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Peritoneal dialysis: Its indications and contraindications
Abstract
Global utilization of peritoneal dialysis ranges from 6% to 91% in various parts of the world. This paper reviews the indications and contraindications for chronic peritoneal dialysis (PD), providing evidence when available, and recommendations based on the considerable experience of the authors when evidence is lacking. Strong indications for PD include obligate situations such as vascular access failure and intolerance to hemodialysis (HD); medical preferences such as congestive heart failure, prosthetic valvular disease, and children aged 0-5 years; and social situations such as patient preference and living far from an in-center dialysis unit. The situations where PD is preferred include bleeding diathesis, multiple myeloma, labile diabetes, chronic infections, possibility of transplantation in the near future, age between 6 and 16 years, needle anxiety, and active lifestyle. Situations where PD is not preferred but possible with some special considerations include obesity, multiple hernias, serve backache, multiple abdominal surgeries, impaired manual dexterity, blindness, less-than-ideal home situation, and depression. Relative contraindications for PD include patients with severe malnutrition, multiple abdominal adhesions, ostomies, proteinuria >10 g/day, advanced COPD, ascites, presence of a Le Veen or ventriculo-peritoneal shunt, upper limb amputation with no help at home, poor hygiene, dementia, and those who are homeless. PD is contraindicated in patients with documented Type II ultrafiltration failure, severe inflammatory bowel disease, active acute diverticulitis, abdominal abscess, active ischemic bowel disease, severe active psychotic disorder, marked intellectual disability, and in women starting dialysis in the third trimester of pregnancy. In most of the remaining situations, either HD or PD is equally preferred. To take full advantage of the advances that have occurred over the past decade, successful PD requires committed and knowledgeable physicians and nurses, and a center with at least 20-25 patients on this modality.
... There are social situations to consider, such as patient preference and living far from an incenter dialysis unit [7]. PD is also beneficial in suitable patients as it facilitates home therapy, increases patient autonomy, and improves the quality of life when compared with in-center hemodialysis [8]. ...
... PD has been shown to better prolong residual renal function when compared with HD in patients awaiting renal transplant [9]. Other situations where PD is preferred include bleeding diathesis, multiple myeloma, labile diabetes, chronic infections, age between 6 and 16 years, needle anxiety, and active lifestyle [7]. Peritoneal dialysis has infrequently been utilized for nonrenal indications with variable benefits in conditions such as refractory congestive heart failure [10, 11], hepatic failure [12], hypothermia [13], hyponatremia, dialysis-associated ascites, drug poisonings, pancreatitis [14], and inherited enzyme deficiencies. ...
... One absolute contraindication is the inability of a patient or caregiver to safely and efficiently use the PD catheter and equipment to carry out peritoneal dialysis. Other absolute contrain‐ dications include patients with documented Type II ultrafiltration failure (UF), severe inflammatory bowel disease, active acute diverticulitis, abdominal abscess, active ischemic bowel disease [15], severe active psychotic disorder, marked intellectual disability, and in women, starting dialysis in the third trimester of pregnancy [7]. Relative contraindications for PD include patients with severe malnutrition, multiple abdomi‐ nal adhesions, ostomies [16], proteinuria with protein losses of more than 10 g/day, advanced COPD, ascites, presence of a LeVeen or ventriculoperitoneal shunt, upper limb amputation with no help at home, poor hygiene, dementia, and those who are homeless [7]. ...
In peritoneal dialysis, a well-functioning catheter is of great importance because a dysfunctional catheter may be associated with exit-site infection, peritonitis, reduced efficiency of dialysis and overall quality of treatment, representing one of the main barriers to optimal use of peritoneal dialysis. This chapter reviews the literature on indications and contraindications for peritoneal dialysis, peritoneal dialysis catheter design and materials, the techniques of insertion, complications and method of removal of dialysis catheters.
... However, there are no randomized controlled trials comparing the two modalities. Finally, PD may be favored in patients with vascular access failure, intolerance to HD, congestive heart failure, long distance from dialysis center, and peripheral vascular disease and bleeding diathesis [14]. PD may also be preferred by patients with the possibility of renal Transplantation in the near future, needle anxiety, and active lifestyle [14]. ...
... Finally, PD may be favored in patients with vascular access failure, intolerance to HD, congestive heart failure, long distance from dialysis center, and peripheral vascular disease and bleeding diathesis [14]. PD may also be preferred by patients with the possibility of renal Transplantation in the near future, needle anxiety, and active lifestyle [14]. ...
... 1. Documented loss of peritoneal function such as ultrafiltration failure of the peritoneal membrane. [14,15]. ...
... Mental retardation in the PD patient further increase dependence, and hence, parents are often constrained by family commitments. The primary caregiver for a patient who is not self-sufficient in a CPD program is therefore exposed to burnout syndrome (11)(12)(13). ...
... Our hospital has no committee to deal with this issue; however, we have not encountered such a case to date. On the other hand, mentally retarded children are often not able to (11,14), and it is also clear that these patients can develop severe peritonitis that might require conversion to temporary HD. Mentally retarded PD patients can be prepared for accepting HD treatment by a graduated approach using play therapists and psychologists. ...
... These complications can lead to malfunction of the catheter (15). But even if the catheter functions well, these patients usually have a smaller effective peritoneal surface area because of adhesions and loculations, potentially resulting in either or both of underdialysis and ultrafiltration failure (11). Incisional hernia is a frequent complication of abdominal surgery. ...
Our aim in the present study was to identify outcomes in children with special needs or social disadvantage, or both, receiving chronic peritoneal dialysis (CPD) treatment in a pediatric dialysis unit.
Among 110 children started on CPD in our unit during the period between November 1995 and November 2008, we identified 13 patients (8 girls, 5 boys) with major physical, mental, or psychosocial problems. Age at CPD initiation in the group with disability ranged from 4.0 years to 16.5 years (median: 7.5 years). Under lying diseases were vesicoureteral reflux (4 patients), neuropathic bladder and vesicoureteral reflux (3 patients), chronic pyelonephritis (3 patients), amyloidosis (2 patients), and Alport syndrome (1 patient). Challenges encountered were adverse family or social circumstances (4 patients), cerebral palsy (3 patients), Down syndrome (1 patient), rectovesical fistula in conjunction with ectopic anus and previous multiple abdominal surgery (1 patient), blindness and deafness (1 patient), ventriculoperitoneal shunt (1 patient), colostomy and malnutrition (1 patient), and mental retardation and blindness (1 patient). All catheters were implanted percutaneously.
Median duration of dialysis was 18 months (range: 6 - 124 months). The frequency of peritonitis was not different between children with and without disability (p > 0.05). In children with disability compared with children without disability, the frequencies of catheter-related infections (1 episode/79.3 patient-months vs 1 episode/32.4 patient-months) and of catheter-related non-infectious complications (1 episode/238 patient-months vs 1 episode/115.7 patient-months) were lower (p < 0.05). Chronic peritoneal dialysis was terminated in 5 children (for renal transplantation in 3, switch to hemodialysis in 1, death in 1).
Our results suggest that, with appropriate family support and an experienced multidisciplinary team, CPD can be effectively performed in children with special needs or social disadvantage, or both.
... Furthermore, most studies in PD patients have found similar (if not better) survival in those who are obese versus those with normal body mass index [35,36]. Obese patients may need larger dialysate volumes, usually provided by APD, to achieve adequate Kt/V, although the increase in body mass is not associated with a proportional increase in body water volume [37][38][39]. However, PD may not be the preferred dialysis modality or is relatively contraindicated in patients with morbid obesity [39,40], in which there may be difficulties in peritoneal catheter placement and tunnel healing process, increased risk of pericatheter leak and infection, possible further weight gain due to increased caloric absorption from the dialysate, as well as a risk for abdominal pain or discomfort, and aggravation of dyspnoea, gastro-oesophageal reflux, abdominal hernias or vertebral disease, because of increased intra-abdominal volume and pressure [38,39]. ...
... Obese patients may need larger dialysate volumes, usually provided by APD, to achieve adequate Kt/V, although the increase in body mass is not associated with a proportional increase in body water volume [37][38][39]. However, PD may not be the preferred dialysis modality or is relatively contraindicated in patients with morbid obesity [39,40], in which there may be difficulties in peritoneal catheter placement and tunnel healing process, increased risk of pericatheter leak and infection, possible further weight gain due to increased caloric absorption from the dialysate, as well as a risk for abdominal pain or discomfort, and aggravation of dyspnoea, gastro-oesophageal reflux, abdominal hernias or vertebral disease, because of increased intra-abdominal volume and pressure [38,39]. Use of icodextrin solution may be considered for obese patients as the body weight and fat mass in prospective studies have been shown to be relative stable in patients using one exchange of icodextrin-based solution, compared to patients using glucose-based solutions only [41][42][43]. ...
... The basic choices are between haemodialysis and continuous peritoneal dialysis as shown in Table 3 [28]. ...
... Adequacy of Haemodialysis: The determination of the adequacy of dialysis therapy requires more than routine laboratory studies since malnourished and anorectic patients will make less urea and have a smaller muscle mass with deceptively low blood urea nitrogen and creatinine concentrations. Measurement of the "delivered dose" of dialysis is therefore focused on the removal of urea, an easily measured surrogate marker for uremic toxins [28]. The two most widely used measures of the adequacy of dialysis are calculated from the decrease in the blood urea nitrogen concentration during the treatment, the urea-reduction ratio, and KT/ V. KT/V is a dimensionless index based on the urea clearance rate K, and the size of the urea pool represented as the urea-distribution volume, V. K the sum of clearance by the dialyser plus renal clearance, is multiplied by the time spent on dialysis T. Currently, a urea-reduction ratio of 65 percent and a KT/V of 1.2 per treatment are minimal standards for adequacy, and lower levels of dialysis treatment are associated with increased morbidity and mortality. ...
... Peritoneal dialysis has been appreciated for its relative simplicity, home-based use and providing a better quality of life. It is also the preferred method in patients with vascular access failure and cardiovascular instability [7]. ...
Background
Peritoneal dialysis is a life sustaining renal replacement therapy for patients with end stage renal disease. In comparison to hemodialysis it offers better mobility and independence to patients. A number of techniques including open, laparoscopic and fluoroscopy guided, and their modifications, have been described for intraperitoneal catheter insertion. We describe our technique and results of laparoscopic peritoneal dialysis (PD) catheter insertion at a tertiary care centre in India.
Case series
48 patients were referred from the department of nephrology at our centre for laparoscopic PD catheter insertion. A two port technique was used in 37 patients and three port technique was implemented in the rest for simultaneous adhesiolysis and/or omentectomy. A straight tip catheter was tunneled through the rectus muscle in all patients. Two patients had incisional hernia from a previous abdominal surgery which was repaired concomitantly with onlay meshplasty.
Results
The operative time ranged between 20 and 35 min under general anaesthesia. Three patients were subjected to urgent start dialysis of which one patient developed peridrain leak as an early complication which was managed conservatively. All other patients were commenced on peritoneal dialysis two weeks after surgery. There was no other surgical site occurrence or episodes of peritonitis reported in a 6 month follow up period with the department of nephrology.
Conclusion
In the era of minimal access surgery, the laparoscopic approach is feasible for widespread and safe use for PD catheter insertion. The benefits of PD can thus be made available to patients at civil hospitals even with a basic laparoscopy setup.
... In the same study, improved respiratory parameters were also recorded: progressive increase in pulmonary compliance, and a significant increase in PaO 2 /FiO 2 and FiO 2 ; a fact that had been long known for paediatric population 17 . 17 . ...
Peritoneal Dialysis in adult Intensive Care Unit: Case report and literature review. Aslanidis Th, Martika A, Spaia S Choice of peritoneal dialysis over other renal replacement therapy modalities for adult critically ill patients is still limited; despite the data against it. The present article presents a case of peritoneal dialysis in a patient with intracerebral hemmorhage and reviews the relevant literature.
... 4,5 Peritoneal dialysis (PD) is currently considered the preferred treatment for patients with congestive heart failure, vascular access failure and as a short time bridging therapy to kidney transplantation. 6 The long-term durability of peritoneal dialysis is determined by a solid and functional peritoneal access. Complication-free access depends largely upon a meticulous catheter placement technique and rigorous attention to detail at the time of implantation. ...
Peritoneal dialysis (PD) as a treatment for patients with end-stage renal disease (ESRD) provides a competitive alternative to hemodialysis (HD). Long-term catheter survival remains challenging and techniques are not standardized. Advanced laparoscopic placement with fixation and omentectomy might increase catheter survival. The goal of our study was to evaluate if selective infracolic omentectomy and fixation reduced complications after CAPD catheter placement.
... There are no randomized controlled trials comparing the two modalities; however, PD may be favored in patients with vascular access failure, intolerance to hemodialysis, congestive heart failure, long distance from dialysis center, and peripheral vascular disease and bleeding diathesis. PD may also be preferred by patients with the possibility of renal transplantation soon, needle anxiety, and active lifestyle [3]. ...
Background Different laparoscopic approaches for insertion of a peritoneal dialysis catheter (PDC) have been adopted. Most of these techniques require 2–3 ports. One port laparoscopic technique for PDC placement was introduced by some authors to minimize potential complications. The main drawback of these techniques was the inadequate position of catheter tip and hence affecting its efficacy. The purpose of this study is to evaluate a simple modified laparoscopic technique during insertion of PDC. Results The mean age of these patients was 6 ± 4.1 years. There were 11 females. The mean body weight was 13 ± 3.3 kg. The mean operative time was 35.5 min. No operative complications occurred. Two cases had catheter obstruction. Wound infection developed in three cases. Mean follow-up period was 11 ± 5.3 months Conclusions Laparoscopic insertion of PDC in children suffering end-stage renal disease using a pre-tied catheter tip with V-loc/STRATAFIX ® size 3/0 suture and two-port-only technique was associated with shorter operative time and longer life of catheter without migration or catheter malfunction.
... There are no randomized controlled trials comparing the two modalities; however, PD may be favored in patients with vascular access failure, intolerance to hemodialysis, congestive heart failure, long distance from dialysis center, and peripheral vascular disease and bleeding diathesis. PD may also be preferred by patients with the possibility of renal transplantation soon, needle anxiety, and active lifestyle [3]. ...
Background
Different laparoscopic approaches for insertion of a peritoneal dialysis catheter (PDC) have been adopted. Most of these techniques require 2–3 ports. One port laparoscopic technique for PDC placement was introduced by some authors to minimize potential complications. The main drawback of these techniques was the inadequate position of catheter tip and hence affecting its efficacy.
The purpose of this study is to evaluate a simple modified laparoscopic technique during insertion of PDC.
Results
The mean age of these patients was 6 ± 4.1 years. There were 11 females. The mean body weight was 13 ± 3.3 kg. The mean operative time was 35.5 min. No operative complications occurred. Two cases had catheter obstruction. Wound infection developed in three cases. Mean follow-up period was 11 ± 5.3 months
Conclusions
Laparoscopic insertion of PDC in children suffering end-stage renal disease using a pre-tied catheter tip with V-loc/STRATAFIX ® size 3/0 suture and two-port-only technique was associated with shorter operative time and longer life of catheter without migration or catheter malfunction.
... Local and socio-cultural factors in various countries may limit or amplify the use of PD. Patients on PD account for 6% of ESRD patients in Japan, 13% in the United States, 37% in Canada, 42% in the United Kingdom, 81% in Hong Kong, and 91% in Mexico (3). ...
The viability of home peritoneal dialysis (HPD) is being debated in Arab countries. We therefore undertook the present study to assess the viability of HPD in the Arab culture. Patients and
A total of 100 patients with end-stage renal failure were treated with HPD during the period January 1996 to October 2001.
Continuous ambulatory peritoneal dialysis (CAPD) was performed in 81 patients (81%), and nightly intermittent peritoneal dialysis (NIPD) in 19 patients (19%). The patient group included 54 men (54%) and 46 women (46%) with a mean age of 54.94 +/- 14.58 years. They were followed for a total of 2118.3 patient-treatment months and had a mean dialysis duration of 21.2 +/- 9.97 months. Peritonitis occurred at the rates of 1 episode every 18.5 patient-treatment months (Bieffe L3 double-bag system: Bieffe Medital, Grosotto, Italy), 1 episode every 22.5 patient-treatment months (ANDY Plus system: Fresenius Medical Care, Bad Homburg, Germany), and 1 episode every 23.7 patient-treatment months (NIPD system Fresenius PD-Night: Fresenius Medical Care, Bad Homburg, Germany). Recurrent peritonitis was the main reason (70.6%) for transfer to hemodialysis. A good level of social well-being and rehabilitation was achieved in 49 patients on CAPD (60.5%) and 13 patients on NIPD (68.4%).
We conclude that HPD is a viable modality of renal replacement therapy in Arab countries. By adopting a strict training model, the peritoneal dialysis team can train even patients or caregivers with limited education, preventing peritonitis and promoting the general well-being of patients.
... Adhesions and fibrosis from previous surgeries, infections, and malignancies are relative contraindications to peritoneal dialysis (PD) (1). Extensive abdominal surgical scars may suggest adhesions and/ or fibrosis and such patients are often counseled to avoid PD. ...
... On the contrary, in patients over 60 years of age the longterm use of PD (>2 years) has been associated with increased mortality rates, irrespective of diabetic status or gender [15]. In pediatric patients, PD is strongly indicated for children aged 0-5 years, and should be preferred for those aged 6-16 years [11,16]. However, pretransplantation dialysis resulted to exert no clear effect on the graft outcome in pediatric kidney recipients [10], suggesting the need for further investigation. ...
Delayed graft function (DGF) is a frequent complication of kidney transplantation (KT) that may affect both short- and long-term graft outcome. It has been reported that pretransplantation peritoneal dialysis was correlated with a better recovery of graft function than hemodialysis in adult kidney recipients. However, the effect of pretransplantation dialysis mode (PDM) seemed to be unclear on the early outcome of KT in pediatric recipients. In this study, the potential impact of PDM on early graft function was evaluated in 174 pediatric patients who underwent KT by using cadaveric donors. The primary outcome parameter was the time to reach a serum creatinine (SCr) level 50% of the pretransplantation value [T(1/2(SCr))], while DGF was defined as a T(1/2(SCr)) >3 days after KT (n = 40). By stratifying kidney recipients for normal function graft or DGF, this latter group showed a significantly higher body weight (BW) on the day of KT (P = 0.014), body surface area (BSA) (P = 0.005), warm ischemia time (WIT) (P = 0.022), early SCr on the day 1 after KT (P < 0.001), and T(1/2(SCr)) (P < 0.001), whereas lower urine volume (UV) collected in the first 24 h after KT (P < 0.001) and fluid load (P < 0.001) occurred. Univariate exponential correlation that was carried out between T(1/2(SCr)) and all the other variables had shown a better value than the linear correlation for BW (R(2) = 0.28 vs. R(2) = 0.04), BSA (R(2) = 0.29 vs. R(2) = 0.03), and SCr (R(2) = 0.51 vs. R(2) = 0.28). In a multivariate regression analysis performed by entering T(1/2(SCr)) as dependent variable and following a forward stepwise method, cold ischemia time (CIT) (P = 0.027) but not PDM (P = 0.195) reached significance. In a Cox regression analysis carried out with T(1/2(SCr)) as dependent variable, neither CIT nor PDM gained significance. This study suggests that PDM does not affect early graft function in pediatric kidney recipients.
Chronic kidney disease is currently a pathology of international importance due to the high medical costs it represents for the medical healthcare system in every country and the high number of related complications. It´s a pathology that must be treated by a multidisciplinary medical and surgical team for the best prognosis of the patient. As surgical professionals, we have an essential role in the management of this disease; that is why it is crucial creating a review with unified information and recommendations regarding the open surgical technique for Tenckhoff catheter placement that has shown to be efficient and safe for patients and that is a standard surgical procedure in our environment.
This work describes the experimental design that simulates peritoneal movements with a Stewart platform during automated peritoneal dialysis (APD). The simulated motion includes the involuntary movements made while sleeping. In addition, the work has proposed a mechanism to adapt the parameters inside the artificial peritoneum and validate a novel cycler machine during daily therapy.KeywordsBiomechanicsStewart platformPeritoneal dialysis automatedTestbed
Study objective
The main objective of this study is to test the feasibility of the local anesthetic (LA) Mepivacaine 1% and sedation with Remifentanil as the primary anesthetic technique for the insertion of a peritoneal dialysis (PD) catheter, without the need to convert to general anesthesia.
Methods
We analyzed 27 consecutive end-stage renal disease (ESRD) patients who underwent the placement of a peritoneal catheter at our center between March 2015 and January 2019. The procedures were all performed by a general or vascular surgeon, and the postoperative care and follow-up were all conducted by the same peritoneal dialysis team.
Results
All of the 27 subjects successfully underwent the procedure without the need of conversion to general anesthesia. The catheter was deemed prone to usage in all patients and was found to be leak-proof in 100% of the patients.
Conclusion
This study describes a safe and successful approach for insertion of a PD catheter by combined infiltration of the local anesthetic Mepivacaine 1% and sedation with Remifentanil. Hereby, ESRD patients can be treated without general anesthesia, while ensuring functionality of the PD catheter.
Renal replacement with continuous ambulatory peritoneal dialysis allows patients the freedom to perform dialysis independently and improving their daily life. Peritoneal catheters are placed using variety of modalities by surgeons, nephrologists and interventional radiologists. The technique used for catheter placement plays an important role in the success of peritoneal dialysis, as mechanical complications related to the insertion technique are among the leading causes of peritoneal dialysis failure and need for hemodialysis. With the introduction of less invasive techniques, the use of open insertion technique has fallen to 27% in the United States; however, it continues to remain the main technique used at certain hospitals worldwide and for certain patient populations. One benefit of open peritoneal dialysis catheter insertion is the ability to perform the operation under local anesthesia. This technique, however, is not ideal for patients with severe intraabdominal adhesions, obesity, and abdominal wall defects. Catheter-related outcomes of open peritoneal dialysis catheter placement technique are superior to blind percutaneous insertion method, but inferior to basic and advanced laparoscopic insertion techniques. In this chapter, we describe the history, peri-operative considerations, operative technique and outcomes of open peritoneal dialysis catheter insertion method.
The decision to begin a patient on peritoneal dialysis should be a patient centered approach. For surgeons providing peritoneal access, a thorough knowledge of the anatomy, catheter choices and options for insertion is important. This chapter describes the many types of peritoneal dialysis catheters and compares them. In addition, there is a review of percutaneous, open and laparoscopic implantation techniques applied for peritoneal dialysis, technical considerations, and some of the related early surgical complications.
In the end stage renal disease pediatric and adult patient, peritoneal dialysis can be a cornerstone to survival and enhanced quality of life. Successful establishment of reliable peritoneal surgical access is essential. Peritoneal dialysis (PD) access creation is straightforward yet fraught with numerous largely avoidable complications.
Review of the literature from four decades of global heterogeneous practices and their associated diverse outcomes have elucidated some best practices. These optimal practices in preoperative preparation for peritoneal dialysis access are expressed in four concepts: (1) preoperative screening, risk stratification and optimization (2) patient training (3) preoperative site mapping (4) coordination of care with the entire team.
Peritoneal dialysis (PD) remains the treatment modality of choice for renal failure in both the neonatal and pediatric population. Patient selection, technical consideration to access insertion, and management of access-related complications are of great interest as laparoscopic placement becomes more common. The SAGES Guideline for Laparoscopic Peritoneal Dialysis Access Surgery, published in October 2014, is the only evidence-based clinical practice guideline for laparoscopic PD catheter currently available. Additionally, these guidelines provide the most comprehensive review to date, along with expert opinion on management of the more common perioperative complications. It has been well established that the incidence of infection and catheter malfunction is similar between open surgical and laparoscopic catheter placement. However, a major advantage of laparoscopic PD catheter placement is complete visualization of the peritoneal cavity which allows for simultaneous abdominal procedures, adhesiolysis to increase peritoneal surface, and omentectomy to prevent catheter malfunction.
Patients with chronic renal failure may necessitate renal replacement therapy. Probably, the most advantageous therapy in terms of survival is kidney transplantation, but no more than 30 to 40% of patients are suitable for it. Therefore, more than two thirds of patients require chronic haemodialysis or peritoneal dialysis. Both methods seem to offer adequate replacement of renal function, at least for a certain period. Peritoneal dialysis is a form of self-treatment that allows a more independent life style. Currently, it is used by approximately 14% of the dialysis population worldwide. Via diffusion, ultrafiltration and convective forces, the regularly changed intraabdominal dialysate eliminates solutes, salts and fluid from the systemic circulation, thereby enabling adequate detoxification. Various technical systems, manual and automated, are available to perform dialysate exchanges. Volume and composition of the dialysate are tailored according to the individual patient's needs. Potential infectious complications are peritonitis, tunnel- and exit-site-infection. Accurate care is needed to keep the rate of infection acceptably low (e.g. peritonitis rate: 1 per 2 to 5 patient years). Although the complications are different from those of haemodialysis, the morbidity of technique related complications measured by in-hospital days per year is virtually identical. Non-infectious complications include an increased incidence of herniation, overhydration, haemoperitoneum and back pain. In conclusion, peritoneal dialysis may be recommended to patients with chronic renal failure, especially when this treatment modality is seen as part of an integrated care approach.
Background:
The treatment of refractory ascites remains a challenge in cirrhosis with ascites and end-stage renal disease (ESRD). Successful experiences with continuous ambulatory peritoneal dialysis (CAPD) for treatment of ESRD patients with ascites secondary to liver cirrhosis have been reported, but the CAPD modality has the drawback of protein loss and was observed to cause patients to become severely malnourished. We devised a CAPD method for treatment of ascites without protein loss. We use a peritoneal dialysis (PD) system to drain ascitic fluid and to reinject concentrated ascites into the abdomen after extracorporeal ultrafiltration of the ascitic fluid using a hemodialysis dialyzer and pump. Here, we report our experience with 2 cirrhotic patients with ascites treated by this method.
Patients and method:
Ascites are collected by gravity through a Y transfer set into a 3-L plastic bag for intravenous hyperalimentation. The ascitic fluid drained is removed by a pump at a rate of 200 mL/min (AK-90: Gambro Lundia, Lund, Sweden) and passed through a hollow-fiber dialyzer with triacetate membrane (FB-210G: Nipro, Osaka, Japan). Heparin (5,000 U) is infused into the inflow line at the start of the session only. At the end of treatment, about 500 mL concentrated ascitic fluid is returned to the peritoneal cavity by gravity through the Y transfer set. Case 1: A 77-year-old female was referred to us because of massive ascites from hepatic cirrhosis associated with hepatitis B infection and renal insufficiency. Abdominal paracentesis was required once weekly for recurrence of massive ascites. As a result, the patient was obliged to stay in the bed almost all day, and her nutritional condition deteriorated because of poor appetite and respiratory compromise. Using the Y transfer set, we commenced using our method, and performed it thrice or twice weekly. After 9 months of treatment, the patient's body weight was being maintained at 52 kg, and her serum albumin level had risen from 2.4 g/dL to 3.4 g/dL without albumin administration. Case 2: A 61-year-old male with diabetes from the age of 51 was diagnosed with hepatitis C at age 53. At age 60, his renal function deteriorated, requiring hemodialysis (HD). After 3 months, abdominal distention was noted, and HD was frequently complicated by low blood pressure, large weight gains between HD treatments, and interruption of HD sessions. Albumin administration was required to treat the low blood pressure. Ascites was poorly controlled using HD, and tense ascites developed, requiring repeated paracentesis for comfort. At first during application of our method, ascitic fluid volume was 6 L per thrice-weekly HD session. After 5 months, ascitic fluid volume had diminished to about 2 - 3 L per HD session, and we decreased the frequency of our method to once weekly. Protein levels in the ascitic fluid were 6 g/dL at the start of treatment and decreased to 2 - 3 g/dL after 6 months. Hemodynamic instability during HD was reduced.
Conclusion:
We conclude that management of refractory ascites by using a PD system with extracorporeal ultrafiltration by an HD dialyzer is useful. The technique compensates for the drawbacks of PD management of ESRD patients with ascites, although further experience with the technique is necessary.
Technological advances such as those that allow the delivery of an adequate dialysis dose to a larger percentage of patients, minimization of peritoneal membrane damage with more biocompatible solutions, and lower peritonitis rates will undoubtedly improve retention of patients on peritoneal dialysis (PD) for longer periods. Currently, only 15% of the world dialysis population is managed by PD. Peritoneal dialysis has many advantages over hemodialysis, and if end-stage renal disease (ESRD) patients are fully informed about them, the proportion of patients who would prefer this treatment would rise to 25%-30%. An integrated approach to the treatment of ESRD could start with PD in a large percentage of patients, especially those who will receive a kidney transplant within 2 - 3 years. With the present epidemic of ESRD, this approach could lead to a significant saving, relieve the pressure on dialysis units, and allow a larger number of ESRD patients to be treated.
We conducted a 4-year retrospective study (1996-1999) in order to assess the abdominal events in patients on peritoneal dialysis (PD), as well as the technique failure and the death incidence. We enrolled 127 patients in two french dialysis centers, who presented 9 enteric bacterial peritonitis (13.2% of the total peritonitis episodes), occurring 7.6 +/- 7.9 months after PD treatment. Surgery (8 patients) and definitive technique failure (7 patients) were necessary. Hernias were the most frequent with 32.6% of the total abdominal complications. They were either umbilical (7 patients), or inguinal (5 patients) or hiatal (3 patients). Six patients continued on PD without disruption whereas 6 patients had a transient stop and thereafter returned to PD. The other abdominal complications such as gastric and duodenal ulcus (5 patients), oesophagogastric reflux (5 patients), liver diseases (9 patients) occurred during PD treatment without any relationship with the treatment modality. In the diabetic population, abdominal complications were not more frequent but they took place more quickly than in the non diabetic population (5.5 +/- 3.8 months versus 12.9 +/- 16.3 months with p < 0.01). A rapid diagnosis, especially in case of enteric peritonitis, is mandatory to avoid "abdominal catastrophes" mainly due to visceral injury. The incidence of hernia could be decreased if a good clinical approach is effective before PD treatment.
The goal of this paper was to review the viability of peritoneal dialysis (PD) in patients with spina bifida and/or ventriculoperitoneal shunt (VPS).
Pediatric dialysis unit in a tertiary-care hospital.
The course and outcome in 9 children, 5 from the authors' experience and 4 from reported experience, are analyzed.
One patient died of a cause unrelated to PD or VPS, 2 were transferred to hemodialysis because of recurrent peritonitis, 1 discontinued PD transiently, 2 were transplanted, and 3 continue on PD. Six of these 9 children had a functioning VPS, and none presented evidence of ventriculitis or VPS dysfunction, even though 4 had PD-related peritonitis. One child presented with a massive PD-related hydrothorax.
(1) Having a VPS is not an absolute contraindication to PD; the available data support the viability of PD in patients with spina bifida and/or a VPS. (2) If cerebrospinal fluid diversion is needed simultaneously or after starting PD, an extraperitoneal site should be a better choice than VPS. This should avoid the risk of intra- and postoperative infection in the PD catheter secondary to surgical intervention for VPS insertion. (3) Loss of peritoneal function is a potential late risk related to cerebrospinal fluid and PD. (4) Spina bifida patients on PD present specific diagnostic challenges due to overlapping symptoms (e.g., vomiting, abdominal tenderness, fever) secondary to PD- or VPS-related complications (e.g., peritonitis, visceral injury by devices) or primary disease (e.g., neurogenic bladder, pyelonephritis), with inherent risks of delaying adequate treatment. Cloudy peritoneal effluent is an early indication of peritonitis, although it is not specific. (5) Early evaluation by a pediatric surgeon and a neurosurgeon is required for effective management of complications and selection of more efficient individualized therapeutic alternatives. Prompt treatment of complications is crucial. A registry of children with spina bifida on PD and the accumulation of a large population followed up for longer periods will provide an objective assessment of their problems and management.
Interviewing the prospective patient for peritoneal dialysis (PD) is a critical step in the development of a relationship between the patient and the PD nurse. Individualizing information for the patient and significant others promotes confidence in making an informed decision. This article presents a five-step approach for interviewing the potential patient for PD.
The elderly are a fast growing population in the United States, and they have a high prevalence of chronic kidney disease. The elderly are particularly susceptible to kidney damage from age-related declines in glomerular filtration as well as kidney damage from chronic disease states such as diabetes mellitus, hypertension, glomerular, and tubulointerstitial disorders. A significant number of elderly individuals are reaching end-stage renal disease that require renal replacement therapy. This expanding population provides a challenge for health-care providers because the elderly are often referred late to a nephrologist, have a shortened survival on renal replacement therapy as compared with younger individuals, and suffer from more comorbidities such as cardiovascular disease, malnutrition, and hearing and visual disabilities. The elderly also have difficulties with dialysis vascular access and often are not candidates for renal transplantation. Despite these obstacles, age alone is not a justification for withholding diagnostic or therapeutic interventions, because many elderly individuals have an improvement in their quality of life and social support once their kidney disease is identified and treated.
In older textbooks the use of peritoneal dialysis (PD) in patients with liver cirrhosis and/or ascites was contraindicated. Only a small number of papers have focused on this problem and they mainly consist of case reports and retrospective studies of small numbers of patients. In addition, most nephrologists' experience of performing PD in patients with liver diseases is rather limited. Nevertheless, for these patients PD offers a wide range of advantages, such as a simplified ascites management, since repeated abdominal punctures become unnecessary. Furthermore, because of continuous peritoneal ultrafiltration, hemodynamic tolerance during PD is significantly better than in hemodialysis and results in a markedly lower frequency of hypotensive episodes. The risk of nosocomial infection with hepatitis B or C viruses can also be reduced by treating these patients with home PD. Although some authors suggest that PD patients with liver cirrhosis have an especially increased risk of Gram-negative peritonitis, currently available data show controversial results. There is also little information in the literature on the impact of increased peritoneal protein loss on malnutrition and outcome of these patients. Nevertheless, recent studies have shown that protein loss into the peritoneal cavity in PD patients with liver cirrhosis is high only initially, stabilizing at a lower level in the further course of treatment. In conclusion, in patients with end-stage renal disease suffering from liver cirrhosis and/or ascites, PD can be considered as a good or adequate treatment option.
Most physicians do not consider peritoneal dialysis (PD) to be the treatment of choice in obese patients with end-stage renal failure. In some but not all studies the incidence of infectious complications (catheter-associated infections and peritonitis) is higher than in patients with normal body mass index (BMI). Although mathematical models show that even continuous ambulatory PD with a daily dialysate treatment volume of 12 litres does not provide sufficient clearances in patients weighing 80 kg, adequate dialysis has been achieved in clinical studies in patients with BMI up to 46 kg/m2. Residual renal function is a very important factor for survival in patients undergoing PD and might be influenced by body weight; however, data are controversial, showing either a negative influence of high BMI on renal clearance or no association. The incidence of peritoneal leaks in PD is higher in obese patients than in other patients, because of the raised intra-abdominal pressure. In contrast, hernias do not occur more frequently in overweight PD patients and the risk of hernias seems to be greater in patients with lower BMI. It is well known that mortality rates of overweight patients on hemodialysis are lower than in those with normal body weight, but data on the influence of BMI on survival in PD patients are more controversial. In conclusion, there is no evidence that PD is absolutely contraindicated in patients with high BMI, especially if patients have a strong preference for this type of treatment.
Selection of the initial dialysis modality is crucial in the treatment of end-stage renal disease (ESRD) patients. Several patient- and physician-related factors play important roles in the decision between peritoneal dialysis (PD) and hemodialysis (HD). Although HD is the most common dialysis modality in the United States, in some studies PD has shown a survival advantage over HD, at least in the first 2 years of dialysis treatment, especially in non-diabetic patients and in young patients with diabetes. Other advantages accrue to early PD use in many patients. An integrated care approach with "healthy start" and PD as the initial renal replacement therapy, followed by timely transfer to HD once complications arise, may improve the long-term survival of ESRD patients.
Peritoneal dialysis (PD) has been accepted as a treatment option for patients with end-stage renal disease, yet experience with PD in Arab countries is limited. This study was undertaken to evaluate the outcome and survival of different PD modalities. All patients managed at the Mubarak Al-Kabeer Hospital Kuwait between August 1982 and December 2003 using PD for three months or more were included in the study. Demographic features, outcome and survival of the patients were analyzed. Four hundred and fifteen patients with end-stage renal failure were admitted into the PD program. Their mean age was 52.06 +/- 16.43 years. Hospital-based intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), nightly intermittent peritoneal dialysis (NIPD) and continuous cycling peritoneal dialysis (CCPD) were preferred by 203 (48.9%), 176 (42.4%), 30 (7.2%) and 6 (1.4%) patients respectively. The mean duration of follow up was 12.7 +/- 11.7 months. Fifty-five (13.3%) patients were continuing on PD, 55 (13.3%) had shifted to hemodialysis, 73 (17.6%) underwent renal transplantation, 114 (27.5%) died, 34 (8.2%) returned to their native countries, 79 (19%) transferred to other centers and follow up was lost for 5 (1.45%) patients. Patient survival at two years was 56%, 72% and 87% in IPD, CAPD and NIPD respectively. Technique survival at two years was 60.6%, 75.4% and 100% in IPD, CAPD and NIPD respectively. Peritoneal dialysis modalities provide a feasible modality of renal replacement therapy. The overall outcome and patient and technique survival in home PD modalities were better than hospital-based PD.
Long-term dialysis in children with multiple handicaps has become easier with the advent of continuous ambulatory peritoneal dialysis (PD). Due to the widespread use of PD and the long survival of patients with spina bifida, an increasing number of patients with spina bifida are on PD. The viability and safety of PD in spina bifida patients with a ventriculoperitoneal shunt (VPS) have been a matter of concern. Some authors consider the presence of a VPS a relative contraindication for PD, but more recent reports suggest that PD under close monitoring is not contraindicated. We report a 17-year-old girl born with meningomyelocele, hydrocephalus and neurogenic bladder who was maintained on VPS. She reached end-stage renal failure 17 years later and was put on PD based on family and patient preference. She had an uneventful course in the initial 9 months, but later developed fungal peritonitis which was successfully managed with catheter withdrawal and an intravenous antifungal agent (amphotercin 0.75 mg/kg). Simultaneous ventricle-aspirated cerebrospinal fluid was sterile. To our knowledge, this is the first report of fungal infection in such a patient. Although we share the view that PD is not an absolute contraindication in patients with a functioning VPS, its likely complications, especially infectious complications in developing countries, should be kept in mind before initiating PD in such patients.
Background: In 29 CAPD (continuous ambulatory peritoneal dialysis) patients the height and diurnal variation of the blood pressure (BP) and heart-rate (HR) were analyzed by means of 24-hour ambulatory blood pressure monitoring (ABPM). Methods: Normal diurnal variation was defined as a fall of 10% or more during nighttime (NT) compared with daytime (DT) BP or HR (DT = 10.00 a.m.-9.00 p.m., NT = midnight-06.00 a.m.). To evaluate high BP in the course of time we used the concept of ''whole-day BP load'', defined as the percentage of BP readings above 140/90 mmHg during a 24-h period. A ''hypertensive BP load'' was defined as a systolic BP (SEP) load of more than 50% and/or a diastolic BP (DBP) load in excess of 40%. In addition to analysis of the circadian rhythm of BP and HR and the prevalence of a hypertensive BP load in CAPD patients, the influence of various factors such as gender, creatinine clearance, recombinant human erythropoietin, antihypertensive medication, haematocrit, whole-day BP load, and the nightly dialysis glucose concentration on the diurnal variation of BP and HR were studied. Results: Based on the 95% confidence intervals for the proportional nocturnal decrease, normal diurnal variation of BP and HR was present in most CAPD patients. No correlation could be demonstrated between a blunted circadian rhythm and the variables mentioned above. However, when other time-period definitions (DT = 6.00 a.m.-11.00 p.m., NT = 11.00-6.00 and DT = 8.00 a.m.-8.00 p.m., NT = 8.00 p.m.-8.00 a.m.) were applied to the data, considerably fewer patients displayed normal diurnal variation. Whereas all patients showed normal home BP readings, ABPM of 21 out of 29 patients displayed a hypertensive BP load. Conclusion: The majority of our CAPD patients exhibited normal diurnal variation of SEP and DBP depending, however, on the definitions of DT and NT used. The absence of a normal circadian rhythm could not be explained by any of the variables analyzed. Surprisingly, uncontrolled hypertension, as defined by a hypertensive BP load, was found in 72% of the patients.
The aim of the present multicenter study was to assess quality of life of Dutch dialysis patients 3 months after the start of chronic dialysis treatment. The quality of life was compared with the quality of life of a general population sample, and the impact of demographic, clinical, renal function, and dialysis characteristics on patients' quality of life was studied. New end-stage renal disease (ESRD) patients who were started on chronic hemodialysis or peritoneal dialysis in 13 dialysis centers in The Netherlands were consecutively included. Patients' self-assessment of quality of life was measured by the SF-36, a 36-item Short Form Health Survey Questionnaire encompassing eight dimensions: physical functioning, social functioning, role-functioning physical, role-functioning emotional, mental health, vitality, bodily pain, and general health perceptions. One hundred twenty hemodialysis and 106 peritoneal dialysis patients completed the SF-36. Quality of life of hemodialysis and peritoneal dialysis patients was substantially impaired in comparison to the general population sample, particularly with respect to role-functioning physical and general health perceptions. Mean role-functioning physical and general health perceptions scores of the hemodialysis patients corresponded with the lowest scoring 8% and 12%, respectively, of the reference group. Mean role-functioning physical and general health perceptions scores of the peritoneal dialysis patients corresponded with the lowest scoring 10% and 12%, respectively, of the reference group. Hemodialysis patients showed lower levels of quality of life than peritoneal dialysis patients on physical functioning, role-functioning emotional, mental health, and pain. However, on the multivariate level, we could only demonstrate an impact of dialysis modality on mental health. A higher number of comorbid conditions, a lower hemoglobin level, and a lower residual renal function were independently related to poorer quality of life. The variability of the SF-36 scores explained by selected demographic, clinical, renal function, and dialysis characteristics was highest for physical functioning (29.7%). Explained variability of the other SF-36 dimensions ranged from 6.9% for general health perceptions to 15.4% for vitality. We conclude that quality of life of new ESRD patients is substantially impaired. Comorbid conditions, hemoglobin, and residual renal function could explain poor quality of life only to a limited extent. Further research exploring determinants and indices of quality of life in ESRD patients is warranted. From a clinical perspective, we may conclude that quality of life should be considered in the monitoring of dialysis patients.
To determine whether obvious hemodynamic advantages of continuous ambulatory peritoneal dialysis (CAPD) over intermittent hemodialysis are reflected in superior cardiac structure and function, 16 of 55 analyzed CAPD patients (CAPD duration: 28 months) were followed over 35 months with echocardiography in a prospective analysis: 26 patients had died. LV dimensions (end-diastolic: 52 +/- 7 vs. 51 +/- 8 mm; control vs. follow-up) and systolic function (ejection fraction: 63 +/- 10 vs. 59 +/- 14%) were normal. Major findings were an increase in the amount of initially observed LV hypertrophy (251 +/- 68 vs. 342 +/- 135 g; p less than 0.03) and a decrease in mean LV volume/mass ratios (0.73 +/- 0.17 vs. 0.54 +/- 0.13; p less than 0.001). Excluding patients with dilated cardiomyopathy and valve disease, the amount of progression in LV hypertrophy was related directly to mean arterial pressure and cardiac output (n = 12; p less than 0.02) despite extensive use of antihypertensive medication (1.9 +/- 1.3 vs. 1.5 +/- 1.4 drugs/patient). No correlation was found with diastolic blood pressure, hemoglobin, serum parathyroid hormone, creatinine, urea, age, or CAPD duration. We conclude that LV hypertrophy is frequent in CAPD patients and further increases during long-term CAPD treatment. Factors contributing to the progression of LV hypertrophy are hypertension and hypercirculation.
Continuous ambulatory peritoneal dialysis (CAPD) is associated with obvious hemodynamic and blood purification advantages over intermittent hemodialysis. To determine whether this is reflected in favorable left ventricular (LV) structure and function, a group of 55 normotensive patients (aged 58.4 +/- 11.0 years) undergoing CAPD was analyzed by means of echocardiography. Characteristic findings were LV hypertrophy (158 +/- 50 gm/m2), mainly the result of septal thickening (13.3 +/- 2.8 mm), and left atrial dilatation (40.9 +/- 7.4 mm). Mean LV diameter in end diastole and end systole and posterior wall thickness were normal. Parameters of LV systolic function (ejection fraction [EF]: 62.0 +/- 13.0%; velocity of circumferential fiber shortening [Vcf]: 1.58 +/- 0.46 circ/sec) were in the upper normal range at a hyperdynamic circulatory state (cardiac index [CI] 4.67 +/- 1.82 L/min/m2. The amount of LV hypertrophy was related to the amount of hypercirculation (CI: p less than 0.001; hemoglobin: p less than 0.025) and quality of blood purification (creatinine, urea: p less than 0.02) but not to blood pressure, age, or duration of dialysis. Left atrial dilatation was inversely related to LV systolic function (EF, Vcf: p less than 0.001) and directly related to LV muscle mass (p less than 0.02). A low prevalence (13%) of pericardial effusion was independent of blood purification. We conclude that in normotensive patients receiving CAPD, a high prevalence of left atrial dilatation and asymmetric septal hypertrophy is found, the latter being related both to the amount of hypercirculation and the quality of blood purification.
This study examines factors associated with employment status in a stratified subsample of the Michigan End-Stage Renal Disease Study population. To reduce the variation in employment potential, the subsample consisted of nondiabetic patients aged 20 to 64 years. The patients were stratified on the basis of their treatment histories as follows: (1) treated by in-center hemodialysis only; (2) primarily treated by continuous ambulatory peritoneal dialysis; and (3) failed continuous ambulatory peritoneal dialysis, substituted by another form of dialysis. A significantly higher percentage of the patients undergoing stable continuous ambulatory peritoneal dialysis were in the labor force than were those undergoing in-center hemodialysis (27.4% vs 9.6%). Using logistic regression, even when adjusted for sex, race, age, education, marital status, primary diagnosis, and duration of end-stage renal disease, the stable continuous ambulatory peritoneal dialysis group was significantly more likely to be employed than the group undergoing either in-center hemodialysis only or the group that failed continuous ambulatory peritoneal dialysis.
Continuous ambulatory peritoneal dialysis (CAPD) often leads to better control of hypertension. In order to evaluate the effects of such improved blood pressure control on left ventricular (LV) hypertrophy and LV function, a group of 18 patients with a history of hypertension were followed for changes in LV anatomy and function (with M-mode echocardiography) over a 6 to 12 month period after initiation of CAPD. All patients had echocardiographic evidence of increased LV mass related to concentric and eccentric hypertrophy. On CAPD, blood pressure decreased (greater than 5 mm Hg) in 12 patients. LV mass decreased in 15 patients and increased in one. A decrease in both wall thickness and LV dimension contributed to the fall in LV mass on CAPD. Initially, LV dimension exceeded normal in 9 out of 18 patients. On CAPD, LV dimension decreased to near normal in size in six, and no patient developed LV dilation on CAPD. Four patients initially had a decreased fractional shortening and ejection fraction; three of these normalized while on CAPD and no patient deteriorated. These results indicate that CAPD improves LV hypertrophy by normalizing both volume and pressure overload. These effects may prevent deterioration in LV function in patients with still normal LV function, and may improve LV function in patients who already exhibit decreased LV performance.
We analyzed routine serum potassium concentration measurements and conditions temporally associated with abnormalities in potassium concentration in outpatients on chronic hemodialysis (136 nondiabetics, 36 diabetics) and continuous ambulatory peritoneal dialysis (16 nondiabetics, 10 diabetics). The following potassium concentration frequencies were found: prehemodialysis, nondiabetics: normal 51.3%, severe hyperkalemia (greater than 6.0 mmol/l) 10%, severe hypokalemia (less than 3.0 mmol/l) 0.3%; diabetics: normal 57.8%, severe hyperkalemia 8.7%, severe hypokalemia 0.5%. Peritoneal dialysis, nondiabetics: normal 73.7%, severe hyperkalemia 0.6%, severe hypokalemia 4.9%; diabetics: normal 72.5%, severe hyperkalemia 0.9%, severe hypokalemia 2.9%. Normokalemia and severe hypokalemia were significantly (chi 2 test) more frequent in peritoneal dialysis than in prehemodialysis, whereas severe hyperkalemia was more frequent in prehemodialysis serum samples. No difference was found between nondiabetics and diabetics for either form of dialysis. 50% of prehemodialysis episodes of hyperkalemia were diet-induced. Hyperkalemic drugs and anuria were not associated with a higher risk of prehemodialysis hyperkalemia, but each one of 3 abnormalities, very high BUN (greater than 40 mmol/l), metabolic acidosis (TCO2 less than 15 mmol/l) and, in diabetics, severe hyperglycemia (serum glucose greater than 30 mmol/l), was associated with a statistically higher risk of hyperkalemia.
Diabetic nephropathy is becoming a major and growing cause of endstage renal disease (ESRD) in all industrialized countries [1, 2]. In Europe, the number of patients with diabetic nephropathy and ESRD that have been put on renal replacement therapy has increased rapidly during the last years. By the end of 1980, diabetic patients accounted for 3% of all patients alive and treated by a dialysis method or living with a functioning graft [1]. As demonstrated by recent results [1, 3, 4–6] exclusion of insulin-dependent diabetic (IDD) patients from renal function replacement therapy is no longer acceptable when treatment facilities are available; therefore, time has come for a critical appraisal of the results obtained with different dialysis techniques in a diabetic population.
Continuous ambulatory peritoneal dialysis (CAPD), a valuable alternative to hemodialysis in treating ESRD [7–12] is currently quoted as a satisfactory dialysis method for IDD patients [5, 6, 13–17]. Recently very encouraging results observed in 20 patients have been reported by Amair et al [18]. However, small series and too brief follow-up periods have not allowed valid comparisons between CAPD and other modes of therapy in a diabetic population. In this study, we report our experience with 24 IDD patients treated by CAPD over a 40-month period.
During the last quarter of 1992, 984 patients from 13 dialysis centers in the Provence-Alpes-Côte-d'Azur region in France participated in a multicenter cross-sectional study to determine the prevalence, the risk factors, and the clinical consequences of infection by the hepatitis C virus (HCV). Serum samples were tested for anti-HCV antibodies using second-generation enzyme-linked immunosorbent assay (ELISA). In the case of a positive result, a combination test was performed using second-generation recombinant immunoblot (RIBA) or direct detection of HCV-RNA by nested polymerase chain reaction (PCR). Collected data included the patient's age, gender, cause of the kidney disease, type of dialysis treatment, number of years on dialysis, weekly dialysis time, drug addiction, co-infection with hepatitis B virus and human immunodeficiency virus (HIV), number of kidney transplants, number of blood transfusions, and history of acute or chronic hepatitis. Chronic HCV infection was detected in 232 (23.6%) patients, whereas only 71 (7.2%) were infected by HBV. Logistic-regression analysis showed that HCV infection was associated with dialysis over a long period, numerous blood transfusions, female gender, kidney grafts, HBV infection, hemodialysis, and acute as well as chronic hepatitis. Multiple-correspondence analysis confirmed that the contamination was both transfusional and nosocomial. These results underscore the need for a strict compliance with "universal precautions" (Centers for Disease Control [CDC], Atlanta) in dialysis units and raise the question as to whether anti-HCV-positive patients should be isolated.
To evaluate (1) the disease course, (2) the response to recombinant human erythropoietin (rHuEPO), and (3) the morbidity and mortality of patients with end-stage renal disease (ESRD) due to multiple myeloma (MM) who were treated with continuous ambulatory peritoneal dialysis (CAPD) DESIGN: Retrospective study.
Tertiary teaching hospital--The Toronto Hospital, Toronto, Ontario, Canada.
Seven patients with ESRD due to MM who were treated with CAPD.
Mean age of the patients was 77.2 years (median 80 years, range 65-88 years). Two were in stage IB, 1 was in stage IIB, and the remaining 4 were in stage IIIB, according to Durie and Salmon's staging. Three patients received rHuEPO; 2 of these also were receiving chemotherapy for myeloma. The mean rHuEPO requirement was 277 U/kg/wk, which was more than other ESRD patients' requirements. Mean duration of CAPD was 20.6 months (6-58 months). The peritonitis rate was one episode in 14.4 months. The frequency of hospitalization was once in 5.6 months, and the mean number of days spent in hospital was 20 days per year. Quality of life did not get worse and, if anything, improved marginally while they were on CAPD. Three patients died after a mean survival of 32.7 months, and the remaining 4 patients are still alive.
Myeloma patients with ESRD do fairly well on CAPD without deterioration in their quality of life and with an acceptable peritonitis rate.
To better define the survival and quality of life of patients with major left ventricular systolic dysfunction and end-stage renal disease treated by continuous ambulatory peritoneal dialysis (CAPD), we reviewed all cases who started CAPD between May 1984 and March 1993 who had an isotopic left ventricular ejection fraction (LVEF) < or = 35%. Seventeen patients (12 men and five women with a mean age of 51.6 +/- 14.9 years) met the inclusion criteria. Mean isotopic LVEF before initiation of CAPD was 24.8% +/- 8.2%. All patients were symptomatic from congestive heart failure. Thirteen patients were classified as New York Heart Association grade III or IV. Continuous ambulatory peritoneal dialysis was associated with a significant improvement of isotopic LVEF, of functional status, and of blood pressure control. In 10 patients with a second measurement on CAPD, LVEF increased from a mean value of 23.2% +/- 9.1% to a mean value of 30.3% +/- 8.1% (P < 0.01). This represents a 30% increase of LVEF. After 6 months on CAPD, 94% of patients were classified as New York Heart Association grade I or II. Actuarial survival rates were 94%, 80%, and 64% at 12, 18, and 24 months, respectively. The mean duration of CAPD was 24 +/- 17 months. These results suggest that current CAPD treatment is an elective modality of treatment in patients with concomitant heart and renal failure.
In this study we compared the influence of 2 different modalities of treatment, CAPD and hemodialysis, on the prevalence and severity of left ventricular hypertrophy and cardiac arrhythmias of chronic renal failure patients. We compared 27 patients on the CAPD program with 27 patients on the chronic hemodialysis matched for sex, age, and duration of dialysis treatment. The prevalence of hypertension was significantly lower in CAPD than in hemodialysis patient (41% vs. 81%, p = 0.0023). Blood pressure levels were also lower in CAPD than in hemodialysis patients (systolic pressure 124.9 +/- 4.7 vs. 154.8 +/- 4.6 mm Hg, p < 0.0001; diastolic pressure 77.5 +/- 2.9 vs. 93.3 +/- 2.8 mm Hg, p = 0.0001). Left ventricular hypertrophy (LVH) was present in 52% of CAPD and in 93% of hemodialysis patients (p = 0.0008). Severe cardiac arrhythmias (Lown 3-4) occurred in only 4% of CAPD and in 33% of the hemodialysis group (p = 0.0149). The lower frequency of LVH in CAPD might explain the lower incidence of severe arrhythmias.
In 29 CAPD (continuous ambulatory peritoneal dialysis) patients the height and diurnal variation of the blood pressure (BP) and heart-rate (HR) were analyzed by means of 24-hour ambulatory blood pressure monitoring (ABPM).
Normal diurnal variation was defined as a fall of 10% or more during nighttime (NT) compared with daytime (DT) BP or HR (DT = 10.00 a.m.-9.00 p.m., NT = midnight-06.00 a.m.). To evaluate high BP in the course of time we used the concept of "whole-day BP load", defined as the percentage of BP readings above 140/90 mmHg during a 24-h period. A "hypertensive BP load" was defined as a systolic BP (SBP) load of more than 50% and/or a diastolic BP (DBP) load in excess of 40%. In addition to analysis of the circadian rhythm of BP and HR and the prevalence of a hypertensive BP load in CAPD patients, the influence of various factors such as gender, creatinine clearance, recombinant human erythropoietin, antihypertensive medication, haematocrit, whole-day BP load, and the nightly dialysis glucose concentration on the diurnal variation of BP and HR were studied.
Based on the 95% confidence intervals for the proportional nocturnal decrease, normal diurnal variation of BP and HR was present in most CAPD patients. No correlation could be demonstrated between a blunted circadian rhythm and the variables mentioned above. However, when other time-period definitions (DT = 6.00 a.m.-11.00 p.m., NT = 11.00-6.00 and DT = 8.00 a.m.-8.00 p.m., NT = 8.00 p.m.-8.00 a.m.) were applied to the data, considerably fewer patients displayed normal diurnal variation. Whereas all patients showed normal home BP readings, ABPM of 21 out of 29 patients displayed a hypertensive BP load.
The majority of our CAPD patients exhibited normal diurnal variation of SBP and DBP depending, however, on the definitions of DT and NT used. The absence of a normal circadian rhythm could not be explained by any of the variables analyzed. Surprisingly, uncontrolled hypertension, as defined by a hypertensive BP load, was found in 72% of the patients.
We report here the demography and results of renal replacement therapy in Canada from 1981 to 1992. The new case rate for patients entering renal replacement therapy programs in Canada has increased dramatically over the last 12 years, from 49.9 per million to 98.4 per million of the population. The largest increases have been among the elderly, from 146.2 per million in 1981 to 381.9 per million in 1992 for those aged 65 to 74 years. There has been an even more dramatic increase for those over 75 years, from 83.6 per million in 1981 to 261.6 per million in 1992. There has been a similar increase in the prevalence rate, with an increase from 229.1 per million in 1981 to 518.5 per million in 1992. The hemodialysis rate for 1992 was 172.2 per million and that for peritoneal dialysis was 103.1 per million of the population. The renal transplantation rate also increased from 20 per million in 1981 to 34.8 per million in 1988, but unfortunately has decreased to 27.5 per million in 1992. Diabetes is now the most common primary renal diagnosis, having increased from 15% in 1981 to 24% in 1992. The 5-year survival rate of all patients on renal replacement therapy was 55%. For nondiabetic patients, the 5-year survival rate ranged from 85% for the those aged 15 to 44 years to 20% for those over 65 years. Among diabetic patients, the 5-year survival rate declined from 58% for the 15 to 44 year age group to 10% for those over 65 years.
Continuous ambulatory peritoneal dialysis (CAPD) may not be tolerated by patients with chronic obstructive pulmonary disease (COPD) because of increased abdominal pressure in the standing position after instillation of peritoneal fluid. We report, here, a patient with COPD who had marked distress while on CAPD but was more comfortable with supine intermittent peritoneal dialysis. It is probable that the continuous high intraperitoneal pressure during CAPD caused diaphragmatic fatigue. During intermittent peritoneal dialysis, the supine position induces the least increase in intraperitoneal pressure; it may be the preferred mode of peritoneal dialysis for patients with COPD.
We performed a cross-sectional study to establish the hepatitis C virus (HCV) serologic status for all French patients undergoing peritoneal dialysis (PD) on January 1, 1995. We listed a total of 1508 patients, and the exhaustiveness rate was about of 75% of the whole French PD population treated at this date. Only 47 of the 1508 patients were anti-HCV positive (HCV+): the global HCV prevalence was 3.12%. HCV+ patients were treated by PD for a longer time than HCV-patients (4 +/- 4 vs 2 +/- 2 years; p < 0.001); 89% of the HCV+ patients received blood transfusions; 60% had been previously treated by hemodialysis, and 26% previously received a kidney transplantation. In 49% of the HCV+ patients, HCV antibodies were discovered before the start of the peritoneal dialysis program, and a seroconversion was observed in only 4 (0.27%) of them during the PD treatment. All these patients received blood transfusion. In patients without past history of hemodialysis or transplantation (exclusively treated by PD), HCV prevalence was 1.5%, not far off that of the general population. Peritoneal dialysis seems not to be an additional risk factor for hepatitis C infection in France.
This study compared the status and adequacy of blood pressure (BP) control in 21 ESRD patients treated with HD and CAPD at different time periods. Patients were considered to be hypertensive it they were receiving antihypertensive medications during the study period. During HD, 9 of the 21 patients (43%) required antihypertensive drugs to control their hypertension; whereas, during CAPD, the number of patients taking antihypertensive drugs increased to 15 (71%) (p < 0.05). Adequate control of hypertension (systolic BP < 150 mmHg and/or diastolic BP < 90 mmHg) was achieved in 17 patients (81%) during HD compared to 11 patients (52%) during CAPD (p < 0.05). Average ultrafiltration rate was 1.28 +/- 0.1 l/day during HD and 1.30 +/- 0.2 l/day during CAPD (p = NS). Mean Kt/V during HD was 1.24 +/- 0.1; whereas, mean weekly Kt/V during CAPD was 1.81 +/- 0.2. There were no significant differences in hematocrit or usage of recombinant human erythropoietin (rHuEPo) between the two treatment modalities. However, the weekly dose of rHuEpo was higher during HD than during CAPD (p < 0.05). Mean body weight was significantly higher (p < 0.01) and serum albumin was lower (p < 0.05) during CAPD than during HD in the same group of patients. We conclude that hypertension appears to be controlled better by HD than by CAPD in ESRD patients. The gain in body weight observed with CAPD treatment may reflect an increase in total body fluid volume which may partly explain why hypertension is less adequately controlled during CAPD than during HD treatment.