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Advances in Peritoneal Dialysis, Vol. 22, 2006

Dana Negoi, Barbara F. Prowant, Zbylut J. Twardowski

Current Trends in the Use of Peritoneal Dialysis Catheters

patients. Variations of the Tenckhoff catheter have been designed over the years in a search for the ideal PD catheter: an access that can provide reliable dialysate flow rates with fewer complications. In 2005, we conducted an international survey to estimate preferences and practices in regard to the use of new PD catheters during 2004. Materials and methods A PD catheter questionnaire was distributed in March 2005 in the registration packets at the 25th Annual Dialysis Conference, in Tampa, Florida. Respondents were asked to indicate the types of catheters implanted in their program in 2004 and to specify the prevailing implantation technique. Only one respondent from each center was allowed to complete the questionnaire. Demographic data included the location of the program, number of years the PD program had been in existence, and total number of chronic PD patients in the program (which was used as a surrogate for number of prevalent catheters). Results We received 111 responses from a combination of adult and pediatric dialysis units, but we entered only 65 of the responses (58.5%) into the final analysis: 52 responses from adult programs and 13 responses from pediatric centers. Of the original responses, 53 were incomplete or seemed to be inaccurate. The most common problem was that the total number of catheters said to be implanted in 2004 was equal to the total number of chronic PD patients cared for at the time of the questionnaire, and yet none of the programs had been in existence for only one year. We considered these responses to be erroneous because they seemed actually to signify prevalent, not incident catheters, and they did not reflect current preferences, which was the goal of the survey. We tried to verify these responses by contacting the respondents who had voluntarily provided contact information, but we were able to correct only 7 responses. All other surveys in which the total number of catheters inserted in 2004 was equal

The Tenckhoff catheter was developed in 1968 and has been widely used since for chronic peritoneal dialysis (PD) patients. Variations of the Tenckhoff catheter have been designed over the years in a search for the ideal PD catheter--an access that can provide reliable dialysate flow rates with few complications. Currently, data derived from randomized, controlled, multicenter trials dedicated to testing how catheter design and placement technique influence long-term catheter survival and function are scarce. As a result, no firm guidelines exist at the national or international levels on optimal PD catheter type or implantation technique. Also, no current statistics on the use of PD catheters are available. The last survey was carried out using an audience response system at the Annual Peritoneal Dialysis Conference in Orlando, Florida, in January 1994. The present analysis is based on a new survey done at the 2005 Annual Dialysis Conference in Tampa, Florida. It is a snapshot of preferences in catheter design and implantation technique in 2004 from an international sample of 65 respondent chronic PD centers. The Tenckhoff catheter remains the most widely used catheter, followed closely by the swan-neck catheter, in both adult and pediatric respondent centers. Double-cuff catheters continue to be preferred over single-cuff catheters, and coiled intraperitoneal segments are generally preferred over straight intraperitoneal segments. Surgical implantation technique remains the prevailing placement method in both pediatric and adult respondent centers. Key words Peritoneal dialysis access, peritoneal catheter, catheter survey, Tenckhoff catheter, swan-neck catheter, catheter cuff, coiled catheter, catheter implantation Introduction The Tenckhoff catheter was developed in 1968 and is still widely used for chronic peritoneal dialysis (PD)

From: University of Missouri­Columbia, School of Medicine, Division of Nephrology, Columbia, Missouri, U.S.A.

148 to or greater than the total number of chronic patients cared for at the time of the survey were excluded from the analysis. Acute dialysis programs in the United States provided 3 responses. All indicated that they implanted only Tenckhoff catheters in 2004, but did not offer numbers. One adult center from Europe indicated that they cared for 100 chronic patients, but had implanted 700 Vicenza catheters and 6 Ronco catheters in 2004. This European program was the only respondent indicating the use of Vicenza and Ronco catheters. These dialysis centers were not included in the final analysis. Catheters in adults In the adult sample sub-analysis, 4 centers from Canada reported more than 148 prevalent catheters; however, 1 of the 4 centers did not report the number of chronic PD patients cared for at the time of the survey. Two centers that indicated they were located in Mexico or Central America had a total of 520 prevalent catheters. Nine centers from Europe had a combined total of 415 catheters. In the United States, 36 respondent centers had 921 prevalent catheters. The only center from Australia or the South Pacific that responded had 25 prevalent catheters. There were no respondent centers from Asia, Africa, or South America. The total number of prevalent catheters in the analyzed centers in March 2005 was more than 2029. Approximately half (1102) had been implanted in 2004: 152 in Canada, 555 in the United States, 200 in Mexico or Central America, 186 in Europe, and 9 in Australia. Table I shows the types of catheters implanted in 2004 in the adult sample. Overall, the Tenckhoff catheter remains the most widely used catheter in the adult population. Figure 1 shows that 65% of all catheters implanted worldwide in 2004 in the responding adult PD centers were Tenckhoff catheters. The next most popular catheter is the swan-neck catheter, accounting for 26% of all catheters implanted in 2004. When analyzed by region, the Tenckhoff catheter is still the most widely used, except in Europe. Respondent centers from Canada indicated that 72% of new catheters were Tenckhoff catheters, and 28% were Toronto Western Hospital catheters. In the United States, 59% of the newly implanted catheters were Tenckhoff catheters, 36% were swan-neck catheters, and 5% were Cruz catheters. Of the catheters

Negoi et al. implanted in 2004 in Mexico or Central America, 100% were Tenckhoff catheters. Interestingly, in Europe, based on responses from 9 centers, the use of swan-neck catheters (49%) is preferred over Tenckhoff catheters (38%). Of the 52 centers included in the adult sub-analysis, 13 (25%) used more than one type of catheter--typically, two different types. With regard to the number of cuffs, virtually all respondent adult PD centers used double-cuff catheters in 2004. Table I shows that 1014 of 1102 new catheters (92%) were double­cuffed; 1.5% were triplecuffed, and 4% were single-cuffed. In Canada, all new catheters reported had two cuffs. Double-cuff catheters represented 94% of the catheters implanted in the United States, 95% in Mexico and Central America, and 80.5% in Europe. Catheters with coiled intraperitoneal segments were preferentially used in the adult sample. Of all catheters, 68% were coiled. That percentage represents a 20% increase when compared with the results obtained in the 1994 survey (1). The use of catheters with a bent or curved intramural segment is increasing in Europe, representing 48% of newly implanted catheters as compared with 37.6% with straight intramural segments (Table I). Overall, most newly implanted catheters have a straight intramural segment (69%). In the United States, catheters with a bent intramural segment represent 41% of newly implanted catheters. As Table II shows, surgical implantation remained the method of choice in 2004: 72% of all centers indicated that surgical implantation was the prevailing method. Catheters in children For the pediatric sub-analysis, responses were received from 13 centers: 2 centers from Canada, with 10 prevalent catheters; 1 center from Asia, with a total of 16 catheters in use; 6 centers from the United States, with 89 total catheters; 3 centers from Europe, with 62 prevalent catheters; and 1 center from Mexico, with 150 chronic catheters. The responding pediatric centers had a total of 327 prevalent catheters. Of these, 85% were implanted in 2004 as follows: 8 catheters in Canada, 52 in the United States, 105 in Mexico, 110 in Europe, and 5 in Asia. Table III shows the numbers and types of catheters implanted in 2004 in the sample

Current Trends in PD Catheters

TABLE I Types and numbers of catheters implanted in 2004 in adult patients Segment shape IP IM Straight Straight Coiled Coiled Straight Straight Straight Straight Straight Bent 13 85 9.0 55.0 18 3.2 44 24.0 12 8.0 Mexico and U.S.A. Central America Europe (n) (%) (n) (%) (n) (%) 1 8 11 0.2 1.4 2.0 120 60.0 60 32.0 10 70 5.0 35.0 10 5.5

149

Catheter type Tenckhoff Tenckhoff Tenckhoff Tenckhoff Tenckhoff Swan-neck Tenckhoff Swan-neck Tenckhoff Swan-neck Missouri Swan-neck Missouri Swan-neck presternal Swan-neck Moncrief­ Popovich Swan-neck other Cruz (pail handle) Toronto Western Hospital Others Total

Cuffs (n) Single Double Single Double

Canada (n) (%)

Australia and South Pacific Total (n) (%) (n) (%) 9 100.0 30 90 11 3.0 8.0 1.0

307 55.0

500 45.0 85 62 7.7 5.6

Double Unknown Double Straight

Double

Coiled

Bent

104 19.0

33 18.0

137 12.4

Double

Straight

Bent

2

0.3

2

0.2

Double

Coiled

Bent

50

9.0

50

4.5

Triple

Coiled

Bent

16

3.0

16

1.5

Double

Coiled

Bent

5

1.0

12

6.5

17

1.5

Bent

4

0.7

4

0.4

Double

Coiled

Bent

29

5.2

29

2.6

Double Straight + discs

Straight

42

28.0

42

4.0

27 14.0 152 100 555 100 200 100 186 100 9 100

27

2.5

1102 99.9

IP = intraperitoneal; IM = intramural.

pediatric population. The catheter most commonly used worldwide in 2004 in the pediatric sample was again the Tenckhoff catheter. Regional distribution of the new catheters implanted in 2004 in the pediatric sample shows that, in

Canada, Tenckhoff and swan-neck catheters were used equally; in the respondent U.S. centers, slightly more Tenckhoff catheters than swan-neck catheters were used. In Mexico and Asia, the Tenckhoff catheter was the only catheter used. As was the case in the adult

150

Negoi et al. equally represented. In Europe, almost all catheters (97%) are double-cuffed, and in the only Asian center, all catheters used are double-cuffed. The types of intraperitoneal segments in pediatric catheters varied by location. The single responding program from Mexico and the one from Asia used only catheters with straight intraperitoneal segments in 2004. In contrast, new catheters implanted at centers in Canada, the United States, and Europe had coiled intraperitoneal segments almost exclusively. Overall, straight and coiled intraperitoneal segments were represented almost equally: 43% and 57% respectively. As in the adult programs, surgical implantation was the prevailing technique used by the pediatric centers (Table IV). Discussion In the early days of PD, Tenckhoff developed a safe and dependable PD catheter still widely used today. Many variations in catheter design have been developed over the years with the goal of improving catheter function and survival while reducing complications such as leaks and infections (2). About 20% of instances of PD technique failure and transfer to hemodialysis are attributable to complications of the PD catheter. The most common catheter-related complication is infection, which accounts for more than 75% of catheter losses. Only 25% of catheters are lost (3) because of technical problems (for example, dialysate leaks or drainage failures). Currently, data derived from randomized controlled multicenter trials dedicated to testing how catheter design and placement technique influence long-term catheter survival and function are lacking. As a result, there are no firm guidelines at the national or international levels on PD catheter type or implantation technique. The present analysis examined the practices of 65 international chronic PD centers concerning current use of all available PD catheters. The questionnaire was distributed in the registration packets at the Annual Dialysis Conference. More than 2000 international participants were present at the conference, but only 111 centers choose to respond to the survey. It is difficult to speculate why the response rate was so low; the survey was designed to be short and self-explanatory. Some regions--particularly Australia, Asia, and Mexico--were underrepresented at the meeting. We had to exclude 46 responses from the final analysis

1 Types of catheters implanted in adults in 2004 in all centers

FIGURE

TABLE II

Prevailing implantation techniques in adult patients in

2004 Mexico Australia and and Implantation Central South technique Canada U.S.A. America Europe Pacific Total Surgical Peritoneoscopic Fluoroscopic guidance Tenckhoff trocar Total 2 1 1 2 4 33 1 2 2 10 1 25 6 1 7 1 1 36 8 1 5 50

population, more swan-neck catheters than Tenckhoff catheters were implanted in 2004 by European pediatric centers. With the regard to number of cuffs, double-cuff catheters are used twice as often overall as are singlecuff catheters in the pediatric centers, but regional differences exist. In Canada, the United States, and Mexico, single- and double-cuff catheters are approximately

Current Trends in PD Catheters

TABLE III

151

Types and numbers of catheters implanted in 2004 in pediatric patients Catheter type Cuffs (n) Single Double Single Double Double Double Segment shape IP IM Straight Straight Coiled Coiled Straight Coiled Straight Straight Straight Straight Bent Bent Canada (n) (%) U.S.A. (n) (%) Mexico (n) (%) 60 45 4 50 23 44 7 14 22 42 52 100 57 43 Europe (n) (%) Asia Total (n) (%) (n) (%) 60 21 5 100 60 21 30 11 15 6 115 41 5 100 280 100

Tenckhoff Tenckhoff Tenckhoff Tenckhoff Swan-neck Tenckhoff Swan-neck Tenckhoff Total

10 3 8

9 3 7

4 8

50 100

105 100

89 81 110 100

TABLE IV

Prevailing implantation techniques in pediatric patients

in 2004 Implantation technique Canada U.S.A. Mexico Europe Asia Total Surgical Peritoneoscopic Fluoroscopic guidance Tenckhoff trocar Total 2 4 1 1 1 2 6 1 2 1 1 1 1 8 2 1 1 12

because they reported prevalent rather than incident catheters when the intent of the study was to estimate the preference and practice at the time of the survey. The outcome of the survey may not be representative for the entire worldwide PD population because of the low response rate and absence of data from some regions. The centers that responded to the current survey use the Tenckhoff catheter most often, with the swanneck catheter being the next most popular. These results are similar to those from the previous survey, conducted in 1994 at the Annual Dialysis Conference, except that the use of swan-neck catheters is increasing in Europe in both adult and pediatric respondent centers. In the previous report, Tenckhoff catheters were the preferred catheters in Europe. It may be that the distribution of catheter use has not changed significantly in the last decade because the acquired evidence does not strongly support the superiority of any other catheter over the original Tenckhoff catheter, especially in preventing peritonitis. Some evidence shows that the use of catheters with a permanent bend in the intramural segment is

beneficial, because these catheters are associated with fewer episodes of early outflow obstruction and catheter migration as compared with straight catheters traversing an arcuate tunnel, and these may be associated with a reduced incidence of catheter infection (4). Use of swan-neck catheters is increasing (1,5). In the 1994 survey (1), a dramatic increase in their use was noted in North America, and it now seems that Europe is following the same trend. A committee of the International Society for Peritoneal Dialysis (3,4) suggested that preferential use of catheters with permanent bend might be beneficial. Double-cuff catheters continue to be preferred over single-cuff catheters by both adult and pediatric respondent centers. Most catheters had two cuffs in both the current and the previous survey. The intraperitoneal segment of PD catheters can be coiled or straight. The coiled catheter is associated with less inflow pain, and was preferentially used in the adult sample in our survey. Of all new catheters, 70% had a coiled intraperitoneal segment in the 2004 adult sample, and that percentage represents an increase of 20 percentage points as compared with the 1994 survey. In children, coiled catheters are also preferentially used in Canada, the United States, and Europe. The respondent centers from Mexico, Central America, and Asia used all straight catheters in their pediatric patients in 2004. Interestingly, in Mexico and Central America, 60% of the reported adult catheters had coiled intraperitoneal segments, suggesting that the preference in this region regarding the type of intraperitoneal segment might differ in adults and in children. The pediatric PD literature does not support the use of one type of catheter over another. In a recent systematic review of available randomized controlled trials of peritoneal catheters, straight and coiled intraperitoneal segments were found to be

152 associated with similar rates of peritonitis, exit-site and tunnel infection, and catheter removal and replacement events (6). Regarding implantation technique, the surgical approach is still preferred in the adult and pediatric samples alike. Conclusions The Tenckhoff catheter remains the most widely used PD access in adult and pediatric programs; however, use of the swan-neck catheter is increasing. Worldwide, double-cuff catheters and coiled intra-abdominal segments predominate. Most centers (75% of adult centers and 69% of pediatric centers) use only one type of catheter. Acknowledgments The authors are grateful to Harold Moore for his support in editing the figure included in the article. References

1 Twardowski ZJ, Nolph KD, Khanna R, Prowant BF. Computer interaction: catheters. Adv Perit Dial 1994; 10:11­18. 2 Twardowski ZJ. History of peritoneal access develop-

Negoi et al.

ment. Int J Artif Organs 2006; 29:2­40. 3 Gokal R, Alexander S, Ash S, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. Official Report from the International Society for Peritoneal Dialysis. Perit Dial Int 1998; 18:11­33. 4 Flanigan M, Gokal R. Peritoneal catheters and exitsite practices toward optimum peritoneal access: a review of current developments. Perit Dial Int 2005; 25:132­9. 5 Thodis E, Passadakis P, Lyrantzopooulos N, Panagoutsos S, Vargemezis V, Oreopoulos D. Peritoneal catheters and related infections. Int Urol Nephrol 2005; 37:379­93. 6 Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Catheter-related interventions to prevent peritonitis in peritoneal dialysis: a systematic review of randomized, controlled trials. J Am Soc Nephrol 2004; 15:2735-46.

Corresponding author: Dana Negoi, MD, University of Missouri­Columbia, School of Medicine, Department of Medicine, Division of Nephrology, MA 436, One Hospital Drive, Columbia, Missouri 65212 U.S.A. E-mail: [email protected]

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