Catheter type, placement and insertion techniques for preventing peritonitis in peritoneal dialysis patients

Giovanni FM Strippoli; Allison Tong; David W Johnson; Francesco Paolo Schena; Jonathan C Craig

doi:10.1002/14651858.CD004680.pub2

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Figure 1

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Analysis 1.1

Comparison 1 Laparoscopy versus laparotomy, Outcome 1 All‐cause mortality.

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Analysis 1.2

Comparison 1 Laparoscopy versus laparotomy, Outcome 2 Peritonitis.

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Analysis 1.3

Comparison 1 Laparoscopy versus laparotomy, Outcome 3 Peritonitis rate (patient‐months).

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Analysis 1.4

Comparison 1 Laparoscopy versus laparotomy, Outcome 4 Exit‐site/tunnel infection.

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Analysis 1.5

Comparison 1 Laparoscopy versus laparotomy, Outcome 5 Catheter removal or replacement.

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Analysis 1.6

Comparison 1 Laparoscopy versus laparotomy, Outcome 6 Technique failure.

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Analysis 2.1

Comparison 2 Buried (subcutaneous) versus non‐buried catheter, Outcome 1 All‐cause mortality.

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Analysis 2.2

Comparison 2 Buried (subcutaneous) versus non‐buried catheter, Outcome 2 Peritonitis rate (patient‐months).

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Analysis 2.3

Comparison 2 Buried (subcutaneous) versus non‐buried catheter, Outcome 3 Exit‐site/tunnel infection rate (patient‐months).

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Analysis 2.4

Comparison 2 Buried (subcutaneous) versus non‐buried catheter, Outcome 4 Technique failure.

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Analysis 3.1

Comparison 3 Midline versus lateral insertion, Outcome 1 All‐cause mortality.

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Analysis 3.2

Comparison 3 Midline versus lateral insertion, Outcome 2 Peritonitis.

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Analysis 3.3

Comparison 3 Midline versus lateral insertion, Outcome 3 Exit‐site/tunnel infection.

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Analysis 3.4

Comparison 3 Midline versus lateral insertion, Outcome 4 Catheter removal or replacement.

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Analysis 4.1

Comparison 4 Straight versus coiled, Outcome 1 All‐cause mortality.

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Analysis 4.2

Comparison 4 Straight versus coiled, Outcome 2 Peritonitis.

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Analysis 4.3

Comparison 4 Straight versus coiled, Outcome 3 Peritonitis rate (patient‐months).

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Analysis 4.4

Comparison 4 Straight versus coiled, Outcome 4 Exit‐site/tunnel infection.

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Analysis 4.5

Comparison 4 Straight versus coiled, Outcome 5 Exit‐site/tunnel infection rate (patient‐months).

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Analysis 4.6

Comparison 4 Straight versus coiled, Outcome 6 Catheter removal or replacement.

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Analysis 4.7

Comparison 4 Straight versus coiled, Outcome 7 Technique failure.

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Analysis 5.1

Comparison 5 Single versus double cuff, Outcome 1 All‐cause mortality.

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Analysis 5.2

Comparison 5 Single versus double cuff, Outcome 2 Peritonitis.

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Analysis 5.3

Comparison 5 Single versus double cuff, Outcome 3 Exit‐site/tunnel infection.

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Analysis 5.4

Comparison 5 Single versus double cuff, Outcome 4 Catheter removal or replacement.

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Analysis 6.1

Comparison 6 Immobilisation versus no immobilisation, Outcome 1 Peritonitis.

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Analysis 6.2

Comparison 6 Immobilisation versus no immobilisation, Outcome 2 Exit‐site/tunnel infection.

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Table 1. Published guidelines on catheter related interventions in peritoneal dialysis

Guideline	Country	Year	Recommendation
Kidney Diseasese Outcome Quality Initiative (K‐DOQI)	United States of America	2000	No guideline
British Renal Association (BRA)	United Kingdom	2002	Catheter type: No peritoneal dialysis catheter has proven to be superior to the standard double cuff Tenckhoff catheter. In paediatric populations, no peritoneal dialysis catheter has proven to be superior to the standard double cuff Tenckhoff catheter. Swan neck tunnel, two cuff and downward pointing exit‐site may have an advantage. No guideline on catheter placement
Canadian Society of Nephrology (CSN)	Canada	2003	No guideline
European Best Practice Guidelines (EBPG)	Europe	2003	No guideline
International Society of Peritoneal Dialysis (ISPD)	Not applicable	2000	No catheter appears to be superior to the standard two cuff Tenckhoff catheter. Double cuff catheters are recommended to reduce peritonitis and improve catheter survival time. Peritoneal entry should be lateral or paramedian. Exit‐site should be facing downwards or be directed laterally. Upward‐directed exit sites should in general be avoided
Caring for Australians with renal Impairment (CARI)	Australia	2003	No peritoneal dialysis catheter has proven to be superior in the prevention of peritonitis (level III evidence). There is no technique of insertion of a peritoneal dialysis catheter that has consistently proven to be superior in the prevention of peritonitis (level II evidence)

Table 1. Published guidelines on catheter related interventions in peritoneal dialysis

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Table 2. Electronic search strategies

Database searched	Search terms
CENTRAL (Issue 2 2004)	#1 peritoneal next dialysis #2 PERITONEAL DIALYSIS (MeSH explode)) #3 pd or capd or ccpd #4 #1 or #2 or #3 #5 PERITONITIS (MeSH) #6 periton* #7 #5 or #6 #8 #4 and #7
MEDLINE (1966 to April 2004)	1 exp Peritoneal Dialysis/ 2 peritoneal dialysis.tw. 3 (PD or CAPD or CCPD).tw. 4 or/1‐3 5 Catheters, Indwelling/ 6 catheter$.tw. 7 or/5‐6 8 Peritonitis/ 9 peritonitis.tw. 10 (periton$ and infect$).tw. 11 or/8‐10 12 and/4,7,11 13 pc.fs. 14 (plac$ or insert$).tw. 15 (break‐in or immobil$).tw. 16 surg$.tw. 17 or/13‐16 18 12 and 17 19 and/4,11,13 20 18 or 19

Table 2. Electronic search strategies

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Comparison 1. Laparoscopy versus laparotomy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	2	193	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.52, 2.26]

2 Peritonitis Show forest plot	3	238	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.41, 1.15]

3 Peritonitis rate (patient‐months) Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Exit‐site/tunnel infection Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

5 Catheter removal or replacement Show forest plot	2	90	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.49, 2.13]

6 Technique failure Show forest plot	3	206	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.45, 1.08]

Comparison 1. Laparoscopy versus laparotomy

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Comparison 2. Buried (subcutaneous) versus non‐buried catheter

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	2	119	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.39, 2.08]

2 Peritonitis rate (patient‐months) Show forest plot	2	2511	Risk Ratio (M‐H, Random, 95% CI)	1.16 [0.37, 3.60]

3 Exit‐site/tunnel infection rate (patient‐months) Show forest plot	2	2511	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.39, 3.42]

4 Technique failure Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 2. Buried (subcutaneous) versus non‐buried catheter

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Comparison 3. Midline versus lateral insertion

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Peritonitis Show forest plot	2	120	Risk Ratio (M‐H, Random, 95% CI)	0.65 [0.32, 1.33]

3 Exit‐site/tunnel infection Show forest plot	2	120	Risk Ratio (M‐H, Random, 95% CI)	0.56 [0.12, 2.58]

4 Catheter removal or replacement Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 3. Midline versus lateral insertion

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Comparison 4. Straight versus coiled

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	4	209	Risk Ratio (M‐H, Random, 95% CI)	0.26 [0.07, 0.99]

2 Peritonitis Show forest plot	5	324	Risk Ratio (M‐H, Random, 95% CI)	1.14 [0.73, 1.79]

3 Peritonitis rate (patient‐months) Show forest plot	4	2589	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.63, 1.26]

4 Exit‐site/tunnel infection Show forest plot	6	332	Risk Ratio (M‐H, Random, 95% CI)	1.26 [0.91, 1.73]

5 Exit‐site/tunnel infection rate (patient‐months) Show forest plot	3	1993	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.73, 1.47]

6 Catheter removal or replacement Show forest plot	5	275	Risk Ratio (M‐H, Random, 95% CI)	1.11 [0.53, 2.31]

7 Technique failure Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 4. Straight versus coiled

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Comparison 5. Single versus double cuff

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 All‐cause mortality Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Peritonitis Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

3 Exit‐site/tunnel infection Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4 Catheter removal or replacement Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 5. Single versus double cuff

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Comparison 6. Immobilisation versus no immobilisation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Peritonitis Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2 Exit‐site/tunnel infection Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

Comparison 6. Immobilisation versus no immobilisation

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