Innovation in Technology II: Changed and Improved Design. PD Catheters- designs. Bharat Sachdeva MD LSU Shreveport

Transcription

1 Innovation in Technology II: Changed and Improved Design PD Catheters- designs Bharat Sachdeva MD LSU Shreveport

2 What s at risk? Why Is Material/Design Important? Reduce risk for transfer to HD Displacement Catheter survival Cuff extrusion Leakage Exit-site infection Peritonitis

3 Tenkhoff Catheter: Initial Method Introduced in 1968 Tenkhoff H & Schechter H, Trans Am Soc Artif Intern Organs 14:181,1968 From: PD:A Historical Review by W.Drukker In Replacement of Renal Function by Dialysis

4 PD Catheter Material Catheters are made either of polyurethane or silicone Exit-site, antibiotic prophylaxis either mupirocin or gentamicin - may damage polyurethane catheters Manifestations of Damage: Opacification of catheter Leaks leading to peritonitis Cruz polyurethane catheters were withdrawn from the market August 2010 Silicone rubber is the most frequently biocompatibility lack of trauma to surrounding tissues minimal leeching of plasticizers thinner catheter walls with larger

5 Catheter Coatings Catheter coatings with various materials with the aim of reducing infection have been tried Silver coated catheters Antibiotic bonded catheters failed to reduce catheter related infections Dasgupta MK. Silver-coated catheters in peritoneal dialysis. Perit Dial Int 17:S142-S145, 1997 Trooskin SZ, Harvey RA, Lennard TWJ, Greco RS. Failure of demonstrated clinical efficacy of antibiotic-bonded continuous ambulatory peritoneal dialsysis (CAPD) catheters. Perit Dial Int 10:51-59, 1990

6 PD Catheter Designs

7 PD Catheter Design PD catheters can be divided in 2 segments Tunneled the number of cuffs pre- formed bend or not swan-neck, pail-handle or straight Intra Peritoneal Segment Straight Coiled Self Locating Straight: perpendicular discs (Toronto - Western, rarely used) T-fluted catheter (Ash Advantage) with grooved limbs positioned against the parietal peritoneum

8 PD Catheter lumen Internal diameters of PD catheters Outer diameter ~ 5 mm 2.6 mm: Standard Tenckhoff catheter 3.1 mm: Cruz catheter 3.5 mm: Flex-neck A. Flex-Neck Tenckhoff catheter, silicone B. Cruz Tenckhoff catheter, polyurethane C. Standard Tenckhoff catheter, silicone D. Intraperitoneal limb of the T-fluted catheter

9 Catheter design and outcomes Cochrane Database Syst Rev. 2004

10 Catheter design and outcomes Kidney International 2013

11 Straight versus coiled PD catheter 37 trials patients Risk of peritonitis (5 trials, 324 patients) RR 1.14; 95% CI 0.73 to 1.79 Peritonitis rate (4 trials, 2589) RR 0.89; 95% CI 0.63 to 1.26 Exit-site/tunnel infection infection (6 trials, 332 patients) RR 1.26; 95% CI 0.73 to 1.47 Catheter removal/replacement (5 trials, 275 patients) RR 1.11, 95% CI 0.53 to 2.31 Cochrane Database Syst Rev. 2004

12 Catheter design and outcomes Kidney International; 10,

13 Catheter design and outcomes Kidney International; 10,

14 Self Locating Catheter Peritoneal Dialysis International, Vol. 19, pp ; 1999

15 Self Locating Catheter Peritoneal Dialysis International, Vol. 24, pp ; 2004

16 Self Locating Catheter Percentages of total, minor, and major dislocation in patients with Tenckhoff catheter (black bars) and self-locating catheter (grey bars) over a period of 24 months Peritoneal Dialysis International, Vol. 24, pp ; 2004

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18 Peritonitis Rate 0.42 PPY compared to 1.5 PPY in their center (Austin) prior to use of the M-P Catheter (Buried for 4.5 wks) No Bacterial contamination at exit site No Motion at SQ cuff, better healing Complete growth along the long SQ cuff Catheter could be used for acute start of dialysis

19 Review of Buried catheters N Time 1 Catheters Embedded Patency 2 Patency Peritonitis Alvaro* NR NR 0.7 vs 0.5 Park* NR NR 0.80 Dannielson >6 NR NR 0.3 vs 0.45 Brown , 12, >.36 >.31 Junejo Elhassan NR Crabtree NR

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21 Emergent and Urgent Peritoneal Dialysis instead of Hemodialysis with a Central Venous Catheter Mukesh Sharma, M.D., M.S., Kenneth Abreo, M.D., Bharat Sachdeva, M.D. Louisiana State University Health Sciences Center, Shreveport, LA Background Patients and Methods In the US, 60-80% incident ESRD patients start hemodialysis (HD) with a central venous catheter (CVC), resulting in an unacceptably high morbidity and mortality associated with catheter related infections/inflammation. Selecting Peritoneal Dialysis (PD) as the initial dialysis modality may be an excellent CVC avoidance strategy in selected patients and may help decrease both morbidity and mortality. Five patients who were declared ESRD were selected for this study. Patients were educated on the merits of different dialysis modalities by their Nephrologist and selected PD over HD. Of these Three patients underwent EPD and Two patients underwent UPD. Indications for EPD and UPD are listed in Table 2. Two EPD and one UPD patients received 1-3 HD treatments through a temporary CVC prior to PDC placement for indications listed in Table 1. Interventional Nephrologists placed Peritoneal Dialysis Catheters within 48 hours of patients choice of PD. All catheters were placed using the modified Seldinger s technique under fluoroscopy and Procedure Sedation Analgesia(Conscious Sedation). A purse string suture was placed in the anterior rectus sheath encircling the catheter to prevent PD fluid leak in some patients. Patients resumed renal diet within 2 hours post procedure. Low volume (1 liter) exchanges were used with the patient in supine position within 24 hrs in EPD patients and within 2 weeks in UPD patients. Patients were followed in the outpatient PD clinic after discharge for continuation of low volume exchanges and PD training. Regular volume exchanges were started within a month of Peritoneal dialysis catheter placement in all patients. We describe a case series of newly declared ESRD patients without established ArterioVenous dialysis access, who were initiated on peritoneal dialysis as their initial modality for chronic dialysis. Table 1: Laboratory Data Patient # Pre-PD Creatinine (mg/dl) * 3* Purpose of the Study To demonstrate that Peritoneal Dialysis can be safely used as a choice of dialysis modality in emergent and urgent settings in carefully selected and appropriate patients. This approach avoids placement of Tunneled central venous catheters in ESRD patients without a working vascular access at the time of initiation of dialysis. Discharge Pre-PD Discharge Creatinine BUN BUN (mg/dl) (mg/dl) (mg/dl) Pre-PD Potassium (mmol/l) Discharge Potassium (mmol/l) Pre-PD Bicarbonate (mmol/l) Discharge Bicarbonate (mmol/l) Pre-PD= before start of PD/HD; Discharge=hospital day of discharge, * One HD treatment for Hyperkalemia each, HD for 3 days for volume overload Conclusions Table 2: Demographics # PD Type Age (years) Race Gender Baseline egfr (ml/min) Definitions 1 EPD 30 AA Male 4 Uremia Emergent Peritoneal Dialysis (EPD): Starting Peritoneal Dialysis immediately (24-48 h) after PD catheter (PDC) placement Urgent Peritoneal Dialysis (UPD): Starting Peritoneal Dialysis after 48 hours but within 2 weeks of PDC placement. 2* EPD 62 AA Male 11 Hyperkalemia 3* EPD 57 AA Female 8 Hyperkalemia 4 UPD 21 AA Female 10 Uremia 5 UPD 62 W Female 11 Volume Indication *One HD treatment for Hyperkalemia each, HD for 3 days for volume overload, AA=African American, W=White Emergent or Urgent PD should be considered in all incident ESRD patients and chronic PD catheter can be placed using minimally invasive technique in an interventional suite. Low volume exchanges in supine position, within 24 hours of PD catheter placement are well tolerated without early leak. Tunneled dialysis catheters can this way be avoided in incident ESRD patients without established Arterio-Venous Access. PDC insertion at short notice is a sine qua non for EPD and UPD.

22 Recomendations Peritoneal Dialysis International, Vol. 30, pp

23 Guideline 5: Facilities Guideline 5.1 Dedicated area be used for catheter insertion with appropriate staffing and patient monitoring facilities (1A) Guideline 5.2 No particular catheter type is proven to be better than another (2C) Guideline 5.3 Catheter of a suitable size should be used (2C) Guideline 5.4 PD catheters should be inserted as day case procedures as long as this does not compromise the quality of care (2C)

24 Summary 1960 s: Tenckhoff catheter remains the prototype Dozens of new models have been proposed, but none has significantly reduced the predominance of the first catheter No convincing prospective data demonstrate the superiority of any peritoneal catheter

25 Summary Probably best to avoid polyurethane catheters entirely Selection of swan-neck or straight catheters may be determined by belt line and exit site location Straight catheters may have lower migration risk Urgent Start PD: TDC last approach! Insertion technique Arcuate subcutaneous tunnel Downward direction: Intraperitoneal and exit site