Risk factors associated with peritoneal dialysis catheter survival: a 9-year single-center study in 315 patients

Percutaneous versus surgical catheter insertion for peritoneal dialysis: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Peritoneal dialysis (PD) is used as a kidney replacement therapy for patients with kidney failure. Institutional practices vary considerably, and the optimal technique for insertion of PD catheters is unknown. This study compared the efficacy and safety of surgical versus percutaneous approaches to PD catheter insertion for patients with end-stage kidney disease.

METHODS

Electronic databases (MEDLINE, Embase, CENTRAL) were systematically searched and analysed for relevant randomized controlled trials (RCTs). Eligible RCTs for inclusion were those that compared surgical versus percutaneous approaches to catheter insertion for patients undergoing PD dialysis. Outcomes of interest were patient- and catheter-related complications. In this study risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

RESULTS

Four studies (397 participants) were included. With regards to surgical approaches, only one study evaluated laparoscopic insertion; all other studies reported on open surgical techniques. Percutaneous insertion techniques varied significantly between the studies. No difference in patient mortality was found (RR = 0.82, 95% CI = 0.43-1.57, I2 = 0%). Percutaneous techniques were associated with lower rates of early peritonitis (RR = 0.34, 95% CI = 0.12-0.91, I2 = 0%) and long-term catheter failure (RR = 0.69, 95% CI = 0.47-1.00, I2 = 0%) than surgical approaches. Percutaneous catheter insertion was also associated with reduced late peri-catheter leak rates (RR = 0.35, 95% CI = 0.12-0.98, I2 = 0%) and peri-procedural complications (RR = 0.25, 95% CI = 0.07-0.90, I2 = 0%). The overall risk of bias was moderate, and certainty of evidence was low or very low.

CONCLUSIONS

Whilst percutaneous PD insertion techniques may have lower early and late complications compared to surgical technique, there was a lack of high-quality evidence comparing outcomes between contemporary percutaneous and surgical PD catheter insertion techniques. Future RCTs are required to compare the safety and efficacy of modern percutaneous with laparoscopic techniques.

A modified open surgical revision technique for malfunctioning peritoneal dialysis catheter

Backgrounds: The malfunction of peritoneal dialysis (PD) catheter is still an intractable problem. A modified open surgical revision technique with suturing fixation and without catheter removal for malfunctioning catheter was developed to evaluated the efficacy and safety between simultaneous catheter replacement technique.

Methods: A total of 167 PD patients with malfunctioning catheter were retrospectively reviewed. For the salvage of PD catheters, patients underwent modified open surgical revision (group A) or simultaneous catheter replacement (group B). The baseline characteristics before operation, perioperative condition, complications and outcomes were compared between both groups.

Results: Patients of group A showed significantly shorter operative time (67.4 ± 22.1 versus 82.8 ± 21.1 min, p = 0.009), less postoperative pain score within 24 h (median 0.0 versus 2.0, p < 0.001), quicker start of PD (1.06 ± 0.31 versus 1.89 ± 0.89 days, p < 0.001), shorter length of stay (9.89 ± 5.11 versus 12.55 ± 7.37 days, p = 0.020) than group B. In terms of complications, the incidence of recurred catheter malfunction in group A was significantly lower than those in group B (1/114 versus 12/53, p < 0.001). There were no significant differences in mechanical complications (bloody effluent, dialysate leakage, and hernia) and early peritonitis between the groups. The group A patients had a favorable catheter survival rate compared with group B (log-rank, p = 0.004).

Conclusions: Our modified open surgical revision technique is a safe, simple and fast method, and offers a better outcome with minimal risk of recurrence of catheter malfunction without additional cost and equipment. This technique is worthy of clinical application.

Peritoneal Dialysis in Critically Ill Patients: Time for a Critical Reevaluation?

Peritoneal dialysis (PD) as an AKI treatment in adults was widely accepted in critical care settings well into the 1980s. The advent of extracorporeal continuous KRT led to widespread decline in the use of PD for AKI across high-income countries. The lack of familiarity and comfort with the use of PD in critical care settings has also led to lack of use even among those receiving maintenance PD. Many critical care units reflexively convert patients receiving maintenance PD to alternative dialysis therapies at admission. Renewed interest in the use of PD for AKI therapy has emerged due to its increasing use in low- and middle-income countries. In high-income countries, the coronavirus disease 2019 (COVID-19) pandemic, saw PD for AKI used early on, where many critical care units were in crisis and relied on PD use when resources for other AKI therapy modalities were limited. In this review, we highlight advantages and disadvantages of PD in critical care settings and indications and contraindications for its use. We provide an overview of literature to support both PD treatment during AKI and its continuation as a maintenance therapy during critical illness. For AKI therapy, we further discuss establishment of PD access, PD prescription management, and complication monitoring and treatment. Finally, we discuss expansion in the use of PD for AKI therapy extending beyond its role during times of resource constraints.

The Influence of Peritoneal Dialysis Catheter Tip Design on Technique Survival: A Retrospective Observational Study

Introduction

The clinical practice guidelines for peritoneal access state that no particular peritoneal dialysis catheter (PDC) type has been proven superior to another. We present our experience with the use of different PDC tip designs.

Method

The study is a retrospective, real-world, observational, outcome analysis correlating the PDC tip design (straight vs. coiled-tip) and technique survival. The primary outcome was technique survival, and the secondary outcome included catheter migration and infectious complications.

Result

A total of 50 PDC (28 coiled-tip and 22 straight-tip) were implanted between March 2017 and April 2019 by using a guided percutaneous approach. The 1-month and 1-year technique survival in the coiled-tip PDC was 96.4% and 92.8%, respectively. Of the two coiled-tip catheters lost, one was a consequence of the patient having undergone live related kidney transplantation. The corresponding 1-month and 1-year technique survival with straight-tip PDC was 86.4% and 77.3%, respectively. When compared to straight-tip PDC, the use of coiled-tip PDC was associated with fewer early migration (3.6% vs. 31.8%; odds ratio (OR): 12.6; 95% confidence interval (CI): 1.41-112.39; P = 0.02) and a trend toward favorable 1-year technique survival (P = 0.07; numbers needed to treat = 11). Therapy-related complications noted in the study included peri-catheter leak and PD peritonitis. The PD peritonitis rate in the coiled-tip and straight-tip group was 0.14 and 0.11 events per patient year, respectively.

Conclusion

The use of coiled-tip PDC, when placed using a guided percutaneous approach, reduces early catheter migration and shows a trend toward favorable long-term technique survival.

Continuous ambulatory peritoneal dialysis catheter insertion by open technique: 20-year experience from a single center

Introduction

Continuous ambulatory peritoneal dialysis (CAPD) catheter placement is a part of renal replacement therapy. We describe our 20-year experience in using the open technique and assess its safety, efficacy, and outcome in the treatment of end-stage renal disease patients.

Methods

In a retrospective study, we analyzed data of all patients who had a CAPD catheter placed using our open dissection technique using local anesthesia over the previous 20 years, with minimum 1 year of follow-up. Intraoperative data, postoperative data, and complications were noted.

Results

A total of 1410 cases were included in the study. The mean duration of follow-up was 72 ± 18 months (range 12-120 months). The mean operative time was 19 ± 7.5 min and mean hospital stay was 3 ± 1 days. No major intraoperative complications were noted. We observed a peritonitis rate of 0.49 episodes/patient/year. The most common reason for permanent catheter removal was refractory peritonitis in 21%, followed by flow failure in 7%, and ultrafiltration failure in 6.5%. The death-censored technical survival rate was 94.3%, 83.2%, 75.9%, 69.2%, and 60.6% patients at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively.

Conclusions

The open dissection method of peritoneal dialysis catheter insertion using local anesthesia at well-experienced center is a simple, painless, and uncomplicated procedure with excellent outcomes. Optimal exposure, judicious use of energy source, and using appropriate technique provide good technical success rate with lesser complications.

Outcomes of Percutaneous Peritoneal Dialysis Catheters Insertion by Interventional Radiologists: A Single-Institution Experience

Purpose This article evaluates the short- and long-term outcomes of percutaneous peritoneal dialysis (PD) catheters inserted by interventional radiology service and analyzes the factors that affect the sustainability of patent and functional PD catheters.

Patients and Methods Retrospective single-institution study between April 2015 and February 2021. A total of 131 patients (75 males) were enrolled with mean age of 50 ± 19.6 years with an average body mass index (BMI) of 28 ± 7 kg/m2. Technical and clinical success were evaluated. Catheter-related complications were classified into mechanical and nonmechanical categories, including infectious complications. Indications for removal were analyzed.

Results Technical and clinical success were 100%. The average dwelling time for the entire cohort was 497.5 ± 462.3 days. Forty-six patients (35%) were on PD at the last follow-up with an average dwelling time of 492 days. PD-related complications were reported in 79/131 (60.3%) patients, including peritonitis (40.46%; 53/131), followed by malposition/migration (12.21%; 16/131), tunnel/exit site infection (10.69%; 14/131), and dysfunction (12.21%; 16/131). The incidence of peritonitis within 30 days postinsertion was 9.43% (5/53). The average interval between insertion and migration was 100.5 ± 144.8 days (95% confidence interval, 6.9–14.4). There was a trend for a higher rate of malposition/migration in patients with higher BMI (p = 0.0561). Causes for PD catheters removal were: (1) infection-related (24.4%; 32/131), (2) renal transplant recipients (16%; 21/131), (3) mechanical complications (13.7%; 18/131), and (4) patient's preference (7.6%; 10/131).

Conclusion Percutaneous PD catheter placement by interventional radiologists provides acceptable long-term outcomes and complication rates that meet the recommended standards.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

Percutaneous Versus Surgical Insertion of Peritoneal Dialysis Catheters: A Systematic Review and Meta-Analysis

Background:

Home-based peritoneal dialysis (PD) is an alternative to facility-based hemodialysis and has lower costs and greater freedom for patients with kidney failure. For a patient to undergo PD, a safe and reliable method of accessing the peritoneum is needed. However, different catheter insertion techniques may affect patient health outcomes.

Objective:

To compare the risk of infectious and mechanical complications between surgical (open and laparoscopic) PD catheter insertion and percutaneous catheter insertion.

Design:

Systematic review and meta-analysis.

Setting:

We searched for observational studies and randomized controlled trials (RCTs) in CENTRAL, EMBASE, MEDLINE, PubMed, and SCOPUS from inception until June 2018. Data were extracted by 2 independent reviewers based on a preformed template.

Patients:

Adult (aged 18+) patients with kidney failure who underwent a PD catheter insertion procedure.

Measurements:

We analyzed leak, malfunction, and bleed as early complications (occurring within 1 month of catheter insertion). Infectious complications (exit-site infections, tunnel infections, and peritonitis) were presented as both early complications and with the longest duration of follow-up.

Methods:

Random effects meta-analyses with the generic inverse variance method to estimate pooled rate ratios and 95% confidence intervals. We quantified heterogeneity by using the I2 statistic for inconsistency and assessed heterogeneity using the χ² test. Sensitivity analysis was performed by removing studies at high risk of bias as measured with the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool.

Results:

Twenty-four studies (22 observational, 2 RCTs) with 3108 patients and 3777 catheter insertions were selected. Data from 2 studies were unable to be extracted and were qualitatively assessed. In the remaining 22 studies, percutaneous insertion was associated with a lower risk of both exit-site infections (risk ratio [RR] = 0.36, 95% confidence interval [CI] = 0.24-0.53, I² = 0%) and peritonitis (RR = 0.52, 95% CI = 0.36-0.77, I² = 3%) within 1 month of the procedure. There was no difference in mechanical complication rates between the 2 techniques.

Limitations:

Lack of consistency in the time periods for the various outcomes reported, risk of bias concerns with respect to population comparability, and the inability to analyze individual component causes of primary nonfunction (catheter obstruction, catheter migration, and leak).

Conclusions:

Our meta-analysis suggests differences in early infectious complications in favor of percutaneous insertion and no significant differences in mechanical complications compared with surgical insertion. These findings have implications on the direction of PD programs in terms of maximizing operating room resources.

Assessment of complications and short-term outcomes of percutaneous peritoneal dialysis catheter insertion by conventional or modified Seldinger technique

Objective

To explore the efficacy and short-term complications of a modified technique to percutaneously insert a peritoneal dialysis catheter.

Methods

We reviewed the outcomes of 94 patients who underwent peritoneal dialysis catheterization between October 2017 and April 2020. Of these, 47 cases were placed by a conventional Seldinger technique, whereas 47 cases were placed by a modified technique based on the Seldinger method. The success rates of the catheter insertion and three-month postoperative complications were compared between these two groups.

Results

The catheter insertion success rates were comparable between the two groups: 93.6% in the conventional technique group and 97.9% in the modified technique group (p = 0.307). The incidence of postoperative catheter migration was lower using the modified technique (4.3%) than the conventional technique (18.3%) (p = 0.037). None of the patients in the modified technique group had postoperative dialysate leakage, whereas this occurred in 9.0% of patients in the conventional technique group (p = 0.036). There were no statistically significant differences in the incidence of postoperative bleeding, infection, or visceral damage between the two groups.

Conclusions

The modified Seldinger technique for percutaneous peritoneal dialysis catheter insertion reduced the short-term postoperative complications of catheter migration and dialysate leakage, with a comparable successful catheter insertion rate compared with the conventional Seldinger technique.

Establishment of a prediction model for early and mid-term complications for patients undergoing catheter insertion for peritoneal dialysis

Objective

To investigate the factors involved in early and mid-term complications after catheter insertion for peritoneal dialysis and to establish prediction models.

Methods

A total of 158 patients with peritoneal dialysis in the Department of Nephrology of our hospital were retrospectively analyzed. General information, laboratory indices, early complications (within 1 month after the operation), mid-term complications (1–6 months after the operation), and other relevant data were recorded. Multivariate logistic regression analysis was performed to establish a prediction model of complications and generate a nomogram. Receiver operating characteristic (ROC) curve analysis was used to evaluate the efficacy of the model.

Results

Among the patients, 48 (30.8%) had early complications, which were mainly catheter-related complications, and 29 (18.4%) had mid-term complications, which were mainly abdominal infection and catheter migration. We constructed a prediction model for early complications (area under the curve = 0.697, 95% confidence interval: 0.609–0.785) and mid-term complications (area under the curve = 0.730, 95% confidence interval: 0.622–0.839). The sensitivity was 0.750 and 0.607, and the specificity was 0.589 and 0.765, respectively.

Conclusions

Our prediction model has clinical significance for risk assessment of early and mid-term complications and prevention of complications after catheterization for peritoneal dialysis.

Peritoneal Dialysis Catheter Insertion by Nephrologist Using Minilaparotomy: Do Survival and Complications Vary in Obese?

Introduction:

Peritoneal dialysis catheter (PDC) placement for chronic kidney disease (CKD) amongst overweight and obese patients is difficult owing to deeper operating field. Literature being discordant on survival and complications in this patient subset, we attempted to analyse this research question in Indian population.

Materials and Methods:

We retrospectively analysed PDC inserted by nephrologist using surgical minilaparotomy for survivals and complications amongst 'overweight and obese' cohort ('O') at two tertiary care government hospitals in India, and compared results with normo-weight cohort ('N'), with 12−36 months follow-up.

Results:

245 PDCs were inserted by surgical minilaparotomy and 'N' to 'O' ratio was 169:76. 'O' group were more rural residing (P = 0.003) and post-abdominal surgery (P = 0.008) patients. The 1, 2, and 3-year death censored catheter survival rate was 98.6%, 95.8%, and 88.2% respectively in 'O' group, and 97.6%, 94.5% and 91.8% in 'N' group respectively (P = 0.52). Patient survival (P = 0.63), mechanical complications (P = 0.09) and infective complications (P = 0.93) were comparable despite technically challenging surgery in 'O' group. Refractory peritonitis related PDC removal was comparable (P = 0.54). Prior haemodialysis or catheter related blood stream infections or diabetes were non-contributory to results.

Conclusions:

Catheter survival and patient survival amongst obese and overweight CAPD patients was non-inferior to normal weight patients. Mechanical, and infective complications were comparable despite technically challenging abdominal terrain in 'O' group. The overall CAPD performance was good amongst obese and overweight.

Salvage of Malfunctioning Peritoneal Dialysis Catheters: An Algorithm for Recanalization and Repositioning

A peritoneal dialysis catheter salvage algorithm was developed and performed for 40 patients with documented catheter malfunction (obstruction and/or malposition) referred to the interventional radiology suite. This procedure utilized a metallic stiffener for repositioning and rotating dual guide wires for recanalization. A retrospective analysis of 35 cases of fluoroscopic manipulation showed that in 83% of the cases, the catheters were successfully repositioned and/or recanalized, and in 59%, they remained patent at 30 days. No major adverse events occurred. The results suggest that this algorithm is a safe and effective approach to salvage malfunctioning peritoneal dialysis catheters and that a trial of fluoroscopic salvage can be considered prior to surgical intervention.

Surgical versus percutaneous catheter placement for peritoneal dialysis: an updated systematic review and meta-analysis

BACKGROUND

No consensus currently exists regarding the optimal approach for peritoneal dialysis catheter placement. We aimed to compare the outcomes of percutaneous and surgical peritoneal dialysis catheter placement.

METHODS

A systematic review of the literature was performed using the MEDLINE, Cochrane Library, and Scopus databases (end-of-search date: August 29th, 2020). We included studies comparing percutaneous (blind, under fluoroscopic/ultrasound guidance, and "half-perc") and surgical peritoneal dialysis catheter placement (open and laparoscopic) in terms of their infectious complications (peritonitis, tunnel/exit-site infections), mechanical complications (leakage, inflow/outflow obstruction, migration, hemorrhage, hernia, bowel perforation) and long-term outcomes (malfunction, removal, replacement, surgery required, and mortality).

RESULTS

Thirty-four studies were identified, including thirty-two observational studies (twenty-six retrospective and six prospective) and two randomized controlled trials. Percutaneous placement was associated with significantly lower rates of tunnel/exit-site infection [relative risk (RR) 0.72, 95% confidence interval (CI) 0.56-0.91], catheter migration (RR 0.68, 95% CI 0.49, 0.95), and catheter removal (RR 0.73, 95% CI 0.60-0.88). The 2-week and 4-week rates of early tunnel/exit-site infection were also lower in the percutaneous group (RR 0.45, 95% CI 0.22-0.93 and RR 0.41, 95% CI 0.27-0.63, respectively). No statistically significant difference was observed regarding other outcomes, including catheter survival and mechanical complications.

CONCLUSION

Overall, the quality of published literature on the field of peritoneal dialysis catheter placement is poor, with a small percentage of studies being randomized clinical trials. Percutaneous peritoneal dialysis catheter placement is a safe procedure and may result in fewer complications, such as tunnel/exit-site infections, and catheter migration, compared to surgical placement.

PROTOCOL REGISTRATION

PROSPERO CRD42020154951.

How To Build a Successful Urgent-Start Peritoneal Dialysis Program

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter-related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.

A disposable, ultra-fine endoscope for non-invasive, close examination of the intraluminal surface of the peritoneal dialysis catheter and peritoneal cavity

The ability to visualize intraluminal surface of peritoneal dialysis (PD) catheter and peritoneal cavity could allow elucidation of the cases of outflow problems, and provide information on changes to the peritoneal membrane leading to encapsulating peritoneal sclerosis. A non-invasive examination that allows those monitoring in need is desirable. We have developed a disposable ultra-fine endoscope that can be inserted into the lumen of the existing PD catheter, allowing observation of the luminal side of the catheter and peritoneal cavity from the tip of the PD catheter, with minimum invasion in practice. In a pre-clinical study in pigs and a clinical study in 10 PD patients, the device provided detailed images, enabling safe, easy observation of the intraluminal side of the entire catheter, and of the morphology and status of the peritoneal surface in the abdominal cavity under dwelling PD solution. Since this device can be used repeatedly during PD therapy, clinical application of this device could contribute to improved management of clinical issues in current PD therapy, positioning PD as a safer, more reliable treatment modality for end-stage renal disease.

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.

Impact of obesity on dialysis and transplant and its management

Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.

Spontaneous Fracture in Intramural and Intra-Abdominal Segments of Peritoneal Dialysis Catheters Presenting as Outflow Failure

We herewith report 2 unusual cases of spontaneous peritoneal dialysis (PD) catheter fracture in intramural and intra-abdominal segments, respectively, in PD patients with long vintage. There were no associated infections or mechanical trauma. The patients presented with PD catheter outflow failure. Both the patients had their catheter replaced and resumed PD without any further issues. Probable causes and comparison with the reported cases are discussed.

Effects of early detection of peritoneal catheter migration on clinical outcomes: 15-years experiences from a single centre

Aim

Catheter migration is an important cause of catheter malfunction in peritoneal dialysis (PD). The purpose of this study was to investigate the effect of early detection of catheter migration on clinical outcomes.

Methods

A retrospective review of 135 consecutive patients initiating PD immediately following catheter insertion from 2002 to 2017 was undertaken. In order to detect catheter migration without malfunction early, serial abdominal‐pelvic radiographic examinations were performed according to a predefined protocol. Conservative management with rigorous catharsis was undertaken to correct catheter migration. A Kaplan–Meier method was used to calculate survival rate.

Results

Mean follow‐up period was 42.8 ± 34.9 months. Catheter migration occurred in 62.4%. Among them, 85.9% occurred within the first 2 weeks after catheter insertion. There were no significant associations between catheter migration and variables such as gender, obesity, DM and type of catheter. Success rate of conservative management with rigorous catharsis was 91.1%. Catheter survival at 1 and 5 years were 91.5% and 64.6% in the migration group and 81.2% and 69.9% in the non‐migration group, respectively (Log–rank test, P = 0.915). Patient survival at 1 and 5 years were 96.8% and 85.8% in the migration group and 91.9% and 82.3% in the non‐migration group, respectively (P = 0.792).

Conclusion

Early detection of PD catheter migration allowed the migrated tip to be easily corrected with conservative management. Once the migrated catheter tip was restored, catheter migration itself did not affect catheter survival. These findings suggest that early detection and correction of catheter migration is important for improving clinical outcomes.

In this retrospective study of 135 peritoneal dialysis patients, serial X‐rays were used for early detection of catheter migration. In over 90% patients, conservative management with rigorous catharsis (defined as an increase in stool frequency more than four times a day) was successful in restoring normal catheter position and function when the problem is identified early.

Reducing the occurrence rate of catheter dysfunction in peritoneal dialysis: a single-center experience about CQI

To reduce the occurrence rate of peritoneal dialysis (PD) catheter dysfunction caused by catheter displacement or plugging, this study screened all patients with peritoneal dialysis catheterization from 2002 to 2015 from the Third Xiangya Hospital of Central South University. There were 256 patients before continuous quality improvement (CQI) (from 2002 to 2007) and 813 patients after CQI (from 2008 to 2015). The occurrence rate of catheter dysfunction was 5.9% in the preCQI group: seven cases were associated with peritonitis, six cases were involved in omentum wrapping, one case was blocked by oviduct, and one case was blocked by blood clot. Through PDCA (plan-do-check-act) four-step of CQI, the following measures were adopted: (1) Preoperative: treat complications, enema and urine catheterization (2) Intraoperative: strengthen analgesia, Lower the insert position of catheter to 7.5 ∼ 8.5 cm above the pubic symphysis, extending the straight distance of catheter in rectus abdominis and decrease the times of peritoneal dialysis catheter implantation. (3) Postoperative: strengthen the training of nurses, patients and their families. (4) strengthen anticoagulation therapy during peritonitis treatment. (5) use laparoscopic technology for refractory patients, and so on. The occurrence of catheter dysfunction was 1.5% in the postCQI group (p < 0.05): two cases were associated with peritonitis, ten cases were involved in omentum wrapping. The measures we adopted in CQI reduce the occurrence rate of catheter displacement or plugging in peritoneal dialysis.

Outcomes of Simultaneous Peritoneal Dialysis and Arteriovenous Fistula Placement in End-Stage Renal Disease Patients

Peritoneal dialysis (PD) interruption requiring hemodialysis (HD) is not uncommon and its frequently abrupt nature prevents timely creation of permanent HD access and avoidance of central venous catheters (CVC). We retrospectively studied a cohort of 24 end-stage renal disease (ESRD) patients (mean age 50.7 years, 83.3% African-Americans, 58.3% females, time on dialysis interquartile range [IQR] 0 - 65 days) who had simultaneous PD catheter insertion and backup arteriovenous fistula (AVF) creation between January 1, 2012, and December 31, 2013. The primary outcome of interest was the percent of patients receiving HD through the backup AVF at the time of PD interruption. A median (IQR) for PD catheter use after its insertion was 10.5 (2 - 20) days. After the mean follow-up of 19.6 months, 12 patients remained on PD, 2 patients received a kidney transplant, and 1 patient died. The overall AVF patency was 66.7%. A total of 9 (37.5%) patients had PD interruption requiring permanent (8 patients) or temporary (1 patient) HD after the mean (standard deviation [SD]) follow-up of 12.3 (8.2) months. Arteriovenous fistula was used as the initial access in 4 patients, and in 3 patients the original AVF was used after additional surgical revision. Forty-four percent of patients with a backup AVF fistula avoided CVC at the time of PD interruption requiring HD. The simultaneous AVF creation at the time of PD catheter insertion reduced but did not fully eliminate CVC at the time of PD interruption. Larger studies are needed to evaluate the utility of a backup AVF in PD patients.

Wang's Forceps-Assisted Percutaneous Insertion and Fixation of Peritoneal Dialysis Catheter

Percutaneous insertion of peritoneal dialysis catheters is theoretically most preferred by nephrologists because of the advantages of bedside performing, surgery independence, and minimal injury over other procedures of catheter placement such as open surgical dissection or laparoscopic operation. However, blindly placing catheters in the percutaneous procedure brings the risk of catheter malposition or bowel perforation; this largely retarded it's implementation. We had previously developed a novel technique termed "Wang's forceps-assisted catheter insertion and fixation," which had been successfully applied in the open surgical catheter insertion and displaced catheter reposition in our center. In this study, we further explored the possibility of applying the Wang's forceps in the procedure of percutaneous catheter insertion both in porcine model and patients with end stage renal disease (ESRD). A total of three miniature pigs successfully received percutaneous catheter insertion using Seldinger's technique with Wang's forceps assistance. The catheters were all placed in the right position and functioning well in dialysate drainage. This novel method of percutaneous catheter insertion was then performed on 20 ESRD patients. The procedure showed effective time-saving with the average operating time of 29.2 ± 3.53 min and was well tolerated by patients with minimal pain and injury. During a follow-up time of 6 months, no complications of catheter displacement, leakage, or blockade occurred. Our preliminary observation demonstrates that utilization of Wang's forceps in a percutaneous procedure conferred benefits of accurately placing and fixing catheters while preserving the merits of minimal invasion and simple performance.

Preliminary Evaluation of the Viability of Peritoneal Drainage Catheters Implanted in Rats for Extended Durations

Purpose/Aim: In developing a novel peritoneal oxygenation therapy, catheters implanted into the peritoneal cavity became obstructed with omental tissue and prevented the infusion and removal of fluid from the peritoneal cavity. The obstruction of peritoneal catheters is a significant failure in researching various peritoneal treatments as further fluid administration is no longer possible. The purpose of this preliminary study was to determine the most effective catheter design for infusion and removal of fluid into the peritoneal cavity of rats. Materials and Methods: Four types of catheters were tested including the Jackson-Pratt, round fluted drain, flat fluted drain, and an original design. Three of each catheter type were surgically placed into the peritoneal cavity of rats (n = 12). In order to test the efficacy of each catheter, saline was infused and extracted twice daily. Catheters were scored on a weighted scale based on the amount of time they remained patent, the subjective force needed for extraction/infusion, and the amount of saline removed. Results: The round and flat fluted drain catheters remained patent for the full duration of the study (12 days) compared to the other models which failed after 7 days. These catheters also yielded a high average for extracted saline volume and an easy extraction/infusion. Conclusions: The round and flat fluted drain catheters were recognized as viable options to be used in rats for peritoneal drain studies of up to 12 days.

Identification of the appropriate fixation site to avoid peritoneal catheter migration based on a mechanical analysis

Aim: To conduct mechanical analysis on the relationship between abdominal wall fixation point and the displacement of catheter top, and establish the finite element model for the complex forces and conditions that the catheter wears in human abdominal cavity, in order to provide the scientific basis for optimizing the catheter position in abdominal wall fixation method.

Methods: Using the PIPE59 finite elements to divide units, and taking the lower part of catheter, that is, below interior polyester cuff to simulate and compute the displacement formula.

Results: The whole model includes a total of 1701 units. Periodic load was used to simulate the dynamic pressure that peritoneal dialysis catheter gets in abdominal cavity. The load direction was perpendicular to the catheter axis. We used pressure amplitude, duration and frequency as the boundary conditions, and adjusted the fixation point of the catheter lower part at the same time, thus calculating the extreme displacement value of the catheter top end with changing parameter conditions. We also did fitted regression on the results and obtained the displacement formula: y = 0.2 × 0.87^x (y: the end displacement of peritoneal dialysis catheter, x: the distance between fixation point and the interior polyester cuff), R²: .982. Simulation the catheter maximal displacement on flat surface demonstrated that additional catheter fixation at the site of 9 cm or more below the internal cuff significantly restricted the catheter migration.

Conclusions: The optimal position of fixation point in peritoneal dialysis is about 9 cm away from the interior polyester cuff.

Surgical versus percutaneous techniques for peritoneal dialysis catheter placement: A meta-analysis of the outcomes

Background

Peritoneal dialysis (PD) is an effective method of renal replacement therapy for end-stage renal disease patients. The PD catheter could be inserted by surgical (open surgery/laparoscopic-assisted) or percutaneous techniques. However, the efficacy of the techniques, including catheter survival and catheter related complications, is still controversial.

Method

The dataset was defined by searching PubMed, EMBASE, Google Scholar and the Cochrane database that had been published until July 2014. The meta-analysis was performed using Review Manager Software version 5.2.6.

Result

The final analysis was conducted on 10 studies (2 randomized controlled studies (RCTs) and 8 retrospective studies), including 1626 patients. The pooled data demonstrate no significant difference in 1-year catheter survival (OR = 1.04, 95% CI = 0.52–2.10, P = 0.90) between surgical and percutaneous groups. However, the sensitivity analysis of the RCTs demonstrated that the incidence of overall infectious (OR = 0.26, 95% CI = 0.11–0.64, P = 0.003) and overall mechanical complications (OR = 0.32, 95% CI = 0.15–0.68, P = 0.003) were significantly lower in the percutaneous groups than the surgical groups. Furthermore, the subgroup analyses revealed no significant difference in the rates of peritonitis, tunnel and exit site infection, leakage, inflow-outflow obstruction, bleeding and hernia by comparing the methods.

Conclusion

The results showed that the placement modality did not affect 1-year catheter survival. Percutaneous catheter placement is as safe and effective as surgical technique.

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Peritoneal dialysis (PD) is an effective and less costly method of renal replacement therapy for end-stage renal disease patients (ESRD). Peritoneal dialysis is more effective in preserves renal function while awaiting renal transplantation, faster restoration of diuresis and better quality of life as a home treatment than hemodialysis.

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Currently, there is no consensus for preferring type of catheter and the catheter placement method because of each modality has its pros, cons, and post-operative complication. Thus, the authors performed a meta-analysis an attempt to clarify the comparison of the outcomes of both techniques (such as a 1-year catheter survival, infectious complication, and mechanical complication).

Outcomes of dialysis catheters placed by the Y-TEC peritoneoscopic technique: a single-center surgical experience

BACKGROUND

In the last few years, peritoneal dialysis (PD) catheter placement techniques and outcomes have become important because of the growing population of PD patients. Although there are a growing number of catheters placed by the minimally invasive Y-TEC peritoneoscopic technique, there are still limited data on outcomes for these catheters, especially those placed by a surgeon. We aimed to conduct a retrospective study of our experience with PD catheters placed by the Y-TEC peritoneoscopic technique in our institution.

METHODS

We reviewed patients with peritoneoscopic PD catheter insertion over the last decade and described their complications and outcomes. In a secondary analysis, we compared the outcomes and complications of these catheters with those with open placement placed by the same surgeon.

RESULTS

We had complete data on 62 patients with peritoneoscopic catheter placement during the study period. The mean age was 55 years, 48.4% were females and the most common cause of end-stage renal disease was diabetes mellitus (33%). Surgical complications were seen in only 6/62 (9.6%) and peritonitis in 16/62 (26%) of peritoneoscopic catheters. Most catheters were used after 2 months of placement, while 12.3% were used within 2 months. When compared with 93 patients with open placement of catheters as a secondary analysis, peritoneoscopic catheters were found to have a higher 2-year survival.

CONCLUSION

Our large series of peritoneoscopically placed catheters by a surgeon demonstrate low surgical complications and peritonitis rates as well as superior 2-year survival compared with open placement of catheters.

Type of peritoneal dialysis catheter and outcomes

In peritoneal dialysis (PD), a well-functioning catheter is of great importance, because a dysfunctional catheter may be associated with incidence of peritonitis, efficiency of dialysis, and to the overall quality of treatment, representing one of the main barriers to optimal use of PD. When considering the relationship between PD catheter type and outcomes, we should keep in mind the different types of available PD catheters, those that are most commonly used in clinical practice, and the available head-to-head comparisons in the literature. The main differences in PD catheter design include the number of cuffs, the shape of subcutaneous tract (straight vs. swan neck), and the shape of intraperitoneal tract (straight vs. coiled). The availability of the best catheter design and materials, along with a skillful management of PD access, may have the greatest impact on long-term patient outcome on PD. It is now established that the use of straight catheters may improve outcomes and technique survival, but further advances in PD catheter technology can potentially improve technique survival. The self-locating PD catheter is a well established device that has not been fully studied and it may represent, based on the available observational evidence and on the clinical experience, an already existing technological advance deserving further studies.

Peritoneal Dialysis as a First versus Second Option after Previous Haemodialysis: A Very Long-Term Assessment

For renal replacement therapy, overall survival is more important than the choice of currently available individual therapy. Objectives. To compare patients and technique survival on peritoneal dialysis as first treatment (PDF) versus after previous haemodialysis (HDPD) and other indicators of follow-up. Methods. We prospectively studied 110 incident patients, during the period from August 4, 1993, to June 30, 2012, for patients and technique survival (Kaplan-Meier) (log rank P < 0.05). Results. Groups: (A) PDF: 37 patients, 24 females, age: 52.2 ± 14.9 years old, time at risk: 2123 patient-months (p/m), mean: 57 ± 42 months; (B) HDPD: 73 patients, 42 females, age: 52.45 ± 14.7 years old, time in haemodialysis: 3569.2 (p/m), range: 3-216 months, mean: 49 ± 45 months, time at risk in PD: 3700 (p/m), mean: 51 ± 49 months. Patients' survival: (A) PDF: 100%, 76.6%, 65.6%, and 19.7%; (B) HDPD: 95.4%, 65.6%, 43%, and 43% at 12, 60, 120, and 144 months, respectively, P = 0.34.

TECHNIQUE

(A) PDF: 100%, 90%, 59.8%, and 24%; (B) HDPD: 94%, 75%, 32%, and 32% at 12, 60, 120, and 144 months, respectively, P = 0.40. Conclusions. Comparable patient and technique survival were observed. Peritoneal dialysis enables a greater extension of renal replacement therapy for patients with serious difficulties continuing with haemodialysis.

Peritoneal Dialysis Access: Open versus Laparoscopic Surgical Techniques

Aim

To outline pros and cons with the open and laparoscopic techniques when placing peritoneal dialysis (PD) catheters.

Background

Controversy exists regarding which technique, the open and laparoscopic, if any, is superior to the other. In addition, there is the question of which approach is best in rescuing malfunctioning PD catheters.

Results

Rather than promoting one doctrine fits all, philosophically, doing the right thing for the patient by specific criteria is ethically the better model. These specific selection criteria include patient characteristics, the team's skills and knowledge and institutional resources and commitment. Also, the sophistication of a PD unit for training and monitoring of patients is crucial for successful outcomes. Open paramedian and two laparoscopic approaches are described in detail, outlining advantages and disadvantages of each, with suggestions when one method is preferred.

Conclusions

In general, the laparoscopic technique is associated with longer operative times, higher costs and the need to utilize general anesthesia. It is, however, the preferred method when rescuing malfunctioning catheters and may increase the PD patient population in patients with previous abdominal surgeries. The dialysis access surgeon should be familiar with both open and laparoscopic techniques and appropriately choose the ideal method based upon the individual patient and institutional resources.

Peritoneal dialysis associated infections: An update on diagnosis and management

Peritoneal dialysis (PD) is associated with a high risk of infection of the peritoneum, subcutaneous tunnel and catheter exit site. Although quality standards demand an infection rate < 0.67 episodes/patient/year on dialysis, the reported overall rate of PD associated infection is 0.24-1.66 episodes/patient/year. It is estimated that for every 0.5-per-year increase in peritonitis rate, the risk of death increases by 4% and 18% of the episodes resulted in removal of the PD catheter and 3.5% resulted in death. Improved diagnosis, increased awareness of causative agents in addition to other measures will facilitate prompt management of PD associated infection and salvage of PD modality. The aims of this review are to determine the magnitude of the infection problem, identify possible risk factors and provide an update on the diagnosis and management of PD associated infection. Gram-positive cocci such as Staphylococcus epidermidis, other coagulase negative staphylococcoci, and Staphylococcus aureus (S. aureus) are the most frequent aetiological agents of PD-associated peritonitis worldwide. Empiric antibiotic therapy must cover both gram-positive and gram-negative organisms. However, use of systemic vancomycin and ciprofloxacin administration for example, is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis - success rate of 77%. However, for fungal PD peritonitis, it is now standard practice to remove PD catheters in addition to antifungal treatment for a minimum of 3 wk and subsequent transfer to hemodialysis. To prevent PD associated infections, prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage should be employed. Mupirocin treatment can reduce the risk of exit site infection by 46% but it cannot decrease the risk of peritonitis due to all organisms.