Firing on both cylinders: The case for dual-pathway peritoneal dialysis catheter insertion

Peritoneal dialysis (PD) is being promoted worldwide and timely access to reliable PD catheter insertion and revision are critical determinants of program success.^1–7 While many experts believe that advanced laparoscopic placement of catheters is superior to other approaches, there are no randomized controlled trials to corroborate this, although investigators in the Netherlands reported an ongoing trial, the results of which are yet to be published. ⁸ Trials comparing basic laparoscopy, open surgical, and percutaneous approaches were single center, had small sample sizes, and have not shown a consistent advantage of one technique over another in terms of patient or catheter outcomes.^9–13 Whether there are populations of patients who have equivalent outcomes with either surgical or percutaneous placement, or populations where one technique is preferred over another is not clear.

In this issue of Peritoneal Dialysis International, Hill et al. present an interesting, timely, and policy-relevant cost-effectiveness analysis that compares two models of service delivery: a dual insertion pathway for PD catheter placement (surgical and medical) and surgical insertion alone. ¹⁴ The study leverages data from the U.K. PD Catheter Study and demonstrates that a dual insertion pathway improves clinical outcomes and yields modest cost savings compared to surgical insertion alone. ¹⁵

The original U.K. PD Catheter Study included 784 first PD catheter insertions at 44 of the 72 sites in the United Kingdom. The cost-effectiveness analysis is conducted from the health system perspective and simulates patient trajectories from the time of catheter insertion and estimates lifetimes costs and quality-adjusted life years (QALYs). The dual insertion pathway was associated with fewer PD-related complications, longer time on PD, improved quality of life (0.12 QALYs), and marginally lower costs (£214 savings), making it a dominant strategy in the base case analysis. The probability of cost-effectiveness exceeded 99% at conventional thresholds. These findings support the adoption of dual-insertion pathways.

This study has several key strengths. First, it is based on one of the largest, prospective, multicenter cohort studies of PD catheter insertion done to date. Second, the authors take a comprehensive approach to modeling clinical outcomes, quality of life, and costs over the lifetime of the patient. Third, the incorporation of U.K.-specific measures of health utility and costs, in combination with clinical outcome data from the majority of PD centers, provides information that is relevant to service planning and health care policy in the United Kingdom and beyond.

There are several limitations that warrant caution when interpreting the results or generalizing them to other jurisdictions. First, the authors demonstrate that their findings are robust to ranges of model parameters in sensitivity analyses, but they do not vary the estimate of the relative effectiveness of medical and surgical catheter placement, which is the key variable in the analysis, and based on observational data. At a minimum, it would have been interesting to vary it over a plausible range, if even to reflect the uncertainty of the estimate in the original study on which it's based. It is important to also consider the relative effectiveness of these two techniques may vary by region, operator expertise and experience, and patient selection. ¹⁶ Percutaneous placement of catheters appears to be much more widespread in the United Kingdom and operators likely have more experience with that approach. There are also technical considerations that are worth noting, including the fact that the majority of catheters in both medical and surgical groups had a deep cuff placed in the midline. ¹⁵ The paramedian approach was used in only 14% of medically placed catheters and 24% of surgically placed catheters, but is the approach recommended by guidelines and allows for rectus sheath tunneling and placement of the deep cuff in the rectus muscle. ¹⁷ Second, the authors make the assumption that the patient populations undergoing surgical placement of PD catheters in both groups are equivalent, but when both techniques are available, there would likely be some patient selection that might introduce bias and impact the surgical outcomes observed. Third, all surgical approaches and all medical approaches to PD catheter placement were lumped together and compared. While there are no randomized data to confirm there is a difference in outcomes, it's possible certain techniques, like advanced laparoscopy, are superior and focusing exclusively on these approaches might tilt the balance in favor of one group, if used exclusively.

The findings of this study should be reassuring for programs that only have access to a single method of insertion and access to resources or personnel is limited, as both medical and surgical pathways appeared equivalent. Further, there are centers that might not have access to PD catheter insertion and attracting or training percutaneous (medical) operators is likely more feasible than funding and developing a surgical program. They can confidently pursue this path knowing that they are likely to have acceptable outcomes.

While the preferred method of PD catheter insertion will continue to be debated, the broader impacts of a dual insertion pathway are important to consider. A medical pathway for placement of PD catheters may increase the accessibility and timeliness of PD catheter placement, make the introduction of an urgent start PD program feasible, and expand the pool of potential PD candidates to those who can’t tolerate a general anesthetic. In addition, access to surgical services is important in complex cases or when dealing with complications or the need for catheter revision or replacement.

From a clinical perspective, this study further highlighted the significant risk of PD catheter-related complications. In the U.K. PD Catheter Study, the risk of catheter-related events in the first year of therapy was 61% and nearly 30% of patients had catheter dysfunction that led to interruption of therapy or transfer to HD. ¹⁵ Prior studies have suggested that nearly one-quarter of PD patients experienced a catheter-related complication, such as flow restriction, pain, leaks, or infections, in the first six months of PD and up to 20% terminated therapy.^18,19 This is important to consider when counseling patients about PD catheter insertion and setting expectations.

However, there are still outstanding questions and future work should focus on the identification of clinical and technical factors that contribute to catheter-related complications. Are we able to identify operators who achieve excellent outcomes with each technique, and if so, what is different about them? Are these operator characteristics as important, or more important, than method of insertion? Are there geographic differences in outcomes that must be considered in decision-making? Perhaps, there are subgroups of patients who do better with one approach and some who would have good outcomes with either. This should only be examined in cohorts who are candidates for both options. Finally, the role of advanced techniques such as omentopexy, adhesiolysis, and rectus sheath tunneling to reduce catheter malfunction are not clear and warrant further study.

In conclusion, the findings from Hall et al. support a strategy of investing in multidisciplinary, flexible programs of PD access creation to achieve the goal of maximizing the safe and effective use of PD therapy. Investigators should build on this foundation to further refine PD catheter insertion strategies, incorporate patient preferences, and realize the goals of accessibility, efficiency, and sustainability in kidney care.