Continuous Ambulatory Peritoneal Dialysis Program Research Articles

Study of Caregiver Burden in Continuous Ambulatory Peritoneal Dialysis

Background Increased caregiver burden undermines caregivers’ mental and physical health and is an under recognized but critical aspect for the success of continuous ambulatory peritoneal dialysis (CAPD). This study was undertaken to quantify and identify the factors determining CAPD caregiver burden. Materials and Methods A cross-sectional study was conducted among 51 caregivers of CAPD patients visiting the centers from July to August 2023. Caregiver burden score was determined using “Zarit Burden Interview” by interview method. Results The mean age of caregivers was 42.8 ± 10.83 years with 52.9% females. The mean Zarit burden score of the caregivers was 29.18 ± 11.81. Younger caregivers experienced significantly higher burden (r = −0.34, P = 0.013). Lesser educated caregivers were perceiving a higher burden. Lower socioeconomic strata people had significantly higher burden (P < 0.001) and especially so when there was a loss in income attributed to caregiving. Patients who were covered by state insurance experienced a notably lower caregiver burden (19.2 ± 6.1) when compared to those who were self-financed (32.4 ± 11.08) or had company insurance (37.2 ± 13.6). Gender, religion, marital status, and type of family had no bearing on the caregiver burden. Conclusion Age, loss of income, education, and socioeconomic status are important determinants of caregiver burden. State sponsored program lowers caregiver burden significantly. A CAPD program should address these factors to mitigate caregiver burden.

Continuous Ambulatory Peritoneal Dialysis Cost-Effectiveness in National Health Insurance Era of Indonesia

Essential treatments for patients with end-stage renal disease include Renal Replacement Therapy (RRT) consisting of hemodialysis, peritoneal dialysis, and kidney transplantation. In 2014, dialysis coverage in Indonesia was more than 1.5 trillion, making it the second highest expense in the National Health Insurance (BPJS) expenses. This study compared the cost-effectiveness between Continuous Ambulatory Peritoneal Dialysis (CAPD) and Hemodialysis (HD) in patients treated in Dr. Hasan Sadikin General Hospital. Data were collected from the Urology Department from 2014 to 2017. This was a retrospective observational study on 3 groups of patients: patients with effective CAPD each year as the first group; patients who had experienced repair of CAPD and continued to use it as the second group; and patients who discontinued CAPD due to complications and returned to hemodialysis as the third group. Each group expense was calculated with standard cost insurance for one year in the hospital. The expense was then be compared to the expense of hemodialysis for one year. A total of 89 patients in the CAPD program from 2014–2017 were treated at the department. When compared to HD, the first, second, and third group of CAPD patients experienced a cost reduction of IDR 23.227.857/person, IDR 18.127.857/person, and IDR 1.661.972.000, respectively. Total savings from the CAPD program in the hospital was IDR 1.661.972.000 from 2014. It is then concluded that CAPD could reduce the burden of government insurance in a cost-effective manner and is considered a treatment of choice in the National Health Insurance Era.

#5521 TENCKHOFF CATHETER EXIT-SITE INFECTION BY ACTINOMYCES ODONTOLYTICUS: A RARE CASE

Abstract Background and Aims Actinomyces odontolyticus is an anaerobic Gram-positive bacteria, which can be found among the commensal flora of the mouth and oropharynx. Diagnosis of infections due to this microorganism can be difficult because of its rarity, indolent course and lack of specific symptoms. Only one case of exit-site infection (ESI) due to Actinomyces odontolyticus in a patient on continuous ambulatory peritoneal dialysis (CAPD) has been reported. This work aims to report a case of ESI due to this rare agent. Method We present a case of Tenckhoff catheter ESI due to Actinomyces odontolyticus in a patient on CAPD. Results Case report: We report the case of a 26-year-old woman with a personal history of dyslipidemia, arterial hypertension and end-stage chronic kidney disease caused by Alport Syndrome in a CAPD program since April 2016. In June 2020, the patient presented an episode of refractory ESI due to methicillin-sensitive Staphylococcus aureus and was submitted to a shaving of the external cuff of the Tenckhoff catheter, with good subsequent evolution. The patient had no complications related to the catheter until April 2021, when she presented purulent drainage through the exit-site associated with erythema of the surrounding area. The consecutive exit-site swabs were negative. She underwent antibiotic therapy with cotrimoxazole for 2 weeks with apparent resolution. However, in May 2021, the patient presents again erythema and purulent drainage and, at that time, a rare agent was isolated in the swab: Actinomyces odontolyticus with resistance to penicillin, amoxicillin, ceftriaxone and cotrimoxazole. Given this isolation, the patient was treated with doxycycline 100mg every 12 hours for 4 weeks. The evolution was favorable with resolution of the infection and absence of recurrence for a 6-month follow-up. At the end of this follow-up time, the patient was transplanted. Conclusion Actinomyces odontolyticus is a bacteria of the commensal flora of the oral cavity and upper gastrointestinal tract, which can acquire pathogenicity in situations of impaired mucosal integrity and in immunosuppressed patients. Infections caused by this agent are rare and represent a diagnostic challenge due to its growth in an anaerobic environment and prolonged isolation time (5 days to 4 weeks). The immunosuppression conferred by chronic kidney disease and the history of external cuff shaving may have propitiated the infection by this rare opportunistic agent in our patient. The ESI presented for the patient in the previous month, which did not have an identified agent, was possibly caused by Actinomyces odontolyticus, but it was not isolated probably due to culture difficulties. The treatment of Actinomyces infections is generally conservative with 2 to 4 weeks of high-dose of intravenous penicillin, followed by 2 to 6 months of oral antibiotic therapy. In case of allergy, regimens with ceftriaxone, doxycycline, clindamycin or carbapenems are recommended. There is no consensus on the duration of treatment, with some authors recommending a minimum of 2 to 6 weeks. The mentioned patient was treated with 4 weeks of doxycycline according to the sensitivity test and the result was favorable, without the need to remove the catheter.

Peritoneal and Urinary Sodium Removal in Refractory Congestive Heart Failure Patients Included in an Ambulatory Peritoneal Dialysis Program: Valuable for Monitoring the Course of the Disease

Introduction: Spot urinary sodium emerged as a useful parameter for assessing decongestion in patients with congestive heart failure (CHF). Growing evidence endorses the therapeutic role of continuous ambulatory peritoneal dialysis (CAPD) in patients with refractory CHF and kidney disease. We aimed to examine the long-term trajectory of urinary, peritoneal, and total (urinary plus peritoneal) sodium removal in a cohort of patients with refractory CHF enrolled in a CAPD program. Additionally, we explored whether sodium removal was associated with the risk of long-term mortality and episodes of worsening heart failure (WHF). Methods: We included 66 ambulatory patients with refractory CHF enrolled in a CAPD program in a single teaching center. 24-h peritoneal, urinary, and total sodium elimination were analyzed at baseline and after CAPD initiation. Its trajectories over time were calculated using joint modeling of longitudinal and survival data. Within the framework of joint frailty models for recurrent and terminal events, we estimated its prognostic effect on recurrent episodes of WHF. Results: At the time of enrollment, the mean age and estimated glomerular filtration rate were 72.8 ± 8.4 years and 28.5 ± 14.3 mL/min/1.73 m², respectively. The median urinary sodium at baseline was 2.34 g/day (1.40–3.55). At a median (p25%–p75%) follow-up of 2.93 (1.93–3.72) years, we registered 0.28 deaths and 0.24 episodes of WHF per 1 person-year. Compared to baseline (urinary), CAPD led to increased sodium excretion (urinary plus dialyzed) since the first follow-up visit (p < 0.001). Over the follow-up, repeated measurements of total sodium removal were associated with a lower risk of death and episodes of WHF. Conclusions: CAPD increased sodium removal in patients with refractory CHF. Elevated sodium removal identified those patients with a lower risk of death and episodes of WHF.

PENGARUH TELENURSING TERHADAP KUALITAS HIDUP PASIEN PENYAKIT GINJAL KRONIK YANG MENJALANI CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) DI RS PGI CIKINI JAKARTA

The Effect of Telenursing on the Patient's Quality of Life Chronic Kidney Disease with Continuous Ambulatory Peritoneal Dialysis Background: Chronic kidney disease is an irreversible disruption of kidney function and requires renal replacement therapy. As a substitute for continuous kidney function, one of them is Continuous Ambulatory Peritoneal Dialysis. Objective : to determine the effect of telenursing on the quality of life of the patients with chronic kidney disease undergoing Continuous Ambulatory Peritoneal Dialysis program. Methods: This research is a quasi-experimental pretest-postest approach with control group design. The sample consisted of 60 patients, the intervention group and the control group with 30 respondents each who were taken by purposive sampling. Assessment of quality of life using the KDQOL TM36 questionnaire. Telenursing intervention through the Pd Ez Mobile application in the intervention group for 4 weeks and was observed for the 2nd and 4th weeks in June-July 2020. Results: the quality of life before the telenursing intervention was poor (60%) and after the intervention was good (73, 3). The results of the Wilcoxon different test showed a difference in telenursing services with an increase in the quality of life of 15.66 or 13.55% with a value of p = 0.000 (p <0.05). Conclusion: There was no interaction effect of telenursing use in CKD patients who underwent CAPD on improving their quality of life (p <0.05) and showed an increase in quality of life 82.2 times compared to those without telenursing intervention.

Continuous Ambulatory Peritoneal Dialysis Peritonitis Guidelines - Consensus Statement of Peritoneal Dialysis Society of India - 2020.

Continuous ambulatory peritoneal dialysis (CAPD) related peritonitis is a major cause of technique failure, morbidity, and mortality in patients on CAPD. Its prevention and management is key to success of CAPD program. Due to variability in practice, microbiological trends and sensitivity towards antibiotics, there is a need for customized guidelines for management of CAPD related peritonitis (CAPDRP) in India. With this need, Peritoneal Dialysis Society of India (PDSI) organized a structured meeting to discuss various aspects of management of CAPDRP and formulated a consensus agreement which will help in management of patients with CAPDRP.

Predictors of survival in continuous ambulatory peritoneal dialysis patients: a five-year prospective study.

Our objective was to examine the influence of various demographic, clinical, and enrollment biochemical variables on the long-term survival of continuous ambulatory peritoneal dialysis (CAPD) patients. This was a prospective cohort study investigating the relationship between demographics and enrollment biochemical markers and mortality in CAPD patients in a CAPD unit in a large tertiary care teaching hospital. One hundred and sixty-nine patients in the CAPD program were enrolled between 1989 and 1994, and were followed up to 60 months. Independent predictors of mortality determined by Cox proportional hazards model included age, diabetes, serum albumin and creatinine. Enrollment level of serum albumin, and creatine can predict mortality in CAPD patients up to 60 months. Markers of visceral and somatic nutrition at enrollment are important predictors of mortality in CAPD patients up to five years.

Expanding CAPD in Low-Resource Settings: A Distance Learning Approach.

Despite growing need, treatment for end-stage renal disease is limited in low- and middle-income countries due to resource restraints. We describe the development of an educational curriculum and quality improvement program to support continuous ambulatory peritoneal dialysis (CAPD) performed primarily by non-nephrology providers in Sri Lanka. We developed a program of education, outcome tracking, and expert consultation to support providers in Kandy, Sri Lanka. Education included videos and in-person didactics covering core topics in CAPD. Event-tracking sheets recorded root causes and management of infections and hospitalizations. Conferences reviewed clinical cases and overall clinic management. We evaluated the patient census, peritonitis rates, and root causes and management of infections over 1 year. The curriculum was published through the International Society of Nephrology online academy. High provider turnover limited curriculum assessments. The CAPD patient census rose from 63 to 116 during the year. The peritonitis rate declined significantly, from 0.8 episodes per patient-year in the first 6 months to 0.4 in the latter 6 months, though the most common root causes of peritonitis, related to contamination events and hygiene, persisted. The appropriate ascertainment of culture data and prescription of antibiotics also increased. Our project supported the expansion of a CAPD program in a resource-limited setting, while also improving peritonitis outcomes. Ongoing challenges include ensuring a durable educational system for rotating providers, tracking outcomes beyond peritonitis, and formalizing management protocols. Our program can serve as an example of how established dialysis programs can support the burgeoning work of providers in resource-limited setting.

Continuous ambulatory peritoneal dialysis: perspectives on patient selection in low- to middle-income countries.

Chronic kidney disease is a major public health problem that continues to show an unrelenting global increase in prevalence. The prevalence of chronic kidney disease has been predicted to grow the fastest in low- to middle-income countries (LMICs). There is evidence that people living in LMICs have the highest need for renal replacement therapy (RRT) despite the lowest access to various modalities of treatment. As continuous ambulatory peritoneal dialysis (CAPD) does not require advanced technologies, much infrastructure, or need for dialysis staff support, it should be an ideal form of RRT in LMICs, particularly for those living in remote areas. However, CAPD is scarcely available in many LMICs, and even where available, there are several hurdles to be confronted regarding patient selection for this modality. High cost of CAPD due to unavailability of fluids, low patient education and motivation, low remuneration for nephrologists, lack of expertise/experience for catheter insertion and management of complications, presence of associated comorbid diseases, and various socio-demographic factors contribute significantly toward reduced patient selection for CAPD. Cost of CAPD fluids seems to be a major constraint given that many countries do not have the capacity to manufacture fluids but instead rely heavily on fluids imported from developed countries. There is need to invest in fluid manufacturing (either nationally or regionally) in LMICs to improve uptake of patients treated with CAPD. Workforce training and retraining will be necessary to ensure that there is coordination of CAPD programs and increase the use of protocols designed to improve CAPD outcomes such as insertion of catheters, treatment of peritonitis, and treatment of complications associated with CAPD. Training of nephrology workforce in CAPD will increase workforce experience and make CAPD a more acceptable RRT modality with improved outcomes.

Age-related differences in the quality of life in end-stage renal disease in patients enrolled in hemodialysis or continuous peritoneal dialysis

BackgroundThe aim of the present study was to compare the experience elderly and younger patients in terms of emotional status, disease perception, methods of coping with the end-stage renal disease (ESRD) stress, and health-related quality of life in 2 different settings of renal replacement therapy: hemodialysis (HD) and continuous ambulatory peritoneal dialysis programs (CAPD). Specifically, we hypothesized that younger people will more frequently use goal-oriented strategies to cope with illness-related stress and elderly patients will use more strategies related to the control of emotion.Material/MethodsA total of 69 HD patients, 40 CAPD patients, and 89 healthy volunteers were analyzed. The Situation and Trait Anxiety Inventory, the Profile of Mood States, the Cognitive Stress Appraisal Questionnaire, and the Nottingham Health Profile were used to assess anxiety, long-term emotional status, coping mechanisms, and health-related quality of life. Data were collected on several biochemical and demographic variables.ResultsOur study revealed that younger and elderly people on dialysis faced quite different problems. Younger people in both RRT groups had statistically higher assessment of ESRD as loss or challenge and they more frequently used distractive and emotional preoccupation coping strategies. Depression, confusion, and bewilderment dominate the emotional status of both patient populations, especially in the younger cohort. Both HDyoung and CAPDyoung patients complained more about lack of energy, mobility limitations, and sleep disturbances as compared to their elderly HD and CAPD counterparts.ConclusionsThere are different needs and problems in younger and elderly patients on renal replacement therapy. Younger people required more ESRD-oriented support to relieve their health-related complaints to the level observed in their peers and needed extensive psychological assistance in order to cope with negative emotions related to their disease.

Continuous Ambulatory Peritoneal Dialysis and Clinical Outcomes in Patients With Refractory Congestive Heart Failure

Introduction and objectivesPeritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction. MethodsA total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60mL/min/1.73 m2), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses. ResultsThe peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001). ConclusionsIn refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes.

Diálisis peritoneal ambulatoria continua y evolución clínica de pacientes con insuficiencia cardiaca congestiva refractaria

Introduction and objectivesPeritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction. MethodsA total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60mL/min/1.73 m2), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses. ResultsThe peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001). ConclusionsIn refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes.Full English text available from:www.revespcardiol.org

Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure

Continuous ambulatory peritoneal dialysis (CAPD) has been proposed as an additional therapeutic resource for patients with advanced congestive heart failure (CHF). The objective of this study was to determine the therapeutic role of CAPD, in terms of surrogate endpoints, in the management of patients with advanced CHF and renal dysfunction. A total of 57 candidates with New York Heart Association (NYHA) class III/IV CHF, renal dysfunction (glomerular filtration rate < 60 mL/min/1.73 m(2)), persistent fluid congestion despite loop diuretic treatment, and at least two previous hospitalizations for acute heart failure (AHF) were invited to be included in the CAPD programme; however, 25 patients were finally included. The primary outcome was evaluated by the change at 6 and 24 weeks for the Minnesota Living With Heart Failure Questionnaire (MLWHFQ), the 6 min walk test (6MWT), NYHA class, serum natriuretic peptides [brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)], serum carbohydrate antigen 125 (CA125), and hospitalization rates for AHF. CAPD was associated with a substantial improvement in the MLWHFQ (-21.3, P < 0.001; and -20.4, P < 0.001), the 6MWT (54.0, P < 0.001; and 45.6, P = 0.023), and NYHA class (-1.0, P < 0.001; and -1.4, P < 0.001) at 6 and 24 weeks, respectively. The Ln(CA125) decreased markedly (-0.8, P = 0.003; and -0.98, P = 0.003), with no effect on BNP and NT-proBNP. There was a marked reduction in the number of days hospitalized for AHF (6 month post-CAPD vs. 6 months pre-CAPD: -84%; P < 0.001). In advanced CHF and renal dysfunction, CAPD was associated with short/mid-term improvement in severity parameters, with an acceptable rate of side effects.

Commencing peritoneal dialysis with 1.1% amino acid solution does not influence biochemical nutritional parameters in incident CAPD patients

Objective: To evaluate the influence of 1.1% amino acid dialysis solutions on nutritional parameters in incident continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: The effect of daily use of 1.1% amino acid solution was studied retrospectively in 32 incident CAPD patients (14 women and 18 men, mean age 54 ± 13 years) who began CAPD at our tertiary university hospital between July 2005 and February 2009 (amino acid solution (AAS) group). Serum total protein, albumin, and creatinine were assessed for all patients prior to dialysis and at the end of the study period. Thirty-two control patients (12 women and 20 men, mean age 52 ± 14 years) who started peritoneal dialysis with a standard CAPD program were also investigated and grouped as the dextrose solution (DS) group. Results: Baseline serum albumin levels were significantly lower in the AAS group compared to the DS group (3.4 ± 0.4 g/dL vs. 3.7 ± 0.5 g/dL, p = 0.011). At the end of the 12-month follow-up period, mean serum albumin levels had decreased from 3.4 to 3.3 g/dL in the AAS group (p = 0.218) and increased from 3.7 to 3.8 g/dL in the DS group (p = 0.360). Overall, no significant changes were observed in serum total protein, creatinine, or albumin in either group. Conclusions: Amino acid solutions conferred no demonstrable benefit on biochemical parameters in incident CAPD patients. The effects of AAS may be different when added to the CAPD regimen of patients undergoing prior CAPD treatment.

Continuous Ambulatory Peritoneal Dialysis in Egypt: Progression despite Handicaps

Despite the well-known advantages of continuous ambulatory peritoneal dialysis (CAPD), it continues to be grossly underutilized in many developing countries. However, some developing countries, such as Mexico, use the modality very effectively. In view of this, we started the first CAPD program in Egypt. Since its start in 1997, our program has treated 33 patients. Straight double-cuffed Tenckhoff catheters were surgically placed in all patients. Twin-bag systems were used. All patients underwent monthly clinical and biochemical assessment and measurement of Kt/V urea. Peritonitis and exit-site infection rates were monitored. Most treated patients were adult and female. Mean age was 31.7 years and mean follow-up duration was 18 months. Peritonitis rate was 1 episode /21.3 months and was easily managed in most patients. Staphylococcus aureus was the most commonly isolated organism (24%) but 49% of cases were culture negative. There were no exit-site infections. Mean weekly Kt/V urea was 1.78 +/- 0.23. We report the successful development of a small CAPD program in Egypt, made possible by well-established financial support, a motivated team of doctors and nurses, and good patient selection and training.

The Development of a Continuous Ambulatory Peritoneal Dialysis Program in Indonesia

Chronic kidney disease is prevalent in Indonesia, running at 29.1% in the population at risk (hypertension, diabetes, and proteinuria). In a recent survey, the incidence rate for end-stage renal disease (ESRD) was 30.7 per million population (pmp), and the prevalence rate was 23.4 pmp. In 2006, about 10,000 patients were being treated with hemodialysis. Nevertheless, many ESRD patients remained untreated. Financial problems, scarcity of dialysis facilities, and insufficient numbers of skilled health care providers were among reasons why renal replacement treatment is not so well developed in Indonesia. The continuous ambulatory peritoneal dialysis (CAPD) program begun in 1985 was slowly growing until an economic crisis in 1998. Afterward, with new development of CAPD and government support, the number of patients on CAPD increased. In the middle of 2007, CAPD patients numbered 774 in total. Drop-out rates remained high, because of death, infection, and catheter failure. Almost all new CAPD patients are older than 35 years of age, and the technique is still costly: 51% of patients receive 4 daily exchanges, costing $6,000 annually; the rest receive 3 daily exchanges, costing $4,800 annually. Government insurance reimburses only 3 exchanges. Expensive drugs such as erythropoietin, intravenous iron, and vitamin D(3) are not covered by insurance. The infection rate for the most recent year was 1 episode in 47.17 patient-months. The cost of antibiotic treatment to cure peritonitis is still expensive. Many patients experience some complication related to catheter obstruction or hemorrhage. In Indonesia, CAPD is relatively new and just beginning to progress. In our archipelago, with its many islands and limited resources and investment, CAPD may be the better choice of therapy. More training is needed to increase the number of skilled and experienced doctors, nurses, and other CAPD team members. We hope that CAPD can be made more affordable for ESRD patients.

Continuous ambulatory peritoneal dialysis. 5-year clinical experience

Continuous ambulatory peritoneal dialysis (CAPD) is, next to conventional home dialysis, a world-wide method of treating chronic renal failure. This is the report of clinical experience of 34 CAPD patients who, from October 1978 to the end of 1983, had undergone 642 treatment months. The incidence of peritonitis after introduction of a new connector system in 1983 was reduced to 1 per 46 CAPD treatment months. In only 7 patients was it necessary to discontinue CAPD for reasons connected with the type of dialysis. No patient requested discontinuance of CAPD. Suitable bag and tube materials, adequate space, and well trained personnel are decisive for a successful CAPD programme, in addition to careful selection of patients. The latter aims at optimal patient motivation for the treatment method which, in principle, is more cost effective than home dialysis. In so far as patients fulfil the requirements for home dialysis they can be excellently rehabilitated.

Laparoscopic Revision of a Malfunctioning Peritoneal Dialysis Catheter in an Infant: A Hard Case

PURPOSE This video shows the laparoscopic management of a malfunctioning Tenckhoff peritoneal dialysis catheter and the release of extensive intraperitoneal adhesions in 5 months old and 4200 grams male infant. MATERIAL AND METHODS The baby was on continuous ambulatory peritoneal dialysis program since the first month of life due to bilateral multicystic dysplastic kidney disease and his history had: peritonitis twice; Tenckhoff catheter replacement once and repositioning twice; omentectomy; hydrocelectomy and inguinal hernia repair. 15 days old Tenckhoff catheter was obstructed and the blood K+ was 6.1 mEq/ml. So, it was decided to salvage the Tenckhoff catheter laparoscopically. RESULTS A laparoscope was introduced with open port technique and extensive peritoneal adhesions were seen and the Tenckhoff catheter was also enveloped by fibrotic tissue and wrapped by the colon tightly. Intraperitoneal adhesions were freed, the colon was unwrapped and the catheter was taken out the fibrous sheath. After achieving correct outflow, Tenckhoff catheter was repositioned. Intraperitoneum was irrigated with antibiotics and heparin. Total operative time was 1 hour by 2 ports and the patient returned to peritoneal dialysis 8 hours from the operation. CONCLUSIONS Laparoscopy, for which previous abdominal surgery and intraperitoneal adhesions are accepted as relative contraindications, could be performed successfully by open port technique in a 4200 gr. infant with extensive intraperitoneal adhesions. This procedure should be accepted as lifesaving by the advantage of immediate return of the peritoneal dialysis.

The Prevalence and the Characteristics of Tuberculosis Patients Undergoing Chronic Dialysis Treatment: Experience of a Dialysis Center in Southeast Turkey

Tuberculosis remains a significant health problem for patients receiving chronic dialysis. The purpose of this study was to evaluate the prevalence, clinical characteristics, and outcomes of tuberculosis among patients with end-stage renal failure (ESRF) undergoing chronic hemodialysis and continuous ambulatory peritoneal dialysis. Between 1999 and 2006, we diagnosed 21 active tuberculosis patients among a total of 674-dialysis patient in our dialysis center (582 patients on hemodialysis and 92 patients on continuous ambulatory peritoneal dialysis program). Fourteen patients developed extrapulmonary tuberculosis (generally tuberculous lymphadenitis, n = 8) and seven patients developed pulmonary tuberculosis. All patients who developed tuberculosis after starting dialysis had low creatinine clearances and, in general, anemia and hypoalbuminemia. Three of patients greater than 40 years died. In conclusion, tuberculous lymphadenitis was the most frequent form of extrapulmonary tuberculosis in our dialysis population. If no cause is found despite extensive investigations in an end stage renal failure case with fever, loss of weight, and/or atypical lymphadenopathy, the physician should consider the possibility of tuberculosis. Finally, it was considered that ESRF is associated with depressed immune system and elevated risk of tuberculosis; thus, in this population, clinicians must evaluate patients carefully.

Heparin-Induced Thrombocytopenia Type II: A Serious Hazard in Preemptive Renal Transplantation: A Case Report

Heparin-induced thrombocytopenia (HIT) type II (HIT II), is an immune-mediated complication of heparin therapy, associated with arterial and venous thrombosis. Herein we have reported a case of a 23-year-old woman who developed HIT following a living related donor, preemptive, renal transplantation. The patient was preoperatively exposed to both unfractionated and low-molecular-weight heparin as she underwent five hemodialysis sessions. HIT caused right common and external iliac vein and renal graft artery thrombosis, resulting in graft loss. Heparin-free hemodialysis was continued, and the patient was successfully treated with anticoagulation by the direct thrombin inhibitor lepirudin for both the thromboses and for hemodialysis. Finally, she was accepted for the continuous ambulatory peritoneal dialysis program. This report highlighted the importance of clinical awareness as far as previous heparin exposure is concerned for establishing an early diagnosis and delivering treatment of this life-threatening prothrombotic complication of heparin administration.