Continuous Peritoneal Dialysis Research Articles

Evaluating Peritoneal Fluid Transport in Continuous Peritoneal Dialysis Patients: A Practical Approach

Background/Aims: Evaluating the peritoneal fluid kinetics is of clinical importance in peritoneal dialysis treatment. We have previously developed a simple way to evaluate the peritoneal fluid transport characteristics in continuous ambulatory peritoneal dialysis patients which, however, cannot be applied to those patients on a fixed dialysis schedule. Therefore, in the present study, we tested the possibility to vary the peritoneal dwell time and tried to develop a more patient-friendly ultrafiltration (UF) collection protocol. Methods: The patients’ UF volume was recorded for 10 days. All patients recruited were asked to perform their usual dialysis exchanges with, however, a special UF data collection protocol to improve the accuracy of computer simulation: at least one dwell of 2–4 h, one of 4–7 h, and one of more than 7 h. The fluid transport model was applied to the pooled UF volume for fluid kinetics simulation, and the data from the following day’s UF records using the same glucose concentration and dwell time were used to evaluate reliability and accuracy of the simulated UF value. Results: Fifty-two chronic peritoneal dialysis patients were included in the present study. All of the UF data could be used in the computer simulation, and there was a significant negative correlation between fluid absorption rate (K_e; see text) and actual UF volume on the following day using a glucose concentration of 1.5% and a dwell time of 4 h (r = –0.336, p < 0.05). The estimated UF values correlated significantly with the actually measured UF values. The variability of the results, expressed by the width between the 95% limits of agreement, fell within –139.2 to 131.9 ml, while the mean difference was –3.7 ml. Conclusions: Our present study showed that varying the peritoneal dwell time was a patient-friendly UF data collection protocol for continuous ambulatory peritoneal dialysis patients on a fixed dialysis schedule. Applying the fluid transport model and nonlinear least squares regression analysis to pooled UF values might be a good and simple way to predict the peritoneal UF capacity.

Measuring Kt/V Urea and PCR in CCPD

Can you provide a protocol for measuring dialysis and renal clearances for continuous cyclic peritoneal dialysis (CCPD)?

Nutritional Recommendations for Patients Undergoing Continuous Peritoneal Dialysis

Seminars in DialysisVolume 5, Issue 2 p. 136-141 Nutritional Recommendations for Patients Undergoing Continuous Peritoneal Dialysis Linda M. McCann, Corresponding Author Linda M. McCann From the Satellite Dialysis Centers, Inc., Redwood City, California (LMM), and Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Texas A&M University College of Medicine, Temple, Texas (CJF)Linda M. McCann, Nutrition Services Coordinator, Satellite Dialysis Centers, Inc., 345 Convention Way, Suite B, Redwood City, CA 94063-1402.Search for more papers by this authorCharles J. Foulks, Charles J. Foulks From the Satellite Dialysis Centers, Inc., Redwood City, California (LMM), and Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Texas A&M University College of Medicine, Temple, Texas (CJF)Search for more papers by this author Linda M. McCann, Corresponding Author Linda M. McCann From the Satellite Dialysis Centers, Inc., Redwood City, California (LMM), and Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Texas A&M University College of Medicine, Temple, Texas (CJF)Linda M. McCann, Nutrition Services Coordinator, Satellite Dialysis Centers, Inc., 345 Convention Way, Suite B, Redwood City, CA 94063-1402.Search for more papers by this authorCharles J. Foulks, Charles J. Foulks From the Satellite Dialysis Centers, Inc., Redwood City, California (LMM), and Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Texas A&M University College of Medicine, Temple, Texas (CJF)Search for more papers by this author First published: April 1992 https://doi.org/10.1111/j.1525-139X.1992.tb00131.xCitations: 5AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume5, Issue2April 1992Pages 136-141 RelatedInformation

An initial experience of continuous peritoneal dialysis in children in the armed forces

Background: Continuous peritoneal dialysis (CPD) is a modality of renal replacement therapy in children with renal failure. A retrospective study analysis of CPD data over four years at our center was carried out. Methods: Ten children with renal failure on CPD were included. Depending on the supply, peritoneal dialysis (PD) fluids of two different brands were used in the same patients over time. The patient months of CPD were divided into two groups based on the brand of PD fluid used. The rates of complications with the two different fluid brands were compared. Results: The mean age of our patients was 8.8 ± 2.51 years (range 4 – 13), with a total of 141 patient months of CPD. The mean follow up period was 13.6 months (range 1–48). The commonest underlying renal pathology was focal segmental glomerulosclerosis in 30%, followed by cresentric glomerulonephritis in 20%. Peritonitis rate was 0.48 episodes per patient year. Patients in Group I had one episode of peritonitis per 53.5 patient months and Group II had one episode per 7.25 patient months (p= 0.021, relative risk of 7.3). Patients in Group I had one episode of hypertensive encephalopathy per 107 patient months and Group II had one episode per 4.8 patient months (p= 0.001, relative risk of 21.9). On analyzing the outcome, four patients were eventually transplanted, three continued on CPD awaiting a renal transplant, two died and one recovered spontaneously. Conclusion: CPD is an effective bridge to renal transplant in children with end stage renal disease. The risk of developing peritonitis and hypertensive encephalopathy varied with the brand of fluid used over time in the same set of patients.

Effect of Two-Hour Daily Hemodialysis and Sham Dialysis on Breath Isoprene Exhalation

Isoprene, a volatile hydrocarbon produced by the human organism, is currently being extensively investigated because the mechanisms underlying its endogenous origin are unknown and because experiments suggest it is toxic and cancerogenous. Previous reports of increases in breath isoprene concentrations during 4-hour, thrice-weekly hemodialysis, but not during continuous ambulatorial peritoneal dialysis, prompted us to assess the behavior of isoprene in another dialytic modality, i.e., short daily hemodialysis (short DHD). Furthermore, in order to determine whether removal of solutes and/or contact of blood with the dialytic membrane influenced the metabolism of isoprene, we performed a sham short hemodialysis session in a subgroup of 8 patients (sham short HD), i.e., with blood flowing through a dialyzer but without dialysate and ultrafiltration. The present study evaluates the effects of a two-hour short DHD and a two-hour session of sham HD on isoprene breath levels, as determined by gas chromatography before, during and after sessions. Parallel analyses of ambient air and monitoring of blood pressure and heart rate were performed. Both short DHD and sham DHD induced an increase in breath isoprene exhalation in all patients without being associated with significant hemodynamic variations. These findings suggest that the increase in breath isoprene after a session of hemodialysis is neither a reaction to mevalonate depletion nor to metabolic variations induced by the depurative effect, because these changes do not occur during sham HD. It is not related to hemodynamic changes because none were observed in this experimental model. The isoprene increase seems to be of metabolic origin and appears to be connected in some way with the extracorporeal circuit. These interesting findings provide a further impulse to study the biosynthetic pathways involved and to investigate the medical and biological significance of isoprene in humans.

Alltagsprobleme im Umgang mit terminal niereninsuffizienten Patienten

Practitioners and physicians working in emergency rooms are often confronted with dialysis patients or patients who have received a kidney transplant. For dialysis patients, the mode of dialysis treatment needs to be assessed and dialysis access should be secured. Furthermore, the indications for the next dialysis treatment need to be determined. Dialysis patients often present themselves because of fluid overload, hypo- or hypertensive episodes, electrolyte disturbances, fever or cardiovascular events. Patients undergoing continuous peritoneal dialysis are at an increased risk of infection of the catheter or of peritonitis. Patients with a renal transplant require continuation of their immunosuppression and the function of the transplant should be monitored. These patients often present with infections in which case the degree of immunosuppression may need to be reduced. Vaccinations as well as an increased risk for malignancies require special attention in these patients.

Development of a computer-aided diagnosis system for continuous peritoneal dialysis: An availability of the simultaneous numerical optimization technique for kinetic parameters in the peritoneal dialysis model

We developed a novel diagnostic system for continuous peritoneal dialysis, which evaluates the peritoneal permeability and hydraulic conductance (peritoneal function) by applying the kinetic model and a clinical test with minimum nursing time. Kinetic parameters for the peritoneal function were determined by the simultaneous numerical optimization techniques (SNOT). Furthermore dialysis outcome and ultrafiltration volume were estimated and predicted by using the kinetic model with a set of optimal kinetic parameters, which were in agreement with measured data ( r 2 > 0.82 ) . The clinical implementation of the SNOT is very useful to explore the better prescriptions for each patient's clinical condition.

Advances in the Technology of Automated, Tidal, and Continuous Flow Peritoneal Dialysis

Automated peritoneal dialysis (APD) has undergone substantial growth in recent years because of an increased demand for higher doses of peritoneal dialysis (PD) treatment and a need to improve quality of life for patients. The evolution of this treatment is closely linked with the development of new automatic machines and with recent advances in prescription and monitoring of PD treatment. In the present article, we describe the characteristics of the new generation of APD cyclers with particular regard to adequacy targets and safety. There is renewed interest in continuous-flow peritoneal dialysis (CFPD), because of a belief that new peritoneal access technologies will make the success of this modality a possibility. In the CFPD technique, a certain amount of fluid is constantly present in the abdomen, and constant inflow and outflow are maintained without interruption thanks to paired indwelling catheters. The PD solution is used either in a single pass or in a recirculation loop with a regeneration systems (sorbent cartridge or dialyzer).

How to Improve Survival in Geriatric Peritoneal Dialysis Patients

Recently, more elderly patients who are independent or able to live at home with the support of family are opting for continuous ambulatory peritoneal dialysis (CAPD). At the end of 2005, the annual statistical survey conducted by the Japanese Society for Dialysis Therapy indicated that the mean age of patients at initiation of dialysis treatment is 66.2 years. Only 3.6% of the overall end-stage renal disease population were treated with CAPD, and this small number of elderly patients was treated with CAPD despite the many merits of peritoneal dialysis (PD) for the elderly. In the present study, we reviewed our experience with patients 65 years of age and older at the start of PD and the results from two multicenter studies on PD treatment in elderly patients in Japan. Study 1: Of 313 PD patients at Okayama Saiseikai General Hospital between January 1991 and June 2006, 166 patients 65 years of age and older were studied. The characteristics of these elderly PD patients were reviewed to determine which elderly patients can continue PD for more than 5 years, and what the causes of death and the effects of icodextrin were in elderly PD patients. Study 2: A multicenter study of 421 patients introduced to PD from April 2000 to December 2004 in Japan was carried out by the Japanese Society for Elderly Patients on Peritoneal Dialysis to retrospectively analyze patient survival and technique survival and to find factors that have the potential to influence prognosis in these patients. Study 3: A review of the PD management and nursing-care insurance system (long-term care insurance) targeted patients 65 years of age and older who were initiated onto PD from January 2000 to June 2002 at 82 centers in Japan. The review found 765 patients under the age of 65 years (62.6%), and 458 patients 65 years of age and over (37.4%). Data on 409 elderly PD patients from 73 centers were analyzed. Study 1: In 166 elderly patients, 27 (16.3%; 18 women, 9 men) continued PD for more than 5 years at our hospital. The original disease was chronic glomerulonephritis in 21 patients, diabetic nephropathy in 2 patients, nephrosclerosis in 2 patients, and polycystic kidney disease in 2 patients. The causes of death in the elderly PD patients at our hospital were heart failure (20.3%), cerebrovascular disease (17.7%), myocardial infarction (15.2%), debilitation (12.7%), peritonitis (7.6%), and pneumonia (3.8%). We observed significant differences in ultrafiltration, body weight, sodium, chloride, red blood cells, and hematocrit after using icodextrin in 14 elderly PD patients. Also, use of icodextrin in the daytime helps the family supporting an elderly member on PD by reducing the number of exchanges. Study 2: The average age of 421 patients in 37 hospitals throughout Japan was 76.4 years. Women accounted for 41% of all patients. The average modified (exclusive of factors of aging) Charlson comorbidity index (CCI) was 3.7. The modified CCI was an important factor not only in patient survival but also in technique survival. Patient survival was significantly different for the three modified CCI groups (CCI<3, 3<or=CCI<5, 5<or=CCI). Factors that influenced patient survival included patient choice of modality, modified CCI, exchanges performed by family members, and age at the start of PD. Factors that influenced technique survival included patient choice of modality, modified CCI, and exchanges performed by family members. Age at the start of PD was not a significant factor influencing technique survival. Study 3: Most elderly PD patients were living with family; 7% were living alone. At the start of PD, 24% of elderly PD patients were covered by nursing-care insurance, including 11% of young elderly patients (65-74 years of age), 35% of old elderly patients (75-84 years of age), and 29% of very old elderly patients (85 years of age or older). Patients 75 years of age or older were covered by nursing-care insurance more frequently than were patients under 75 years of age. Nevertheless, at the start of dialysis, fewer than 10% of elderly patients were using nursing-care insurance for PD. In elderly patients, PD has good outcomes, especially in nondiabetic patients, in patients with few comorbidities, and in patients managing PD by themselves. In introducing dialysis in elderly patients, PD should be the treatment of choice. A more secure support system should be established to allow the elderly to choose PD treatment.

Peritoneal Dialysis in Croatia

To present the state of renal replacement therapy (RRT) in Croatia, assess the quality of dialytic treatment, verify the value of peritoneal dialysis (PD), and promote expansion of PD in Croatia based on results attained locally. According to the integrative care concept, PD is the best way to start life-long RRT. Croatian nephrologists have adopted the policy of increasing the use of PD. However, evidence for recommendations were obtained in specific circumstances and might not be relevant elsewhere. The aim of this observational study is to compare the outcome of PD with that of hemodialysis (HD), as practiced in Croatia. Since 2000, the Croatian Registry for Renal Replacement Therapy has been collecting individual patient data for all patients on RRT, with complete coverage. As of 31 December 2004, there were 251 prevalent patients on PD (continuous ambulatory PD and automated PD) in Croatia, accounting for 7% of all patients on RRT and giving a prevalence of 57 patients per million population. From 1 January 2000 to 31 December 2004, 377 patients started PD and were followed from the first day of RRT. For 80% of them, PD was the first mode of RRT. The probability of staying on PD for 5 years was 31% [95% confidence interval (CI) 29-32]. Five-year technique survival (excluding transplanted, recovered, and deceased patients) was 68% (95%CI 65-70). For survival analysis and comparison between PD and HD, only patients on the same method from the start of their RRT were included. Patients changing treatment were censored after 60 days (intention-to-treat analysis). Unadjusted 5-year survival in the PD-first group (301 patients) was 60% (95%CI 54-65), which is significantly better than in the 2789 HD-first patients (42%, 95%CI 40-44; log-rank p < 0.0001). When data were stratified for age and diabetes, 5-year mortality rates on HD were higher in all strata. Only in patients >/=70 years old was the advantage of PD less impressive. Standardized mortality ratio was 1.85 (p < 0.01) in favor of PD. Hazard ratio of HD versus PD was 2.1 (95%CI 1.6-2.8). After adjustments for age, gender, diabetes, and nephroangiosclerosis, the hazard ratio settled at 1.5 (95%CI 1.1-1.9). In Croatia, PD is used mostly as the first RRT. Almost one third of patients continue PD for 5 years due to good patient and technique survival. Starting RRT with PD offers 50% superior 5-year survival in comparison to HD. Dialysis patients in Croatia would benefit from an expanded PD program.

Utilization of Peritoneal Dialysis in the Acute Setting

Peritoneal dialysis (PD), although classically described and utilized in the treatment of patients with end-stage renal disease, can also be utilized in the acute setting in different clinical situations. Recent studies showed that, in patients with acute renal failure, it is possible to obtain reasonable dialysis doses with adequate metabolic and electrolytic control and low incidence of complications by utilizing continuous PD through a cycler at high volume. In patients with congestive heart failure without end-stage renal disease, PD is capable of promoting clinical improvement with slow removal of liquids, becoming an attractive alternative for situations of rapidly or slowly worsening cardiac function. In patients submitted to chronic hemodialysis but who have vascular access difficulties, PD can also be utilized as a "bridge," thereby avoiding the use of central venous catheters, which can be associated with infectious complications such as bacterial endocarditis. New studies must be realized showing other indications for PD.

Outcome and Survival in Different Peritoneal Dialysis Modalities

Peritoneal dialysis (PD) has been accepted as a treatment option for patients with end-stage renal disease, yet experience with PD in Arab countries is limited. This study was undertaken to evaluate the outcome and survival of different PD modalities. All patients managed at the Mubarak Al-Kabeer Hospital Kuwait between August 1982 and December 2003 using PD for three months or more were included in the study. Demographic features, outcome and survival of the patients were analyzed. Four hundred and fifteen patients with end-stage renal failure were admitted into the PD program. Their mean age was 52.06 +/- 16.43 years. Hospital-based intermittent peritoneal dialysis (IPD), continuous ambulatory peritoneal dialysis (CAPD), nightly intermittent peritoneal dialysis (NIPD) and continuous cycling peritoneal dialysis (CCPD) were preferred by 203 (48.9%), 176 (42.4%), 30 (7.2%) and 6 (1.4%) patients respectively. The mean duration of follow up was 12.7 +/- 11.7 months. Fifty-five (13.3%) patients were continuing on PD, 55 (13.3%) had shifted to hemodialysis, 73 (17.6%) underwent renal transplantation, 114 (27.5%) died, 34 (8.2%) returned to their native countries, 79 (19%) transferred to other centers and follow up was lost for 5 (1.45%) patients. Patient survival at two years was 56%, 72% and 87% in IPD, CAPD and NIPD respectively. Technique survival at two years was 60.6%, 75.4% and 100% in IPD, CAPD and NIPD respectively. Peritoneal dialysis modalities provide a feasible modality of renal replacement therapy. The overall outcome and patient and technique survival in home PD modalities were better than hospital-based PD.

Single meal food intake characteristics reliably predict nutrition status and body composition in patients undergoing continuous peritoneal dialysis

This study aimed to determine whether single meal food intake characteristics measured via visual analogue scales (VAS) predict appetite and have a clinical impact on continuous ambulatory peritoneal dialysis (PD) patients. The nutritional status of 50 continuous ambulatory PD patients (30 men, mean age 44.26 +/- 13.53 years, and 20 women, mean age 48.70 +/- 12.53 years) at a single tertiary referral hospital was evaluated via subjective global assessment and VAS questionnaires. The Spearman correlation coefficient was used to evaluate the linear association between continuous variables, while the two-sample Student's t-test was performed to compare ghrelin levels between the two groups. P-values less than 0.05 were considered to be of statistical significance. Subjective global assessment was correlated with VAS scores in each single patient. VAS score for fullness sensation was significantly positively correlated with age (r = 0.41, P = 0.02), triceps skin fold (r = 0.46, P = 0.01), waist-hip ratio (r = 0.50, P = 0.005) and fat content (r = 0.37, P = 0.04), and significantly negatively correlated with daily energy (r = -0.36, P = 0.04) and protein intake (r = -0.52, P = 0.003). By contrast, serum ghrelin level and the four VAS scores were not correlated. Single meal food intake characteristics can reliably estimate nutrition status and predict body composition in patients undergoing continuous PD.

Intra-Peritoneal Administration of Potassium and Magnesium: A Practical Method to Supplement These Electrolytes in Peritoneal Dialysis Patients

Background. Malnutrition and gastrointestinal (GI) losses are frequently encountered in peritoneal dialysis patients, leading to hypokalemia and hypomagnesemia. Oral supplementation is limited by patients' compliance, as well as GI side effects. Methods. Among the 27 patients on continuous cyclic peritoneal dialysis (CCPD) in whom we had one-year data, 15 (55%) were on oral potassium (K) supplements and 10 (37%) were on oral magnesium (Mg) supplements. Hypokalemia and hypomagnesemia persisted in 3 (11%) patients despite oral supplementation. We examined the efficacy and tolerability of intra-peritoneal (IP) K and Mg administration. Four grams of magnesium sulfate (MgSO4) and/or 60–80 mEq of potassium chloride (KCl) were added to a 2 liter, 2.5% peritoneal dialysis solution bag, and it was used as the last dwell in five CCPD patients. We serially measured serum K and Mg concentrations at 2, 4, and 6–8 hour intervals, drained the fluid, and measured serum concentrations at 20–24 hours. Results. Mean serum K concentration increased from a baseline of 3.2 mEq/L to 4.1, 4.2, 4.1, and 4.2 mEq/L at 2, 4, 6–8, and 20–24 hours post IP administration of KCl, respectively. Similarly, mean serum Mg concentration increased from a baseline of 1.5 mg/dL to 2.5, 2.9, 2.6, and 2 mg/dL at 2, 4, 6–8, and 20–24 hours post-IP administration of MgSO4, respectively. Patients tolerated IP replacement very well, and there were no adverse events. Serum K and Mg concentrations normalized in all patients. Conclusion. IP administration is a safe, practical, and effective method to supplement K and Mg in peritoneal dialysis patients.

Serum Leptin, Resistin, and Lipid Levels in Patients with End Stage Renal Failure with Regard to Dialysis Modality

Little information is available on the relationship between serum resistin levels and other adipokines with serum lipid levels and insulin resistance in uremic patients under different dialysis modalities. Methods. This study investigated the effects of dialysis modality on serum leptin, adiponectin, resistin, interleukin 6 (IL-6), and tumor necrosis factor (TNF) α levels in age, sex, and total adipose tissue mass (TATM); matched 30 hemodialysis (HD) patients, 30 continuous peritoneal dialysis (CAPD) patients, and 30 healthy controls; and evaluated the relationship between these adipokines and dyslipidemia and insulin resistance. Results. Serum resistin, adiponectin, IL-6, TNF-α, and high sensitive C reactive protein (hsCRP) levels were significantly increased in dialysis patients compared to controls (p < 0.05). In CAPD patients, serum leptin, resistin, triglycerides, and total cholesterol levels were higher than those in HD patients (p < 0.05). Leptin levels were positively correlated with TATM, serum triglycerides, total cholesterol, and low density lipoprotein (LDLc) levels in both dialysis groups. Resistin levels were found to positively correlate with TATM and triglycerides in CAPD patients. No relationship was found between the homeostasis model assessment-insulin resistance index (HOMA-IR) and adipokines studied. Conclusion. Serum leptin, resistin, triglycerides, and total cholesterol levels were higher in CAPD patients. Leptin levels were positively correlated with TATM, serum triglycerides, total cholesterol, and LDLc levels in dialysis patients. Resistin levels were positively correlated with TATM and triglycerides in CAPD patients. Glucose load during CAPD may be an important factor in increased in leptin, resistin, triglycerides, and total cholesterol levels in CAPD patients. These results highlight the importance of leptin and resistin as determinants of dyslipidemia, especially in CAPD patients.

O SIGNIFICADO DE VISITA DOMICILIAR PARA USUÁRIOS DE UM PROGRAMA DE DIÁLISE PERITONEAL AMBULATORIAL CONTÍNUA (CAPD) EM GOIÂNIA

ABSTRACT - This study approaches the need and the importance of home visit by the user's meaning about the program of continuous peritoneal dialysis (CAPD). The objective was to know and to analyze the meaning of home visit for users of the program CAPD of a public general hospital in Goiânia. The data was collected through questionnaire application previously elaborated. The home visit developed by nurses has great importance for the user's of the program. Thus we concluded that the home visit in CAPD is a procedure that assists most of the users of that program, assisting to their needs, collaborating with a specialized treatment and of quality. The nurse educational activities is a fundamental factor to the implantation of the program guaranteeing to the continuity the quality of the treatment.

“Sweet” hydrothorax complicating chronic peritoneal dialysis

Massive pleural effusion occurring during continuous peritoneal dialysis (PD) is a rare, life-endangering complication of this procedure. We describe a case of a patient with type 2 diabetic end-stage renal disease (ESRD) treated by PD who had new-onset dyspnea, right pleural effusion, and uncontrolled hyperglycemia. Respiratory distress and pleural effusion progressed quickly during the course of dialysis. A large volume of a “sweet” fluid with a high glucose content was evacuated from the pleural space. Immediate improvement in the patient's condition and glucose control followed discontinuation of PD and initiation of hemodialysis.

Perioperative Management of Peritoneal Dialysis Patients Undergoing Hernia Surgery without the use of Interim Hemodialysis

To review the feasibility of undertaking elective hernia repair in peritoneal dialysis (PD) patients without converting them to hemodialysis. A 10-year retrospective review of prospectively collected data. PD unit of a university-based hospital. All patients received regular exchanges until the morning of the surgery and remained off dialysis for the first 48 hours postoperatively. After that, PD was gradually reintroduced. The patients on continuous ambulatory PD (CAPD) received intermittent PD (IPD) 3 times per week for 10 hours per day for 2 weeks, followed by 5 exchanges of low volume (1-1.5 L) CAPD for 2 weeks, returning to the pre-surgery prescription by 4 weeks. Patients on continuous cycling PD (CCPD) received 1 week of IPD followed by 4 weeks of nocturnal IPD and returned to the original dose in 5 weeks. Between 1 April 1995 and 31 March 2005, 50 consecutive patients were managed by this protocol. Average age was 65 years and 67.7% were males. The original disease was diabetes mellitus (19 patients), hypertension (6), chronic glomerulonephritis (13), polycystic kidney disease (6), and others (6). The types of abdominal hernias included umbilical (25 patients), inguinal (18), incisional (5), and epigastric (2). 42 patients were on CAPD and 8 on CCPD. Average duration of PD prior to development of hernia was 16.4 months. Average pre-surgery creatinine was 673 mumol/L, increasing to 968 mumol/L on IPD. Serum potassium increased from 3.4 to 4.7 mmol/L. No episodes of hyperkalemia were noted. The average total follow-up was 33.4 months. None of the patients had leakage or early hernia recurrence due to early resumption of PD; 13 patients had recurrence of the same hernia after a median 19.9 months; 4 patients had hernias at different sites after an average of 55 months. Based on this experience, we recommend that PD patients undergoing elective abdominal hernia surgery should continue PD according to the prescribed protocol. Interim hemodialytic support does not appear to be necessary in most patients.

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 role of tidal peritoneal dialysis in modern practice: A European perspective

Tidal peritoneal dialysis (TPD) has been introduced to optimize adequacy of peritoneal dialysis (PD). Early studies reported similar or even better small solute clearances with TPD than those achieved with continuous ambulatory peritoneal dialysis or continuous cyclic peritoneal dialysis. However, in many studies treatment volumes were much higher during TPD compared with other PD modalities. Based on current evidence, TPD provides no advantage of increased small solute clearances, middle molecule clearances, or peritoneal ultrafiltration as compared to non-tidal automated peritoneal dialysis (APD) when dialysate flow is kept constant. However, TPD reduces drainage pain and nightly alarms during cycler treatment. Tidal volume should be kept as high as possible in these patients, especially in those with low average peritoneal transport rates. Based on theoretical considerations and little evidence, TPD could provide better clearances than conventional APD when a very high dialysate flow (>or=5 l/h) is used. Such dialysate flow rates are not routinely prescribed in home APD patients. However, they may be interesting for in-center PD patients. One randomized crossover trial reported higher small solute clearances with TPD compared to non-tidal APD in patients with acute renal failure. TPD is also the preferred treatment modality in patients with ascites as it allows a controlled outflow of fluid from the peritoneal cavity. Newer treatment modalities, for example, continuous flow PD, may be interesting alternatives in an effort to increase efficacy of PD in the future. However, because such treatment regimens are expensive and elaborate they have not been established for routine use until now.