Choosing between peritoneal dialysis and haemodialysis: a critical appraisal of the literature

In France, incidence and prevalence of end-stage renal disease (ESRD) are increasing, requiring a more rational use of available replacement therapies. To help practitioners make their choice between treatment modalities of peritoneal dialysis (PD) and haemodialysis (HD), critical appraisal of relevant literature has been conducted. Although few absolute or relative contraindications for PD and HD exist, arguments in favour of one versus the other dialysis technique can be made. When patients receive adequate and complete information, their preference is neutral between PD and HD. To date, no trial presenting a convincing level of evidence has been published which demonstrates the superiority of one technique compared to the other. Relative to mortality, it appears that no difference can be observed between the two modalities. However, in those instances where patients expect a rapid transplantation, PD is the preferred technique. This analysis suggests that peritoneal dialysis and haemodialysis are not competitive but rather complementary treatments. It is therefore interesting to identify the reasons supporting the various choices between the two different treatment modalities amongst France's regions. Access to transplant, economic or organizational factors must be considered.     

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

Despite the decrease in peritonitis rate from touch contamination caused by the use of disconnect systems, technique failure in peritoneal dialysis (PD) from pericatheter and exit-site infections in PD remains unchanged. This indicates a failure of current PD catheters to prevent bacterial transfer from exit site to the peritoneal cavity. In 1991, Moncrief and Popovich introduced a new catheter design and implantation technique to address this problem. The catheter is made of silastic, has a coiled tip with 2 cuffs, and an arcuate bend between the cuffs. This would prevent catheter malfunction and leakage of PD fluid. The implantation technique involves embedding of the external segment of the catheter in the subcutaneous tunnel at insertion. The catheter segment is kept embedded for 4 to 6 weeks before externalization. This procedure will allow time for tissue ingrowth on into the external cuff and catheter surfaces between the 2 cuffs, preventing bacterial colonization of the catheter surfaces from the exit wound and thereby reducing pericatheter infections. Thus, the new technique will establish a more effective bacteriologic barrier between the exit wound and the peritoneal cavity than the conventional catheters. Ten years after validation of the catheter design and implantation technique by Moncrief and Popovich, various clinical studies confirm that this new technique of catheter implantation increases catheter life expectancy and reduces pericatheter infections in PD. Like the arteriovenous fistula of haemodialysis, this new catheter remains embedded in subcutaneous tunnel, is exteriorized electively when patient needs to be started on dialysis, and reduces pericatheter and exit-site infections in PD. The new technique, therefore, is widely accepted as a simple, safe, and cost-effective procedure for quality care of PD patients around the world.     

Laparoscopic-assisted placement of peritoneal dialysis catheters: implantation technique and results

BACKGROUND: Peritoneal dialysis is a generally accepted method for the treatment of patients with end-stage renal failure. The laparoscopic placement of peritoneal dialysis catheters is a well-established technique and offers some advantages, such as a safer placement of the catheter, less post-operative complications, and a longer functional survival, compared to the conventional open technique. The aim of this study was to describe our implantation technique and to determine the results of our approach. PATIENTS AND METHODS: Between January 2000 and February 2006, 47 patients with end-stage chronic renal failure underwent a laparoscopic peritoneal dialysis catheter insertion procedure. Perioperative and follow-up data were collected prospectively. RESULTS: The mean operating time was 35 minutes (range, 16-100). There was no perioperative morbidity. Nine (19.1%) patients experienced 10 mechanical complications: fluid leakage in 6 (12.8%) patients, acute hydrothorax in 1 (2.1%), catheter tip migration in 2 (4.3%), and catheter obstruction in 1 (2.1%) patient. Episodes of peritonitis were observed in 5 (10.6%) patients. One (2.1%) patient developed a catheter infection. In 3 (6.4%) patients, a port site hernia occurred that required surgical repair, 5 (10.6%) patients underwent laparoscopic revisions owing to mechanical complications, 9 (19.1%) patients underwent renal transplantation, and 6 (12.8%) patients died during the later follow-up. After a mean follow-up time of 17 months (range, 2-76), 30 (63.8%) catheters are still in use for dialysis. CONCLUSIONS: The functional outcome of the dialysis catheters was satisfactory in the majority of patients in this study. The described technique for catheter implantation is simple and safe, and in our opinion, the laparoscopic technique should be considered as the method of choice in patients with end-stage chronic renal failure.     

A new technique for insertion of the Tenckhoff peritoneal dialysis catheter

To eliminate the discomfort caused by surgical methods and the risks involved using the trocar, for 1 year we have been using a new technique for insertion of peritoneal catheters (PC). We devised a steel instrument, vaguely resembling a rhinoscope, composed of two semicones. The handles are connected by a screw to permit dilatation of the semicones. After local anesthesia, an introducer needle is inserted into the peritoneal cavity. A guide-wire is passed through the needle which is then withdrawn and our instrument is placed around the guide and gently pushed into the peritoneal cavity. The guide is now removed and squeezing the handles of the instrument we introduce the PC up to 2 cm beyond the first Dacron cuff. When the catheter is in place, the instrument is removed and a subcutaneous tunnel may be made. We have used this method for 25 patients. 14 were new cases while 11 underwent PC repositioning. For all patients this new method proved to be excellent with practically no leakage and PC were utilized immediately or after only 24 h. We emphasize the brief time for PC insertion, the minimum discomfort and the simplicity of the technique.     

腹膜透析套管针穿刺置管术和传统开腹置管术的回顾性病例对照研究

目的 回顾性分析腹膜透析套管针穿刺置管术和传统开腹置管术的临床应用效果.方法 采用单中心回顾性病例对照研究.纳入2016年1月至2018年5月在成都医学院第一附属医院行腹膜透析置管手术并术后规律随访的125例维持性腹膜透析患者作为研究对象,根据不同手术方式分为两组,接受套管针穿刺置管术的患者64例(A组),接受传统开腹...     

Videolaparoscopic implantation of long-term peritoneal dialysis catheters

Implantation of peritoneal dialysis catheters by traditional laparotomy or trocar/guidewire techniques leaves the operator blind to the actual location and configuration of the peritoneal catheter tubing; it is associated with drainage dysfunction from catheter obstruction in 10–22% of catheter placements. This report presents a laparoscopic technique that allows accurate tube placement with complete visualization of the implant procedure. The peritoneal dialysis catheter was implanted through a port inserted in a paramedian location. Videoscopic monitoring was performed through a second port inserted in a pararectus location on the opposite side of the abdomen. Nitrous oxide gas was utilized for peritoneal insufflation thus permitting the procedure to be accomplished under local anesthesia. Follow-up of ≤12.7 months (median, 4.4) for the first 28 patients revealed a high rate of successful catheter function with an outflow obstruction rate of 3.6%. The procedure was well tolerated by patients under local anesthesia on an outpatient basis. Videolaparoscopy is ideally suited for peritoneal dialysis catheter implantation. Visual conformation of proper catheter location and configuration during the implant process are associated with lower incidences of outflow failure.     

Analysis of a new technique to stabilize the chronic peritoneal dialysis catheter

A significant cause of morbidity for peritoneal dialysis patients is catheter dysfunction. In our experience, the most common cause of catheter dysfunction was cephalad migration of the catheter tip out of the true pelvis. A new technique for catheter placement that reduces catheter migration from 35% to 6% (P less than .01 chi 2) is described. Our results demonstrate that peritoneal catheters which dysfunction because of catheter flip generally do so in the first 3 months.     

超声引导下腹直肌鞘神经阻滞在腹膜透析管植入术中的应用

目的观察超声引导下腹直肌鞘神经阻滞在终末期肾病患者腹膜透析管植入术中的麻醉效果。方法选择择期行腹膜透析管置入术终末期肾病患者75例,男38例,女37例,年龄18~65岁,BMI 18.5~24.0 kg/m2,ASAⅢ级,采用随机数字法分为三组,A组:全身麻醉组,麻醉方法为全凭静脉麻醉;B组:腹直肌鞘神经阻滞组,手术侧腹直肌鞘内注射0.5%罗哌卡因15 ml;C组:局部浸润麻醉组,1%利多卡因+0.5%罗哌卡因在手术切口和手术路径进行局部浸润麻醉。记录入室时(T0)、麻醉诱导后10 min(T1)、手术开始即刻(T2)、手术开始后20 min(T3)、手术结束时(T4)的HR和MAP。记录患者术后2、4、8、12、24 h运动VAS评分、Ramsay镇静评分,记录手术时间和不良反应。结果与T0时比较,T1~T3时A组HR明显减慢、MAP明显降低(P0.05);T2、T3时C组HR明显增快、MAP明显升高(P0.05);B组不同时点HR和MAP差异无统计学意义。与T1时比较,T2、T3时C组HR明显增快、MAP明显升高(P0.05),与T2、T3时比较,T4时C组HR明显减慢、MAP明显降低(P0.05)。术后2、4、8、12、24 h B组运动VAS评分明显低于A组和C组(P0.05)。C组术中总体补救镇痛次数明显多于B组(P0.05)。A组和B组手术时间明显短于C组(P0.05)。三组均未发生不良反应。结论超声引导下腹直肌鞘神经阻滞在终末期肾病患者腹膜透析管植入术中麻醉效果确切、无不良反应,值得在临床推广。     

Technic for implantation of the Oreopoulos-Zellerman catheter in peritoneal dialysis

The continuous ambulatory peritoneal dialysis is a routine measurement under certain circumstances in nephrological units, which is preferentially performed in patients who cannot be adapted to haemodialysis. Certain risks are inherent in this method. They are dependent on the patient himself as well as on measurement used. Typical complications are canalicular infections along the catheter loop, intra- and extraabdominal dislocations of the catheter tube, abdominal wall leaking and the CAPD-peritonitis. Our own patients are analyzed according to this aspect; the value of a standardized technique of implantation of the Oreopoulos-Zellermann-Catheter is described with regard to the reduction of surgical risks.     

Laparoscopic implantation of swan neck presternal peritoneal dialysis catheters

The swan neck presternal peritoneal dialysis catheter provides an alternative location from which a catheter can exit the skin when an abdominal site is not suitable. The exit site is in the upper anterior chest. The presternal catheter was designed for patients who would not ordinarily be considered for peritoneal dialysis because of body habitus, presence of stomas, or urinary-fecal incontinence. In its original design, the catheter can be implanted only by open dissection. We present a modification of the catheter system and describe an operative technique in which the catheter can be inserted laparoscopically. Eight patients underwent laparoscopic implantation of presternal catheters by this technique. During follow-up ranging from 2.9 to 12.4 months (average, 5.3 months), no instances of catheter dysfunction, leakage around the cannula, hernia, or loss secondary to infection occurred. We foresee greater use of the swan neck presternal peritoneal dialysis catheter once surgeons become more familiar with its ease of insertion and if the device can be made available as a single-package system compatible with laparoscopic implantation.     

代谢综合征在腹膜透析患者中的初探

代谢综合征(MS)是心血管病(CVD)的多种危险因素在个体内集结的状态.MS患者CVD患病率及病死率是非MS者的2～3倍,腹膜透析患者又比普通人群CVD发病率明显增高.但腹膜透析人群MS的患病情况、相关因素,与CVD的关系等研究还较少,且目前尚无公认的MS诊断标准,对于腹膜透析患者用哪个标准更合适尚无研究.我们的研究希望解决上述问题.     

Complications and catheter survival with prolonged embedding of peritoneal dialysis catheters.

BACKGROUND: Our centre uses a modification of the Moncrief technique of embedding peritoneal dialysis (PD) catheters. We undertook this study to test the hypothesis that catheter survival on PD is a function of the time a catheter is left embedded prior to use. METHODS: Data were retrospectively abstracted from review of patient records of those who received a first PD catheter over a 5-year period. Patients were divided into tertiles based on the number of days between insertion of the catheter and exteriorization to create three equal groups representing early (group 1, 11-47 days), mid (group 2, 48-133 days) and late (group 3, 134-2041 days) exteriorization strategies. RESULTS: 435 embedded PD catheters were inserted, 349 were exteriorized and total observation period was 5624 patient-months. Time to catheter loss was shortest in group 1 and longest in group 2 (P = 0.04). The overall rate of primary catheter failure was 6% and was significantly different in the three groups (6.9% in group 1, 1.7% in group 2 and 9.4% in group 3, P = 0.04). The time to first episode of peritonitis was longest in group 3 and shortest in group 1 (group 1 versus group 3, P = 0.009; group 2 versus group 3, P = 0.03). Adjusted peritonitis rates, however, were not different between the three groups. CONCLUSIONS: Mechanical complications and catheter loss are associated with the length of time a catheter is embedded. We recommend insertion 6 weeks to 5 months ahead of the need for PD to maximize catheter survival.     

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.     

Prevention of membrane damage in patient on peritoneal dialysis with new peritoneal dialysis solutions

Peritoneal dialysis (PD) is now an established and successful alternative to hemodialysis. Multiple studies have confirmed its equivalent dialysis adequacy, mortality and fluid balance status, at least for the first 4–5 years. Peritoneal membrane failure is now one of the leading cause of technique failure. This review describes the role of glucose, glucose degradation product, pH, lactate, advanced glycosylation end product (AGE) in causing this membrane damage, and gives insight how the use of newer peritoneal dialysis fluids (PDFs) containing icodextrin, amino acids and bicarbonate buffer can prevent peritoneal membrane damage.     

Initial survival advantage of peritoneal dialysis relative to haemodialysis.

BACKGROUND: The influence of dialysis modality on prognosis is controversial. In the absence of randomized trials, epidemiological investigations present the best method for studying the problem. METHODS: 4568 haemodialysis (HD) and 2443 peritoneal dialysis (PD) records in 4921 dialysis patients treated between 1990 and 1999 were retrieved from the Danish Terminal Uremia register in order to determine the influence of dialysis form on prognosis. The register is national, comprehensive, and incident. RESULTS: Factors reducing survival included age, cardiovascular disease, malignancy, lung disease, diabetes, alcoholism, haematological disease, but not sex or hypertension. Transplant non-candidacy was associated with an adjusted relative risk of 4.7 (CI 4.0-5.6). PD mortality relative to HD (after correction for comorbidity and transplant candidacy) was 0.65 (CI 0.59-0.72, P<0.001) on an "as treated" and "history" analysis and 0.86 (CI 0.78-0.95, P<0.01) on an intention-to-treat (ITT) analysis. The difference was confined to the first 2 years of dialysis. Change in dialysis modality was associated with increased mortality, and change from PD to HD with an accelerated mortality for the first 6 months. This was presumably due to the transfer of sick PD patients, but did not explain the difference. The relative advantage of PD was lower for diabetic patients, where it was not significant on ITT analysis. Dialysis prognosis improved by 14% during the period, with similar results for HD and PD patients. PD patients who were subsequently transplanted had a significantly shorter time to onset of graft function (3.5 vs 5.1 days, P<0.05). CONCLUSIONS: These results show a survival advantage for PD during the first 2 years of dialysis treatment. This may be due to unregistered differences in comorbidity at the start of treatment, or may be causal, possibly due to better preservation of residual renal function. The study lends credence to the "integrative care" approach to uraemia, where patients are started on PD and transferred to HD when PD related mortality increases.