Predictive factors for Peritoneal Dialysis Catheter Survival: a ten-year single center study

Abstract

Introduction and Objectives: Timely insertion and adequate management of peritoneal dialysis catheter (PDC) related complications are crucial for the success of Peritoneal Dialysis. The aim of this study was to review the peritoneal dialysis catheter outcomes at our center, identifying factors that influence catheter survival.

Materials and Methods: A retrospective study was conducted on 146 PD patients who received their first PDC between August/ 2012 and July/2022. The mean follow-up was 26.5 ± 22.7 months.

Results: Mean age was 55.1 ± 16.6 years, and 58.2% were male. Peritonitis occurred in 75 patients (51.4%), with 26 (34.7%) requiring catheter removal. Mechanical complications were observed in 66 patients (45.2%), with 16 requiring catheter removal. Catheter survival at 12, 24, and 36 months was 80.2%, 72.4%, and 61.6%, respectively. Non-infectious complications (p=0.006) and peritonitis episodes (p=0.017) were associated with higher rate of PDC-associated removal. In the multivariate analysis, non-infectious complications were the only independent variable significantly associated with catheter survival (Hazard ratio 2.53; 95% CI 1.383–4.624). No association was found between PDC survival and age, diabetic status, obesity, prior kidney transplant, previous abdominal surgery, or method of catheter insertion.

Conclusions: Despite the significant number of infectious complications, including peritonitis, these did not result in a substantial decrease in catheter survival in the multivariate analysis. These findings emphasize the importance of effectively managing non-infectious complications to ensure successful and long-term use of PDCs. Preventive measures, such as omentectomy simultaneously with PDC implantation, may be considered on a case-by-case basis.

INTRODUCTION

Peritoneal dialysis (PD) is a well-established renal replacement therapy for patients with end-stage renal disease (ESRD). The success of peritoneal dialysis as renal replacement therapy depends on a well-functioning peritoneal catheter[1].

Complications associated with PD catheters (PDC) significantly contribute to patient morbidity, leading to interruptions in treatment and decreased dialysis efficacy[2][3]. These complications often cause the need to transfer to hemodialysis, hospitalization, and surgical procedures.

The success and longevity of PD are frequently challenged by both infectious and non-infectious complications [1,2].

Infections, particularly peritonitis, are widely recognized as major causes of technique failure and morbidity in PD patients[1][2][4][5]. Peritonitis not only compromises immediate health but also has long-term implications on the functionality and survival of the PD catheter. Prevention and effective treatment of peritonitis is critical to reduce technique failure and the need for catheter removal[4].

Non-infectious complications, although less frequently discussed, also pose significant challenges to the survival of PD catheters and overall patient outcomes[3][6]. These include mechanical issues such as outflow failure, catheter migration, and omental wrapping, as well as hernias, hemoperitoneum, and dialysate leaks[7]. Such complications can lead to recurrent interventions, increased healthcare costs, and reduced adherence to PD therapy[8].

This study aims to review the peritoneal dialysis catheter (PDC) outcomes at our center and to identify factors that significantly influence catheter longevity, providing insights that can enhance management strategies for maintaining PD efficacy.

MATERIAL AND METHODS

We conducted a retrospective study including all PD patients who had their first PD catheter implanted between the 1st of August 2012 and the 31st of July 2022 in our institution.

All catheters were double-cuffed, pig-tailed Tenckhoff catheters. Most PD catheters were placed surgically by two surgeons (mini-laparotomy or laparoscopy). A minority of catheters (n=8) were placed percutaneously by one nephrologist, using the Seldinger technique.

The medical records of the 146 patients included in the study were reviewed for their demographic and clinical characteristics, including age, gender, underlying etiology of ESRD, comorbidities, and prior abdominal surgeries. During the follow-up, we collected data regarding infectious and non-infectious complications. Early complications were defined as those developing within 30 days after PDC insertion, whereas late complications were defined as those developing after 30 days.

The primary endpoint was PD catheter failure, defined as the removal of the PD catheter due to catheter-related complications. The catheter-related complications were divided into infectious and non-infectious. PD catheter infectious complications included exit-site infections (ESI), tunnel infections (TI), and peritonitis. The non-infectious complications included outflow failure due to catheter migration/ mal-positioning, omental wrap, catheter leakage, post-incisional hernia, hemoperitoneum, and pleuro-peritoneal shunt.

The catheter survivor was defined as a patient who had maintained PD by the end of follow-up or had PDC removal due to issues unrelated to PDC, such as patient death, kidney transplantation, patient demand, inadequate PD, or improved residual renal function.

Statistical analyses were performed using IBM SPSS, version 28 (SPSS, Chicago, IL, USA). Categorical variables are expressed as numbers and percentages, and continuous variables are expressed as mean ± standard deviation. The Pearson χ2 test or Fisher’s exact test was used to analyze categorical variables. For continuous variables, the means were compared using the Student’s t-test. Kaplan-Meier curves were used to estimate catheter survival. Cox regression model was used to identify factors that were independently associated with catheter survival. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Patient characteristics

The study population included 85 men (58.2%) and 61 women (41.8%). The mean age at the PDC insertion time was 55.1 ± 16.6 years (Table I.)

The mean follow-up was 26.5 ± 22.7 months. Chronic glomerulonephritis was the most common etiology of stage 5 chronic kidney disease (n=49, 33.6%), followed by diabetes mellitus (n=41, 28%). Ninety patients (61.6%) had one or more comorbidities, and 51 (34.9%) of them had diabetes mellitus. Seventeen (11,6%) had previous abdominal surgery: cholecystectomy in 7, hysterectomy in 3, appendicectomy in 3, previous kidney transplant in 3, and total gastrectomy with Roux-en-y oesophagojejunostomy in one patient.

Table I.Patient demographic and clinical characteristics

BASELINE CHARACTERISTICS
Age (years), mean (SD)	55.1 16.7
Sex (male), n (%)	85 (58.2)
Etiology of chronic kidney disease, n (%)
Chronic glomerulonephritis	49 (33.6)
Diabetes mellitus	41 (28)
Chronic tubulointerstitial nephritis	17 (11.6)
Polycystic kidney disease	5 (3.4)
Hypertension	4 (2.7)
Others	9 (6.2)
Unknown	21 (14.4)
One or more comorbidities, n (%)	90 (61.6)
Diabetes mellitus	51 (34.9)
Major cardiovascular disease*	38 (26)
Obesity	32 (21.9)
Prior kidney transplant	19 (13.0)
Previous abdominal surgery, n (%)	17 (11.6)
PD catheter insertion technique, n (%)
Mini-laparotomy	90 (61.6)
Laparoscopy	48 (32.9)
Seldinger (percutaneously)	8 (5.5)

In 90 patients (61.6%), the PDC was inserted using a mini-laparotomy approach, whereas the laparoscopic method was used in 48 patients (32.9%). Only 8 patients (5.5%) had their catheter placed percutaneously using the Seldinger technique.

PD-related infectious complications

The total number of patients who experienced one or more episodes of peritonitis during the follow-up period was 75 (51.4%). Among these, 48 patients had a single episode, while 27 patients had more than one episode of peritonitis. Twenty-six patients (34.7%) required removal of their peritoneal dialysis catheter due to refractory peritonitis.

Thirty-four patients (23.3%) had a single episode of PD catheter-related exit site or tunnel infection, while 43 (29.5%) had more than one event. The number of early ESI/TI

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