- Email: [email protected]
Our Timing to Remove Peritoneal Catheter Dialysis After Kidney Transplant
Our Timing to Remove Peritoneal Catheter Dialysis After Kidney Transplant G. Peluso ,*, P. Incollingo , N. Carlomagno , V. D’Alessandro ,b, V. Tammaro , M. Caggiano , M.L. Sandoval Sotelo , N. Rupealta , M. Candida , G. Mazzoni , S. Campanile , G. Chiacchio , A. Scotti , and M.L. Santangelo -
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a
Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples; bKidney Transplantation Center and Retroperitoneal Surgery, University Hospital Federico II of Naples
ABSTRACT Background. Patients on peritoneal dialysis treatment represent 15% of the global dialysis population. The major complication of peritoneal dialysis is catheter and peritoneal infection. Peritoneal dialysis patients who receive kidney transplants are at increased risk of infection because of immunosuppressive therapy. Aim. The purpose of this study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and reduction of septic risk. Method of Study. We analyzed the outcomes of 65 patients on peritoneal dialysis who underwent kidney transplant between 2000 and 2016. Results. In 61 cases there was an immediate graft functional recovery. In 4 cases there was a delayed graft function (DGF), and we performed a hemodialysis with temporary placement of a venous catheter. In all patients we removed peritoneal dialysis catheter 30 to 45 days after transplant. There has been 1 case of catheter infection, which was treated with antibiotic therapy. Discussion. Our average time to remove the peritoneal dialysis catheter was shorter than times in previous studies, between the 30th and 45th postoperative day. In the 4 cases in which there has been a DGF, we performed hemodialysis treatment to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures. Conclusion. Our experience show that the 30th to 45th postoperative day is a good time frame, better yet a good watershed between the safe removal of peritoneal catheter when patients have a stabilized renal function and the possibility of leaving it in situ, to resume peritoneal dialysis in case of persistent DGF.
P
ATIENTS on peritoneal dialysis (PD) treatment represent 15% of the global dialysis population [1]. In the literature there are many studies comparing PD and hemodialysis (HD) and their influence on post-transplant results. Some authors point out how PD is associated with a lower incidence of delayed graft function (DGF) than HD [2e5]. Snyder et al also found DGF to be less common in PD patients but reported a higher rate of early graft failure and graft thrombosis in the PD group compared with HD patients [6]. ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e4 (2018)
Other authors have not reported an association between pretransplant dialytic modality and post-transplant outcomes. Grant information: The authors declare that they did not have any funding. *Address correspondence to Gaia Peluso, Operative Unit of General Surgery and Kidney Transplant Unit, Advanced Biomedical Science Department, University Federico II of Naples, via Pansini 5, 80131 Naples, Italy. Tel: 0817463897, Fax: 0817462637. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.04.075
1
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Kramer et al, in a study that included more than 29,000 patients from 16 European countries showed different results depending on the statistical analysis performed [7], and a recent article by Dipalma et al showed how dialysis modality does not influence the graft outcome or the patient survival [8]. All these authors agree that the major preoccupation regarding PD is catheter infection and its related peritonitis, especially in the post-transplant period, because infection rate is already increased in transplant recipients [9e12]. In our opinion, this is the most common catheter-related problem in the kidney transplant population. The most frequent complication of PD reported in the literature is infection [13e15]. Initially infection can affect the catheter in its outer part, then spread to the subcutaneous tissues, and, in severe cases, result in peritonitis. These complications usually depend on catheter type, incorrect surgical procedure, poor catheter management and patient characteristics [16e21]. PD patients who undergo to kidney transplant are at increased risk of catheter infection because of immunosuppressive therapy, so it is advisable to remove the catheter as soon as possible. The purpose of our study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and on reduction of septic risk.
METHODS OF STUDY We performed a retrospective study analyzing the outcomes of the transplants performed in our center between January 2000 and December 2016. In the time of study, 670 end-stage renal disease patients underwent kidney transplant in our center; 65 of these patients were receiving PD treatments (Table 1). They all had a double-cuff Tenckhoff catheter and had a PD treatment before the surgical procedure. No patients had a recent episode of catheter infection or peritonitis. During the hospital stay the catheters were disinfected daily and the patients performed daily maintenance after the hospital discharge. All patients received kidneys from deceased donors, and the immunosuppressive treatment consisted of basiliximab given at induction and on the fourth postoperative day, corticosteroids with scaling dosages, and cyclosporine or tacrolimus with doses that were established daily based on blood levels.
RESULTS
Our patients were 36 women and 29 men, with a mean age of 32 years (range, 20e54 years) and a mean time of PD of 24 months. In all patients, we removed PD catheter 30 to 45 days after transplant. The removal procedure was performed under local anesthesia and was not linked to any complications in all 65 patients (Table 1). During the same hospital stay, the patients underwent the removal of the ureteral stent. All patients signed a consent form for the surgical procedure, which comprises their consent for the storage and use of their data [22]. In 61 cases, there was an immediate functional recovery of the graft that did not require dialysis after transplant. In
PELUSO, INCOLLINGO, CARLOMAGNO ET AL
the 4 cases in which there was DGF, we performed a hemodialysis with temporary placement of a venous catheter. A total of 64 patients did not present any sign of infection, neither local nor systemic linked to the peritoneal catheter, in the days following the transplant. Only 1 patient, with a functioning transplanted kidney, while waiting for the removal of the catheter, developed a catheterrelated infection on 20th day after the transplant with skin redness but without catheter leakage, abdominal pain, or any evidence of peritonitis, which resolved with antibiotic therapy and did not require early catheter removal. DISCUSSION
The main problem of peritoneal catheter in patients undergoing kidney transplant is the timing of its removal: the surgeons have to identify the correct time interval to use it. Removing it too soon can preclude a resumption of PD in case of prolonged DGF or permanent graft failure; on the other hand, leaving it in the site for too long increases the risk of infection. The few reports on this subject show different views regarding the pediatric population. In 1994 Palmer et al described how they preferred to remove the catheter at the time of hospital discharge [23]. In 2001, Arbeiter et al analyzed the risks and benefits of the removal of the Tenckhoff catheter in the pediatric population at the transplant time. The risk is linked to its possible need in case of DGF, whereas the benefits are linked to lower risk of infection and avoidance of a second surgical procedure. They stated that the optimal time of its removal is approximately 1 month after transplant because the majority of PD in the post-transplant period occurred in that time frame [24]. More recently in 2016, Malek and colleagues studied 33 pediatric patients and analyzed the previous data in the literature, stating that the time should be decided for each patient according to individual characteristics [25]. There are few studies regarding the adult population. In 2012 Warren et al suggested removing the PD catheter during the kidney transplant to avoid catheter-related risks [26]. Other authors, instead, affirm that it is best to remove the catheter after the graft function is stabilized [27]. Accordingly, the latest European Guidelines state that the catheter can be left in situ for 4 to 16 weeks [28]. Table 1. Peritoneal Dialysis Patients Undergoing Kidney Transplant at Federico II Transplant Centre-Naples With a Total of 670 Kidney Transplants Performed Between 2000e2016 Patients on peritoneal dialysis Complications linked to peritoneal catheter Immediate functional recovery Delayed graft function Catheter removal after transplant Anesthesia Operative time
65 1 exit-site infection, treated with antibiotic therapy 61 4* 35 days (range, 30e45 days) Local anesthesia (mepivacaine 2% 20 mL) 20e30 min
*Patients underwent hemodialysis procedure. Catheter removal was performed 43 and 45 days after transplant.
CATHETER REMOVAL AFTER KIDNEY TRANSPLANT
In our experience the average time to remove catheter in adult kidney transplant patients was shorter than other experiences, ranging between the 30th and the 45th postoperative day, and we have not observed any significant related complications. We believe that in this time frame, transplanted kidney function is usually stabilized, the patient’s general condition is improved, and catheter removal can be safely performed with low risks (including infection). With periodic maintenance of the catheter, the risk of developing an infection is low and more curable. Moreover, in the 4 cases in which there was DGF, we opted for a hemodialysis treatment with placement of a temporary venous catheter to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures [29e31]. The use of peritoneal catheter shortly after the transplant is controversial. Although some authors state how PD can safely be performed, especially if the peritoneal cavity is not opened during the transplant [25,28,32], other authors believe that it is feasible but linked to an increased risk of infection, wound complications, leakage, and development of peritonitis; therefore, they support the use of HD [26,27,33e35]. The use of PD after transplant is more secure in the pediatric population because their peritoneum has less likely received any kind of insult. On the other hand, in the adult population its use is linked to more risks because of previous abdominal operations or inflammations. We agree with the authors who discourage the use of PD catheter in the days after renal transplant. Moreover, we think that in case of persistent DGF, after the 30th to 45th postoperative day, it is possible to stop hemodialysis, remove venous catheter, and safely resume PD with no effects on the peritoneum and the transplanted kidney while waiting for the recovery of graft function. CONCLUSION
The removal of the peritoneal catheter in kidney transplant patients is a simple, safe, and quick procedure performed under local anesthesia and well tolerated by the patient. Our experience shows that the 30th to 45th post-transplant day is a good time frame, better yet a good watershed between the option to remove peritoneal catheter safely when patients have a stabilized renal function and the possibility to leave it in situ, when patients have a persistent DGF to resume PD. REFERENCES [1] Thodis E, Passadakis P, Lyrantzopooulos N, Panagoutsos S, Vargemezis V, Oreopoulos D. Peritoneal catheters and related infections. Int Urol Nephrol 2005;37:379e93. [2] Joseph JT, Jindal RM. Influence of dialysis on posttransplant events. Clin Transplant 2002;16:18e23. [3] Van Biesen W, Vanholder R, Van Loo A, Van Der Vennet M, Lameire N. Peritoneal dialysis favorably influences early graft function after renal transplantation compared to hemodialysis. Transplantation 2000;69:508e14. [4] Vanholder R, Heering P, Loo AV, Biesen WV, Lambert MC, Hesse U, et al. Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis. Am J Kidney Dis 1999;33:934e40.
3 [5] Pérez Fontán MP, Rodríguez-Carmona A, García Falcón T, Moncalián J, Oliver J, Valdés F. Renal transplantation in patients undergoing chronic peritoneal dialysis. Perit Dial Int 1996;16:48e51. [6] Snyder JJ, Kasiske BL, Gilbertson DT, Collins AJ. A comparison of transplant outcomes in peritoneal and hemodialysis patients. Kidney Int 2002;62:1423e30. [7] Kramer A, Jager KJ, Fogarty DG, Ravani P, Finne P, PérezPanadés J, et al. Association between pre-transplant dialysis modality and patient and graft survival after kidney transplantation. Nephrol Dial Transplant 2012;27:4473e80. https://doi.org/10.1093/ ndt/gfs450. [8] Dipalma T, Fernández-Ruiz M, Praga M, Polanco N, González E, Gutiérrez-Solis E, et al. Pre-transplant dialysis modality does not influence short- or long-term outcome in kidney transplant recipients: analysis of paired kidneys from the same deceased donor. Clin Transplant 2016;30:1097e107. https://doi.org/ 10.1111/ctr.12793. [9] Santangelo M, Clemente M, Spiezia S, Grassia S, Di Capua F, La Tessa C, et al. Wound complications after kidney transplantation in nondiabetic patients. Transplant Proc 2009;41: 1221e3. https://doi.org/10.1016/j.transproceed.2009.03.098. [10] Santangelo M, De Rosa P, Spiezia S, Spinosa G, Grassia S, Zuccaro M, et al. Healing of surgical incision in kidney transplantation: a single transplant center’s experience. Transplant Proc 2006;38:1044e6. [11] Capone D, Tarantino G, Gentile A, Sabbatini M, Polichetti G, Santangelo M, et al. Effects of voriconazole on tacrolimus metabolism in a kidney transplant recipient. J Clin Pharm Ther 2010;35:121e4. https://doi.org/10.1111/j.1365-2710. 2009.01070.x. [12] Criscitiello C, Viale G, Gelao L, Esposito A, De Laurentiis M, De Placido S, et al. Crosstalk between bone niche and immune system: osteoimmunology signaling as a potential target for cancer treatment. Cancer Treat Rev 2015;41:61e8. https://doi.org/ 10.1016/j.ctrv.2014.12.001. [13] Berman SJ, Johnson EW, Nakatsu C, Alkan M, Chen R, LeDuc J. Burden of infection in patients with end-stage renal disease requiring long-term dialysis. Clin Infect Dis 2004;39:1747e53. [14] Toyohara T, Ubara Y, Higa Y, Suwabe T, Hoshino J, Sumida K, et al. Prognosis of patients on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years. Intern Med 2011;50: 2519e23. [15] Xie JY, Chen N, Ren H, Huang XM, Zhu P. Prospective studies on applications of a two-cuff Swan neck catheter and a Tenckhoff catheter to Chinese CAPD patients. Clin Nephrol 2009;72:373e9. [16] Flanigan M, Gokal R. Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Perit Dial Int 2005;25:132e9. [17] Piraino B. Peritonitis as a complication of peritoneal dialysis. J Am Soc Nephrol 1998;9:1956e64. [18] Davenport A. Peritonitis remains the major clinical complication of peritoneal dialysis: the London, UK, peritonitis audit 2002-2003. Perit Dial Int 2009;29:297e302. [19] Ponce D, de Moraes TP, Pecoits-Filho R, Figueiredo AE, Barretti P. Peritonitis in children on chronic peritoneal dialysis: the experience of a large national pediatric cohort. Blood Purif 2018;45: 118e25. https://doi.org/10.1159/000484344. [20] Piscitelli P, Santoriello A, Buonaguro FM, Di Maio M, Iolascon G, Gimigliano F, et al. Incidence of breast cancer in Italy: mastectomies and quadrantectomies performed between 2000 and 2005. J Exp Clin Cancer Res 2009;28:86. https://doi.org/10.1186/ 1756-9966-28-86. [21] Criscitiello C, Giuliano M, Curigliano G, De Laurentiis M, Arpino G, Carlomagno N, et al. Surgery of the primary tumor in de novo metastatic breast cancer: to do or not to do? Eur J Surg Oncol 2015;41:1288e92. https://doi.org/10.1016/j.ejso.2015.07.013. [22] Ferrarese A, Pozzi G, Borghi F, Pellegrino L, Di Lorenzo P, Amato B, et al. Informed consent in robotic surgery: quality of
4 information and patient perception. Open Med (Wars) 2016;11: 279e85. https://doi.org/10.1515/med-2016-0054. [23] Palmer JA, Kaiser BA, Polinsky MS, Dunn SP, Braas C, Waltz R, et al. Peritoneal dialysis catheter infections in children after renal transplantation: choosing the time of removal. Pediatr Nephrol 1994;8:715e8. [24] Arbeiter K, Pichler A, Muerwald G, Mueller T, Bidmon B, Balzar E, et al. Timing of peritoneal dialysis catheter removal after pediatric renal transplantation. Perit Dial Int 2001;21:467e70. [25] Melek E, Baskın E, Gülleroglu KS, Kırnap M, Moray G, Haberal M. Timing for removal of peritoneal dialysis catheters in pediatric renal transplant patients. Exp Clin Transplant 2016;14(Suppl. 3):74e7. [26] Warren J, Jones E, Sener A, Drage M, Taqi A, Griffin S, et al. Should peritoneal dialysis catheters be removed at the time of kidney transplantation? Can Urol Assoc J 2012;6:376e8. https://doi. org/10.5489/cuaj.12112. [27] Pampa-Saico S, Caravaca-Fontán F, Burguera-Vion V, Nicolás VD, Yerovi-León E, Jimenez-Álvaro S, et al. Outcomes of peritoneal dialysis catheter left in place after kidney transplantation. Perit Dial Int 2017;37:651e4. https://doi.org/10.3747/pdi. 2017.00031. [28] Dombros N, Dratwa M, Feriani M, Gokal R, Heimbürger O, Krediet R, et al. European best practice guidelines
PELUSO, INCOLLINGO, CARLOMAGNO ET AL for peritoneal dialysis. 9 PD and transplantation. Nephrol Dial Transplant 2005;20(Suppl. 9):ix34e5. [29] Santangelo M, Zuccaro M, De Rosa P, Tammaro V, Grassia S, Federico S, et al. Older kidneys donor transplantation: five years’ experience without biopsy and using clinical laboratory and macroscopic anatomy evaluation. Transplant Proc 2007;39: 1835e7. [30] De Rosa P, Santangelo M, Ferrara A, Pelosio L, Vallefuoco DM, Caggiano L, et al. Suboptimal kidney: the experience of a single transplant unit. Transplant Proc 2004;36:488e90. [31] De Rosa P, Santangelo M, Scala A, Vallefuoco DM, Caggiano L, Imbriaco M, et al. Difficult vascular conditions in kidney transplantation. Transplant Proc 2006;38:1040e3. [32] Gokal R, Kost S. Peritoneal dialysis immediately post transplantation. Adv Perit Dial 1999;15:112e5. [33] Tsakiris D, Bramwell SP, Briggs JD, Junor BJR. Transplantation in patients undergoing capd. Perit Dial Int 1985;5:161e4. [34] O’Donoghue D, Manos J, Pearson R, Scott P, Bakran A, Johnson R, et al. Continuous ambulatory peritoneal dialysis and renal transplantation: a ten-year experience in a single center. Perit Dial Int 1992;12:242, 245e9. [35] Bakir N, Surachno S, Sluiter WJ, Struijk DG. Peritonitis in peritoneal dialysis patients after renal transplantation. Nephrol Dial Transplant 1998;13:3178e83.
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a
Operative Unit of General Surgery and Kidney Transplantation, Advanced Biomedical Science Department, University Federico II of Naples; bKidney Transplantation Center and Retroperitoneal Surgery, University Hospital Federico II of Naples
ABSTRACT Background. Patients on peritoneal dialysis treatment represent 15% of the global dialysis population. The major complication of peritoneal dialysis is catheter and peritoneal infection. Peritoneal dialysis patients who receive kidney transplants are at increased risk of infection because of immunosuppressive therapy. Aim. The purpose of this study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and reduction of septic risk. Method of Study. We analyzed the outcomes of 65 patients on peritoneal dialysis who underwent kidney transplant between 2000 and 2016. Results. In 61 cases there was an immediate graft functional recovery. In 4 cases there was a delayed graft function (DGF), and we performed a hemodialysis with temporary placement of a venous catheter. In all patients we removed peritoneal dialysis catheter 30 to 45 days after transplant. There has been 1 case of catheter infection, which was treated with antibiotic therapy. Discussion. Our average time to remove the peritoneal dialysis catheter was shorter than times in previous studies, between the 30th and 45th postoperative day. In the 4 cases in which there has been a DGF, we performed hemodialysis treatment to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures. Conclusion. Our experience show that the 30th to 45th postoperative day is a good time frame, better yet a good watershed between the safe removal of peritoneal catheter when patients have a stabilized renal function and the possibility of leaving it in situ, to resume peritoneal dialysis in case of persistent DGF.
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ATIENTS on peritoneal dialysis (PD) treatment represent 15% of the global dialysis population [1]. In the literature there are many studies comparing PD and hemodialysis (HD) and their influence on post-transplant results. Some authors point out how PD is associated with a lower incidence of delayed graft function (DGF) than HD [2e5]. Snyder et al also found DGF to be less common in PD patients but reported a higher rate of early graft failure and graft thrombosis in the PD group compared with HD patients [6]. ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, XX, 1e4 (2018)
Other authors have not reported an association between pretransplant dialytic modality and post-transplant outcomes. Grant information: The authors declare that they did not have any funding. *Address correspondence to Gaia Peluso, Operative Unit of General Surgery and Kidney Transplant Unit, Advanced Biomedical Science Department, University Federico II of Naples, via Pansini 5, 80131 Naples, Italy. Tel: 0817463897, Fax: 0817462637. E-mail: [email protected] 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.04.075
1
2
Kramer et al, in a study that included more than 29,000 patients from 16 European countries showed different results depending on the statistical analysis performed [7], and a recent article by Dipalma et al showed how dialysis modality does not influence the graft outcome or the patient survival [8]. All these authors agree that the major preoccupation regarding PD is catheter infection and its related peritonitis, especially in the post-transplant period, because infection rate is already increased in transplant recipients [9e12]. In our opinion, this is the most common catheter-related problem in the kidney transplant population. The most frequent complication of PD reported in the literature is infection [13e15]. Initially infection can affect the catheter in its outer part, then spread to the subcutaneous tissues, and, in severe cases, result in peritonitis. These complications usually depend on catheter type, incorrect surgical procedure, poor catheter management and patient characteristics [16e21]. PD patients who undergo to kidney transplant are at increased risk of catheter infection because of immunosuppressive therapy, so it is advisable to remove the catheter as soon as possible. The purpose of our study is to show our ideal timing to remove peritoneal catheter after kidney transplant, which gives adequate security on renal function recovery and on reduction of septic risk.
METHODS OF STUDY We performed a retrospective study analyzing the outcomes of the transplants performed in our center between January 2000 and December 2016. In the time of study, 670 end-stage renal disease patients underwent kidney transplant in our center; 65 of these patients were receiving PD treatments (Table 1). They all had a double-cuff Tenckhoff catheter and had a PD treatment before the surgical procedure. No patients had a recent episode of catheter infection or peritonitis. During the hospital stay the catheters were disinfected daily and the patients performed daily maintenance after the hospital discharge. All patients received kidneys from deceased donors, and the immunosuppressive treatment consisted of basiliximab given at induction and on the fourth postoperative day, corticosteroids with scaling dosages, and cyclosporine or tacrolimus with doses that were established daily based on blood levels.
RESULTS
Our patients were 36 women and 29 men, with a mean age of 32 years (range, 20e54 years) and a mean time of PD of 24 months. In all patients, we removed PD catheter 30 to 45 days after transplant. The removal procedure was performed under local anesthesia and was not linked to any complications in all 65 patients (Table 1). During the same hospital stay, the patients underwent the removal of the ureteral stent. All patients signed a consent form for the surgical procedure, which comprises their consent for the storage and use of their data [22]. In 61 cases, there was an immediate functional recovery of the graft that did not require dialysis after transplant. In
PELUSO, INCOLLINGO, CARLOMAGNO ET AL
the 4 cases in which there was DGF, we performed a hemodialysis with temporary placement of a venous catheter. A total of 64 patients did not present any sign of infection, neither local nor systemic linked to the peritoneal catheter, in the days following the transplant. Only 1 patient, with a functioning transplanted kidney, while waiting for the removal of the catheter, developed a catheterrelated infection on 20th day after the transplant with skin redness but without catheter leakage, abdominal pain, or any evidence of peritonitis, which resolved with antibiotic therapy and did not require early catheter removal. DISCUSSION
The main problem of peritoneal catheter in patients undergoing kidney transplant is the timing of its removal: the surgeons have to identify the correct time interval to use it. Removing it too soon can preclude a resumption of PD in case of prolonged DGF or permanent graft failure; on the other hand, leaving it in the site for too long increases the risk of infection. The few reports on this subject show different views regarding the pediatric population. In 1994 Palmer et al described how they preferred to remove the catheter at the time of hospital discharge [23]. In 2001, Arbeiter et al analyzed the risks and benefits of the removal of the Tenckhoff catheter in the pediatric population at the transplant time. The risk is linked to its possible need in case of DGF, whereas the benefits are linked to lower risk of infection and avoidance of a second surgical procedure. They stated that the optimal time of its removal is approximately 1 month after transplant because the majority of PD in the post-transplant period occurred in that time frame [24]. More recently in 2016, Malek and colleagues studied 33 pediatric patients and analyzed the previous data in the literature, stating that the time should be decided for each patient according to individual characteristics [25]. There are few studies regarding the adult population. In 2012 Warren et al suggested removing the PD catheter during the kidney transplant to avoid catheter-related risks [26]. Other authors, instead, affirm that it is best to remove the catheter after the graft function is stabilized [27]. Accordingly, the latest European Guidelines state that the catheter can be left in situ for 4 to 16 weeks [28]. Table 1. Peritoneal Dialysis Patients Undergoing Kidney Transplant at Federico II Transplant Centre-Naples With a Total of 670 Kidney Transplants Performed Between 2000e2016 Patients on peritoneal dialysis Complications linked to peritoneal catheter Immediate functional recovery Delayed graft function Catheter removal after transplant Anesthesia Operative time
65 1 exit-site infection, treated with antibiotic therapy 61 4* 35 days (range, 30e45 days) Local anesthesia (mepivacaine 2% 20 mL) 20e30 min
*Patients underwent hemodialysis procedure. Catheter removal was performed 43 and 45 days after transplant.
CATHETER REMOVAL AFTER KIDNEY TRANSPLANT
In our experience the average time to remove catheter in adult kidney transplant patients was shorter than other experiences, ranging between the 30th and the 45th postoperative day, and we have not observed any significant related complications. We believe that in this time frame, transplanted kidney function is usually stabilized, the patient’s general condition is improved, and catheter removal can be safely performed with low risks (including infection). With periodic maintenance of the catheter, the risk of developing an infection is low and more curable. Moreover, in the 4 cases in which there was DGF, we opted for a hemodialysis treatment with placement of a temporary venous catheter to avoid, in the immediate postoperative period, direct insults to the peritoneum by local dialysis procedures [29e31]. The use of peritoneal catheter shortly after the transplant is controversial. Although some authors state how PD can safely be performed, especially if the peritoneal cavity is not opened during the transplant [25,28,32], other authors believe that it is feasible but linked to an increased risk of infection, wound complications, leakage, and development of peritonitis; therefore, they support the use of HD [26,27,33e35]. The use of PD after transplant is more secure in the pediatric population because their peritoneum has less likely received any kind of insult. On the other hand, in the adult population its use is linked to more risks because of previous abdominal operations or inflammations. We agree with the authors who discourage the use of PD catheter in the days after renal transplant. Moreover, we think that in case of persistent DGF, after the 30th to 45th postoperative day, it is possible to stop hemodialysis, remove venous catheter, and safely resume PD with no effects on the peritoneum and the transplanted kidney while waiting for the recovery of graft function. CONCLUSION
The removal of the peritoneal catheter in kidney transplant patients is a simple, safe, and quick procedure performed under local anesthesia and well tolerated by the patient. Our experience shows that the 30th to 45th post-transplant day is a good time frame, better yet a good watershed between the option to remove peritoneal catheter safely when patients have a stabilized renal function and the possibility to leave it in situ, when patients have a persistent DGF to resume PD. REFERENCES [1] Thodis E, Passadakis P, Lyrantzopooulos N, Panagoutsos S, Vargemezis V, Oreopoulos D. Peritoneal catheters and related infections. Int Urol Nephrol 2005;37:379e93. [2] Joseph JT, Jindal RM. Influence of dialysis on posttransplant events. Clin Transplant 2002;16:18e23. [3] Van Biesen W, Vanholder R, Van Loo A, Van Der Vennet M, Lameire N. Peritoneal dialysis favorably influences early graft function after renal transplantation compared to hemodialysis. Transplantation 2000;69:508e14. [4] Vanholder R, Heering P, Loo AV, Biesen WV, Lambert MC, Hesse U, et al. Reduced incidence of acute renal graft failure in patients treated with peritoneal dialysis compared with hemodialysis. Am J Kidney Dis 1999;33:934e40.
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