IMPLANTE DE CATÉTER PARA DP PELO NEFROLOGISTA

IMPLANTE  DE    

CATÉTER  PARA  DP    

PELO  NEFROLOGISTA

Domingos Candiota Chula

Hospital  Universitário  Evangélico  de  Curi7ba   Hospital  de  Clínicas  da  UFPR  

Brasil  2012  

•

Aproximadamente   97.000   pacientes   em   diálise  

(es7ma7va).    

•

8,4% em Diálise Peritoneal.

•

50% dos pacientes preferem DP.

Schreiber MJ - JASN 2001 Shabass B - JASN 2000

Algumas  jus7fica7vas…  

•  Dificuldades  técnicas  e  logís7cas  para  realizar  os  implantes  dos   catéteres  peritoneais.  

•  Tempo  de  espera  necessário  entre  a  admissão  do  paciente  e  o   implante  cirúrgico.  

•  Baixa  prevalência  da  confecção  de  um  acesso  adequado  antes  da   indicação  de  diálise.  

•  Complicações  relacionadas  ao  catéter  e  sua  implantação:  5  a  

10%  das  transferências  de  pacientes  para  HD.                

“Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal 


dialysis access program.”


Asif A et al. 


Seminars in Dialysis 16:266-271, 2003


Tempo médio da admissão do paciente até o implante:

•  Nefrologista: até 7 dias.

•  Cirurgião: 7 a 14 dias, demorando até 4 semanas.

Aumento de 86% no número de pacientes em DP com a equipe da Nefrologia Intervencionista!

“Interventional Nephrology in Brazil: 
 Current and Future Status”


Nascimento MM, Chula DC, Campos RP, Nascimento DE, Riella MC
 Seminars in Dialysis – Vol 19, No 2 (March-April) 2006

•

56%  dos  nefrologistas  não  são  treinados  para  

implantar  catéteres  de  CAPD.  

•

3%  realizam  implantes  por  peritoneoscopia.  

•

12%  realizam  implantes  cirúrgicos.  

•

90%  dos  nefrologistas  têm  interesse  em  ser  

Quem  deve  implantar  o  catéter?  

•

  ISPD      

•

  K/DOQI      

•

  CSN      

•

  BRA  2002      

OPERADOR  COMPETENTE  E  

EXPERIENTE!

•

2005:  Treinamento  em  Nefrologia  

Intervencionista.  

•

2006:  1

Curso  de  Nefrologia  Intervencionista  

durante  o  1

 _{Congresso  Sul  Brasileiro  de}  

Nefrologia.  

•

2009:  Centro  de  Nefrologia  Intervencionista  

Preparo  pré-­‐operatório  

•

  Fleet  enema  ou  laxa7vos  e  an7-­‐fisé7cos  na  véspera.  

•

Jejum  de  12  horas  antes  do  procedimento.  

•

Profilaxia:  Keflin  1g  EV  –  1  hora  antes.  

•

Sedação  com  Midazolan  15mg  por  via  oral  ou  7,5mg  

Percutaneous and Surgical Insertion of Peritoneal Catheter in Patients Starting in Chronic Dialysis Therapy:

A Comparative Study

Domingos Candiota Chula,*† Rodrigo Peixoto Campos,* M!arcia Tokunaga de Alc^antara,* Miguel Carlos Riella,*‡ and Marcelo Mazza do Nascimento*†

*Centro de Nefrologia Intervencionista da Fundac! ~ao Pr!o-Renal de Curitiba, Curitiba, Brazil, †Departamento

de Clinica M!edica, Universidade Federal do Paran!a, Paran!a, Brazil, and ‡Pontif!ıcia Universidade Cat!olica do Paran!a, Paran!a, Brazil

ABSTRACT

Percutaneous peritoneal catheter insertion can be

performed by trained nephrologists. The objective of this study was to compare the outcome of peritoneal dialysis (PD) catheters percutaneous inserted with the traditional surgical technique. One hundred twenty-one PD cathe-ters were placed in 121 stage-5 Chronic kidney disease patients using three techniques: percutaneous insertion (Group P, n = 53), percutaneous insertion guided by radioscopy (Group R, n = 26), and surgical insertion (Group S, n = 42). The mean age of the whole cohort

was 57 _{! 16 years and 54% were male. Patients and}

catheter outcomes were followed up prospectively for 19 months. Gender, age, body mass index, previous

abdominal surgeries, and the prevalence of diabetes mell-itus were not significantly different among the groups as well as the incidence of bleeding and the presence of catheter dysfunction. In addition, the incidence of exit-site infections and peritonitis was not significantly differ-ent among the groups. Finally, the survival catheter rate was not significantly different by the end of the follow-up of 19 months (70% in P grofollow-up, 85% in R, and 70% in S group (log rank = 0.88, p = 0.95). The outcome of percutaneous implanted catheters, which were inserted by a trained nephrologist, did not demonstrate to be

inferior as compared with the traditional surgical

approach.

According to the latest Brazilian national dialysis census, it is estimated that less than 10% of all dialysis patients are in peritoneal dialysis (PD) treat-ment, and that this situation has not been modified during this last decade (1,2). One of the possible reasons to explain this scenario might rely on the technical and logistic difficulties in PD catheter insertions. The delay in PD catheter placement might be related to the absence of trained nephrolo-gists who are able to perform this procedure (3,4).

The traditional approach to PD catheter insertion is through the surgical technique, which is usually performed by a surgeon. More recently, percutane-ous insertion using a trocar device or by

peritoneos-copy have been reported and could be an

alternative to the traditional surgical insertion (5–7). In fact, other reports have shown that percutaneous PD catheter placement can be performed by a trained nephrologist, at patient’s “bedside,” which

could increase the number of patients in PD who could start renal replacement therapy (RRT) (7).

The aims of the present study were to compare three PD catheter insertion techniques: (i) percuta-neous technique; (ii) percutapercuta-neous technique guided by radioscopy; and (iii) surgical insertion performed by a trained surgeon. Patients and catheter out-comes as well as mechanical and infectious complications were prospectively evaluated.

Methods

Between June 1st, 2006 and January 1st, 2008, the Interventional Nephrology Group of Pro-Renal Foundation in Brazil implanted 129 PD catheters in chronic kidney disease (CKD) stage-5 patients who were initiating in RRT. The patients were distrib-uted into three groups according to the technique used for PD catheter insertion: Group P (percutane-ous technique), Group R (percutane(percutane-ous technique guided by radioscopic), and Group S (surgical tech-nique). The procedures were scheduled by our staff who had no access to patient and clinical informa-tion. The patients were allocated to Groups R and

Address correspondence to: Marcelo Mazza do Nasci-mento, Saldanha Marinho 1453, 80430-160 Curitiba, Paran!a, Brazil, e-mail: marcelomazza@ufpr.br.

Seminars in Dialysis—2013 DOI: 10.1111/sdi.12147

© 2013 Wiley Periodicals, Inc.

1

•

121  implantes  peritoneais:  

•

53  por  trocáter  “às  cegas”.  

•

26  por  trocáter  guiados  por  radioscopia.  

Disfunção  do  catéter

p=0,2

The main censoring causes were patient death,

transfer to HD, renal transplantation, transfer to

another PD center, catheter removal by abdominal

surgery, and partial recovery of renal function.

Statistical Analysis

Data were presented as mean

_{! standard}

devia-tion or medians and ranges, according to the

nor-mal distribution. The comparison between the two

groups was performed using the Student t-test for

normally

distributed

variables,

while

Mann–

Whitney test was used for variables with abnormal

distribution. The analysis of categorical variables

was performed with contingency tables using

chi-squared test. The Kaplan–Meier method was used

for survival analysis. To determine survival, patients

were followed up for a 19-month period until

cathe-ter removal or censoring. A p value of less than

0.05 was considered significant. The calculation of

the incidence of peritonitis episodes was made

according to recommendation of ISPD: PD months

divided by the number of peritonitis episodes. The

results were expressed as the monthly intervals

between episodes (10).

Results

Gender, age, BMI, presence of abdominal scars,

and a previous history of diabetes were not

signifi-cantly different among the three groups as shown in

Table 1.

No Infectious Complications

Bleeding of surgical wound requiring dressing

change within 24 hours after catheter insertion was

observed in 3 patients in Group P, 2 in Group R,

and 4 in Group S (p = 0.77). The most common

noninfectious complication in the three groups was

CD, which was observed in 24 patients (19.8%),

without a significant difference among the groups

(p = 0.20). The presence of CD was associated with

tip catheter displacement in 17 (70.1%) of the 24

cases.

Early CD was verified in twelve of the 24 patients

(50%). The incidence of this complication was not

different among the three groups (four patients in

Group P, five in Group R, and three in group S;

p = 0.19). Moreover, only 2 cases of CD (8.3%)

were observed in a period longer than 12 weeks

after the catheter insertion (one in Group P and the

other one in group S) (Fig. 1). The presence of

scars

from

previous

abdominal

surgeries

was

observed in 25 of the 121 patients (20.6%) and had

no influence on CD in the whole groups (p = 0.22).

Finally, there were no cases of intestinal

perfora-tion, massive peritoneal bleeding, suture dehiscence,

incisional hernia, extrusion of external sleeve, or

dialysate sequestration in subcutaneous tissue in

any group.

Infectious Complications

Regarding the incidence of exit-site infection,

there was no significant difference among the

groups. One surgical wound infection was present

in Group P, and two cases of subcutaneous tunnel

infection, one in Group R and the other one in

group S, were observed. Peritonitis was the most

frequent infectious complication in all groups with

an overall incidence of 1/29.5 episode months (0.40

episodes/patient-year). However, the incidence of

peritonitis did not differ among the groups (Group

S; 1/27.1 months Group P; 1/31.7 months, Group

S; 1/31.1 months (p = 0.43)). In the whole cohort,

only 3 episodes occurred in the first 4 weeks after

the procedure, (2 cases in group P and 1 case in

group S). No significant difference in the median

time that elapsed between catheter insertion and the

first episode of peritonitis was verified (17.3 (3–89)

weeks in group P, 24.8 (10.5–79) in group R, and

35.2 (2–114) in group S (p = 0.31)). Finally, there

was no significant difference in the number of

peri-tonitis episodes among the groups as shown in

Fig. 2.

Follow-up and Catheter Survival

Forty-six (38%) of the 121 patients in the study

had discontinuation of follow-up by censoring. The

main causes of censoring were: death (n = 20),

transfer to HD (not related to CD) (n = 10), kidney

transplantation (n = 8), transfer to another dialysis

center (n = 4), and catheter removal by abdominal

!"#$ %& !"#$% ' !"#$ % ( !"#$ % & !"#$ %' !"#$ %( ) * + , -$ . /0 " #1 2 % 34 # 50 4 %6)7)8

!"#$%

&"'(

Fig. 1. Early vs. late catheter dysfunction.

!"# $%9& !"#$ %9' !"# $% ( !"# $%9& !"#$ %9' !"# $%9( ) *) +) ,) :) ;)) )(#*'+,*'*- .+/)(#*'+,*'*-%6)<)8 2%34#5049#19%0"3=#>3=34

Fig. 2. Incidence of peritonitis in the three groups.

Incidência  de  peritonite

The main censoring causes were patient death,

transfer to HD, renal transplantation, transfer to

another PD center, catheter removal by abdominal

surgery, and partial recovery of renal function.

Statistical Analysis

Data were presented as mean

_{! standard}

devia-tion or medians and ranges, according to the

nor-mal distribution. The comparison between the two

groups was performed using the Student t-test for

normally

distributed

variables,

while

Mann–

Whitney test was used for variables with abnormal

distribution. The analysis of categorical variables

was performed with contingency tables using

chi-squared test. The Kaplan–Meier method was used

for survival analysis. To determine survival, patients

were followed up for a 19-month period until

cathe-ter removal or censoring. A p value of less than

0.05 was considered significant. The calculation of

the incidence of peritonitis episodes was made

according to recommendation of ISPD: PD months

divided by the number of peritonitis episodes. The

results were expressed as the monthly intervals

between episodes (10).

Results

Gender, age, BMI, presence of abdominal scars,

and a previous history of diabetes were not

signifi-cantly different among the three groups as shown in

Table 1.

No Infectious Complications

Bleeding of surgical wound requiring dressing

change within 24 hours after catheter insertion was

observed in 3 patients in Group P, 2 in Group R,

and 4 in Group S (p = 0.77). The most common

noninfectious complication in the three groups was

CD, which was observed in 24 patients (19.8%),

without a significant difference among the groups

(p = 0.20). The presence of CD was associated with

tip catheter displacement in 17 (70.1%) of the 24

cases.

Early CD was verified in twelve of the 24 patients

(50%). The incidence of this complication was not

different among the three groups (four patients in

Group P, five in Group R, and three in group S;

p = 0.19). Moreover, only 2 cases of CD (8.3%)

were observed in a period longer than 12 weeks

after the catheter insertion (one in Group P and the

other one in group S) (Fig. 1). The presence of

scars

from

previous

abdominal

surgeries

was

observed in 25 of the 121 patients (20.6%) and had

no influence on CD in the whole groups (p = 0.22).

Finally, there were no cases of intestinal

perfora-tion, massive peritoneal bleeding, suture dehiscence,

incisional hernia, extrusion of external sleeve, or

dialysate sequestration in subcutaneous tissue in

any group.

Infectious Complications

Regarding the incidence of exit-site infection,

there was no significant difference among the

groups. One surgical wound infection was present

in Group P, and two cases of subcutaneous tunnel

infection, one in Group R and the other one in

group S, were observed. Peritonitis was the most

frequent infectious complication in all groups with

an overall incidence of 1/29.5 episode months (0.40

episodes/patient-year). However, the incidence of

peritonitis did not differ among the groups (Group

S; 1/27.1 months Group P; 1/31.7 months, Group

S; 1/31.1 months (p = 0.43)). In the whole cohort,

only 3 episodes occurred in the first 4 weeks after

the procedure, (2 cases in group P and 1 case in

group S). No significant difference in the median

time that elapsed between catheter insertion and the

first episode of peritonitis was verified (17.3 (3–89)

weeks in group P, 24.8 (10.5–79) in group R, and

35.2 (2–114) in group S (p = 0.31)). Finally, there

was no significant difference in the number of

peri-tonitis episodes among the groups as shown in

Fig. 2.

Follow-up and Catheter Survival

Forty-six (38%) of the 121 patients in the study

had discontinuation of follow-up by censoring. The

main causes of censoring were: death (n = 20),

transfer to HD (not related to CD) (n = 10), kidney

transplantation (n = 8), transfer to another dialysis

center (n = 4), and catheter removal by abdominal

!"#$ % & !"#$% ' !"#$ % ( !"#$ %& !"#$ %' !"#$ %( ) * + , -$ . /0 " #1 2 % 34 # 50 4 %6)7)8

!"#$%

&"'(

Fig. 1. Early vs. late catheter dysfunction.

!"# $%9& !"#$ %9' !"# $% ( !"# $%9& !"#$ %9' !"# $%9( ) *) +) ,) :) ;)) )(#*'+,*'*- .+/)(#*'+,*'*-%6)<)8 2%34#5049#19%0"3=#>3=34

Fig. 2. Incidence of peritonitis in the three groups.

Sobrevida  da  técnica

surgery (n = 2). Moreover, two patients had their catheters removed because of partial recovery of renal function. Catheter survival, estimated from Kaplan–Meier curve, did not differ among the groups (Fig. 3).

Discussion

In the present day, nephrologists are faced with the need of providing to ESRD patients a full-time assistance. In recent years, interventional nephrol-ogy (IN) has aroused increasing interest (11,12) worldwide. In 2000, the American Society of Diag-nostic & Interventional Nephrology (ASDIN) was created with the purpose of promoting education, training, research, and accreditation in nephrology-related procedures (13). More recently, an essay related to Brazilian nephrologists verified the incre-ment of personal interest of these professionals in IN. Interestingly, 87% of the respondents, who completed the questionnaire, reported a desire to be trained in IN procedures. When they were asked about PD catheter insertion, only 44% answered that they were able to perform this procedure. Among them, the most commonly used technique to catheter insertion was percutaneous using a trocar device (69% of the answers) (14).

In accordance with our results, the multicenter study, called Brazilian Peritoneal Dialysis Multicen-tric Study, (BRAZPD), which analyzed 736 inserted PD catheters in 93 Brazilian centers from 2004 to 2007, demonstrated that only 22% of the PD cathe-ters were implanted by nephrologists. According to this study, in 69% of the centers, all catheters were placed by surgeons. In addition, the BRAZPD also showed that the rates of mechanical and infectious complications were similar to those in procedures performed by surgeons or nephrologists (15).

It is important to stress that some obese patients, with a BMI higher than 40 Kg/m2 were included (data not shown) as well as patients with abdominal scars. These patients had no difference in terms of catheter outcome, which could indicate that in some selected cases the presence of these comorbidities do not constitute an absolute contraindication to their

inclusion in PD programs. Similar data were observed in two other recent studies in which the presence of previous abdominal surgeries did not increase the incidence of mechanical or infectious complications (16,17).

Bleeding of surgical wound has been little reported in the literature. The few studies describing this condition reported incidences ranging from 0.7 to 9% (18–20). In the present study, there were some cases in which it was necessary to change the dressing within 24 hours after the procedure; in all cases, the mere replacement of the compression dressing was sufficient to stop bleeding. The most common noninfectious complication in the present study was CD. The incidence of this complication according to some reports varies between 3.2 and 34.7%, in percutaneous insertions, which did not use image guidance (21–25), whereas in surgical insertions, CD has been verified to take place from 3.2 to 20% of the procedures according to the report (26–31). On the other hand, a CD rate of 20% (32–35) has been observed in PD catheters, which were placed by radioscopy guidance. Another study demonstrated no CD in 19 radioscopy-implanted catheters (35). It seems, based on our results, that the use of radioscopy did not add any benefit on catheter outcome as compared with the other two techniques.

In the present study, the fact that almost 90% of the cases of CD have occurred in the first 12 weeks after catheter placement (50% within the first 4 weeks,) shows that this is a predominantly early complication, as other authors have already reported (36). The similar results among the three groups indicate that the CD rate could not depend on the catheter insertion technique.

Concerning the incidence of dialysate leakage, there are even more conflicting results in the litera-ture. In percutaneous insertions, not guided by radioscopy, it has been reported that the incidence of this complication can be higher than 20–30% (26–29). On the other hand, with regard to surgical technique, this specific complication is apparently less common ranging from 0.9 to 15.3% (31,34).

Dialysate leakages were not observed in any patient from groups P and R, and in only 2 cases from group S. As the break-in period was variable and the incidence of leakage was very low, it was not possible to associate the occurrence of this com-plication with the early use of catheter. These results suggest that the presence of dialysate leakage might depend not only on the chosen insertion technique but also on some specific technical aspects followed, such as the muscular fixation of the internal cuff.

No case of intestinal perforation was verified in the present study. In fact, in 79 (65%) of the 121 catheter placements, the punctures of the peritoneal cavity were performed by trocar device. These results indicate that a well-planned and imple-mented technique may avoid the need for direct or indirect visualization of the peritoneal cavity during the procedure.

Fig. 3. Catheter survival during 19 months of follow-up.

•

532  implantes  em  455  pacientes.  

•

Implante  percutâneo  com  trocáter.  

According to the latest Brazilian national dialysis census, it is estimated that less than 10% of all dialysis patients

are in peritoneal dialysis (PD) treatment, and that this

situation has not been modified during this last decade (1,2).

One of the possible reasons to explain this scenario might be related to the absence of trained nephrologists who are able to perform peritoneal dialysis catheter (PDC) insertion. (3,4).

More recently, percutaneous insertion using a trocar device or by peritoneoscopy have been reported and could be an alternative to the traditional surgical insertion (5–7).

Objective

This study was performed to evaluate the efficiency, the c o m p l i c a t i o n p r o f i l e a n d t h e o u t c o m e o f percutaneously placed PDC.

Our study population comprised 455 patients (55±17 years; 51%males) in whom 532 PDC were inserted blindly with a Tenckhoff trocar between January 2006 and December 2011 at our Interventional Nephrology Center (Pro-Renal Brazil Foundation).

Early complications related to insertion included: four (0,7%) placement failures, three cases (0,5%) of bowel perforation , eight (1,5%) significant surgical wound bleeding and fifty five (10%) tip catheter migration (twenty-six out of them (47%) were successfully repositioned) (Fig. 2).

Most common late complication and frequent cause for catheter removal was intractable and recurrent peritonitis which has been verified in eighty one patients (15%).

In addition, exit site infection was present in twenty two patients (4%). Technical survival at 1 and 2 years was 80% and 60%, respectively (Fig.3).

After 72-months follow-up, the survival rate by Kaplan–Meier analysis was significantly different according to the presence of peritonitis (!2=13.85; p<0,001) (Fig. 4).

Finally, in the multivariate analysis only the presence of peritonitis was a significant risk factor for decreased catheter survival (HR=1.83; 1.35-2.47; IC (95%)).

PDC inserted percutaneously, by trained nephrologists, was associated with a very low complication rate and high

primary success rate. This approach had reduced waiting

time for PDC insertion and increased PD penetration in our dialysis population.

1. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2012. Available at http://www.sbn.org.br, accessed April 18, 2012

2. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2006. Available at: http://www.sbn.org.br, accessed April 18, 2012

3. Asif A, Byers P, Gadalean F, Roth D: Peritoneal dialysis underutiliza- tion: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 16(3):266–271, 2003 4. Troidle L, Kliger A, Finkelstein F: Barriers to utilization of chronic peritoneal dialysis in network #1, New England. Perit Dial Int 26 (4):452–457, 2006

5. Ortiz AM, Ferandez MA, Troncoso PA, Guzman S, Del Campo F, Morales RA: Outcome of peritoneal dialysis: Tenckhoff catheter sur- vival in a prospective study. Adv Perit Dial 20:145–149, 2004

6. Noidara Y, Ikeda N, Kobayashi K, Watanabe Y, Inoue T, Gen S, Kanno Y, Nakamoto H, Suzuki H: Risk factors and cause of removal of peritoneal dialysis catheter in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 24:65–68, 2008

7. Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A: Does catheter insertion by nephrologists improve peritoneal dialysis utiliza- tion? A multicenter analysis Semin Dial 18(2): 157–160, 2005

.

Six Years Experience with Blind Percutaneous Insertion of Peritoneal

Dialysis Catheters at a Brazilian Interventional Nephrology Center

Ricardo P. Franco, Marcelo M. Nascimento, Natasha Constancio, Joao R. Zahdi, Luciana S. C. De Oliveira, Leonardo C. Ribeiro, Itamara P. Danucalov, Tobias Siemens, Margarete M. Da Silva, Marcia T. Alcantara, Miguel C. Riella and Domingos C. Chula

Interventional Nephrology Center, Pro-Renal Brazil Foundation, Curitiba, Parana, Brazil

Background

Methods

Results

Conclusion

Reference

!"#$%>%%'()*+)+,%57,="=(-%=5$%?+,")04"35

Resultados  

•

51%  do  sexo  masculino;  

•

Média  de  idade  de  56  anos;  

•

Diabetes  (35%)  e  hipertensão  (35%)  as  

Resultados  

•

Em  4  casos  não  houve  sucesso  na  tenta7va  de  

implante.  

•

Sangramento  significa7vo  de  FO:  1,5%  (8  

casos).  

•

Disfunção  do  catéter:  13,9%  (74  casos).    

•

Entre  os  cateteres  com  disfunção,  26  (37%)  

According to the latest Brazilian national dialysis census, it

is estimated that less than 10% of all dialysis patients

are in peritoneal dialysis (PD) treatment, and that this

situation has not been modified during this last decade

(1,2).

One of the possible reasons to explain this scenario might

be related to the absence of trained nephrologists who are

able to perform peritoneal dialysis catheter (PDC) insertion.

(3,4).

More recently, percutaneous insertion using a trocar device

or by peritoneoscopy have been reported and could be an

alternative to the traditional surgical insertion (5–7).

Objective

This study was performed to evaluate the efficiency, the

c o m p l i c a t i o n p r o f i l e a n d t h e o u t c o m e o f

percutaneously placed PDC.

Our study population comprised 455 patients (55±17

years; 51%males) in whom 532 PDC were inserted

blindly with a Tenckhoff trocar between January 2006

and December 2011 at our Interventional Nephrology

Center (Pro-Renal Brazil Foundation).

Early complications related to insertion included: four

(0,7%) placement failures, three cases (0,5%) of bowel

perforation , eight (1,5%) significant surgical wound

bleeding and fifty five (10%) tip catheter migration

(twenty-six out of them (47%) were successfully

repositioned) (Fig. 2).

Most common late complication and frequent cause

for catheter removal was intractable and recurrent

peritonitis which has been verified in eighty one

patients (15%).

In addition, exit site infection was present in twenty two

patients (4%). Technical survival at 1 and 2 years was

80% and 60%, respectively (Fig.3).

After 72-months follow-up, the survival rate by

Kaplan–Meier analysis was significantly different

according to the presence of peritonitis (

!

2=13.85;

p<0,001) (Fig. 4).

Finally, in the multivariate analysis only the presence of

peritonitis was a significant risk factor for decreased

catheter survival (HR=1.83; 1.35-2.47; IC (95%)).

PDC inserted percutaneously, by trained nephrologists, was

associated with a very low complication rate and high

primary success rate. This approach had reduced waiting

time for PDC insertion and increased PD penetration in our

dialysis population.

1. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2012. Available at http://www.sbn.org.br, accessed April 18, 2012

2. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2006. Available

at: http://www.sbn.org.br, accessed April 18, 2012

3. Asif A, Byers P, Gadalean F, Roth D: Peritoneal dialysis underutiliza- tion: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 16(3):266–271, 2003 4. Troidle L, Kliger A, Finkelstein F: Barriers to utilization of chronic peritoneal dialysis in network #1, New England. Perit Dial Int 26 (4):452–457, 2006

5. Ortiz AM, Ferandez MA, Troncoso PA, Guzman S, Del Campo F, Morales RA: Outcome of

peritoneal dialysis: Tenckhoff catheter sur- vival in a prospective study. Adv Perit Dial 20:145–149, 2004

6. Noidara Y, Ikeda N, Kobayashi K, Watanabe Y, Inoue T, Gen S, Kanno Y, Nakamoto H, Suzuki H: Risk factors and cause of removal of peritoneal dialysis catheter in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 24:65–68, 2008

7. Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A: Does catheter insertion by

nephrologists improve peritoneal dialysis utiliza- tion? A multicenter analysis Semin Dial 18(2): 157–160, 2005

.

Six Years Experience with Blind Percutaneous Insertion of Peritoneal

Dialysis Catheters at a Brazilian Interventional Nephrology Center

Ricardo P. Franco, Marcelo M. Nascimento, Natasha Constancio, Joao R. Zahdi, Luciana S. C. De Oliveira, Leonardo C. Ribeiro,

Itamara P. Danucalov, Tobias Siemens, Margarete M. Da Silva, Marcia T. Alcantara, Miguel C. Riella and Domingos C. Chula

Interventional Nephrology Center, Pro-Renal Brazil Foundation, Curitiba, Parana, Brazil

Background

Methods

Results

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Reference

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No peritonitis

Peritonitis

Email: ricardoportiolli@gmail.com

1,0

0,9

0,8

0,7

0,6

0,5

0,4

0,3

0,2

0,1

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0

500

1000

1500

2000

Taxa de peritonite: 1 episódio a cada 35 pacientes/mês

According to the latest Brazilian national dialysis census, it is estimated that less than 10% of all dialysis patients

are in peritoneal dialysis (PD) treatment, and that this

situation has not been modified during this last decade (1,2).

One of the possible reasons to explain this scenario might be related to the absence of trained nephrologists who are able to perform peritoneal dialysis catheter (PDC) insertion. (3,4).

More recently, percutaneous insertion using a trocar device or by peritoneoscopy have been reported and could be an alternative to the traditional surgical insertion (5–7).

Objective

This study was performed to evaluate the efficiency, the c o m p l i c a t i o n p r o f i l e a n d t h e o u t c o m e o f percutaneously placed PDC.

Our study population comprised 455 patients (55±17 years; 51%males) in whom 532 PDC were inserted blindly with a Tenckhoff trocar between January 2006 and December 2011 at our Interventional Nephrology Center (Pro-Renal Brazil Foundation).

Early complications related to insertion included: four (0,7%) placement failures, three cases (0,5%) of bowel perforation , eight (1,5%) significant surgical wound bleeding and fifty five (10%) tip catheter migration (twenty-six out of them (47%) were successfully repositioned) (Fig. 2).

Most common late complication and frequent cause for catheter removal was intractable and recurrent peritonitis which has been verified in eighty one patients (15%).

In addition, exit site infection was present in twenty two patients (4%). Technical survival at 1 and 2 years was 80% and 60%, respectively (Fig.3).

After 72-months follow-up, the survival rate by Kaplan–Meier analysis was significantly different

according to the presence of peritonitis (!2=13.85;

p<0,001) (Fig. 4).

Finally, in the multivariate analysis only the presence of peritonitis was a significant risk factor for decreased catheter survival (HR=1.83; 1.35-2.47; IC (95%)).

PDC inserted percutaneously, by trained nephrologists, was associated with a very low complication rate and high

primary success rate. This approach had reduced waiting

time for PDC insertion and increased PD penetration in our dialysis population.

1. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2012. Available

at http://www.sbn.org.br, accessed April 18, 2012

2. Brasilian Society of Nephrology: Brasilian Society of Nephrology Annual Census 2006. Available at: http://www.sbn.org.br, accessed April 18, 2012

3. Asif A, Byers P, Gadalean F, Roth D: Peritoneal dialysis underutiliza- tion: the impact of an

interventional nephrology peritoneal dialysis access program. Semin Dial 16(3):266–271, 2003 4. Troidle L, Kliger A, Finkelstein F: Barriers to utilization of chronic peritoneal dialysis in network #1, New England. Perit Dial Int 26 (4):452–457, 2006

5. Ortiz AM, Ferandez MA, Troncoso PA, Guzman S, Del Campo F, Morales RA: Outcome of

peritoneal dialysis: Tenckhoff catheter sur- vival in a prospective study. Adv Perit Dial 20:145–149, 2004

6. Noidara Y, Ikeda N, Kobayashi K, Watanabe Y, Inoue T, Gen S, Kanno Y, Nakamoto H, Suzuki H: Risk factors and cause of removal of peritoneal dialysis catheter in patients on continuous ambulatory peritoneal dialysis. Adv Perit Dial 24:65–68, 2008

7. Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A: Does catheter insertion by

nephrologists improve peritoneal dialysis utiliza- tion? A multicenter analysis Semin Dial 18(2): 157–160, 2005

.

Six Years Experience with Blind Percutaneous Insertion of Peritoneal

Dialysis Catheters at a Brazilian Interventional Nephrology Center

Ricardo P. Franco, Marcelo M. Nascimento, Natasha Constancio, Joao R. Zahdi, Luciana S. C. De Oliveira, Leonardo C. Ribeiro,

Itamara P. Danucalov, Tobias Siemens, Margarete M. Da Silva, Marcia T. Alcantara, Miguel C. Riella and Domingos C. Chula

Interventional Nephrology Center, Pro-Renal Brazil Foundation, Curitiba, Parana, Brazil

Background

Methods

Results

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Conclusion

Reference

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Seldinger

 –  resultados  preliminares  

•

163  implantes,  desde  janeiro  de  2012.  

IMPLANTE

PERCUTÂNEO

SEMPRE?

Peritoneal Dialysis

Access: What’s the

Best Approach?

Riella M.C. · Chula D.C.

Ronco C, Rosner MH, Crepaldi C (eds): Peritoneal Dialysis – State-of-the-Art 2012. Contrib Nephrol. Basel, Karger, 2012, vol 178, pp 221– 227.