Moncrief-Popovich catheter and implantation technique: the AV fistula of peritoneal dialysis

Unveiling the Intricacies: Exploring Stepwise Initiation of Peritoneal Dialysis in a Single-Center Setting

Background and Objectives: Chronic kidney disease (CKD) poses a significant global health challenge, necessitating effective renal replacement therapies. Peritoneal dialysis (PD) offers a patient-friendly, home-based alternative to hemodialysis. The Stepwise Initiation of Peritoneal Dialysis (SIPD) method, used in the SPD group and involving a gradual introduction of PD, presents a potential advantage over traditional protocols, yet the scientific literature on its efficacy and safety is limited. Materials and Methods: We conducted a retrospective analysis of 39 end-stage renal disease patients undergoing SIPD and 78 patients receiving conventional PD (CPD) at a single center from 1 January 2010 to 31 December 2023. Patients were matched for age and sex. Surgical techniques, early and late complications, infection rates, and catheter survival were evaluated. Data were analyzed using statistical methods, including the chi-square test, t-test, and negative binomial regression. Results: The mean break-in period was significantly more extended for the SPD group (176.05 ± 154.39 days) compared to the CPD group (26.87 ± 58.45 days). Early complications were similar between groups, but late complications, including peritonitis, were significantly higher in the CPD group. The SPD group experienced fewer infection events (28 vs. 80, p = 0.043). Median catheter survival times were 1486 days for SPD and 1774 days for CPD, with no statistical difference. Age was a significant factor in peritonitis incidence, increasing with age in both groups. Conclusions: Our study suggests that SPD may reduce the incidence of catheter-related infections and peritonitis compared to CPD. The extended break-in period in SPD could enhance tissue healing and reduce biofilm formation, thereby contributing to fewer infectious complications. Despite these findings, no significant difference in overall catheter survival was observed. Further multi-center studies with larger sample sizes are recommended to confirm these results and explore the economic impact of SPD vs. CPD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Successful Initiation of Dialysis with a 20-Year-Old Buried Peritoneal Dialysis Catheter: Case Report and Literature Review

Buried peritoneal dialysis (PD) catheters are typically inserted several weeks or months before the anticipated need for dialysis. Occasionally, renal function unexpectedly stabilizes after the surgery, and a patient may go years before the catheter is needed. We report a case of successful initiation of PD with a twenty-year-old buried catheter. We outline the steps needed to optimize the catheter function and review the benefits of the buried PD catheter.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

Histological reaction of sintered nanohydroxyapatite-coated cuff and its fibroblast-like cell hybrid for an indwelling catheter

Rapid tissue-ingrowth of a sintered hydroxyapatite(HAp)-coated and cell-hybrid subcutaneous cuff equipped with an indwelling catheter was developed. The rod-like HAp nanoparticles were coated by covalent bonding on the surface of the silk fibroin (SF) fibers for about 100 microm of the length. The fibers were transplanted three-dimensionally on a cuff substrate made of silicone elastomer with an adhesive. The fibroblast-like cells, explanted and proliferated from skin tissue containing the epidermis, dermis, and subcutaneous tissue of Japanese white rabbits, were incubated on the three-dimensional cuff for three days. Three types of cuff--polyester, HAp-coated, and cell-hybrid cuffs--were percutaneously implanted into the backs of the same animals for 3 and 7 days. The subcutaneous tissues around the cuffs were stained with hematoxylin-eosin. Immunohistochemical staining to identify macrophages and alpha-smooth muscle actin (alpha-SMA) was also done and examined by light microscopy. The alpha-SMA-positive area was very limited in the polyester cuff group even after 7 days, although many macrophages infiltrated into the fibers. In the cell-hybrid cuff group, on the other hand, an alpha-SMA-positive area was formed extensively after 3 and 7 days, causing severe inflammation. In the HAp-coated cuff group, an alpha-SMA-positive area was formed among the fibers with little inflammation. The extent order of the alpha-SMA-positive area was cell-hybrid cuff >> HAp-coated cuff >> polyester cuff, while the degree of inflammatory cells order was cell-hybrid cuff >> polyester cuff >> HAp-coated cuff.

Selected best demonstrated practices in peritoneal dialysis access

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.

A Prospective Study to Compare Subcutaneously Buried Peritoneal Dialysis Catheter Technique with Conventional Technique

AIMS

To reduce peritoneal dialysis-related infections, Moncrief-Popovich (MP) designed a special catheter and implantation technique. Herein we report our experience of patients treated with the MP and conventional approach.

METHODS

A total of 214 patients were divided into three groups according to catheter type and implantation technique: group A received a MP catheter (MPC) via MP technique (n = 27); group B received Tenckhoff catheters via MP technique (n = 32), and group C received Tenckhoff catheters via conventional technique (n = 155). Data were collected for infection and catheter survival.

RESULTS

The catheter survival and peritonitis rate was similar in our study groups. Age was found to be the significant factor associated with peritonitis rate.

CONCLUSIONS

Although the MP technique was not associated with a lower peritonitis rate in our practice, the possible benefit of less healthcare costs is still considerable.

Use of the embedded peritoneal dialysis catheter: Experience and results from a North American Center

Since 2000, the Ottawa Hospital Home Dialysis Program has used a variation on the embedded peritoneal dialysis catheter technique described by Moncrief et al. In this paper, we describe our approach to placement of peritoneal access and report our experience with 304 embedded catheters placed between January 2000 and December 2003. We review the advantages and disadvantages of this technique and describe factors that have been important to the success of our program.