Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome

The most commonly used technique for insertion of peritoneal dialysis (PD) catheters is open surgical approach by minilaparotomy. Percutaneous implantation via the peritoneoscopic technique is expanding. Studies have suggested that PD catheters placed peritoneoscopically have longer survival rate than surgically placed ones. However, these studies were not randomized, where the surgical group had more patients who were obese or had prior abdominal surgery, and therefore, the selection of patients may have biased the results. We conducted a prospective randomized study in which patients underwent PD catheter placement by either the surgical or the peritoneoscopic technique. In the period from October 1992 through October 1995, 148 double-cuff, curled-end, swan-neck PD catheters were placed in 148 patients. The outcome of the 76 patients in whom the PD catheters were placed peritoneoscopically was compared with that of the 72 patients in whom the catheters were placed surgically. Early peritonitis episodes (within 2 weeks of catheter placement) occurred in 9 of 72 patients (12.5%) in the surgical group, versus 2 of 76 patients (2.6%) in the peritoneoscopy group (P = 0.02). This higher rate of infection was most likely related to a higher exit site leak in the surgical group (11.1%) as compared with the peritoneoscopy group (1.3%). Moreover, peritoneoscopically placed catheters were found to have better survival (77.5% at 12 months, 63% at 24 months, and 51.3% at 36 months) than those placed surgically (62.5% at 12 months, 41.5% at 24 months, and 36% at 36 months) with P = 0.02, 0.01, and 0.04, respectively. We conclude that peritoneoscopically placed PD catheters have a longer survival rate than surgically placed ones. Furthermore, the rate of exit site leak and early infection is lower in the peritoneoscopic method.     

Shorter break-in period is a viable option with tighter PD catheter securing during the insertion

Background: Recent single-arm studies reported good catheter outcome despite shorter break-in periods after peritoneal dialysis (PD) catheter insertions. These results were attributed to tight catheter securing during the insertions. Objective: To compare catheter-related outcomes after different break-in periods in the tightly secured PD catheters. Patients and Methods: The study cohort comprised 48 patients, who underwent catheter insertions with the modified insertion technique. Based on the duration of break-in period, the patients were grouped into a shorter break-in period arm, with break-in period of 7 days or less and a standard break-in period arm, with break-in period of about 2 weeks. Mean patient follow up was 9.68 ± 4.35 months, with a similar follow-up duration between the two break-in period arms (P = 0.94). Results: In the study cohort, the incidence of pericatheter leaks, pericatheter haemorrhage, catheter malfunction and peritonitis was 2/48 (4%), 1/48 (2%), 1/48 (2%) and 3/48 (6%), respectively. There was no other-site leak, bowel perforation, hernia formation or wound dehiscence. Of these complications, two pericatheter leaks, one catheter malfunction and three peritonitis episodes followed standard break-in periods, whereas, one pericatheter haemorrhage occurred in the shorter break-in period arm. Conclusion: After a tight catheter securing during the insertions, overall pericatheter leak incidence remained low in the whole study cohort, and it did not worsen despite a shorter break-in period. Future studies with larger patient numbers are needed to validate the role of shorter break-in period in PD practice.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff 双涤纶套直管（直管）与鹅颈卷曲管（卷曲管）在腹膜透析（PD）时的技术生存率。 方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料。按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症。 结果 置入直管者122例,卷曲管者86例。直管和卷曲管出口感染率分别为22.1%和19.8%（P = 0.786）;腹膜炎发生率分别为31.1%和22.1% （P = 0.159）,卷曲管组略低于直管组,但差异无统计学意义。共有27例患者（13.0%）拔管,其中直管17例（13.9%）,卷曲管10例（11.6%）（P = 0.680）。直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存率差异无统计学意义（P = 0.103）。 结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义。鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管。     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

两种腹膜透析管在腹膜透析时的技术生存率比较

目的 比较传统Tenckhoff双涤纶套直管(直管)与鹅颈卷曲管(卷曲管)在腹膜透析(PD)时的技术生存率.方法 回顾分析1999年1月至2007年12月在北京协和医院PD中心接受PD并获长期随诊的208例患者的资料.按置入PD管形态的不同将患者分2组,比较组间的技术生存率及透析管相关并发症.结果 置入直管者122例,卷曲管者86例.直管和卷曲管出口感染率分别为22.1%和19.8%(P=0.786);腹膜炎发生率分别为31.1%和22.1%(P=0.159),卷曲管组略低于直管组,但差异无统计学意义.共有27例患者(13.0%)拔管,其中直管17例(13.9%),卷曲管10例(11.6%)(P=0.680).直管和卷曲管的中位数生存时间分别为25个月和22个月,技术生存差异无统计学意义(P=0.103).结论 直管与卷曲管的出口感染率、腹膜炎发生率及技术生存率差异均无统计学意义.鹅颈卷曲管价格较高,医生可根据患者具体情况选择透析管.     

Should peritoneal dialysis catheters be removed at the time of kidney transplantation?

Background:

Delayed graft function (DGF) following transplantation necessitates support in the form of hemodialyis (HD) or peritoneal dialysis (PD). However, post-transplant PD-related complication and failure rates are unknown.

Methods:

We studies patients who were on PD at the time of kidney transplantation over a 4-year period at two separate institutions.

Results:

Of the 137 PD patients, 19 had their catheters removed at the time of transplant. Of the remaining 118 patients, 89% had immediate graft function. PD-related complications in this group included peritonitis (n=5), catheter-related infections (n=2) and emergency laparotomy (n=1). Of the 15 patients requiring post-transplant PD, 33% developed peritonitis and 20% had fluid-leaks necessitating HD. Overall, leaving a PD catheter in situ post- transplantation is associated with 7% rate of peritonitis versus 0% if removed (p < 0.05).

Conclusions:

PD catheter removal should be considered at the time of renal transplantation, as postoperative PD-related failure/complication rates are high.     

Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit.

OBJECTIVE: We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction. METHODS: We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004. RESULTS: Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omentopexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months. CONCLUSIONS: Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.     

Trisodium citrate 4%--an alternative to heparin capping of haemodialysis catheters.

BACKGROUND: Central venous catheters (CVCs) continue to be used at a high rate for dialysis access and are frequently complicated by thrombus-related malfunction. Prophylactic locking with an anticoagulant, such as heparin, has become standard practice despite its associated risks. Trisodium citrate (citrate) 4% is an alternative catheter locking anticoagulant. METHODS: The objective was to prospectively study the clinical effectiveness, safety and cost of citrate 4% vs heparin locking by comparing rates of CVC exchanges, thrombolytic use (TPA) and access-associated hospitalizations during two study periods: heparin period (HP) (1 June 2003-15 February 2004) and Citrate Period (CP) 15 March-15 November 2004. Incident catheters evaluated did not overlap the two periods. RESULTS: There were 176 CVC in 121 patients (HP) and 177 CVC in 129 patients (CP). The event rates in incident CVC were: CVC exchange 2.98/1000 days (HP) vs 1.65/1000 days (CP) (P = 0.01); TPA use 5.49/1000 (HP) vs 3.3/1000 days (CP) (P = 0.002); hospitalizations 0.59/1000 days (HP) vs 0.28/1000 days (CP) (P = 0.49). There was a longer time from catheter insertion to requiring CVC exchange (P = 0.04) and TPA (P = 0.006) in the citrate compared with the heparin lock group. Citrate locking costs less than heparin locking but a formal economic analysis including indirect costs was not done. CONCLUSION: Citrate 4% has equivalent or better outcomes with regards to catheter exchange, TPA use and access-related hospitalizations compared with heparin locking. It is a safe and less expensive alternative. Randomized trials comparing these anticoagulants with a control group would definitively determine the optimal haemodialysis catheter locking solution.     

Factors associated with early peritoneal dialysis catheter malfunction

BackgroundPeritoneal dialysis (PD) catheter obstruction often leads to surgical revision and may require transition to hemodialysis. The purpose of this study was to evaluate risk factors (including omentectomy) associated with early PD catheter obstruction (< 6 months from insertion).MethodsA retrospective review of all PD catheters inserted at a single high-volume referral center (2005–2018) was performed. 185 PD catheters were placed in 123 patients (45 female). Potential risk factors for early catheter obstruction were analyzed using Chi-square analysis (p < 0.05 considered statistically significant).ResultsMedian age at catheter insertion was 3.42 years (3 days–39 years). Early catheter obstruction occurred in 42 cases (22.7%). Median time to early obstruction was 24 days (3–118 days). Previous PD catheter placement (p = 0.9) or prior abdominal surgery (p = 0.89) was not associated with obstruction. Weight ≥ 10 kg (p = 0.011) and age ≥ 1 year (p = 0.048) were associated with a significantly higher incidence of obstruction. Overall, omentectomy was associated with a trend in reduction of early obstruction in patients with weight ≥ 10 kg (p = 0.08) and significantly in patients ≥ 1 year (p = 0.028).ConclusionEarly PD catheter obstruction appears to occur more often in older patients with a higher weight. Concomitant omentectomy seems beneficial at reducing early catheter obstruction events in those patients.Type of studyRetrospective comparative study.Level of evidenceIII.     

One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion

Background. When a peritoneal dialysis catheter is inserted intra-abdominally in a patient starting peritoneal dialysis (PD) there is always a risk for postoperative wound infection and peritonitis. At our centre, PD is started immediately after the dialysis catheter is inserted. This may increase the postoperative risk for peritonitis and wound infection. The aim of this prospective, randomized, study was to evaluate whether the incidence of microbial growth postoperatively (within 10 days) after catheter insertion could be reduced by prophylactic antibiotic therapy. Subjects and methods. During a period of 27 months, 38 patients, who consecutively entered the PD programme, (11 women and 27 men, mean age 57 years) were included in the study. Eighteen patients were given cefuroxime 1.5 g i.v. preoperatively and 350 mg i.p. in the first dialysis bag (containing 1 litre fluid) as prophylaxis. Twenty patients were not given prophylactic antibiotics (control group). All catheter insertions were performed in an operating theatre by the same surgeons using the same technique. Results. In the test group, none of the patients showed microbial growth in the dialysis fluid during the post-operative period, while in the control group six of 20 patients (30%) suffered from such growth (P=0.021) Conclusions. Prophylactic treatment by cefuroxime i.v. pre- an i.p. perioperatively may reduce the risk for microbial growth and peritonitis after insertion of a Tenckhoff catheter.     

Percutaneous and Surgical Insertion of Peritoneal Catheter in Patients Starting in Chronic Dialysis Therapy: A Comparative Study

Percutaneous peritoneal catheter insertion can be performed by trained nephrologists. The objective of this study was to compare the outcome of peritoneal dialysis (PD) catheters percutaneous inserted with the traditional surgical technique. One hundred twenty‐one PD catheters were placed in 121 stage‐5 Chronic kidney disease patients using three techniques: percutaneous insertion (Group P, n = 53), percutaneous insertion guided by radioscopy (Group R, n = 26), and surgical insertion (Group S, n = 42). The mean age of the whole cohort was 57 ± 16 years and 54% were male. Patients and catheter outcomes were followed up prospectively for 19 months. Gender, age, body mass index, previous abdominal surgeries, and the prevalence of diabetes mellitus were not significantly different among the groups as well as the incidence of bleeding and the presence of catheter dysfunction. In addition, the incidence of exit‐site infections and peritonitis was not significantly different among the groups. Finally, the survival catheter rate was not significantly different by the end of the follow‐up of 19 months (70% in P group, 85% in R, and 70% in S group (log rank = 0.88, p = 0.95). The outcome of percutaneous implanted catheters, which were inserted by a trained nephrologist, did not demonstrate to be inferior as compared with the traditional surgical approach.