Erratum: Outcomes of fluoroscopic and ultrasound-guided placement versus laparoscopic placement of peritoneal dialysis catheters.

[This corrects the article DOI: 10.1093/ckj/sfx132.].

Outcomes of fluoroscopic and ultrasound-guided placement versus laparoscopic placement of peritoneal dialysis catheters.

BACKGROUND: Several peritoneal dialysis catheter (PDC) placement techniques have been described. The objective of this study was to compare the fluoroscopy and ultrasound guidance technique with the laparoscopic technique. METHODS: We retrospectively reviewed the medical records of 260 patients who had their first PDC placed between January 2005 and June 2016. We compared the outcomes of the fluoroscopic and ultrasound-guided catheter placement technique (radiologic group, n = 50) with the laparoscopic catheter placement technique (laparoscopic group, n = 190). The primary endpoint was complication-free catheter survival at 365 days. Secondary endpoints were complication-free catheter survival at 90 days, overall catheter survival at 90 and 365 days, median days to first complication and median days to catheter removal. RESULTS: In the radiologic group, the complication-free catheter survival at 90 and 365 days was 64% and 48%, respectively, while in the laparoscopic group it was 71% (P = 0.374) and 53% (P = 0.494), respectively. Catheter malfunction was significantly higher in the laparoscopic group (30%) compared with the radiologic group (16%, P = 0.048). The overall catheter survival at 90 and 365 days was 76% and 52%, respectively, in the radiologic group, while in the laparoscopic group it was 88% (P = 0.0514) an 48% (P = 0.652), respectively. There was no significant difference in the median days to first complication and the median days to catheter removal between the two groups (P = 0.71). CONCLUSION: The technique of fluoroscopic and ultrasound-guided PDC placement is a clinically effective and safe alternative to laparoscopic catheter placement with similar survival and complication rates.

Kinetic Modeling of Incremental Ambulatory Peritoneal Dialysis Exchanges.

♦ BACKGROUND: Incremental peritoneal dialysis (PD), the gradual introduction of dialysate exchanges at less than full-dose therapy, has been infrequently described in clinical reports. One concern with less than full-dose dialysis is whether urea clearance targets are achievable with an incremental regimen. In this report, we used a large database of PD patients, across all membrane transport types, and performed urea kinetic modeling determinations of possible incremental regimens for an individual membrane type. ♦ METHODS: Using a modified 3-pore model of peritoneal transport, various incremental manual continuous ambulatory PD (CAPD) exchanges employing glucose and/or icodextrin were evaluated. Peritoneal urea clearances from those simulations were added to residual kidney urea clearance for patients with various glomerular filtration rates (GFRs), and the total weekly urea clearance was then compared to the total weekly urea Kt/V target of 1.7. All 4 peritoneal membrane types were modeled. For each simulated prescription, net ultrafiltration and carbohydrate absorption were also calculated. ♦ RESULTS: Incremental CAPD regimens of 2 exchanges a day met adequacy targets if the GFR was 6 mL/min/1.73 m2 in all membrane types. For regimens employing 3 exchanges a day, Kt/V targets were achieved at GFR levels of 4 to 5 mL/min/1.73 m2 in high transporters to low transporters but higher tonicity 2.5% glucose solutions or icodextrin were required in some regimens. ♦ CONCLUSIONS: This work demonstrates that with incremental CAPD regimens, urea kinetic targets are achievable in most new starts to PD with residual kidney function. Incremental PD may be a less intrusive, better accepted initial treatment regime and a cost-effective way to initiate chronic dialysis in the incident patient. The key role of intrinsic kidney function in incremental regimens is highlighted in this analysis and would warrant conscientious monitoring.

The curious right-sided predominance of peritoneal dialysis-related hydrothorax.

A known complication of peritoneal dialysis is the movement of dialysate into the pleural space, termed hydrothorax. Peritoneal dialysis-related hydrothorax is almost uniformly right-sided and represents one of many presentations of the porous diaphragm syndrome. In addition to diaphragm porosity, the inherent intestinal circulation, lower hydrostatic pressure in the right upper quadrant and liver capsule may contribute to this right-sided predominance. Similar right-sided presentations have been described in Meigs syndrome, bilious effusions with gastric or duodenal perforations, hepatic hydrothorax and nephrotic syndrome-related chylothorax. PD-related hydrothorax can be repaired by pleurodesis or video-assisted thoracoscopy followed by resumption of peritoneal dialysis.

Peritoneal dialysis prescription during the third trimester of pregnancy.

Management of the pregnant patient on peritoneal dialysis (PD) is potentially challenging because uterine enlargement may negatively affect catheter function and prescribed dwell volumes. Additional reports of the management of these patients are needed. Here, we describe a near-full-term delivery in a 27-year-old woman who had been on dialysis for 7 years. Peritoneal dialysis was continued during the entire pregnancy. In the third trimester, a higher delivered automated PD volume allowed for adequate clearance and control of volume status. A decision to hospitalize the patient to limit activity and facilitate the delivery of increased dialysate is believed to have contributed to the successful outcome for mother and infant. Our report discusses the management of this patient and reviews published dialysis prescriptions used during the third trimester of pregnancy in patients treated with PD.

Economic evaluation of urgent-start peritoneal dialysis versus urgent-start hemodialysis in the United States.

Patients presenting late in the course of kidney disease who require urgent initiation of dialysis have traditionally received temporary vascular catheters followed by hemodialysis. Recent changes in Medicare payment policy for dialysis in the USA incentivized the use of peritoneal dialysis (PD). Consequently, the use of more expeditious PD for late-presenting patients (urgent-start PD) has received new attention. Urgent-start PD has been shown to be safe and effective, and offers a mechanism for increasing PD utilization. However, there has been no assessment of the dialysis-related costs over the first 90 days of care. The objective of this study was to characterize the costs associated with urgent-start PD, urgent-start hemodialysis (HD), or a dual approach (urgent-start HD followed by urgent-start PD) over the first 90 days of treatment from a provider perspective. A survey of practitioners from 5 clinics known to use urgent-start PD was conducted to provide inputs for a cost model representing typical patients. Model inputs were obtained from the survey, literature review, and available cost data. Sensitivity analyses were also conducted. The estimated per patient cost over the first 90 days for urgent-start PD was $16,398. Dialysis access represented 15% of total costs, dialysis services 48%, and initial hospitalization 37%. For urgent-start HD, total per patient costs were $19,352, and dialysis access accounted for 27%, dialysis services 42%, and initial hospitalization 31%. The estimated cost for dual patients was $19,400. Urgent-start PD may offer a cost saving approach for the initiation of dialysis in eligible patients requiring an urgent-start to dialysis.

Early technique success after initiation of treatment with urgent-start peritoneal dialysis.

In the United States, interest has recently been renewed in the more urgent initiation of peritoneal dialysis (PD) to avoid temporary vascular access catheters in appropriate patients presenting late in the course of their kidney disease. Urgent-start PD programs have been established across the country, requiring new infrastructure and processes of care. Less is known about early technique success after urgent initiation of PD. In this report, we describe 90-day technique success and causes of hospitalization in 81 patients initiating PD in our urgent-start pathway.

Urgent-start peritoneal dialysis: nursing aspects.

Urgent-start peritoneal dialysis (PD) refers to the initiation of dialysis soon after a PD catheter placement and is a treatment option available to the late-referred patient with advanced kidney disease. This article reviews nursing aspects of urgent-start PD and can serve as a guide for this evolving clinical pathway that can provide renal replacement therapy for a critical segment of the population with Stage 5 chronic kidney disease who require renal replacement therapy.

Best practices consensus protocol for peritoneal dialysis catheter placement by interventional radiologists.

Peritoneal dialysis (PD) catheters can be placed by interventional radiologists, an approach that might offer scheduling efficiencies, cost-effectiveness, and a minimally invasive procedure. In the United States, changes in the dialysis reimbursement structure by the Centers for Medicare and Medicaid Services are expected to result in the increased use of PD, a less costly dialysis modality that offers patients the opportunity to receive dialysis in the home setting and to have more independence for travel and work schedules, and that preserves vascular access for future dialysis options. Placement of PD catheters by interventional radiologists might therefore be increasingly requested by nephrology practices, given that recent publications have demonstrated the favorable impact on PD practices of an interventional radiology PD placement capability. Earlier reports of interventional radiology PD catheter placement came from single-center practices with smaller reported experiences. The need for a larger consensus document that attempts to establish best demonstrated practices for radiologists is evident. The radiologists submitting this consensus document represent a combined experience of more than 1000 PD catheter placements. The authors submit these consensus-proposed best demonstrated practices for placement of PD catheters by interventional radiologists under ultrasonographic and fluoroscopic guidance. This technique might allow for expeditious placement of permanent PD catheters in late-referred patients with end-stage renal disease, thus facilitating urgent-start PD and avoiding the need for temporary vascular access catheters.

Hypoalbuminemia in peritoneal dialysis patients.

Clinicians caring for patients on peritoneal dialysis (PD) have relied on a variety of laboratory measures to assess the health of patients and their response to treatment. Traditionally, serum albumin has been an indicator of nutrition status and has therefore been included in monthly blood testing in most centers. The development of hypoalbuminemia in dialysis patients has been associated with increased mortality and often leads to interventions such as trials of nutritional supplements. In PD, hypoalbuminemia combined with ongoing losses of protein into effluent raise particular concerns with clinicians. Serum albumin may be affected by a variety of non-nutrition factors such as inflammation, volume status, and comorbidities. Albumin synthesis in the liver exceeds, in most cases, albumin losses in urine or effluent. Interpreting the medical implications of declining serum albumin in PD patients can therefore be a challenge. This paper reviews protein balance in PD. The nutritional and non-nutritional factors affecting serum albumin are discussed, with specific emphasis on how membrane physiology contributes to dialysate protein losses. A general clinical approach to the PD patient developing hypoalbuminemia is discussed.

Hemoperitoneum in a peritoneal dialysis patient from a retroperitoneal source.

Hemoperitoneum in peritoneal dialysis patients is a known but infrequent complication. Hemoperitoneum is more frequent in women because of its association with a variety of gynecologic presentations such as reflux menstruation, ovulation, endometrial tissue implants within the peritoneal cavity (endometriosis), and bleeding follicular cysts. Other intraperitoneal causes of hemoperitoneum include minor catheter or abdominal trauma, vascular anomalies, or hepatic or splenic cysts. Less frequently encountered is a presentation of hemoperitoneum from a retroperitoneal source. These presentations result either from peritoneal inflammation and subsequent peritoneal bleeding or retroperitoneal cavity pathology rupturing into the peritoneal cavity. Here, we present the case of a peritoneal dialysis patient presenting with hemoperitoneum several days after undergoing cardiac catheterization. The catheterization was complicated by a large retroperitoneal hematoma. Details of the case are reported, and other retroperitoneal causes of hemoperitoneum are reviewed.

Infrastructure requirements for an urgent-start peritoneal dialysis program.

Patients with advanced chronic kidney disease nearing dialysis but without pre-established access almost uniformly initiate dialysis with a temporary central venous catheter. These catheters are associated with high rates of infection and flow disturbances, requiring removal and subsequent replacement. Many of these patients might be candidates for peritoneal dialysis (PD), but because of the absence of prior catheter placement, the default initial modality is hemodialysis. Recent reports, however, have demonstrated the feasibility of initiating PD urgently despite the late referral for access placement. Urgent-start PD clinical pathways require a unique infrastructure and treatment approach. This article reviews the salient features required to establish an urgent-start PD program.

Automated peritoneal dialysis prescriptions for enhancing sodium and fluid removal: a predictive analysis of optimized, patient-specific dwell times for the day period.

BACKGROUND: Remaining edema-free is a challenge for many automated peritoneal dialysis (APD) patients, especially those with fast ("high") transport characteristics. Although increased use of peritoneal dialysis (PD) solutions with high glucose concentrations may improve volume control, frequent use of such solutions is undesirable. METHODS: We used the 3-pore kinetic model to evaluate 4 alternative therapy prescriptions for the APD day exchange in anuric patients with high, high-average, and low-average transport characteristics. Four prescriptions were modeled: Therapy 1: Optimal, individualized dwell times with a dry period. Therapy 2: Use of a midday exchange. Therapy 3: Use of an icodextrin-containing dialysate during a 14-hour dwell. Therapy 4: Use of optimal, individualized dwell times, followed by an icodextrin dwell to complete the daytime period. The alternative therapies were compared with a reference standard therapy using glucose solution during a 14-hour dwell. The nighttime prescription was identical in all cases (10 L over 10 hours), and all glucose solutions contained 2.27% glucose. Net ultrafiltration (UF), sodium removal (NaR), total carbohydrate (CHO) absorption, and weekly urea Kt/V for a 24-hour period were computed and compared. RESULTS: The UF and NaR were substantially higher with therapy 1 than with standard therapy (1034 mL vs 621 mL and 96 mmol vs 51 mmol respectively), without significant changes in CHO absorption or urea Kt/V. However, therapy 1 resulted in reduced ß2-microglobulin clearance (0.74 mL/min vs 0.89 mL/min with standard therapy). Compared with therapy 1, therapy 2 improved UF and NaR (1062 mL vs 1034 mL and 99 mmol vs 96 mmol); however, that improvement is likely not clinically significant. Therapy 2 also resulted in a higher Kt/V (2.07 vs 1.72), but at the expense of higher glucose absorption (difference: 42 g). The UF and NaR were highest with a long icodextrin-containing daytime dwell either preceded by a short optimized dwell (1426 mL and 155 mmol) or without such a dwell (1327 mL and 148 mmol). CONCLUSIONS: The 3-pore model predictions revealed that patient-specific optimal dwell times and regimens with a longer day dwell might provide improved UF and NaR options in APD patients with a variety of peritoneal membrane transport characteristics. In patients without access to icodextrin, therapy 1 might enhance UF and NaR and provide a short-term option to increase fluid removal. Although that approach may offer clinicians a therapeutic option for the overhydrated patient who requires increased UF in the short term, APD prescriptions including icodextrin provide a means to augment sodium and fluid removal. Data from clinical trials are needed to confirm the predictions from this study.

Peritoneal dialysis technique success during the initial 90 days of therapy.

Comparisons of technique success by peritoneal dialysis (PD) modality have typically excluded the initial 90 days of therapy. We analyzed a database of 51,469 new PD starts from 2004 to 2008 in the United States. The analysis concentrated on the initial 90 days of therapy to determine technique success and the impact of the continuous ambulatory PD (CAPD) and automated PD (APD) modalities. Overall, 13.3% of patients stopped PD within 90 days. Of patients starting directly on APD, 14.3% stopped PD within 90 days. Of patients starting on CAPD, 12.6% stopped PD within 90 days, and 63.4% changed to APD within 90 days. Only 3.3% of the latter patients failed to reach 90 days of therapy. By comparison, technique failure occurred in 28.8% of those initiating with and remaining on CAPD. We conclude that initial training to perform CAPD, with timely transfer to APD within the first 3 months, was associated with the greatest technique success at 90 days. The reasons for that success are unclear, and further research should be directed to determining factors responsible. It is possible that patients trained initially to CAPD but converted to APD have a greater understanding of the total therapy, which improves confidence. Those converted to APD may be more appreciative of the lifestyle benefits of APD, which translates into improved compliance; alternatively, technical factors associated with APD may be responsible. Those technical factors may include improved catheter function in the recumbent position during APD or the reduced infection risk associated with just 2 connect/disconnect procedures in APD compared with 8 in CAPD.

Urgent-start peritoneal dialysis: report from a U.S. private nephrology practice.

Urgent-start peritoneal dialysis (PD) can be defined as initiation of PD within 2 weeks of catheter insertion. Urgent-start PD can be offered to patients who are referred late to a nephrologist and who would typically be initiated on hemodialysis with a temporary vascular access. An urgent-start PD capability requires expedited options education, catheter placement, unique change in the PD unit infrastructure, and new processes of care. This report describes the urgent-start PD program established by a nephrology private practice in the United States. Operational aspects of the program and initial clinical results are described.

Neighborhood location, rurality, geography, and outcomes of peritoneal dialysis patients in the United States.

BACKGROUND: The adjusted 5-year survival for dialysis patients in the United States is 33%-35%, and patients treated with peritoneal dialysis (PD) have a high risk of transfer to hemodialysis (HD). No data are available on the effect of neighborhood characteristics or regional differences on the outcomes of PD patients in the United States. METHODS: We analyzed the relationships of selected patient demographics, socio-economic characteristics of the dialysis unit's neighborhood, "rurality," and geographic location with transfer to HD and with a composite outcome of transfer to HD or death, for all PD patients in the United States who, between 2004 and 2009, used supplies manufactured by Baxter Healthcare (n = 58 700). RESULTS: Over a median follow-up of 18.7 months, 29% of patients transferred to HD (median time to HD transfer: 49 months), and 54% reached the composite outcome. More than 20% of the events occurred within the first 90 days of PD start. The risk for each of the study outcomes was higher for patients who had received any previous treatment with HD, for those treated in units located in areas with a higher proportion of black residents, and for those living in remote rural areas. Furthermore, the risk for reaching either of the study outcomes was consistently lower for patients treated in units located in California, Alaska, Hawaii, Guam, the Mariana Islands, and American Samoa. CONCLUSIONS: We observed significant regional differences in the outcomes of PD patients in the United States that have not previously been reported. Understanding the differences in clinical practice that underlie these regional differences might help to further improve PD outcomes.

Intermittent peritoneal dialysis: urea kinetic modeling and implications of residual kidney function.

BACKGROUND: Intermittent peritoneal dialysis (IPD) is an old strategy that has generally been eclipsed, in the home setting, by daily peritoneal therapies. However, for a select group of patients with exhausted vascular access or inability to receive PD at home, in-center IPD may remain an option or may serve as an incremental strategy before initiation of full-dose PD. We investigated the residual kidney clearance requirements necessary to allow thrice-weekly IPD regimens to meet current adequacy targets. METHODS: The 3-pore model of peritoneal transport was used to examine 2 thrice-weekly IPD dialysis modalities: 5 - 6 dwells with 10 - 12 L total volume (low-dose IPD), and 50% tidal with 20 - 24 L total volume (high-dose IPD). We assumed an 8-hour dialysis duration and 1.5% dextrose solution, with a 2-L fill volume, except in tidal mode. The PD Adequest application (version 2.0: Baxter Healthcare Corporation, Deerfield, IL, USA) and typical patient kinetic parameters derived from a large dataset [data on file from Treatment Adequacy Review for Gaining Enhanced Therapy (Baxter Healthcare Corporation)] were used to model urea clearances. The minimum glomerular filtration rate (GFR) required to achieve a total weekly urea Kt/V of 1.7 was calculated. RESULTS: In the absence of any dialysis, the minimum residual GFR necessary to achieve a weekly urea Kt/V of 1.7 was 9.7 mL/min/1.73 m(2). Depending on membrane transport type, the low-dose IPD modality met urea clearance targets for patients with a GFR between 6.0 mL/min/1.73 m(2) and 7.6 mL/min/1.73 m(2). Similarly, the high-dose IPD modality met the urea clearance target for patients with a GFR between 4.7 mL/min/1.73 m(2) and 6.5 mL/min/1.73 m(2). CONCLUSIONS: In patients with residual GFR of at least 7.6 mL/min/1.73 m(2), thrice-weekly low-dose IPD (10 L) achieved a Kt/V urea of 1.7 across all transport types. Increasing the IPD volume resulted in a decreased residual GFR requirement of 4.7 mL/min/1.73 m(2) (24 L, 50% tidal). In patients with residual kidney function and dietary compliance, IPD may be a viable strategy in certain clinical situations.