Providing Quality in Peritoneal Dialysis Annette Butler and Mark Denton

Provision of quality involves provision of choice PD vs Haemodialysis

Peritoneal Dialysis allows for: A flexible lifestyle and independence No need for vascular access / needles Done at home / less travel Easy to do during vacations Often done during sleep

Cont’d Preserves native renal function Perhaps less need for fluid and dietary restriction Generally associated with fewer ‘ups and downs’

All too frequently patients are directed down haemodialysis pathway Crash landers Ease of placement of permcath vs PD catheter Worry about exposure of patient for general anaesthetic Less well developed PD service

Hypothesis Nephrologist placement of PD catheters using percutaneous method under local anaesthetic will enable greater choice and increase utilization of PD

Our data:

Approx 60 in each group No difference in catheter survival or peritonitis rates No difference in complications such as – Exit site leaks – Primary or secondary drainage failure

What is our protocol Patients swabbed and decolonised if staph carriage Picolax sachet night before Day case Cefuroxime iv; Temazepam and tramadol premed Procedure performed and discharge that evening Dressing day 5; Sutures removed day 10 Aim for training 3 to 4 weeks post

Results Attempted 32 catheter insertions 5 failed attempts No complications of insertion – Bowel perforation – Bladder perforation

Reasons for failure 1 st in patient with hx of miliary TB. – GA insertion also failed 2 nd and 3 rd successful GA placement 4 th discontinued due to complaints of pain – Also failed GA insertion 5 th attempted catheter reinsertion/manipulation – Also failed GA manipulation

Successes 27 out of 32 successful catheter insertions 22 out of 27 started PD Total of 150 months of PD

Reasons for not starting PD 5 out of 27 not started PD 1 catheter removed after 6 months due to renal recovery 2 catheters placed in patients with CCF for ascites drainage 2 awaiting training

Infection rates 3 patients with peritonitis – Staph epi – Enterococcus – MSSA Infection rate 1 every 38 months peritoneal dialysis No peritonitis occuring within one month of insertion One exit site infection (MSSA)

Other complication No exit site or midline incision PD leakage One patient has drainage problems 6 months after starting. Attempted manipulation failed. Now on HD One patient has pain on drainage corrected by tidal PD and use of physioneal

Patient Complexity Mean age: 54 (30 to 90) 4 previous transplant 2 had previous hysterectomy 1 had cholecystectomy 3 had PCKD

Summary We have established a nephrologist based service for PD catheter placement under local anaesthetic High success rate No complications Increase in PD patient numbers Enjoy the video!