Peritoneal catheter insertion: combating barriers through policy change

Abstract

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the COVID-19 pandemic. Peritoneal Dialysis (PD) is the more commonly used home therapy option. This paper provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19, and a roadmap of potential policy solutions. To substantiate the analysis, the paper includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure, and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate trainings, and sharing decision-making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to: improve the awareness and feasibility of PD among patients and the health care workforce; enhance and promulgate trainings for clinicians – both surgical and medical – to insert PD catheters; and fund personnel, pathways and physical facilities for PD catheter insertion.

Peritoneal dialysis and acute kidney injury in acute brain injury patients

“…One of the barriers in several centers for the use of PD in AKI is the insertion of the PD catheter, preferring CRRT or even IHD over PD for this reason. 61,62 Insertion techniques can be divided into percutaneous, open surgical and laparoscopic. There is no demonstrated benefit of one technique over another, so it depends on the availability and skill of the operator.…”

“…There is no demonstrated benefit of one technique over another, so it depends on the availability and skill of the operator. 62 However, the catheter installed by a trained nephrologist without the need for an operation theater access or general anesthesia is associated with similar or higher rates of successful PD utilization. 61 The percutaneous technique is feasible to be performed at the bedside under local anesthesia, avoiding risks and complications of general anesthesia (including volatile anesthetics with risk of increase CBF and nephrotoxicity), even in obese patients guided with ultrasound.…”

“…61 The percutaneous technique is feasible to be performed at the bedside under local anesthesia, avoiding risks and complications of general anesthesia (including volatile anesthetics with risk of increase CBF and nephrotoxicity), even in obese patients guided with ultrasound. [62][63][64] In cases of nonsedated patients who require sedation for the installation of the catheter, controllable and safe options regarding ICP, CBF, and brain metabolism are short-acting sedatives such as propofol or ketamine. Avoid midazolam, which has no analgesic effect and could generate a reduction in ICP, brain metabolism, an unpredictable awakening, and interferes in the neurological evaluation of these patients.…”

“…One of the barriers in several centers for the use of PD in AKI is the insertion of the PD catheter, preferring CRRT or even IHD over PD for this reason 61,62 . Insertion techniques can be divided into percutaneous, open surgical and laparoscopic.…”

“…Insertion techniques can be divided into percutaneous, open surgical and laparoscopic. There is no demonstrated benefit of one technique over another, so it depends on the availability and skill of the operator 62 . However, the catheter installed by a trained nephrologist without the need for an operation theater access or general anesthesia is associated with similar or higher rates of successful PD utilization 61 .…”