Sclerosing peritonitis with gross peritoneal calcification: a case report.

We report the case of a patient on dialysis for 13 years, including continuous ambulatory peritoneal dialysis (CAPD) for 11 years, who developed sclerosing peritonitis with gross peritoneal calcification. The patient first presented with abdominal pain in January 1990, when peritoneal calcification was detected for the first time. Her symptoms settled spontaneously and 1 year later she presented with acute peritonitis and adynamic ileus. The peritonitis settled with antibiotics and Tenchkoff catheter removal, but the ileus persisted. She was commenced on long-term parenteral nutrition, but never recovered useful bowel function. After 8 weeks of hemodialysis and total parenteral nutrition, a further laparotomy for an acute abdomen showed what appeared to be extensive bowel infarction and peritoneal calcification. She died several days later. Of significance, peritoneal calcification was first noted on x-ray and computed tomography (CT) scan while the patient was still largely asymptomatic and before peritoneal ultrafiltration capacity was significantly impaired. Unlike other reported cases of calcifying peritonitis, sclerosing peritonitis was present and calcification was far more extensive. It was not associated with factors such as frequent infective peritonitis or acetate dialysate. Calciphylaxis was not present nor was there any abnormality of calcium-phosphate metabolism. The outcome of this case suggests that patients with recurrent or persistent bowel symptoms on long-term CAPD should have early abdominal x-ray or CT scanning to exclude sclerosing peritonitis or bowel calcification. If present, consideration should be given to transferring the patient to another therapeutic dialysis modality if possible.     

Clinical effects of long-term use of neutralized dialysate for continuous ambulatory peritoneal dialysis.

The long-term effects of neutralized dialysate used in continuous ambulatory peritoneal dialysis (CAPD) were evaluated in 8 well-controlled patients. Twelve milliliters of 8.4% sodium bicarbonate was added to Dianeal PD-1 immediately before every administration. The final pH was 6.8 and the concentration of sodium bicarbonate was 6 mmol/l. The final sodium level was 138 mEq/l. This dialysate was used for 5 months. For 2 months before and 3 months after this period, Dianeal PD-2 was used as the dialysate for comparison. Blood bicarbonate levels significantly improved during the use of the neutralized dialysate. Blood sodium, chloride and magnesium levels and the effluent volume significantly increased. Sodium balance improved during the period when neutralized dialysate was used. Total leukocyte counts in the effluent decreased, and leukocyte viability increased. Abdominal distention, abdominal pain during instillation, nausea and headache improved. No side effects, including peritonitis, occurred during the trial of neutralized dialysate. The results suggest that this dialysate was less irritating to the peritoneal membrane than the control dialysate and that the therapeutic effects were satisfactory.     

Potassium supplementation via the dialysate in continuous ambulatory peritoneal dialysis

A small percentage of patients treated with continuous ambulatory peritoneal dialysis (CAPD) may become hypokalemic. Since both the intravenous and oral routes for potassium repletion have disadvantages, we studied the feasibility, effectiveness, and safety of acute potassium loading via the dialysate in patients on CAPD. Five patients were studied during an exchange containing 20 mEq/L of potassium. This was well tolerated and led to a gradual increase in the plasma potassium concentration (.44 +/- .11 mEq/L) as about three-fourths of the intraperitoneal load was absorbed, most of it by two hours. The greatest increase in the plasma potassium concentration was .63 mEq/L. A separate patient developed intense abdominal pain during an exchange containing 40 mEq/L of potassium. We conclude that the dialysate is a safe and effective route for acute potassium repletion during CAPD when the dialysate potassium concentration does not exceed 20 mEq/L.     

Group B Streptococcus (Streptococcus agalactiae) peritonitis associated with continuous ambulatory peritoneal dialysis (CAPD)

Streptococcus agalactiae typically induces serious infections in pregnant women and newborns. Nonpregnant adult patients can also be infected and mortality rate exceeds 40%. CAPD peritonitis is very rarely induced by S. agalactiae. Seven cases have been described previously and all had a very severe course, which included bacteremia, septic shock and death. A 27-year-old male with end-stage renal disease due to membranoprolipherative glomerulonephritis type I, who was on CAPD for 17 months, was admitted with the clinical and laboratory picture of CAPD peritonitis. Severe abdominal pain, shaking chills and fever 38.5 microC were also observed at presentation. Streptococcus agalactiae was isolated from the peritoneal fluid and blood culture was sterile. Under treatment with ceftazidime and tobramycin (i.p.) and vancomycin (i.v.) cultures became negative after 48 hours, abdominal symptoms resolved after 12 days and WBC count in the dialysate normalized after 14 days. As a possible source of infection the patient's partner was shown to be a vaginal carrier of a clone of S. agalactiae identical to that isolated in the peritoneal fluid. S. agalactiae is a rare cause of CAPD peritonitis with potentially very serious consequences. Anal or genital tract colonization is, in general, the source of contamination with S. agalactiae. The microbiological findings in the case presented here suggest that colonization of the patient or of his close environment may be important in the pathogenesis of S. agalactiae-induced CAPD peritonitis.     

Comparison of buffering capacity in patients on hemodialysis and continuous ambulatory peritoneal dialysis

A standard acid loading test was used to assess the buffering capacity in 9 hemodialysis (HD) and 25 continuous ambulatory peritoneal dialysis (CAPD) patients. There was a significant increase in H+ concentration and a decrease in plasma bicarbonate levels after the acid loading in all patients; however, PaCO2 did not change significantly. CAPD patients tolerated the acid load better, at least in the first 2 h, than HD patients. The brief duration of experiments did not allow us to observe differences, if any, in the recovery rates between HD and CAPD patients. CAPD patients tolerated the acid load equally, whether studied with or without fresh dialysate in the peritoneal cavity. Their tolerance to the acid load did not change with an increasing duration of the CAPD therapy. Baseline values and acid tolerance curves were similar in CAPD patients on regular Dianeal (lactate 35 mEq/l) and Dianeal PD2 (lactate 40 mEq/l). It is concluded that the buffering capacity is marginally higher in CAPD than in HD patients, although the baseline acid-base parameters were essentially identical.     

Chemical peritonitis associated with high dialysate acetaldehyde concentrations.

BACKGROUND: During the standard heat sterilization process of lactate-buffered peritoneal dialysis (PD) solutions, glucose degrades to form compounds called glucose degradation products such as acetaldehyde, formaldehyde, or glyoxal. Despite evidence that these products may be responsible for some in vitro cytotoxic effects induced by commercially available PD fluids, data on their acute or chronic effects on the human peritoneum is scarce. SUBJECTS AND METHODS: This case presentation is based on an observation of 21 aseptic peritonitis cases of unknown aetiology. All cases appeared within one month in a university hospital PD unit that had a peritonitis rate of 1 episode/26 patient months and 55 active patients on CAPD. Acetaldehyde level in the bags was assayed by gas chromatography. RESULTS: Twenty-one patients presented with signs of peritonitis including cloudy dialysate and abdominal tenderness with additional abdominal pain in 11 patients and vomiting in one. In all cases, cultures and Gram stains were negative for micro-organisms. Fever was not observed in any patient. Average dialysate white blood cell count was 1795/mm(3). All patients were free of intraperitoneal medication when symptoms appeared. Patients were using PD solutions from a newly established domestic production plant. Apparently all patients with symptoms of peritonitis used bags with the same lot number and the solution in the bags appeared to be darker in colour than that in bags with other lot numbers. Chemical analysis of the unused PD solution samples revealed acetaldehyde levels of 17-20 p.p. m. in bags containing darker solution, which is very high compared with the usual acetaldehyde level of 6 p.p.m. in heat-sterilized PD solutions. CONCLUSIONS: Based on the above findings, we hypothesize that higher levels of acetaldehyde and possibly other glucose degradation products may have been an aetiological factor in these 21 cases of chemical peritonitis. Our observation suggests that acetaldehyde, in concentrations 3-4 times higher than the usual level in commercially available PD solutions, may induce acute sterile peritonitis in CAPD patients.     

Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids.

BACKGROUND: Icodextrin dialysate used for peritoneal dialysis contains an iso-molar glucose polymer solution, which provides sustained ultrafiltration over long dwell times and is considered a valuable approach to reduce intraperitoneal glucose exposure. However, several side effects have been described, including abdominal pain and allergic and hypersensitivity reactions. Also, reactions compatible with chemical peritonitis have been reported. Over the period of a few months (January 2002-May 2002), a remarkable increase in the number of continuous ambulatory peritoneal dialysis (CAPD) patients using icodextrin dialysate diagnosed with sterile peritonitis was observed in our unit. METHODS: Five of the CAPD patients using icodextrin dialysate in our unit and diagnosed with sterile peritonitis were screened for leucocyte count and leucocyte differentiation during a follow-up period of 77 +/- 23 days. In addition, expression of CD14, a receptor for lipopolysaccharide (LPS), on the peripheral and peritoneal monocyte population was analysed. These results were compared to CAPD patients suffering from bacterial peritonitis. RESULTS: The peritoneal leucocyte count of CAPD patients using icodextrin dialysate and diagnosed with sterile peritonitis did not decrease significantly before treatment with icodextrin dialysate was interrupted, whereas it currently disappeared within 2-4 days in proven bacterial peritonitis. The sterile, cloudy icodextrin effluent contained an excess of macrophages on the day of diagnosis, whereas in bacterial peritonitis essentially an increase in the granulocyte population was observed. No elevation in the eosinophil population was observed. In contrast to bacterial peritonitis, we observed no increase in CD14 expression on the peripheral and peritoneal macrophages on the day of presentation and during the follow-up period. CONCLUSIONS: Specific batches of the icodextrin CAPD fluids contain a macrophage chemotactic agent, which causes a sustained inflammatory state in the peritoneal cavity. Because no increase in the expression of the LPS receptor CD14 could be observed, the increased peritoneal leucocyte count is probably not caused by LPS or LPS-like (possibly peptidoglycan-like) contamination.     

Successful maintenance of continuous ambulatory peritoneal dialysis in a patient after fungal peritonitis and dialysate leakage

Fungal peritonitis (FP) and dialysate leakage have often been reported in association with continuous ambulatory peritoneal dialysis (CAPD), which has to be discontinued in many cases due to these complications. This report describes the first case of dialysate leakage into the urinary bladder of a 70-year-old male patient, after the area of the left ureteral ostium had been very deeply resected. The leakage probably led to severe fungal peritonitis developing 1 day after the ostium resection. The ostium resection was performed in November 2003 after detection of a carcinoma in situ (Cis) in this area and after previous bilateral nephroureterectomies due to multifocal urothelial carcinoma in the kidneys, ureters and bladder. In spite of prior fungal peritonitis and dialysate leakage, CAPD could be successfully initiated 41 days after biochemical manifestation of peritonitis and could be maintained in the patient because of the following reasons: early and effective treatment of FP with fluconazole and voriconazole, spontaneous occlusion of the slitted ostium area, allowance of enough healing time after 2 major abdominal surgeries, during which the patient was placed on extracorporal hemodialysis (which had been started 1 day after nephroureterectomy and ended after the antimycotic treatment) and thorough monitoring of the patient after starting CAPD. In January 2004, the patient could be placed on a cycler peritoneal dialysis and was fully rehabilitated 1 year later.     

Abdominal catastrophes and other unusual events in continuous ambulatory peritoneal dialysis patients

Primary bacterial peritonitis and catheter-associated infections compose the large majority of abdominal events in continuous ambulatory peritoneal dialysis (CAPD) patients. Yet occasionally primary pathology involving the abdominal viscera develops, and surgery is frequently considered. The early manifestations of intraabdominal inflammation or bleeding in patients undergoing CAPD depend on the pathological process, its access to the peritoneal cavity, and whether generalized bacterial peritonitis supervenes to obscure helpful physical findings. Clear dialysate is not a reliable sign that major pathology is absent, nor does initial stabilization of the clinical course with antibiotic therapy uniformly indicate that surgery will not be necessary. Polymicrobial peritonitis may develop in cholecystitis, pancreatitis, or from a colonic source, the latter featuring more bacterial species and more gram-negative and anaerobic organisms. A history directed at progression of symptoms and sites of abdominal discomfort and an examination for deep local tenderness and bowel incarcerated in an abdominal wall hernia are essential. Measurement of dialysate amylase and Gram stain of dialysate for food fibers may be helpful. Imaging techniques such as abdominal radiographs for dilated bowel or free subdiaphragmatic air, ultrasonography of the gallbladder or pancreas, computed tomographic (CT) scanning of the lower abdomen, and water-soluble contrast colonic studies may help identify the pathologic process. Special studies such as these should be considered early in the course of suspected unusual abdominal events in patients on CAPD.     

Peritoneal kinetics in children undergoing continuous ambulatory/cycling peritoneal dialysis

We present a report on peritoneal kinetics in children undergoing continuous ambulatory/cycling peritoneal dialysis (CAPD/CCPD). The effect of long-term treatment with CAPD/CCPD, peritonitis episodes, and dialysate inflow volume on peritoneal kinetics in children was evaluated. Peritoneal kinetic studies (PKSs) were performed in 47 pediatric patients at different times following initiation of CAPD/CCPD. In 18 of these patients, PKSs were repeated up to four times with an unchanged dialysate inflow volume after up to 55 months of CAPD/CCPD treatment. The PKS consisted of a 120-minute dwell with a 1.5% dextrose dialysate solution. Peritoneal clearance, dialysance, and dialysate to plasma (D/P) concentration ratios were calculated after 30, 60, and 120 minutes. The results of the serial PKSs demonstrate stable peritoneal creatinine and urea-N clearance, dialysance or D/P concentration ratios. Furthermore, there was no adverse effect of 32 peritonitis episodes. Finally, inflow volumes correlated directly with clearances of creatinine (P less than .01), urea-N (P less than .001), and potassium (P less than .001), and there was an inverse relationship to the D/P concentration ratios of creatinine (P less than .01), urea-N (P less than .01), potassium (P less than .01), and uric acid (P less than .01). Thus, CAPD/CCPD is a useful and effective long-term treatment modality for pediatric patients. Maximal dialysate inflow volumes should be provided to enhance peritoneal kinetics.     

Benefits of Low Dose Immunoglobulin in the Treatment of Refractory CAPD Peritonitis and Longevity of Technical Survival on CAPD

In this study we investigated the long term results of intraperitoneal immunoglobulin (Ig) treatment in continuous ambulatory peritoneal dialyses (CAPD) patients with refractory or relapsing peritonitis. Sixteen CAPD patients (4 female, 12 male) with a mean age of 53 ± 11 years (40–80), with a mean CAPD duration of 46.2 ± 4.8 months (17–75) were included in the study. The patients included had a diagnosis of either refractory or relapsing peritonitis unresponsive to appropriate antibiotic therapy. 0.5 g of Ig was added to every exchange bag qid as an adjunctive therapy to the culture based antibiotherapy for 7 days. Intraperitoneal Ig treatment was found to be successful in treating peritonitis in all but one patient. Interestingly, following Ig treatment, long term peritonitis rate decreased significantly compared to the period before treatment (before: 2.2 ± 0.6 episodes/patient/year vs. after: 0.6 ± 0.17 episodes/patient/year; P = 0.019). The mean CAPD duration after Ig treatment was 30.5 ± 5.4 (4–64) months. Out of 16 patients, one patient who was unresponsive, had his catheter removed and was switched to hemodialysis, and four patients with preexisting ultrafiltration failure or inadequate dialysis problems were transferred to hemodialysis after successful treatment of their peritonitis, one patient was transplanted and 10 patients continued on CAPD. We conclude that low dose Ig treatment may be beneficial in the treatment of refractory or relapsing CAPD peritonitis possibly through restoring impaired host defense within peritoneal cavity. This therapy, by preventing further peritonitis attacks, may prolong survival on CAPD.     

Calcium mass transfer in peritoneal dialysis patients using 2.5 mEq/l calcium dialysate.

Standard peritoneal dialysate has a relatively high calcium concentration of 3.5 mEq/l. Peritoneal dialysis patients thus gain calcium from the dialysate which contributes to the risk of hypercalcemia. Dialysate with 2.5 mEq/l calcium is now available. Theoretically, using dialysate with this calcium content, calcium transfer should be negative (from the patient into the dialysate) when the patient is hypercalcemic, and positive when the patient is normocalcemic or hypercalcemic. Thus, 2.5 mEq/l calcium dialysate may allow larger doses of calcium carbonate to be prescribed. We compared calcium mass transfer (CMT) in 17 stable peritoneal dialysis patients using 3.5 and 2.5 mEq/l calcium dialysate. A solution of 2.05 l, 1.5 g/dl dextrose was dwelled for 4 hours. Calcium was measured in the drained dialysate and serum (total and ionized). Mean CMT was 0.7 +/- 0.5 mEq/exchange using 3.5 mEq/l calcium dialysate and -0.9 +/- 0.9 mEq/exchange using 2.5 mEq/l calcium dialysate (p less than 0.0001). At the time of the CMT studies, the mean serum ionized calcium levels were identical for the two groups (2.6 mEq/l). CMT correlated inversely with serum total calcium, serum ionized calcium, and drained dialysate volume. During hypercalcemia calcium transfer was from the dialysate to the patient when 3.5 mEq/l calcium dialysate was used, but from the patient to the dialysate when 2.5 mEq/l calcium dialysate was used. We conclude that 2.5 mEq/l calcium dialysate is effective in removing calcium and will be helpful in preventing hypercalcemia when large doses of oral calcium compounds are prescribed as a phosphate binder.     

Evaluation of continuous ambulatory peritoneal dialysis

This study was undertaken to ascertain whether 19 patients maintained on continuous ambulatory peritoneal dialysis (CAPD) for at least 1 year experienced any deterioration in peritoneal membrane function. Selected serum chemistries and skinfold measurements were also evaluated to determine whether patients dialyzed by CAPD could maintain a normal nutritional status. This study demonstrates that patients maintained on CAPD had stable dialysate protein losses, glucose absorption from the dialysate, and constant urea, creatinine, and sodium removal. When these patients were subdivided by incidence of peritonitis, the group with a lower incidence of peritonitis (one episode every 349 +/- 155 SEM days) showed stable serum protein concentration and improvement in upper arm area whereas the group with a high incidence of peritonitis (one episode every 95 +/- 7 SEM days) showed a reduction in upper arm muscle area. Thus, our data suggest that over a 1-year period, there is no deterioration in peritoneal membrane characteristics and CAPD is effective in maintaining the nutritional status of the patient. However, both membrane function and nutritional status may be impaired by frequent episodes of infection.     

Progressive calcifying peritonitis: a new complication of CAPD? Report of two cases

The authors report the history of two patients treated with CAPD who developed a progressive calcifying peritonitis (PCP). The symptoms include abdominal pain, impairment of bowel movements, sterile effluent dialysate and progressive development of peritoneal calcifications. The etiology of the PCP remains elusive, but dialysate with acetate, high peritonitis incidence and continuous lavage as treatment for peritonitis are suspected to play a role in its evolution.     

Plasma and dialysate immunoglobulin G in continuous ambulatory peritoneal dialysis patients: a multicenter study

Peritoneal dialysate immunoglobulin (Ig)G concentrations were measured in 120 continuous ambulatory peritoneal dialysis (CAPD) patients evaluated at four dialysis centers in different countries to assess the normal range for dialysate IgG and to investigate the relationships of this protein levels with peritoneal episodes, For 65 of these patients, plasma IgG levels were determined, and IgG clearances were calculated. The mean dialysate concentration of IgG was 6.9 +/- 4.2 mg/dl, and there was no difference between men and women or between patients who had or had not previously undergone hemodialysis. Dialysate IgG concentrations were significantly related to residual renal creatinine clearance and negatively correlated with dialysate volume, plasma albumin and total protein. There were no significant correlations between IgG levels in the dialysate and age, protein losses in the dialysate, time on CAPD or time from the last peritonitis episode. Plasma and dialysate IgG were unrelated to the incidence of peritonitis, statistical analysis being performed with different methods. These results suggest that IgG levels in the dialysate or plasma are not a major factor in the prevention of CAPD peritonitis.     

Current Issues of Continuous Ambulatory Peritoneal Dialysis

Abstract: This paper concerns the overall median technical survival of chronic continuous ambulatory peritoneal dialysis (CAPD) patients and treatment in the 6 years since the commencement of CAPD at the Jikei University Hospital. Diabetic end-stage renal disease (ESRD) patients showed 5 years' survival, apparently shorter than that of nondiabetic ESRD which was 7 years. From this fact, the question of whether CAPD is the best dialytic option in diabetic ESRD should be reevaluated. Although a remarkable reduction in the incidence of peritonitis has been seen, generally ranging from 1 episode/40 patient months to 60 patient months or more in Japan, one serious issue still to be addressed is exit site/skin tunnel infection. The incidence is around 1 episode/30 patient months in our hospital. Discovering how to prevent this infection is a matter of some urgency. Peritoneal dialysis is a limiting dialytic modality as far as the biomembrane used. Although the precise mechanisms deteriorating the peritoneal function are still obscure, the treatment of sclerosing encapsulated peritonitis is also an urgent matter. Regarding bone disease and metastatic calcification, adynamic bone disease is frequently observed in ESRD patients. However, the pathogenesis of this morbidity has not been clarified. Treatment of extraosseous calcification in vessels and periarticular, and visceral organs should be developed. New dialytic alternatives to glucose and/or lactate-based solutions have been under experimental study. Until a new solution is delivered commercially, CAPD will remain a transient therapy. Our large study of CAPD patients revealed that 26% were malnourished. The biochemical parameters, amount of daily protein intake, and KT/V did not show significant differences between those patients identified as well nourished versus malnourished. The causes of malnutrition should be considered from other points of view such as endocrinological circumstances. Newer therapeutic approaches to malnutrition are also required.     

Simultaneous peritoneal dialysis catheter insertion and removal in catheter-related infections without interruption of peritoneal dialysis

Catheter-related infections result in high patient morbidity, the need for temporary haemodialysis, and high costs. These infections are the main cause of limited technique survival in peritoneal dialysis. We introduced a protocol for the simultaneous peritoneoscopic insertion and removal of peritoneal catheters in patients with catheter-related infections. Peritoneal dialysis was continued the day after surgery using low-volume dwells and a dry abdomen during the daytime. The dialysate leukocyte count had to be below 100/mm³ before exchanging catheters, which was performed under antibiotic therapy based on culture sensitivity. The old catheter was removed after the new catheter had been inserted in the opposite abdominal region. CAPD patients were switched to APD for 1 week, which made prolonged hospitalization necessary. Simultaneous catheter insertion and removal was performed 25 times in 22 patients on CCPD and 15 times in 14 patients on CAPD. In CCPD patients, peritoneal dialysis was restarted after 1.0+0.1 days in 24 cases. One patient had sufficient residual renal function and discontinued CCPD until day 10. In 10 CAPD patients (11 procedures) APD was started 1.3±0.2 days after the procedure with CPD beginning 7.1±0.6 days thereafter. Three CAPD patients preferred haemodialysis and restarted CAPD 10.0±2.1 days after surgery. One patient continued CAPD the day after surgery. In addition to minor complications (e.g. position-dependent outflow problems), dialysate leakage occurred in two patients. Two patients developed peritonitis within the first 30 days after surgery, one of which was procedure related. One patient had severe lower gastrointestinal bleeding 2 weeks after the procedure, which was not related to the catheter replacement. Ultimately, in 38 of 40 procedures the patients could successfully continue peritoneal dialysis. We conclude that simultaneous insertion and removal of a peritoneal dialysis catheter without interruption of peritoneal dialysis is a safe procedure in patients with catheter-related infections.     

Serum and peritoneal fluid amylase levels in CAPD. Normal values and clinical usefulness

The mean serum amylase of 42 asymptomatic CAPD patients was elevated but was not significantly different from that of a group of chronic hemodialysis patients. Serum amylase levels in CAPD patients with peritonitis were not elevated with respect to asymptomatic patients. Amylase activity was not detectable in the peritoneal fluid of 38/42 asymptomatic patients and 6/13 peritonitis patients and was present at low levels in the other 11 patients. Patients with other abdominal conditions (pancreatitis, cholecystitis and small bowel perforation) had very marked elevations of serum and/or peritoneal fluid amylase which differentiated them from the asymptomatic and peritonitis patients. Although hyperamylasemia is common in asymptomatic CAPD patients and in those with peritonitis, measurement of serum and peritoneal fluid amylase levels is useful in the evaluation of CAPD patients presenting with abdominal symptoms.     

Idiopathic eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: experience with percutaneous catheter placement

BACKGROUND: Peritoneal fluid eosinophilia (PFE), which is classically associated with idiopathic eosinophilic peritonitis (EP), has been known as a common event in patients on continuous ambulatory peritoneal dialysis (CAPD). However, our recent retrospective study of CAPD patients following percutaneous catheter placement showed that PFE occurred rarely. The aim of this prospective study was to clarify the incidence and characteristics of idiopathic EP and PFE in patients on CAPD following percutaneous catheter placement. METHODS: Forty-eight patients on CAPD following percutanous catheter placement were recruited for the present study. Peritoneal dialysis was initiated immediately after catheter insertion without break-in period. A cytological study of dialysate was performed on days 1, 2, 3, 4, 5, 6, 7, 14 and 30 after initiation of CAPD, and then monthly for 6 months. In addition, a cytological study was performed also when a patient revealed abdominal pain or cloudy peritoneal effluent. RESULTS: PFE developed in three (6.3%) patients during the study period. The incidence of idiopathic EP and PFE without any clinical findings suggestive of PD-related peritonitis was 2.1% and 4.2% respectively. All cases of PFE, including idiopathic EP, developed on a mean of 13 day following initiation of CAPD and resolved spontaneously after a mean of 7 days. There was no significant difference in IgE levels or the occurrence of peripheral blood eosinophilia between patients with PFE and those without. CONCLUSION: Idiopathic EP is infrequent among patients on CAPD following percutaneous catheter placement, but should be differentiated from infectious PD-related peritonitis.     

Surgical aspects of the Tenckhoff peritoneal dialysis catheter. A 7 year experience

The experience with CAPD using the Tenckhoff catheter in 115 patients over a 7 year period has been reviewed. The general indications for CAPD in the patient with chronic renal failure are the mental and physical ability of the patient or his relatives to perform CAPD. In our series, diabetes mellitus has been a relative indication for CAPD, because diabetic patients often have vascular disease severe enough to make long-term hemodialysis difficult. The general contraindications are abdominal problems such as hernias, abdominal wall infections, inflammatory bowel disease, adhesions, and gastrointestinal stomas. Other contraindications are lumbar disk disease and respiratory insufficiency. The surgical principles of catheter insertion have been described. Complications associated with the Tenckhoff catheter were either mechanical (intraabdominal organ injury, incisional hernia, catheter leakage, catheter occlusion, or catheter dislodgement), or infectious (peritonitis or abdominal wall infection). The single most common organism isolated from effluent dialysate in 65 patients with peritonitis was Staphylococcus epidermidis in six patients (9.2 percent), and in 20 patients (30.8 percent), no organism could be isolated. For those patients who had peritonitis, the average frequency was at 8.9 months of CAPD. There were only three deaths (3 percent) directly related to the Tenckhoff catheter and these were due to peritonitis and sepsis. Only 22 (19 percent) of the 115 patients in this series had to discontinue CAPD because of its ineffectiveness or the patient's or relative's inability to perform CAPD.