Search

Background and Objective The downward directed exit of the swan neck catheter may decrease the risk of exit-site infection (ESI). The percentage of migrations of the swan neck catheter seems to be less than the conventional Tenckhoff catheter and the swan neck catheter is more expensive and cannot be manipulated by guidewire technique if tip migration occurs. In this study, the conventional Tenckhoff catheter was used. The straight tunnel was converted to an arcuate one using the triple incision method, resulting in a downward directed exit. The arcuate tunnel was created by passing the catheter through an additional incision located between the paramedian incision and the exit site. We compared the infective and mechanical complications of the Tenckhoff catheter with a downward exit, implanted using the triple incision method, with the swan neck catheter. Patients and Methods 101 new peritoneal dialysis patients were prospectively randomized to receive either the Tenckhoff catheter with a downward exit, implanted using the triple incision method, or the swan neck catheter. Each patient was followed up for 24 months. 50 patients were in the triple incision method group (TIMG) and 51 were in the swan neck catheter group (SNCG). Results Over a mean period of 18.9 ± 8.0 months of follow-up, ESI occurred in 35 patients (70%) in TIMG and 37 patients (72.5%) in SNCG ( p = 0.83). The ESI rates were 0.71 and 1.0 episodes/catheter-year in TIMG and SNCG respectively ( p = 0.21). The peritonitis rates were similar in the 2 groups (0.64 episodes/year in TIMG and 0.68 episodes/year in SNCG, p = 0.47). More patients in TIMG had tip migration [15 patients (30%) in TIMG vs 10 patients (19.6%) in SNCG] but the difference was not statistically significant. Repositioning of the catheter by guidewire manipulation was successful in patients in TIMG but not in SNCG. Overall catheter survival at 12 and 24 months was 95% and 83% in TIMG and 93% and 79% in SNCG respectively ( p = 0.72). Conclusion By using the conventional Tenckhoff catheter with a downward exit created using the triple incision method, high catheter survival rates with infective and mechanical complication rates similar to those of the swan neck catheter can be achieved. The triple incision method has the additional advantages of lower cost and the catheter can be manipulated by guidewire technique if tip migration occurs.

Objective We studied the effectiveness of a screening program for peripheral vascular disease (PVD) carried out by trained renal nurses in patients with and without diabetes on continuous ambulatory peritoneal dialysis (CAPD). Patients and Methods We recruited 30 stable diabetic and 30 stable non diabetic CAPD patients into this cross-sectional study. Trained renal nurses measured the patients’ ankle-to-brachial systolic pressure index (ABI) using a Doppler ultrasound machine and their foot vibration perception (VPT) using a biothesiometer, and administered a questionnaire on foot symptoms. An ABI < 1.0 was regarded as abnormal and suggestive of the presence of PVD. An ABI < 0.7 or > 1.3 was regarded as severely abnormal. Findings for VPT were classified as normal or abnormal. Patients were then followed for 1 year for any overt development of clinical PVD, leg complications, and other vascular complications and for clinical outcome. Results The mean age of the patients was 63 ± 9 years, and the ratio of men to women was 1:1.3. An abnormal ABI was seen in 22 patients (37%). The questionnaire detected clinical PVD symptoms in 3 patients. Abnormal ABI and VPT findings were more frequent in diabetic patients. After 12 months of follow-up, patients with an abnormal ABI (and particularly those with a severely abnormal ABI) were more likely to develop leg complications and any type of cardiovascular disease than were patients with a normal ABI. Foot vibration perception had no predictive value on subsequent development of leg complications. When risk factors including age, ABI, and VPT were analyzed by logistic regression, only ABI was a significant independent predictor of subsequent lower-limb vascular complications [odds ratio (OR): 21.0; 95% confidence interval (CI): 2.35 to 187.0; p = 0.00064]. The OR for moderately abnormal ABI was 13.0 (95% CI: 1.015 to 166.3); for severely abnormal ABI, it was 27.4 (95% CI: 2.35 to 187.0, p = 0.0045). Conclusions Measurement of ABI by Doppler ultrasound is a useful and effective screening test for PVD in CAPD patients. In this study, VPT was not shown to be predicative of future leg complications, indicating that peripheral neuropathy plays a less important role in the development of such complications. Our results proved that trained renal nurses can play an active role in detecting foot problems in renal patients by ABI measurement.

Objective We undertook to study the attitudes toward dialysis of patients approaching end-stage renal failure and to analyze those attitudes from a cultural perspective. Setting The study was performed in the pre-dialysis clinic of a tertiary referral renal center. Patients All patients of Chinese ethnic origin seen in the pre-dialysis clinic from 1995 to 2000 for assessment of dialysis therapy were included. Method We performed a retrospective analysis of patient records with regard to attitudes of the patients toward dialysis, reasons for those attitudes, and factors that could lead to a subsequent change in attitude. Results We assessed 462 patients over the 6-year period. Their mean age was 65.5 ± 13.3 years, and 43.9% of the patients had diabetes. Peritoneal dialysis (PD) was offered to 74% of the patients, and hemodialysis (HD) to 3.9%. Among the patients offered PD, only 44% accepted dialysis. After counselling, 54% of the patients who originally declined PD ultimately accepted it. The major reasons for refusing PD were the ideas of “having lived long enough” and “lack of family support.” Most other reasons could be overcome by counselling. Only a minority of patients demanded hemodialysis. Conclusions Declining an offer of dialysis was common. Counselling helped patients to accept PD. Certain cultural elements that hindered acceptance of dialysis were involved in the ideas of “having lived long enough” and “lack of family support.” Those cultural elements should be tackled more specifically during counselling.

Objective To investigate an outbreak of peritonitis in intermittent peritoneal dialysis (IPD) patients. Design An outbreak investigation was performed to identify the etiology of the polymicrobial outbreak, and a retrospective case-control study was conducted to assess the risk factors for development of peritonitis. Setting Renal dialysis center. Patients Ten episodes of peritonitis occurred in 8 of 61 patients over a 6-month period in which 669 IPD procedures were analyzed. Interventions Field visit to renal dialysis center to examine the entire IPD procedure, inspect the hospital environment, and perform air bacterial count. Main Outcome Measures The environmental factors and risk factors contributing to the polymicrobial peritonitis outbreak in IPD patients. The incidence of IPD peritonitis was determined before and after interventions. Results The causative organisms included Acinetobacter baumanii ( 6 ), Stenotrophomonas maltophilia ( 2 ), Pseudomonas aeruginosa ( 1 ), Candida albicans ( 1 ), C. tropicalis ( 1 ), Enterococcus ( 3 ), and Enterobacteriaceae ( 2 ). Four episodes of peritonitis involved infection by more than one organism. Air sampling of the environment detected a median of 110 colony forming units of bacteria per cubic meter of air, 10% of which were found to be Acinetobacter baumanii. The source of this polymicrobial outbreak was attributed to the bamboo scaffolding structure covering the external wall of the hospital during renovation. A retrospective case-control study indicated that the absence of the flush-before-fill step was a risk factor for development of peritonitis. Conclusion In addition to invasive aspergillosis in transplant or oncology patients, Acinetobacter peritonitis in dialysis patients should be considered another microbial cause of outbreak associated with hospital renovation.

Continuous ambulatory peritoneal dialysis (CAPD) is the prevailing mode of renal replacement therapy in Hong Kong and the routine practice is three 2 L daily exchanges with four exchanges reserved for patients with ultrafiltration problems or clinically inadequate dialysis. In our hospital, Tung Wah Hospital, adequacy of dialysis assessment by urea kinetics was conducted after 1993 and adjustment of dialysis regime according to Kt/V was made only after 1995. This study represented the survival data of CAPD patients in our center before the urea kinetics era. From 1983 to 1994, we have accepted 569 patients into our CAPD program with a mean age ±SD of 47.8 ±15.4 and incidence of diabetes of 17.9%. The overall patient survival rates were 92%, 56% and 26% at 1, 5 and 10 years respectively. The corresponding technique survival rates were 97%, 86% and 60%. A cross-sectional analysis of the CAPD population from 1993 to 1994 showed that only 5% of patients were on four 2 L exchanges and the mean Kt/V was 1.76 ±0.35 and creatinine clearance 58.1 ±23.2 L/week/1.73 m2. The patient and technique survival rates were comparable to western centers with a higher mean Kt/V and creatinine clearance. Our data showed that favorable clinical outcome can be achieved with three 2 L daily exchange regime in Chinese patients. This indicates different Kt/V standards may exist for different racial populations.

A prospective randomized study of the prevention of candida peritonitis (CP) in continuous ambulatory peritoneal dialysis patients using oral nystatin given concomitantly with antibiotic therapy was carried out for 2 years. Patients were randomized into two groups. Nystatin tablets 500,000 units four times a day were given to group 1 but not group 2 patients whenever antibiotics were prescribed. There were 199 patients at risk (mean follow-up, 18.0 months) in group 1 and 198 patients at risk (mean follow-up, 16.6 months) in group 2. The peritonitis and antibiotic prescription rates were comparable between the two groups. There were four episodes of CP in four patients in group 1 and 12 episodes in 11 patients in group 2. The probability of CP-free survival at 2 years was higher in group 1 compared with group 2 (0.974 v 0.915; P < 0.05). However, only three (75%) CP episodes in group 1 and six (50%) in group 2 were considered "antibiotics related." The incidence of antibiotics-related CP was 1.39 and 3.19 per 100 peritonitis episodes and 0.66 and 1.43 per 100 antibiotic prescriptions in groups 1 and 2, respectively (P = NS). We conclude that oral nystatin prophylaxis with each antibiotic prescription reduced the rate of CP in patients on continuous ambulatory peritoneal dialysis irrespective of its apparent temporal relationship to antibiotic prescription.

Our objectives were to study long-term patient survival and dialysis adequacy of continuous ambulatory peritoneal dialysis (CAPD) patients treated with a standard regime of three 2-L daily exchanges. It was a retrospective analysis of patient survival and cross-sectional analysis of adequacy of dialysis. The setting was a dialysis unit in a tertiary referral center of a teaching hospital. All patients (n = 507) accepted into the CAPD program from 1983 to June 1994, were analyzed for survival. Adequacy of dialysis was analyzed in all existing patients in 1993 to 1994. The overall patient survival was 93%, 71%, and 57% at one, three, and five years, respectively. The three-year survival rate was 40% for diabetics and 78% for nondiabetics. It was 86%, 85%, 64%, and 43% for patients aged

Objective To compare the clinical outcome and cost-effectiveness of three techniques for continuous ambulatory peritoneal dialysis (CAPD): the conventional spike technique (C), the O-set (0), and UVXD (U, ultraviolet irradiation connection box). Design A randomized and prospective comparison of three CAPD techniques. Setting A tertiary referral and a satellite dialysis center.. Patients: One hundred patients with end-stage renal failure between 10 and 70 years of age, with good handeye coordination and not anticipated to receive a living related transplant within 6 months. Interventions Patients were randomized by referral to a table of random numbers to perform one of the three CAPD techniques. Main Outcome Measures Training time, details of peritonitis and exit-site infection (ESI) including the costs of antibiotic treatment, outpatient visits, hospital stays, technique, and patient survival were analyzed after a minimum follow-up period of one year. Results There were 38, 31, and 31 patients in groups C, 0, and U, respectively, and the total observation periods were 838,802, and 745 patient-months, respectively. The peritonitis rates for C, 0, and U were 21.5, 30.8, and 29.8 patient-months/episode, respectively. The corresponding ESI rates were 16.4,14.9, and 24 patient-months/ episode, respectively. When the time from the commencement of CAPD to the first infection was expressed using the Kaplan-Meier life table analysis, 39.5%, 67.7%, and 61.3% of patients in Groups C, 0, and U were free from peritonitis at one year (p = 0.088). The corresponding figures for ESI were 52.6%, 48.4%, and 61.3% (p = 0.35). There was no significant difference in technique survival in the three treatment groups. An analysis of the costs related to the use of antibiotics, outpatient visits, and hospital stays necessary for the treatment of peritonitis and ESI and those related to training time, additional equipment, and consumables required for the three CAPD techniques showed that, overall, the cost in 0 was the lowest, followed by U and C (U.S. $158, $170, and $179 per patient-month, respectively). Conclusion It was concluded that the O-set is a more cost-effective CAPD technique than UVXD, while both are more cost-effective than the conventional spike technique.

Thalassemia is a common genetic disorder among the South Chinese. To see if thalassemia would adversely affect the erythrocyte response to recombinant human erythropoietin (rHuEPO, Epogen) in dialysis patients, the response to rHuEPO in 4 dialysis patients with thalassemic traits (thal-t) was compared with that of 4 control patients who were matched for age, sex, mode of dialysis and baseline hemoglobin levels over a 6-month period. Patients with thal-t showed a reduced erythrocyte response to rHuEPO compared to control dialysis patients as reflected by a reduced reticulocyte index, a slower rise in hemoglobin or hematocrit levels, requirement of a higher cumulated dose of rHuEPO to achieve a target hemoglobin of 10 g/dl and a higher maintenance dose of rHuEPO. A dialysis patient with hemoglobin H disease (HbHD) was also studied. He failed to respond to rHuEPO despite that the dose was increased to 250 U/kg/week. In contrast, his matched control dialysis patient, despite a lower baseline hemoglobin level (6.1 versus 8.8 g/dl), was able to reach a target hemoglobin level of 10 g/dl by 6 weeks and could be maintained at this level with 50 U/kg/week. The patient with HbHD had splenomegaly and a higher baseline serum erythropoietin level, reticulocyte count, serum bilirubin, serum ferritin and serum iron saturation than control patients and patients with thal-t. It was concluded that thal-t reduces the erythrocyte response to rHuEPO in dialysis patients and that in the presence of active hemolysis and enhanced endogenous erythropoietin secretion, dialysis patients with HbHD are resistant to treatment with rHuEPO.

The present study compared oral versus Intraperitoneal (ip) ciprofioxacin (ciproxin) as primary treatment of bacterial peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD) In a randomized, prospective trial. A total of 54 episodes In 46 patients were recruited for study. After excluding nonbacterial episodes and those not treated according to protocol, 48 episodes evenly divided between the two treatment arms were eligible for analysis. The primary cure rate was 41.7% and 66.7%, respectively, In the oral and Ip treatment group. Half of those who tailed or relapsed were due to Infection with resistant, mostly grampositive bacteria, which accounted for 79% of culture-positive episodes. Of the gram-positive Isolates 42.3% were either resistant or Intermediately susceptible to ciproxin compared to 16.7% of gram-negative Isolates. The high level of bacterial resistance to ciproxin and treatment failure rate were related to the previous exposure to fluoroquinolones. Inadequate trough peritoneal drug levels also accounted for the failures in the Ip but not the oral treatment group. We conclude that oral ciproxin is ineffective as a primary treatment of CAPD peritonitis in patients previously exposed to fluoroquinolones and that when administered Ip, a dose of 50 mg/L Instead of 25 mg/L of ciproxin should be used as maintenance In order to achieve adequate trough peritoneal drug levels.

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.

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.

Objective To examine the natural history of Pseudomonas aeruginosa (PSA) exit-site infections (ESI) in patients treated with antibiotics with or without surgical interventions. Design Retrospective record review from May 1994 to April 1997. Setting A single dialysis unit in a district hospital. Patients The review included 353 patients who had undergone continuous ambulatory peritoneal dialysis (CAPD). Outcome Measures The prevalence and etiology of ESI, the treatment regimen for PSA ESI, and the outcome of treatment. Results The prevalence of ESI was 55%. A total of 131 episodes (range 1 -5) of PSA ESI occurred in 78 (40.2%) of the 194 patients who experienced ESI. Among these 78 patients, 4 groups with different outcomes were identified.ln group 1,35 patients (44.9%) were treated successfully with antibiotic therapy alone. Among these 35 patients, 4 developed PSA peritonitis at a mean of 5 months (range 2 -10 mth) after apparent clinical resolution of PSA ESI. Two of the 4 patients switched to long-term hemodialysis (HD) because of peritoneal failure. In group II, 8 patients (10.3%) responded to a combination of antibiotics and shaving of the external cuff. In group III, 21 patients (26.9%) with recurrent ESI underwent elective Tenckhoff catheter removal and reinsertion. One of the 21 patients had relapse of PSA ESI 14 months after the operation. In group IV, 14 patients (17.9%) had recurrent PSA ESI that failed to respond to multiple courses of antibiotics and shaving of the external cuff. Consent for Tenckhoff catheter removal was not obtained and 4 of these 14 patients subsequently developed PSA peritonitis. One of the 4 patients changed to permanent HD due to peritoneal failure. Conclusions Considering the increased risk and the poor outcome of PSA peritonitis in patients with persistent PSA ESI, early Tenckhoff catheter removal is recommended if the patient fails to respond to antibiotics with or without externalization of the external cuff.

Cefazolin plus netilmicin versus cefazolin plus ceftazidime for treating CAPD peritonitis: Effect on residual renal function. Background The International Society for Peritoneal Dialysis (ISPD) treatment guidelines for continuous ambulatory peritoneal dialysis (CAPD) peritonitis 2000 recommended the use of cefazolin plus ceftazidime as the initial empirical therapy in patients with residual renal function (RRF). However, this treatment regimen has not been compared with the conventional regimen of cefazolin plus netilmicin in prospective, randomized controlled trials. Methods Stable CAPD patients who developed clinical evidence of peritonitis were randomized to receive intraperitoneal (i.p.) cefazolin plus netilmicin or cefazolin plus ceftazidime once daily in the long dwell for 14 days. For patients with RRF (>1 mL/minute) before entry into the study (N = 50), RRF and 24-hour urine volume were measured at days 1, 14, and 42 after commencement of i.p. antibiotic treatment. Results One hundred and two patients were recruited into the study. The primary cure rates of i.p. cefazolin plus netilmicin and cefazolin plus ceftazidime were 66.7% and 64.7%, respectively. The overall cure rate for the 2 treatment regimens was 82.3% for both. Seven patients (14%) from each treatment group required removal of the dialysis catheters due to treatment failure. Relapse of peritonitis occurred in 2 patients (4%) in both treatment groups. Thirty-six patients with RRF at baseline achieved primary cure of their peritonitis by the assigned antibiotics. In this subgroup of patients, their RRF and daily urine volume showed significant reduction at day 14 and returned to near baseline values at day 42. The degree of reduction in RRF and urine volume did not differ significantly between the patients treated with cefazolin plus netilmicin and cefazolin plus ceftazidime. Conclusion Intraperitoneal cefazolin plus netilmicin and cefazolin plus ceftazidime have similar efficacy as empirical treatment for CAPD peritonitis. In CAPD patients with RRF, significant but reversible reduction in RRF and 24-hour urine volume could occur after an episode of peritonitis, despite successful treatment by i.p. antibiotics. The effect of i.p. cefazolin plus netilmicin, or i.p. cefazolin plus ceftazidime on RRF in CAPD patients with peritonitis does not appear to be different. Our findings do not support the routine use of cefazolin and ceftazidime as the empirical treatment for CAPD peritonitis.