NDT Advance Access originally published online on April 16, 2007
Nephrology Dialysis Transplantation 2007 22(7):2045-2051; doi:10.1093/ndt/gfm150
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A ten-year single-centre experience in children on chronic peritoneal dialysis—significance of percutaneous placement of peritoneal dialysis catheters
Department of Pediatrics, Tepecik Teaching and Research Hospital, Izmir, Turkey
Correspondence and offprint requests to: Dr Nejat Aksu, Ça
lar Cad. Cumhuriyet Sitesi No:74/3 Emlak Konutlar
, 35410 Gaziemir, 
zmir, Turkey. Email: muratanil1969{at}hotmail.com
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Abstract |
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Background. Chronic peritoneal dialysis (CPD) in children is an important modality of renal replacement therapy. The ideal method for inserting CPD catheters remains still controversial. Minimal invasive techniques are becoming more popular. This study was performed in order to evaluate the efficiency, the complication profile and the survey of percutaneously placed CPD catheters in children, retrospectively.
Methods. This study was carried out on 108 peritoneal catheters implanted in 93 patients (45 girls, 48 boys), aged 8.0 ± 4.2 years (range: 3 months to 16 years) during the period between December 1995 and November 2005. In the study group, 32 children were transplanted, 15 were transferred to haemodialysis and 18 patients died. All catheters implanted by percutaneous route were Tenckhoff swan-neck double-cuff paediatric catheters. Placement procedure was performed in our unit by us. Statistical analysis was made by chi-square and Kaplan–Meier methods.
Results. During 2670 CPD months we observed a total of 108 catheter-related complications: 82 catheter infections including exit-site and/or tunnel infection (1/32.5 patient-months), 10 dislocations, six drainage problems and six kinks. The incidence of all complications was one complication every 24.72 dialysis months. Overall, the incidence of peritonitis was one episode per 18.1 patient-months. Pseudomonas spp. and Staphylococcus aureus were the two most common causes of infections. Fifteen catheters were removed due to catheter-related causes: drainage problems (six patients), catheter dislocation (three patients), omental capture (two patients) kink (two patients) and tunnel infection (two patients). The catheter survival rate was 92.4% at 1 year, 83% at 2 years and 63% at 10 years; patient survival in the 93 children was 91% at 1 year, 84% at 2 years and 48% at 10 years. Younger patients were at increased risk of exit-site and tunnel infections (P < 0.05) but the difference in catheter survival time between the age groups was not significant (P > 0.05). In complications, no statistical difference was observed between early and delayed catheter use groups (P > 0.05). We compared the two periods (period 1, December 1995 to November 2000; period 2, December 2000 to November 2005), for complications of CPD. The risk of catheter migration was greater in period 1 than in period 2 (P = 0.04).
Conclusions. The percutaneous technique performed by experienced nephrologists is a reliable, safe and cost-effective method for placement of PD catheters. In our opinion, the skill for CPD catheter placement must be part of the paediatric nephrologist training.
Keywords: catheter; catheter-related complications; children; chronic peritoneal dialysis; percutaneous placement; peritonitis
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Introduction |
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Chronic peritoneal dialysis (CPD) is an effective therapy in the management of children with end-stage renal disease (ESRD) awaiting transplantation [1,2]. CPD catheters are the most successful of all transcutaneous access devices, with longevity and successful function measured in years rather than days to months [3]. However, complications related to the peritoneal catheter, such as peritonitis, exit-site infection, tunnel infection, pericatheter leakage, or mechanical dysfunction, and incorrect positioning of the catheter within the abdomen causing failure of fluid drainage remain troublesome [1,4]. Currently, the success of peritoneal dialysis (PD) catheters depends more on placement technique than on their design. The three commonly used techniques for PD catheter insertion are surgical, percutaneous (Seldinger, blind trochar) and laparoscopic. The ideal method of insertion of a PD catheter remains debatable. The most commonly used technique is the open surgical approach [4,5]. Of the three techniques, only the laparoscopic insertion allows for direct visualization of the intraperitoneal structures; so, its use is rapidly expanding [3–6]. However, in our opinion, in order to better manage their patients, concerning all potential catheter-related complications, nephrologists should be able to perform percutaneous catheter placement. We believe that a centre's experience and degree of specialization towards percutaneous PD catheter placement strongly impact on PD outcome.
In this study, therefore, we retrospectively evaluated the results of percutaneously placed PD catheters by experienced paediatric nephrologists in our centre.
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Methods |
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The study was conducted at the Department of Pediatric Nephrology, Izmir Tepecik Training and Research Hospital, Turkey. Children with ESRD, who were on PD from December 1995 to November 2005, were included in the study. Children were excluded from the study if the PD catheter was used for acute renal failure. Patients' medical records were retrospectively reviewed using a standardized data collection form. Before the PD catheter insertion, the children and their families were educated about renal replacement therapy and presented with dialysis modality choices. Written informed consent was obtained from parents of children for the choice of renal replacement modality.
All PD catheters were placed percutaneously (Seldinger technique) by an experienced paediatric nephrologist. We used swan-neck (Tenckhoff), double-cuffed catheters with coiled tips.
Pre-operative laboratory results included complete blood count (CBC), basic metabolic panel, prothrombin time, partial thromboplastin time, typing and screening for two units of blood. A bowel enema was performed to all children 45 min before catheter insertion to prevent bowel perforation. The urinary bladder was also emptied.
Catheter insertion
The percutaneous PD catheter placement was performed under local anaesthesia in the procedure room. All procedures were carried out under strict aseptic conditions (for doctors: cap, mask, sterile gown and double sterile gloves; for nurses: cap, mask and sterile glove; for patient: mask and cap). After the children were laid in supine position, the skin was prepared with antiseptic solution (baticon) five times. Under local anaesthesia, a 1.5 cm vertical incision at the linea alba 2 cm below the umbilicus was made. Blunt dissection was carried down to the subcutaneous tissue until the rectus sheath was seen. A blind trochar was inserted and passed the peritoneum at an angle of 90° with one breakthrough, then directed caudally towards the left iliac fossa at an angle of 45°. The PD catheter, which was washed with heparinized solution, was threaded on a stiffening stylet and introduced towards the left iliac fossa until the patient experienced a pain at the perianal region. According to the pain experienced, the tip of catheter was placed in the Douglas pouch. Approximately 50–100 ml heparinized saline is infused rapidly; its outflow is assessed to confirm adequate function. After the trochar was removed, the inner cuff of the PD catheter was fixed at the fascia of the rectus muscle. After that, a subcutaneous tunnel for the catheter was fashioned with a specially designed hook-shaped stylet. The end of the catheter was attached to the stylet and the tip of the hook was pushed through the subcutaneous tissue in a right latero-caudal direction. The proximal end of the catheter was pulled through the exit-site and positioned so that the inner cuff was located at the peritoneal entry at the fascia of the rectus muscle and the second cuff was >2 cm from the exit site. The titanium adaptor was added to the proximal end of the catheter. The operation was completed by closing the incision with two or three sutures. The skin was cleaned with antiseptic solution five times again. The mupirocin ointment was applied to the catheter exit site and tip of the tunnel followed by covering with a transparent, oxygen-permeable dressing.
After a training phase, the children were discharged from the hospital. The children were observed for 1 week, at which time their wounds were checked and the dressings were changed. The parents performed PD (either continuous ambulatory or automated PD) at home. At least once monthly, all children were assessed in the nephrology clinic. A CBC, blood chemistry, including estimation of the residual renal function, and microbiological and biochemical examinations of the dialysate effluent were done. On this occasion, the dialysis nurse checked the parental skills in PD. In addition, the dialysis nurses made home visits two times in a year.
We studied the demographic characteristics of the children (age, sex, primary renal diagnosis), catheter survival, patient survival and the incidence of catheter-related complications. All catheters were evaluated for mechanical and infectious complications. Follow-up was from the date of catheter insertion to the date the catheter was removed. For children who transferred to another centre while still on dialysis therapy, the day of transfer was counted as the last day of follow-up, with a minimum follow-up of 3 months. Functioning catheters in children who died or transferred to another renal replacement therapy were considered as failed. If a patient required multiple catheters, each was analysed as a separate case. To evaluate the risk of the time of use of the PD catheter on complications, we divided catheters into two groups. An ‘early use’ group defined as PD catheter use within the first 14 days of placement and a ‘delayed use’ group defined as catheter use after 14 days of placement. To evaluate the effect of our experience of PD catheter on complications, we divided catheters into two periods. ‘Period 1’ was between December 1995 and November 2000. ‘Period 2’ was between December 2000 and November 2005.
Diagnosis of peritonitis was made if peritoneal effluent showed a white blood cell count >100/mm3, of which at least 50% were polymorphonuclear neutrophils, with or without the presence of abdominal pain and cloudiness of the effluent. We defined exit-site infection as pericatheter erythema, or drainage, or both; a positive culture result was not mandatory. Criteria for tunnel infection diagnosis were erythema, oedema and tenderness over the subcutaneous portion of the catheter. When an infection was suspected, samples from the exit site and/or peritoneal fluid were obtained for culture prior to initiation of treatment. Empirical antibiotic therapy with cefazolin and ceftazidime was the initial therapy in patients with peritonitis. For exit-site infection, the initial therapy was with a local mupirocine ointment. We defined mechanical complications as non-infectious complications related to the catheter (drainage problems, catheter migration, kink).
Statistical analysis
Chi-square analysis was used for categorical variables. Differences between groups were tested with one-way ANOVA. The survival curves were determined using the Kaplan–Meier method. Values of P < 0.05 were accepted as significant. The SPSS 11.0 statistical software program (SPSS, Chicago, Illinois, USA) was used for this analysis.
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Results |
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Between December 1995 and November 2005, 93 children (45 girls, 48 boys) diagnosed with ESRD at the department of Pediatric Nephrology, Izmir Tepecik Training and Research Hospital, were dialysed with chronic PD. The mean age of the diagnosis of ESRD was 8.0 ± 4.2 years (range: 3 months to 16 years); the mean age at the start of dialysis was 9.1 ± 4.3 years (range: 4 months to 16 years); the average follow-up period after catheter insertion was 28.7 ± 23.5 months (range: 10 days to 109 months). At dialysis initiation, the number of children younger than 2 years of age was seven (7.5%), between 3 and 5 years of age 20 (21.5%) and the number between 6 and 10 years and above 10 years of age was 33 (35.5%) for each age group.
The 93 patients in the study had 108 PD catheters placed. There were 80 patients (86%) with one catheter, 11 patients (11.8%) with two catheters, and two patients (2.2%) with three catheters. Fifteen catheters were removed from 13 patients. The most common reason for PD catheter removal was drainage problems (six patients). Other causes for catheter loss included catheter dislocation (three patients), omental capture (two patients), kink (two patients), and tunnel infection (two patients). Nine open surgical and three laparoscopic operations were performed to rescue catheters. At the time of this report, 21 children (22.6%) were still being actively followed with a functioning catheter. The latter 72 cases included 32 transplants (34.4%), 18 exitus (19.4%), 15 changes to haemodialysis (16.1%), 4 transfers to other centres (4.3%), and 3 temporary discontinuations of dialysis (3.2%).
Table 1 shows the incidence of renal diseases that caused ESRD in treated children. Among these, urological diseases (49.6%) were the most common with the dominance of vesicoureteral reflux (22.6%). Primary glomerulonephritides made up the second main group, and focal segmental glomerulosclerosis (17.2%) was the most common diagnosis in this group.
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During 2670 CPD months, we observed a total of 108 catheter-related complications and an overall incidence of one episode every 24.72 patient-months. Catheter infection (exit-site and tunnel infections) was the most common catheter-related complication with an overall incidence of one episode every 32.5 patient-months (0.36 per patient-year). The overall peritonitis rate was one episode every 18.1 patient-months (total 147 peritonitis episodes) (Table 2). Table 3 shows the causative organisms of catheter-related infections and peritonitis.
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During the observation period, the catheter survival rate was 92.4% at 1 year, 83% at 2 years and 63% at 10 years; mean cumulative survival time of the catheters was 81 months (Figure 1). Patient survival in the 93 children was 91% at 1 year, 84% at 2 years and 48% at 10 years. The overall mean cumulative survival time of the patients on CPD was 75.5 months (Figure 2).
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We assessed the impact of patient age on complication rate. In this analysis, younger patients were at increased risk of exit-site (P = 0.04) and tunnel infections (P = 0.03). The frequency of peritonitis and non-infectious complications was not different between the age groups (P > 0.05). The mean cumulative survival time of the catheters was 46.1 ± 7.5 months among <2 years age group, 74.4 ± 9.5 months among 3–5 years, 54.0 ± 7.3 months among 6–10 years and 87.1 ± 9.4 months among >10 years. The difference in catheter survival time between the age groups was not significant (P = 0.15), as shown in Figure 3.
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There were 60 children (64.5%) in the ‘early use’ group and 33 children (35.5%) in the ‘delayed use’ group. There was no statistical difference in complications between these two groups (P > 0.05). The mean cumulative survival time of the catheters was 77.2 ± 7.7 months in ‘early use’ group and 68.6 ± 9.9 months in ‘delayed use’ group (P > 0.05) (Figure 4).
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The total number of children enrolled in the study was 43 during period 1 and 76 during period 2 (a group of children who were followed up in period 1 plus new patients). There were not any significant differences in the mean age of children, sex, the mean age at the diagnosis of ESRD and the mean duration of follow-up between the two periods (P > 0.05).
We compared the two periods for complications of CPD. The risk of catheter migration was greater in period 1 than in period 2 (P = 0.04). There was not any significant difference in other complications between periods 1 and 2 (P > 0.05). The mean cumulative survival time of the catheters was 44.6 ± 1.8 months in period 1 and 55.2 ± 3.9 months in period 2 (P > 0.05). The mean cumulative survival time of the patients was 42.9 ± 2.2 months in period 1 and 56.4 ± 3.8 months in period 2 (P > 0.05).
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Discussion |
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It is well known that the management of access is a key factor for the improvement of PD technique survival. It requires the establishment of a dedicated team that should ideally consist of nephrologists, surgeons and nurses. The experience of the team is more important than the type of catheter and the implantation technique used in the management of PD patients [7]. Our paediatric nephrology team consists of one paediatric nephrologist, three paediatricians, one general practitioner and three nurses over the 10 years. All of the PD catheters were placed percutaneously by the same paediatric nephrology team. In this study, we showed that our results were comparable with the limits of a desirable adult PD centre and similar to the findings in the paediatric literature.
The incidence of peritonitis has a significant impact on the success of CPD [8–10]. The most common complication in our series was infection, with peritonitis in first place. The overall peritonitis rate was one episode per 18.1 patient-months (0.66 episode per patient-year) in our study population. The reported peritonitis rates vary from one episode per 19.9 patient-months or 0.17 episode per patient-year to one episode per 13.2 patient-months or 0.82 episode per patient-year [8–13]. In our study, the peritonitis rate is lower than the results from most of the other countries, and similar to the findings from Turkey.
Catheter-related infections remain one of the most common causes of treatment failure in patients on CPD [10]. Infections (exit-site and tunnel) were the most frequent catheter-related complications in the present study. In our analysis, the overall catheter-related infections rate was one episode per 32.5 patient-months (0.36 episode per patient-year). Our incidence of catheter-related infections is well within the accepted limits [1,9,14].
It has been reported that the most common non-infectious catheter-related complications are leakage and catheter malfunction [3,15]. Dialysate leakage can occur in as many as 5.8–25% of patients [1,14,16,17]. However, in the present study, catheter dislocation (46.1%) was the most common cause of non-infectious complication of PD. Surprisingly, we did not observe leakage in our series. Additionally, neither hydrothorax nor pericardial effusion nor hernia developed in our series.
Nevertheless, in the paediatric population, the results of catheter-related complications are different. Most of them reported that catheter-related infections were the main cause of PD catheter complication [1,10,14,18,19]. Others reported that non-infectious complications (especially leakage and catheter-malfunction) were the most common catheter-related complications [12,16]. The major complication of PD catheters during the follow-up period was catheter-related infections (exit-site and tunnel infections) in our study.
The principal major complication of percutaneous placement as a ‘blind’ technique is the risk of inadvertent puncture of the abdominal viscera [3,15]. In our study, we had no episode of bowel perforation despite the large number of PD catheters placed in the percutaneous technique.
Catheter survival in this report would seem to be comparable to that reported by other studies. In the paediatric literature, catheter survival rates were 78.1% at 12 months, 58.5% at 24 months and 34.6% at 48 months in the Italian registry [14]; 97% at 12 months, 92% at 24 months and 82% at 5 years in a study from Greece [18]; 83% at 3 years and 71% at 5 years in the Japanese registry [19]; and 95% at 12 months and 69% at 5 years in the Turkish registry [2]. In these studies, surgical placement was the main technique. One of the staff of our centre implanted the PD catheters through a percutaneous technique in the present study and our rates were similar with the Turkish registry. The most common reason for PD catheter removal (failure) in literature was infection [1,911,14,18]. In this study, unlike other paediatric studies, catheter malfunction was the most frequent catheter removal reason.
In the present study, patient survival rate was found to be lower than that in the Japanese [19], Italian [11] and American [20] series. Our rates were similar to the Turkish registry and better than the Indian series [12]. It can be speculated that PD was preferred as the most reasonable dialytic modality for critically ill patients, which partly contributes to this high mortality rate in our series [2].
In fact, in younger children, the incidence of catheter-related infections (exit-site/tunnel infections) is much higher [1,14]. Similarly, we found that younger children were associated with a higher risk for catheter-related infections. But, we did not observe increased risk of peritonitis with young ages. In our study, young age added no additional risk to the complications of leakage or catheter malfunction like in other paediatric studies [2,14].
Although technique survival was found to be shorter in children younger than 2 years of age compared with those older than 10 years of age, we did not find any statistically significant difference between the age groups. However, on analysing catheter survival in young children, worse catheter survival rate was observed in literature [2,14]. The small numbers of patients in the younger age group may be related to this result in our series.
Immobilization of the catheter in the post-operative period and delayed use of the PD has been employed to reduce catheter-associated infection. The impact of delaying the use of PD catheters is not well established [1,16]. Early or delayed use of PD catheters is a risk factor for dialysate leak [1,21]. However, catheter-related infections and leakage were the two major complications in our study; time for initiation of PD added no additional risk to the catheter complications and catheter survival rates between early and delayed use groups were not statistically significant. Catheter malfunction was the second most common non-infectious complication but its risk was not different between early and delayed use groups in our study.
To evaluate our cumulative experience, we compared the two follow-up periods. No significant differences in PD-related infections were observed between the two follow-up periods. But, the rate of catheter dislocation in period 2 was significantly lower than in period 1. In period 2, catheter survival rate was found to be better than in period 1. However, this difference was not statistically significant. In our opinion, the similar results in infection rate could be related to standardized and precise implantation technique and post-implantation care by the same team in both follow-up periods. The significant improvement in the catheter dislocation rate indicates the progressive increase in experience in percutaneous implantation technique by the paediatric nephrology staff. The longer catheter survival rate in period 2 could be a natural result of our desire to pay more precise attention to details for more successful catheter implantation and care.
Nephrologists should make the critical decisions regarding the choice of access devices and methods for placement [3]. Asif et al. [22] showed that, the average time interval between first contact and actual placement of a PD catheter by a nephrologist is shorter than referral to a surgeon. So, an interventional nephrology (IN) education program can have a dramatic impact on patient choice and PD growth. Percutaneous placement of PD catheters by nephrologists is convenient, can be performed anywhere in a hospital, and have the advantage of being low cost. This blind technique is a well-tolerated, rapidly performed bedside procedure that allows a rapid initiation of CPD [3,15].
The performance of nephrology-related procedures by interventional nephrologists is a significant advance leading towards the optimal care of patients with renal disease. Recent data demonstrate that a nephrologist with proper training can perform these procedures safely and effectively [6]. The involvement of many players (radiologists, surgeons) has fragmented medical care and has resulted in delays in medical procedures that have compromised patient care and satisfaction. Nephrologists aware of this situation have sought formal training in many of these procedures and have introduced a new paradigm of nephrology care, the IN [23]. The American Society of Diagnostic and Interventional Nephrology (ASDIN) has established accreditation guidelines for training centres and certification guidelines for individual physicians to obtain the necessary skills in PD catheter placement [24]. In recommendations for the training of European paediatric nephrologists by the European Society for Paediatric Nephrology, define a paediatric nephrologist who can acquire the application of PD, haemodialysis, and related techniques [25]. There is also a need to develop innovative training programs for paediatric nephrology skills in developing countries. The trainees should acquire skills for application of PD and related techniques, together with peritoneal and vascular access for acute and chronic problems [26]. Nephrology practices are moving towards total dialysis care. In our opinion, similarly with this trend, a paediatric nephrologist who follows-up the children with ESRD must act as an interventional nephrologist. Therefore, the skill for placement and removal of the PD catheter, like other interventions related with ESRD, must be part of the paediatric nephrologist training.
In conclusion, we believe that this study of percutaneously placed PD catheters demonstrates that, in the hands of experienced nephrologists and CPD nurses, with proper education and training of CPD patients, and the percutaneous technique is a reliable, safe and cost-effective method for placement of PD catheters.
Conflict of interest statement. None declared.
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Accepted in revised form: 27. 2.07
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