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In the present study, we examined the risk factors and causes for removal of the
peritoneal dialysis (PD) catheter in patients on continuous ambulatory PD (CAPD).
Data were collected from the records of patients who received CAPD therapy from
1995 to 2007 in the Department of Nephrology, Saitama Medical University. During
that time, 473 patients were introduced onto CAPD therapy and the PD catheter was
removed from 63 patients. Catheters were removed in 30 patients (47%) because
of peritoneal infection, in 11 (17%) because of dialysis failure, in 8 (13%) because
of neoplasm of the gastrointestinal tract, in 6 (10%) because of perforation of the
gastrointestinal tract, in 2 (3%) because of laceration of PD catheter, and in 3 each
(5%) because of transplantation and home hemodialysis therapy. Duration of CAPD
was 5.6 +/- 1.2 years. In patients who experienced peritoneal infection, causative
organisms were Staphylococcus (mainly methicillin-resistant S. aureus), Candida,
Pseudomonas, and non tuberculous Mycobacterium. Failure to continue PD therapy
related to dialysis deficiency. All patients were examined for encapsulating
peritoneal sclerosis (EPS) by computed tomography (CT) enhanced using contrast
material. In 9 cases in which the CT findings indicated EPS, treatment with oral
prednisolone (20 mg daily) was started; the dose was then gradually reduced over
1 year. After removal of the PD catheter, no patient developed EPS. All removed
catheters were examined using electron microscopy. The catheters from patients
who experienced PD peritonitis revealed biofilm formation; however, no biofilm
formation was found in PD catheters removed from patients without infection.
Despite appropriate antibiotic therapy, peritoneal infection remains the major cause
of PD catheter removal. Biofilm formation might be an obstacle to PD continuation.
Goh YH.
Ogunc G.
Crabtree JH.
Twardowski ZJ.
The first peritoneal accesses were devices that had been used in other fields
(general surgery, urology, or gynecology): trocars, rubber catheters, and sump
drains. In the period after World War II, numerous papers were published with
various modifications of peritoneal dialysis. The majority of cases were treated with
the continuous flow technique; rubber catheters for inflow and sump drains for
outflow were commonly used. At the end of the 1940s, intermittent peritoneal
dialysis started to be more frequently used. Severe complications of peritoneal
accesses created incentive to design accesses specifically for peritoneal dialysis. The
initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel
for the first time designed a soft, polyvinyl intraperitoneal tube with metal weights
to keep the catheter tip in the pelvic gutter where the conditions for drain are the
best. In the 1950s, intermittent peritoneal dialysis was established as the preferred
technique; polyethylene and nylon catheters became commercially available and
peritoneal dialysis was established as a valuable method for treatment of acute
renal failure. The major breakthrough came in the 1960s. First of all, it was
discovered that the silicone rubber was less irritating to the peritoneal membrane
than other plastics. Then, it was found that polyester velour allowed an excellent
tissue ingrowth creating a firm bond with the tissue. When a polyester cuff was
glued to the catheter, it restricted catheter movement and created a closed tunnel
between the integument and the peritoneal cavity. In 1968, Tenckhoff and
Schechter combined these two features and designed a silicone rubber catheter with
a polyester cuff for treatment of acute renal failure and two cuffs for treatment of
chronic renal failure. This was the most important development in peritoneal access.
Technological evolution never ends. Multiple attempts have been made to eliminate
remaining complications of the Tenckhoff catheter such as exit/tunnel infection,
external cuff extrusion, migration leading to obstruction, dialysate leaks, recurrent
peritonitis, and infusion or pressure pain. New designs combined the best features
of the previous ones or incorporated new elements. Not all attempts have been
successful, but many have. To prevent catheter migration, Di Paolo and his
colleagues applied the old idea of providing weights at the catheter tips to Tenckhoff
catheters. In another modification, Twardowski and his collaborators created a
permanent bend to the intra-tunnel portion of the silicone catheter to eliminate cuff
extrusions. The Tenckhoff catheter continues to be widely used for chronic
peritoneal dialysis, although its use is decreasing in favor of swan-neck catheters.
Soft, silicone rubber instead of rigid tubing virtually eliminated such early
complications as bowel perforation or massive bleeding. Other complications, such
as obstruction, pericatheter leaks, and superficial cuff extrusions have been
markedly reduced in recent years, particularly with the use of swan-neck catheters
and insertion through the rectus muscle instead of the midline. However, these
complications still occur, so new designs are being tried.
[Article in Japanese]
The introduction of a double-cuff swan neck type catheter has reduced the
frequency of peritonitis. The frequency of complications associated with insertion of
this catheter has remained unknown. We evaluated these complications in patients
aged < 20 years at the start of the chronic peritoneal dialysis using double-cuff
swan neck catheters. SUBJECTS AND METHODS: The data from 221 double-cuff
swan neck catheters of 126 patients inserted in our hospital between 1990 and
2001 were compared with 102 single-cuff straight catheters of 54 patients between
1982 and 1990. The frequency of catheter-related complications, such as
dislocation, leakage with in/outflow malfunction and infection(exit-site/tunnel
infection and peritonitis within a month after catheter insertion) were estimated.
RESULTS: We observed 37 dislocations(17%), 37 leakages(17%) and 36
infections(16%) of all double-cuff swan neck catheters. Twenty-nine catheters were
removed due to catheter-related complications: 18 dislocations(8%), 2
leakages(1%) and 9 infections(4%). Catheter removal due to dislocation occurred
significantly more frequently in 12% of children who were > or = 6 years old than in
1% of children < 6 years old(p = 0.002). Eighty-three percent of dislocations could
be returned by the whiplash method(alpha-replacer, JMS, Tokyo). Of all single-cuff
straight catheters, 10 catheters were removed due to catheter-related
complications: 4 dislocations(4%), 6 leakages(6%) and 12 infections(12%).
CONCLUSION: A single-cuff straight type catheter was more frequently replaced
because of leakage and infection than a double-cuff swan neck type catheter. A
double-cuff swan neck catheter was more frequently replaced because of dislocation
than a single-cuff straight catheter. When a double-cuff swan neck catheter is
inserted particularly in older children, care should be taken to avoid dislocation.
Cochrane Renal Group, Centre for Kidney Research, NHMRC Centre for Clinical Research
Excellence in Renal Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead,
2145, NSW, Australia. gfmstrippoli@katamail.com
Cochrane Renal Group, Centre for Kidney Research, NHMRC Centre for Clinical Research
Excellence in Renal Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead,
2145, NSW, Australia. gfmstrippoli@katamail.com
Bonifati C, Pansini F, Torres DD, Navaneethan SD, Craig JC, Strippoli GF.
St Vincent's Hospital, Nephrology, Level 4, Clinical Sciences Building, Fitzroy, VIC, Australia,
3065. kwiggins@medstv.unimelb.edu.au
Randomized, double-blind trial of antibiotic exit site cream for prevention of exit
site infection in peritoneal dialysis patients.
Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents
Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce
Pseudomonas aeruginosa or other Gram-negative infections, which are associated
with considerable morbidity and sometimes death. Patients from three centers (53%
incident to PD and 47% prevalent) were randomized in a double-blinded manner to
daily mupirocin or gentamicin cream to the catheter exit site. Infections were
tracked prospectively by organism and expressed as episodes per dialysis-year at
risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin
cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr
with mupirocin (P = 0.005). Time to first catheter infection was longer using
gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using
gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site
infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis
rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gram-
negative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared
with mupirocin cream, respectively. Gentamicin use was a significant predictor of
lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P
< 0.03), controlling for center and incident versus prevalent patients. Gentamicin
cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and
other Gram-negative catheter infections and reduced peritonitis by 35%,
particularly Gram-negative organisms. Gentamicin cream was as effective as
mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site
should be the prophylaxis of choice for PD patients.
Piraino B.
Piraino B.
Peritoneal dialysis related infections include infection of the catheter exit site,
subcutaneous pathway, or effluent. Exit-site infections, predominately owing to
Staphylococcus aureus, are defined as purulent drainage at the exit site, although
erythema may be a less serious type of exit-site infection. Tunnel infections are
underdiagnosed clinically, and sonography of the tunnel is useful to delineate the
extent of the infection and to evaluate response to antibiotic therapy. S aureus
infections occur more frequently in S aureus carriers and immunosuppressed
patients and can be reduced by mupirocin prophylaxis either intranasally or at the
exit site. Patients with peritonitis present with cloudy effluent and usually pain,
although 6% of patients may initially have pain without cloudy effluent. A white
blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear
cells, has long been the hallmark of peritonitis. Empiric therapy is controversial,
with some recommending cefazolin and others vancomycin (with cefatazidime for
Gram-negative coverage). The choice should depend on the center's antibiotic
sensitivity profile; those centers with a high rate of Enterococcus- or methicillin
resistant organisms should use vancomcycin. Peritonitis episodes occurring in
association with a tunnel infection with the same organism seldom resolve with
antibiotics and require catheter removal. Other indications for catheter removal are
refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff
involvement that does not respond to antibiotic therapy (based on ultrasound
criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal
pathology. Centers can reduce dialysis related infections to very low levels by
proper catheter selection and insertion, careful selection and training of patients,
avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus.
Further research is required to identify methods to reduce the risk of enteric
peritonitis. Copyright 2000 by the National Kidney Foundation, Inc.
OBJECTIVE: To propose guidelines for treatment based on the study of early and
late outcome after various surgical procedures for sclerosing encapsulating
peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication
is intestinal obstruction. Ideal treatment is resection of the membrane, whenever
possible. Mortality and morbidity, however, have not been well analyzed. METHODS:
The case records and histopathological reports of 32 operated cases of SEP (18
centers during 16 years) were retrospectively studied. Patients underwent four
types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12),
enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal
resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were
considered as idiopathic. Medical and surgical antecedent history for the 27 other
cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or
benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4),
generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n =
3). Indications for operation included subacute (n = 22) or acute intestinal
obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4)
and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1).
Seven patients had two associated clinical presentations. All cirrhotic patients with
ascites and the asymptomatic patient were in group 4. None of the imaging
techniques (plain radiograms, barium follow-through, sonograms and CT scans)
were formally contributive to the preoperative diagnosis of SEP. RESULTS: In group
1, both complicated patients, one with an inadvertent intraoperative intestinal
wound, the other with a postoperative intestinal leak, healed uneventfully. In group
2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3
consequent deaths. One further patient died of persistent intestinal obstruction. In
group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2
deaths, one due to persistent intestinal obstruction associated with anastomotic
leakage and the other due to ventricular fibrillation, were noted. In group 4, there
were no intraoperative wounds, no postoperative morbidity or deaths. The median
follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each
group) experienced transient episodes of subacute intestinal obstruction between 1
month and 6 years after discharge, none of which required a repeat operation. Eight
patients (in all groups) died of their initial cancer between 4 and 75 months after
discharge. CONCLUSIONS: Our results suggest that: (1) resection of the membrane
should be attempted when feasible; (2) in case of inadvertent intestinal wound(s),
the most proximal one should be brought out as a stoma, and partial resections
should not be anastomosed primarily, but (3) no surgical treatment is required in
ascites, asymptomatic SEP or subacute intestinal obstruction.
Tzamaloukas AH, Gibel LJ, Eisenberg B, Goldman RS, Kanig SP, Zager PG,
Elledge L, Wood B, Simon D.
Dialysate leaks, which occurred in 386 CAPD patients over 11 years, were analyzed
retrospectively. 18 patients developed 21 early leaks (within 30 days of catheter
insertion) and 18 patients developed 28 late leaks (beyond 30 days of catheter
insertion). 8 patients had multiple (2-6) leaks. Both early and late leaks, particularly
if they were multiple, were associated with conditions that affect adversely tissue
healing and tensile strength. Median surgical insertion was apparently associated
with a higher incidence of early leaks. Early leaks were manifested externally,
usually through the exit site, and did not require imaging. Late leaks were
manifested usually by poor dialysate outflow, localized edema and subcutaneous
fluid collections. One third of the late leaks required radiological imaging. Hernias
caused 42% of the late leaks. Early leaks were managed by temporary
discontinuation of CAPD alone (57%) or surgery. Most late leaks (67%) required
surgery. Conservative means (change to IPD, observation) were applied for the
management of a few late leaks. Both early and late leaks resulted frequently in
replacement of peritoneal catheters, but only late leaks resulted in permanent
discontinuation of peritoneal dialysis. Paramedian surgical insertion, waiting period
of 10-14 days between catheter insertion and initiation of CAPD, and low starting
dialysate volumes have resulted in apparent reduction of the incidence of the early,
but not of the late leaks. Dialysate leaks have serious consequences on the
performance of CAPD. Early leaks differ from late leaks in some clinical
manifestations. Preventive measures have decreased the incidence of early, but not
of the late leaks.
Del Peso G, Bajo MA, Costero O, Hevia C, Gil F, Díaz C, Aguilera A, Selgas R.
BACKGROUND: Patients treated with peritoneal dialysis (PD) have increased intra-
abdominal pressure and a high prevalence of abdominal wall complications.
OBJECTIVE:The purpose of this study was to determine the incidence of hernias and
peritoneal leaks in our PD patients and to investigate their potential risk factors.
PATIENTS: We studied 142 unselected patients treated with PD during the past 5
years, including those that were already on PD and those that started PD during this
period. Mean age was 54 years and mean follow-up on PD was 39 months. 72
patients had been treated with only continuous ambulatory PD (CAPD), 8 with
automated PD (APD), and 62 with both modalities. RESULTS: 53 patients (37%)
developed hernia and/or leak. A total of 39 hernias and 63 leaks were registered.
The overall rates were 0.08 hernias/patient/year and 0.13 leaks/patient/year. 17
patients had both abdominal complications. Hernia was most frequently located in
the umbilical region, and the most frequent site of leakage was the pericatheter
area. Both complications appeared more frequently during the CAPD period (87% of
hernias, 81% of leaks). The rate of hernias was higher in patients treated only with
CAPD than in those that used only cyclers [0.08 vs 0.01 hernias/patient/year, not
significant (NS)]. No patient treated only with APD had peritoneal leak; 25%
(18/72) of patients treated with CAPD developed this complication (p = 0.18, NS).
Dialysate exchange volumes ranged from 2000 to 2800 mL. 25 (66%) patients
required surgical repair of the hernia, with recurrence in 7 patients (28%). 27
(84%) patients with leaks were initially treated with transitory temporary transfer to
hemodialysis, low volume APD, or intermittent PD for 4 weeks. The leak recurred in
half of the cases and surgical repair was necessary in 12 cases. The development of
hernia and/or leak did not correlate with gender, diabetes, duration of follow-up,
type of PD, history of abdominal surgery, or with the largest peritoneal exchange
volume used. Polycystic kidney disease was the only factor associated with higher
rate of hernias (p = 0.005), whereas increased age (p = 0.04) and higher body
mass index (p = 0.03) were significantly associated with the appearance of leaks.
CONCLUSION: Abdominal hernias and peritoneal leaks are very frequent in the PD
population. Advanced age, polycystic kidney disease, and high body mass index are
independent risk factors for their development. Automated PD with low daytime fill
volume should be considered in all patients at risk for hernias and/or leaks.
Links
Department of Medicine III, Division of Nephrology and Dialysis, Medical University Vienna,
Vienna, Austria. andreas.vychytil@meduniwien.ac.at
New Haven CPD, Renal Research Institute, St Raphael's Hospital, Yale University School of
Medicine, New Haven, CT 06511, USA.
The role of tidal peritoneal dialysis (TPD) has been the subject of several studies
over the past 30 years. The use of the newest generation of cyclers combined with
the increasing number of chronic peritoneal dialysis (CPD) patients being
maintained on cycler therapy has stimulated a reexamination of the role of TPD in
the care of CPD patients. Several studies over the past decade have examined
solute clearances with TPD in patients. These studies suggest that TPD does not
result in an increase in clearances when compared to conventional intermittent
peritoneal dialysis (IPD). TPD is now primarily used for comfort in patients who
experience pain at the start of inflow and/or at the end of outflow. In TPD, the
presence of at least some fluid in the abdomen during the exchanges generally
eliminates these episodes of pain. It has recently been suggested that accurate
assessment of drain and fill phases during automated PD may be helpful in
redefining a role for TPD in CPD patients. If the 'slow' drainage time can be kept to
a minimum, then it is possible that the efficiency of PD could be enhanced. Defining
the critical volume and then optimizing the TPD regimen could perhaps increase the
clearances noted with TPD.
Piraino B.
Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Piraino@pitt.edu
Flanigan M, Gokal R.
OBJECTIVE: This review updates the 1998 International Society for Peritoneal
Dialysis (ISPD) recommendations for peritoneal dialysis catheters and exit-site
practices (Gokal R, et al. Peritoneal catheters and exit-site practices toward
optimum peritonealaccess: 1998 update. Perit Dial Int 1998; 18:11-33.) DESIGN:
DATA SOURCES: The Ovid and PubMed search engines were used to review the
Medline databases of January 1980 through June 2003. Searches were restricted to
human data; primary key word searches included dialysis, peritoneal dialysis, and
continuous ambulatory peritoneal dialysis cross referenced with access, catheter,
dialysis catheter, peritoneal dialysis catheter, and Tenckhoff catheter. Related
searches were provided via the PubMed related articles link. Study Selection:
Reports were selected if they provided identifiable information on catheter design,
catheter placement technique, and survival or placement complications. Reports
without such data were excluded from review. Each study was then categorized by
its characteristics: single-center or multicenter; retrospective or prospective;
controlled trial, with or without random patient assignment; or review article. MAIN
RESULTS: There are few randomized controlled evaluations testing how catheter
design and/or placement influence long-term survival and function, and these are
typically conducted at a single center. The majority of reports represent
retrospective single-center experiences, and these are supplemented by occasional
multicenter data registries. CONCLUSIONS: There is substantial variability in
catheter outcomes between centers, and this variability is more closely correlated
with operator and center characteristics than with catheter design. Some catheter
designs appear to impact long-term catheter success, and, in some cases, specific
patient characteristics and dialysis formats combine with specific catheter designs to
influence catheter survival. Most reporters prefer two-cuff designs and placement of
the deep cuff at an intramuscular location. Intramuscular cuff placement results in
fewer pericatheter leaks and hernias, but makes catheter removal more difficult.
High-risk patients (those with previous pelvic surgery) benefit from visual inspection
of the peritoneum during catheter placement, and in randomized controlled trials,
catheters with pre-shaped arcuate subcutaneous segments ("swan neck" designs)
reduce the risk of early drainage failure via "migration."
The Tenckhoff catheter was developed in 1968 and has been widely used since for
chronic peritoneal dialysis (PD) patients. Variations of the Tenckhoff catheter have
been designed over the years in a search for the ideal PD catheter--an access that
can provide reliable dialysate flow rates with few complications. Currently, data
derived from randomized, controlled, multicenter trials dedicated to testing how
catheter design and placement technique influence long-term catheter survival and
function are scarce. As a result, no firm guidelines exist at the national or
international levels on optimal PD catheter type or implantation technique. Also, no
current statistics on the use of PD catheters are available. The last survey was
carried out using an audience response system at the Annual Peritoneal Dialysis
Conference in Orlando, Florida, in January 1994. The present analysis is based on a
new survey done at the 2005 Annual Dialysis Conference in Tampa, Florida. It is a
snapshot of preferences in catheter design and implantation technique in 2004 from
an international sample of 65 respondent chronic PD centers. The Tenckhoff
catheter remains the most widely used catheter, followed closely by the swan-neck
catheter in both adult and pediatric respondent centers. Double-cuff catheters
continue to be preferred over single-cuff catheters, and coiled intraperitoneal
segments are generally preferred over straight intra-peritoneal segments. Surgical
implantation technique remains the prevailing placement method in both pediatric
and adult respondent centers.
Twardowski ZJ.
The first peritoneal accesses were devices that had been used in other fields
(general surgery, urology, or gynecology): trocars, rubber catheters, and sump
drains. In the period after World War II, numerous papers were published with
various modifications of peritoneal dialysis. The majority of cases were treated with
the continuous flow technique; rubber catheters for inflow and sump drains for
outflow were commonly used. At the end of the 1940s, intermittent peritoneal
dialysis started to be more frequently used. Severe complications of peritoneal
accesses created incentive to design accesses specifically for peritoneal dialysis. The
initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel
for the first time designed a soft, polyvinyl intraperitoneal tube with metal weights
to keep the catheter tip in the pelvic gutter where the conditions for drain are the
best. In the 1950s, intermittent peritoneal dialysis was established as the preferred
technique; polyethylene and nylon catheters became commercially available and
peritoneal dialysis was established as a valuable method for treatment of acute
renal failure. The major breakthrough came in the 1960s. First of all, it was
discovered that the silicone rubber was less irritating to the peritoneal membrane
than other plastics. Then, it was found that polyester velour allowed an excellent
tissue ingrowth creating a firm bond with the tissue. When a polyester cuff was
glued to the catheter, it restricted catheter movement and created a closed tunnel
between the integument and the peritoneal cavity. In 1968, Tenckhoff and
Schechter combined these two features and designed a silicone rubber catheter with
a polyester cuff for treatment of acute renal failure and two cuffs for treatment of
chronic renal failure. This was the most important development in peritoneal access.
Technological evolution never ends. Multiple attempts have been made to eliminate
remaining complications of the Tenckhoff catheter such as exit/tunnel infection,
external cuff extrusion, migration leading to obstruction, dialysate leaks, recurrent
peritonitis, and infusion or pressure pain. New designs combined the best features
of the previous ones or incorporated new elements. Not all attempts have been
successful, but many have. To prevent catheter migration, Di Paolo and his
colleagues applied the old idea of providing weights at the catheter tips to Tenckhoff
catheters. In another modification, Twardowski and his collaborators created a
permanent bend to the intra-tunnel portion of the silicone catheter to eliminate cuff
extrusions. The Tenckhoff catheter continues to be widely used for chronic
peritoneal dialysis, although its use is decreasing in favor of swan-neck catheters.
Soft, silicone rubber instead of rigid tubing virtually eliminated such early
complications as bowel perforation or massive bleeding. Other complications, such
as obstruction, pericatheter leaks, and superficial cuff extrusions have been
markedly reduced in recent years, particularly with the use of swan-neck catheters
and insertion through the rectus muscle instead of the midline. However, these
complications still occur, so new designs are being tried.
PMID: 16485237 [PubMed - indexed for MEDLINE]
Mitra A, Teitelbaum I.
[Article in Italian]
De Vecchi AF.
Evaluation of peritoneal catheters is based on the material, the number and type of
cuffs, the length and intraperitoneal shape of the catheter, and its site of insertion.
Final cost is another important issue which should take into account differences in
the incidence of complications, in the number of hospitalizations, and in the
simplicity of catheter insertion. Double-cuff catheters are used more than single-cuff
catheters. The most commonly used catheter shapes are the classical Tenckhoff, the
swan neck, the coil, and self-locating catheters. The latter are more expensive than
Tenckhoff catheters but seem to offer some advantages, even if not sustained by
adequate controlled trials so far. In addition, placement of these catheters may
require different techniques or skills compared to the classical Tenckhoff. The most
recent Italian guidelines based only on grade 1 and 2 evidence exclude that the
type of catheter may influence the infection rate. There are no data from
prospective controlled studies to evaluate the incidence of mechanical
complications, hospitalization and technique survival. With regard to dialysis
systems, it is still unclear if new plastic materials may offer any advantage over
PVC. There is grade 1 evidence that Y-set and double-bag systems reduce the
peritonitis rate compared to standard 1-way systems. The available data do not
indicate significant differences in the incidence of peritonitis using Y-set compared
with double-bag systems. The higher cost of double-bag systems is counteracted by
shorter and easier training and by better acceptance by the patients.