Search

Background Starting dialysis is an important life event. The prevalence and evolution of psychological symptoms at commencement of long-term dialysis is unclear. We examined the prevalence of and risk factors for depression and anxiety, and the quality of life (QOL) of incident peritoneal dialysis (PD) patients, and also the change of these parameters in the first year of PD in relation to clinical outcomes under the PD-first policy. Methods All patients commencing long-term PD from March 2011 to April 2015 were asked to complete the Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life-BREF and the Kidney Disease Quality of Life Instrument Short Form questionnaire. Patient demographics and the incidence of hospitalization, peritonitis, exit-site infection, and all-cause mortality were studied. The HADS was repeated after 9 – 12 months. Results A high depression score was present in 39.6% of 191 patients at commencement of PD and was more common in diabetes patients (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.09 – 3.81). A high anxiety score was present in 23.6%, and the risk factors included younger age (OR 0.96 per year, 95% CI 0.94 – 0.99) and diabetes (OR 2.59, 95% CI 1.20 – 5.57). Both high depression and anxiety scores were associated with an inferior QOL, overall and across most QOL domains. Depression and anxiety symptoms did not change in the first year of PD and were not associated with short-term clinical outcomes. Conclusions High depression and anxiety scores were prevalent in incident PD patients where PD-first policy is adopted and were associated with inferior QOL. There was no improvement after 1 year of PD. The impact of strategic interventions targeting patient groups at risk such as those with diabetes or of younger age warrants further investigation.

Background Nonadherence to hand hygiene and aseptic regimen, dialysis environment guidelines, and catheter and exit-site care guidelines are risk factors of peritonitis. However, little is known about the psychosocial factors that account for the nonadherent behavior of patients undergoing peritoneal dialysis (PD). Applying the health belief model, this study seeks to enhance the understanding of psychosocial influences on patients’ nonadherent behavior to the 3 regimen components. Methods Through referrals by 7 Hong Kong renal patient support groups, we surveyed patients undergoing PD treatment. Results A total of 244 Hong Kong PD patients completed the questionnaires. About 90% of the patients reported no deviation from catheter and exit-site care guidelines. However, the nonadherence rates of hand hygiene and aseptic regimen and of dialysis environment guidelines were 30.3% and 23%, respectively. Longer time on PD treatment and lower family monthly income were associated with nonadherence to dialysis environment guidelines. Employed patients tended toward nonadherence to catheter and exit-site care guidelines twice as much as unemployed patients. Of the 5 health beliefs, perceived benefits, perceived barriers, and efficacy belief were significant predictors of nonadherence to the 3 regimen components. Conclusions The findings of this study inform the design of intervention to change patients’ behavior in regimen nonadherence for preventing peritonitis. To identify the target audience for adherence intervention based on the 3 regimen components, the results suggest dividing patients into subgroups according to their sociodemographic background. To foster behavioral change, health communicators should address patients’ health beliefs when formulating intervention strategies.

Background The impact of a low-glucose peritoneal dialysis (PD) regimen on biomarkers of peritoneal inflammation, fibrosis and membrane integrity remains to be investigated. Methods In a randomized, prospective study, 80 incident PD patients received either a low-glucose regimen comprising Physioneal (P), Extraneal (E) and Nutrineal (N) (Baxter Healthcare Corporation, Deerfield, IL, USA) (PEN group), or Dianeal (control group) for 12 months, after which both groups continued with Dianeal dialysis for 6 months. Serum and dialysate levels of vascular endothelial growth factor (VEGF), decorin, hepatocyte growth factor (HGF), interleukin-6 (IL-6), macrophage migration inhibitory factor (MIF), hyaluronan (HA), adiponectin, solubleintracellular adhesion molecule (s-ICAM), vascular cell adhesion molecule-1 (VCAM-1) and P-selectin, and dialysate cancer antigen 125 (CA125), were measured after 12 and 18 months. This paper focuses on results after 12 months, when patients in the PEN group changed to glucose-based PD fluid (PDF). Results At the end of 12 months, effluent dialysate levels of CA125, decorin, HGF, IL-6, adiponectin and adhesion molecules were significantly higher in the PEN group compared to controls, but all decreased after patients switched to glucose-based PDF. Macrophage migration inhibitory factor level was lower in the PEN group but increased after changing to glucose-based PDF and was similar to controls at 18 months. Serum adiponectin level was higher in the PEN group at 12 months, but was similar in the 2 groups at 18 months. Body weight, residual renal function, ultrafiltration volume and total Kt/V did not differ between both groups. Dialysate-to-plasma creatinine ratio at 4 h was higher in the PEN group at 12 months and remained so after switching to glucose-based PDF. Conclusion Changes in the biomarkers suggest that the PEN PD regimen may be associated with better preservation of peritoneal membrane integrity and reduced systemic vascular endothelial injury.

Objectives The risk of development of enteric peritonitis in Chinese peritoneal dialysis (PD) patients with colonic diverticulosis is not known. There have been no reports on whether colonic diverticulosis may affect peritonitis outcomes. The objectives of this study were to examine whether colonic diverticulosis is a risk factor for the development of enteric peritonitis and to study its influence on the outcome of enteric peritonitis. Patients and Methods All continuous ambulatory PD patients that had barium enema and colonoscopic examinations performed between January 1994 and January 2006 were included. They were divided into 2 groups: patients with diverticulosis and patients without diverticulosis. Their demographic and clinical characteristics, colonic examination findings, and peritonitis data were compared and analyzed. Results 104 Chinese patients received 110 colonoscopies and 51 barium enema examinations. 25 patients (24.0%) had colonic diverticulosis. Patients with diverticulosis were older (65.4 ± 14.7 vs 58.4 ± 14.0 years, p = 0.033). The most common site of involvement of diverticulosis was the ascending colon (56%). 128 episodes of enteric peritonitis were recorded in 49 patients. Compared with patients without enteric peritonitis, more patients in the enteric peritonitis group had diverticulosis (38.8% vs 10.9%, p = 0.001) and diverticulosis most often involved the ascending colon (20.4% vs 7.3%, p = 0.082). Multivariate logistic regression analysis showed that the presence of diverticulosis (hazard ratio 5.17, 95% confidence interval 1.86 – 14.40; p = 0.002) and diverticulosis involving the ascending colon (hazard ratio 6.89, 95% confidence interval 1.43 – 33.32, p = 0.016) were independent risk factors for the development of enteric peritonitis. Enteric peritonitis in patients with diverticulosis had a higher but nonsignificant treatment failure rate (26.9% vs 18.4%, p = 0.282). Conclusion In this selected cohort of PD patients with indications of colonic examinations, diverticulosis, especially involving the ascending colon, may be a risk factor for the development of enteric peritonitis. Colonic diverticulosis does not appear to affect the outcome of enteric peritonitis. Further studies are warranted to determine ways to prevent enteric peritonitis in PD patients with diverticulosis.

Background Peritonitis is the major complication in patients undergoing maintenance peritoneal dialysis (PD) and is associated with a significant risk of mortality. Previously, we have shown that patients treated for peritonitis and having prolonged elevation of C-reactive protein (CRP) are associated with higher mortality. The underlying cause for the chronic systemic inflammation remains unknown. We studied serum procalcitonin (PCT), which has been reported as an accurate marker for infection and inflammation, with respect to being a diagnostic and prognostic indicator of persistent chronic inflammation after peritonitis in patients with PD-related peritonitis. Methods We conducted a prospective study on PD patients that developed PD-related peritonitis. Blood samples obtained at routine check-up before the onset of peritonitis were taken as baseline (D0). When patients developed PD-related peritonitis, serial blood samples were obtained on day 1 (D1), day 7 (D7), and day 42 (D42) for PCT, CRP, and other inflammatory markers. Patients were followed up for at least 2 years, during which outcomes of peritonitis and causes of death were recorded. Serum levels of CRP and PCT at day 42 were analyzed to assess for long-term prognosis. Results 35 patients [female 42.9%; mean age 63.8 ± 13.1 years; 12 (34.3%) diabetics] were recruited. The onset of peritonitis was 3.61 ± 3.56 years after PD initiation and median residual renal function at that time was 1.06 (range 0 – 6.1) mL/min. Median total white cell counts in PD effluent at days 1, 3, 7, and 42 were 3505/mm3 (range 377 – 20500/mm3), 297 (8 – 5880)/mm3, 34 (0 – 5290)/mm3, and 10 (0 – 115)/mm3, respectively. Twelve (34.3%) and 14 (40%) PD effluents grew gram-positive and gram-negative micro-organisms respectively; others were culture negative. Median PCT was increased significantly at day 1 [2.00 (0.12 – 58.7) ng/mL, p < 0.001], day 7 [0.76 (0.13 – 15.25) ng/mL, p < 0.001], and day 42 [0.30 (0.13 – 0.79) ng/mL, p = 0.005] compared to baseline [0.20 (0.09 – 0.69) ng/mL]. Seven of 35 patients had false-negative results on day 1 (range 0.12 – 0.46) when PCT 3.0 mg/L) were associated with poorer long-term survival ( p = 0.04) but elevated PCT at the 25th, 50th, or 75th percentiles failed to provide prognostic value. Conclusions PD patients after peritonitis may be associated with prolonged systemic inflammation. CRP was a better serum marker for monitoring inflammatory status and predicting long-term prognosis in our study. Although serum PCT is elevated in some patients at the time of peritonitis, its value in making a diagnosis and predicting long-term prognosis remains doubtful.

ObjectiveWe compared outcomes for catheters with different configurations: conventional straight, swan-neck straight tip, and swan-neck curled tip.DesignThe study was conducted as a prospective randomized controlled trial in the continuous ambulatory peritoneal dialysis (CAPD) unit of a university center.Patients and MethodsWe randomized 93 new regular CAPD patients without prior peritoneal dialysis (PD) catheter insertion to receive a conventional straight, double-cuffed catheter (CS), a swan-neck straight catheter (SNC), or a swan-neck curled tip catheter (SNC) in 2:1:1 ratio.ResultsThe exit-site infection (ESI) rate was slightly lower with swan-neck catheters as compared with straight catheters, but the difference was not statistically significant. The peritonitis rate and overall catheter survival were similar. In Staphylococcus aureus nasal non carriers as compared with carriers, ESI-free catheter survival was significantly better with swan-neck catheters ( p = 0.0302 and p = 0.82 respectively). As compared with SC catheters, SNC catheters had a significantly higher migration rate ( p = 0.022).ConclusionsSwan-neck catheters were associated with a slightly better ESI rate, but SNC catheters are not routinely recommended because of a high migration rate. The SNS catheter is therefore recommended as the first-line catheter of choice, particularly in populations with a low rate of S. aureus nasal carriage.

Objective The ISPD 2005 guidelines for peritonitis recommend antibiotic prophylaxis for patients undergoing colonoscopy with polypectomy while on continuous ambulatory peritoneal dialysis (CAPD) but there is little literature to support this recommendation. This study aimed to look into the risks and outcomes of peritonitis after colonoscopy in CAPD patients. Patients and Methods All records of flexible colonoscopy performed on our CAPD patients from January 1994 to January 2006 were retrieved. Demographic and clinical data, use of antibiotics before colonoscopy, endoscopic findings, procedure performed, and peritonitis data were analyzed. Results 77 CAPD patients underwent 97 colonoscopies. No peritonitis developed in the 18 cases where antibiotics were given before colonoscopy. Among those without antibiotic prophylaxis, 4 episodes of peritonitis occurred within 24 hours after the procedure and 1 occurred 5 days later. All responded to intraperitoneal antibiotics. Colonic biopsy and polypectomy were not associated with more peritonitis (2 in 41 with biopsy vs 3 in 38 without biopsy, p = 0.67; 1 in 30 with polypectomy vs 4 in 49 without polypectomy, p = 0.64). Conclusion The risk of peritonitis after colonoscopy without antibiotic prophylaxis was 6.3%. All peritonitis episodes responded to intraperitoneal antibiotics. Colonic biopsy or polypectomy did not appear to increase the risk of peritonitis. Although statistically not significant when compared with patients without antibiotic prophylaxis, we observed no peritonitis after colonoscopy in patients that were given antibiotics for prophylactic purposes or for other reasons. The efficacy of prophylactic antibiotics would be better defined by large randomized trials.

To determine the risk factors and outcomes of peritonitis caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in continuous ambulatory peritoneal dialysis (CAPD).Episodes of E. coli CAPD peritonitis in our unit from October 1994 to August 2003 were reviewed. Demographic data, underlying medical conditions, recent use of gastric acid inhibitors (including H2 antagonist and proton pump inhibitor), recent antibiotic therapy, antibiotic regimen for peritonitis episodes, sensitivity test results of the E. coli isolated, and clinical outcomes were examined.Over a 10-year study period, 88 episodes of E. coli peritonitis were recorded; 11 of the 88 cases were caused by ESBL-producing E. coli. Recent use of cephalosporins and gastric acid inhibitor were associated with the development of ESBL-producing E. coil peritonitis. Compared with non-ESBL-producing E. coli peritonitis, more cases in the ESBL-producing E. coli group developed treatment failure (45.5% vs 13.0%, p = 0.02) and died of sepsis (27.3% vs 3.9%, p = 0.02). Peritoneal failure rate was higher in the ESBL-producing E. coli group, although the difference was not statistically significant (18.2% vs 3.9%, p = 0.12).Peritonitis caused by ESBL-producing E. coli is associated with worse clinical outcomes. The use of cephalosporins and gastric acid inhibitors may contribute to its development. Further studies are warranted to investigate and determine the predisposing factors for ESBL-producing E. coli peritonitis.

Background Patients on continuous ambulatory peritoneal dialysis (CAPD) with Pseudomonas aeruginosa exit-site infection (ESI) refractory to antibiotic treatment often require replacement of their peritoneal dialysis catheter (PDC). The optimal interval between removal and reinsertion of the PDC is not known. There are relatively few data on the feasibility of simultaneous removal and reinsertion of dialysis catheters for the treatment of P. aeruginosa ESI. Methods We retrospectively reviewed the short- and long-term outcomes of all CAPD patients who had undergone simultaneous removal and reinsertion of their PDC for the treatment of refractory P. aeruginosa ESI in our hospital between January 1994 and December 2003. During the operation, the old catheter was removed first and a new catheter was inserted into the opposite side of the abdomen. All patients received 7 days of antibiotic therapy postoperatively. CAPD was resumed after 2 weeks of intermittent peritoneal dialysis. Results Over a 10-year period, 37 CAPD patients underwent the operation. Mean age of the patients was 59.5 ± 10.9 years. The interval between the diagnosis of ESI and the operation was 16.7 ± 6.9 weeks. The patients received 7.6 ± 2.5 weeks of antibiotic treatment before the procedure. Early postoperative complications were uncommon. None of the patients developed ESI within 4 weeks after the operation. At 1 year after the operation, 3 patients (8%) had developed recurrence of P. aeruginosa ESI 24 – 40 weeks postoperatively. Peritonitis due to P. aeruginosa was not observed. Conclusions We conclude that simultaneous removal and reinsertion of the PDC is feasible in eradicating refractory ESI due to P. aeruginosa. This procedure alleviates the need for temporary hemodialysis and allows continuation of peritoneal dialysis.