Impact of Peritoneal Dialysis Catheter Insertion by a Nephrologist: Results of a Questionnaire Survey of Patients and Nurses

Transcription

1 Advances in Peritoneal Dialysis, Vol. 31, 2015 Naoki Washida, 1 Kayoko Aikawa, 2 Shuji Inoue, 3 Takahiro Kasai, 1 Keisuke Shinozuka, 1 Kohkichi Morimoto, 1 Kozi Hosoya, 4 Koichi Hayashi, 1 Hiroshi Itoh 1 Impact of Peritoneal Dialysis Catheter Insertion by a Nephrologist: Results of a Questionnaire Survey of Patients and Nurses Peritoneal dialysis (PD) is an excellent dialysis modality, but it is underutilized in the United States and Japan. In the present study, we evaluated the impact of interventional nephrology in PD on the impressions held by patients and nurses about selection of a renal replacement therapy and the complications associated with PD therapy. Over a period of 7 years, PD catheter insertion in 120 patients with end-stage renal disease (age: 63.0 ± 13.3 years) was performed by nephrologists at Keio University Hospital or Saitama Medical Center. A questionnaire survey evaluating the advantages and disadvantages of this interventional nephrology approach in PD was distributed to 72 PD patients and to 53 nurses in charge of those patients. After interventional nephrology in PD was adopted, the number of patients selecting PD therapy increased. The incidence of peritonitis was relatively low (1 episode in patient months). Responses to the questionnaire survey showed that neither patients nor nurses were concerned about catheter insertion by physicians, and no communication problems between the patients, nurses, and physicians were reported. Approximately 60% of the nurses specializing in PD therapy showed higher motivation with interventional nephrology, which might have a favorable effect on the selection of PD therapy, on the incidence of peritonitis, and on the tripartite communication between patients, nurses, and physicians. From: 1 Department of Internal Medicine, Keio University School of Medicine, and 2 Department of Nursing, Keio University Hospital, Tokyo, Japan; 3 Department of Nephrology, Saitama Medical Center, Saitama; and 4 Department of Nephrology, Saiseikai Central Hospital, Tokyo, Japan. Key words Interventional nephrology, peritoneal dialysis catheter Introduction Peritoneal dialysis (PD) is an indispensable therapy for end-stage renal disease (ESRD). Although PD offers many advantages as a therapeutic strategy, it is performed only in 6.4% of the patients with ESRD in the United States (1) and in 3.2% of those in Japan. Reasons for this situation vary (2 5). Insertion of the PD catheter is essential before PD start, and long-term catheter maintenance is a key factor for successful outcomes, but a variety of problems can arise unless physicians are deeply involved in catheter placement and maintenance. For example, initiation of PD therapy can be delayed if the patient is referred to a surgeon for catheter insertion. That delay might divert a patient s interest away from PD therapy (5,6) and might also result in difficulties managing a variety of problems that require surgical intervention, including tunnel infection and other catheter-related disorders after PD therapy commences. The appropriate time to exchange an infected catheter can also be missed. Alternatively, if physicians have no experience in conducting surgical procedures related to catheter maintenance, they might stick to redundant use of antibiotics in cases of catheter-related infection, which could provoke antibiotic resistance and further aggravation of peritonitis. Notably, the withdrawal rate because of peritonitis is reported to be high among PD patients in Japan (7), thereby possibly hindering the widespread penetration of PD therapy. Finally, if a surgeon inserts the PD catheter and a physician manages maintenance of the PD catheter, poor communication between the two staffs might cause critical problems. An evaluation of the effect of catheter insertion by nephrologists on the impressions of PD held by

2 60 Interventional Nephrology in PD Therapy patients and nurses therefore appears important. Another interesting question is whether catheter placement operations conducted by physicians per se affect the relationships between physicians and patients and between physicians and nurses. Methods Our questionnaire study was conducted at Keio University Hospital and Saitama Medical Center, where physicians had been performing PD catheter placement operations since September Questionnaires were designed to elicit from PD patients and their nurses the advantages and disadvantages attached to the PD catheter placement when the operation was performed by physicians (Table I). The questionnaires were designed to be completed in 5 minutes. During the study, swan-neck double-cuffed catheters with straight tips (JB5A or JB6A: Medionics International, Markham, ON, Canada) were inserted under spinal anesthesia (97 patients) or under local anesthesia (3 patients). We calculated the percentages of patients in whom peritonitis occurred, the catheter survived, peritonitis was cured, PD was discontinued, and perioperative complications occurred. The percentage of patients in whom the catheter survived was compared depending on whether a surgeon or a physician performed the catheter insertion. The study was approved by the Ethics Committee of Keio University School of Medicine and by Saitama Medical Center. After each patient and nurse was provided with a detailed explanation of the study, written informed consent to participation was obtained. Outsiders irrelevant to the PD medical team requested participation (completion of the questionnaire) from all the nurses involved in PD treatment and from all the PD patients. Answers to the patient and nurse portions of the questionnaire were collected in suggestion boxes. The outsiders analyzed the submitted questionnaires, thus guaranteeing that no individual could be identified by their answers. Furthermore, the nurses and the patients were all informed that they would not be disadvantaged in any way if they did not participate and that anonymity of the answers to the questionnaires was ensured. The statistical analysis used chi-square tests, and the level of significance was set at a probability of less than The statistical evaluation was carried out by 3 people who were blinded to the treatment outcomes and the patient information. Results At the two hospitals, catheter insertions were performed by physicians in 105 patients starting September Figure 1 shows the temporal change in the number of patients in whom PD therapy was introduced or discontinued at Keio University Hospital. The number of patients receiving PD therapy markedly increased after physicians began to perform the PD catheter insertion operations. Table II shows the baseline characteristics of the patients. The mean age of the 120 patients treated during the study period (92 men, 28 women) was 63.0 ± 13.3 years. The percentage of patients with diabetic nephropathy was 31.7%. Table III shows the operation time for catheter insertion, the peritonitis rate, the percentage of patients in whom the catheter survived, and the percentage of patients in whom PD was discontinued. The results obtained for those variables in the present study were equivalent to or better than results previously reported (6). Table IV summarizes catheter-related complications by placement group (physicians or surgeons). Perioperative catheter blockade associated with fallopian tube wrapping occurred in 1 patient, but PD therapy was able to continue after fimbriectomy. Other complications included leakage from the catheter exit site (n = 1), pericatheter bleeding (n = 1), intestinal perforation (n = 1), and bladder perforation (n = 1). Exit-site leakage was managed by catheter exchange, and PD therapy was resumed after 2 weeks. Postoperative hemorrhage occurred 1 week after catheter insertion, but PD was resumed after hemostasis and removal of the hematoma. In the patients with intestinal perforation and bladder perforation, the perforations were sutured during the catheter insertion procedure, and PD was successfully continued. Questionnaires were completed by 72 of the 105 patients who had undergone PD catheter insertion by a physician (55 men, 17 women) and by 53 of the 70 nurses who were involved in the management of PD therapy. Patient responses information provided before pd catheter insertion With respect to the intelligibility of the explanation about PD therapy in the choice of renal replacement therapy, 97.2% of the patients felt that

3 Washida et al. 61 table i The questionnaire, with aggregated results For patients (1) Was the explanation of peritoneal dialysis (PD) therapy in the choice of renal replacement therapy readily intelligible? Very easy Fairly easy No opinion Not very easy Not easy (2) Was the explanation of PD catheter placement readily intelligible? Very easy Fairly easy No opinion Not very easy Not easy (3) How did you feel when you were told that a physician was planning to perform the PD catheter insertion? o I felt safe because PD catheter insertion would be performed by the physician who was already treating me. [58 patients (80.6%)] o I was worried about the physician s surgical skill. [5 patients (6.9%)] o I felt nothing special. [9 patients (12.5%)] (4) Did the explanation that a physician would perform PD catheter insertion affect your selection of renal replacement therapy? Very much Slightly No opinion Hardly at all Not at all (5) Who would you like to conduct the PD catheter insertion operation? Rank (1) (2) (3) (4) TOTAL Physicians who have Physicians who have Surgeons who have Surgeons who have a lot of experience of PD catheter insertion little experience of PD catheter insertion a lot of experience of PD catheter insertion little experience of PD catheter insertion Unknown (6) Regarding spinal anesthesia, o I was comfortable to recover quickly from spinal anesthesia without intubation. [6 patients (8.3%)] o I felt relaxed because I was able to get in contact with my physician. [23 patients (31.9%)] o I felt relaxed when I heard music. [4 patients (5.6%)] o I was nervous when I heard the physician and his colleagues talking with each other. [6 patients (8.3%)] o I would have preferred general anesthesia. [7 patients (9.7%)] (7) Regarding the severity of pain you felt after the operation, Hardly any pain Bearable pain Unbearable pain (8) Did you feel comfortable with the PD catheter insertion operation by your physician? I felt at ease I felt fairly at ease No opinion I hardly felt at ease I didn t feel at ease at all (9) Did you have no hesitation in conveying any problems such as pain and anxiety you had during PD catheter insertion? I did not hesitate I hardly hesitated No opinion I hesitated slightly I hesitated

4 62 Interventional Nephrology in PD Therapy table i Continued For patients (10) Comments obtained from patients after PD catheter insertion I felt safe because the same physician treated me before, during, and after PD catheter insertion. I felt safe because the physician and I had good communication. I felt safe because the physician was knowledgeable about PD. I felt free to talk to the physician during PD catheter insertion because the physician has always treated me. I feel free to ask questions about postoperative care and daily life and to express my wishes. Explanations provided before and after PD catheter insertion were easy because the physician was knowledgeable about PD. (11) Did you hesitate to tell your physician about the pain or any problems such as anxiety you felt after PD catheter insertion? I did not hesitate I hardly hesitated No opinion I hesitated slightly I hesitated (12) Did you hesitate to ask your physician about PD catheter maintenance? I did not hesitate I hardly hesitated No opinion I hesitated slightly I hesitated (13) Did you have any problems during the 3 months after PD catheter placement? Problems in 11 patients (15.3%) were reported. Problems: Granulation in 2 patients Chronic exudate (pus) in 2 patients Pain and pus There was liquid leaking from the end of the metal outside the catheter. I telephoned the physician and rushed to hospital. I developed pus. I am a bit worried because I am advised that pus may occur again. I had no pain, but developed mild bleeding and pus. I developed pus without pain about 6 months after PD catheter insertion, but it was cured by disinfection. I was taking a bath 3 or 4 times a week. This might have caused the pus. I had slight bleeding, but it resolved with medication. I had no problems. I did not wash the insertion site until I was advised to do so. When I washed the insertion site, I pulled the catheter and there was bleeding. Scabbing and inflammation around the insertion site. (14) Did you find any difficulty in having contact with your physician when a problem occurred? I could not get in contact with my physician. (0 patients) o o o I could contact my physician who had performed PD catheter insertion. (49 patients) Others (4 patients) For nurses I definitely think so I probably think so No opinion I hardly think so I do not think so (1) Do you think that patients are more likely to select PD therapy if you explain that your physician will perform PD catheter insertion? (2) Do you think that patients are able an explanation about the operation of PD catheter insertion better if the physician who will conduct the operation explains it?

5 Washida et al. 63 table i Continued For nurses (3) Do you think that you can help patients have better relationship with the physician if the physician per se explains the operation of PD catheter insertion as an operator? (4) Do you think that physicians do not possess sufficient knowledge about the PD catheter insertion operation? (5) Do you think that physicians do not receive sufficient training for PD catheter insertion? (6) Do you think that a physician can manage the wound/catheter exit site properly for long-term catheter survival because a physician performs PD catheter insertion? (7) Do you think that a physician can do surgical procedures for catheter maintenance with a quick response because a physician is able to conduct operations associated with PD? (8) Do you think that patients and nephrologists will have a good relationship because nephrologists are involved in the selection of treatment for end-stage renal disease? (9) Do you think that you can communicate with a physician more easily if a physician performs PD catheter insertion? (10) Do you think that you would have a higher motivation to support PD if a physician performed PD catheter insertion? (11) Do you think that you can convey more easily the patients anxiety or requests to the physician before PD catheter insertion if the physician per se performs catheter insertion? (12) Do you think that you have no hesitation in asking a physician questions before PD catheter insertion if the physician performs catheter insertion? (13) Do you think that you can easily provide the physician with a patient s requests about catheter maintenance and pain control after PD catheter insertion because a physician performs the catheter insertion operation? (14) Do you think that you can easily ask the physician about postprocedural catheter maintenance and pain control because the physician performs PD catheter insertion? the explanation was very easy (n = 51) or fairly easy (n = 19). With respect to the simplicity of the explanation about the PD catheter placement operation, all patients felt that the explanation was either very easy (n = 55) or fairly easy to understand (n = 17). With respect to the plan that a physician would carry out the PD catheter insertion operation, 80.6% of the patients indicated feeling at ease. Only 6.9% felt concern about the physician s surgical skill. With respect to the question about whether PD catheter placement by a physician affected the patient s selection of treatment for ESRD, 50.7% of the patients responded not at all (n = 22) or hardly at all (n = 14), but 32.4% answered very much (n = 17) or slightly (n = 6). The answers varied from patient to patient. pd catheter insertion With respect to the person that the patient would like to conduct the PD catheter insertion operation, 59 patients (83.1%) selected Physicians who have a lot of experience with PD catheter insertion and 11 patients (15.5%) selected Surgeons who have a lot of experience with PD catheter

6 64 Interventional Nephrology in PD Therapy table ii Baseline characteristics of the study patients Characteristic Value Patients (n) 120 Mean age (years) 63.0±13.3 Sex (n men/women) 92/28 Cumulative duration of follow-up (pt-mos) 2528 Causes of ESRD [n (%)] Diabetes mellitus 38 (31.7) Chronic glomerulonephritis 42 (35.0) Hypertension 32 (26.7) ADPKD 3 (2.5) Others 5 (4.2) Pt-mos = patient months; ESRD = end-stage renal disease; ADPKD = autosomal-dominant polycystic kidney disease. figure 1 Change over time in the number of peritoneal dialysis inductions and withdrawals at Keio University Hospital. insertion as a priority. Figure 2 summarizes the answers to this question. With respect to spinal anesthesia, approximately half the patients felt relaxed because they were awake during the operation (37.5%) or comfortable because of quick recovery from spinal anesthesia (8.3%). However, 7 patients (9.7%) would have preferred to have had general anesthesia. With respect to the severity of pain felt after the operation, almost all patients (93.1%) had minimal (n = 20) or bearable pain (n = 47). With respect to the PD catheter insertion operation by the patient s physician, 97.2% of the patients felt at ease (n = 58) or fairly safe (n = 12). With respect to the question Did you have no hesitation in conveying any problems such as pain and anxiety you had during the PD catheter insertion operation, 92.9% of the patients answered I did not hesitate (n = 49) or I hardly hesitated (n = 16). Most patients answered that they felt safe and at ease during the PD catheter insertion operation. the period after pd catheter insertion With respect to the question Did you hesitate to tell your physician about postoperative pain or any problems such as anxiety you felt after PD catheter insertion, 91.7% of the patients answered I did not hesitate (n = 49) or I hardly hesitated (n = 17). With respect to the question Did you hesitate to ask your physician about PD catheter maintenance, table iii Technical data and treatment outcomes for 120 patients Parameter Value Mean operation time (minutes) 62.7±7.2 Catheter survival [n (%)] 112 (93.3) Peritonitis morbidity (eps/pt mos) 1/101.1 PD withdrawal rate [n (%)] 35 (29.2) Mortality [n (%)] 15 (12.5) Eps/pt-mos = episodes per patient months. 77.8% of the patients answered I did not hesitate (n = 56), and 18.1% of the patients answered I hardly hesitated (n = 13), for a total of 95.8% (n = 69). With respect to the sequelae occurring during the 3 months after PD catheter placement, 11 patients (15.3%) had a problem of some kind, including, in 8 patients, a local infection or its associated symptoms. With respect to the accessibility of the patient s physician when any problem occurred, 92.5% of the patients answered I could contact my physician (n = 49). No patient answered I could not get in contact with my physician. Nurse responses Of the 53 nurses, 19 had less than 5 years of experience, 5 had 5 9 years of experience, 10 had years of experience, and 18 had more than 15 years of experience (Figure 3). Experience for 1 nurse was unavailable. Experience of surgical procedures was reported by 18 nurses (34.6%).

7 Washida et al. 65 table iv Catheter-associated complications by placement group Catheter placement group Variable Surgeons a Nephrologists a Present study Procedures (n) Mean patient age (years) 55±18 52± ±13.3 With diabetes mellitus [n (%)] 11 (11) 16 (12) 38 (31.7) Cumulative follow-up (pt-mos) Dialysate leakage (n) Early Late Pericatheter bleeding (n) Obstruction (n) Migration (n) Omental wrapping (n) Fallopian tube wrapping (n) Perforation (n) Colon Urinary bladder a From Ozener et al., 2001 (6). figure 2 Patient answers to the question Who would you like to perform PD [peritoneal dialysis] catheter insertion? explanations and agreements patients are more likely to select PD therapy if you explain that your physician will perform PD catheter insertion, 29 nurses answered no opinion (54.7%), and 14 nurses answered probably (26.4%). patients are able an explanation about the PD catheter insertion operation better if the physician who will conduct the operation explains it, 28 nurses answered probably (52.8%). you can help patients have a better relationship with the physician if the physician per se explains the PD catheter insertion operation as an operator, 75.5% of the nurses answered probably (n = 25) or definitely (n = 15). patients and nephrologists will have a good relationship because nephrologists are involved in the selection of the treatment for ESRD, 88.7% of the nurses answered probably (n = 27) or definitely (n = 20). figure 3 Experience levels of the nurses who answered the questionnaire. issues before pd catheter insertion you can convey more easily the patients anxiety

8 66 Interventional Nephrology in PD Therapy or requests to the physician before PD catheter insertion if the physician per se performs catheter placement, 30 nurses answered probably (56.6%). you have no hesitation in asking a physician questions before PD catheter insertion if the physician performs catheter insertion, 27 nurses answered probably (50.9%) and 15 nurses answered definitely (28.3%). pd catheter insertion physicians do not possess sufficient knowledge about the PD catheter insertion operation, 24 nurses answered hardly (45.3%); 15 nurses answered no opinion (28.3%). physicians do not receive sufficient training for PD catheter insertion, 21 nurses answered hardly (39.6%); 16 nurses answered no opinion (30.2%). you can communicate with a physician more easily if a physician performs PD catheter insertion, 67.9% of the nurses answered probably (n = 26) or definitely (n = 10); 10 nurses answered no opinion. catheter maintenance a physician can manage the wound/catheter exit site properly for long-term catheter survival because a physician performs PD catheter insertion, 69.8% of the nurses answered probably (n = 27) or definitely (n = 10). a physician can do surgical procedures for catheter maintenance with a quick response because a physician is able to conduct operation associated with PD, 73.6% of the nurses answered probably (n = 26) or definitely (n = 13). you can easily provide the physician with a patient s requests on catheter maintenance and pain control after PD catheter insertion because the physician performs the catheter insertion operation, 83.0% of the nurses answered probably (n = 28) or definitely (n = 16). you can easily ask the physician about postprocedural catheter maintenance and pain control because the physician performs PD catheter insertion, 58.5% of the nurses answered probably (n = 31), and 11.3% answered no opinion (n = 6). motivation for pd you will have higher motivation to support PD therapy if a physician performs PD catheter insertion, 20.8% of the nurses answered probably (n = 11), but 60.4% answered no opinion. Among the 10 nurses in charge of PD treatment, 6 answered definitely (n = 3) or probably (n = 3). However, 2 nurses answered no opinion, 1 answered hardly, and 1 answered unknown. Discussion Underutilization In the United States, Japan, and other (developed) countries, PD is underutilized for a number of reasons (8 12). One of the important reasons is that just 2.3% of PD catheters are placed by nephrologists (13). Typically, the PD catheter insertion operation is performed by surgeons who do not have enough knowledge about PD therapy or the appropriate method of catheter insertion. They also lack the experience to select an appropriate catheter exit site and usually perform a midline laparotomy, instead of a transperitoneal rectus incision, which is more prone to tunnel infection and subsequent peritonitis. Furthermore, compared with the transperitoneal rectus incision, the lower-abdominal median incision is associated with a relatively high incidence of dialysate leaks and flow dysfunction: 1.9% 11.1% and 10.4% 19.4% respectively (13,14 17). Among the patients treated during our study period, those incidence rates were 0.95% and 1.9% respectively. Finally, surgeons usually prefer general anesthesia during the PD catheter placement operation, although they often perform the surgery to create an arteriovenous fistula in preparation for hemodialysis under local anesthesia (11). It has been reported that PD catheter placement by nephrologists is associated with an increased number of patients on PD therapy (11,12,18). In the present study, the number of patients on PD therapy increased

9 Washida et al. 67 after 2007, when catheter insertion by physicians instead of by surgeons was started (Figure 1). In fact, the percentage of patients treated with PD in the present series (approximately 9%) is three times the mean rate in Japan (2.9%) a finding suggesting that if a nephrologist has built up a favorable relationship with a patient during ESRD management, the patient is not concerned about the PD catheter insertion operation being performed by the highly experienced nephrologist. Rather, operation by the nephrologist per se would facilitate perioperative management, including the operative schedule and indications for an unroofing procedure. Although PD catheter insertion requiring an abdominal incision renders patients more nervous, a well-established relationship between patient and physician should mitigate the patient s anxiety. The results of our questionnaire survey actually endorse that conjecture. Improved catheter survival Catheter survival is a factor critical to the success of PD therapy. Several lines of study so far have reported that PD catheter placement by nephrologists is associated with better outcomes (11,18,19). The present study shows that the incidence of peritonitis is low, most likely because nephrologists not only perform PD catheter placement but also manage PD catheter care and any complications. In cases of tunnel infection, for example, they are able to manage the problem promptly by implementing an unroofing operation and catheter replacement. Such decisions could prevent a subsequent peritonitis and improve catheter survival. Furthermore, physician involvement might contribute to a lowering of the incidence of refractory peritonitis caused by drug-resistant bacteria, potentially avoiding discontinuation of PD therapy and improving the prognosis of the patients. Impact on patients and nurses The present study was conducted to evaluate the impact of PD catheter placement by nephrologists on the opinions of patients and nurses. The questionnaire survey discovered that most patients understand the explanation of PD therapy provided by their physicians and feel safe and at ease before, during, and after PD catheter placement. Furthermore, the ability of a physician who has detailed knowledge about PD therapy to perform the PD catheter insertion operation will promote patient acceptance of PD therapy with few concerns, which consequently could lead to wider dissemination of the modality. Responses to the questionnaire survey by nurses showed that PD catheter placement by physicians markedly improves the tripartite communication between nurses, patients, and physicians. Nurses overall did not have a solid motivation to assist with PD therapy when physicians per se, compared with surgeons, performed the PD catheter insertion operation. Nevertheless, the motivation of the nurses who were actually in charge of PD therapy was higher; as many as 60% of them contributed actively to PD treatment. It is thus anticipated that information obtained from patients is readily conveyed by the nurses who take care of those patients to the nephrologists and that the contribution of nurses specializing in PD therapy to the PD treatment strategy is enhanced. Although the present questionnaire survey did not target physicians, the results suggest that the physicians who perform PD catheter insertion are more interested in PD and have better relationships with the nurses and patients. Conclusions The present study indicates that patients feel safe and at ease when physicians conduct the PD catheter insertion operation and that the relationships between nurses, physicians, and patients is improving. Those factors contribute to the amelioration of outcomes in PD therapy and therefore allow a large number of patients to adopt PD as a first-line therapeutic strategy in ESRD. Nevertheless, the time required for physicians to learn PD catheter insertion is an obstacle to widespread dissemination, and a well-organized training system must be established. Study limitations Caveat is in order because the present study was retrospective and uncontrolled and could potentially carry some bias. Furthermore, the method of used (that is, a questionnaire survey) to evaluate the impact of the PD catheter insertion operation by a physician on the opinions and impressions of patients and nurses relies on subjective judgment. Nevertheless, to the extent that PD therapy is still seldom performed in Japan, we infer that the results of the present study contribute substantially to the wider distribution of PD therapy. Further prospective studies are required to confirm our findings.

10 68 Interventional Nephrology in PD Therapy Acknowledgments We thank the patients and nurses who participated in the study. Disclosures The authors have no conflicts of interest to declare. References 1 U.S. Renal Data System. USRDS 2006 annual data report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; Asif A, Pflederer TA, Vieira CF, Diego J, Roth D, Agarwal A. Does catheter insertion by nephrologists improve peritoneal dialysis utilization? A multicenter analysis. Semin Dial 2005;18: Novak M, Bender F, Piraino B. Why is peritoneal dialysis underutilized in the United States? Dial Transplant 2008;37:90. 4 Van Biesen W, Veys N, Lameire N, Vanholder R. Why less success of the peritoneal dialysis programmes in Europe? Nephrol Dial Transplant 2008;23: Goh BL, Ganeshadeva YM, Chew SE, Dalimi MS. Does peritoneal dialysis catheter insertion by interventional nephrologists enhance peritoneal dialysis penetration? Semin Dial 2008;21: Ozener C, Bihorac A, Okoglu E. Technical survival of PD catheters: comparison between percutaneous and conventional surgical techniques. Nephrol Dial Transplant 2001;16: Mizuno M, Ito Y, Tanaka A, et al. Peritonitis is still an important factor for withdrawal from peritoneal dialysis therapy in the Tokai area of Japan. Clin Exp Nephrol 2011;15: Hingwala J, Diamond J, Tangri N, et al. Underutilization of peritoneal dialysis: the role of the nephrologist s referral pattern. Nephrol Dial Transplant 2013;28: Grapsa E. Is the underutilization of peritoneal dialysis in relation to hemodialysis, as renal replacement therapy, justifiable worldwide? Yes or no. Hippokratia 2011;15(suppl 1): Tesar V. Peritoneal dialysis in the elderly is its underutilization justified? Nephrol Dial Transplant 2010;25: Asif A. Peritoneal dialysis access-related procedures by nephrologists. Semin Dial 2004;17: Asif A, Byers P, Gadalean F, Roth D. Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program. Semin Dial 2003;16: Crabtree JH. Who should place peritoneal dialysis catheters? Perit Dial Int 2010;30: Zaman F. Peritoneal dialysis catheter placement by nephrologist. Perit Dial Int 2008;28: Haggerty SP, Zeni TM, Carder M, Frantzides CT. Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit. JSLS 2007;11: Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial 2001;14: Gadallah MF, Pervez A, EL-Shahawy MA, et al. Peritoneoscopic versus surgical placement of Tenckhoff catheters; a prospective randomized study on outcome. Am J Kidney Dis 1999;33: Gadallah MF, Ramdeen G, Torres-Rivera C, et al. Changing the trend: a prospective study on factors contributing to the growth rate of peritoneal dialysis programs. Adv Perit Dial 2001;17: Kelly J, McNamara K, May S. Peritoneoscopic peritoneal dialysis catheter insertion. Nephrology (Carlton) 2003;8: Corresponding author: Naoki Washida, md, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo Japan. Naoki_Washida@yahoo.co.jp