Stratification of Risk Factors of Complications Associated with Peritoneal Dialysis Catheter Placement

Abstract

Background:

Peritoneal dialysis (PD) is a frequent method for renal replacement therapy in pediatric population. However, PD is associated with a high incidence of early and late complications. Thus, this study aims to evaluate the perioperative factors associated with these complications.

Methods:

Clinical records of patients who had peritoneal dialysis catheter (PDC) placement between January 2013 and June 2016 were retrospectively analyzed. Sociodemographic and perioperative variables were recorded and analyzed.

Results:

A total of 92 patients required PDC insertion. Primary PDC failure occurred in 21.74% of cases, and 17.39% required reoperation. The most common complication was occlusion (13.04%), followed by leak (8.7%). Age younger than 1 year and weight less than 10 kg were significant risk factors for catheter dysfunction, reoperation, leak, PDC occlusion, hernia, and death. The open technique was associated with higher risks of operation, leak, and peritonitis than the laparoscopic technique. Placement of the catheter by the laparoscopic technique reduced the odds of occlusion by 38%.

Conclusions:

Patients younger than 1 year and weighing less than 10 kg have an increased risk of complications and death, regardless of the technique used. The most frequent complication is catheter failure; however, the laparoscopic technique appears to reduce this complication.

Introduction

Peritoneal dialysis (PD), first described by Tenckhoff in 1968, is the gold standard treatment for pediatric patients with kidney failure, offering benefits over hemodialysis such as preservation of residual kidney function, lower incidence of complications, shorter hospital stays, better pain control, and improved cost-effectiveness and nutritional status.^1,2 However, PD may result in complications that can lead to catheter dysfunction and removal, which can be mechanical or infectious and related to various factors, including medical and nutritional status, surgical technique, and postoperative complications.³

There are three different approaches for catheter placement: laparotomy, laparoscopy, and percutaneous puncture. Percutaneous puncture is not recommended for children due to its association with higher rates of complications such as intestinal perforation and catheter failure.^1,4 Laparoscopy is a safe and effective method compared with the open technique, with similar rates of catheter dysfunction and infection but has advantages such as better aesthetic results, shorter hospital stays, and better pain control. The literature does not show a significant difference in catheter dysfunction and complications between the two approaches, although some authors report a lower incidence of leaks with laparoscopy.^4,5

Thus, choosing between open and laparoscopic techniques for peritoneal dialysis catheter (PDC) placement can be challenging for pediatric surgeons because of the lack of studies comparing complications of catheter failure between both techniques. This study aims to analyze the risk factors associated with PDC placement using laparoscopic or open techniques and to evaluate complications related to the patient's condition and the postoperative period in pediatric patients undergoing PDC placement in our institution, providing insight into the short-term outcomes of each approach.

Methods

Study population

This study is a retrospective analysis of patients who underwent PDC placement between January 2013 and June 2016 at Hospital Fundación HOMI in Bogotá, Colombia.

All patients provided informed consent before the procedure, and the study protocol was approved by the institution's review board committee. The protocol was implemented according to the provisions of the Declaration of Helsinki and Good Clinical Practice guidelines.

Inclusion and exclusion criteria

The inclusion criteria were all patients who underwent PDC placement by different approaches (open versus laparoscopy) at the institution from January 2013 to June 2016. The exclusion criteria were patients who could not have proper follow-up. Follow-up was conducted until the removal of the catheter, the last medical visit, or death.

Data collection

Relevant data were collected from the patients medical records, including mortality, incisional hernia, reoperation, catheter failure secondary to leak, occlusion, infection such as peritonitis (defined by a positive peritoneal culture), abdominal wall infection (subcutaneous tunnel), and other complications (catheter rupture, erosion). Spearman's and Pearson's methods were used to correlate some variables (the presence of infection, reoperation, and hernia) with the surgical approach used for catheter placement. In addition, the total complications were correlated with the weight and age of the patients. For statistical analysis, we used the Statistical Package for the Social Sciences (SPSS) version 18 for Apple.

The procedures were performed by 12 pediatric surgeons under general anesthesia. Each surgeon chose the open or laparoscopic technique based on their criteria and expertise. In all cases, omentectomy was performed (in laparoscopy through the umbilical port). The catheters used were 30 cm length (straight), 40 cm (curled), and 57 cm (curled with introducer kit for the Seldinger technique).

Definitions

Therapeutic success was defined as the PDC that did not have any complication and did not require reoperation. The leak was defined as filtration around the catheter and from the incision site. Incisional hernia was defined as an abnormal protrusion or hernia sac through a scar of a surgical procedure.

Results

Patient's demographics

The study included a total of 92 patients, of whom 37 were female and 55 were male. The mean age was 7.59 years, ranging from 3.65 to 17 years (standard deviation [SD]: 5.92). Patients were grouped by age as follows: 9.79% were younger than 1 month, 16.3% were between 1 month and 1 year old, 17.39% were between 1 and 5 years old, 15.22% were between 5 and 10 years old, and 41.3% were older than 10 years. Patients were also grouped by weight, with 56.52% weighing more than 10 kg. The mean weight was 24.37 kg, ranging from 0.87 to 106 kg (SD: 18.96) (Table 1).

Table 1.

Patient's Demographic Characteristics

Demographic	n (%)
Gender
Female	37 (40.2)
Male	55 (59.8)
Comorbidities
Prematurity	12 (13.04)
AKI	38 (41.32)
CKD	29 (31.51
Acute exacerbation of CKD	19 (20.63)
No data	6 (6.54)
Previous intervention
Previous abdominal surgery	45 (48.90)
Previous PDC placement	32 (34.81)

AKI, acute kidney injury; CKD, chronic kidney disease; PDC, peritoneal dialysis catheter.

Regarding patient comorbidities, 13.04% were premature at the time of the procedure, 41.32% had acute kidney injury (AKI), 31.51% had chronic kidney disease (CKD), 20.63% had acute exacerbation of chronic renal failure, and no data were available for 6.54% of patients. In addition, 48.90% of children had previous abdominal surgery, and 34.81% had previously undergone PD placement.

Of the PD placements, the curled catheter was used in 56.53% (52) of patients and the straight catheter was used in 17.39% (15) of patients. In 26.08% (33) of cases, no data were found regarding catheter type. The most used catheter length was 57 cm in 36.96% of cases, although the catheter length was not recorded in 32.61% of cases. The mean days with catheter was 48.62 days, ranging from 1 to 480 days (SD: 77.44). The time from catheter placement to first use was 1.22 ± 0.26 days, ranging from 0.5 to 19 days (SD: 2.5). Surgical techniques were categorized as either open surgery or laparoscopic surgery. Of the patients, 75% underwent open surgery and 25% underwent laparoscopic surgery.

Complications

Complications were observed in 21.74% of catheters placed, with 17.39% requiring reoperation. The main cause of failure was occlusion in 13.04% of patients, followed by leak in 8.7%. Peritonitis, abdominal wall infection, and catheter site hernia were found in 7.61%, 4.35%, and 2.17% of patients, respectively. Of patients requiring reintervention, 81.25% had catheter dysfunction. No other complications were observed after reoperation (Table 2).

Table 2.

Complications Associated with Peritoneal Dialysis Catheter Placement

Complication	n (%)
Catheter failure	20 (21.74)
Occlusion	12 (1.304)
Leak	8 (8.69)
Reoperation	16 (17.39)
Peritonitis	7 (7.61)
Subcutaneous tunnel infection	4 (4.35)

In addition, 5.43% of patients experienced two or more complications. Of these, 1.08% had hernia and leak, 1.08% had peritonitis and catheter occlusion upon catheter return, 1.08% had peritonitis, subcutaneous tunnel infection, and catheter occlusion, 1.08% had leak and rupture of the catheter, and 1.08% had leak and blockage in the catheter.

Age-based complications

Of the patients who required reoperation, 50% were younger than 1 year, and 47.3% of those with catheter failure were younger than 1 year. In a multivariable analysis, we observed that children younger than 1 year were 3.75 times more likely to require reoperation (confidence interval [CI]: 1.21–11.5, P = .04), 3.48 times more likely to experience catheter dysfunction (CI: 1.2–10, P = .004), 5.7 times more likely to experience leakage (CI: 1.24–26.06, P = .04), 3.44 times more likely to experience catheter occlusion (CI: 0.98–11.99, P = .03), and 2.9 times more likely to develop postoperative incisional hernia (CI: 0.17–48, P = .005). There were no significant differences in subcutaneous tunnel infection or peritonitis according to different age groups. Also, children younger than 1 year had 2.18 times the likelihood of mortality (0.68–6.97, P = .015), and premature children had 3.79 times the risk of death (0.57–24.9, P = .04).

Regarding prematurity, we found an increased risk of reoperation (1.2 for premature newborns or patients) and a 2.7 times higher risk of catheter malfunction, both with P < .05. Other complications such as leakage, wall infection, or peritonitis showed no statistical differences associated with prematurity.

Weight-based complications

Of the patients with dysfunctional catheters, 52.6% weighed less than 10 kg, and 85.1% of those patients were operated on using the open technique. They were 3 times more likely to require reoperation (CI: 0.98–9, P = .03), 3.6 times more likely to experience catheter malfunction (CI: 1.2–10, P = .05), 9 times more likely to experience leakage (CI: 1.68–48, P = .005), and 2.8 times more likely to experience occlusion (CI: 0.81–9.67, P = .023). There were no significant differences in subcutaneous tunnel infection, peritonitis, or the presence of postoperative hernia.

Complications according to the surgical technique

In a univariate analysis, the risk of reoperation was three times higher (63%) when the catheter was placed using the open technique compared with the laparoscopic technique, which was statistically significant (P < .05). The risk of leakage was 2.48 times higher with the open technique compared with the laparoscopic placement, which was also statistically significant (P < .05). In addition, the risk of presenting peritonitis was twice as high with the open surgery technique, which was also statistically significant (P < .05).

Performing the procedure using the laparoscopic technique reduced the probability of obstruction by 38%, with a CI of 0.16–2.29 and a P value of .006. However, regarding the infection of the subcutaneous tunnel and the presence of postoperative hernia, there were no statistically significant differences between the two surgical techniques (Table 3).

Table 3.

Complications According to the Surgical Technique

Complication	Open technique, % (n)	Laparoscopic technique, % (n)	P
Catheter failure	16.3 (15)	5.43 (5)	.0018
Reoperation	13.04 (12)	4.08 (4)	.043
Occlusion	8.69 (8)	4.34 (4)	.286
Leak	9:58 pm	1.08 (1)	.048
Peritonitis	6.52 (6)	1.08 (1)	.071
Subcutaneous tunnel infection	3.26 (3)	1.08 (1)	.306
Postoperative hernia	1.08 (1)	1.08 (1)	1.00

When it came to patients who had previous surgery and PDC, surgeons chose the open technique 1.69 times more often if they had previous surgery, with a CI of 0.64–4.43 and a P value of .009. There was also a 1.29 times higher risk of performing open surgery if the child had a previous catheter, with a CI of 0.47–3.58 and a P value of .002.

Complications according to the type of catheter

In our institution, the 57 cm length catheter has an introducer kit (with needle and tunneling stylet for placement by the Seldinger video-assisted technique), whereas the other lengths (30 and 40 cm) do not have the kit. Using this method, we found a 62% reduction in the risk of presenting catheter failure, with a CI of 0.11–1.26 and a P value of .022. The risk of leakage was reduced by 78%, with a CI of 0.025–1.87 and a P value of .021. In addition, the risk of occlusion was reduced by 70%, with a CI of 0.061–1.47 and a P value of .022. However, with this technique, there was an increased risk of infection of the abdominal wall (tunnel) by 75%, with a CI of 0.23–13 and a P value of .0034.

Regarding the straight or curled catheter, we found that the catheter was seven times more likely to fail if it was straight, with a CI of 2.04–24.5 and a P value of .013. In addition, there was a 30 times higher chance of leakage if the catheter was straight, with a CI of 3.31–282 and a P value of .018. Furthermore, there was a 2.14 times higher risk of occlusion with straight catheters, with a CI of 0.53–8.54 and a P value of .015. No increased risk of infection was found when a straight catheter was used.

Discussion

Since the introduction of peritoneal access after World War II, there have been numerous modifications in the design of catheters. However, in 1968, Tenckhoff and Schechter developed a silicone rubber catheter with a single or two polyester cuffs that became the standard for the treatment of acute and chronic renal failure.⁶ Placing dialysis catheters in the pediatric population is challenging due to the high rate of complications involved. Therefore, researchers aim to identify perioperative risk factors and modifiable factors to improve outcomes.

In Radtke et al.'s study, the incidence of reoperation in the first 6 months was 24.3%, and Stewart et al. reported a total of 45.7% of complications.^3,7 However, in our study, we found a lower complication rate than them, with 21.74% of dysfunction catheters and a reoperation rate of 17.39%. The main complications were related to catheter infections (peritonitis and infection of the insertion site) and dysfunction (leakage, occlusion).

Radtke et al.'s study showed that the most frequent complication was infection (peritonitis) in 18.6% of patients, followed by occlusion in 12.9% of patients.⁵ In Stewart et al.'s study, occlusion was reported as the first complication in 34% of cases.⁷ Nevertheless, catheter occlusion is not a common complication in the first months postoperatively, but rather years later.⁸ In our study, the most frequent complication was occlusion, followed by leak, with no differences between the open and laparoscopic technique. We also reported peritonitis in a minor proportion regarding those studies, with only 7.61% of patients.

Regarding age, Phan et al.⁹ showed that patients younger than 1 year had higher rates of reoperation, leakage, and hernias, with increased mortality. Prematurity was associated with postoperative hernias, but not with higher rates of reoperation or other complications. In our study, patients younger than 1 year had a higher risk of reintervention, catheter failure, and postoperative hernia, and in the premature population, we identified an increased risk for catheter failure and mortality. There was no statistically significant difference in the incidence of abdominal wall infection, peritonitis, or postoperative hernia in patients weighing less than 10 kg.

In 2003, Lo et al. conducted the first prospective randomized trial and found that curled catheters had a higher migration rate than straight catheters.¹⁰ In contrast, in 2017, Borzych-Duzalka et al. reported in their cohort study that the use of Tenckhoff curled catheters with a swan neck tunnel was associated with a high risk of reintervention for catheter placement revision.³ Nevertheless, Hagen et al. published a meta-analysis of 13 randomized controlled trials on PDC placement, which showed that there was no significant difference in the incidence of infection, peritonitis, catheter dysfunction, or leakage between curled and straight catheters.^10,11 In our study, we found that the straight tip catheter failed more frequently than the curled catheter, presenting 30 times more leaks than the curled catheter and with higher rates of reoperation.

As described by Stringel et al., laparoscopy offers more benefits over open surgery, allowing for complete visualization of the peritoneal cavity, more precise placement of the catheter, the ability to perform omentectomy, and the treatment of other complications such as adhesions or inguinal hernias.^1,12 Two meta-analyses have shown no difference between the two surgical approaches.^11,14 In 2012, Xie et al. found that laparoscopic PDC placement prolonged the operating time, but there were no differences in complications such as leaks, catheter migration, or hernias.^13–15 In our univariate analysis, we found significant differences depending on the surgical technique used, independent of age and weight. The risk of reoperation and catheter leakage was greater when the surgery was performed through an open technique. Moreover, performing the procedure using the laparoscopic technique resulted in a 38% reduction in catheter occlusion.

Our findings support the hypothesis that the laparoscopic technique is superior to the open technique for PDC placement in children, with lower rates of complications (less probability of reoperation, less risk of catheter leakage, and obstruction). We recommend using pigtail catheters, and their placement should be done using the video-assisted Seldinger technique kit (less risk of dysfunction), considering that patients younger than 1 year and weighing less than 10 kg have a higher risk of complications and death, regardless of the technique used.

Placing the PDC using the video-assisted Seldinger technique showed a reduced risk of catheter failure by 62%, as well as a decreased risk of leakage and occlusion. This may be related to the chosen technique, as the long preperitoneal tunnel with pelvic direction allows the catheter to enter the abdominal cavity obliquely and not perpendicularly, maintaining the pelvic position for longer, helping to decrease the risk of leakage. In addition, the kit allows for a tighter insertion, decreasing the risk of major openings in the abdominal wall. Our results showed that the Seldinger technique was the most appropriate for PDC placement.

The main limitation of this study is that it is an observational retrospective study without randomization and no control group. It is, therefore, subject to selection bias. Also, we combine data from patients with acute kidney disease and CKD, and there may be differences regarding complications among these patients that were not considered. In addition, the lack of statistical significance may be explained by the size of our cohort and the number of variables assessed. Furthermore, studies will be necessary to be prospective, comparing indications and techniques.

Conclusions

In conclusion, our study suggests that children younger than 1 year and weighing less than 10 kg are at an increased risk of complications and death, regardless of the technique used for PDC placement. The most common complication observed was catheter failure, primarily due to device obstruction. However, our findings suggest that the laparoscopic technique may help reduce the risk of catheter failure compared with the open technique. We recommend the use of pigtail catheters, with their placement done using the video-assisted Seldinger technique kit to reduce the risk of dysfunction.

Further prospective studies are needed to compare the indications and techniques used in PDC placement to determine optimal strategies for reducing complications and improving patient outcomes.

Footnotes

Acknowledgments

To Dr. Lorena Lamprea and Dr. Diego Holguin for their help and support to make this study.

Authors' Contributions

D.A.H.S.: Conceptualization, writing, formal analysis, writing original draft. I.J.: Editing, writing, analysis. D.M.V.: Editing, writing, analysis. M.P.: Editing, writing, analysis. D.H.: Software and analysis. I.D.M.R.: Review, methodology (lead).

Disclosure Statement

No competing financial interests exist.

Funding Information

All authors state no funding was received for this study.

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