Catheter-Related Interventions to Prevent Peritonitis in Peritoneal Dialysis

Abstract

Abstract. As many as 15 to 50% of end-stage kidney disease patients are on peritoneal dialysis (PD), but peritonitis limits its more widespread use. Several PD catheter-related interventions (catheter designs, surgical insertion approaches, and connection methods) have been purported to reduce the risk of peritonitis in PD. The goal was to assess the trial evidence supporting their use. The Cochrane CENTRAL Registry, MEDLINE, EMBASE, and reference lists were searched for randomized trials of catheter types and related interventions in PD. Two reviewers extracted data on the rates of peritonitis and exit-site/tunnel infection, catheter removal/replacement, technique failure, and all-cause mortality. Analysis was by a random effects model, and results are expressed as relative risk and 95% confidence intervals. Thirty-seven eligible trials (2822 patients) were identified: eight of surgical strategies of catheter insertion, eight of straight versus coiled catheters, 10 of Y-set versus conventional spike systems, four of Y-set versus double-bag systems, and seven of other interventions. Despite the large total number of patients, few trials covered the same interventions, small numbers of patients were enrolled in each trial, and the methodologic quality was suboptimal. Y-set and twin-bag systems were superior to conventional spike systems (seven trials, 485 patients; relative risk, 0.64; 95% confidence intervals 0.53 to 0.77), and no other catheter-related intervention was demonstrated to prevent peritonitis in PD. This systematic review demonstrates that of all catheter-related interventions designed to prevent peritonitis in PD, only disconnect (twin-bag and Y-set) systems have been proved to be effective (compared with conventional spike systems). Despite the importance of PD as a renal replacement therapy modality and the large number of patients who receive it, it is still not known whether any particular PD catheter designs, implantation techniques, or modalities are effective, given the limitations of available trials.

ISPD Position Statement on Reducing the Risks of Peritoneal Dialysis–Related Infections

“…Manual spiking should be avoided as much as possible; if spiking is required, assist devices may be used. A systematic review concluded that of all catheter-related interventions designed to prevent peritonitis in PD, only disconnect (twin-bag and Y-set) systems have been proved to be effective (compared with conventional spike systems) (58). Close attention must therefore be paid to the connection methodology.…”

“…"Flush before fill" reduces the risk of contamination (51)(52)(53)(54)(55)(56)(57)(58) Data to show that spiking leads to peritonitis are abundant. Furthermore, for both CAPD and APD, flushing with dialysate before filling the abdomen has been shown to decrease the risk of peritonitis from contamination.…”

Peritoneal Dialysis: A Primary Care Perspective

“…Thus peritonitis remains the most important complication and a leading cause of hospitalization and technique failure. 16 Despite significant improvement in the incidence, peritonitis rates of Ͼ0.5 episodes per patient per year are still common. 16 Peritonitis presents with abdominal pain, fever, and cloudy dialysate containing more than 100 white cells/mm 3 with greater than 50% polymorphonuclear leukocytes.…”

“…16 Despite significant improvement in the incidence, peritonitis rates of Ͼ0.5 episodes per patient per year are still common. 16 Peritonitis presents with abdominal pain, fever, and cloudy dialysate containing more than 100 white cells/mm 3 with greater than 50% polymorphonuclear leukocytes. 17 Most cases of peritonitis can be treated on an out-patient basis by intraperitoneal antibiotics.…”

Growing a peritoneal dialysis program: A single‐center experience

“…30 No signifi cant difference in risk of peritonitis has been observed with the design of catheters, surgical techniques used to place the catheters (laparoscopic versus open surgical), or location of catheter exit sites (pre-sternal or abdominal). 31,32 Quality improvement initiatives in PD, using a comprehensive approach that includes use of prophylactic antibiotics for peritonitis, exit site and catheter care, and training and retraining of patients can go long way in having positive effects on reducing rates of peritonitis and exitsite infection. PD outcomes can be further improved by implementation of continuous quality improvement (CQI) programs to track the root cause of peritonitis as well as rates of exit-site infection, peritonitis, and technique failure by careful data collection and providing feedback to the PD team so that appropriate interventions can be implemented.…”