Continuous Ambulatory Peritoneal Dialysis Catheter Research Articles

Prognosis of Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD) for Over 10 Years

Patients who have been on continuous ambulatory peritoneal dialysis (CAPD) for over 10 years are known to have a risk of developing encapsulating peritoneal sclerosis (EPS). However, the prognosis of patients on CAPD for over 10 years remains unclear. To better understand the efficacy of a variety of treatments for EPS, we retrospectively reviewed 25 patients who started CAPD at Toranomon Hospital from 1981 to 1997 and continued it for longer than 10 years. The CAPD catheter was removed without peritoneal lavage in the initial 3 patients and they developed massive ascites. They all died of infection without resolution of the ascites. Accordingly, in the remaining 13 patients who did not undergo kidney transplantation, peritoneal lavage therapy was performed for 12 months before removing the CAPD catheter. As a result, 4 patients did not develop EPS. However, 9 patients had EPS with ascites, among whom 4 died of EPS-related diseases and 5 are alive. Five patients underwent cadaveric donor kidney transplantation. At the time of surgery, the CAPD catheter was removed without peritoneal lavage; 1 patient suffered from massive ascites immediately, although this subsided within 3 months after kidney transplantation, and 4 patients remain free from EPS-related symptoms and are doing well. Kidney transplantation may be an option for preventing EPS. This study showed that improvement of the uremic state as well as treatment with immunosuppressants including corticosteroids may contribute to preventing EPS.

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS USING STRAIGHT TYPE VS COILED TYPE TENCKHOFF CATHETER IN END-STAGE RENAL DISEASE PATIENTS AT SARDJITO HOSPITAL

Objective: The purpose of this study was to compare straight type versus coiled type Tenckhoff catheter for continuous ambulatory peritoneal dialysis (CAPD) in end stage renal disease. Material & method: A prospective cohort study enrolled end-stage renal disease patients undergoing CAPD for renal replacement therapy in Urology and Nephrology Department, Sardjito Hospital from January to December 2007. Identity and type of Tenckhoff catheter were recorded. Patients were grouped into two groups who used straight type catheter and coiled type catheter for CAPD, then observed for post-operative complication. Statistical analysis was done using SPSS 14.0 with chi-square test. Results: There were 27 patients included in this study. The cause of end-stage renal disease was mostly DM and hypertension. The most common complication after operation was catheter obstruction (9 patients). Another complication was intraabdominal bleeding (1 patient), and catheter migration (1 patient). In patients with straight catheter (20 patients), there were 8 patients (40%) with complication. In patients with coiled catheter (7 patients), there were 3 patients (42%) with complication. There was no significant difference in complications between straight and coiled catheter groups (p = 0,895). Conclusion: The result of this study revealed that no significant difference in complication between straight and coiled catheter for CAPD in end-stage renal disease patients

Peritoneal Dialysis in Argentina. A Nationwide Study

Correspondence to: J. Lobo, Correa 2864, Buenos Aires, 1429 Argentina. jlobo@intramed.net.ar Received 11 September 2009; accepted 22 June 2010. Although most patients on dialysis are in the USA, Europe, and Japan, the highest rate of growth is expected to take place in the countries of Asia, Middle East, Latin America, and Africa (1). In Latin America, between the years 1992 and 2004 the prevalence of patients on renal replacement therapy (RRT) rose from 129 to 447 patients per million population (pmp) (2). Peritoneal dialysis (PD), like RRT in general, has spread widely around the world and its prevalence varies according to the different regions and countries (3–5). Some of the recent publications reporting its use in Latin American countries are listed in Table 1 (6–13). Argentina is a country in southern South America with a territory of 2791810 km2 (Figure 1). In 2007, its estimated population was 39356000 and its average population density was 14.1 inhabitants/km2 (14). That year, the Gross Domestic Product per capita was US$6050, life expectancy was 75 years, and 98.5% of children were enrolled in primary school (15). The National Health System (NHS) is covered by the Public Health System, the Social Securities, and the Private Health System. Through the Mandatory Medical Program, the NHS provides patients with a variety of essential services, such as hemodialysis (HD) and PD (16). In Argentina, the use of intermittent PD started in the 1960s. Toward the end of 1978, the first catheter for continuous ambulatory PD (CAPD) was implanted in a patient in Buenos Aires, with material produced locally. In 1980, Travenol materials became available, which reduced the rate of peritonitis from 1 episode every 4 months to 1 episode per year. In the late 1990s, PD became more widely known and had its main development (17). In spite of the rapid introduction of the double-bag system and the increased availability of cycling machines for automated PD (APD), the proportion of patients on PD compared to HD was still low, with a prevalence of only 5.5% at the end of the decade (18). Afterward, with the economic crisis in 2001, the cost of PD rose steeply and many patients had to be transferred to HD. At present, as will be discussed later, the use of PD is low. PD IN THE DEVELOPING WORLD

Laparoendoscopic Single-Site (LESS) nephrectomy in a patient undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD)

Purpose: To assess the feasibility, safety, and outcomes of transumbilical single port laparoscopic nephrectomy in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD) treatment. Materials and Methods: A patient was a 62-year-old woman who had been using CAPD for 4 months because of end-stage renal disease (ESRD) secondary to diabetic nephropathy. She was referred to the urology clinic, due to suffering from the left pyonephrosis and non-functioning kidney with a proximal ureteric stone. Then she underwent percutaneous nephrostomy to drain the pus. After this resolved, she underwent LESS nephrectomy. Medical records were reviewed, and laboratory values and outcomes were analyzed. Results: The procedure was successfully completed without conversion to conventional laparoscopic or open surgery. Operative time was 160 minutes. Moreover, the specimen can be easily and rapidly extracted through the TriPort without the use of an additional entrapment bag. Estimated blood loss was 200 mL and pain scale was 0-1, with no morphine requirements. On the same day of the operative procedure, a double-lumen hemodialysis (HD) catheter was introduced for postoperative HD. The patient underwent hemodialysis treatment via a subclavian catheter after the operation and she was discharged home on the sixth postoperative day with a functioning CAPD catheter, with no further problems. After 2 weeks, the patient switched from HD to CAPD without complications. Pathological analysis revealed chronic pyelonephritis. Postoperative hematocrit, blood urea nitrogen, and creatinine were 39.3%, 22 mg/dL, 2.3 mg/dL respectively. The scars receded into the umbilicus and were hardly visible. Conclusion: LESS nephrectomy is a feasible technique with advantages of less pain, shortened convalescence, improved cosmesis, and absence of wound complications. Int Braz J Urol. 2010; 36 (Video #9): 781_2 Available at: www.brazjurol.com.br/videos/november_december_2010/Permpongkosol _781_782video.htm Correspondence address: Dr. Sompol Permpongkosol Division of Urology Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University Rama 6 Road Bangkok, 10400, Thailand Email: sompolpermpong@gmail.com doi: 10.1590/S1677-55382010000600032

Advanced Laparoscopic Techniques Significantly Improve Function of Peritoneal Dialysis Catheters

Continuous ambulatory peritoneal dialysis (CAPD) catheters provide a preferred alternative to hemodialysis in a growing population with chronic kidney disease. However, CAPD catheters traditionally have been associated with a high rate of nonfunction with both open and laparoscopic procedures. New advanced laparoscopic techniques using rectus sheath tunneling and omentopexy have been reported to improve catheter function. This study retrospectively reports the Cleveland Clinic experience during the transition from basic to advanced laparoscopic techniques from June 2002 to July 2008. A total of 197 patients were identified: 68 who underwent insertion with basic techniques and 129 who received catheters with advanced techniques. Primary nonfunction, procedural complications, and overall nonfunction rate were analyzed using the most recent follow-up to June 2008. Primary nonfunction occurred in 25 of 68 (36.7%) patients in the basic group; this occurred in only 6 of 129 patients (4.6%) in the advanced group (p < 0.0001). The overall rate of complications including nonfunction from primary and secondary sources, peritoneal leak, peritonitis, port-site hernia, and bleeding occurred in 31 of 68 (45.6%) patients in the basic group and 21 of 129 (16.28%) patients in the advanced group (p < 0.0001). These data clearly show a significant improvement in CAPD catheter function using omentopexy and rectus sheath tunneling. These advanced laparoscopic techniques should become the preferred method of CAPD catheter insertion.

Acute peritonitis due to Corynebacterium ulcerans in a patient receiving continuous ambulatory peritoneal dialysis: a case report and literature review

A 55-year-old Japanese woman receiving continuous ambulatory peritoneal dialysis (CAPD) was admitted to our service with abdominal pain and cloudy peritoneal fluid. Laboratory data revealed a white blood cell count of 7.20 × 10(9 )cells/L, hemoglobin 9.8 g/dl, hematocrit 29.0%, platelet count 284 × 10(9 )cells/L, and C-reactive protein (CRP) 0.109 g/L. Peritoneal fluid white blood cell count of 2,000 cells/µl suggested acute peritonitis. An empiric trial of cefazolin and ceftazidime, subsequently switched to meropenem, vancomycin, minocycline, and amikacin, did not improve the patient's symptoms. The peritoneal fluid collected before initiation of antibiotic therapy grew Corynebacterium ulcerans. Ampicillin/sulbactam was started based on the culture and sensitivity data. On hospital day 8, the CAPD catheter was removed due to no clinical improvement and persistently increased levels of CRP to 0.0174 g/L. A 14-day course of ampicillin/sulbactam improved her clinical condition and laboratory data. Microbiological analysis revealed that C. ulcerans isolated from this patient did not produce diphtheria toxin. C. ulcerans was not isolated from her dog's oral and nasal cavities during a search for the route of her infection. We recommend that in patients with peritoneal dialysis, special attention should be paid to Corynebacterium peritonitis, especially due to C. ulcerans, which may produce diphtheria toxin, be resistant to multiple antibiotics, and frequently become recurrent.

Peritonitis Due to Candida rugosa: The First Case Report

Editor: A 31-year-old female patient who had been receiving continuous ambulatory per itoneal dialysis (CAPD) therapy for approximately 2 years because of end-stage renal disease of unknown cause presented with abdominal pain, nausea, vomiting, and cloudy dialysate for 3 days. She had no history of peritonitis. The exit site and tunnel of the CAPD catheter were found to be normal. White blood cell (WBC) count of the peritoneal fluid was 1200/mm 3 , with lymphocytes predominant. Gram stain of the peritoneal fluid did not show any microorganisms. After microbiological evaluation, she was empirically started on an antibiotic regimen consisting of cefazolin and amikacin intraperitoneally. Despite the empiric combined antibiotic treatment, the patient’s clinical status did not improve. Her peritoneal fluid WBC count continued to be 600 ‐ 800/mm 3 , with lymphocytes predominating. On the ninth day after her admission to the hospital, yeast growing in the peritoneal fluid culture was identified as Candida rugosa. For the strain of Candida rugosa isolated from the patient, the minimum inhibitory concentrations of amphotericin B, fluconazole, ketoconazole, and itraconazole were 0.5 μL/mL, 1.5 μL/mL, 0.032 μL/mL, and 2 μL/mL, respectively. The CAPD catheter was removed immediately and intravenous antifungal therapy with amphotericin B was started. She was switched to hemodialysis. Three weeks later, the patient’s clinical condition was entirely recovered. Intravenous amphotericin B was continued for 6 weeks and she was discharged without any problem. Candida non-albicans species have emerged over the past 15 years due to the widespread use of fluconazole and other well-tolerated antifungal agents and the increasing numbers of at-risk patients (1). Candida rugosa is a well-described cause of mastitis and other infections in dairy herds and it is an emerging fungal pathogen in humans, with frequency of isolation increasing from 0.03% to 0.4% between 1997 and 2003 in a large international repository of clinical isolates (2,3). Infections caused by Candida rugosa are frequently associated with burn wounds, surgical nystatin prophylaxis, catheters, and other intravenous devices, as in our patient (4‐7). In treating fungal CAPD-related peritonitis, immediate catheter removal is indicated because fungal peritonitis

Percutaneous continuous ambulatory peritoneal dialysis (CAPD) catheter insertion – a preferred option for developing countries

Continuous ambulatory peritoneal dialysis (CAPD) as a modality of renal replacement therapy in patients with chronic kidney disease stage 5 (CKD 5) has the advantage of being a home-based therapy and is a preferred option in patients with inadequate access to haemodialysis and transplantation facilities and in those infected with HIV and other blood-borne viruses. While open surgical CAPD catheter placement has been the conventional mainstay of access placement, percutaneous techniques are being increasingly used with similar success rates. We report our experience over the past two years with blind insertion of the swan neck percutaneous double-cuffed Tenckhoff CAPD catheter using a trocar. There was considerable decrease in hospital stay and surgical costs. There was only one major complication of injury to the jejunal mesenteric artery requiring emergency laparotomy in one patient. In three patients, drain of peritoneal fluid was inadequate, presumably due to omental wrapping around the in-dwelling catheter, and required surgical removal of the omentum.

Tenckhoff catheter obstruction without peritonitis caused by Curvularia species

Peritonitis remains the most common complication of peritoneal dialysis (PD). Staphylococci are responsible for the majority of all PD-related peritonitis episodes (Piraino B et al., Perit Dial Int 2005; 25: 107–31). While fungal peritonitis is relatively uncommon, Candida albicans accounts for the majority of fungal peritonitis episodes (Wang AY et al., Am J Kidney Dis 2000; 36: 1183–92). Fungal peritonitis caused by Curvularia species is extremely rare and has been reported in only a few cases (Pimentel JD et al., J Clin Microbiol 2005; 43: 4288–92; Ujhelyi MR et al., Rev Infect Dis 1990; 12: 621–7). Herein we report a case with continuous ambulatory peritoneal dialysis (CAPD) catheter obstruction caused by Curvularia species in the absence of any signs or symptoms of peritonitis.

Continuous ambulatory peritoneal dialysis catheter placement: Is omentectomy necessary?

Context:There are different methods of continuous ambulatory peritoneal dialysis (CAPD) catheter placement. Open surgical technique is a widely followed method. The complication rate following catheter placement varies and catheter blockage due to omental plugging is one of the main reasons.Aim:To analyze the need for routine omentectomy during CAPD catheter placement.Materials and Methods:This was a retrospective analysis of 58 CAPD catheter placements performed between July 2002 and June 2007. Tenckhoff double cuffed catheter was used in all. The postoperative complications were analyzed.Results:There were 44 males and 14 females. The mean age was 51 years ranging from 15 to 76 years. Of these, 40 (69%) patients underwent omentectomy (group A) and 18 (31%) did not (group B). Laparoscopic and open techniques were performed in 5 and 53 patients, respectively. Omentectomy was not performed in 13 patients with open technique and all the five in the laparoscopic group. One patient in group A developed hemoperitoneum which was treated conservatively. None from group A developed catheter blockage, whereas five (27.8%) from group B developed catheter blockage postoperatively. The median time interval between the primary procedure and development of catheter blockage was 45 days (ranged from 14 to 150 days).Conclusions:Omentectomy during CAPD catheter placement prevents catheter blockage and secondary interventions.

The Effect of an Anti-adhesion Agent in Continuous Ambulatory Peritoneal Dialysis (CAPD) Catheter Insertion Operation

Purpose: Continuous ambulatory peritoneal dialysis (CAPD) is an important method of performing renal replacement therapy in patients with chronic renal failure. A significant complication of CAPD is malfunction of the catheter because of catheter adhesion that leads to catheter malposition. So we evaluated the effect of an anti-adhesive agent called Guardix-Sol ⓡ . Methods: We prospectively evaluated the clinical results of 78 patients who had received CAPD catheter insertion from Sep. 2007 to May 2009. A test group of 34 patients used the anti-adhesion agent and a control group of 44 patients did not use it. All the procedures were standardized and performed by a single surgeon. Results: The patients consisted of 49 males and 29 females. The common reasons for CAPD insertion were diabetic nephropathy (47 patients) and hypertension (20 patients). Fifteen patients needed reposition operations during their postoperative course, which were done under spinal anesthesia. Out of 15 patients, 3 were from the test group (Guardix-Sol ⓡ group) and 12 from the control group (P=0.0526). All the repositioned patients had a malpositioned catheter because the greater omentum had adhered to the catheter, except for one patient in each group (P=0.0315). Conclusion: Using an anti-adhesive agent for CAPD insertion is an effective method to reduce the incidence of greater omental adhesion. So the rate of reoperation cases for catheter repositioning is decreased.

An Animal Study of a Newly Developed Skin‐Penetrating Pad and Covering Material for Catheters to Prevent Exit‐Site Infection in Continuous Ambulatory Peritoneal Dialysis

Because currently available peritoneal dialysis catheters are not sufficiently biocompatible with the skin and subcutaneous tissue at the site of penetration, exit-site infection due to pericatheter pocket formation caused by epidermal downgrowth over a long period of time has increasingly become a problem. We developed a new, biocompatible, segmented polyurethane porous material and devised a novel skin-penetrating pad, the form and material of which we optimized for application in peritoneal dialysis catheters. For the extent of tissue ingrowth into this porous material to be examined, test materials with different pore diameters were inserted into hollow silicone tubes and implanted in the subcutaneous tissue of a goat. Four weeks later, the tubes were extracted, and, after the extent of granulation tissue ingrowth was measured, histopathological evaluation was made. Our novel skin-penetrating pad has three disklike layers of the segmented polyurethane material with different pore sizes, into the center of which a polyurethane catheter is inserted. These pads were implanted in the skin of a goat and clinically observed over a 2-year period, after which they were extracted and histopathologically analyzed. In accordance with actual clinical procedures, a commercial CAPD catheter equipped with our skin-penetrating pad was left indwelling in a goat for 4 months, and the performance of the pad was evaluated after repeated periodic infusion and drainage of the dialysate in and out of the abdominal cavity. There was no inflammation of the ingrown tissue in the pores of the segmented polyurethane material as well as the surrounding tissue, which indicated favorable tissue biocompatibility. The extent of tissue ingrowth was greater as the pore size of the material was larger, and the tissue tended to be mature, mainly consisting of collagenous fibers. The skin-penetrating pad using the porous material, of which tissue ingrowth was thus optimized, tightly adhered to the goat skin throughout the 2-year experimental period without any special wound care such as cleansing or disinfection. The performance of the skin-penetrating pad was similarly favorable when attached to a commercial continuous ambulatory peritoneal dialysis catheter. The newly developed segmented polyurethane porous material had excellent tissue biocompatibility and tissue ingrowth. The skin-penetrating pad devised by using this porous material did not cause epidermal downgrowth, suggesting that it may be effective for the prevention of exit-site infection.

Relapsing Peritonitis Caused by Bordetella bronchiseptica in Continuous Ambulatory Peritoneal Dialysis Patient: A Case Report

Bordetella (B) bronchiseptica is a common veterinary pathogen, but has rarely been implicated in human infections. Most patients with B. bronchiseptica infections are compromised clinically such as in patients with a malignancy, AIDS, malnutrition, or chronic renal failure. We experienced a case of relapsing peritonitis caused by B. bronchiseptica associated with continuous ambulatory peritoneal dialysis (CAPD). A 56-yr-old male, treated with CAPD due to end stage renal disease (ESRD), was admitted with complaints of abdominal pain and a turbid peritoneal dialysate. The culture of peritoneal dialysate identified B. bronchiseptica. The patient was treated with a combination of intraperitoneal antibiotics. There were two further episodes of relapsing peritonitis, although the organism was sensitive to the used antibiotics. Finally, the indwelling CAPD catheter was removed and the patient was started on hemodialysis. This is the first report of a B. bronchiseptica human infection in the Korean literature.

THE RISK FACTORS AND OUTCOME OF FUNGAL PERITONITIS IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS PATIENTS

Aim: To determine the risk factors and outcome of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 7-year period. Patients and Methods: This retrospective study was conducted on 30 cases of fungal peritonitis in CAPD patients during a 7-year period (2000–2007). The diagnosis was based on elevated CAPD effluent count and isolation of fungi. Patients were evaluated for previous episode of bacterial peritonitis. Results: The incidence of fungal peritonitis was 16.2%. Age varied between 8 and 75 years, with a mean age of 57 years. Twenty-three were males (76.7%) and seven were females (23.3%). Seventeen patients (56.6%) had previous episodes of bacterial peritonitis that was treated with multiple antibiotics. The common fungus was Candida species (50%). CAPD catheter removal and initiation of antifungal therapy was done for all patients. Reinsertion was done for three (10%) patients. Mortality rate was 20%. Conclusion: Patients with previous bacterial peritonitis and antibiotic usage are at greater risk of developing fungal peritonitis.

Induction of continuous ambulatory peritoneal dialysis after retroperitoneoscopic nephrectomy

Induction of continuous ambulatory peritoneal dialysis (CAPD) as treatment of end-stage renal disease is difficult for patients requiring nephrectomy with traditional surgery, and usually hemodialysis is selected for these patients. In a 61-year-old woman with end-stage renal failure a left renal tumor was diagnosed by abdominal ultrasonography, enhanced computed tomography and magnetic resonance imaging. Following an urology consultation, we decided to perform left kidney nephrectomy. We estimated that she had to undergo dialysis permanently after nephrectomy. She desired to be treated by CAPD, however, we decided after allowing for a postoperative period for complete healing of the peritoneum to avoid complications. This is why during the interim period between surgery and induction of CAPD she underwent hemodialysis (HD) in a local outpatient HD center and in our hospital. We selected a retroperitoneoscopic approach for nephrectomy. Pathology evaluation revealed a renal cell carcinoma. 4 months after nephrectomy, CAPD catheter implantation was performed by using laparoscopy and CAPD was started. At the present time, the patient is doing well on CAPD. To our knowledge, there are no clear indications regarding initiation of peritoneal dialysis after nephrectomy. The retroperitoneoscopic approach for nephrectomy allows for initiation of peritoneal dialysis after nephrectomy within a relative short postoperative period.

Diffuse punctate calcifications involving the colonic region

A 50-year-old gentleman diagnosed as having diabetic nephropathy, with end-stage renal disease (ESRD) one year ago, was advised continuous ambulatory peritoneal dialysis (CAPD) in view of repeated access failure in hemodialysis. His blood urea was 102 mg/dl; serum creatinine, 9.1 mg/dl; corrected serum calcium, 8.7 mg/dl and serum phosphorus level, 7.4 mg/dl. He underwent percutaneous Tenckhoff CAPD catheter insertion. A plain X-ray of the abdomen (erect) was obtained to confirm the position of the catheter [Fig. 1]. Fig. 1 Plain X-ray abdomen (erect) of the patient The X-ray showed diffuse punctate calcifications in the region of the colon along with the CAPD catheter in-situ. Calcifications observed in flat plate films of the abdomen can be broadly divided into two types: those that are confined to a particular organ and those diffusely occupying the whole abdomen. In our patient, the distribution was more suggestive of punctate discrete calcifications in the region of the large intestine. He was on lanthanum carbonate 500 mg thrice a day for his hyperphosphatemia. Recently, reports of incidentally discovered calcific shadows in the colonic region amongst patients on Lanthanum carbonate have been published.1,2 Lanthanum is a rare earth metal bearing atomic number 57, which is close to that of Barium (56). This phenomenon is important since misdiagnosis and endoscopic procedures can be avoided. This method can also be used to assess drug compliance.2

Does Previous Abdominal Surgery Increase Postoperative Complication Rates in Continuous Ambulatory Peritoneal Dialysis?

This study was to compare the postoperative complication rates of continuous ambulatory peritoneal dialysis (CAPD) catheter insertion via open technique between two groups of patients, those with and those without a history of previous abdominal surgery. A review was carried out in 122 patients over a 2-year period. The patients were divided into two groups: those with and those without previous lower abdominal surgery. All patient records were retrospectively analyzed until the time of catheter failure or to current time if alive and receiving CAPD. Patient characteristics, operative factors, and postoperative complications were recorded. Postoperative complications were reported as catheter malfunction in 16 patients and CAPD-related peritonitis in 36 patients. The complication rates in the group of patients with previous abdominal surgery were 16.7% catheter malfunction and 33.3% CAPD-related peritonitis. In patients without previous lower abdominal surgery, a catheter malfunction rate of 12.5% and a peritonitis rate of 28.8% were seen. The operation time in patients with previous abdominal surgery was longer than that in patients without previous abdominal surgery. However, no statistically significant difference in postoperative complication rates was detected between patients with and patients without previous lower abdominal surgery. CAPD remains a reliable modality in the treatment of end-stage renal disease and does not increase postoperative complications in patients with previous abdominal surgery.

Aspergillus oryzae Peritonitis in CAPD: Case Report and Review of the Literature

Fungal peritonitis is a rare, but serious, complication of continuous ambulatory peritoneal dialysis (CAPD). We report a case of peritonitis caused by Aspergillus oryzae in a man on CAPD therapy who was treated successfully with amphotericin B and caspofungin, followed by itraconazole and removal of the peritoneal catheter. A oryzae was identified by using sequence analysis of the ribosomal DNA genes. Of 10 reported cases since 2003, the mortality rate was 30%. Removal of the CAPD catheter and systemic antimycotic therapy are essential to achieve clinical cure in patients with fungal CAPD-related peritonitis.

Selected best demonstrated practices in peritoneal dialysis access

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall.

The Comparison in Terms of Early Complications of a New Technique and Percutaneous Method for the Placement of CAPD Catheters

Background. Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. Subjects and method. Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. Results. In all of the subjects, dialysis was started soon after catheter placement. No per-operative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. Conclusion. The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.