In addition to being a continuous daily home therapy, peritoneal dialysis (PD) offers a number of advantages for end-stage renal disease (ESRD) patients. Nevertheless, PD remains an underutilized form of renal replacement therapy. Recent data demonstrate that over 50% of ESRD patients in the United States prefer and request PD as the modality of choice for renal replacement therapy. However, only 12% of ESRD patients are initiated on this form of therapy. A variety of factors including timely insertion of PD access are likely responsible for the dramatic underutilization of PD. Recent attention has focused on increasing the use of this important modality of renal replacement therapy. To this end, interventional nephrologists have taken the initiative in performing PD access-related procedures, including catheter insertion, catheter removal, and repositioning of a migrated catheter. The safety and success of PD access-related procedures by nephrologists have been well documented.
This chapter provides a review of PD catheter types, catheter placement procedures, and management of some catheter-related complications. It emphasizes the importance, feasibility, and advantages of PD access procedures by nephrologists.
Chronic PD catheters are designed to be used for many months or years. They are constructed of soft materials ssuch as silicone rubber or polyurethane. The intraperitoneal portion usually contains 1-mm side holes, although one version has linear grooves or slots rather than side holes. All chronic PD catheters have one or two extraperitoneal Dacron cuffs that promote a local inflammatory response. This produces a fibrous plug that fixes the catheter in position, preventing fluid leaks and bacterial migration around the catheter. Chronic PD catheters are the most successful of all transcutaneous access devices, with longevity measured in years rather than days to months. Peritoneal access failure, however, is still a source of frustration for all continuous ambulatory peritoneal dialysis (CAPD) programs, and it is the reason why about 25% of patients drop out. Increasing the success of a CAPD program requires optimal use of peritoneal catheters. Currently, the method of catheter placement has more effect on outcome than catheter choice.
As shown in Figure 58–1, at first there appears to be a bewildering variety of chronic PDs. However, each portion of the catheter has only a few basic design options.
Currently available peritoneal catheters; combinations of intraperitoneal and extraperitoneal designs.
There are four designs of the intraperitoneal portion:
Straight Tenckhoff, with an 8-cm portion containing 1-mm side holes.
Curled Tenckhoff, with a coiled 16-cm portion containing 1-mm side holes.
Straight Tenckhoff, with perpendicular discs (Toronto-Western, rarely used).
T-fluted catheter (Ash Advantage) a T-shaped catheter with grooved limbs positioned against the parietal peritoneum.
There are three basic shapes of the subcutaneous portion between the muscle wall and the skin exit site:
Straight or gently curved.