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Rationale & Objective: Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia. Study Design: Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques. Setting & Participants: Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system. Exposure: PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques. Outcomes: One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time. Analytical Approach: Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques. Results: We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P = 0.01). Major complications were <1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P = 0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P < 0.001). Limitations: Retrospective study with practice preference influenced by timing, local expertise, and resources. Conclusions: Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD. Plain-Language Summary: Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable 1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.
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Rationale & Objective: It is a common practice to start patients in urgent need of dialysis on hemodialysis via a central venous catheter. Because central venous catheter use is associated with increased risk of infections, hospitalizations, and mortality, urgent start peritoneal dialysis (PD) increasingly represents a viable alternative. This study aimed to examine clinical outcomes, complications, mortality, and modality retention in patients who initiated urgent start PD. Study Design: Retrospective cohort study. Setting and Participants: Eighty-four adult members of a large integrated health care system who initiated urgent start PD between January 1, 2011, and December 31, 2014. Exposure: Urgent start PD. Outcomes: Retention rates at 30, 90, and 365 days; time to the development of noninfectious and infectious complications, modality failure, and all-cause mortality. Analytical Approach: Cumulative incidence of all-cause mortality was estimated using the Kaplan-Meier method. Retention rates for PD were computed using binomial proportions. Results: Occurrence of major complications was less than 5%. Catheter malfunction occurred in 6% of cases; of those, catheter patency could be established in 80%. Infectious complications occurred in 20% of patients who initiated PD and included peritonitis and exit site infections. At 365 days after initiation, the cumulative incidence of all-cause mortality was 9.7% (95% CI, 4.7%-19.4%). PD retention rates were 98.8%, 91.3%, and 80.0% at 30 days, 90 days, and 1 year, respectively. Limitations: Retrospective cohort design, a well-matched comparable group of urgent start hemodialysis patients could not be identified, small number of patients in a single integrated health care system, uncertain or limited generalizability of findings to other health care systems. Conclusions: At 1 year after initiation, patients who initiated urgent start PD had high survival and modality retention rates. In unplanned initiation of dialysis, urgent start PD is a viable and sustainable option and should be considered in selected patients to optimize care.
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IMPORTANCE: Despite favorable national trends in the incidence of end-stage renal disease (ESRD) from 2008 to 2011, ESRD incidence has been increasing recently, and less than 10% of patients with ESRD start renal replacement therapy with peritoneal dialysis (PD) in the United States. Given known and potential advantages of PD over hemodialysis, the Kaiser Permanente Northern California integrated health care delivery system implemented a program to expand use of PD. OBJECTIVES: To describe the system-level approach to expansion of PD use and temporal trends in initiation and persistence of PD and its associated mortality. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included adult members of a large integrated health care delivery system in Northern California who initiated chronic dialysis therapy from January 1, 2008, through December 31, 2018. Data were analyzed from March 1, 2018, through May 31, 2019. EXPOSURE: From 2008 to 2018, Kaiser Permanente Northern California implemented a multidisciplinary, system-wide approach to increase use of PD that included patient and caregiver education, education and support tools for health care professionals, streamlined system-level processes, monitoring, and continuous quality improvement. MAIN OUTCOMES AND MEASURES: Temporal trends in the proportion of patients starting chronic dialysis with PD vs hemodialysis compared with national trends. Secondary outcomes included persistence of PD at 1 year in those initiating it and standardized 1-year mortality rates in those initiating PD or hemodialysis. RESULTS: Among 13 500 eligible health plan members in the study population (7840 men [58.1%] and 5660 women [41.9%]; mean [SD] age, 64.3 [14.4] years), initiation of PD increased from 165 of 1089 all new dialysis patients (15.2%) in 2008 to 486 of 1438 (33.8%) in 2018, which was substantially higher than national trends (6.1% in 2008 and 9.7% in 2016). Among the 2974 patients who initiated PD from 2008 to 2017, 2387 (80.3%) continued PD at 1 year after initiation, with a significant increase in age-, sex-, and race-standardized rates from 2008 (69.1%) to 2017 (84.2%). Age-, sex-, and race-standardized 1-year mortality for patients receiving PD and hemodialysis did not change significantly across this 10-year period (17.3% to 15.5% for hemodialysis, P = 0.89 for trend; and 5.5% to 7.3% for PD, P = 0.12 for trend). CONCLUSIONS AND RELEVANCE: This study suggests that large-scale expansion of PD is feasible using a multidisciplinary, integrated, coordinated care approach; we believe these findings represent a national opportunity to improve outcomes for patients with advanced kidney disease.