis in modern renal replacement therapy

Most patients starting dialysis can choose between peritoneal dialysis and haemodialysis. There is little evidence proving that one form of dialysis is better than the other; although there may be an early advantage to peritoneal dialysis (PD) in young patients with residual function this effect is short-lived. Technique failure develops after years on PD so dialysis modality will often change during a long dialysis career. Quality of life studies, which must be interpreted carefully, indicate that patients require information about the impact of dialysis on their lifestyle as well as health-related outcomes so that they can choose the most suitable dialysis modality. Increasing numbers of frail elderly patients are starting dialysis; support in the home by nursing staff may facilitate the use of PD in this group. In the UK guidelines prioritise the patient's choice of dialysis modality (where feasible) based on good quality predialysis education. Cost of treatment is generally lower on PD, which is particularly recommended for patients with residual renal function and few comorbidities.

Prolonged Duration of Peritoneal Dialysis Catheter Embedment Does not Lower the Catheter Success Rate

Objective

Since 2000, we have used the Moncrief–Popovich technique as our standard method for peritoneal dialysis (PD) catheter insertion. The subcutaneous portion of the catheter is externalized immediately before initiation of PD. We undertook the present review to investigate whether duration of catheter embedment affects catheter or patient outcome.

Methods

All catheters inserted beginning 1 January 2000 and externalized by 31 December 2008 were included. The primary outcome was catheter survival. Secondary outcomes were catheter patency (no fibrin plug or omental wrap) and complications within 90 days after externalization. A standard peritoneal equilibration test was used to classify peritoneal membrane transport status. Proportional hazards regression models were used to test whether duration of embedment affected catheter outcomes. The models treated embedment duration as both a continuous predictor and a categorical predictor categorized by tertile.

Results

A total of 134 catheters were implanted and externalized. Twelve patients received 2 catheters each. To ensure statistical independence of the observations, 12 of the latter 24 catheters were excluded (1 chosen randomly from each patient), resulting in a useable sample size of 122 catheters. The total duration of observation was 2359 patient–months. The median duration of catheter embedment was 40.5 days (range: 2 – 788 days). After controlling for sex, race, age, and diabetes status, embedment duration did not have a significant effect on catheter survival as a continuous predictor or as a categorical predictor. Additionally, the 95% confidence interval for the 30-day effect of embedment duration ruled out a change of more than 20.6% in the hazard of catheter malfunction or infection. Of the studied catheters, 89.3% were patent and functioned properly immediately upon externalization. The remaining 13 catheters (10.7%) lacked patency on externalization because of fibrin plug or kinking ( n = 10) or omental wrap ( n = 3); however, 12 of the 13 non-patent catheters were corrected laparoscopically, and the patients resumed PD. Only 1 patient transferred to hemodialysis. Overall, 121 of 122 buried catheters (99.2%) were used for PD. Other complications within 90 days of catheter externalization included incision site and tunnel infection in 2 cases (1.6%), exit-site leak in 2 cases (1.6%), and coagulase-negative staphylococcal peritonitis in 1 case (0.8%).

Conclusions

Duration of catheter embedment before externalization did not affect catheter survival and did not influence subsequent peritoneal membrane transport status. The overall effect of increasing embedment duration by 30 days is, at most, a 20.6% increase or decrease in the hazard of catheter failure, but the actual hazard may be much smaller or nonexistent. Larger studies are needed to further explore the ideal duration of embedment.