RESUMO
Introduction: How patient, center, and insertion technique factors interact needs to be understood when designing peritoneal dialysis (PD) catheter insertion pathways. Methods: We undertook a prospective cohort study in 44 UK centers enrolling participants planned for first catheter insertion. Sequences of regressions were used to describe the associations linking patient and dialysis unit-level characteristics with catheter insertion technique and their impact on the occurrence of catheter-related events in the first year (catheter-related infection, hospitalization, and removal). Factors associated with catheter events were incorporated into a multistate model comparing the rates of catheter events between medical and surgical insertion alongside treatment modality transitions and mortality. Results: Of 784 first catheter insertions, 466 (59%) had a catheter event in the first year and 61.2% of transitions onto hemodialysis (HD) were immediately preceded by a catheter event. Catheter malfunction was less but infection was more common with surgical compared with medical insertions. Participants at centers with fewer late presenters and more new dialysis patients starting PD, had a lower probability of a catheter event. Adjusting for these factors, the hazard ratio for a catheter event following insertion (medical vs. surgical) was 0.70 (95% confidence interval [CI] 0.43 to 1.13), and once established on PD 0.77 (0.62 to 0.96). Conclusion: Offering both medical and surgical techniques is associated with lower catheter event rates and keeps people on PD for longer.
RESUMO
BACKGROUND: High-quality peritoneal dialysis (PD) catheter insertion pathways are essential for optimal access to the therapy. Dialysis outcomes are influenced by a range of patient and center-related factors, and there is a need to better understand these so that catheter insertion pathways can be better matched to individual circumstances. OBJECTIVES: To examine how patient- and center-related factors influence the choice of catheter insertion pathways for a PD patient, and the impact of such factors and pathways on patient outcomes, and specifically, to compare the occurrence of and recovery from PD catheter-related adverse events and mortality in individuals who had surgical catheter insertion with those who had medical catheter insertion, and evaluate health economics. STUDY DESIGN: A prospective multi-center cohort study of incident PD patients at catheter insertion. This is an ancillary study nested within the International Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). METHODS: Patients will be recruited during a 30-month recruitment period at 45 United Kingdom (UK) renal facilities, with a minimum 12-month follow-up. A graphical Markov model will be fitted to describe the associations between patient demographics, comorbidities, and catheter insertion pathways that are not explained by center practices and their impact on the occurrence of catheter-related adverse events, and patient-reported outcomes. The model will also explore the extent to which the catheter insertion pathway is determined by the center practice patterns, accounting for patient mix. Multi-state models will compare the rate of occurrence of a PD catheter-related adverse event, recovery from this, and mortality in individuals who had surgical catheter insertion compared with those who had medical catheter insertion, accounting for competing events, and adjusting for patient and center factors. A health economics evaluation will establish which, if any, catheter insertion pathway is superior in terms of cost effectiveness. DISCUSSION: The study will provide information on which catheter insertion pathways are better according to individual characteristics and whether it is acceptable for dialysis units to rely on a single catheter insertion technique or whether they should invest in developing flexible pathways that incorporate both medical and surgical PD catheter insertion techniques.