Peritoneal dialysis access outcomes reported in randomized controlled trials: A systematic review

A Novel Approach to Repositioning Peritoneal Dialysis Catheters

Introduction

Peritoneal dialysis (PD) is a crucial kidney replacement therapy for patients with end-stage kidney disease. Despite its advantages over hemodialysis (HD), long-term success can be hindered by catheter dysfunction, which often necessitates revision. Currently, surgical treatment methods for PD catheter malfunction include fluoroscopy-guided procedures and laparoscopic or open surgery to salvage or replace the catheter. Here, we introduce the first novel, minimally invasive surgery for repositioning PD catheters.

Methods

From November 2021 to May 2024, 8 patients with PD catheter dysfunction underwent this innovative procedure at the Department of Nephrology, Sichuan Provincial People's Hospital. Surgical Procedure: On the side of the original abdominal incision, blunt separation was used to find the PD catheter tunnel segment. The anterior rectus abdominal muscle sheath was incised, followed by separation of the deep polyester sleeve. The original catheter was exposed in the abdominal port or purse-string suture, and the intra-abdominal segment of the dialysis catheter was pulled out. Blunt cleaning around the periphery was performed to ensure that the PD catheter was smooth, and a rigid guidewire was placed through the intra-abdominal segment of the proximal end of the catheter of the first lateral hole. The intra-abdominal segment of the PD catheter was placed into the pelvis via the original catheter in the abdominal port. Clinical data were retrospectively collected, and patients were followed up for safety and efficacy assessment.

Results

In a study involving 8 patients, no significant complications were observed, with an immediate imaging success rate of 100% and a clinical PD catheter reset success rate of 75%. The catheter remained patent until the end of the study, with a mean follow-up time of 17.25 ± 9.25 months.

Conclusion

This new method for resetting dysfunctional PD catheters demonstrates technical feasibility, simplicity, cost-effectiveness, and safety. It has the potential to emerge as an alternative, particularly suitable for resource-limited settings.

Comparative analysis of complications and technique survival in peritoneal dialysis catheter insertion: single purse-string suture vs. double purses-string suture

OBJECTIVE

Single- and double-purse-string suture methods are both widely used in open surgical catheterization for peritoneal dialysis. This study aimed to compare the post-insertion complications and technical survival of the two methods.

METHODS

This retrospective study matched 142 patients who underwent peritoneal catheterization using the single- (Group S) or double- (Group D) purse-string suture method. Baseline clinical data and complications were recorded, and technical and patient survival rates were evaluated over 3 years.

RESULTS

There were no significant intergroup differences in terms of infection complication rates (S, 2.8% vs. D, 5.6%, p = 0.377) or non-infection complication rates (2.1% vs. 2.8%, p = 1.000) within the first month post-insertion. The Kaplan-Meier estimates of technical survival at 1, 2, and 3 years were 96.3%, 90.4%, and 85.9% in group S and 89.9%, 86.7%, and 84.8% in group D, respectively (log-rank test, p = 0.439). Additionally, patient survival rates were comparable between groups over the 3-year follow-up (log-rank test, p = 0.647).

CONCLUSIONS

This study revealed that the single- and double-purse-string suture catheter insertion methods have similar post-insertion complication and technical survival rates. These data suggest that the single-purse-string suture method can be adopted as standard practice for peritoneal dialysis catheter placement.

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.

A Nationwide Comparative Analysis of Peritoneoscopic and Laparoscopic Techniques for Peritoneal Dialysis Catheter Insertion in Brunei Darussalam

KEY POINTS

Peritoneoscopic and laparoscopic peritoneal dialysis catheter insertions are complementary to each other, and each has its niche in a successful peritoneal dialysis program. Future studies need to use standardized definitions to enable comparisons across jurisdictions, and this study is the first to do so.

BACKGROUND

Brunei Darussalam introduced peritoneoscopic insertion of peritoneal dialysis catheter (PDC) as a new method in 2014. The aim of this study was to compare outcomes of PDC insertion technique in the country, using proposed standardized definitions of outcomes.

METHODS

This study used retrospective analysis of all PDCs inserted from January 1, 2015, to December 31, 2020, in the country. Outcomes of both peritoneoscopic and laparoscopic insertion methods were analyzed. Four main categories of outcomes were assessed—(1) operative-related outcomes, (2) infective outcomes, (3) mechanical outcomes, and (4) time on peritoneal dialysis (PD) therapy.

RESULTS

During the study period, 145 PDCs were inserted: 49 (33.8%) were by peritoneoscopy and 96 (66.2%) by laparoscopy. The median time on PD therapy was 54.2 months. Those with a higher body mass index and history of previous abdominal or pelvic surgery were more likely to undergo laparoscopic method. There was no significant difference in overall infective and mechanical outcomes between the two methods. There was however significantly more postoperative pain observed in the peritoneoscopic group than in the laparoscopic group (8.2% versus 1.0%, P = 0.045). During the study period, there were 49 dropouts to hemodialysis, about half were due to infection. However, there was no statistically significant difference observed in time on PD therapy between the two groups (hazard ratio 0.87 in laparoscopic group compared with peritoneoscopic group, 95% confidence interval, 0.49 to 1.54; P=0.636).

CONCLUSIONS

Peritoneoscopic and laparoscopic PD catheter insertions are both complementary to each other in our local setting. This study has enabled us to scrutinize our PD program, regarding our PDC insertion experience, with the aim to sustain PD growth in the country.

Influence of peritoneal dialysis catheter type on complications and long-term outcomes: an updated systematic review and meta-analysis

BACKGROUND

There is currently no consensus regarding the optimal type of peritoneal dialysis catheter (PDC). We compared the outcomes of PDCs according to the number of cuffs, intercuff and intraperitoneal segment shape, and presence of a weighted tip.

METHODS

A systematic review of the literature was performed using the MEDLINE and Cochrane Library databases (end-of-search date: October 16th, 2019). We included studies comparing double-cuff vs. single-cuff, swan-neck vs. straight-neck, coiled-tip vs. straight-tip, and weighted vs. non-weighted PDCs for the outcomes of interest. We performed meta-analyses using the random-effects model. We assessed the risk of bias using the Newcastle-Ottawa scale and the Cochrane Collaboration's Tool.

RESULTS

In total, 38 studies were identified, of which 20 were randomized controlled trials (RCTs) and 18 were observational studies. No statistically significant differences were detected between double-cuff vs. single-cuff, swan-neck vs. straight-neck, and coiled-tip vs. straight tip PDCs in any of the outcomes of interest. Weighted catheters were associated with significantly lower rates of tunnel infection (relative risk [RR] 0.52, 95% confidence interval [CI] 0.31-0.95, p = 0.03), migration (RR 0.07, 95% CI 0.03-0.16, p < 0.001), drainage failure (RR 0.62, 95% CI 0.39-0.96, p = 0.03), cuff extrusion (RR 0.40, 95% CI 0.21-0.74, p < 0.001), and complication-related removal (RR 0.53, 95% CI 0.44-0.64, p < 0.001).

DISCUSSION

Among the different types of PDCs, weighted catheters result in lower complication rates and superior long-term outcomes compared to non-weighted catheters. Other aspects of the catheter design do not significantly affect PDC outcomes.

PROTOCOL REGISTRATION

PROSPERO 2020 CRD42020158177.