Importance of peritoneal dialysis catheter insertion by nephrologists: practice makes perfect.

‘Practice makes perfect’ is one of the most oft-heard aphorisms during our years of upbringing and education. Indeed, we believe that this rule makes perfect sense when applied to the practice of peritoneal dialysis. To date, there have been no robust randomized trials qualified enough to stir the cauldron that determines superiority (if any) of one dialysis modality over another. Although everyone agrees that selection of peritoneal dialysis versus haemodialysis is an individualized choice, the optimal means of patient selection is hotly debated [1]. The key question is whether patients have shown better survival with one particular modality of dialysis versus another. Accumulating evidence shows an important role for the centre effect in determining treatment success. For example, data from population-based or nationwide cohorts show that increasing cumulative numbers of treated peritoneal dialysis patients are associated with improved patient survival during peritoneal dialysis [2]. In Canada, technique failure rates and covariate-adjusted mortality decreased significantly with increasing numbers of peritoneal dialysis patients being treated (by each individual centre) [3]. For example, patients treated by centres with >500 cumulative peritoneal dialysis patient counts had a 29% reduction in mortality risk. When the centres were further classified by the utility of peritoneal dialysis, significantly lower technique failure rates were found in centres having a higher percentage of patients initiating dialysis on peritoneal dialysis [3]. Similar results were found in the Dutch dialysis registry analysis [4], the United States Renal Data System and in more recent cohorts from the United States [5–7]. To put these registry data in context, it is possible that nephrologists from centres with more experience and specialization with peritoneal dialysis provided more effective management of infectious complications, peritoneal access creation, volume status and cardiovascular disease. What then are the implications for peritoneal catheter insertion by nephrologists? The practice of peritoneal dialysis catheter insertion by nephrologists substantially contributes to treatment outcomes, in part, because it enhances peritoneal dialysis penetration and because of the consistent salutary effect of centre size on technique success rates and patient survival outcomes. Why does insertion of peritoneal dialysis catheters by nephrologists matter? This issue is more than just the mere need for continuity in patient care. In all likelihood, the ultimate goal is to provide timely and effective catheter insertion without unduly long waiting times or delay, during which potential candidates for peritoneal dialysis may lose interest in this dialysis modality. In an age where tight operating theatre schedules have become the rule rather than the exception, referral to a surgeon (and scheduling an operating theatre) for catheter insertion becomes the rate-limiting step for initiating peritoneal dialysis. In addition, there is a dearth of committed surgical teams having a keen interest in peritoneal catheter placement in most dialysis centres. A lengthy waiting list for catheter insertion is demoralizing for both renal physicians and patients alike, causing an ultimate erosion of confidence in peritoneal dialysis. In this context, catheter insertion by nephrologists is a critical component of a successful peritoneal dialysis programme. There is a plethora of evidence to suggest that catheter insertion by nephrologists improves peritoneal dialysis utilization and increases the peritoneal dialysis population growth rate [8– 11]. Importantly, catheter insertion by nephrologists was paralleled by a change in the number of peritoneal dialysis patients in each centre. For instance, initiation of catheter insertion by nephrologists in three centres in the United States was associated with a 22–32% increase in the number of peritoneal dialysis patients [8], whereas a return to catheter insertion by surgeons led to a decline in the peritoneal dialysis population [8]. In other studies, a similar growth in the peritoneal dialysis penetration was seen following the development of comprehensive infrastructure and support systems that included catheter insertion by nephrologists [9–11]. In particular, a universal policy of catheter insertion by nephrologists in one Malaysian dialysis unit was associated with a dramatically increased penetration ratio of peritoneal dialysis compared to haemodialysis, representing a quadrupling from that of the national average [11]. Together, these studies show that peritoneal dialysis catheter insertion by nephrologists reduces the waiting times and therefore enhances peritoneal dialysis uptake; the latter