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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 intra-peritoneal segments. Surgical implantation technique remains the prevailing placement method in both pediatric and adult respondent centers.

Background: The presternal peritoneal catheter is composed of two silicone rubber tubes joined by a titanium connector at the time of implantation, and has an exit on the chest., Objective: Comparison of survival and complication rates of Swan neck abdominal catheters with those of the presternal catheter., Design: Nonrandomized study with prospective collection of data between August 1991 and October 1997., Setting: Tertiary referral center., Patients: In 57 patients, 58 presternal catheters and, in 81 patients, 86 abdominal catheters were implanted. Patients chose the type of catheter; however, obese individuals and those with ostomies and previous catheter problems were encouraged to opt for the presternal catheter. Others chose the presternal catheter in order to take tub baths or use a whirlpool., Main Outcome Measures: Life-table analyses of catheter survival censored for transplant, transfer, and death; reasons for catheter removal due to complications; and patient satisfaction., Results: Two-year survival probabilities were 0.95 and 0.75 for presternal and abdominal catheters, respectively. Nine abdominal catheters were removed due to exit/tunnel infections (including five with peritonitis), and four due to peritonitis. External cuff shaving in four presternal catheters has extended survival for more than 1 year. Four presternal catheters were removed due to peritonitis. No catheters in either group were lost due to leakage or obstruction. The peritonitis rate was 1 episode per 37.4 patient-months and 1/20.5 patient-months for presternal and abdominal catheters, respectively. These differences are not significant. Patient acceptance of the presternal catheters was excellent; in the latest period, from January to October 1997, presternal catheters were chosen by 15/24 patients., Conclusions: The trend to improved outcomes in presternal catheters continues to validate the rationale for presternal catheter design. Decreased frequency of exit/tunnel infection may be due to more effective immobilization on the chest, less trauma, and avoidance of submersion in stagnant water. No specific contraindications to use of the presternal catheter have been identified.

Background: Damage to the peritoneal dialysis catheter may be due to wear from long-term use, exposure to antibacterial agents (strong oxidants), and accidental injury from sharp objects. Repair of such catheter, if not associated with subsequent complications, would extend catheter life and reduce costs and patient inconvenience related to catheter replacement., Objective and Design: Retrospective analysis of seven peritoneal catheters repaired 11 times over a 15-year period by splicing the old catheter with an extension tube using the Peri-Patch Repair Kit (Quinton Instrument Co., Bothwell, WA, U.S.A.)., Results: The life of these seven catheters was extended by a mean of 26 months (range 1-87 months), without increasing infection rates after splicing. The peritonitis rate after catheter splicing was 0.40 per year, not higher than the overall rate (0.76 per year) in our center during the same time period. Exit-site infections occurred in 6 patients after catheter splicing. Only one infection was related to trauma during the procedure and resulted in chronic exit infection; the catheter was eventually removed. In this patient, damage to the catheter was less than 1.5 cm from the exit site., Conclusions and Recommendations: Splicing of the damaged peritoneal catheter, if properly done, is a safe procedure and can significantly prolong catheter life. We recommend that measures to prevent catheter damage, such as avoiding the use of scissors and other sharp objects, should be emphasized during the initial patient education and training. Alcohol and iodine should not be used on silicone rubber catheters. We suggest that the patient should report catheter damage immediately and come to the clinic within a few hours for catheter splicing (if possible) and prophylactic antibiotic to prevent peritonitis. Finally, we recommend that repair of the catheter should not be attempted if the breakage is less than 2 cm from the exit site, unless done as an emergency procedure if immediate catheter replacement cannot be performed.

Objective: The purpose of the study was to obtain information from nephrology nurses on existing policies and protocols related to peritoneal catheter exit site care and treatment of exit site infections., Design: This was an explorative, descriptive study., Sample/setting: Fifty-four nurses who attended the 1995 Consensus Conference on Peritoneal Dialysis at the 26th Annual American Nephrology Nurses' Association National Symposium completed a survey questionnaire on exit site care and management of exit site infections., Methods: A survey was mailed to nephrology nurses preregistered to attend the 1995 ANNA Consensus Conference related to peritoneal dialysis at the 26th National Symposium. Surveys were also collected at the meeting., Results: Hydrogen peroxide and povidone iodine are frequently used in the nursing care of both healing and chronic exit sites. Almost all of the dialysis units require patients to stabilize or secure the catheter. The majority of respondents had a standardized method of assessing exit sites. Risk factors for exit site infections are presented for both the immediate post-catheter insertion period and the well-healed exit site. There were many different combinations of cleansing agents used to treat inflamed and infected exit sites., Conclusions: Procedures for exit site care vary widely. Prospective, randomized studies of exit site care protocols and cleansing agents are necessary to determine the most effective procedures to promote healthy exit sites.

Nursing interventions related to peritoneal catheter exit-site infection include an emphasis on prevention and early diagnosis as well as exit-site care. The key elements to prevention of exit-site infections are avoiding trauma to the exit-site and tunnel, avoiding gross contamination of the exit-site, and cleaning a wet or dirty exit-site as soon as possible. Early diagnosis of exit-site infection is promoted by (1) teaching the patient or caregiver to assess the exit-site and tunnel routinely and to promptly recognize and report signs and symptoms of inflammation, and (2) routine exit-site evaluation by health care providers in the outpatient clinic. Care of the infected exit-site should focus on preventing cross contamination, keeping the exit-site dry, avoiding trauma and irritation, and in addition to routine care, may require removal of stubborn crusts and cauterization of proud flesh. Topical soaks and therapy have been recommended, but improvement of infected exit-sites has not been consistently documented.

Contrary to peritonitis, where the clinical presentation is clearly different from that of normal, there is a spectrum of appearances from uninfected to infected exit sites. This led to imprecise definitions of exit-site infection, difficulties in interpreting the results of various studies, and many, varied treatment recommendations. We have performed 565 evaluations of 61 healed exit sites in 56 patients. The exit and the sinus were inspected using a Zeiss prism loupe with 4.5x magnification for the presence, absence, intensity, and/or characteristics of specific attributes such as swelling, color, crust, drainage, granulation tissue, and epithelium in the sinus. Pictures of the external exit and the visible sinus tract were then drawn and photographs of the exit site and visible sinus tract were taken. Visual attributes discerned by loupe inspection were verified by review of photographs. A new classification was developed with six distinct categories of exit appearances: acute infection, chronic infection, external cuff infection, equivocal, good, and perfect. Finally, the category of traumatized exit was established, because trauma may result in various appearances. The outcomes in each category were correlated with treatment measures in a 5-year longitudinal study. The validity of this classification and its applicability to clinical practice was subjected to further investigation in a cross-sectional study. Forty-five patients were evaluated only once by ZJT using a Zeiss prism loupe and by the primary nurse, who used a handheld magnifier. The features were recorded and classification was made. The results of loupe and magnifier evaluations were then compared regarding agreement in discerning features. In 41 evaluations (91%) there was agreement. The new classification may be useful in making treatment decisions, in reporting exit-site infection data, and in designing improved prospective, randomized studies.

The study goals were (1) to describe the natural healing process post peritoneal dialysis catheter implantation; (2) to discern factors that predispose to exit infection; (3) to recognize signs of early exit-site infection; and (4) to ascertain the influence, if any, of the healing process on subsequent peritonitis rates and final catheter outcomes. There were 226 evaluations of 43 exits [range 3-6 per exit, mean 5.2 + or - 1.1 (SD)] in 41 patients. Eleven exits were in the parasternal area and 32 exits were in the abdomen. Exit sites and sinus tracts were examined weekly for 6 weeks with a magnifying loupe and macro-photographed. Cultures were taken from sterile saline sinus washouts, periexit smears, and nares. Exit sites were categorized into four types: (1) fast-healing exits had no drainage or minimal moisture deep inside by the third week; epidermis started to enter into the sinus within 2-3 weeks, progressed steadily, and covered at least half the visible sinus tract 4-6 weeks after implantation; (2) in slow-healing exits without infection, epidermis started to enter into the sinus after 3 weeks or progressed slowly and did not cover half the visible sinus by 5 weeks; the sinus might have had serous or serosanguineous, but never purulent, drainage persistent up to 4 weeks; (3) healing interrupted by infection initially looked identical to the fast-healing exit, but within 6 weeks the epidermis did not progress or regress, granulation tissue became soft or frankly fleshy; drainage increased and/or became purulent; (4) in slow-healing exits due to early infection, granulation tissue became soft or fleshy and/or drainage became puru lent by 2-3 weeks; sinus epidermization was delayed or progressed slowly, only after infection was appropriately treated. Compared with patients with fast-healing exits, patients with early infected exits were more likely (although not significantly) to be diabetics, to have an abdominal catheter, wound hematoma, higher body mass index, and higher percentage of positive cultures for Staphylococcus aureus in nares. Early colonization of the exit was the most significant factor in determining the healing pattern: the later the colonization, the better the healing. Positive culture from either washout or periexit smear one week after implantation was associated with early exit infection, a higher peritonitis rate, and a high probability of catheter loss due to an exit/tunnel infection, and higher peritonitis rate; however, the time to the first peritonitis episode was not shorter than in the groups with later exit colonization. We postulate that exit infections and peritonitis rates may be decreased by delaying exit colonization using prophylactic antibiotics for at least 2 weeks after implantation and sterile exit dressing procedure for the entire healing time of approximately 6 weeks.

A previous study showed that silver-coating peritoneal catheters tended to decrease the incidence of early exit-site infections in rats. This study was designed to further evaluate the healing, biocompatability, and external tunnel morphology of standard and silver-coated catheters. Catheters were coated with silver by an ion beam-assisted process. Fourteen male Sprague-Dawley rats underwent implantation of either a standard or silver-coated double-cuff peritoneal catheter. Weekly observation and photographs documented exit-site characteristics. Erythema, exudate, loose fit, and poor hair growth were evidence of an inflamed exit. Overt infection was indicated by the presence of three or more of the following: erythema, purulent exudate, exuberant granulation tissue, loose fit, and poor hair growth. Animals were sacrificed at six weeks, and catheters were removed and processed for histology of the external tunnel. Multiple measurements were taken using a Filar eyepiece, and data were expressed as a mean of several readings. Inflammation, vascularity, and fibrosis were judged semiquantitatively. At the end of six weeks, six of the seven exits of the silver catheters showed excellent healing, while one exit site had signs of excessive inflammation. Four of the exit sites of the standard catheters healed well, two were inflamed, and one was overtly infected. The sinus tract of the standard and silver catheters had similar characteristics: keratinized and nonkeratinized epithelium lined the external part of the sinus tract and merged into granulation tissue. A fibrous sheath was noted in some sinus tracts between the granulation tissue and the cuff. The cuff evoked a foreign body reaction, with fibrosis, multiple giant cells, and vascularization. Poorly healing or infected sinus tracts had highly vascular granulation tissue with overlying exudate. The cuff of these catheters had marked inflammation and scanty giant cells, although collagen bundle thickness was similar to the well-healing catheters. In conclusion, silver-coating potentially enhances healing of the exit sites of peritoneal catheters. Additionally, the similarity of the tunnel histomorphology of standard and silver catheters confirms the favorable biocompatibility of silver.

The swan neck presternal catheter is composed of two flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. The exit site is located in the presternal or parasternal area. The catheter located on the chest was designed to reduce the incidence of exit site infections compared with peritoneal dialysis catheters with abdominal exit sites. From August 1991 to May 1995, 24 swan neck presternal catheters have been implanted in 24 patients for the following reasons: obesity nine patients, ostomies three patients, a suprapubic catheter one patient, previous problems with abdominal catheters two patients, desire to use a bathtub five patients, need to use a whirlpool one patient, need to wear sweatpants with an elastic waistband one patient, and body image two patients. In the same period, 47 abdominal swan neck catheters were implanted in 44 patients who preferred catheters with the exit on the abdomen. Presternal catheters tended to perform better regarding exit and tunnel infections, even though they were implanted in several patients in whom regular catheters with the exit on the abdomen would be difficult or impossible to implant. Two-year survival probability of presternal catheters was 0.88 +/- 0.14 (+/- SE). Recurrent/refractory peritonitis was the only reason of catheter failure. The differences in results between presternal and abdominal catheters were statistically insignificant; only the use of antibiotics to treat exit site infection was significantly higher with abdominal catheters. Patient acceptance of the exit position was good; at least seven patients preferred presternal catheter for psychological or body image reasons. We conclude that the swan neck presternal catheters provide excellent results comparable to those achieved with swan neck abdominal catheters. The catheter seems suitable for any patient commencing peritoneal dialysis and is particularly useful in extremely obese patients (body mass index > 40 kg/m2) and those with ostomies. The catheter exit location in the chest may be preferred by some patients, both men and women, for psychological or body image reasons. No specific contraindications to the presternal catheter implantation have been identified.

Silver is known to have powerful antibacterial properties against a variety of micro-organisms and has a low toxicity and a favorable biocompatibility profile. This study was designed to evaluate the effectiveness of silver-coated catheters in preventing early exit-site infection and to assess tunnel morphology. Seven male Sprague-Dawley rats underwent simultaneous implantation of two double-cuffed, silver-coated silicone rubber and standard silicone rubber catheters. Weekly observations and photographs documented exit-site characteristics. The animals were sacrificed and catheters removed and processed for histopathology of the external tunnel at 5 weeks. Exit sites of silver-coated catheters tended to have less inflammation and infection and healed better than those of uncoated catheters; however, these data did not achieve significance using the Wilcoxon signed-rank test. Sections of the external tunnel of well-healing exit sites showed an epithelialized tract with granulation tissue near the cuff and significant invasion of the external cuff by collagen with a mild neutrophilic inflammatory response. In contrast, the histology of the external tunnel of infected exists revealed exudate overlying inflammatory granulation tissue and a variable degree of fibrosis of the cuff. When the exit sites appeared similar, no significant histopathological differences in sinus tract and cuff morphology were noted with either silver or standard catheters. In conclusion, these findings suggest that silver coating of catheters may decrease the incidence of early exit-site infections and allow better ingrowth of the catheter.

A computer interaction session conducted during the 14th Annual Peritoneal Dialysis Conference in Orlando, Florida, on January 24, 1994, revealed the preferences and practices of 650-690 respondents voting on questions related to peritoneal catheters. Compared to the surveys conducted in 1987 and 1989, the most striking change was an increase in the use of catheters with the bent intramural segment, particularly the Swan neck catheter, and an increase in the use of catheters with the coiled intraperitoneal segment. The Tenckhoff catheter continued to be the most popular, although its use was decreasing. The remaining catheters were used in small numbers. The vast majority of nephrologists remain convinced of the superiority of double cuff catheters over single cuff ones, and the use of the former continued to exceed 70%. Essentially no change occurred in the method of catheter placement; surgical dissection (72.7%) remained the most popular implantation method. Surgeons were primarily responsible for catheter implantations (87.4% of votes). The use of prophylactic antibiotics prior to catheter implantation seems to be increasing. The majority of respondents did not consider a Staphylococcus aureus nasal carrier status as important in the development of catheter-related infections, as indicated by the small number of centers where routine culture of nares was performed. The majority of institutions delayed ambulatory peritoneal dialysis after catheter implantation, but ambulatory peritoneal dialysis was started in some centers (5.7% of votes) in the immediate postimplantation period.

A survey was developed to determine the prevalence of specific components of postoperative and chronic peritoneal catheter exit-site care procedures. Surveys were mailed to approximately 1800 participants of the 1991 Peritoneal Dialysis Conference; 585 surveys (80.6% from the United States and 96% from adult units) were analyzed. The most frequent components of postoperative exit-site care were the use of prophylactic antibiotics, daily dressing changes, procedures limited to specially trained staff, use of sterile technique, povidone iodine and hydrogen peroxide as cleansing agents, and gauze dressings. The most frequent components of chronic exit-site care procedures were daily care done with shower or bathing, antibacterial or pure soap for cleansing, hydrogen peroxide only as needed, catheter stabilization, dressings optional, and gauze dressings when used. Twice daily exit care, change in cleansing agent, and topical antibiotics were recommended for inflamed or infected exit sites. There were significant differences between the United States and other locations, particularly in the type of cleansing agent, use of hydrogen peroxide, and use of dressings for chronic care. Pediatric programs (all located in the United States or Canada) differed somewhat from adult programs in North America. Pediatric patients and their families were significantly more likely to be trained to do postoperative dressing changes and significantly less likely to perform exit-site care at the time of showering or bathing.

From the beginning of our continuous ambulatory peritoneal dialysis (CAPD) program in January 1977 until June 1985, we used Tenckhoff and Toronto Western Hospital catheters. Throughout these years catheter survival probabilities of about 30% at three years persisted unchanged and were similar to survival probabilities reported by the National CAPD Registry special survey for these catheters. The first improvement in catheter results regarding leaks was noted after the adoption of lateral catheter insertion. Malfunction was less using swan neck prototypes from August 1985 to April 1986. The latter catheters were made of 80 degrees arc angle tubing between 8.5 cm spaced cuffs and were inserted in a reversed U-shape tunnel with the incision at the top of the tunnel. The use of these catheters was abandoned because of high cuff extrusion and exit infection rates. The next generation of swan neck catheters, the swan neck Missouri 2 and 3 catheters with straight intraperitoneal segments, improved the results dramatically. These catheters were made of 180 degrees arc angle tubing between 5 or 3 cm spaced cuffs. The estimated survival probability of 61% at three years more than doubled compared to previously used catheters. Recently we modified the intraperitoneal segment of the catheters, replacing the straight segment with a coiled one. These modified catheters, the swan neck Missouri coiled catheters, have been used exclusively since February 1990. In addition to an acceptable survival probability of 88% at one year, there are two major advantages of these catheters, the same as for other coiled catheters: elimination of infusion pain due to a jet effect and pain related to straight catheter tip pressure on the peritoneum experienced by some patients.

The Swan Neck Missouri catheters are designed to reduce major complications including 1) exit/tunnel infections, by a downward directed exit hole; 2) pericatheter leaks, by placement of the deep cuff in the rectus muscle; 3) catheter tip migration, by caudal direction of the intraperitoneal segment; and 4) outer cuff extrusion, by a permanent bend between the 5 cm or 3 cm spaced cuffs in SN-M2 and SN-M3 catheters, respectively. Between April 1986 and April 1990, 103 swan neck catheters were implanted. Comparison of prospective data from 103 swan neck catheters and retrospective data from 148 standard (Tenckhoff and Toronto Western Hospital) catheters implanted between January 1982 and June 1985 showed reduced complication rates with swan neck catheters. An overall survival of 64% at 36 months for swan neck catheters is significantly better than that of 29% for standard catheters.

We initiated a therapeutic program of continuous ambulatory peritoneal dialysis for patients with chronic renal failure. Our program resulted in many episodes of peritonitis arising from contamination due to the technical aspects of the procedure. Microbiologic evaluation showed that 73% of 97 episodes were culture positive, with gram-positive organisms causing most of the cases, especially early in dialysis. Gram-negative rods tended to occur later. Gram stains of dialysate effluent resulted in a disappointingly low yield of only 9% positivity. Cell counts were a dependable indicator of the presence of peritoneal inflammation and also of therapeutic success. Most patients responded well to intraperitoneal cephalothin, 125 mg/L for 10 to 14 d. The occurrence of peritonitis resulted in 0.93 years of hospitalization during the total of 15.45 patient-years on dialysis, which essentially negated the financial advantages of this method of treatment of chronic renal failure. For this to be a successful mode of therapy, advances in the prevention of peritonitis must be made.