In this episode, host Dr. Aparna Baheti interviews interventional nephrologist Dr. Satyaki Banerjee about peritoneal dialysis, including indications, placement technique, and tips for preventing complications.

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SHOW NOTES

Dr. Banerjee is an interventional nephrologist at a private practice OBL in Albuquerque, NM. He has completed around 750 PD catheter placements to date. Indications for PD include patients with renal failure and a glomerular filtration rate (GFR) less than 15%. Regardless of the etiology of renal failure (i.e. hypertension, diabetes), or symptoms (i.e. uremia, volume overload), PD, like hemodialysis (HD), is an option. PD is becoming increasingly popular due to patients’ ability to do it from home rather than at a dialysis clinic 3 days per week. It also empowers patients to manage their own health. Though obesity used to be a contraindication for PD, it no longer is, and Dr. Banerjee frequently places PDs in patients with a BMI of 40. The only contraindication is an abdominal wall with extensive scarring that prevents the location of a clear window.

Next, Dr. Banerjee overviews his PD workup. He does a consultation that includes an ultrasound of the abdominal wall (to verify the absence of a hernia or diastasis recti), discussion of risks, and review of post-procedure instructions. The night before, he gives his patients 60mL of lactulose after a liquid diet that evening. Before the procedure, he ensures his patients' bowel and bladder are empty, and places a foley catheter if there is concern for bladder obstruction. He holds Coumadin and Eliquis for 2 days prior to the procedure, and Aspirin and Plavix the day of. His goal for INR is less than 1.5. If they are hyperkalemic, he gives Lokelma, a new powder medication, which he prefers over Kayexalate. He measures the patient's beltline, and where they wear their pants, and always asks if they would prefer the catheter on their right or left.

Dr. Banerjee discusses his method for placing PD catheters. He uses a triple prep of chlorhexidine, iodine, and ChloraPrep. He starts by doing a scout x-ray to mark the pelvic rim. He accesses the peritoneum from a paraumbilical approach, just lateral to the spine, and always goes through the rectus muscle. He injects lidocaine until he reaches the posterior rectus sheath, where he switches to contrast. He likes to see a spider web dissipation of contrast to confirm he is intraperitoneal. He prefers a stiff glide for his wire, and an 18 French peel away. After introducing the wire, if it forms the classic loop around the pelvis, then he proceeds to serial dilation. PD catheters are different than PleurX catheters because they have a swan neck and a double cuff. The deep cuff must be in or on the rectus muscle, and the swan neck should be hanging over the rectus. He uses a Vicryl purse-string suture to anchor the deep cuff. He tunnels about 2 inches away from the deep cuff, with the superficial cuff ending in the subcutaneous fascia. He infuses antibiotics through the catheter, usually vancomycin and cefepime. His PD patients can start dialysis the day after the procedure. He then sees his patients one week later for a dressing change and 2 weeks later for a second dressing change and to review home instructions with the PD nurse.

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