Peritoneal Dialysis Underutilization: The Impact of an Interventional Nephrology Peritoneal Dialysis Access Program

Abstract

Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.

Successful Models of Interventional Nephrology at Academic Medical Centers

“…Successful AMC-based programs have seen improvement in the overall care of dialysis-access patients, with equal success for patients on peritoneal dialysis and those on hemodialysis. For example, peritoneal dialysis utilization improved by 32% at the University of Miami after the interventional nephrology program's establishment (2). Peritoneal dialysis catheters placed by nephrologists have been reported to survive longer with lower incidence of leaks and peritonitis compared with surgical placements (17,18).…”

“…While nephrologists' surgery and radiology colleagues have made concerted efforts to deliver timely care, treatment delays persist (1)(2)(3). To optimize care, procedural aspects of nephrology have steadily evolved over the past decade.…”

Underutilization of Peritoneal Dialysis

“…An advantage of percutaneous and laparoscopic methods is that they can be incorporated into a nephrology outpatient service, thus further shortening waiting times. 26 However, few programs provide this facility 13 Agencies That Provide Funding for ESRD Care Should Find Peritoneal Dialysis Attractive. As a home therapy, the overall costs of peritoneal dialysis are lower than costs at dialysis centers and satellite hemodialysis centers.…”

Comparison of Modified Sutureless Peritoneal Dialysis Catheter Placement with Conventional Technique: A Prospective Study

“…However, the percutaneous PD catheter insertion technique has not been universally accepted due to the early mechanical complications and the potential risk for bowel perforation associated with its blind puncture method [7,8]. Hence, there have been several attempts to maximize the advantages of percutaneous PD catheter insertion, while minimizing its disadvantages [9].…”

“…The availability of timely PD catheter insertion, low rate of complication related with procedure and the low rate of catheter failure with efforts of nephrologists are important requisites that will increase the utility of CAPD and reduce patient morbidity [7].…”