Risk Factors and Management of Catheter Malfunction During Urgent-Start Peritoneal Dialysis

Background: Catheter malfunction is a common complication of peritoneal dialysis (PD). This study aimed to retrospectively analyze the risk factors and management of catheter malfunction in urgent-start PD.Methods: Patients who underwent urgent-start PD were divided into catheter-malfunction and control groups. Baseline demographic and laboratory data of the two groups were compared, and the risk factors for catheter malfunction were analyzed. Primary outcome measure was catheter survival, and the secondary outcomes were surgical complications and malfunction treatment.Results: Total of 700 patients was analyzed, among whom 143 (20.4%) experienced catheter malfunctions, specifically catheter migration (96, 67.1%), omental wrapping (36, 25.2%), and migration plus omental wrapping (11, 7.7%). Catheter survival time in the malfunction group (202.5 ± 479.4 days) was significantly shorter than that in the control group (1295.3 ± 637.0 days) (P < 0.001). Multivariate analysis revealed higher body mass index [hazard ratio (HR), 1.061; 95% confidence intervals (CI), 1.010–1.115; P = 0.018], lower surgeon count (HR, 1.083; 95% CI, 1.032–1.136; P = 0.001), and higher serum potassium (HR, 1.231; 95% CI, 1.041–1.494; P = 0.036) as independent risk factors for catheter malfunction, while older age (HR, 0.976, 95% CI, 0.962–0.991; P = 0.002) and colonic dialysis (HR, 0.384; 95% CI, 0.254–0.581; P < 0.001) as protective factors. Further subgroup analysis revealed a shorter catheter survival time in patients with younger age ( ≤ 40 years), higher serum potassium levels (≥5 mmol/L), while a longer catheter survival time in patients with colonic dialysis. PD tube and subcutaneous tunnel preservation was successful in 41 out of 44 patients with omental wrapping. All patients had good post-incision prognoses.Conclusions: Urgent-start PD is safe and effective for unplanned PD patients. Adequate pre-operative colonic dialysis and serum potassium level control are conducive in preventing catheter malfunction. Conservative treatment is effective in managing catheter migration alone, while preservation of the PD tube and the subcutaneous tunnel is effective for omental wrapping.

Medicazione a base d’argento nella gestione dell’emergenza cutanea

Introduction: Exit-site (ES) and tunnel infections are the main infectious complication in peritoneal dialysis (PD); they also are risk factors for the development of peritonitis, for catheter removal and for dialysis drop-out. Up to now, besides the recommendations of the Guidelines there is no uniformity, nor on the classification, nor on the treatment strategies of the infected ES. Recent experiences are reported with alternative types of dressings that aim to reduce the incidence of ES infection and consequently of the subcutaneous tunnel. Methods: The Tuscan group conducted a retrospective observational study of 10 patients on PD who, showing signs of a suspected but not ascertained infection (negative microbiological culture), such as redness, edema, secretion, scab, had been medicated with silver-ions releasing Exit-Pad Ag. The aim was to evaluate and classify the evolution of ES lesions, in order to confirm the preventive efficacy of the silver-ions releasing dressing compared to the traditional ones. Results: After 4 weeks of treatment with Exit Pad Ag maintained in situ for 72 h, 6 patients no longer had any signs of inflammation. In 2 cases, several weeks of treatment were necessary to achieve a complete recovery, while in 2 other cases the signs of inflammation became negative in less time (2 weeks, 1 week). Conclusions: With the utilization of an alternative dressing such as Exit-Pad Ag on PD patients showing early signs of inflammation, the onset of a true infection can be prevented, with a progressive improvement of the ES.

Clinical outcomes of transposed brachial-basilic vein fistula: Tunneling versus elevation

Background: The Kidney Disease Outcome Quality Initiative (KDOQI) suggests a transposed brachial basilic vein fistula (TBBVF) in the patients who have good likelihood of long-term survival. To superficialize the basilic vein, a disconnected basilic vein is anterolaterally transposed inside a subcutaneous tunnel. A simple elevation in situ is an alternative technique. The aim of this study was to compare clinical outcomes of TBBVF according to the type of superficialization. Methods: A total of 42 patients (mean age of 66 years, male: 45%) who underwent a TBBVF from April 2014 to March 2019 at our hospital were retrospectively reviewed. The method of superficialization (tunneling ( n = 18) vs elevation ( n = 24)) was determined by the surgeon’s preference. It was done as a one-stage surgery. There was not any statistically significant difference in demographic or clinical characteristics of patients between the two groups. As early outcomes, postoperative mortality and morbidity were investigated. For clinical outcomes, primary patency, primary-assisted patency, and secondary patency were analyzed for both groups. Results: There was a case of a 30-day mortality in the elevation group. Regarding morbidities, there was a postoperative bleeding in the tunneling group and a steal syndrome in the elevation group. The mean follow-up was 28 months (range, 0–63 months). There was no significant difference in primary patency (64.8% vs 77.5% in 1 year and 54.0% vs 54.1% at 3 year; p = 0.816), primary-assisted patency (88.9% vs 86.5% in 1 year and 88.9 vs 81.4 at 3 year; p = 0.624), or secondary patency (100% vs 86.5% in 1 year and 100% vs 86.5% at 3 year; p = 0.126) between the two groups. Conclusions: Clinical outcomes of TBBVF showed no significant difference between tunneling and elevation groups. Thus, TBBVF can be done with either method.

The Application of Skin Expander in Subcontaneous Cystoplasty: A Novel Method to Solve the Dysfunction of Bladder

The patients of neurogenic bladder or radical cystectomy suffered much of the bladder dysfunction, leading mass wealth losses and misfortune of individual and society. We designed a new method to solve the problem: subcontaneous cystoplasty. Three skin expanders were buried around the abdominal ureter exit after cutaneous ureterostomy, then the inner skin bag were constructed by the expanded skin. The subcutaneous tunnel connected to the urine bag were pressed outside by belt to control the voiding. Skin urethra bulge, controlling the direction of the urination, located at the terminal of subcutaneous tunnel. Patients can put pressure to the subcontaneous urine bag to exhaust the urine. It may affect the appearance, but it can avoid many defects caused by ileocolic-cystoplasty, and may help neurogenic patients get ride of external urine bags.

The Application of Skin Expander in Subcontaneous Cystoplasty: A Novel Method to Solve the Dysfunction of Bladder

The patients of neurogenic bladder or radical cystectomy suffered much of the bladder dysfunction, leading mass wealth losses and misfortune of individual and society. We designed a new method to solve the problem: subcontaneous cystoplasty. Three skin expanders were buried around the abdominal ureter exit after cutaneous ureterostomy, then the inner skin bag were constructed by the expanded skin. The subcutaneous tunnel connected to the urine bag were pressed outside by belt to control the voiding. Skin urethra bulge, controlling the direction of the urination, located at the terminal of subcutaneous tunnel. Patients can put pressure to the subcontaneous urine bag to exhaust the urine. It may affect the appearance, but it can avoid many defects caused by ileocolic-cystoplasty, and may help neurogenic patients get ride of external urine bags.

Reverse Sural Flap for Repair of Foot and Ankle Defects: Our Cases, Modifications, and a Literature Review

Introduction: Reverse-flow sural flap is a valuable option in cases of lower extremity repair. In this study, we aimed to present our sural flap applications and modifications for the treatment of ankle and foot defects and to evaluate our results in the light of historical process and current literature. Materials and Methods: A reverse-flow fasciocutaneous flap was performed in 14 patients to repair foot and ankle defects. In 6 cases (42.86%), we chose to perform interpolation sural flaps where we aimed to repair the distal defects of the foot and/or in order to prevent patients from having trouble wearing shoes due to bulkiness of the flap pedicle at the ankle. In other cases (tunnel flap group, 57.14%), the pedicle of the flap was passed through the subcutaneous tunnel. Wide and meticulous dissection of the tunnel, nitroglycerine application on the flap, and close flap monitoring were our protective measures. Our results were analyzed statistically. The literature review was performed from Medline and PubMed. Results: Sural flap repair was performed in 14 patients. The mean age was 32.75 years. Etiologic factors were traffic accidents, spinal cord injuries, and hyperkeratotic lesions. The defects were localized in the ankle or proximal foot in 12 (85.71%) patients and the distal foot in the remaining patients (14.29%). The mean area of the defects was 46.75 cm2. Partial necrosis at the distal flap developed in 2 (25%) cases in the tunnel group and in 1 (16.67%) in the interpolation group (3 cases in total, 21.43% in the study population). No statistical difference was found between the flap groups in terms of patient distribution and complications. Conclusion: Wide dissection of the subcutaneous tunnel through which the pedicle is passed (in the tunnel group), application of nitroglycerin, meticulous hemostasis, and postoperative follow-ups are important factors for a successful reverse sural flap application. Sural interpolation modification is advantageous in several cases as the flap can reach farther and does not cause bulkiness in the ankle that would impair shoe wear. However, the disadvantage is that it requires 2 sessions.

Tunneled Ipsilateral Sheath: A Novel Technique in Endovascular Management of Superficial Femoral Artery Ostial Lesions

Ostial lesions of the superficial femoral artery preclude the use of ipsilateral common femoral artery antegrade approach. Access via either the contralateral common femoral or the brachial arteries are the 2 alternative classical approaches. Conversely, using an ipsilateral antegrade approach, through a partially inserted sheath, usually leaves the sheath insecure and frequently hits ostial lesion itself during insertion. Dislodgment from the artery frequently occurs, resulting in loss of access. We describe a technique whereby we insert 2 to 3 cm of the sheath into the common femoral artery and the remaining part of the sheath resides in a fashioned subcutaneous tunnel of the lowermost abdomen. Technical details are provided as well as the results of using this technique on 37 patients. The technique is safe, easy to perform, and reproducible.

Modified over-the-wire technique for infected tunneled cuffed dialysis catheters exchange: a precious salvage procedure

Background: One of the major troubles related to tunnelled cuffed catheters for hemodialysis is infection. The outcomes of conservative treatment, as an attempt to access salvage, are often poor.Methods: In the present retrospective study, authors reviewed all the patients who underwent infected tunneled cuffed dialysis catheter exchange through a modified over the wire technique. Briefly, this technique consisted in creating a new subcutaneous tunnel away from the old one, preserving the insertion site of the catheter to the vein.Results: Authors have performed infected catheter exchange with this technique in 59 patients. The success rate was 93.2%. Median follow-up was 9 months. There were only 4 patients with signs and symptoms of recurrent catheter infection treated with catheter removal.Conclusions: The modified technique may provide multiple benefits for patients with ESRD. Low recurrence rates, anatomic site preservation and cost effectiveness are some of the advantages of this technique.