PD Access is Access to PD:
Jeffrey Perl MD
Nephrology Program
St. Michael’s Hospital
Friday April 7, 2017
Western Canada PD Days
Vancouver, British Columbia [email protected]
Disclosure:
• I do not put in PD Catheters
Fresh Out of Nephrology Fellowship
Jeff, I want you to grow
PD
#!@&!#$^
What Was Limiting Growth In Our Program ?
What Are The Steps For PD Initiation ?
Step 1: Identify patient with ESRD
Step 2: Assess for PD eligibility
Step 3: Patient must be offered PD
Step 4: Patient must choose PD
Step 5: Attempt a PD catheter
Step 6: Start PD therapy
Blake et al, Perit Dial Int. 2013 May-Jun;33(3):233-41
Mina’s Job Description Nurse Navigator & PD Access Coordinator
• ORN Ontario Renal Network = BC Provincial Renal Agency
• Each Regional Renal Program has Independent Dialysis and Body Access Coordinators
• Facilitate patient education and assessment for home dialysis and appropriate body access
• Participated in a province-wide quality improvement collaborative to facilitate improvements in the uptake of independent dialysis and appropriate body access
Measure PD Access Function Locally
Show Your Operators The Data
ISPD-NAC PD catheter registry 9
Why you should join 1) Help create better clear
definitions for catheter related complications
2) Benchmark your results to a wide range of programs in North America
3) Identify key practices that improve patient results
4) Participate in peer reviewed research
St. Michael’s Hospital (2005-2008)
Number of insertions
Flow dysfunction (%)
IR 61 13 (21.3%)
Surgical (open) 50 13 (26%)
Surgical (laparoscopy)
6 2 (33.3%)
Show Your Operators Unacceptable Results
Exit Site At The Belt Line
Anchoring Suture at the Exit Site
Then Show These Results And Talk To Your Hospital Administration Team
1. Develop a PD Access Team
PD Access Coordinator Surgeon
Nephrologist
PD Access Team
o PD access coordinator o Former home dialysis nurse o Modality Education to all Patients in Program o Works closely with surgeon and navigates the perioperative process
o IR o Received additional training in PD catheter insertion o Meet annually to review and audit data o Easy and ready accessibility for urgent PD catheter insertion o Support for PD catheter dysfunction with manipulation
o Surgeon o Laparoscopic Training o Received advanced training through a formal PD Catheter University o Mentorship from another center and surgeon (Dr. Todd Penner)
o Nephrologist o Resource for PD access coordinator on challenging cases o Exteriorized embedded PD catheters when placed o Works with team to determine break in period and initial prescription considerations.
2. Secure Operating Room/Theatre Time
• A lot of unused and funded OR time for living donor kidney transplants • Borrowed from that to allow one full PD OR per day
3. Fill That Operating Room Theatre Time
• Who needs a PD catheter is variable from month to month • Realized the same number of cases weren’t happening every month • Embedded PD catheter program implemented to fill the gaps
Algorithm For PD access at St. Michaels
Need for PD access
Interventional Radiology
Advanced Laparoscopic
embedded
Non-embedded
Laparoscopic
Urgent ?
Yes and uncomplicated abdomen No or yes and/or
complicated abdomen
Concern re GA? Yes and uncomplicated abdomen
Yes and complicated abdomen Laparoscopic
Under local (refer out)
PD < 1month
PD > 1month
no
IR PD Catheter Insertion
Total # of PD catheter inserted
34 26
43 35
9 17
20
20
0
10
20
30
40
50
60
70
2013 2014 2015 2016
OR IR
66 PD catheter insertion for 65 pt
40 started on PD Primary function 8 never started PD 3 went to
other centers
4 complications • 1-Bowel injury • 1-Bladder injury • 1- Infection • 1- Leak
• Recovered -1 • Died – 3
14 Catheter malfunction (21%)
Died
13 had Manipulation 1- declined manipulation
2 successful 9- Operative revision
1- Unsuccessful declined PD
1- IR replacement – (+ Leak)
1- leak – self resolved
Pre-Manipulation Antibiotics
Fibrin Sheath Demonstration With Stiff Wire Manipulation
4 IR cases with catheter flipped – All needing surgical revision (3 went)
3 OR cases with catheter flipped – All needing surgical revision
Number of Pts had manipulations
2013-2016 – 31 New Manipulation procedures
IR = 13 (20%) OR 18= (16%)
Successful = 2 Unsuccessful-11 (85%)
Successful =5 Unsuccessful-13 (72%)
Revision = 9 Revision = 11
Success among flipped catheters = 0 % Unflipped Catheters =22 %
Findings At Operative Revision for IR and OR Placed Catheters
Findings At Revision OR (n=11) IR (n=9)
Omental wrap 4 – 36% 8 – 89%
Fibrin clot 4 – 36% 1 – 11%
Bowel wrap/ fat 2 – 18% 1 – 11%
Procedures At Revision OR IR
Omentopexy 4 -36% 8 -89%
Lysis of Adhesions 3 – 27% 1 – 11%
Variation By Operator?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Operator A Operator B Operator C
Complication/Need forProcedure.
Unassisted Function
Fluoroscopic Manipulations: The Ottawa Experience
Miller et al Clin J Am Soc Nephrol 7: 795–800, May, 2012
Embedded PD Catheters
Dr. Jason Lee and PD access Program St. Michael’s Hospital
Learnt How to Exteriorize PD Catheters
PD Prevalence
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
PD
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2008-2012 2012-2016
Body Access Type At 90 Days After RRT Initiation – KCC Clinic 2008-2016
PD CVC AVF/AVG
Good Communication is Key
Referral Patterns Among Suboptimal Dialysis Starts in Canada
McFarlane…. Mendelssohn et al Nephrol Dial Transplant (2011) 0: 1–6
START Follow-Up Study: Suboptimal Starts Despite Early Referral
N= 128 % Patient-related delays
40 31%
Acute on CKD 40 31% Surgical delays 21 16% Late decisions by team
11 9%
Other 16 13%
Mendelssohn et al NDT 2012 in press
Suboptimal Starts: The role of The Nephrologist
Mendelssohn et al NDT 2012 in press
Nephrologist
Wide Variation by Nephrologist
Current State: HD With a Catheter is the Default Therapy In Urgent Dialysis Starts
Current State
Embedded PD Catheters
Moncrief/Moncrief Popovich Technique
Original concept: sterile environment reduction in bacterial
biofilm Reduction infection risk
Possible Advantages of Embedded PD Catheters
1. Embedded catheter can be left buried for an ‘’indefinite’’ period of time
2. The incision/stab into the peritoneal cavity can heal
3. Once the catheter exteriorized, full-volume PD can be commenced immediately
4. The patient has an access that is“ready to go”, like an AVF
5. Elective insertion when patient stable and greater flexibility in scheduling with limited or unreliable operating room time.
6. Prolonged healing – reduced risk of leak/cuff migration
Possible Advantages of Embedded PD Catheters
7. Stages patient readiness for dialysis -Overwhelming to couple dialysis access with dialysis initiation
8. Stages patient readiness for dialysis -Overwhelming to couple dialysis access with dialysis initiation
Possible Disadvantages of Embedded PD Catheters
1. Two procedures required
2. Higher risk of catheter non-use a) Death b) Modality Change c) Transplantation
The Ottawa Canada Experience
Brown et al Nephrol Dial Transpl 2008
435 Embedded Catheters: Jan 2000-Dec 2005
349 Embedded Catheters Exteriorized
50 Remain Embedded
38 (9%) Not Exteriorized • 10 Died • 10 Transplant • 11 Changed
Modality • 1 Transferred • 6 complications
The Ottawa Canada Experience
Brown et al Nephrol Dial Transpl 2008
Tertiles of Time Embedded Overall Median 83 days (36-122 days)
P value
Tertile 1 11-47 days
Tertile 2 48-133 days
Tertile 3 134-2041 days
Mean Time embedded (days)
30 + 9 84 + 24 486 + 372 <0.001
Primary failure rate
6.9% 1.7% 9.4% 0.04
Leaks at 30 days
4.3% 3.4% 3.4% NS
Intervention for mechanical complication
7.8% 6% 15.4% 0.04
The Ottawa Experience
Group 2
The Portuguese Experience
• 467 patients underwent implantation – 211 by mini-laparotomy – 76 by Seldinger (blind) technique – 180 by mini-laparotomy and embedding
• Break-in period: – Seldinger 20 (1-99) days – Mini-laparotomy 26 (0-396) days – Moncrief Popovich 55 (5-991) days
Brum et al NDT 2010:25 3070-3075
PD Catheter Outcomes
*
*
* Perc
ent
Brum et al NDT 2010:25 3070-3075
> 6 months - 15.7% < 6 months - 4.7% P=0.07
Catheter Survival
Brum et al Nephrol Dial Transplant 2010
embedded Embedded Catheter
Brum et al NDT 2010:25 3070-3075
University of Colorado Experience
Review of embedded catheters 2000-2008
122 catheters in analysis 90% functioned upon
exteriorization other 10% (13 catheters):
fibrin plug/kink/wrap all but 1 corrected via
laparoscopy duration of embedding did not
affect function
Group 1: 2-34 days Group 2: 34-53 days Group 3: 53-788 days
Elhassan et al PDI 2011 31:558-564
Embedded Catheters: Summary of Additional Studies
Author N Proportion never used
Mean/median time to use (weeks)
Initial drainage problems
Primary Non-function
Prischl et al 26 19% 11.4 (4-96) 29% 0%
Danielsson et al 30 0% 7.1 (1-170) 0% 0%
McCormick et al 266 11% 13.1 (5-42) 11% 7%
Junejo et al 20 10% 15.7 (5-127) 10% -
Brum et al 180 - 7.9 (<1- 141) 7.2% -
Elhassan et al 122 - 6 (<1 –112) 10.7% 10.7%
Prischl et al NDT 1997; 12:1661-7 Danielsson et al, PDI 2002; 22:211-9 McCormick et al KI Suppl2006; 70 s38-43 Junejo et al, PDI 2008;28:305-8 Brum et al, NDT 2010; 25:3070-75 Elhassan et al PDI 2011 31:558-564
Fibrin Plug Within Exteriorized Embedded Catheter
ina
eff
Plugging the end of the catheter prior to catheter embedding
Slide courtesy Dr. John Crabtree
§ Manufactured for Boston Scientific Corp * Page DE, Turpin C. Perit Dial Int 2000; 20:85-86.
Some Practical Clinical “Perls” That have helped us “Mina’’ a Time (1)
• Always have a PD catheter repair kit handy at the time of exteriorization
• If possible: don’t exteriorize at the 11th hour
– Warn patients that a revision might happen and don’t make them feel bad
– If it doesn’t work don’t let them pick up anxious energy from team
Some Practical Clinical “Perls” That have helped us “Mina’’ a Time (2)
• If your program eradicates S. Aureus carriage, try to do so before exteriorization
• An aggressive bowel routine is very important before exteriorization
• People should pee first • If an inpatient – no SC injections at the
abdomen (i.e. heparin, insulin)
Reviewing Our Own Data
Review Outcomes
Assessment of Insertion Techniques on Peritoneal Dialysis Catheter Outcomes: Comparison after Implementation of Dedicated Advanced Laparoscopic Program Tarek Al-Zahrani1, Mina Kashani2, Daniela Ghiculete1, Phillip McFarlane2, Jeffrey Perl2, Jason Y Lee1
1 – Division of Urology, Department of Surgery 2 – Division of Nephrology, Department of Medicine
LAP (n=47) OS (n=35) FG (n=159) PD initiated 93% 84% 79% Early mechanical complications (< 2months)
5% 33% 18%
Need for manipulation revision
8% 38% 18%
Embedded PD Catheters Feb 2012-
Oct 2016 = 71
16 Still Embedded 52 Exteriorized 3 Primary non use 2Passed Away, 1 TX
13 Complications 39 Uncomplicated
1 Catheter Injury 9 Catheters non functioning needed
Manipulation Reinsertion on PD
5 Successful Surgical
Revision On PD
3 Manipulation Successful on PD
1 went to HD
1 Bleeding
On HD
No leaks
Non- Embedded PD Catheters Feb 2012-
Oct 2016 = 81
15 from other centres 63 Followed up 3 Primary non use
1 died 1 pain 1 leak
14 Complications 47 Uncomplicated
1 Leak (P) 10 Catheters non functioning needed
Manipulation + Surgical Revision On HD
7 Successful Surgical
Revision On PD
3 Surgical Revision not
Successful went to HD
OR note: -PD revision - had ++ adhesions and omentum had somehow attached to more proximal end of catheter. Now flushed well after omentopexy and lysis of adhesions -adhesions caused obstruction of last catheter. Removed. New PD inserted
3 Manipulation without Revision
On PD
Primary and Secondary PD Catheter Malfunction: Embedded vs. Non-embedded
0%
5%
10%
15%
20%
25%
Embedded Non-embedded
Primary Non FunctionSecondary Non-FunctionPe
rcen
t
Total n =52 Total n =63
Primary Non-function – did not work without an intervention – manipulation and/or revision Secondary Non-function – despite revision, non-function persisted
In Embedded Catheters flow dysfunction occurred
in 14.3% Overall function: 98%
In John Crabtree’s report PDI -2015
Transitional Care When The Access is in Need of Repair !
eGFR at Insertion of Embedded PD Catheters
0
5
10
15
20
25
30
eGFR
at I
nser
tion
Total n= 71
Days to Exteriorization
4
6
2
4
8
5
12 12
0
2
4
6
8
10
12
14
< 30 30 -60 60 - 90 90 - 120 120 - 180 180 - 240 240 - 360 > 360
Num
ber o
f Pat
ient
s
Days
Total n = 53
Days to Exteriorization
4
6
2
4
8
5
12 12
0
2
4
6
8
10
12
14
< 30 30 -60 60 - 90 90 - 120 120 - 180 180 - 240 240 - 360 > 360
Num
ber o
f Pat
ient
s
Days
Total n = 53 With complications = 9
2
2
2 2
1
KFRE and EGFR As Predictors of Time From Insertion to Exteriorization
38/52 who had information on KFRE 52/52 information on eGFR
R² = 0.3879
0
0.2
0.4
0.6
0.8
1
1.2
0 200 400 600 800 1000 1200
KFRE
(2yr
s)
Days to Exteriorization
R² = 0.1206
0
5
10
15
20
25
0 200 400 600 800 1000 1200
GFR
_epi
(CKD
)
Days to Exteriorization
Other Predictors of Embedding Time
Crabtree et al , PDI 2015, n=107 embedded n=84 exteriorized n=9 futile
Key Points (1):
• Early-referred patients are also at risk for urgent dialysis starts
• A team approach important for a successful PD access program is critical
• Not just the surgeon
• You don’t know your program has a problem until you measure it. • Still challenged with our IR catheters • Need benchmark for functional PD catheters. • POET of PD access?
• Transitional care my minimize attrition from PD after PD catheter complications
• Once patients go to the abyss of In-centre HD they may be lost forever • Modality change inertia • Need to stay home-focused and with home-dialysis like-minded individuals
Key Points (2):
• Embedding PD Catheters May Attenuate The risk of suboptimal
starts among early referred patients: ? optimal duration of embedding to maximize success KFRE functions as a good predictor of exteriorization time. Literature confounded by method of access insertion, and catheter type Similar if not improved catheter survival compared to other techniques No strong trend towards reduction in the risk of infection Inherent higher rate of PD non-use ? The patient reported experience Sometimes emotional readiness for dialysis and clinical readiness are
very different
Growth Wouldn’t be possible without Working Together As A Team !!!!
Thank You