The outcomes of percutaneous versus open placement of peritoneal dialysis catheters

A New, Safe, and Effective Technique for Percutaneous Insertion of a Peritoneal Dialysis Catheter

A properly functioning peritoneal catheter is an essential element of effective peritoneal dialysis (PD). Currently, there are three techniques available for PD catheter placement, which include open surgery, laparoscopic surgery, and percutaneous catheter placement (PCP). Currently, no particular catheter placement approach has been proven with certainty to provide superior outcomes. We present a new modified PCP method with the use of the Veress needle covered with an intravascular catheter (IC) and preliminary clinical results of PD catheter placements with this new technique. The endpoints used in the study were 1-year technical survival of the catheter, and the incidence of early (1 month) mechanical as well as infection complications. The catheter was implanted in 24 patients. The catheter survival rate was 100%; however, in two cases, the catheters were removed due to complications not associated with PD treatment. No early mechanical complications such as bleeding, hematoma, perforations, internal organ damage, exit site leaks, or hernia in the place of insertion were observed. Similarly, no early infectious complications were observed. During the 1-year follow-up, no catheter migration occurred. Our results showed that the new PCP technique is a safe and easy procedure that minimizes the occurrence of both mechanical and infectious complications and ensures good catheter survival.

Inpatient peritoneal dialysis catheters placed across the United States during a 3-year period: Lessons learned from 15,000 patients

BACKGROUND

Peritoneal dialysis is a popular option for patients with end-stage renal disease. A recent presidential executive order has incentivized in-home end-stage renal disease treatments, leading to an increase in peritoneal dialysis use. Guidelines exist for creating and maintaining peritoneal dialysis access without addressing the optimal technique. This study evaluates nationwide peritoneal dialysis catheter placement practices and their long-term outcomes.

METHODS

Retrospective cohort analysis of Nationwide Readmission Database from 2017 to 2019. Patients with end-stage renal disease undergoing inpatient peritoneal dialysis catheter placement were included. Six-month readmissions, mortality, and peritoneal dialysis catheter-specific outcome measures were assessed among survivors of admission, including catheter leakage, mechanical breakdown, displacement, revision or replacement, removal, exit site infections, intra-abdominal abscess, and sepsis. Binary logistic regression analyses were performed.

RESULTS

In the study, 14,863 patients with inpatient peritoneal dialysis catheter insertions were identified, of which 7,096 were analyzed (4,150 [59%] laparoscopic, 1,781 [25%] fluoroscopic, 1,165 [16%] open), 847 (12%) had major complications, 931 (13%) were readmitted, and 102 (1.4%) died within 6 months. Univariate analyses demonstrated that laparoscopy had higher mechanical complications, exit-site infections, catheter revision, and removal within 6 months, and fluoroscopy had higher sepsis and mortality. Multivariate analyses showed fluoroscopy was associated with intraabdominal abscess (adjusted odds ratio, 2.36; P = .025), laparoscopy with exit-site infections (adjusted odds ratio, 0.49; P = .005), and open surgery with catheter displacement (adjust odds ratio, 2.95; P = .021).

CONCLUSION

This is the first large-scale study on inpatient peritoneal dialysis catheter placement outcomes in the United States. Fluoroscopic and open surgical placements are routinely performed, but laparoscopy remains the mainstay with fewer exit-site infections. Overall, peritoneal dialysis is a safe option, with 1 in 9 patients having an infectious or mechanical complication within 6 months. Furthermore, large-scale prospective studies are warranted to identify the optimal placement technique.

Peritoneal Dialysis Catheter Complications after Insertion by Surgeons, Radiologists, or Nephrologists

SIGNIFICANCE STATEMENT

The Advancing American Kidney Health Initiative aims to increase rates of utilization of peritoneal dialysis (PD) in the United States. One of the first steps to PD is successful catheter placement, which can be performed by surgeons, interventional radiologists, or nephrologists. We examined the association between operator subspecialty and risk of needing a follow-up procedure in the first 90 days after initial PD catheter implantation. Overall, we found that 15.5% of catheters required revision, removal, or a second catheter placement within 90 days. The odds of requiring a follow-up procedure was 36% higher for interventional radiologists and 86% higher for interventional nephrologists compared with general surgeons. Further research is needed to understand how to optimize the function of catheters across different operator types.

BACKGROUND

The US government has implemented incentives to increase the use of PD. Successful placement of PD catheters is an important step to increasing PD utilization rates. Our objective was to compare initial outcomes after PD catheter placement by different types of operators.

METHODS

We included PD-naïve patients insured by Medicare who had a PD catheter inserted between 2010 and 2019. We examined the association between specialty of the operator (general surgeon, vascular surgeon, interventional radiologist, or interventional nephrologist) and odds of needing a follow-up procedure, which we defined as catheter removal, replacement, or revision within 90 days of the initial procedure. Mixed logistic regression models clustered by operator were used to examine the association between operator type and outcomes.

RESULTS

We included 46,973 patients treated by 5205 operators (71.1% general surgeons, 17.2% vascular surgeons, 9.7% interventional radiologists, 2.0% interventional nephrologists). 15.5% of patients required a follow-up procedure within 90 days of the initial insertion, of whom 2.9% had a second PD catheter implanted, 6.6% underwent PD catheter removal, and 5.9% had a PD catheter revision within 90 days of the initial insertion. In models adjusted for patient and operator characteristics, the odds of requiring a follow-up procedure within 90 days were highest for interventional nephrologists (HR, 1.86; 95% confidence interval [CI], 1.56 to 2.22) and interventional radiologists (odds ratio, 1.36; 95% CI, 1.17 to 1.58) followed by vascular surgeons (odds ratio, 1.06; 95% CI, 0.97 to 1.14) compared with general surgeons.

CONCLUSIONS

The probability of needing a follow-up procedure after initial PD catheter placement varied by operator specialty and was higher for interventionalists and lowest for general surgeons.

Optimizing peritoneal dialysis initiation: A comparative cohort study of catheter placement methods for shortening break-in periods

INTRODUCTION

Peritoneal dialysis (PD) guidelines recommend a 14-day break-in period after catheter placement, yet this period could be shortened with new insertion techniques.

METHODS

We conducted a prospective cohort study to compare percutaneous vs. surgical catheter insertion in a newly established PD program. The break-in period was intentionally shortened to <24 h to start PD almost immediately.

RESULTS

We included 223 subjects who underwent percutaneous (34%) or surgical (66%) catheter placement. Compared to the surgical group, the percutaneous group had a higher proportion of early dialysis initiation within 24 h (97% vs. 8%, p < 0.001), similar successful initiation rates (87% vs. 92%, p = 0.34), and shorter lengths of stay (12 [9-18] vs. 18 [14-22] days, p < 0.001). Percutaneous insertion increased the likelihood of successful PD initiation within 24 h (OR 74, 95% CI 31-182), without increasing major complications.

CONCLUSION

Percutaneous placement could represent a cost-effective and efficient technique to shorten break-in periods.

Optimizing peritoneal dialysis catheter placement

Long-term success of peritoneal dialysis as a kidney replacement therapy requires a well-functioning peritoneal dialysis catheter. With ongoing reductions in infectious complications, there is an increased emphasis on the impact of catheter-related and mechanical complications. There is currently a marked variation in the utilization of various types of catheters (double cuff vs single cuff, coiled tip vs straight tip), methods of catheter insertion (advanced laparoscopic, open surgical dissection, image guided percutaneous, blind percutaneous), timing of catheter insertion, location of catheter placement (pre-sternal v. abdominal) and peri-operative practices. Specialized approaches to catheter placement in clinical practice include use of extended catheters and embedded catheters. Marked variations in patient lifestyle preferences and comorbidities, specifically in high acuity patient populations (polycystic kidney disease, obesity, cirrhosis) necessitate individualized approaches to catheter placement and care. Current consensus guidelines recommend local procedural expertise, consideration of patient characteristics and appropriate resources to support catheter placement and long-term functioning. This review focuses on an overview of approaches to catheter placement with emphasis on a patient-centered approach.

Clinical Application of Peritoneal Dialysis Catheterization without Capsular Puncture Technique

Objective

To summarize the advantages of peritoneal dialysis (PD) catheters without capsular puncture (only one pneumoperitoneum needle) puncture technique conducted by our center.

Methods

The study examines the clinical data of PD patients (including the general situation of patients, intraoperative and postoperative characteristics, and complications) undergoing pneumoperitoneum needle catheterization from January 2019 to May 2021 in the Department of Nephrology at the First Affiliated Hospital of Hebei North University (the largest peritoneal dialysis center in Zhangjiakou).

Results

A total of 153 surgical cases were collected. There were 91 males and 62 females. The mean (± standard deviation) age was 56.1 ± 18.6 years, and the mean (± standard deviation) follow-up time was 16.7 ± 8.2 months. The average operation time was 30.33 minutes with a standard deviation of 14.80 minutes. The length of abdominal incision is 2.38 ± 0.42 cm, and the blood loss was about 26.3 ± 9.2 ml, including 2 cases of laparoscopic reposition of drift tube, 0 case of pipe blockage, 3 cases of fluid leakage, 1 case of peritoneal dialysis catheter tunnel infection, 4 cases of outlet infection, 12 occurrences of peritonitis, 121.3 patient months in peritonitis, and 0 times in omentum wrapping without bladder injury, incisional hernia, or intestinal injury.

Conclusion

Relative to open operation, the peritoneal dialysis (PD) catheters with pneumoperitoneum needle puncture technique has the following advantages: simpler operation, shorter operation time, less bleeding, less injury, less complications, and higher safety. Moreover, there are no additional costs compared with open operation. Thus, the technique is recommended for clinical applications.

Success rates and safety of a modified percutaneous PD catheter placement technique: Ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar

BACKGROUND

We modified the blind Seldinger technique by incorporating ultrasound guidance and the use of a multifunctional bladder paracentesis trocar for PD catheter (PDC) placement, which can be easily performed by a nephrologist and is a feasible technique. To compare success rates and safety of our modified percutaneous PD catheter placement technique to open surgery.

METHODS

Two hundred and twelve stage-5 chronic kidney disease(CKD) patients receiving PD therapy from June 2016 to June 2019 were included, 105 patients treated by ultrasound-guided percutaneous placement of peritoneal dialysis catheters using a multifunctional bladder paracentesis trocar (Group A) and 107 patients receiving open surgical placement (Group B). Outcomes of patients via either catheter placement technique were retrospectively compared. The clinical success rate as defined by proper catheter drainage within 4 weeks after placement, complication rates (both technical complications and infections), and 1-year catheter survival were compared.

RESULTS

There was no significant difference in sex ratio, age, or previous abdominal surgery history between groups (P > .05). Both surgical time and incision length were significantly shorter in Group A than in Group B (P < .05). Clinical success rate was also higher inGroup A (P < .05). Moreover, Group A demonstrated lower overall complication rates (P < .05) and lower incidence rates of early peritonitis, initial drainage disorder, and peritubular leakage (all P < .05). One-year catheter survival was also higher in Group A (P < .05).

CONCLUSION

Percutaneous placement of PD catheters using our modified technique demonstrates superior success rates and safety compared to open surgery. In addition, our modified technique can be a better alternative to traditional Seldinger percutaneous catheterization for its higher success rate and safety, more accurate positioning.

The "Half-Perc" technique using a simple modified metal trocar for peritoneal dialysis catheter placement: results of a 3-year follow-up of 280 patients and a literature review

PURPOSE

There is an ongoing debate about the ideal technique for peritoneal dialysis (PD) catheter insertion in patients with end-stage renal disease (ESRD). A half-percutaneous ("Half-Perc") technique shares some of the advantages of both percutaneous technique and traditional open surgery. This retrospective study aimed to evaluate the clinical feasibility, safety, and effects of the "Half-Perc" technique for PD catheter placement, and to compare the clinical outcomes of the "Half-Perc" technique with various imaging-assisted percutaneous techniques from the current literature.

METHODS

We included 280 consecutive patients with ESRD who underwent the "Half-Perc" insertion of the first PD catheter between September 2016 and September 2019. We recorded baseline characteristics, operative parameters, catheter-related complications, catheter survival, and the reason behind PD cessation.

RESULTS

We included 174 men and 106 women, with a mean age of 50.4 years (range, 11-85 years). The mean operative time was 28.8 min (range, 15-38 min) and technical success rate was observed in 278 patients (99.3%). There were 28 episodes (10%) of mechanical complications with initial catheters occurring during the follow-up. Catheter malfunctions were the most common mechanical complication and were observed in 15 patients. Peritonitis was the most frequent catheter-related complication, with 32 episodes of peritonitis observed in 29 (10.4%) patients. After a mean follow-up period of 15.4 months (range, 2-36 months), 235 patients (83.9%) survived with their initial PD catheter by the end of the study. Of the 280 patients analyzed, 35 patients (12.5%) ceased PD at some stage during follow-up. The most common reason for PD cessation was kidney transplantation (18 patients (6.4%)), followed by death (9 patients (3.2%)) and switch to hemodialysis (HD) (7 patients (2.5%)), and recovery of renal failure (1 patient (0.4%)).

CONCLUSION

The "Half-Perc" technique, including a modified metal trocar, is a simple, safe, and effective method for PD catheter placement that can be used for patients with ESRD.

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.

Comparison of Outcomes between Percutaneous and Surgical Placement of Peritoneal Dialysis Catheters in Uremic Patients: A Meta-Analysis

BACKGROUND

The optimal technique for inserting peritoneal dialysis catheters in uremic patients remains debated. This meta-analysis aimed to summarize the current evidence evaluating the efficacy and safety of percutaneous insertion methods compared to surgical methods.

METHOD

A literature search was performed in the PubMed, EMBASE, Cochrane, and Web of Science databases. The primary outcome was defined as catheter survival. The secondary outcomes were mechanical and infectious complications related to catheter insertion.

RESULTS

Twenty studies were finally identified, including 2 randomized controlled trials. The pooled results of catheter survival, overall mechanical complications, and infectious complications were not significant (odds ratio [OR] = 1.10, 95% confidence interval (CI) = 0.76-1.57, p = 0.62; OR = 0.73, 95% CI = 0.48-1.11, p = 0.14; and OR = 0.64, 95% CI = 0.37-1.09, p = 0.14, respectively). Comparison stratified by the blind percutaneous method versus open surgery indicated a lower overall number of mechanical complications (OR = 0.54, 95% CI = 0.31-0.93, I2 = 72%) and malposition rate (OR = 0.56, 95% CI = 0.34-0.90, I2 = 0%). The leakage rate was higher in the blind percutaneous group than in the open surgery group (OR = 2.55, 95% CI = 1.72-3.79, I2 = 0%); the guided percutaneous method achieved a similar leakage risk to the surgical methods.

CONCLUSIONS

The blind percutaneous method performed better with fewer overall mechanical complications and less malposition than open surgery. The leakage risk was higher in the blind percutaneous group, while the guided percutaneous placement group showed similar outcomes to the surgical method groups. Percutaneous methods also had a lower infection risk, which needs further evidence to be confirmed.

Pneumoperitoneum needle vs. introducer needle: Comparison of complications and short-term outcomes in percutaneously inserted peritoneal dialysis catheters in naïve abdomens

Percutaneous peritoneal dialysis catheter (PDC) insertion for continuous ambulatory peritoneal dialysis (CAPD) entails a higher risk of complications such as bowel injury, vascular injury, and catheter migration compared to the surgical insertions. We conducted a comparative analysis of two techniques of peritoneal entry for PDC insertion by Seldinger technique. We performed a retrospective review of 426 percutaneously inserted PDCs in nonobese naïve abdomens for CAPD at two tertiary care teaching hospitals in India over 6 years. Comparison of various mechanical complications, and short-term catheter survival was done between use of introducer needle (Group "I") and spring-loaded pneumoperitoneum (Veress) needle (Group "V"). Group "I" to "V" patient ratio was 277:149. Group "I" had heavier patients (p = 0.03) whereas "V" group had a dominance of diabetes (p = 0.009) and prior hemodialysis patients (p = 0.03). At 3 months, the odds of mechanical complications (OR = 0.27, p = 0.004), PDC migration (OR = 0.18, p = 0.02), and omental wrapping (OR = 0.13, p = 0.04) were less in "V" group. No bowel injury occurred with Veress needle use. At 6 months, "V" group had higher odds of event-free sustained PDC tip position (OR = 0.39, p = 0.003), and catheter survival (p = 0.03), and the cumulative events were lesser too (p = 0.002). Refractory peritonitis and deaths with functioning catheter were comparable between both the groups. In this first-of-its-kind study, spring-loaded Veress pneumoperitoneum needle use was safer, entrusted sustained PDC tip position in pelvis, and had a better catheter survival compared to use of introducer needle for peritoneal entry in percutaneously inserted PDCs. These findings should be confirmed by a randomized controlled study.

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.

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.

Different techniques for peritoneal dialysis catheter implantation: A systematic review and network meta-analysis

The current consensus recommended the peritoneal dialysis catheter (PDC) techniques based on the patients' anesthesia situation and previous abdominal surgery. However, the research comparing of all the existing PDC techniques is lacking. The objective was to compare the efficacy and safety of PDC techniques by network meta-analysis (NMA). A systematic review of databases was conducted to identify eligible studies. NMA was used to estimate the ranking for endpoints. Our NMA included 41 studies (9 randomized controlled trials (RCTs) and 32 observational trials) and enrolled 3902 patients, comparing three techniques: the laparoscopic catheterization (LC), open surgery catheterization (OSC), and percutaneous catheterization (PC). NMA in RCTs showed OSC had the highest incidence of catheter mechanical dysfunction, PC and LC were very similar, but this result had no statistical difference. NMA in observational studies showed that LC had the highest 1-year catheter survival but without statistical difference (LC vs. OSC: odds ratio (OR) 1.75, 95% credible intervals (CrIs) 0.90-3.40; PC vs. OSC: OR 1.55, 95% CrIs 0.80-2.97; PC vs. LC: OR 0.88, 95% CrIs 0.54-1.44). OSC had the lowest incidence for bleeding. The complications of leakage, peritonitis, and exit/tunnel infection were inconclusive due to the inconsistent results between RCTs and observational studies. Our NMA revealed LC may have the best 1-year catheter survival. PC and LC might be efficacious in lowering the mechanical dysfunction. OSC had the lowest incidence for bleeding. More RCTs with larger scale and higher quality are needed in order to obtain more credible evidence.

Comparison of peritoneal dialysis catheter insertion techniques by nephrologists: Surgical vs blind methods

BACKGROUND

The aim of the present study was to perform a comparative analysis of peritoneal dialysis catheter (PDC) insertion between blind and surgical methods by nephrologists.

PATIENTS AND METHODS

The present study enrolled 249 peritoneal dialysis patients who received first-time PDC insertion. All PDC insertions were performed using either the blind or surgical method. In our hospital during the study period, two of three nephrologists performed the blind method routinely in all eligible patients (blind group), and one of three nephrologists performed the surgical method in all eligible patients (surgical group). Catheter outcomes, including infectious or mechanical complications, functional parameters, and catheter survival, were evaluated.

RESULTS

The numbers of patients underwent surgical or blind methods were 105 and 144, respectively. The use of systemic analgesics in the surgical group was higher than that in the blind group. The operation time was longer in the blind group than in the surgical group. The D0 level and peritoneal Kt/V were similar between the two groups. There was no significant difference in infectious and mechanical complications between the two groups. The catheter survival and intervention-free survival were similar between the two groups (P = .995 for catheter survival and P = .723 for intervention-free survival).

CONCLUSION

Our study shows that catheter outcomes are similar between blind and surgical insertion techniques performed by nephrologists. These findings reveal that patients without previous major abdominal surgery would be suitable to receive any one of the two methods according to the operator-friendly technique.

Ultrasound-guided percutaneous peritoneal dialysis catheter insertion using multifunctional bladder paracentesis trocar: A modified percutaneous PD catheter placement technique

Background

To evaluate the efficacy and safety of ultrasound‐guided percutaneous peritoneal dialysis catheter insertion using multifunctional bladder paracentesis trocar.

Methods

A retrospective review of 103 ESRD patients receiving percutaneous PD catheter insertion using a multifunctional bladder paracentesis trocar under ultrasound guidance at a single center between May 2016 and May 2018. Mechanical complications and catheter survival were evaluated over a 12‐month follow‐up.

Result

Catheterization using this technique required only 10‐30 minutes from the beginning of local anesthesia to the end of skin suture at the puncture site (mean 18 ± 7 minutes) and an incision length of 2‐4 cm. Moreover, only four of 103 cases required catheter removal due to poor drainage within one month after surgery, with a success rate of 96.19%. Among failures, omentum wrapping was cause in two cases, catheter displacement in one case, and protein clot blockage in one case, while there were no instances of organ injury, severe hemorrhage, peritubular leakage, hernia, peritonitis, or exit infection within one month of PD catheter insertion. Catheter survival at 1 year was 92.2%.

Conclusion

Percutaneous PD catheter insertion using a multifunctional bladder paracentesis trocar and ultrasound guidance is a feasible technique for ESRD patients.

Outcomes of peritoneal dialysis catheter configurations and pelvic fixation

Background

Laparoscopic peritoneal dialysis catheter placement has expanded indications, although a relative paucity of data exists about the best configuration for improving outcomes. The purpose of this study is to investigate the role of different catheter configurations and pelvic fixation on catheter and patient outcomes.

Methods

Retrospective chart review of patients undergoing peritoneal dialysis catheter implantation between January 1, 2013, and December 31, 2016. All procedures were conducted laparoscopically at a single center. Statistical analyses were conducted using Stata/SE 14.2.

Results

Buried catheter configuration was a statistically significant predictor of peritonitis compared to unburied configuration (P = 0.008). Buried catheter was exteriorized at 100 days (SD 107.8). A longer length of time to exteriorization significantly correlated with peritonitis, need for revision, and need for revision pelvic fixation (P < 0.05). Additionally, initial pelvic fixation was a significant predictor of revision (HR 3.94).

Conclusions

Peritoneal dialysis catheter placement via a laparoscopic approach can be successfully performed in a diverse patient mix with positive results. However, buried catheter configuration and prophylactic pelvic fixation should be carefully employed in select patients.

Continuous Ambulatory Peritoneal Dialysis Catheter Insertion Technique: A Comparative Study of Percutaneous versus Surgical Insertion

Continuous ambulatory peritoneal dialysis (CAPD) is a standard renal replacement therapy, but there is a lack of consensus for catheter insertion method and type of catheter used. We retrospectively analyzed 140 peritoneal dialysis catheters (PDC) inserted in 139 CAPD patients by two methods; percutaneous (Group “P,” n = 47) and surgical mini laparotomy (Group “S,” n = 93) technique over a 39-month period, with cumulative experience of 2415 catheter-months: 745 catheter-months for Group “P” and 1670 catheter-months for Group “S.” Break-in period was shorter in Group “P” (P = 0.002) whereas primary nonfunction rate was comparable (P = 0.9). The mean catheter survival was better in Group “S” (17.95 ± 10.96 months vs. 15.85 ± 9.41 months in “P” group, P = 0.05) whereas the death-censored and overall catheter survival was comparable in both groups. PDC removal due to refractory peritonitis was also comparable. Mechanical complications were more in “P” group (P = 0.049), leading to higher catheter removal (P = 0.033). The peritonitis rates were higher in “P” group (1 episode per 24.8 catheter-months vs. 1 episode per 34.8 catheter-months in “S” group, P = 0.026) and related to a higher number of rural patients in the group (P = 0.04). Patient survival was comparable. There was no effect on episodes of peritonitis in those CAPD patients who had diabetic etiology or prior hemodialysis catheter-related sepsis, age, and PDC insertion method.

Peritoneal Dialysis Catheter Insertion by Surgical Minilaparotomy: Outcome Analysis between Nephrologist and Surgeon

Surgical minilaparotomy technique of Tenckhoff catheter placement is rarely practiced by nephrologists. There is a scarcity of data comparing technique and outcomes of surgically inserted peritoneal dialysis catheters by surgeon and nephrologist. We retrospectively analyzed 105 Tenckhoff catheters inserted by surgical minilaparotomy ("S" [surgeon], n = 43 and "N" [nephrologist], n = 62) in end-stage renal disease. Comparative analysis of surgical technique, survivals, and complications between both groups was done. "N" group observed two major advantages; shorter break-in (P < 001) and early continuous ambulatory peritoneal dialysis rehabilitation. Cumulative catheter experience was 1749 catheter-months: 745 and 1004 catheter-months in "S" and "N" groups, respectively. "N" group had a better overall catheter and patient survival, and a statistically insignificant mechanical complications, seen mostly in obese and post-abdominal surgery patients, without fatality or catheter loss. Peritonitis rates (P = 0.21) and catheter removal due to refractory peritonitis (P = 0.81) were comparable. The technique used is practical and aids early break-in, yields better results, and later on, helps in easy and uncomplicated PDC removal as and when indicated. Mechanical complications, mostly bleeding, were managed conservatively without any catheter or patient loss. This method should be encouraged among nephrologists and nephrology residents.

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).

Single port laparoscopic and open surgical accesses of chronic peritoneal dialysis in children: A single center experience over 12 years

INTRODUCTION:

The aim of this study was to evaluate patients with end stage renal failure (ESRD) who underwent chronic peritoneal dialysis (CPD). The clinical outcomes of laparoscopic and open placements of catheters were compared.

MATERIALS AND METHODS:

We reviewed 49 (18 male and 31 female) children with CPD according to age, sex, cause of ESRD, catheter insertion method, kt/V rate, complications, presence of peritonitis, catheter survival rate between January 2002 and February 2014.

RESULTS:

Thirty-three patients were with open placement and 16 patients were with laparoscopic placement. The rate of the peritonitis is significantly less in patients with laparoscopic access than open access (n = 4 vsn = 25) (P <0.01). Patients with peritonitis were younger than those who had no attack of peritonitis (10.95 ± 0.8 years vs 13.4 ± 0.85 years). According to the development of complications, significant difference has not been found between the open (n = 9) and laparoscopic (n = 3) approaches except the peritonitis. Catheter survival rate for the first year was 95%, and for five years was 87.5%. There was no difference between open and laparoscopic group according to catheter survival rate. The mean kt/V which indicates the effectiveness of peritoneal dialysis was mean 2.26 ± 0.08. No difference was found between laparoscopic and open methods according to kt/V.

CONCLUSION:

Laparoscopic placement of CPD results in lower peritonitis rate. Catheter survival rate was excellent in both groups. Single port laparoscopic access for CPD catheter insertion is an effective and safe method.

Analysis of Hospitalization after Peritoneal Dialysis Catheter Implantation

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BACKGROUND

Implantation of the peritoneal dialysis catheter (PDC), usually an elective procedure, may necessitate unexpected hospitalization and even transfer to intensive care due to the multiple comorbidities and inherent instability of the end-stage renal disease patient. Information on hospitalization after PDC implantation is limited and details about the reason for hospitalization are lacking. ♦

METHODS

We performed a cohort study in consecutive patients who underwent PDC implantation at a single institution from September 2007 to September 2013. Clinical characteristics of enrolled patients, technique of the implantation procedure, and all-cause unexpected hospitalization and morbidity within 14 days after implantation were analyzed. ♦

RESULTS

Excluding the patients with pre-arranged admission, a total of 246 patients receiving 252 PDC implantations during the 6 years were studied. After 39 procedures (15.5%), patients had an unexpected hospital stay or re-admission due to operative complications (33.3%), worsening of disease (35.9%), or a single-night hospital stay for observation (30.8%). Compared with discharged patients, the patients with unexpected hospitalization were older (p = 0.001), experienced higher rates of previous episodes of heart failure (p = 0.006) and heart disease (p < 0.001), had more use of general anesthesia (GA) (p = 0.046), underwent more added procedures during the implantation (p = 0.02), and had more episodes of flow obstruction and peritonitis after implantation (p = 0.012 and p < 0.001, respectively). Using a multivariable logistic regression, we showed that age, cardiac morbidity, use of general anesthesia, PDC flow problems and peritonitis after implantation were independent predictors of all-cause unexpected hospitalization. ♦

CONCLUSIONS

For the first time, our study analyzed the predictors of unplanned hospitalization after PDC implantation and identified the salient risk factors. Increased focus to identify patients at greatest risk for hospitalization, evaluation of processes of care, and implementation of preventive strategies may be helpful to reduce unplanned hospitalization after catheter insertion.

Superiority of laparoscopy in the peritoneal dialysis catheter reset surgery

Peritoneal dialysis catheter surgery has been used in clinical treatment for nearly 40 years, and open surgery under local anesthesia is the conventional method. However, catheter displacement after open surgery is still the thorny issue during our clinical practice. Then the reset surgery is often required to be taken again. Nowadays, laparoscopic peritoneal dialysis catheter draws our attention due to its advantages of accurate positioning, smaller incision, and less pain, and its clinical application has been limited. While laparoscopic surgery is recognized, there are few relevant studies on whether there is difference during the catheter reset process between the two surgical approaches. In this study, we mainly discussed the rate of secondary catheter migration, the incidence of complications after catheter reset for two surgical approaches and the hospital stay as well as the total clinical cost for the two surgical approaches. In this study, we retrospectively analyzed 25 cases of end-stage renal disease, who received catheterization for peritoneal dialysis and regular peritoneal dialysis in our hospital from March 2010 to December 2013, and had a medical history of catheter migration. We collected the relevant clinical data for all patients. Fifteen patients selected laparoscopic catheter reset, and 10 patients selected the traditional surgical method for catheter reset by themselves. For all patients enrolled, we analyzed the incidence of secondary catheter migration and postoperative complications, hospitalization time, and total cost for different methods of reset. Through the studies above, we found that laparoscopic peritoneal dialysis catheter surgery offered accurate catheter location and a small incision that was easy to heal. Besides, the incidence of postoperative complications for the laparoscopic surgery was lower than that for traditional surgical approach for catheter reset. The average hospitalization time for laparoscopic surgery was shorter than that for the traditional surgical approach. The total cost of laparoscopic surgery was more than that of the traditional surgery. Therefore, the rational application of a laparoscopic peritoneal dialysis catheter and reset surgery can increase the success rate of peritoneal dialysis, reduce the complications, shorten hospitalization time of patients, and thus enhance patient's confidence to stick it out.