Patient and technique survival and factors affecting mortality on peritoneal dialysis in Turkey: 12 years' experience in a single center.

BACKGROUND: We investigated patient and technique survival and factors affecting mortality in Turkish peritoneal dialysis (PD) patients. Patients and METHODS: This was a retrospective study. 423 PD patients were included. The demographic, clinical, and biochemical data were collected from the medical records. Clinical outcomes were mortality and technique failure. RESULTS: Mean age at the start of PD was 46.0 +/- 14.3 years and mean PD duration was 37.1 +/- 28.3 (median: 30, range: 4-137) months. Diabetes mellitus was the most common cause of end-stage renal disease (35.2%), followed by hypertension (14.7%). There were 89 (21.0%) deaths. 25 (5.9%) patients received a kidney transplant, 74 (17.4%) patients were transferred to hemodialysis. Estimation of technique survival by Kaplan-Meier was 96.1%, 83.2%, 67.6%, 45.8%, and 33.6% at 1, 3, 5, 8, and 10 years. Technique failure was associated with peritonitis rate [relative risk (RR): 3.22, p < 0.001] and peritoneal Kt/V urea (RR: 0.38, p = 0.001) in the Cox proportional hazards model analysis. Estimation of patient survival by Kaplan-Meier was 96.9%, 83.8%, 68.8%, 50.2%, and 40.7% at 1, 3, 5, 8, and 10 years, respectively. In the Cox proportional hazards model analysis, age (RR: 1.01, p = 0.05), transfer to PD from hemodialysis (RR: 1.84, p = 0.03), comorbid cardiovascular disease (RR: 1.90, p = 0.004), serum creatinine level (RR: 0.75, p < 0.001), total Kt/V urea (RR: 0.34, p < 0.001), peritonitis rate (RR: 1.87, p < 0.001), and dialysate-to-plasma creatinine ratio (RR: 6.49, p = 0.04) predicted mortality. CONCLUSIONS: Even though we cannot conclude with certainty that survival rates in Turkish patients are better than those in the United States and Europe, our results seem to suggest this and warrant further studies adjusted for more extensive demographic features and comorbidities. The factors affecting mortality in Turkish PD patients are similar to other populations.     

The use of TWH catheters in CAPD patients: fourteen-year experience in technique, survival, and complication rates.

OBJECTIVE: To evaluate the technique of insertion, complication rates, and survival rates of Toronto-Western Hospital (TWH) peritoneal catheters in continuous ambulatory peritoneal dialysis (CAPD) patients. PATIENTS AND METHODS: A total of 222 TWH catheters were inserted into 203 CAPD patients (113 males and 90 females) with end-stage chronic renal failure during a period of 14 years (1 January 1982 to 31 August 1995). The mean age of the patients was 58.5 years (range 18-86 years). For the first 6 years, the peritoneal cavity approach was performed via a lower midline incision (45 insertions), various other approaches (17 insertions), and, finally, for the last 160 insertions (for approximately 8 years) the transverse paraumbilical incision was exclusively employed. The duration of CAPD ranged between 1 to 151 months (mean time 33.2 months). RESULTS: Regarding early and late complications (namely leakages, obstructions, eviscerations, tunnel infections, herniation, and others), as well as catheter survival, the transverse paraumbilical insertion, compared to other approaches, had the smallest number of complications. Thus, early leakage occurred in 5/222 (2.25%) versus 10/222 (4.5%), obstruction nil versus 2/222 (0.9%), and evisceration nil versus 1/222 (0.45%). In addition, as far as the late complications are concerned: tunnel infections 5/222 (2.22%) versus 13/222 (5.85%), herniations 1/222 (0.45%) versus 16/222 (7.3%), and cuff protrusion nil versus 7/222 (3.1%). Finally, overall peritonitis occurred with a rate of one episode every 21.2 months. Actuarial survival for 1 and 3 years was 75% and 37%, respectively. CONCLUSIONS: The transverse paraumbilical incision seems to be the most advantageous approach in inserting (by "surgical method") theTWH catheters. We found it to be a safe, simple, versatile procedure, giving good results in all parameters concerned.     

Peritoneal transport characteristics, comorbid diseases and survival in CAPD patients.

OBJECTIVE: To evaluate the influence of initial peritoneal transport rate, serum albumin concentration, and comorbid diseases on continuous ambulatory peritoneal dialysis (CAPD) patient survival. DESIGN: A prospective single-center study with a long-term follow-up. PATIENTS: A total of 213 consecutive CAPD patients, who underwent a peritoneal equilibration test (PET) at a mean of 7 days (range 3 - 30 days) after beginning CAPD, were included in this study. One hundred twenty patients were male, 116 patients had comorbid diseases, and mean age was 49.5 years (range 18 - 76 years). METHODS: A modified PET was performed using 4.25% glucose dialysis solution. Based on the dialysate-to-plasma creatinine concentration ratio at 4 hours' dwell (D4/P4 Cr, 0.62 +/- 0.14), patients were divided into high (H), high-average (HA), low-average (LA), or low (L) transporters. RESULTS: Of 213 patients, 16.9% were classified as H transporters, 30.5% as HA, 36.6% as LA, and 16.0% as L transporters. The H transporter group had a higher proportion of men, higher proportion of patients with comorbid diseases, lower initial serum albumin concentration, lower D4/D0 glucose, and lower drained volume. The initial D4/P4 Cr correlated with initial serum albumin (r= -0.35, p < 0.001). The patients with comorbid diseases had lower initial serum albumin and higher initial D4/P4 Cr. On Kaplan-Meier analysis, 2-year patient survival of group H was significantly lower compared to the other groups combined (57.1% vs 79.5%, p = 0.009). On Cox proportional hazards analysis, age, comorbid diseases, initial serum albumin concentration, and initial D4/P4 Cr were found to be independent risk factors for mortality. However, in the patients without comorbid diseases, patient survival was not different between group H and the other transport groups combined (p > 0.05), and only age was found to be an independent risk factor for mortality. CONCLUSION: These data suggest that a high peritoneal transport rate at initial PET is associated with high mortality, and that this is in part due to an increased prevalence of comorbid disease in H transporters. These H transporters with comorbid diseases represent a subset of patients with an especially poor prognosis. In patients without comorbid diseases, high transport status or low serum albumin concentration was not an independent risk factor for mortality.     

Early start of CAPD with the Seldinger technique.

The ideal method for inserting continuous ambulatory peritoneal dialysis (PD) catheters remains debatable. Minimally invasive techniques are becoming more popular. The routine recommendation for starting PD is 4 - 6 weeks after catheter insertion. We planned a prospective study to evaluate whether this waiting period is necessary. From January 2003 to July 2004, 42 double-cuff Tenckhoff CAPD catheters were inserted into 41 patients. Percutaneous technique was used and PD was started on the sixth day. Only 2 pericatheter leakages (4.8%) were detected. This procedure is comparatively safe, simple, and less costly than surgical and peritoneoscopic placement. The rate of early pericatheter leakage may be lowered with this technique and PD may be started earlier.     

Comparison of patient and technique survival in continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis: a multicenter study

Patient and technique survival were compared in adult patients new to continuous ambulatory peritoneal dialysis (CAPD) or (primarily) center hemodialysis (HD) in the time period 1981 to 1983, and followed-up in March 1985. Risk factors were identified at entrance into the study, and results were analyzed using Cox's proportional hazards model. For nondiabetic patients, the difference in survival which favored CAPD (relative risk = 0.62) was not significant at the 5% level (p = 0.08). Age was a significant risk factor in both groups. The average number of hospital visits was the same; however, CAPD showed a small but significant increase in average annual hospital days per year (10.14 vs. 9.18). For diabetic patients, there was no significant difference in survival between CAPD and HD. The CAPD group showed a significant increase in hospital visits (relative risk 1.81 vs. 1.40) and average hospital days per year (19.43 vs. 13.41). Both CAPD groups showed significantly higher treatment changeover rates.     

Relationship between adequacy of dialysis and nutritional status, and their impact on patient survival on CAPD in Hong Kong.

OBJECTIVE: Superior patient survival on continuous ambulatory peritoneal dialysis (CAPD) with 3 x 2-L exchanges has been reported from Hong Kong. This study examined the relationship between indices of dialysis adequacy and nutrition and patient survival on CAPD in Hong Kong. DESIGN: A cross-sectional study on prevalent CAPD patients. Patients were assessed for indices of dialysis adequacy and nutritional status with a composite nutritional index (CNI). Patients were then followed for 24 months. Survival data were analyzed according to adequacy indices and nutritional status. SETTING: All prevalent CAPD patients in nine dialysis centers in Hong Kong as of 1 April 1996. MAIN OUTCOME MEASURE: Mortality. RESULTS: 937 patients were assessed: 68.2% were using 3 x 2-L exchanges per day; mean age was 54.6 +/- 13 years. Mean total Kt/V was 1.83 +/- 0.42 and total creatinine clearance was 55.6 +/- 19.5 L/week/1.73 m2. 19% of patients were moderately to severely malnourished according to the CNI. There was no significant correlation between indices of adequacy and serum albumin or CNI. The 1- and 2-year patient survival from the time of assessment was 90.9% and 79.8%. There was a trend toward better survival in patients with Kt/V greater than 2.0, but it was not statistically significant. Peritoneal Kt/V did not impact survival in anuric patients. Malnourished patients had poorer survival than patients who were better nourished (p = 0.0259). After adjusting for age and diabetes, CNI was predictive of mortality but Kt/V and creatinine clearance were not. CONCLUSIONS: This study demonstrates the importance of nutritional status over adequacy indices in predicting patient survival. There was a lack of correlation between nutritional status and conventional indices of dialysis adequacy.     

Gastric emptying and electrogastrography in patients on CAPD.

OBJECTIVE: To evaluate if impaired gastric emptying of digestible solids can explain the disturbed eating behavior in continuous ambulatory peritoneal dialysis (CAPD) patients, and if predialytic and dialytic (CAPD and hemodialysis) patients with impaired gastric emptying have a higher prevalence of electrogastrographic (EGG) abnormalities. DESIGN: Cross-sectional study. After ingestion of a 99mTc-labeled test meal, anterior and posterior 1-minute scintigraphic acquisitions were collected every 5 minutes during the first 50 minutes and thereafter every 10 minutes until 2 hours had elapsed. Simultaneously, cutaneous EGG recorded gastric myoelectric activity. SETTING: The Division of Nephrology and the Department of Nuclear Medicine at the same academic teaching hospital. PARTICIPANTS: Thirty outpatients participated in both the gastric emptying and the EGG studies. Dialysis patients should have been on dialysis for more than 3 months. For comparison, 160 healthy control subjects participated in the gastric emptying study. MAIN OUTCOME MEASURES: The following parameters were used to describe gastric emptying: lag phase 90%, half-emptying time (T50), gastric retention at 90 and 120 minutes (Ret 90/120) and gastric emptying rate (GER, %/min). Electrogastrographic measurements were expressed as percentages of normal slow waves [2.4-3.6 cycles/min (cpm)], bradygastria (1.5-2.4 cpm), and tachygastria (3.6-10 cpm). RESULTS: T50 was prolonged, Ret 90 and Ret 120 were higher, and GER was slower in male CAPD patients compared to male controls. No significant differences were found in postprandial EGG. CONCLUSION: Gastric emptying is impaired in male non-diabetic CAPD patients. However, abnormalities in postprandial EGG cannot explain this finding.     

A multicenter, selection-adjusted comparison of patient and technique survivals on CAPD and hemodialysis

Four hundred and eighty CAPD and 373 HD patients started regular dialysis treatment between 1981 and 1987 in 6 dialysis centers. The CAPD patients were 6 years older, on average, than the HD patients and had more complicating conditions (43.3% with 3 or more coexisting risk factors versus 28.9% with coexisting complications). The 7-year patient survival rate was not significantly different. Cox's proportional hazards regression showed that age, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, diabetes, malignancy and multisystem disease had significant adverse effects on patient survival. After correcting for the influence of these factors, no significant differences in patient survival were seen. However, after 53.5 years of age, the increase in the risk of death was significantly higher in HD than in CAPD patients. Technique survival was significantly different in the 6 centers and was better for HD than for CAPD. There was no statistically significant difference between CAPD and HD technique survival when peritonitis was eliminated as a cause of failure. Based on this 7 year analysis, CAPD would appear to be an excellent alternative to HD.     

Calcium and strontium metabolic studies in patients on CAPD.

BACKGROUND: Strontium is known to affect calcium metabolism both experimentally and in clinical studies on conditions other than end-stage renal failure (ESRF) and continuous ambulatory peritoneal dialysis (CAPD). OBJECTIVE: To investigate Sr metabolism in relation to that of Ca in ESRF patients undergoing CAPD, and the possible influence of the duration of treatment. DESIGN: Cross-sectional observational study. SETTING: University medical center and Institute of Nuclear Physics. PATIENTS: Twenty-four patients on CAPD; 14 chronic renal failure (CRF) patients not on dialysis, and 52 healthy controls. MEASUREMENTS: Calcium and Sr content of serum, urine or dialysate effluent, and selected dietary products. RESULTS: Calcium and Sr are absorbed by the intestinal tract of healthy subjects with equal efficiency. Serum Ca levels were considerably lower in CRF patients than in healthy subjects and patients on CAPD (p < 0.001). Serum Sr was significantly higher in both CAPD and CRF patients than in healthy controls (p < 0.001). The Sr/Ca ratio in the sera of the healthy subjects was defined by the preferential excretion of Sr over Ca by the kidney. This preferential excretion was lost during renal failure. During treatment there was a tendency for the uptake of both Ca and Sr to increase. CONCLUSIONS: Strontium is accumulated in the body during renal failure and CAPD cannot restore normal levels. Considering the varying effects of different doses of Sr on bone metabolism experimentally, it would be interesting to determine by further studies the possible significance of the observed Sr accumulation for renal bone disease.     

Minilaparoscopic extraperitoneal tunneling with omentopexy: a new technique for CAPD catheter placement.

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods. OBJECTIVE: To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff-coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping. SETTING: The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey. PATIENTS AND METHODS: Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 - 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope. RESULTS: All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 - 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 - 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD. CONCLUSION: This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD.