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 perlj@smh.ca

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