Evidence - Peritoneal dialysis: Open catheter insertion in CAPD - general and visceral surgery

Revival of peritoneal dialysis in acute renal failure

Until the early 1990s, the higher complication and mortality rates of peritoneal dialysis (PD) compared with hemodialysis (HD) meant that it was considered a "second class therapy for second class patients seen by second class doctors".[1,2] Survival prognosis has markedly improved since the mid-1990s, and by now HD and PD have similar mortality rates in almost all studies.[3] Still, the advancement of HD modalities over time has significantly lessened the use of PD in acute renal failure.[4,5] However, the last decade has seen an upsurge in acute PD driven by the publication of randomized controlled trials and evidence for its safe use in severe acute renal failure compared with HD.

Since nationwide HD is not widely accessible in developing and emerging countries, they routinely employ acute PD because of its simplicity and resource-saving nature. Nursing care of these patients is much less time consuming and training intensive, and acute PD does not require electricity or running water.[6]

However, the COVID-19 pandemic led to bottlenecks in the management of patients with acute renal failure requiring dialysis, even in Western countries. Because of at times exceptionally high COVID-19 incidences, London and New York successfully established emergency PD teams and bedside nonsurgical catheter placement techniques.[7] PD has been successfully employed in intensive care units in the management of  acute respiratory distress syndrome (ARDS).[8]

Pros of PD versus HD:

·         Presence of the peritoneum as a biocompatible membrane

·         no anticoagulation required ( no need for extracorporeal circulation)

·         Better tolerance in hemodynamically unstable patients and those who do not readily tolerate high volume or electrolyte fluctuations

In HD, dysequilibrium* and rapid volume fluctuations are believed to be responsible for the rapid loss of residual renal function. PD avoids these downsides and rarely results in hypotension. In two randomized controlled trials of acute renal failure, PD shortened the time to recovery of renal function compared with HD.[9,10]

* Dysequilibrium: According to current theory, rapid depletion of retained and osmotically active substances in renal failure (e.g., urea) results in a concentration gradient between the blood and the intercellular space. This gradient causes fluid to enter the intracellular space, resulting in volume redistribution -> nausea, vomiting, hypotension, impaired consciousness, muscle spasms, cerebral seizures, cerebral edema.

One aspect to consider in acute PD, with its required rapid catheterization, is the dependence on other specialties as well as the availability of surgical resources. Therefore, institutions experienced in acute PD will place the catheter percutaneously under local anesthesia and analgesia by interventional nephrologists experienced in ultrasound-guided or blind Seldinger techniques.[11] Percutaneous catheter placement technique is not inferior to laparoscopically guided and open surgical placement and minimizes the risk of leakage compared to open surgical placement. Surgical procedures (open, laparoscopic) should be preferred following major abdominal surgery and suspected peritoneal adhesions.[12,13]

Comparison of open surgical and laparoscopic implantation technique[14]

A prospective randomized study on 148 patients (72 open surgery, 76 laparoscopic) assessed complication rate and functional outcome over a 3-year observation period.

Early complications (all): open 33.3% < > lap. 13.2%

• Peritonitis 12.5% < > 2.6%
• Catheter malfunction 8.3% < > 7.9%
• Leakage 11.1% < >1.3%
• Colon perforation none < > 1.3%
• Bladder perforation 1.4% < > none

Late complications (all): open 61.1% < > lap. 57.9%

• Infections 48.6 % < > 48.7 %
• Catheter malfunction 11.1% < > 7.9%
• Hernia 1.4 % < > 1.3 %
• Catheter malfunction 55.2% < > 32.8%

Catheter functional life

• Late complications 12:: open 62% < > lap. 77.5%
• After 36 months: open 26 % < > lap. 63 %

One innovative approach to improve the biocompatibility of dialysis solutions is the addition of immunomodulatory adjuvants to inhibit local immunocompetence and loss of peritoneal function.[15,16] Also, since dialysis dose can be intensified with a minimal amount of dialysate, it appears that the idea of a wearable artificial kidney may be within the realm of possibility at present.[17] In times of global warming, dialysate regeneration not only saves considerable amounts of water, but also positively impacts the CO2 balance.

(Acute) PD is currently experiencing a revival.

Improving the Outcomes of Peritoneal Dialysis (PD) Catheter Insertion

Occurrence of Emerging Infections After Placement of a Peritoneal Dialysis CatHeter (SINEPHILE)

1. Bloembergen WE (1995) Acomparison of mortality between patients treated with hemodialysis and peritonealdialysis. JAmSocNephrol 6:177–183.

2. Mehrotra R (2016) The current state of peritoneal dialysis. JAmSocNephrol 27:3238–3252.

3. van de Luijtgarden MW (2016) Trends in dialyis modality choice and related patient survival in the

ERA-EDTA Registry over a 20-year period. Nephrol DialTransplant31:120–128.

4. Passadakis P, Oreopoulos D (2003) Peritoneal dialysis in acute renal failure. Int J Artif Organs 26:265–277.

5. Ronco C (2017) Continuous renal replacement therapy: forty-year anniversary. Int J Artif Organs 40:257–264.

6. Chitalia VC, Almeida AF, Rai H et al (2002) Is peritoneal dialysis adequate for hypercatabolic acute renal failure in developing countries? Kidney Int 61:747–757.

7. Bowes E, Joslin J, Braide-AzikiweDCB et al (2021) Acute peritoneal dialysis with percutaneous catheter insertion for COVID-19-associated acute kidney injury in intensive care: experience from

a UK tertiary center .KidneyIntRep 6:265–271.

8. Chen W, Caplin N, El Shamy O et al (2021) Use of peritoneal dialysis for acute kidney injury during the COVID-19 pandemic in New York City: a multicenter observational study. Kidney Int 100:2–5.

9. Al-Hwiesh A, Abdul-Rahman I, Finkelstein F et al (2018) Acute kidney injury in critically ill patients:

a prospective randomized study of tidal peritoneal dialysis versus continuous renal replacement

therapy. TherApherDial 22:371–379.

10. Gabriel DP, Caramori  JT, Martim LC et al (2008)High volume peritoneal dialysis vs daily hemodialysis: a randomized, controlled trial in patients with acute kidney injury. Kidney Int Suppl: S87–S93.

11. Henderson S, Brown E, Levy J (2009) Safety and efficacy of percutaneous insertion of peritoneal dialysis catheters under sedation and local anaesthetic. NephrolDialTransplant 24:3499–3504.

12. Boujelbane L, Fu N, Chapla K et al (2015) Percutaneous versus surgical insertion of PD catheters in dialysis patients: a meta-analysis. JVascAccess 16:498–505.

13. Htay H, Johnson DW, Craig JC et al (2019) Catheter type, placement and insertion techniques for

preventing catheter-related infections in chronic peritoneal dialysis patients. Cochrane Database

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14. Gadallah MF, Pervez A, el-Shahawy MA et al (1999] Peritoneoscopic versus surgical placement of peritoneal dialysis catheters: a prospective randomized study on outcome. Am J Kidney Dis. 33(1):118-22.

15. Ferrantelli E, Liappas G, Vila CuencaMet al (2016) The dipeptide alanyl-glutamine ameliorates

peritoneal fibrosis and attenuates IL-17dependent pathways during peritoneal dialysis. Kidney Int 89:625–635.

16. Vychytil A, Herzog R, Probst P et al (2018) A randomized controlled trial of alanyl-glutamine supplementation in peritoneal dialysis fluid to assess impact on biomarkers of peritoneal health.

KidneyInt 94:1227–1237.

17. Htay H, Gow SK, Jayaballa M et al (2021) Preliminary safety study of the automated wearable artificial kidney (AWAK) in peritoneal dialysis patients. Perit Dial Int 42(4):394-402.