E. Miraflor1, L. SENEKJIAN1 1University Of California – San Francisco, General Surgery – Alameda Health System, San Francisco, CA, USA
Introduction: In patinets with end stage renal disease either peritoneal dialysis (PD) or hemodialysis are methods for renal replacement therapy. The current recommendation is that 30-45% of patients start with peritoneal dialysis for enhanced quality of life, improved mortality and an overall better graft function at the time of transplant. However only 11% of patients worldwide are started on PD. Patient selection is key for success of PD, and historically there has been concern for PD in patients in a safety net hospital system. Language, housing status, and health literacy are some of the many factors cited as barriers to PD implementation. In this integrated public health care system we sought to create a PD program for this population and implement PD as first method of renal replacement therapy.
Methods: Nephrologists with interest in PD and two laparoscopic surgeons created the PD workgroup. We met via zoom to develop a workflow for identifying patients in which PD would be appropriate. The surgeons completed online peritoneal dialysis catheter placement courses and reviewed current techniques. We developed a standard placement protocol, so all catheters were placed in a similar fashion. This included laparoscopic placement, evaluation for and treatment of concurrent hernias and possible omentopexy where necessary.
Results: From June 2021 to December 2022, 24 patients were identified as PD candidates and referred to the surgeons for evaluation. Average age was 53 years old; 8 (33.3%) were female. After evaluation and discussion with patient 16 of the 24 had surgical placement of PD catheter. Four of 16 were placed on patients admitted to the hospital in a semi-urgent basis, the remainder were placed via outpatient surgery. The most common pathology leading to ESRD was diabetes mellitus (DM) 12 (50%). In 3 years of follow up 6 patients had complications. The first developed shortness of breath and was diagnosed with pleuro-peritoneal leak. He did not tolerate PD and was transitioned to HD. 2 patients had difficult drainage at home, however this resolved when they presented to the hospital system. After PD for several sessions 2 patients decided that they could not manage the responsibility of PD and were transitions to HD. Finally, one patient presented with non-functional catheter that at surgery was found to have omental wrapping and after revision had no further issues.
Conclusion: Peritoneal dialysis is a feasible option for patients with newly diagnosed need for renal replacement therapy. In a safety net hospital, there has been some concern about PD however in the time of our program we successfully placed and maintained 16 catheters. Patients at safety net systems should be offered PD as a viable and safe option for renal replacement therapy.