Effect of Prolonged Subcutaneous Implantation of Peritoneal Catheter on Peritonitis Rate during CAPD: A Prospective Randomized Study

Abstract

We conducted a prospective randomized controlled study to confirm our earlier observation that prolonged subcutaneous implantation of peritoneal catheter reduced peritonitis rate when compared to retrospective data from patients with catheters placed by conventional access technique. A total of 60 patients were randomized into two groups: 30 patients had catheters left implanted subcutaneously for 6 weeks (I) and the other 30 patients had catheters inserted by conventional technique and had 6 weeks of break-in period (C). Subgroups of 15 patients each with new and conventional techniques used Y-connector (IY, CY) and remaining patients used standard spikes (IS, CS).Mean age was 47.7 years (range 16–71); 61.0% were male and 44.1% diabetics. Peritonitis, exit site infection, simultaneous peritonitis and exit site infection, and complication related to Staphylococcus or Pseudomonas infections were observed for up to 2 years in each patient after initiation of bag exchange or until termination of CAPD by transfer to hemodialysis or by death.Total duration of observation was 493.2 patient-months for new access technique and 409.6 patient-months for conventional technique. Patients in IY group had the lowest incidence of peritonitis (1/14.9 patient-months) and exit site infection (1/16.8 patient-months) among four subgroups. Peritonitis rate in IY was significantly lower compared to CY or CS. The total peritonitis-free period in those patients who did not experience peritonitis during the observation period was also significantly longer in IY (120 patient-months) than in CY (26 patient-months), IS (10.6 patient-months), or CS (10.4 patient-months). Simultaneous peritonitis and exit site infection was observed in none of IY group but 3 episodes in CY, 4 episodes in IS, and 3 episodes in CS. The rates of complications related to Staphylococcus aureus and Pseudomonas infections were also significantly lower in IY than in CY, IS, or CS. Technique survival did not differ between the two groups.The present results confirm our previous observation that the new access technique reduces the incidence of peritonitis probably by reducing infection via periluminal route. The Y-connector system further reduces peritonitis rate by reducing infection via intraluminal route.

Complications and catheter survival with prolonged embedding of peritoneal dialysis catheters

“…Moncrief and colleagues first promoted the technique of embedding catheters as a means of reducing the risk of peritonitis by allowing the subcutaneous portion of the catheter to heal in a sterile field. This hypothesis was supported by initial data of retrospective and non-randomized nature [2][3][4][5][6], but was not confirmed by randomized controlled trials [7,8]. Our data raise the possibility that the standard healing time of 4-6 weeks used in these studies may not be long enough to allow for an optimal antimicrobial barrier to form.…”

“…This technique calls for burying the free end of the PD catheter under the skin and leaving it embedded for 4-6 weeks before exteriorization to allow for ingrowth of tissue around the superficial cuff in a sterile environment. While there are conflicting data about the efficacy of this method in reducing rates of peritonitis [2][3][4][5][6][7][8][9][10], it does clearly provide for early and anticipatory creation of a PD access in much the same way as does an arteriovenous (AV) fistula for haemodialysis [11].…”

A Prospective Study to Compare Subcutaneously Buried Peritoneal Dialysis Catheter Technique with Conventional Technique

“…Because the MPC has not been readily available, some investigators have substituted a double-cuffed swan-neck catheter with a middle arcuate bend instead, and have reported similar results [10,11] . In our study, we used MP techniques to implant swan-neck Tenckhoff catheters in some of our patients to see if these patients would have a similar reduction in PD-related infections.…”

Catheter-Related Interventions to Prevent Peritonitis in Peritoneal Dialysis

“…The first were studies of surgical approaches for the insertion of the PD catheter. There were eight trials in total (601 patients), of which three (248 patients) compared insertion of the catheter with laparoscopy versus laparotomy, three (233 patients) compared the effect of subcutaneous burying and resting of the catheter for 6 wk versus standard insertion (resting but no subcutaneous burying of catheter), and two (120 patients) compared midline versus lateral insertion (17)(18)(19)(20)(21)(22)(23)(24). The second group of studies compared the use of straight versus coiled catheters.…”