Four-year experience with swan neck presternal peritoneal dialysis catheter

Experience using Presternal Catheter for Peritoneal Dialysis in Poland: A Multicenter Pediatric Survey

← Objectives

Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall.

← Design

A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland.

← Setting

Four pediatric institutions using the SNPC in children: ( 1 ) Medical University of Warsaw, Warsaw; ( 2 ) Childrens’ Memorial Health Institute, Warsaw; ( 3 ) District Children's Hospital, Szczecin; ( 4 ) University of Medical Sciences, Poznan.

← Patients

During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2 – 17.7 years (mean 8 ± 5.8 years), with end-stage renal failure. The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exit-site infections (ESI) with previous abdominal PD catheters.

← Intervention

In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used.

← Results

The mean observation time for the 20 presternal catheters was 24.8 ± 25 months (range 1 – 83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Noninfectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan–Meier method, was 57.5 ± 8.5 months; 50% catheter survival reached 72 months.

← Conclusions

The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications ( i.e., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion.

Exit-Site Infection in Children on Peritoneal Dialysis: Comparison of Two Types of Peritoneal Catheters

Objective

To review our experience with two types of peritoneal catheters, the standard Tenckhoff catheter and the swan-neck presternal catheter (SNPC).

Design

A retrospective study was undertaken to compare exit-site infection (ESI) rates using two types of peritoneal catheters in children.

Setting

Medical University of Warsaw, Warsaw, Poland.

Patients

During the past 10 years, 60 peritoneal catheters were implanted in 50 children with end-stage renal failure: 46 straight, double-cuffed Tenckhoff in 37 children (mean age 11.8 ± 4.2 years, range 3.1 – 18.5 years), and 14 presternal in 13 children (mean age 10.6 ± 5 years, range 0.3 – 17.7 years). The SNPCs were used in special clinical situations such as recurrent ESI with previous abdominal peritoneal catheters, obesity, presence of ureterocutaneostomies, use of diapers, and young age. For the statistical analysis, only the first catheter placed in each child was chosen: 34 standard Tenckhoff catheters and 9 SNPCs.

Intervention

In all children, peritoneal catheters were implanted surgically under general anesthesia by one surgeon; uniform operative technique and perioperative management was used.

Results

The mean observation time for 46 standard Tenckhoff catheters was 23.8 ± 21.1 months, and for 14 SNPCs 25.1 ± 27.0 months. The ESI rate was 1/17.4 patient-months (0.69 episodes/year) for Tenckhoff catheters and 1/70.2 patient-months (0.17 episodes/year) for SNPCs. The observed differences in ESI rates between the groups reported did not achieve statistical significance.

Conclusions

The risk of ESI may be lower with presternal catheters. Confirmation of these findings requires further prospective clinical investigation in large numbers of patients.

Swan Neck Presternal Peritoneal Dialysis Catheter: Five-Year Experience in Children

Objectives

To reduce the incidence of exit-site infection (ESI) a new peritoneal dialysis (PD) catheter, the Swan neck presternal catheter (SNPC), composed of abdominal and presternal parts joined by a titanium connector, with the exit site located on the chest wall, was designed.

Design

A prospective study was undertaken to estimate the usefulness of the SNPC for continuous ambulatory peritoneal dialysis (CAPD) in children.

Setting

University Children's Hospital, Medical Academy, Warsaw, Poland.

Patients

From December 1991 to June 1997, 11 SNPCs were implanted in 10 children for the following reasons: recurrent ESI in 3, the presence of ureterocutaneostomies in 3, obesity in 3, the use of diapers in 2, young age in 1, and fecal incontinence in 1. More than one indication was present in some patients. In 7 patients the SNPC was the first PD catheter inserted.

Intervention

In all children the presternal catheter was implanted surgically by the modification of the technique described by Twardowski et al.

Results

The observation period ranged from 1 -60 months. The rate of ESI was 11162 patient-months. The major complication was trauma of the exit site (4 times in 3 of 10 patients). In spite of leaving an extra length of the catheter in the entire subcutaneous tunnel at the time of implantation, the two parts of the SNPC became disconnected in 2 children (after 7 and 33 months respectively).

Conclusion

Our results achieved with the SNPC in children are very good. The presternal catheter reduces the risk of ESI. However, the chest localization of the exit site does not help to prevent trauma in children. This type of PD catheter should be reserved for patients with specific indications.

Peritoneal Catheters and Exit-Site Practices toward Optimum Peritoneal Access: 1998 Update

The peritoneal catheter is the PD patient's lifeline. Advances in catheter knowledge have made it possible to obtain access to the peritoneal cavity safely and to maintain access over an extended period of time. Catheter-related infections remain a major problem, solutions for which are being actively researched. Nevertheless, the successful outcome of a catheter is very much dependent on meticulous care and attention to detail. Adherence to the principles of catheter insertion and subsequent management and care remain the cornerstone of successful PD access. The guidelines provided in this publication represent a consensus view based on studies from the literature and opinions of experts in this field; it is hoped that implementation of these guidelines will improve catheter-related outcomes and, therefore, enhance patient care.

Recommendations for Treatment of Exit-Site P a Thology

Good local care including measures to prevent trauma keeps healthy exit sites free of infection. Acute infection can be cured with aggressive therapy. Chronic infection may progress to cuff infection, which even when treated, may progress to peritonitis. Cuff and tunnel infections require deroofing, cuff shaving, and/or catheter removal. Therapy may prolong the life of a catheter. An equivocal exit site requires aggressive therapy in order to achieve cure. Local care of the exit should include measures to prevent trauma. Should trauma occur, aggressive therapy that includes a systemic antibiotic should be instituted immediately. Aggressive therapy is particularly indicated during the healing period. Prophylactic antibiotics, systemic or topical, are indicated in trauma, recurrent infection, and may be beneficial during the healing period.

Peritoneal Dialysis in Adult Patients with Permanent Suprapubic Catheter: A Single-Center Experience and Literature Review

Background

The aim of this paper was to review the feasibility of peritoneal dialysis (PD) in the presence of a permanent supra-pubic catheter over a long follow-up period.

Methods

Twelve patients with automated PD and permanent suprapubic catheters were studied for complications over a period of 10 years.

Results

In all 12 patients, PD went smoothly. Two of our patients required removal of the PD catheter due to peritonitis. The overall rate of exit-site infection throughout the study was 41.7/patient-month and the difference between patients 60 years or older and those 25 years or younger was not significant ( p = 0.3673). The overall peritonitis rate for all patients was 38.3 episode/patient-month, and none of the patients with ventriculoperitoneal shunt (VPS) had peritonitis. All patients with episodes of infection responded well to the proper antibiotics.

Conclusions

The available data supported the feasibility of PD in patients with permanent suprapubic catheters; however, a greater number of patients with a longer follow-up period need to be studied to support our results.

Obese and diabetic patients with end-stage renal disease: Peritoneal dialysis or hemodialysis?

Obesity is a chronic disease that is increasingly prevalent around the world and is a well-recognized risk factor for type 2 diabetes and hypertension, leading causes of end-stage renal disease (ESRD). The obese diabetic patient with ESRD is a challenge for the nephrologist with regard to the type of renal replacement therapy that should be suggested and offered to the patient. There is no evidence that either peritoneal dialysis or hemodialysis is contraindicated in obese ESRD patients. In the literature, we can find a discrepancy in the impact of obesity on mortality among hemodialysis vs. peritoneal dialysis patients. Several studies in hemodialysis patients suggest that a higher BMI confers a survival advantage - the so-called "reverse epidemiology". In contrast, the literature among obese peritoneal dialysis patients is inconsistent, with various studies reporting an increased risk of death, no difference, or a decreased risk of death. Many of these studies only spanned across a few years, and this is probably too short of a time frame for a realistic assessment of obesity's impact on mortality in ESRD patients. The decision for dialysis modality in an obese diabetic patient with ESRD should be individualized. According to the results of published studies, we cannot suggest PD or HD as a better solution for all obese diabetic patients. The obese patient should be educated about all their dialysis options, including home dialysis therapies. In this review, the available literature related to the dialysis modality in obese patients with diabetes and ESRD was reviewed.

Comparative analysis of two-piece extended peritoneal dialysis catheters with remote exit-site locations and conventional abdominal catheters

BACKGROUND

An alternative peritoneal catheter exit-site location is sometimes needed in patients with obesity, floppy skin folds, intestinal stomas, urinary and fecal incontinence, and chronic yeast intertrigo. Two-piece extended catheters permit remote exit-site locations away from problematic abdominal conditions.

OBJECTIVE

The effect on clinical outcomes by remotely locating catheter exit sites to the upper abdomen or chest was compared to conventional lower abdominal sites.

METHODS

In a nonrandomized design, peritoneal access was established with 158 extended catheters and 270 conventional catheters based upon body habitus and special clinical needs. Prospective data collection included patient demographics, infectious and mechanical complications, and catheter survival.

RESULTS

Kaplan-Meier survival time until first exit-site infection was longer for extended catheters (p = 0.03). Poisson regression showed no difference in exit site, subcutaneous tunnel, and peritonitis infection rates; however, the proportion of catheters lost during peritonitis episodes was significantly greater for extended catheters (p = 0.007) and appeared to be due primarily to coagulase-negative staphylococcus organisms. Poisson regression showed interactions of body mass index (BMI) and diabetic status in determining catheter loss from peritonitis for both catheter types (p = 0.02). Extended catheter patients had higher BMI and diabetes prevalence (p < 0.0001). Overall extended catheter survival at 1, 2, and 3 years (92%, 80%, 71%) trended lower than conventional devices (93%, 87%, 80%; p = 0.0505).

CONCLUSIONS

Extended catheters enable peritoneal access for patients in whom conventional catheter placement would be difficult or impossible. Certain patient and extended-catheter characteristics may contribute to loss from peritonitis.

American Society of Diagnostic and Interventional Nephrology Section Editor: Stephen Ash: Percutaneous Technique of Presternal Peritoneal Dialysis Catheter Placement

Presternally exiting peritoneal dialysis (PD) catheters have been described as advantageous compared to abdominally exiting catheters with regard to infection, wound healing, and other complications. Placement of such catheters has only been described with open surgical techniques and not by percutaneous means. In this article we describe 15 patients who received percutaneously placed PD catheters with a presternal exit site. These patients received their procedures in an outpatient procedure room performed by an interventional nephrologist. In all but one case, immediate technical success was achieved. In only one case was peritonitis documented. All catheters are still functional, including some with follow-up as long as 15 months. Percutaneous placement of presternally exiting PD catheters is technically straightforward and can avoid an open surgical procedure.

Presternal peritoneal catheter

The swan neck presternal catheter is composed of 2 flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. The exit site is located in the parasternal area. The catheter located on the chest was designed to reduce the incidence of exit site infections compared to peritoneal dialysis catheters with abdominal exits. From August 1991 to September 30, 2001, 974 swan neck presternal catheters were implanted worldwide. At the university of Missouri, 150 of these catheters were implanted and followed for over 130 patient years. Presternal catheters tended to perform better than swan neck abdominal catheters regarding exit and tunnel infections, even though they were implanted in several patients in whom regular catheters with the exit on the abdomen would be difficult or impossible to implant. Two-year survival probability of presternal catheters was 0.95. Recurrent/refractory peritonitis was the only reason for catheter failure. The catheter is particularly useful in obese patients (body mass index >35), patients with ostomies, children with diapers and fecal incontinence, and patients who want to take baths without the risk of exit contamination. Many patients prefer presternal catheter because of better body image. Disadvantages of the presternal catheter are minimal. Compared with abdominal catheters, dialysis-solution flow is slightly slower because of the increased catheter length; however, slower flow is insignificant clinically. There is a possibility of catheter disconnection in the tunnel, but this complication is extremely rare in adults and easily corrected. Finally, the implantation technique is more challenging compared with that of single-piece, abdominal catheters.

Prophylactic treatment of gram-positive and gram-negative abdominal implant infections using locally delivered polyclonal antibodies

The increasing clinical incidence and host risk of biomaterial-centered infections, as well as the reduced effectiveness of clinically relevant antibiotics to treat such infections, provide compelling reasons to develop new approaches for treating implanted biomaterials in a surgical context. We describe the direct local delivery of polyclonal human antibodies to abdominal surgical implant sites to reduce infection severity and mortality in a lethal murine model of surgical implant-centered peritoneal infection. Surgical implant-centered peritonitis was produced in 180 female CF-1 mice by the direct inoculation of surgical-grade polypropylene mesh disks placed in the peritoneal cavity with lethal doses of either methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa. Mice randomly received a resorbable antibody delivery vehicle at the implant site: either a blank carboxymethylcellulose (CMC) aqueous gel or the same CMC gel containing 10 mg of pooled polyclonal human immunoglobulin G locally on the implant after infection, either alone or in combination with systemic doses of cefazolin or vancomycin antibiotics. Human antibodies were rapidly released (first-order kinetics) from the gel carrier to both peritoneal fluids and serum in both infection scenarios. Inocula required for lethal infection were substantially reduced by surgery and the presence of the implant versus a closed lethal peritonitis model. Survival to 10 days with two different gram-negative P. aeruginosa strains was significantly enhanced (p < 0.01) by the direct application of CMC gel containing antibodies alone to the surgical implant site. Human-equivalent doses of systemic vancomycin provided a significantly improved benefit (p < 0.01) against lethal, implant-centered, gram-positive MRSA infection. However, locally delivered polyclonal human antibodies in combination with a range of systemic vancomycin doses against MRSA failed to improve host survival. Successful antibody therapy against gram-negative, implant-centered infections complements the clinically routine use of systemic antibiotics, providing a mechanism of protection independent of antibiotic resistance.

Current and future modalities for functional renal replacement

Approximately 310,000 Americans suffer from end-stage renal disease, with more than 70,000 new cases reported each year. Advances in immunosuppressive therapy for transplanted patients, in addition to the refined care of patients who are dependent on dialysis, have led to an improved survival for patients with renal failure. Structural, molecular, and pharmacologic developments continue to enhance the efficacy and safety of dialysis in the future. In addition, progressive improvements in the past 2 decades in organ transplantation, a greater insight into the immunobiology of graft rejection, and better surgical and medical management have resulted in improved outcomes. Although renal xenotransplantation is still in its early stages of development, additional research is leading this technology forward. Recent successes in harvesting and expanding renal cells in vitro and the development of biologically active synthetic materials allow for the creation of three-dimensional functioning renal units, which, in the future, may be applied ex vivo or in vivo for partial or full replacement of kidney function.