The impact of interventional nephrologists on the growth of a peritoneal dialysis program: Long-term, single-center experience

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The aim of our study was to describe the impact of interventional nephrologists on the growth of a peritoneal dialysis program in a regional center and compare life-threatening complications between both procedures.Material and methodsThis is a study purely descriptive of our daily clinical practice when starting PD catheter procedure in our Nephrology unit. In our PD program, catheter surgery was undertaken by surgeons until 2006. Thereafter up to date, the nephrologists have performed catheter surgery. Our center is a third-level hospital, which attends population of Malaga province (the province has 1,600,000h). The PD and HD incidences during both periods (<2006 vs. >2006) were 5.6% (n=69) vs. 94.4% (n=1169) respectively before 2006 and 11.5% (n=172) vs. 88.5% (n=1322) respectively after 2006 (p=0.0001). A total of 313 consecutive procedures were carried out by the same team interventional nephrologists in the Carlos Haya Regional Universitary Hospital (Málaga, Spain). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> depicts demographic and clinical characteristic of our patients who started PD before and after 2006. We used a dissection technique similar to that previously used by surgeons: tissue layers are dissected and separated under direct vision through a minimal parietal peritoneum dissection without the use of trocar devices. The hospital provides an operating room in order to carry out the technique. Patients are admitted and discharged from hospital on the same day provided there are not relevant clinical complications such as fever, severe abdominal pain, or they have to travel a long distance.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The patients are administered an enema the day before the procedure. On the day of the surgery they are asked to empty their bladders prior to being taken to the operating room. Patients are also given 1g of cefazolin IV prior to the operation. Most procedures are performed under local anesthesia and sedation. Sedation is administered by the nephrologist with the aid of a nurse. The level of sedation is titrated in order to achieve moderate sedation, where the patient is still able to respond and cooperate with the physician performing the procedure when asked to but is semi-asleep otherwise. We also use intravenous desmopresin before the procedure to reduce the bleeding risk as previously reported.<a class="elsevierStyleCrossRef" href="#bib0125">10</a> We mostly use Swan-neck Tenckhoff catheters. In addition, we use tungsten catheter if there is a risk of catheter migration e.g. obese patients. The skin is prepared with povidone iodine and the abdomen is draped as per the abdominal surgery protocol. Lidocaine 2% is infiltrated into the skin as local anesthetic.<a class="elsevierStyleCrossRef" href="#bib0150">11</a>ResultsFrom January 1, 2006 to December 31, 2013 we performed 313 consecutive procedures by nephrologist team: 192 catheter insertions and 121 catheter removals. Patients are admitted and discharged from hospital on the same day. Only two patients have been discharged on the day after the procedure (one because of discomfort and the other because of a long journey home. We used Swan-neck Tenckhoff catheter in all patients. We only used tungsten catheter in two obese patients without any early or late complications. One catheter insertion was made by surgeon team due to simultaneous repair of an inguinal hernia.Likewise, from January 1, 1996 to December 31, 2005 catheter surgery was performed by surgeon team. Clinical characteristics in patients with peritoneal catheter placement by surgeon versus by interventional nephrologist are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Swan-neck Tenckhoff catheter was used in all patients during this period.Surgery complications<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the reasons for catheter removal in patients with peritoneal catheter placement by surgeon versus by interventional nephrologist including procedure-related perioperative complications and complications associated with PD technique. After 2006 we observed seven (2.5%) early complications (<4 weeks) associated with peritoneal catheter surgery: 3 peritonitis episodes, which resolved with antibiotic treatment; 2 hemoperitoneum episodes (one resolved spontaneously but the other required exploratory laparotomy by surgeons); and one complicated hernia through peritoneal catheter exit site and one omental entrapment (both required surgeon intervention by surgeon team). We experienced no episodes of bowel perforation. Finally, other life-threatening complications related to insertion catheter were not observed in our patients during follow-up. Before 2006 one peritonitis episode was observed associated with peritoneal catheter procedure, which resolved with antibiotic treatment.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Since we started performing peritoneal catheter surgery our PD program has increased significantly. The mean catheter peritoneal insertions per year were higher after 2006 compared with prior to 2006 (22.6±5.3 vs 10.4±3.9; p=0.0001).DiscussionInsertion of peritoneal catheter performed by an interventional nephrologists team is a very procedure with a very low incidence of surgical complications and lower sanitary costs compared to surgery performed by surgeons.The number of patients on PD remains low, despite several advantages as compared to HD such as preservation of residual renal function, improved middle molecule clearance, improved fluid and blood pressure control, less likelihood of severe cardiac arrhythmias, reduced mortality (at least in the first years of PD),<a class="elsevierStyleCrossRef" href="#bib0130">12</a> a lower requirement for erythropoietin stimulating agents, a lesser risk of viral transmission, cost-effectiveness and better quality of life and better physician–patient relationship.<a class="elsevierStyleCrossRefs" href="#bib0135">13,14</a> However, one of the main pitfalls concerns the availability of a suitable permanent peritoneal catheter. In fact, catheter-related complications currently are currently the second leading cause of technique failure.<a class="elsevierStyleCrossRef" href="#bib0140">14</a> Another problem is the lack of experience and training on catheter implantation during nephrology fellowship programs, or a lack of interest (or time) by nephrologists in these procedures.<a class="elsevierStyleCrossRefs" href="#bib0160">5–15</a> Consequently, in most centers PD catheter surgery is usually performed by surgeons. Disadvantages arising from this relate to the lack of surgical teams interested in PD catheter insertion, as it is considered less important than other practices.<a class="elsevierStyleCrossRef" href="#bib0130">12</a> This invariably results in an inherent delay that involves potential patients exposure to HD and loss of interest in PD while waiting for the catheter insertion to be performed, as well as potential increase in complications associated with the catheter placement.<a class="elsevierStyleCrossRefs" href="#bib0155">4,13</a> Centers where nephrologists have taken on this surgery have reported better results in terms of complication rates and technique survival, as well as an increase in PD penetration.<a class="elsevierStyleCrossRefs" href="#bib0165">6,14</a> In any case, an experienced surgeon should remain essential to treat any possible severe life-threatening complications. Whether this may contribute to increase peritoneal dialysis program worldwide is undetermined yet. Further studies are needed to elucidate this concern.This study has some limitations. Firstly, this is a study purely descriptive and conclusions should be taken with caution. Secondly, although our patient sample is short, the procedure is performed by the same team and technique which reduces complications and improves the results. Finally, we assume bias derived of retrospective data from patients starting PD before 2006.In conclusion, since the key to a successful PD program is PD catheter survival, the timing and effective insertion of the peritoneal catheter, as well as prompt management of complications arising from catheter procedure are important factors to guarantee technique survival and consequently to increase the PD program. Improving and stimulating nephrologist's training seems necessary since, when these techniques are performed by nephrologists, there is a decreased incidence of complications, a reduced hospitalization cost, and increased autonomy and efficiency. Accordingly, a potential increase in PD program could be expected. However, the availability of an experienced surgeon remains essential to treat any possible severe complications.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres821835" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec818779" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres821836" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec818778" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Surgery complications" ] ] ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack275759" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-05" "fechaAceptado" => "2015-04-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec818779" "palabras" => array:3 [ 0 => "Interventional nephrology" 1 => "Peritoneal dialysis" 2 => "Catheter surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec818778" "palabras" => array:3 [ 0 => "Nefrología intervencionista" 1 => "Diálisis peritoneal" 2 => "Cirugía de catéter" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Although a variety of factors have been deemed responsible, timely insertion of a PD catheter may also be a contributory factor. Furthermore, a good catheter implantation technique is important to allow for effective peritoneal access function and long-term technique survival. Studies regarding results obtained by nephrologists in comparison with surgeons have been limited to small single-center experiences. Thus, the objective of this study was to explore the impact of the peritoneal dialysis (PD) catheter insertion by nephrologists compared to surgeons on early catheter complications and on technique survival. We also examine whether PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD. We performed 313 consecutive procedures: 192 catheter insertions and 121 catheter removal from January 1, 2006 to December 31, 2013. The main reasons for catheter removal were: renal transplantation, 52 (43%) follow of transfer to HD, 48 (40%) and catheter malfunction, 16 (13%). The patients were mostly male (63.4%) with the mean age of 50.8±15.1 years and 23.8 were diabetics. We only observed seven (2.5%) early complications (<4 weeks) associated to peritoneal catheter surgery (3 peritonitis episodes, 2 hemoperitoneum episodes, one complicated hernia and one omental entrapment). There were not significant differences in surgery-related complications in both periods. The penetration ratio of PD after 2006 was 117% higher compared with procedures performing before this date. In conclusions, we have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists with a minimal incidence of complications associated." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La diálisis peritoneal (DP) es un tipo de tratamiento de reemplazo renal infrautilizado. Aunque ello se debe a múltiples factores, la inserción puntual de un catéter de DP también puede ser un factor coadyuvante. Más aún, una buena técnica de implantación del catéter es importante para posibilitar una función de acceso peritoneal eficaz y facilitar la continuidad de la técnica a largo plazo. Los estudios sobre los resultados obtenidos por nefrólogos en comparación con los de los cirujanos se han limitado a pequeñas experiencias de centro único. Por ello, el objetivo de este estudio fue analizar el impacto de la inserción del catéter de diálisis peritoneal (DP) por nefrólogos en comparación con el de los cirujanos cuando surgían las primeras complicaciones con el catéter y en relación con la continuidad de la técnica. También examinamos si la inserción del catéter de DP por nefrólogos tenía un impacto positivo en el aumento del número de pacientes con DP. Llevamos a cabo 313 procedimientos consecutivos: 192 inserciones de catéter y 121 extracciones de catéter entre el 1 de enero de 2006 y el 31 de diciembre de 2013. Las principales razones para la extracción del catéter fueron: trasplante renal, 52 (43%), seguido por transferencia a hemodiálisis (HD), 48 (40%) y funcionamiento defectuoso del catéter, 16 (13%). La mayoría de pacientes era de sexo masculino (63,4%) con una media de edad de 50,8±15,1 años y 23,8 eran diabéticos. Sólo observamos 7 (2,5%) complicaciones tempranas (<4 semanas) asociadas con cirugía de catéter peritoneal (3 episodios de peritonitis, 2 episodios de hemoperitoneo, una hernia complicada y un atrapamiento omental). No hubo diferencias significativas en las complicaciones relacionadas con la cirugía en ambos períodos. La tasa de penetración de la DP desde 2006 fue el 117% superior a la de aquellos procedimientos que se habían llevado a cabo antes de esa fecha. Resumiendo, hemos demostrado que existe un impacto positivo en el aumento de la población con DP cuando los nefrólogos realizan la inserción del catéter con una mínima incidencia de complicaciones asociadas." ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter surgery (N=69) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter nephrologist (N=172) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age ys. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55.3±17.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.8±15.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.056 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes Mellitus N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (23.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular disease* N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 (23.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.5±0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2±2.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.159 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time on PD (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120.9±103 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.9±67.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.044 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Modality of APD* N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (71) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">145 (84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.019 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight (kg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.8±16.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.7±14.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.077 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index (kg/cm2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.6±5.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.5±5.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.964 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cause of ESRD N (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (4.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (7.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 (30.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 (28.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glomerulonephritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (8.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (9.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tubulointerstitial nephropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (14.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (11.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetic nephropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 (15.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1381809.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics in patients with peritoneal catheter placement by surgeon (before 2006) versus by interventional nephrologist (after 2006)." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter surgery (N=69) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter nephrologist (N=172) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Early complications N/%</td><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Peritonitis (1/1.4)</td><td class="td" title="table-entry " align="left" valign="top">Peritonitis (3/1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoperitoneum (3/1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hernia exit site (1/0.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Omental entrapment (1/0.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Late complications N/%</td><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Malfunction catheter (4/25)</td><td class="td" title="table-entry " align="left" valign="top">Malfunction catheter (16/13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaginal leakage (1/0.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Albuginea-peritoneal communication \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1/0.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydrothorax (2/1.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Other causes leading end of PD technique N/%</td><td class="td" title="table-entry " align="left" valign="top">Renal transplant (32/46) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Renal transplant (52/43) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relapsing peritonitis (1/1.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Relapsing peritonitis (4/3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Severe peritonitis (10/8.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infra-dialysis (6/8.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infra-dialysis (34/28.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Recovery renal function (1/0.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1381808.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The reasons for catheter removal of patients who started PD before 2006 versus after 2006." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Spanish Registry of renal patients: dialysis and transplant report 2013. <a href="http://www.senefro.org/modules/webstructure/files/inforreercongsen2014final.pdf">http://www.senefro.org/modules/webstructure/files/inforreercongsen2014final.pdf</a>" ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "ERA-EDTA Registry: ERA-EDTA Registry Annual Report 2012. <a href="http://www.era-edta.org/files/annualreports/pdf/AnnRep2012.pdf">http://www.era-edta.org/files/annualreports/pdf/AnnRep2012.pdf</a>" ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Successful models of interventional nephrology at academic medical centers" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.J. 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We also thank Ian Johnstone for his linguistic assistance in the preparation of the text." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003600000001/v2_201703300133/S2013251415001121/v2_201703300133/en/main.assets" "Apartado" => array:4 [ "identificador" => "42660" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003600000001/v2_201703300133/S2013251415001121/v2_201703300133/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2013251415001121?idApp=UINPBA000064"]

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El impacto de los nefrólogos intervencionistas en el crecimiento de un programa de diálisis peritoneal: la experiencia de un centro único a largo plazo

Silvia Ros-Ruiz

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sirosru@yahoo.es

Corresponding author.

, Ángela Alonso-Esteve, Elena Gutiérrez-Vílchez, Edisson Rudas-Bermúdez, Domingo Hernández

Servicio de Nefrología, Hospital Regional Universitario Carlos Haya/IBIMA, Málaga, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The increasing prevalence of end stage renal disease over recent years has led to an increased number of both dialysis access procedures&#44; that is hemodialysis &#40;HD&#41; and peritoneal dialysis &#40;PD&#41;&#44; as well as an important extra workload for those interventional nephrologists&#44; radiologists or surgeons involved&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;2</span></a> Providing an optimal dialysis access care is very important in patients starting renal replacement therapy because the patient&#39;s outcome depends on the access procedure survival&#44; especially in patients starting peritoneal dialysis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">3&#44;4</span></a> The outcome of the access care provided by nephrologists as well as the procedures they perform are comparable to those provided by surgeons and radiologists&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#8211;6</span></a> The exact proportion of procedures currently performed by nephrologists is unclear&#44; although it is known to be increasing since the establishment of the American Society of Diagnostic and Interventional Nephrology in 2000&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7-9</span></a> In addition there is little information comparing the severe complications of the procedure performed by surgeons versus by nephrologists&#46; The aim of our study was to describe the impact of interventional nephrologists on the growth of a peritoneal dialysis program in a regional center and compare life-threatening complications between both procedures&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">This is a study purely descriptive of our daily clinical practice when starting PD catheter procedure in our Nephrology unit&#46; In our PD program&#44; catheter surgery was undertaken by surgeons until 2006&#46; Thereafter up to date&#44; the nephrologists have performed catheter surgery&#46; Our center is a third-level hospital&#44; which attends population of Malaga province &#40;the province has 1&#44;600&#44;000<span class="elsevierStyleHsp" style=""></span>h&#41;&#46; The PD and HD incidences during both periods &#40;&#60;2006 vs&#46; &#62;2006&#41; were 5&#46;6&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41; vs&#46; 94&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1169&#41; respectively before 2006 and 11&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>172&#41; vs&#46; 88&#46;5&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1322&#41; respectively after 2006 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; A total of 313 consecutive procedures were carried out by the same team interventional nephrologists in the Carlos Haya Regional Universitary Hospital &#40;M&#225;laga&#44; Spain&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> depicts demographic and clinical characteristic of our patients who started PD before and after 2006&#46; We used a dissection technique similar to that previously used by surgeons&#58; tissue layers are dissected and separated under direct vision through a minimal parietal peritoneum dissection without the use of trocar devices&#46; The hospital provides an operating room in order to carry out the technique&#46; Patients are admitted and discharged from hospital on the same day provided there are not relevant clinical complications such as fever&#44; severe abdominal pain&#44; or they have to travel a long distance&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patients are administered an enema the day before the procedure&#46; On the day of the surgery they are asked to empty their bladders prior to being taken to the operating room&#46; Patients are also given 1<span class="elsevierStyleHsp" style=""></span>g of cefazolin IV prior to the operation&#46; Most procedures are performed under local anesthesia and sedation&#46; Sedation is administered by the nephrologist with the aid of a nurse&#46; The level of sedation is titrated in order to achieve moderate sedation&#44; where the patient is still able to respond and cooperate with the physician performing the procedure when asked to but is semi-asleep otherwise&#46; We also use intravenous desmopresin before the procedure to reduce the bleeding risk as previously reported&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> We mostly use Swan-neck Tenckhoff catheters&#46; In addition&#44; we use tungsten catheter if there is a risk of catheter migration e&#46;g&#46; obese patients&#46; The skin is prepared with povidone iodine and the abdomen is draped as per the abdominal surgery protocol&#46; Lidocaine 2&#37; is infiltrated into the skin as local anesthetic&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">From January 1&#44; 2006 to December 31&#44; 2013 we performed 313 consecutive procedures by nephrologist team&#58; 192 catheter insertions and 121 catheter removals&#46; Patients are admitted and discharged from hospital on the same day&#46; Only two patients have been discharged on the day after the procedure &#40;one because of discomfort and the other because of a long journey home&#46; We used Swan-neck Tenckhoff catheter in all patients&#46; We only used tungsten catheter in two obese patients without any early or late complications&#46; One catheter insertion was made by surgeon team due to simultaneous repair of an inguinal hernia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Likewise&#44; from January 1&#44; 1996 to December 31&#44; 2005 catheter surgery was performed by surgeon team&#46; Clinical characteristics in patients with peritoneal catheter placement by surgeon versus by interventional nephrologist are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Swan-neck Tenckhoff catheter was used in all patients during this period&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Surgery complications</span><p id="par0030" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the reasons for catheter removal in patients with peritoneal catheter placement by surgeon versus by interventional nephrologist including procedure-related perioperative complications and complications associated with PD technique&#46; After 2006 we observed seven &#40;2&#46;5&#37;&#41; early complications &#40;&#60;4 weeks&#41; associated with peritoneal catheter surgery&#58; 3 peritonitis episodes&#44; which resolved with antibiotic treatment&#59; 2 hemoperitoneum episodes &#40;one resolved spontaneously but the other required exploratory laparotomy by surgeons&#41;&#59; and one complicated hernia through peritoneal catheter exit site and one omental entrapment &#40;both required surgeon intervention by surgeon team&#41;&#46; We experienced no episodes of bowel perforation&#46; Finally&#44; other life-threatening complications related to insertion catheter were not observed in our patients during follow-up&#46; Before 2006 one peritonitis episode was observed associated with peritoneal catheter procedure&#44; which resolved with antibiotic treatment&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Since we started performing peritoneal catheter surgery our PD program has increased significantly&#46; The mean catheter peritoneal insertions per year were higher after 2006 compared with prior to 2006 &#40;22&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3 vs 10&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;9&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Insertion of peritoneal catheter performed by an interventional nephrologists team is a very procedure with a very low incidence of surgical complications and lower sanitary costs compared to surgery performed by surgeons&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The number of patients on PD remains low&#44; despite several advantages as compared to HD such as preservation of residual renal function&#44; improved middle molecule clearance&#44; improved fluid and blood pressure control&#44; less likelihood of severe cardiac arrhythmias&#44; reduced mortality &#40;at least in the first years of PD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> a lower requirement for erythropoietin stimulating agents&#44; a lesser risk of viral transmission&#44; cost-effectiveness and better quality of life and better physician&#8211;patient relationship&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13&#44;14</span></a> However&#44; one of the main pitfalls concerns the availability of a suitable permanent peritoneal catheter&#46; In fact&#44; catheter-related complications currently are currently the second leading cause of technique failure&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> Another problem is the lack of experience and training on catheter implantation during nephrology fellowship programs&#44; or a lack of interest &#40;or time&#41; by nephrologists in these procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#8211;15</span></a> Consequently&#44; in most centers PD catheter surgery is usually performed by surgeons&#46; Disadvantages arising from this relate to the lack of surgical teams interested in PD catheter insertion&#44; as it is considered less important than other practices&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> This invariably results in an inherent delay that involves potential patients exposure to HD and loss of interest in PD while waiting for the catheter insertion to be performed&#44; as well as potential increase in complications associated with the catheter placement&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;13</span></a> Centers where nephrologists have taken on this surgery have reported better results in terms of complication rates and technique survival&#44; as well as an increase in PD penetration&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;14</span></a> In any case&#44; an experienced surgeon should remain essential to treat any possible severe life-threatening complications&#46; Whether this may contribute to increase peritoneal dialysis program worldwide is undetermined yet&#46; Further studies are needed to elucidate this concern&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study has some limitations&#46; Firstly&#44; this is a study purely descriptive and conclusions should be taken with caution&#46; Secondly&#44; although our patient sample is short&#44; the procedure is performed by the same team and technique which reduces complications and improves the results&#46; Finally&#44; we assume bias derived of retrospective data from patients starting PD before 2006&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion&#44; since the key to a successful PD program is PD catheter survival&#44; the timing and effective insertion of the peritoneal catheter&#44; as well as prompt management of complications arising from catheter procedure are important factors to guarantee technique survival and consequently to increase the PD program&#46; Improving and stimulating nephrologist&#39;s training seems necessary since&#44; when these techniques are performed by nephrologists&#44; there is a decreased incidence of complications&#44; a reduced hospitalization cost&#44; and increased autonomy and efficiency&#46; Accordingly&#44; a potential increase in PD program could be expected&#46; However&#44; the availability of an experienced surgeon remains essential to treat any possible severe complications&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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            0 => "Interventional nephrology"
            1 => "Peritoneal dialysis"
            2 => "Catheter surgery"
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            0 => "Nefrolog&#237;a intervencionista"
            1 => "Di&#225;lisis peritoneal"
            2 => "Cirug&#237;a de cat&#233;ter"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Peritoneal dialysis &#40;PD&#41; is an underutilized form of renal replacement therapy&#46; Although a variety of factors have been deemed responsible&#44; timely insertion of a PD catheter may also be a contributory factor&#46; Furthermore&#44; a good catheter implantation technique is important to allow for effective peritoneal access function and long-term technique survival&#46; Studies regarding results obtained by nephrologists in comparison with surgeons have been limited to small single-center experiences&#46; Thus&#44; the objective of this study was to explore the impact of the peritoneal dialysis &#40;PD&#41; catheter insertion by nephrologists compared to surgeons on early catheter complications and on technique survival&#46; We also examine whether PD catheter insertion by nephrologists has a positive impact on the growth in the number of patients using PD&#46; We performed 313 consecutive procedures&#58; 192 catheter insertions and 121 catheter removal from January 1&#44; 2006 to December 31&#44; 2013&#46; The main reasons for catheter removal were&#58; renal transplantation&#44; 52 &#40;43&#37;&#41; follow of transfer to HD&#44; 48 &#40;40&#37;&#41; and catheter malfunction&#44; 16 &#40;13&#37;&#41;&#46; The patients were mostly male &#40;63&#46;4&#37;&#41; with the mean age of 50&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;1 years and 23&#46;8 were diabetics&#46; We only observed seven &#40;2&#46;5&#37;&#41; early complications &#40;&#60;4 weeks&#41; associated to peritoneal catheter surgery &#40;3 peritonitis episodes&#44; 2 hemoperitoneum episodes&#44; one complicated hernia and one omental entrapment&#41;&#46; There were not significant differences in surgery-related complications in both periods&#46; The penetration ratio of PD after 2006 was 117&#37; higher compared with procedures performing before this date&#46; In conclusions&#44; we have demonstrated a positive impact on the growth of the PD population when catheter insertion is performed by nephrologists with a minimal incidence of complications associated&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La di&#225;lisis peritoneal &#40;DP&#41; es un tipo de tratamiento de reemplazo renal infrautilizado&#46; Aunque ello se debe a m&#250;ltiples factores&#44; la inserci&#243;n puntual de un cat&#233;ter de DP tambi&#233;n puede ser un factor coadyuvante&#46; M&#225;s a&#250;n&#44; una buena t&#233;cnica de implantaci&#243;n del cat&#233;ter es importante para posibilitar una funci&#243;n de acceso peritoneal eficaz y facilitar la continuidad de la t&#233;cnica a largo plazo&#46; Los estudios sobre los resultados obtenidos por nefr&#243;logos en comparaci&#243;n con los de los cirujanos se han limitado a peque&#241;as experiencias de centro &#250;nico&#46; Por ello&#44; el objetivo de este estudio fue analizar el impacto de la inserci&#243;n del cat&#233;ter de di&#225;lisis peritoneal &#40;DP&#41; por nefr&#243;logos en comparaci&#243;n con el de los cirujanos cuando surg&#237;an las primeras complicaciones con el cat&#233;ter y en relaci&#243;n con la continuidad de la t&#233;cnica&#46; Tambi&#233;n examinamos si la inserci&#243;n del cat&#233;ter de DP por nefr&#243;logos ten&#237;a un impacto positivo en el aumento del n&#250;mero de pacientes con DP&#46; Llevamos a cabo 313&#160;procedimientos consecutivos&#58; 192&#160;inserciones de cat&#233;ter y 121&#160;extracciones de cat&#233;ter entre el 1 de enero de 2006 y el 31 de diciembre de 2013&#46; Las principales razones para la extracci&#243;n del cat&#233;ter fueron&#58; trasplante renal&#44; 52 &#40;43&#37;&#41;&#44; seguido por transferencia a hemodi&#225;lisis &#40;HD&#41;&#44; 48 &#40;40&#37;&#41; y funcionamiento defectuoso del cat&#233;ter&#44; 16 &#40;13&#37;&#41;&#46; La mayor&#237;a de pacientes era de sexo masculino &#40;63&#44;4&#37;&#41; con una media de edad de 50&#44;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#44;1&#160;a&#241;os y 23&#44;8 eran diab&#233;ticos&#46; S&#243;lo observamos 7 &#40;2&#44;5&#37;&#41; complicaciones tempranas &#40;&#60;4&#160;semanas&#41; asociadas con cirug&#237;a de cat&#233;ter peritoneal &#40;3&#160;episodios de peritonitis&#44; 2&#160;episodios de hemoperitoneo&#44; una hernia complicada y un atrapamiento omental&#41;&#46; No hubo diferencias significativas en las complicaciones relacionadas con la cirug&#237;a en ambos per&#237;odos&#46; La tasa de penetraci&#243;n de la DP desde 2006 fue el 117&#37; superior a la de aquellos procedimientos que se hab&#237;an llevado a cabo antes de esa fecha&#46; Resumiendo&#44; hemos demostrado que existe un impacto positivo en el aumento de la poblaci&#243;n con DP cuando los nefr&#243;logos realizan la inserci&#243;n del cat&#233;ter con una m&#237;nima incidencia de complicaciones asociadas&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter surgery &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter nephrologist &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>172&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age <span class="elsevierStyleItalic">ys</span>&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">55&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;056&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes Mellitus N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;23&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular disease&#42; N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41 &#40;23&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Charlson index&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;159&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time on PD &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">120&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>67&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;044&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Modality of APD&#42; N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;71&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">145 &#40;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;019&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;077&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Body mass index &#40;kg&#47;cm<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;964&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Cause of ESRD</span> N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;4&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;7&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53 &#40;30&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49 &#40;28&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Glomerulonephritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;9&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tubulointerstitial nephropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;14&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;11&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetic nephropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics in patients with peritoneal catheter placement by surgeon &#40;before 2006&#41; versus by interventional nephrologist &#40;after 2006&#41;&#46;</p>"
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        "etiqueta" => "Table 2"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter surgery &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>69&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Peritoneal catheter nephrologist &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>172&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Early complications N&#47;&#37;</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Peritonitis &#40;1&#47;1&#46;4&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Peritonitis &#40;3&#47;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoperitoneum &#40;3&#47;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hernia exit site &#40;1&#47;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Omental entrapment &#40;1&#47;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Late complications N&#47;&#37;</td><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Malfunction catheter &#40;4&#47;25&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Malfunction catheter &#40;16&#47;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vaginal leakage &#40;1&#47;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Albuginea-peritoneal communication&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#40;1&#47;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydrothorax &#40;2&#47;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Other causes leading end of PD technique N&#47;&#37;</td><td class="td" title="table-entry  " align="left" valign="top">Renal transplant &#40;32&#47;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Renal transplant &#40;52&#47;43&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relapsing peritonitis &#40;1&#47;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Relapsing peritonitis &#40;4&#47;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe peritonitis &#40;10&#47;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infra-dialysis &#40;6&#47;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infra-dialysis &#40;34&#47;28&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recovery renal function &#40;1&#47;0&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The reasons for catheter removal of patients who started PD before 2006 versus after 2006&#46;</p>"
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      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
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            1 => array:3 [
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            4 => array:3 [
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            5 => array:3 [
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                            1 => "R&#46;P&#46; Campos"
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                            3 => "D&#46; Chula"
                            4 => "M&#46;A&#46; Vieira"
                            5 => "M&#46;C&#46; Riella"
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                            1 => "D&#46; Chula"
                            2 => "R&#46; Campos"
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        "texto" => "<p id="par0070" class="elsevierStylePara elsevierViewall">This study was supported&#44; in part&#44; by the I<span class="elsevierStyleGrantSponsor" id="gs1">nstituto de Salud Carlos III and Fondos FEDER&#44; RETIC REDinREN</span>&#44; <span class="elsevierStyleGrantNumber" refid="gs1">RD12&#47;0021&#47;0015</span> grant <span class="elsevierStyleGrantNumber" refid="gs1">ICI14&#47;00016</span> and by grant <span class="elsevierStyleGrantNumber" refid="gs2">PI-0590&#47;2012</span> from the <span class="elsevierStyleGrantSponsor" id="gs2">Consejer&#237;a de Salud del Gobierno de Andaluc&#237;a</span>&#46; The authors thank the Nephrology team from Nephrology Department &#40;Carlos Haya Regional University Hospital&#41; and the Regional Transplant Coordination of Andalusia and all participants in each center for their support in compiling information&#46; We also thank Ian Johnstone for his linguistic assistance in the preparation of the text&#46;</p>"
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Article information

ISSN: 20132514
Original language: English

DOI:10.1016/j.nefroe.2015.04.004

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2024 November	4	8	12
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2024 August	58	57	115
2024 July	31	25	56
2024 June	46	32	78
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2024 March	37	28	65
2024 February	24	29	53
2024 January	32	25	57
2023 December	24	30	54
2023 November	31	28	59
2023 October	79	27	106
2023 September	144	18	162
2023 August	36	26	62
2023 July	46	24	70
2023 June	40	23	63
2023 May	47	24	71
2023 April	33	12	45
2023 March	61	18	79
2023 February	39	19	58
2023 January	18	28	46
2022 December	46	36	82
2022 November	39	33	72
2022 October	46	45	91
2022 September	37	21	58
2022 August	45	51	96
2022 July	28	48	76
2022 June	27	34	61
2022 May	30	31	61
2022 April	20	40	60
2022 March	37	35	72
2022 February	33	44	77
2022 January	31	31	62
2021 December	38	35	73
2021 November	30	34	64
2021 October	37	41	78
2021 September	28	33	61
2021 August	31	42	73
2021 July	30	22	52
2021 June	23	21	44
2021 May	52	34	86
2021 April	74	36	110
2021 March	33	40	73
2021 February	47	18	65
2021 January	38	13	51
2020 December	24	11	35
2020 November	34	14	48
2020 October	30	17	47
2020 September	28	18	46
2020 August	36	7	43
2020 July	21	17	38
2020 June	20	16	36
2020 May	38	11	49
2020 April	21	17	38
2020 March	33	12	45
2020 February	34	24	58
2020 January	36	17	53
2019 December	30	25	55
2019 November	29	17	46
2019 October	13	8	21
2019 September	25	11	36
2019 August	21	13	34
2019 July	26	16	42
2019 June	25	19	44
2019 May	25	15	40
2019 April	46	38	84
2019 March	28	21	49
2019 February	23	14	37
2019 January	23	23	46
2018 December	148	42	190
2018 November	218	30	248
2018 October	217	19	236
2018 September	76	13	89
2018 August	44	24	68
2018 July	53	12	65
2018 June	66	18	84
2018 May	82	13	95
2018 April	82	3	85
2018 March	151	11	162
2018 February	101	5	106
2018 January	102	7	109
2017 December	122	12	134
2017 November	57	9	66
2017 October	30	7	37
2017 September	26	8	34
2017 August	26	7	33
2017 July	25	19	44
2017 June	32	6	38
2017 May	36	8	44
2017 April	33	10	43
2017 March	12	10	22
2017 February	21	12	33
2017 January	7	14	21
2016 December	28	7	35
2016 November	39	20	59
2016 October	52	12	64
2016 September	60	2	62
2016 August	91	5	96
2016 July	126	7	133
2016 June	98	0	98
2016 May	122	0	122
2016 April	53	0	53

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