1. EVC 2015 – Vascular Access Maurizio Gallieni Nephrology and Dialysis Unit – Ospedale San Carlo Borromeo University of Milano, Italy Type of PD catheter and outcome

2. The peritoneal catheter is the PD patient’s lifeline Advances in catheter knowledge have made it possible to obtain access to the peritoneal cavity safely and to maintain access over an extended period of time. Is there hope for more improvement?

3. Stylianou KG and Daphnis EK. Kidney Int 2014; 85, 741–743.

4. Arthur Grollman Forerunner of Contemporary Peritoneal Dialysis In 1951, Arthur Grollman from Southwestern Medical School in Dallas developed a catheter that would make peritoneal dialysis treatment accessible for patients with end-stage chronic kidney disease. Grollman, A., Turner, L.B., and McLean J. A. Intermittent peritoneal lavage in nephrectomized dogs and its application to the human being. Arch Intern Med 1951; 87: 376-390

5. Arthur Grollman Forerunner of Contemporary Peritoneal Dialysis The polyethylene catheter catheter was revolutionary because: it was flexible in design by making very small holes in the distal end he was able to keep the patient's body tissue from impeding the drainage

6. Tenckhoff, H. and Schecter, H. A bacteriologically safe peritoneal access device. Trans Am Soc Artif Intern Organs 1968; 14:181-183. Henry Tenckoff 1968 - The great leap forward Ash - IJAO 2006;29:85

7. NKF Canada - http://www.kidney.ca/Document.Doc?id=753

8. NIDDK booklet “Treatment Methods for Kidney Failure: Peritoneal Dialysis” TRANSFER SET

9. Hydraulic function − Optimal inflow and outflow (fast and complete draining of the peritoneal cavity) − Largest possible internal diameter − Kink resistant − Design preventing obstruction − No migration and displacement − No fluid leakage Biocompatibility − No effect on physiology of abdominal tissues (catheter invisible to body) − No induction of inflammation, sclerosis, and adhesion of the peritoneal membrane The ideal peritoneal catheter

10. Resistance to infection − Act as a barrier against microorganisms present at the exit site, preventing their entry into the subcutaneous tunnel − Absence of factors favoring peritoneal infection (no biofilm, catheter invisible to bacteria and fungi) Surgical handling − Ease of implantation and removal Patient friendliness − Minimal interference with abdominal function and clothing Low cost The ideal peritoneal catheter

11. Visual overview of some types of peritoneal dialysis catheters

12. Types of peritoneal dialysis catheters

13. Straight Tenckhoff

14. Coiled

15. Swan neck – Straight and coiled

16. Missouri

17. Presternal

18. Ash - IJAO 2006; 29: 85 (original by Dr. J. Crabtree) Twardowski ZJ. Presternal peritoneal catheter. Adv Ren Replace Ther. 2002;9:125 Composed of 2 flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. Exit site is located in the parasternal area Designed to reduce the incidence of exit site infections Alternetive catheters: Presternal peritoneal catheter

19. Swan neck Toronto Western Hospital

20. Self-locating (Di Paolo)

21. Which are the most commonly used PD catheters?

22. Type of PD catheters implanted in adults in 2004 Negoi et al. Advances in Peritoneal Dialysis 2006 The Tenckhoff (65%) and the the swan-neck catheter (26%) covered over 90% of patients

23. Type of PD catheter and outcomes

24. JASN 2004; 15:2735 This systematic review demonstrates that of all catheter- related interventions designed to prevent peritonitis in PD, only disconnect (twin-bag and Y-set) systems have been proved to be effective (compared with conventional spike systems). Despite the importance of PD as a renal replacement therapy modality and the large number of patients who receive it, it is still not known whether any particular PD catheter designs, implantation techniques, or modalities are effective, given the limitations of available trials.

25. Straight versus coiled PD catheters: no differences Strippoli G - JASN 2004; 15:2735

26. Straight versus coiled PD catheters: higher all-cause mortality for coiled catheters Strippoli G - JASN 2004; 15:2735 RR: 0.26 (95%CI 0.07-0.99) These results should be interpreted with caution, because no clear differences were observed with respect to peritonitis, exit-site/tunnel infections, catheter removal/replacement, or technique survival, i.e., the inability to show an intervention-related mechanism for reduction in mortality suggests that this is a spurious finding.

27. Kidney International (2014) 85, 920–932 CONCLUSION: Our meta-analysis clearly demonstrates benefits for catheters with a straight intraperitoneal segment. This meta-analysis was carried out to determine whether there is a clinical advantage for one of the PD catheter types or configurations. 13 randomized controlled trials were analyzed.

28. Hagen et al. Kidney Int 2014; 85, 920–932 LIST OF OUTCOMES Catheter survival Peritonitis Exit-site infection Migration Catheter obstruction/dysfunction Leakage Catheter removal COMPARISONS Intraperitoneal segment: coiled vs. straight Subcutaneous segment: straight vs. swan neck Number of cuffs: single cuff vs. double cuff

29. Kidney International (2014) 85, 920–932 Catheter Survival hazard ratio was 2.05 (95%CI 1.1-3.8), favoring straight

31. Stylianou KG and Daphnis EK. Kidney Int 2014; 85, 741–743. The main conclusion we can draw based on the current evidence is that surgically placed double- cuffed straight catheters display better survival rates than surgically placed double-cuffed coiled catheters, for reasons that remain unknown. This new evidence may have a significant impact on our everyday practice. It may offer PD patients a longer stay on the method and may help increase the utilization of PD as a renal replacement therapy.

32. Do we need catheter advances? The Tenckhoff curled and straight PD catheters are still remarkably successful Problems: –outflow failure –peri-catheter leaks –infection

33. The self-locating catheter is similar to the straight Tenckhoff catheter, except at the tip of the catheter, because of the insertion of a small cylinder of tungsten, coated in Silastic. The cylinder weighs 12 g. American Society for Testing and Materials (ASTM) United States specifications: Tungsten is an inert biocompatible substance suitable for use in prostheses Alternative catheters: The self-locating (Di Paolo) catheter

34. A dislocation of a self-locating catheter (left panel) recovered after walking and standing for 2 hours Di Paolo N. IJAO 2006; 29: 113

35. Di Paolo N et al. Perit Dial Int 2004; 24: 359–364 Controlled, non-randomized study comparing 746 pts with the self-locating catheter (68% APD) 216 pts with the straight Tenckhoff catheter (63% APD) The study lasted 24 months; mean observation lasted: self-locating: 14.0 ± 6.0 mo./patient controls: 12.4 ± 4.3 mo./patient Mean age: self-locating: 52 ± 15.1 years controls 54 ± 16.9 years The position of both types of catheter was checked immediately after insertion and every 2 months thereafter by x ray of the abdomen

36. The self-locating (Di Paolo) catheter Di Paolo et al - Perit Dial Int, 2004; 24: 359–364 Displacement Peritonitis, tunnel infections, cuff extrusion, obstruction

37. The self-locating (Di Paolo) catheter Catheter Survival Early and late leakage Di Paolo et al - Perit Dial Int, 2004; 24: 359–364 Self-locating Tenckhoff Dropout from PD Tenckhoff: 38.4% Self-locating: 22.0%

38. Sanchez-Canel JJ et al. Prospective randomized study comparing a single-cuff self-locating catheter with a single-cuff straight Tenckhoff catheter in peritoneal dialysis. Perit Dial Int. 2014 Sep 2. pii: pdi.2013.00315. [Epub ahead of print] The self-locating (Di Paolo) catheter This RCT compared catheter dysfunction in 40 incident PD patients using a self-locating catheter and 38 patients using a straight Tenckhoff catheter. The study confirmed the hypothesis that Tenckhoff catheters have more malfunctions and a lower malposition-free survival rate than self-locating catheters. In particular, multivariate logistic regression analysis indicated an increased probability of malfunction with the use of Tenckhoff catheters (OR = 4.5)

39. PD catheters and outcomes: Conclusions No major breakthroughs in PD catheter technology have been made after the design of the Tenckhoff catheter The straight intraperitoneal segment is superior to the curled configuration Displacement of the catheter tip is still a major problem, which can be much improved by the self- locating catheter which has not been fully studied and may represent, based on the available observational evidence and on the clinical experience, an already existing technological advance.

40. More information in the JVA supplement for EVC 2015: Thank you for the attention and see you in Barcelona at the VAS congress