A New Simplified One-Port Laparoscopic Technique for Peritoneal Dialysis Catheter Placement

♦ Background: Various techniques for laparoscopic insertion of a peritoneal dialysis catheter have been described. Usually 2 - 3 ports are required, and complications related to the port sites (such as abdominal wall hernia, leakage, and hemorrhage) cannot be avoided. To minimize the potential complications, we designed a simplified 1-port laparoscopic technique for peritoneal dialysis catheter placement.♦ Methods: We conducted a retrospective data review of 44 patients who underwent 1-port laparoscopic insertion of a Tenckhoff catheter from June 2009 to February 2011. All patient data, including postoperative complications, were analyzed.♦ Results: The mean follow-up period was 11.52 months. All catheters were working properly, except in 1 patient who developed peritonitis 3 months after catheter placement. (The catheter was removed.) No postoperative abdominal wall hemorrhage, early leaks, hernias, or catheter migration occurred. No exit-site or tunnel infections were observed.♦ Conclusions: Our 1-port laparoscopic technique provides excellent catheter fixation, avoids excessive port sites, and yields good cosmesis. The low complication rate and the simplicity of the method justify its standard use for Tenckhoff catheter placement.     

Structured Outpatient Peritoneal Dialysis Catheter Insertion Is Safe and Cost-Saving

♦ Background: Data about outcomes and costs for peritoneal catheter insertion on an outpatient basis are scarce.♦ Methods: Using patient files, all peritoneal dialysis (PD) catheter insertions performed between 2004 and 2009 in a single-center tertiary care institution for adult patients were located. Patient demographics, complications, hospitalizations, survival, and treatment modality changes were recorded. Procedure-related expenses were valued as actual production costs.♦ Results: During the study period, 106 PD catheters were inserted. In 46 cases, the patients were admitted electively for catheter insertion; 19 catheters were placed during admission for other medical reasons; and 41 catheters were placed on an outpatient basis. Among the study patients (54.7 ± 16.0 years of age), 45% were diabetic. Early (<30 days) catheter-related complications occurred in 22% of patients. The incidences of technique failure and any complication within 90 days were 10% and 38% respectively. The occurrence of complications was not statistically significantly different for outpatients and electively admitted patients. Average costs for catheter insertion were higher in electively hospitalized patients than in outpatients (€2320 ± €960 vs €1346 ± €208, p < 0.000).♦ Conclusions: Compared with an inpatient procedure, outpatient insertion of a PD catheter results in similar outcomes at a lower cost.     

Preperitoneal Tunneling—A Novel Technique in Peritoneal Dialysis Catheter Insertion

♦ Introduction: This study describes a new preperitoneal tunneling (PPT) method for inserting a peritoneal dialysis catheter (PDC), thereby lessening surgical complications and increasing the catheter’s survival.♦ Methods: This new technique was used in 23 cases from December 2005 to January 2007 and followed up until March 2011 (63 months). The procedure was performed laparoscopically under local (16 cases) or general (7 cases) anesthesia by one surgeon. Catheter survival is reported by Kaplan-Meyer analysis.♦ Results: The catheters were mechanically obstructed in 2/23 cases (8.7%); and were withdrawn due to a peritonitis in 2 cases and inadequacy of peritoneal dialysis in 1 case. Ten patients received kidney transplantation and six died before completing this follow-up period. The patients still reaped the benefits of the PDC until receiving a kidney transplant or death. The 5-year survival rate of the catheter was 89%. No incidence of catheter migration, omental wrapping, herniation or leakage was noticed.♦ Conclusion: Preperitoneal tunneling is a simple and safe method for insertion of PDC, and can effectively prevent catheter migration, dislocation and omental wrapping.     

Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings

♦ Background:

Peritoneal catheter tunnel and exit-site infection (TESI) complicates the clinical course of peritoneal dialysis (PD) patients. Adherence to recommendations for catheter insertion, exit-site care, and management of Staphylococcus aureus (SAu) carriage reduces, but does not abrogate the risk of these infections.

♦ Objective:

To reappraise the risk profile for TESI in an experienced center with a long-term focus on management of SAu carriage and a low incidence of these infections.

♦ Method:

Following a retrospective, observational design, we investigated 665 patients incident on PD. The main study variable was survival to the first episode of TESI. We considered selected demographic, clinical, and technical variables, applying multivariate strategies of analysis.

♦ Main results:

The overall incidence of TESI was 1 episode/68.5 patient-months. Staphylococcus aureus carriage disclosed at inception of PD (but not if observed sporadically during follow-up) (hazard ratio [HR] 1.53, p = 0.009), PD started shortly after catheter insertion (HR 0.98 per day, p = 0.011), PD after kidney transplant failure (HR 2.18, p = 0.017), lower hemoglobin levels (HR 0.88 per g/dL, p = 0.013) and fast peritoneal transport rates (HR 2.92, p = 0.03) portended an increased risk of TESI. Delaying PD ≥ 30 days after catheter insertion markedly improved the probability of TESI. Carriage of methicillin-resistant SAu since the start of PD was associated with a high incidence of TESI by these bacteria. On the contrary, resistance to mupirocin did not predict such a risk, probably due to the use of an alternative regime in affected patients.

♦ Conclusions:

Adherence to current recommendations results in a low incidence of TESI in PD patients. Interventions on specific risk subsets have a potential to bring incidence close to negligible levels. Despite systematic screening and management, SAu carriage is still a predictor of TESI. Antibiotic susceptibility patterns may help to refine stratification of the risk of TESI by these bacteria. Early insertion of the peritoneal catheter should be considered whenever possible, to reduce the risk of later TESI.     

Patient Education and Care for Peritoneal Dialysis Catheter Placement: A Quality Improvement Study

♦ Background and Objectives: Peritoneal dialysis catheter (PDC) complications are an important barrier to peritoneal dialysis (PD) utilization. Practice guidelines for PDC placement exist, but it is unknown if these recommendations are followed. We performed a quality improvement study to investigate this issue.♦ Methods: A prospective observational study involving 46 new patients at a regional US PD center was performed in collaboration with a nephrology fellowship program. Patients completed a questionnaire derived from the International Society for Peritoneal Dialysis (ISPD) catheter guidelines and were followed for early complications.♦ Results: Approximately 30% of patients reported not being evaluated for hernias, not being asked to visualize their exit site, or not receiving catheter location marking before placement. After insertion, 20% of patients reported not being given instructions for follow-up care, and 46% reported not being taught the warning signs of PDC infection. Directions to manage constipation (57%), immobilize the PDC (68%), or leave the dressing undisturbed (61%) after insertion were not consistently reported. Nearly 40% of patients reported that their PDC education was inadequate. In 41% of patients, a complication developed, with 30% of patients experiencing a catheter or exit-site problem, 11% developing infection, 13% needing PDC revision, and 11% requiring unplanned transfer to hemodialysis because of catheter-related problems.♦ Conclusions: There were numerous deviations from the ISPD guidelines for PDC placement in the community. Patient satisfaction with education was suboptimal, and complications were frequent. Improving patient education and care coordination for PDC placement were identified as specific quality improvement needs.     

A Modified Open Surgery Technique for Peritoneal Dialysis Catheter Placement Decreases Catheter Malfunction

♦ Background: This retrospective study was conducted to evaluate the effect of a new, modified open surgery technique on catheter-related malfunction.♦ Methods: During the period from January 1997 to June 2009, 216 patients received initial peritoneal catheters. For the present study, patients were divided into four groups according to the catheter types and the surgery techniques:

• TO-S: traditional open surgery, straight Tenckhoff catheter
• TO-C: traditional open surgery, coiled Tenckhoff catheter
• TO-SN: traditional open surgery, swan-neck catheter
• MO-S: modified open surgery, straight Tenckhoff catheter

The modified surgery was characterized by a low incision site, a short intra-abdominal catheter segment and an additional upward straight subcutaneous tunnel.All patients were followed up for 2 years or until death. Survival rates, complications caused by catheter placement, and the probability of malfunction-free catheter survival were compared between the groups.♦ Results: Catheter malfunction was the most frequent mechanical complication, found in 31 patients (14.4%), who experienced 38 malfunctions. Only 2 episodes of catheter malfunction were found in the MO-S group, representing a rate significantly less than those in the TO-S and TO-C groups (both p < 0.05). Kaplan-Meier curves for malfunction-free PD catheter survival showed a significantly different malfunction-free probability for the various groups (p = 0.009). After 2 years of follow-up, 136 patients (63.0%) survived with their initial PD catheter. The initial catheter survival rate was 76.8% in the MO-S group. Kaplan-Meier curves for initial catheter survival showed that the highest survival rate was found in the MO-S group (p = 0.001).♦ Conclusions: The modified open surgery technique is a reliable method for catheter placement.     

Correlation Between Glycemic Control and the Incidence of Peritoneal and Catheter Tunnel and Exit-Site Infections in Diabetic Patients Undergoing Peritoneal Dialysis

♦ Background: Diabetes mellitus, especially if complicated by poor glycemic control, portends an increased risk of infection. The significance of this association in the case of diabetic patients undergoing peritoneal dialysis (PD) has not been assessed.♦ Methods: Using a retrospective observational design, we analyzed the association between glycemic control at the start of PD (estimated from glycosylated hemoglobin levels) and the risk of peritoneal and catheter tunnel and exit-site infections during follow-up in 183 incident patients on PD. We used the median value of glycosylated hemoglobin to classify patients into good (group A) or poor (group B) glycemic control groups. We applied multivariate strategies of analysis to control for other potential predictors of PD-related infection.♦ Results: Groups A and B differed significantly in age, dialysis vintage, use of insulin, and rate of Staphylococcus aureus carriage. Neither the incidence (0.60 episodes in group A vs 0.56 episodes in group B per patient-year) nor the time to a first peritoneal infection (median: 42 months vs 38 months) differed significantly between the study groups. In contrast, group B had a significantly higher incidence of catheter tunnel and exit-site infections (0.23 episodes vs 0.12 episodes per patient-year) and shorter time to a first infection episode (64 months vs 76 months, p = 0.004). The difference persisted in multivariate analysis (adjusted hazard ratio: 2.65; 95% confidence interval: 1.13 to 6.05; p = 0.013). We observed no differences between the study groups in the spectrum of causative organisms or in the outcomes of PD-related infections.♦ Conclusions: Poor glycemic control is a consistent predictor of subsequent risk of catheter tunnel and exit-site infection, but not of peritoneal infection, among diabetic patients starting PD therapy.     

Peritoneal Dialysis for Children with Acute Kidney Injury in Lagos,Nigeria: Experience with Adaptations

♦ Introduction: International professional groups are supporting the training of physicians in developing countries in nephrology, including peritoneal dialysis (PD). This report documents the impact of such efforts in the provision of manual PD for children with acute kidney injury (AKI) in a public hospital in Lagos, Nigeria.♦ Methods: Medical records of all children with AKI managed with PD between July 2010 and March 2013 were reviewed.♦ Results: Seventeen children with a mean (SEM) age of 3.8 (0.8) years received PD for 0 - 18 days; about half were infants. PD was provided manually, frequently with intercostal drains as catheters. Blockage of catheters and peritonitis occurred in 4 (23.5%) and 2 (11.8%) children, respectively. Eight (47.1%) of the 17 children had resolution of AKI and were discharged from hospital. In 4 (57.1%) of the 7 children who died, PD was performed for ≤ 2 days.♦ Conclusion: PD for childhood AKI is feasible in resource-constrained regions with fairly good outcome. Blockage of catheter was the most common complication encountered.     

Comparison of Percutaneous and Open Surgical Techniques for First-Time Peritoneal Dialysis Catheter Placement in the Unbreached Peritoneum

♦ Background:

The percutaneous Seldinger method of peritoneal dialysis catheter (PDC) insertion has gained favor over recent years whereas traditionally it was reserved for patients considered not fit for general anesthesia. This blind technique is believed to be less safe, and is hence avoided in patients with previous laparotomy incisions. Reports on the success of this method may therefore be criticized for selection bias. In those with no prior abdominal surgery the optimal method of insertion has not been established.

♦ Methods:

We retrospectively reviewed the outcomes of first-time PDC placements comparing the percutaneous (group P) and surgical (group S) insertion techniques in patients without a history of previous abdominal surgery in a single center between January 2003 and June 2010. We assessed catheter survival at 3 and 12 months post-insertion and compared complication rates between the two groups.

♦ Results:

A total of 63 percutaneous and 64 surgical catheter insertions were analyzed. No significant difference was noted in catheter survival rates between group P and group S (86.2% vs 80% at 3 months, p = 0.37; and 78.3% vs 71.2% at 12 months, p = 0.42 respectively). Early and overall peritonitis rates were similar (5% vs 5.3%; p = 1, and 3.5 vs 4.9 episodes per 100 patient-months; p = 0.13 for group P and group S respectively). There were also no significant differences between the two groups in exit site leaks (15.9% in group P vs 6.3% in group S; p = 0.15), poor initial drainage (9.5% in group P vs 10.9% in group S, p = 0.34) or secondary drainage failure (7.9% in group P vs 18.8% in group S, p = 0.09).

♦ Conclusion:

This study illustrates the success and safety of percutaneous PDC insertion compared with the open surgical technique in PD naive patients without a history of prior abdominal surgery. Catheter survival was favorable with percutaneous insertion in this low-risk patient population but larger prospective studies may help to determine whether either method is superior. The percutaneous technique can be recommended as a minimally invasive, cost-effective procedure that facilitates implementing an integrated care model in nephrology practice.     

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 (r² = 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.     

Prospective Randomized Study Comparing a Single-Cuff Self-Locating Catheter with a Single-Cuff Straight Tenckhoff Catheter in Peritoneal Dialysis

♦ Objectives:

Peritoneal dialysis (PD) catheters are critical to the success of the technique. However, few studies provide evidence about which design helps to reduce complications. Self-locating catheters (SLCs) are used to avoid displacement of the catheter tip. The incidence of mechanical and infectious complications and catheter survival rate were assessed in Tenckhoff PD catheters.

♦ Design:

The prospective randomized study compared drainage problems in 40 incident PD patients using a single-cuff SLCs and 38 patients using a single-cuff, straight Tenckhoff catheter (TC).

♦ Results:

No significant differences were observed in the number of complications in the Pre period (from the insertion of the catheter to the start of the technique); however, the number of complications was lower in the SLC group during Post (p = 0.021) and Total period (p = 0.048). The number of problems related to catheter malfunction for each period: Pre, Post, and Total, was significantly lower with SLCs vs TCs (p = 0.018, p = 0.001 and p = 0.003, respectively). Problems were solved more easily with SLCs, using laxatives, with less need for fluoroscopic placement and no need for surgical replacement, as opposed to the TC group: Pre (not significant), Post (p = 0.007), and Total (p = 0.011).Median survival was 39.6 months (30.9 – 48.3) for SLCs and 30.1 months (22.6 – 37.5) for TCs, which is not a significant difference. However, SLCs have a higher malposition-free survival rate. Multivariate logistic regression models only included the variable “type of catheter” as a predictor of malfunction during the Pre period (odds ratio [OR] = 4.154). The Post period included the variables, “type of catheter” (OR = 7.701) and “age” (OR = 1.047), and the Total period only included the variable “type of catheter” (OR = 4.487), which indicates an increased probability of malfunction with the use of TCs vs SLCs. The variables (gender, previous intra-abdominal surgery, body mass index (BMI) and diabetes mellitus) did not add predictive value to the models (p > 0.05).

♦ Conclusion:

The study confirms the hypothesis that TCs have more malfunctions and a lower malposition-free survival rate than SLCs, and TCs are considered as the highest risk factor for malfunction during all study periods.     

A Qualitative Systematic Review of the Literature Supporting a Causal Relationship Between Exit-Site Infection and Subsequent Peritonitis in Patients with End-Stage Renal Disease Treated with Peritoneal Dialysis

♦ Objective: The objective of our research was to summarize and review evidence supporting a causal relationship between exit-site infection and peritonitis in peritoneal dialysis (PD) patients.♦ Data Sources: We undertook a qualitative review of studies retrieved from MEDLINE, EMBASE, and PubMed, and supplemented that process with a hand search of references and abstracts in the literature.♦ Study Selection: Our quality criteria were based on the Paediatric Risk of Mortality guidelines, definitions, and recommendations from the International Society for Peritoneal Dialysis (ISPD), and the Bradford Hill criteria for causality. All identified abstracts were reviewed for content. Of 776 abstracts, 59 were selected for full-text evaluation, and 22 of those met the ISPD criteria for good-quality research in PD-related infections. Of the 22 eligible studies, 9 met the study’s quality criteria and were included in the summative analysis. No articles reported sufficient data for a quantitative analysis.♦ Data Extraction: Information on study design, study population characteristics, definitions, peritonitis rates, exit-site care protocol, exit-site treatment protocol, follow-up period, potential bias, and outcomes was extracted. Criteria for including data in the final study were determined using ISPD guidelines.♦ Data Synthesis: Of the 9 included studies, 8 suggested that a history of exit-site infection increased the risk for subsequent peritonitis. Of those studies, 3 met 5 causality criteria, 4 met 4 causality criteria, and 1 met 3 causality criteria.♦ Conclusions: The literature provides weak evidence to support a causal relationship between exit-site infection and subsequent peritonitis. Few criteria for causation were met. We were unable to attribute causation and could assume an association only. The exclusion of studies focusing on PD-related tunnel infections may be viewed as both a strength and a limitation of the present work.     

The Effect of Exit-Site Antibacterial Honey Versus Nasal Mupirocin Prophylaxis on the Microbiology and Outcomes of Peritoneal Dialysis-Associated Peritonitis and Exit-Site Infections: A Sub-Study of the Honeypot Trial

♦ Background:

The HONEYPOT study recently reported that daily exit-site application of antibacterial honey was not superior to nasal mupirocin prophylaxis for preventing overall peritoneal dialysis (PD)-related infection. This paper reports a secondary outcome analysis of the HONEYPOT study with respect to exit-site infection (ESI) and peritonitis microbiology, infectious hospitalization and technique failure.

♦ Methods:

A total of 371 PD patients were randomized to daily exit-site application of antibacterial honey plus usual exit-site care (N = 186) or intranasal mupirocin prophylaxis (in nasal Staphylococcus aureus carriers only) plus usual exit-site care (control, N = 185). Groups were compared on rates of organism-specific ESI and peritonitis, peritonitis- and infection-associated hospitalization, and technique failure (PD withdrawal).

♦ Results:

The mean peritonitis rates in the honey and control groups were 0.41 (95% confidence interval [CI] 0.32 – 0.50) and 0.41 (95% CI 0.33 – 0.49) episodes per patient-year, respectively (incidence rate ratio [IRR] 1.01, 95% CI 0.75 – 1.35). When specific causative organisms were examined, no differences were observed between the groups for gram-positive (IRR 0.99, 95% CI 0.66 – 1.49), gram-negative (IRR 0.71, 95% CI 0.39 – 1.29), culture-negative (IRR 2.01, 95% CI 0.91 – 4.42), or polymicrobial peritonitis (IRR 1.08, 95% CI 0.36 – 3.20). Exit-site infection rates were 0.37 (95% CI 0.28 – 0.45) and 0.33 (95% CI 0.26 – 0.40) episodes per patient-year for the honey and control groups, respectively (IRR 1.12, 95% CI 0.81 – 1.53). No significant differences were observed between the groups for gram-positive (IRR 1.10, 95% CI 0.70 – 1.72), gram-negative (IRR: 0.85, 95% CI 0.46 – 1.58), culture-negative (IRR 1.88, 95% CI 0.67 – 5.29), or polymicrobial ESI (IRR 1.00, 95% CI 0.40 – 2.54). Times to first peritonitis-associated and first infection-associated hospitalization were similar in the honey and control groups. The rates of technique failure (PD withdrawal) due to PD-related infection were not significantly different between the groups.

♦ Conclusion:

Compared with standard nasal mupirocin prophylaxis, daily topical exit-site application of antibacterial honey resulted in comparable rates of organism-specific peritonitis and ESI, infection-associated hospitalization, and infection-associated technique failure in PD patients.     

Minilaparotomy Salvage of Malfunctioning Catheters in Peritoneal Dialysis

♦ Background: Catheter malfunction is a common and significant complication during peritoneal dialysis (PD). We developed a minilaparotomy procedure to rescue malfunctioning catheters and to prevent recurrence of malfunction.♦ Methods: From 2006 to 2011, 11 patients receiving PD had a malfunctioning catheter. In all patients, a 2-cm incision, 5 cm caudally to the previous peritoneal entry site was used to correct the malfunctioning catheter, with concomitant fixation of the catheter to the peritoneum.♦ Results: Catheter tip migration occurred in 7 patients, omental wrapping in 3, and blood clot obstruction in 1. The mean onset time to catheter malfunction was 197.5 days (range: 4 - 1270 days), and the mean operating time was 41 minutes (range: 35 - 56 minutes). There was no recurrence of catheter malfunction and no surgery-related peritonitis.♦ Conclusions: Our minilaparotomy procedure is safe and feasible for the salvage of malfunctioning PD catheters.Key words: Catheter tip migration, omental wrappingCatheter malfunction, defined as mechanical failure in dialysate inflow or drainage, is not uncommon in peritoneal dialysis (PD) patients. The most common causes of catheter malfunction are catheter tip migration and omental wrapping. Catheter malfunction develops in 3.9% - 13.3% of patients with a Tenckhoff catheter (1,2). Catheter malfunction leads to interruption of PD, and a rescue operation such as fluoroscopy-guided manipulation using correction instruments, or laparoscopy or minilaparotomy is usually required (1-10). The success and malfunction recurrence rates vary between methods because of differences in the procedures.We previously introduced a catheter implantation technique using two-point catheter fixation to straighten the intraperitoneal catheter segment (11). In the present study, we extended that idea to the rescue of malfunctioning catheters and the prevention of recurrent catheter migration and omental wrapping.     

Impact of Hernias on Peritoneal Dialysis Technique Survival and Residual Renal Function

♦ Objective: We evaluated the effect of hernias and their surgical or conservative management on peritoneal dialysis (PD) technique survival and residual renal function.♦ Methods: This 10-year single-center retrospective case-control study (January 2001 - January 2011) compared patient survival, PD technique survival, and residual renal function in patients with a history of abdominal hernias and in a control cohort matched for age and PD vintage.♦ Results: Of 73 hernias identified in 63 patients (mean age: 55 years; 63% men), umbilical hernias were the most frequent (40%), followed by inguinal (33%), incisional, and epigastric hernias. Some hernias were surgically repaired before (n = 10) or at the time of PD catheter insertion (n = 11), but most (71%) were diagnosed and managed after initiation of PD.Overall, 49 of 73 (67%) hernias were treated surgically. In 53% of subjects, early postoperative dialysis was not needed; only 7 patients required temporary hemodialysis. The occurrence of a hernia and its treatment did not significantly affect residual renal function. After a hernia diagnosis or repair, 86% of patients were able to continue with PD.♦ Conclusions: The incidence of abdominal hernia and hernia management in patients on PD do not significantly influence residual renal function or PD technique survival. Timely management of hernias is advisable and does not preclude continuation with PD as a dialysis modality.     

32 Years’ Experience of Peritoneal Dialysis-Related Peritonitis in a University Hospital

♦ Background: Peritonitis in peritoneal dialysis (PD) patients can lead to technique failure and contributes to infection-related mortality. Peritonitis prevention and optimization of treatment are therefore important in the care for PD patients. In the present study, we analyzed the incidence of peritonitis, causative pathogens, clinical outcomes, and trends in relation to three major treatment changes that occurred from 1979 onward: use of a disconnect system since 1988, daily mupirocin at the exit-site since 2001, and exclusive use of biocompatible dialysis solutions since 2004.♦ Methods: In this analysis of prospectively collected data, we included peritonitis episodes from the start of PD at our center in August 1979 to July 2010. Incident PD patients were allocated to one of four groups: Group 1 - 182 patients experiencing 148 first peritonitis episodes between 1979 and 1987, before the introduction of the disconnect system; Group 2 - 352 patients experiencing 239 first episodes of peritonitis between 1988 and 2000, before implementation of daily mupirocin application at the catheter exit-site; Group 3 - 79 patients experiencing 50 first peritonitis episodes between 2001 and 2003, before the switch to biocompatible solutions; and Group 4-118 patients experiencing 91 first peritonitis episodes after 2004. Cephradine was used as initial antibiotic treatment.♦ Results: In 32 years, 731 adult patients started PD, and 2234 episodes of peritonitis in total were diagnosed and treated. Of those episodes, 88% were cured with medical treatment only, and 10% resulted in catheter removal. In 3% of the episodes, the patient died during peritonitis. Median time to a first peritonitis episode increased from 40 days for group 1 to 150 for group 2, 269 for group 3, and 274 for group 4. The overall peritonitis rate and the gram-positive and gram-negative peritonitis rates showed a time-trend of decline. However, the duration of antibiotic treatment increased over time, with groups 3 and 4 having the longest duration of treatment, accompanied by a higher percentage of antibiotic switch. Increased resistance to cephradine was found for coagulase-negative Staphylococcus.♦ Conclusions: Peritonitis rates declined significantly over the years because of several changes in PD treatment. However, the need to change the initial antibiotic increased because of diminished antibiotic susceptibility rates over time. Nevertheless, the cure rate was high and remained stable during the entire period analyzed, and the death rate remained low. Consequently, peritonitis is a manageable complication of PD that cannot be considered a contraindication to this mode of renal replacement therapy.     

Report of the First Peritoneal Dialysis Program in Guyana,South America

♦ Introduction: In 2008, we initiated the first Guyanese comprehensive kidney replacement program, comprising hemodialysis (HD), peritoneal dialysis (PD), vascular access procedures, and living-donor kidney transplantation. The government of Guyana, US-based philanthropists, US-based physicians, and Guyanese caregivers teamed up to form a public-private partnership. This pilot program was free of cost to the patients.♦ Methods: From July 2010 to the time of writing, we placed 17 patients with end-stage kidney disease on PD, which was used as a bridge to living-donor kidney transplantation. During the same period, we placed 12 primary arteriovenous fistulae.♦ Results: The 17 patients who received a PD catheter had a mean age of 43.6 years and a mean follow-up of 5.3 months. In that group, 2 deaths occurred (from multi-organ failure) within 2 weeks of catheter placement, and 2 patients were switched to HD because of inadequate clearance. Technical issues were noted in 2 patients, and 3 patients developed peritonitis (treated with intravenous antibiotics). An exit-site abscess in 1 patient was drained under local anesthesia. The peritonitis rate was 0.36 episodes per patient-year. Of the 17 patients who received PD, 4 underwent living-donor kidney transplantation.♦ Conclusions: In Guyana, PD is a safe and cost-effective option; it may be equally suitable for similar developing countries. In Guyana, PD was used as a bridge to living-donor kidney transplantation. We have been able to sustain this program since 2008 by making incremental gains and nurturing the ongoing public-private partnership.Key words: Developing countries, Guyana, South America, outcomes, infection, kidney transplantation, logistics of peritoneal dialysis, supply of dialysis fluidsChronic kidney disease has become a major public health problem—not just in the United States, but worldwide—because the cost of treatment has become a large financial burden for advanced and developing countries alike. Treatment options for end-stage renal disease (ESRD) include kidney transplantation and dialysis. Because the availability of kidney transplantation is limited in developing countries, there is a large and growing need for viable dialysis programs.We report an initiative to introduce renal replacement therapy, including hemodialysis (HD), peritoneal dialysis (PD), and living-donor kidney transplantation in Guyana.     

Does Body Fat Mass Define Survival in Patients Starting Peritoneal Dialysis?

♦ Background and Aims: Peritoneal dialysis (PD) is characterized by a gain in fat mass. Unlike subcutaneous fat, visceral fat is associated with metabolic syndrome and survival. We prospectively examined whether visceral or subcutaneous fat could predict outcome in patients undergoing PD.♦ Methods: We studied 117 new patients (57 men) undergoing PD between February 2006 and November 2011. Baseline body composition was measured on computed tomograms. Visceral obesity was defined as a visceral fat area exceeding 100 cm², and subcutaneous obesity, as a subcutaneous fat area exceeding 130 cm².♦ Results: Among the 117 patients, 37 and 29 were diagnosed with visceral and subcutaneous obesity respectively. Visceral and subcutaneous obesity were both present in 21 patients. In the study population, the 1-year and 5-year survival rates were 94% and 59%. The rates of peritonitis and exit-infection were 0.31 and 0.14 episodes per patient-year. Mortality was greater in patients with visceral obesity than in those without visceral obesity (p = 0.005). Visceral obesity had no influence on peritonitis and exit-infection rates. Subcutaneous obesity was associated neither with survival nor with peritonitis or exit-site infection. In a multivariate Cox regression analysis, visceral obesity was not a risk factor for poor outcome.♦ Conclusions: Increased visceral fat at PD initiation is not an independent predictor of poor survival. Any impact of visceral or subcutaneous fat mass on outcomes in patients undergoing PD would be better defined by larger, long-term studies.     

Surgical management of refractory exit-site/tunnel infection of Tenckhoff catheter: technical innovations of partial replantation.

OBJECTIVE: Catheter-related infection has been the major cause of catheter removal for peritoneal dialysis (PD) patients. A salvage technique--partial replantation of the infected catheter--was developed in our hospital to rescue catheters with refractory exit-site or tunnel infection. PATIENTS: We performed 26 partial replantations of Tenckhoff catheters for 23 patients with refractory exit-site or tunnel infection and 2 patients with near-cuff perforation of the catheter. Their problems were all resolved successfully without interruption of PD. INTERVENTIONS: We removed the infected portion of the catheter and preserved the still-functioning internal conduit, connecting it to a divided new catheter. All of the patients resumed PD immediately after the advancement of the new catheter through a new subcutaneous tunnel and exit site on the opposite side. RESULTS: No technical complications such as disconnection of the catheter or leakage of dialysate were noted. Repeated partial replantation of the catheter was done for 1 patient with a new refractory exit-site infection. Tunnel infection was not an absolute contraindication for this procedure. About one third (34.6%) of our patients had preoperative tunnel infection. CONCLUSION: Partial replantation of a Tenckhoff catheter is a simple and effective procedure for patients with refractory exit-site/tunnel infection and patients with near-cuff perforation of the catheter. Repeated partial replantation is also feasible for repeat exit-site infections.     

Cost Analysis of Hemodialysis and Peritoneal Dialysis Access in Incident Dialysis Patients

♦ Background: Although several studies have demonstrated the economic advantages of peritoneal dialysis (PD) over hemodialysis (HD), few reports in the literature have compared the costs of HD and PD access. The aim of the present study was to compare the resources required to establish and maintain the dialysis access in patients who initiated HD with a tunneled cuffed catheter (TCC) or an arteriovenous fistula (AVF) and in patients who initiated PD.♦ Methods: We retrospectively analyzed the 152 chronic kidney disease patients who consecutively initiated dialysis treatment at our institution in 2008 (HD-AVF, n = 65; HD-CVC, n = 45; PD, n = 42). Detailed clinical and demographic information and data on access type were collected for all patients. A comprehensive measure of total dialysis access costs, including surgery, radiology, hospitalization for access complications, physician costs, and transportation costs was obtained at year 1 using an intention-to-treat approach. All resources used were valued using 2010 prices, and costs are reported in 2010 euros.♦ Results: Compared with the HD-AVF and HD-TCC modalities, PD was associated with a significantly lower risk of access-related interventions (adjusted rate ratios: 1.572 and 1.433 respectively; 95% confidence intervals: 1.253 to 1.891 and 1.069 to 1.797). The mean dialysis access-related costs per patient-year at risk were €1171.6 [median: €608.8; interquartile range (IQR): €563.1 - €936.7] for PD, €1555.2 (median: €783.9; IQR: €371.4 - €1571.7) for HD-AVF, and €4208.2 (median: €1252.4; IQR: €947.9 - €2983.5) for HD-TCC (p < 0.001). In multivariate analysis, total dialysis access costs were significantly higher for the HD-TCC modality than for either PD or HD-AVF (β = -0.53; 95% CI: -1.03 to -0.02; and β = -0.50; 95% CI: -0.96 to -0.04).♦ Conclusions: Compared with patients initiating HD, those initiating PD required fewer resources to establish and maintain a dialysis access during the first year of treatment.