Radiological versus surgical implantation of first catheter for peritoneal dialysis: a randomized non-inferiority trial

• Published in: Nephrology, dialysis, transplantation Vol. 27; no. 11; pp. 4196 - 4204
• Main Authors: Voss, David, Hawkins, Stewart, Poole, Garth, Marshall, Mark
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01.11.2012
• Subjects: Aged; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Catheterization - adverse effects; Catheterization - methods; Catheterization - mortality; Device Removal; Emergency and intensive care: renal failure. Dialysis management; Female; Fluoroscopy - adverse effects; Fluoroscopy - methods; Humans; Intensive care medicine; Kidney Failure, Chronic - therapy; Laparoscopy - adverse effects; Laparoscopy - methods; Laparoscopy - mortality; Male; Medical sciences; Middle Aged; Peritoneal Dialysis - adverse effects; Peritoneal Dialysis - methods; Peritoneal Dialysis - mortality; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the urinary system; Survival Analysis; Treatment Outcome; Kidney disease; RCT; Urinary system disease; Hemodialysis; Catheter; Laparoscopy; Peritoneal dialysis; Extrarenal dialysis; Tenckhoff; Surgical implantation; Surgery; Renal failure; Endoscopy; Comparative study
• DOI: 10.1093/ndt/gfs305
• ISSN: 0931-0509; 1460-2385

The success of peritoneal dialysis (PD) is dependent on timely and adequate PD catheter access. In many centres, including our own, PD catheter insertion technique has evolved by laparoscopic surgery. An alternative method of catheter insertion is performed by radiologists using a percutaneous modified Seldinger technique under fluoroscopic guidance. However, there are no clinical trials comparing these two methods of catheter insertion. From 1 April 1999 to 30 August 2004, we randomly assigned 113 pre-dialysis patients to receive PD catheter insertion using fluoroscopic guidance under local anaesthesia by radiologists or insertion using laparoscopy under general anaesthesia by a surgeon. The primary endpoint was the occurrence of dialysis catheter complications (complication-free catheter survival) by Day 365, a composite endpoint that included complications secondary to mechanical and infectious causes. Secondary endpoints were the occurrence of catheter removal (overall catheter survival) and death from any cause (patient survival) by Day 365, procedure pain, procedure time, procedure room utilization time, length of inpatient admission and direct hospital costs. Results were analysed by univariate and multivariate methods and by Kaplan-Meier survival curves. Complication-free catheter survival was significantly higher at 42.5% [95% confidence interval (CI) 29.3-55] in the radiological group compared with 18.1% (95% CI 8.9-29.8) in the laparoscopic group (P-value = 0.03). Excess complications in the laparoscopic group included peritonitis, peritoneal dialysate leaks and umbilical herniae. One-year overall catheter survival and 1-year subject survival were not different between the groups. Hospital costs were significantly higher in the laparoscopic group by almost a factor of two. Radiological insertion of first PD catheters using fluoroscopy is a clinically non-inferior and cost-effective alternative to surgical laparoscopic insertion.