Advances in peritoneal dialysis. Conference on Peritoneal Dialysis最新文献

A 67-year-old white man with a history of end-stage renal disease receiving peritoneal dialysis (PD) presented with acute onset of vomiting, chills, and abdominal pain. He was diagnosed with PD-associated peritonitis secondary to Pasteurella. After failure of 3 weeks of antibiotic treatment, catheter loss occurred. On follow-up, the patient was found to have extensive intra-abdominal adhesions precluding placement of a new PD catheter.

Peritoneal dialysis (PD) is one of the treatment options for patients with end-stage renal failure. To start PD treatment, a catheter must be placed for access to the abdominal cavity, and it can be placed using surgical, laparoscopic, or percutaneous methods. However, complications can develop during catheter placement.In the present case report, we describe a patient in whom treatment was pursued after an unusual complication rarely mentioned in the literature: a dialysis catheter accidentally inserted percutaneously into the bladder. Under ultrasonography guidance, the catheter was pulled from the urinary bladder and pushed into the intra-abdominal cavity. No complications resulted from the procedure, and the patient proceeded to PD treatment. This case is, to our knowledge, the only such report in the literature.

Compared with hemodialysis (HD), peritoneal dialysis (PD) is associated with reduced cost and improved quality of life. But despite those benefits, PD represents a small percentage of the renal replacement therapy performed. Although a number of factors contribute to that situation, peritoneal drop-out is a complex issue that leads to as much as a 35% annual transition from PD to in-center HD. The reasons for drop-out are multifaceted and include contributions from the patient or caregiver, health care regulatory systems, and factors intrinsic to the PD modality. In this review, we focus on specific causes of PD drop-out and on prevention and intervention strategies that can improve success and duration on PD.

Continuous ambulatory peritoneal dialysis (PD) is one of the treatment methods used for end-stage renal failure. When mechanical complications occur with this treatment method, methods such as tomographic peritoneography, abdominal scintigraphy, and magnetic resonance peritoneography are used to uncover the problem. Here, we report the detection by tomographic peritoneography of a subcutaneous dialysate leak in a patient undergoing PD. The PD catheter was subsequently removed, and a new catheter was inserted. The patient then restarted continuous ambulatory PD without any problem.

Peritonitis is a major complication in peritoneal dialysis (PD) patients, often requiring a switch to hemodialysis (HD). Common sources of bacterial peritonitis are touch contamination and PD catheter-related infection. Intra-abdominal pathology is a less common cause of peritonitis in PD patients, and rarely is Neisseria mucosa the causative organism.We present an uncommon case of N. mucosa peritonitis in a 30-year-old African American female patient treated with nocturnal intermittent PD. The infection occurred in the setting of a translocated intrauterine contraceptive device (IUCD) in the infrahepatic region because of transmural migration. Our patient underwent laparoscopic removal of the IUCD and received empiric intraperitoneal (IP) vancomycin and intravenous ceftriaxone. After the isolate was identified as N. mucosa, her regimen was changed to IP ceftriaxone for a total of 21 days. Cell count after completion of antibiotics showed resolution of the peritonitis. The PD catheter was salvaged and transition to HD was avoided.

Urea kinetics (weekly Kt/V) greater than 1.7 generally define adequate peritoneal dialysis (PD). Adequacy of PD depends on residual renal function and PD clearance. Preserving residual renal function and peritoneal membrane characteristics helps to maintain PD adequacy.The dose of PD can be augmented by increasing the total dialysate volume. Greater volume can be achieved by increasing either the fill volume per exchange or the number of exchanges. Increased time on dialysis can be achieved by keeping PD fluid in the peritoneal cavity at all times. Increasing the convective force enhances solute removal with ultrafiltration.Incremental PD is used during urgent starts and in patients who are newly starting or who have been on PD. Urgent starts require use of frequent low-volume exchanges to avoid leaks at surgical sites. The dialysate volume can be gradually increased provided that no leakage occurs, up to approximately 2 L per exchange on day 14 for an average-size adult. New-start patients require only 1 - 2 exchanges daily if they still have residual renal function. Incremental PD retains patients on PD as residual renal function wanes and peritoneal membrane characteristics change because of dextrose exposure, infection, and inflammation.Use of a cycler permits patients to achieve adequacy by increasing the volume per cycle and the number of cycles per treatment. Using a non-dextrose-based solution, such as icodextrin, allows patients to achieve adequate ultrafiltration with less dextrose exposure.Adequate dialysis can be achieved by manipulating the dialysate dwell volume and the frequency of exchanges, and by optimizing ultrafiltration.

The aim of the present study was to compare the aortic systolic blood pressure (aSBP), heart-rate-adjusted augmentation index (AIx₇₅), and pulse wave velocity (PWV) obtained using the Mobil-O-Graph (IEM, Stolberg, Germany) and SphygmoCor (AtCor, Sydney, Australia) devices in patients receiving peritoneal dialysis (PD).After a 10-minute rest in the supine position, the Mobil-O-Graph and SphygmoCor devices were applied in randomized order in 27 consecutive PD patients. The agreement between the measurements produced by the Mobil-O-Graph and SphygmoCor devices was explored using Bland-Altman analysis.The Mobil-O-Graph-derived aSBP, AIx₇₅, and PWV did not differ from the same measurements obtained with SphygmoCor (aSBP: 120.5 ± 18.2 mmHg vs. 124.4 ± 19.0 mmHg, p = 0.438; AIx₇₅: 27.0% ± 12.4% vs. 24.5% ± 10.6%, p = 0.428; PWV: 9.5 ± 2.1 m/s vs. 10.1 ± 3.1 m/s, p = 0.397). The slight difference in the estimation of aSBP is possibly explained by the difference in brachial SBP used for the calibration of the devices (131.0 ± 20.6 mmHg vs. 134.5 ± 19.7 mmHg, p = 0.525). Mobil-O-Graph-derived measurements correlated strongly with paired measurements obtained with the SphygmoCor device. Bland-Altman plots showed no evidence of asymmetry and a wide range of agreement between the two devices.Our study shows acceptable agreement between Mobil-O-Graph and SphygmoCor in the estimation of arterial stiffness indices in PD patients. Accordingly, the Mobil-O-Graph device accurately performs aortic ambulatory blood pressure monitoring in this population.

To avoid loss of residual renal function (RRF) and to enhance solute clearance, we sometimes, from the initiation of peritoneal dialysis (PD) therapy, combine PD with hemodialysis (HD) that removes little or no fluid. In one typical valuable case, a 51-year-old woman with diabetic nephropathy who selected combined PD and HD therapy as her first dialysis method has continued on that therapy for 10 years. Her dialysis schedule consists of 5 PD days and 1 HD day without fluid removal weekly. Because this combination therapy was proactively started at dialysis initiation, good fluid control could be kept with urinary excretion and PD ultrafiltration. Stable peritoneal equilibration test data indicate that peritoneal resting might be expected to be beneficial for the preservation of peritoneal function. This case demonstrates that proactive combination therapy can be extremely useful for preserving both RRF and peritoneal function, indicating a good prognosis.

The effects of medium- or long-term use of neutral-pH dialysate on peritoneal transport and peritoneal damage have not been sufficiently researched.We retrospectively evaluated time-dependent changes in the dialysate-to-plasma ratio of creatinine (D/P Cr) and biomarkers of peritoneal damage in the effluent of 65 patients who underwent peritoneal dialysis (PD) with neutral-pH dialysate, including 48 who underwent medium-term PD (≥3 years) and 17 who underwent long-term PD (≥5 years).Patients who underwent medium-term PD initially had a D/P Cr of 0.59 (range: 0.53 - 0.74), nonsignificantly changing to 0.65 (range: 0.55 - 0.73), 0.67 (range: 0.56 - 0.74), and 0.67 (range: 0.62 - 0.72) after 1, 2, and 3 years respectively (p = 0.30, p = 0.26, and p = 0.19). Patients who underwent long-term PD initially had a D/P Cr of 0.57 (range: 0.52 - 0.62), nonsignificantly changing to 0.61 (range: 0.52 - 0.69), 0.64 (range: 0.54 - 0.67), 0.62 (range: 0.57 - 0.66), 0.65 (range: 0.50 - 0.72), and 0.61 (range: 0.48 - 0.7) after 1, 2, 3, 4, and 5 years respectively (p = 0.49, p = 0.31, p = 0.24, p = 0.23, and p = 0.46). After 3 years, a significant increase in effluent hyaluronan (HA) from 90 ng/mL initially (range: 66 - 121 ng/mL) to 144 ng/ mL (range: 116 - 216 ng/mL) was observed (p = 0.04).No significant change in D/P Cr was observed in patients who underwent PD with neutral-pH dialysate. However, effluent HA, which is a biomarker for peritoneal damage, increased. In patients using neutral-pH dialysate, D/P Cr cannot be a biomarker for determining PD discontinuation within 5 years, but effluent HA might be useful.

Continuous ambulatory peritoneal dialysis (CAPD) is becoming increasingly known to the patients of Bangladesh, and patient numbers are increasing. Here, we report our experience and clinical outcomes in this field.Our analysis included all CAPD patients managed in a tertiary care hospital in Bangladesh between 2003 and 2015. All patients received a Tenckhoff double-cuff catheter by mini-laparotomy, and twin bags were used in most patients. In acute cases, regular exchanges were started manually with small-volume dwells the same or the next day.During the study period, 500 patients (mean age: 62 ± 18 years; 62% men; 86% percent with diabetes) were managed. Selection of CAPD was made by choice (47%) or for hemodynamic instability (32%), remote residence (17%), or poor vascular access (4%). Total duration of follow-up was 9364 patient-months (range: 1 - 78 months). The peritonitis rate was 1 episode in 30 patient-months. Fewer than 5% of patients required catheter removal. Similarly, the percentages of catheter tip migration and fluid leak were at the lower end. Patient survival was 68%, 48%, 38%, 22%, and 8% at 1, 2, 3, 5, and 7 years. Deaths were mostly attributable to vascular events.In a population with predominantly diabetic patients, CAPD was shown to be a viable mode of renal replacement therapy. The rates of peritonitis and catheter-related complications were low. Survival in the initial years can be considered acceptable.