Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry.

RATIONALE & OBJECTIVE: A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults undergoing their first PD catheter insertion between November 1, 2011, and November 1, 2020, at 11 institutions in Canada and the United States participating in the International Society for Peritoneal Dialysis North American Catheter Registry. EXPOSURE: Prior abdominal procedure(s) defined as any procedure that enters the peritoneal cavity. OUTCOMES: The primary outcome was time to the first of (1) abandonment of the PD catheter or (2) interruption/termination of PD. Secondary outcomes were rates of emergency room visits, hospitalizations, and procedures. ANALYTICAL APPROACH: Cumulative incidence curves were used to describe the risk over time, and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes. RESULTS: Of 855 patients who met the inclusion criteria, 31% had a history of a prior abdominal procedure and 20% experienced at least 1 PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome (adjusted HR, 1.12; 95% CI, 0.68-1.84). Upper-abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes. LIMITATIONS: Observational study and cohort limited to a sample of patients believed to be potential candidates for PD catheter insertion. CONCLUSION: A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to PD. PLAIN-LANGUAGE SUMMARY: Peritoneal dialysis (PD) is a life-saving therapy for individuals with kidney failure that can be done at home. PD requires the placement of a tube, or catheter, into the abdomen to allow the exchange of dialysis fluid during treatment. There is concern that individuals who have undergone prior abdominal procedures and are referred for a catheter might have scarring that could affect catheter function. In some institutions, they might not even be offered PD therapy as an option. In this study, we found that a history of prior abdominal procedures did not increase the risk of PD catheter complications and should not dissuade patients from choosing PD or providers from recommending it.

The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications.

BACKGROUND: This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications. METHODS: Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain. RESULTS: Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions. CONCLUSIONS: People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.

Compatibility and stability of non-ionic iodinated contrast media in peritoneal dialysis solution and safe practice considerations for CT peritoneography.

BACKGROUND: Computerised tomographic (CT) peritoneography is performed on peritoneal dialysis (PD) patients to identify peritoneal boundary defects, dialysate maldistributions and loculated fluid collections. Iodinated contrast media are added to dialysate and infused through the dialysis catheter, and CT images are obtained. Chemical compatibility of contrast media with dialysis solutions has not been studied. In some institutions, pharmacists charged with oversight of compounded sterile preparations have placed a moratorium on the use of contrast media-dialysate mixtures until compatibility data become available. This study was undertaken to examine the compatibility of non-ionic iodinated contrast agents added to PD solution for the performance of CT peritoneography. METHODS: 100 mL of three non-ionic iodinated contrast agents, iopamidol 370 mgI/mL, iohexol 300 mgI/mL and iodixanol 320 mgI/mL, were mixed with 2 L 1.5% dextrose PD solution and stored at 2-8°C, 25°C and 40°C. Observations at predefined intervals were made over 5 days for visual appearance, turbidity, pH, drug concentration and chemical degradation. RESULTS: Iopamidol, iohexol and iodixanol were stable for 5 days under study conditions. The contrast-dialysate mixture remained clear and colourless, no turbidity changes observed, pH and drug concentrations were stable and no increase in existing impurities or new impurities were detected. CONCLUSIONS: The addition of commonly used non-ionic iodinated contrast agents to 1.5% dextrose dialysis solution is chemically stable, meeting the criteria set forth in the standards and guidelines of the US Pharmacopeia and the Institute of Safe Medication Practices. A protocol for performing CT peritoneography is recommended herein to facilitate patient safety and diagnostic reliability of the imaging study.

Patient Selection and Planning for Image-Guided Peritoneal Dialysis Catheter Placement.

Image-guided percutaneous peritoneal dialysis (PD) catheter insertion has become increasingly relied upon to provide urgent access for late presenting kidney failure patients, to overcome surgical backlogs and limited operating room access, to avoid general anesthesia in high-risk patients, and, by itself, as an alternative approach to surgical PD access. Advanced planning for the procedure is essential to assure the best possible outcome. Appropriate selection of patients for percutaneous PD catheter placement, choosing the most suitable catheter type, determining insertion and exit site locations, and final patient preparations facilitate the performance of the procedure, minimizes the risk of complications, and improves the likelihood of providing a successful long-term peritoneal access.

Peritoneal Dialysis Catheter Insertion.

The success of peritoneal dialysis as renal-replacement therapy depends on a well-functioning peritoneal catheter. Knowledge of best practices in catheter insertion can minimize the risk of catheter complications that lead to peritoneal dialysis failure. The catheter placement procedure begins with preoperative assessment of the patient to determine the most appropriate catheter type, insertion site, and exit site location. Preoperative preparation of the patient is an instrumental step in facilitating the performance of the procedure, avoiding untoward events, and promoting the desired outcome. Catheter insertion methods include percutaneous needle-guidewire with or without image guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy. The insertion technique used often depends on the geographic availability of material resources and local provider expertise in placing catheters. Independent of the catheter implantation approach, adherence to a number of universal details is required to ensure the best opportunity for creating a successful long-term peritoneal access. Finally, appropriate postoperative care and catheter break-in enables a smooth transition to dialysis therapy.

Simultaneous Catheter Replacement for Infectious and Mechanical Complications Without Interruption of Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: Conventional management for peritoneal dialysis (PD)-related infectious and mechanical complications that fails treatment includes catheter removal and hemodialysis (HD) via a central venous catheter with the end result that the majority of patients will not return to PD. Simultaneous catheter replacement (SCR) can retain patients on PD by avoiding the scenario of staged removal and reinsertion of catheters. The aim of this study was to evaluate a protocol for SCR without interruption of PD. ♦ METHODS: Clinical outcomes were analyzed for 55 consecutive SCRs performed from 2002 through 2012 and followed through 2013. ♦ RESULTS: Simultaneous catheter replacements were performed for 28 cases of relapsing peritonitis, 12 cases of tunnel infection, and 15 cases of mechanical catheter complications. All cases for peritonitis and tunnel infection and 80% for mechanical complications continued PD on the day of surgery using a low-volume, intermittent automated PD protocol. Systemic antibiotics were continued for 2 weeks postoperatively (up to 4 weeks for Pseudomonas). Simultaneous catheter replacement was performed as an outpatient procedure in 89.1% of cases. Only 1 of 55 procedures was complicated by peritonitis within 8 weeks. No catheter losses occurred during this postoperative timeframe. Long-term, SCR enabled a median technique survival of 5.1 years. ♦ CONCLUSIONS: In most instances, SCR can be safely performed without interruption of PD for selected cases of peritonitis and tunnel infection and for mechanical catheter complications. The procedure spares the patient from a central venous catheter, a shift to HD, the psychological ordeal of a change in dialysis modality, and a second surgery to insert a new catheter.

Peritoneal Dialysis University for Surgeons: A Peritoneal Access Training Program.

UNLABELLED: ♦ BACKGROUND: A functioning catheter is vital to the success of peritoneal dialysis (PD). Catheter complications related to the insertion procedure remain a major hindrance to PD utilization. Most catheters are placed by surgeons. Suboptimal catheter outcomes appear to be related to inadequate training and experience during surgical residency and the absence of educational opportunities to remedy this deficit once the surgeon is in practice. ♦ OBJECTIVE: The aim of this report is to describe a 1-day comprehensive surgeon training program in PD access surgery and to convey the results of the first 7 courses. ♦ METHODS: Needs assessment data served as the foundation for formulating course objectives and content. A disease-based approach to PD was taken to provide both didactic instruction and laboratory exercises. Surgical simulators permitted skills development for each key task in catheter placement. Educational outcomes were measured with pre- and post-tests, course evaluation, and follow-up survey. ♦ RESULTS: Seven courses were attended by 134 surgeons with an average faculty to participant ratio of 1:4 during hands-on laboratory sessions. Pre- and post-testing demonstrated a class-average normalized educational gain of 50%. On a 5-point Likert scale, the course was scored highly on 14 areas of evaluation with average responses ranging from 4.4 to 4.9. A follow-up survey conducted a mean of 28 months after the programs revealed significantly increased utilization of all 10 course-targeted PD access skills. Participants gave mean scores of 4.6 for improved confidence in case management and 4.4 for better catheter outcomes. ♦ CONCLUSIONS: A comprehensive 1-day peritoneal access training course can produce long-term self-assessed improvement in surgical management and PD catheter outcomes.

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 (r(2) = 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.

Peritoneal dialysis catheter implantation: avoiding problems and optimizing outcomes.

The success of peritoneal dialysis (PD) as renal replacement therapy is dependent upon the patient having a functional long-term peritoneal access. There are a number of identified best practices that must be adhered to during PD catheter placement to achieve a durable and infection-resistant access. The clinical setting, available resources, and the employed catheter insertion method may not always permit complete adherence to these practices; however, an attempt should be made to comply with them as closely as possible. Although omission of any one of the practices can lead to catheter loss, departures from some are committed more frequently, manifesting as commonly occurring clinical problems, such as drain pain, catheter tip migration, omental entrapment, pericatheter leaks and hernias, and poor exit-site location. Understanding the technical pitfalls in PD catheter placement that lead to these problems, enable the provider to modify practice habits to avoid them and optimize outcomes.

Peritoneal dialysis catheter embedment: surgical considerations, expectations, and complications.

BACKGROUND: Peritoneal dialysis catheter embedment consists of implanting the catheter far in advance of anticipated need, with the external tubing buried under the skin. The catheter is externalized when initiation of dialysis is required. Details of the surgical procedure and management of associated complications are generally lacking. METHODS: A total of 84 catheters including conventional and extended catheters were embedded and externalized during the study period. Factors influencing duration of embedment, functionality upon externalization, and long-term outcomes were analyzed. RESULTS: Mean duration of embedment was 13.9 months (median 9.4; range .5 to 68.5). Immediate function was exhibited in 85.7% of catheters. Employing laparoscopic revision, 98.8% of embedded catheters were successfully used for peritoneal dialysis. Extended catheters and duration of embedment were important determinants of catheter functionality. CONCLUSIONS: Catheters can be embedded for prolonged periods and still result in functional dialysis access when needed. Complications are few and easily managed.