Peritonitis in continuous ambulatory peritoneal dialysis: impact of a compulsory switch from a standard to a Y-connector system in a single North American Center.

One hundred one continuous ambulatory peritoneal dialysis (CAPD) patients from a single North American center were analyzed in a retrospective and cross-over study for peritonitis rates using a standard system (Travenol System II) or a Y-shaped disconnect-disinfectant system (Travenol O-set). Twenty-one of 34 patients using the standard set (group I) had 53 episodes of peritonitis in 508 patient-months or one episode per 9.6 patient-months. Nine of 17 patients switching from the standard to the disconnect-disinfectant system (group II) experienced 22 episodes of peritonitis in 275 patient-months or one episode per 12.5 patient-months on the standard set, while six patients had 10 episodes of peritonitis in 275 patient-months or one episode per 27.5 patient-months on the disconnect-disinfectant system (P less than 0.04). Twenty-eight of 67 new CAPD patients starting on the disconnect-disinfectant system (group III) had 37 episodes of peritonitis in 1,086 patient-months or one episode per 29.4 patient-months (P less than 0.01 v group I). Exit-site infections (ESI) occurred in 35.3% of patients using the standard set versus 34.3% of those using the O-set. The presence of an ESI was not associated with a higher risk of peritonitis, but modified the bacteriological profile of subsequent peritonitis episodes in patients using the O-set, favoring the organisms isolated from the exit site. Decreases in peritonitis rates with the O-set were due to a reduction of peritonitis episodes secondary to most bacterial agents and not only to skin organisms. Diabetics using intraperitoneal insulin had similar peritonitis and ESI rates as nondiabetics.(ABSTRACT TRUNCATED AT 250 WORDS)     

Impact of new dialysis solutions on peritonitis rates

Peritonitis remains a major cause of morbidity among patients on peritoneal dialysis (PD), yet there is little information about the effect of new biocompatible dialysis solutions on peritonitis rates and treatment. In our unit, information on each peritonitis episode is prospectively collected. Since 2003, bicarbonate/lactate dialysate has been gradually introduced for new patients and for patients experiencing abdominal pain with conventional lactate solutions. From 2002 to 2005, data from 121 episodes of peritonitis (71 automated PD and 50 continuous ambulatory PD) were analyzed; 107 episodes occurred in patients using standard lactate dialysate and 14 episodes in patients using bicarbonate/lactate solution. Patients using bicarbonate/lactate had a significantly lower peritonitis rate of 1 per 52.5 patient-months compared to those using standard lactate dialysate (1 per 26.9 patient-months) (P=0.0179). Response to treatment, however, was not affected by the type of dialysate; cure rates (71.4 and 69.1%, respectively) and recurrence rates (21.4 and 15.8%, respectively) were not significantly different. Catheter removal was required in three (21.4%) patients using bicarbonate/lactate and 23 (22.4%) patients using lactate solution. Use of biocompatible dialysate appears to reduce the peritonitis rate by 50%, although this has to be confirmed in a randomized study. The type of dialysate, on the other hand, does not affect response to treatment.     

Initial Experiences with Continuous Ambulatory Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) has been initiated on 51 patients: 27 females (mean age -- 43.9 years) and 24 males (mean age -- 46.4 years). This group has been observed for a total of 1420 patient weeks of treatment (27.3 patient years). Thirty-six episodes of peritonitis have been noted among 19 patients. The overall incidence was one episode per 39.4 patient weeks. Recurrent episodes of peritonitis resulted in discontinuation of CAPD in five (9.8%) of the patients. Three (5.9%) of the patients were unable to continue with CAPD because of its inability to control extracellular fluid balance. In the patients who transferred from intermittent peritoneal dialysis to CAPD, there was a 4.5 mg/dl drop in serum creatinine and a 34 mg/dl drop in mean BUN values. There was a rise of approximately 2 gm in the hemoglobin levels of this group of patients. If the problem of peritonitis can be solved, CAPD will become the dialytic treatment of choice for the majority of patients with end-stage renal disease.     

Technical survival of CAPD catheters: comparison between percutaneous and conventional surgical placement techniques.

BACKGROUND: Percutaneous peritoneal dialysis catheter (PDC) placement is a well-tolerated, rapidly performed bedside procedure that allows a rapid initiation of CAPD. We compared the technical survival of PDCs while comparing the mode of insertion. METHODS: We retrospectively reviewed 215 PDCs inserted over a 60-month period in 191 patients on CAPD therapy. Of these, 133 were placed percutaneously by nephrology staff (group P) and 82 were placed using conventional surgical techniques by surgical staff (group S). The total experience accumulated was 4000 patient-months: 2260 patient-months in group P and 1740 patient-months in group S. RESULTS: The incidence of complications in PDCs did not differ between the groups (1 episode/33 patient-months in group P and 1 episode/29 patient-months in group S). Two episodes of early leakage and 9 episodes of late leakage were observed in group P compared with one early leakage and 4 episodes of late leakage in group S. Of the mechanical complications in group P, 8.86% were due to catheter malfunction, including catheter tip migration and obstruction, compared with 12.63% in group S. The incidence of catheter infections was 1 episode/73 patient-months in group P and 1 episode/62 patient-months in group S. Significantly more catheters were removed in group S compared with group P (40% vs 16%, P<0.001). One-year and 2-year technical survivals were 90% and 82% in group P, and 73% and 60% in group S (P=0.0032), respectively. CONCLUSIONS: Percutaneous bedside placement of PDCs by nephrologists provides a safe and reliable access for peritoneal dialysis.     

Clinical outcomes of systemic lupus erythematosus patients undergoing continuous ambulatory peritoneal dialysis.

OBJECTIVES: The purpose of this study was to evaluate the outcome of systemic lupus erythematosus (SLE) patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Eighteen SLE patients who had been undergoing CAPD for at least 3 months in our unit were compared with 36 other age- and gender-matched non-diabetic CAPD patients with an underlying primary chronic glomerulonephritis (CGn). The clinical outcome, infective complications, lupus activities, biochemical parameters, haemoglobin level and the use of erythropoietin were reviewed. RESULTS: The duration of dialysis of the two studied groups was not different, with a mean of 35.4 months for the SLE group and 36.7 months for the CGn group. Before dialysis, SLE patients had a significantly lower albumin level (30.4+/-6.6 vs 35.4+/-5.59 g/dl, P<0.01), while the mean haemoglobin levels of the two groups were similar (8.5+/-1.8 g/dl for SLE vs 9.0+/-1.9 g/dl for the control group). However, the weekly dose of erythropoietin (EPO) used was significantly higher in the SLE group (6000 vs 3818 U/week, P<0.01) to maintain a similar haemoglobin level during dialysis. Regarding the infective complications, the SLE group had a higher peritonitis rate (5.7 episodes/100 patient-months vs 2.4 episodes/100 patient-months, P<0.05), and an increase in the non catheter related infection rate (6.67 episodes/100 patient-months vs 1.1 episodes/100 patient-months, P<0.001). However, no significant difference could be demonstrated in the Tenckhoff catheter exit site infection rate (2 episodes/100 vs 1.7 episode/100 patient-months). The number of patients who received a kidney transplant or required a change of mode to haemodialysis was similar among the two groups. Seven patients died during the follow-up period, and the overall mortality rate was much higher in the SLE group than in the control group (0.83/100 vs 0.15/100 patient-months, P<0.05). CONCLUSIONS: SLE patients on CAPD have a significantly lower pre-dialysis serum albumin level and use a higher dose of Epo to achieve a comparable haemoglobin level than other non-diabetic CGn CAPD patients. They also have a poorer prognosis in terms of infective complications and mortality rate.     

Continuous cycling peritoneal dialysis is associated with lower rates of catheter infections than continuous ambulatory peritoneal dialysis

Continuous cycling peritoneal dialysis (CCPD), unlike continuous ambulatory peritoneal dialysis (CAPD), provides freedom from daytime exchanges and is associated with lower rates of peritonitis. However, catheter infection (CI) rates have not been reported for CCPD. Previous data suggested that a CAPD disconnect system (Y-set) was associated with lower rates of CI. These results suggested that patients on CCPD, which is also a disconnect system, might also have low CI rates. We evaluated our CCPD patients for infection rates and compared them with two groups of matched control CAPD patients, one using a spike system and one a Y-set disconnect system to evaluate this hypothesis. The CCPD patients had the lowest rates of CIs (0.5 episodes per year or one episode every 25 months), followed by the CAPD patients using the Y-set (0.8 episodes per year or one episode every 14 months). CAPD patients using the spike system had the highest rates of CIs (1.2 episodes per year or one episode every 10 months). Peritonitis rates followed the same pattern among the patient groups: CCPD, 0.3 episodes per year; CAPD, Y-set 0.5 episodes per year; CAPD, spike system 1.3 episodes per year. Our data suggest that disconnect systems, such as the CAPD Y-set and CCPD, reduce CIs, as well as peritonitis.     

Do the Y-set and double-bag systems reduce the incidence of CAPD peritonitis? A systematic review of randomized controlled trials.

BACKGROUND: Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis. This systematic review sought to determine if modifications of the transfer set (Y-set or double-bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes. METHODS: Based on a comprehensive search strategy, we undertook a systematic review of randomized or quasi-randomized controlled trials comparing double-bag and/or Y-set CAPD exchange systems with standard systems, or comparing double-bag with Y-set systems, in patients with end-stage renal disease (ESRD) treated with CAPD. Only published data were used. Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Its statistical package, Metaview 3.1, calculated an odds ratio (OR) for dichotomous data and a (weighted) mean difference for continuous data with 95% confidence intervals. RESULTS: Twelve eligible trials with a total of 991 randomized patients were identified. In trials comparing either the Y-set or double-bag systems with the standard systems, significantly fewer patients (133/363 vs 158/263; OR 0.33, 95% CI 0.24-0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis was consistently greater. When the double-bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (44/154 vs 66/138; OR 0.44, 95% CI 0.27-0.71) and the number of patient-months on CAPD per episode of peritonitis was also greater. CONCLUSIONS: Double-bag systems should be the preferred exchange systems in CAPD.     

Biocompatibility pattern of a bicarbonate/lactate-buffered peritoneal dialysis fluid in APD: a prospective, randomized study.

BACKGROUND: In chronic ambulatory peritoneal dialysis, bicarbonate-buffered fluids, with their neutral pH and less advanced glycosylation end-products (AGE) and glucose degradation products (GDP), have better biocompatibility than conventional peritoneal dialysis (PD) solutions. That difference may be more beneficial in automated peritoneal dialysis (APD), due to its more frequent exchanges and longer contact times with fresh dialysate. We performed a prospective, randomized study in APD patients to compare the biocompatibility of conventional and bicarbonate/lactate-buffered PD fluids. METHODS: We randomized 14 APD patients to have APD with either conventional or bicarbonate/lactate-based fluids. After 6 months, both groups changed to the other solution. The overall observation period was 12 months. After 1 and 5 months and again after 7 and 11 months, phagocytotic and respiratory burst capacities of effluent peritoneal macrophages were determined. Plasma interleukin (IL)-6 and C-reactive protein (CRP) as well as effluent IL-6, CRP, transforming growth factor (TGF)-beta 1, AGE and CA125 concentrations were measured. Inflow pain was quantified using a patient questionnaire. RESULTS: Respiratory burst capacity remained unchanged and phagocytotic activity increased significantly during APD (P<0.001) with the bicarbonate/lactate fluid. Effluent IL-6 release was significantly lower than with the lactate fluid (P<0.05). While in the effluent TGF-beta 1 was unaffected, AGE concentration was lower after bicarbonate/lactate treatment (P<0.05). Effluent CA125 concentration, an indicator of mesothelial cell integrity, was higher (P<0.05) in neutral effluents. Finally, patients' inflow pain diminished (P = 0.05) when using the neutral fluid. CONCLUSIONS: The use of a neutral PD fluid in APD improved patients' inflow pain as well as biocompatibility parameters reflecting enhanced phagocytotic activity of peritoneal macrophages, reduced constitutive inflammatory stimulation (IL-6), reduced AGE accumulation in the peritoneal cavity and better preservation of the mesothelial cell integrity. From the biocompatibility point of view, a neutral fluid with low GDP content can be recommended as the primary choice for APD.     

The Comparison in Terms of Early Complications of a New Technique and Percutaneous Method for the Placement of CAPD Catheters

Background. Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. Subjects and method. Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. Results. In all of the subjects, dialysis was started soon after catheter placement. No per-operative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. Conclusion. The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.     

Peritoneal dialysis-associated peritonitis in Scotland (1999-2002).

BACKGROUND: Peritonitis is a major complication of peritoneal dialysis (PD). We have performed a national study of all patients on PD in Scotland over a 3.5 year period examining the causes of technique failure, rates of peritonitis, causative organisms, clinical outcomes and differences between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). METHODS: All 10 adult renal units in Scotland participated in the study and the data include all 1205 patients who were on PD in Scotland from January 1999 to June 2002. The data were collected prospectively by the PD nurses and reported to the Scottish Renal Registry every 6 months. RESULTS: Refractory or recurrent peritonitis was the cause of technique failure in 167 patients (42.6% of all cases of technique failure). There were 928 cases of peritonitis in 1487 patient-years, which equates to an overall peritonitis rate of one episode every 19.2 months. The peritonitis rates for APD and CAPD were similar at one episode every 20.3 months and one episode every 18.6 months, respectively. These results include 88 cases of peritonitis due to relapse or re-infection. There was a statistically significant difference (P = 0.012) in peritonitis rates between units using nasal mupiricin (one episode every 21.9 months) and those that did not (one episode every 18.3 months). Coagulase-negative Staphylococcus was the most common cause of peritonitis (29%), although this rate is lower than in historic studies. The overall initial cure rate was 75%. The initial cure rate for APD was 77.2% and for CAPD was 73.7%. No causative organism was isolated in 17% of cases. CONCLUSION: PD-associated peritonitis is the leading cause of technique failure in Scotland. We validate previous studies showing a decrease in the proportion of peritonitis episodes that are caused by coagulase-negative staphylococci. APD peritonitis rates are not significantly better than CAPD peritonitis rates in Scotland, and the initial cure rates for APD and CAPD are similar.     

Long-Term Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Peritonitis: Surgery can be Avoided

INTRODUCTION

Continuous ambulatory peritoneal dialysis (CAPD) has become the preferred method of home dialysis for patients with end-stage renal failure. Peritonitis is a common and serious complication and requires prompt diagnosis and treatment. The aim of this study was to assess what proportion of patients with CAPD peritonitis that required surgical intervention for on-going sepsis or for peritonitis-related bowel obstruction.

PATIENTS AND METHODS

All patients presenting with a first episode of CAPD peritonitis during the 5-year period from 1994–1998 were identified from a prospectively maintained database. Data collected included patient demographics, details of peritonitis episodes and their treatment, and details of any surgical intervention undertaken.

RESULTS

A total of 500 episodes were identified in 168 patients of whom 162 had complete follow-up representing 488 peritonitis episodes. Sixty-three patients experienced one episode of peritonitis, 33 two episodes, 20 had three episodes, and 46 had more than three episodes. None of the patients underwent surgery either primarily or for complications of the infective episode. A total of 465 episodes were due to a single organism (95%) and the remainder were due to multiple organisms (5%). The most common causative organisms were Gram-positive cocci (308 episodes; 71%) followed by Gram-negative bacilli (106 episodes; 24%). In 55 patients (34%), the same organism was implicated in consecutive admissions. Patients with autosomal dominant polycystic kidney disease (ADPKD), whilst accounting for 12 of 169 (7%) patients in the cohort, experienced 23 of 125 (18.4%) episodes of peritonitis by Gram-negative cocci. Such infections were seen in 8 of 12 (66.7%) ADPKD patients and accounted for 23 of 40 (57.5%) infections experienced by the ADPKD patients.

CONCLUSIONS

Whilst CAPD peritonitis is a common problem in the renal failure population, with almost 100 episodes per year, it would appear that most episodes can be managed using intraperitoneal antibiotics without the need for surgical intervention.     

Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis.

BACKGROUND: Automated peritoneal dialysis (APD) and twin-bag (TB) systems are two major peritoneal dialysis (PD) modalities. Published data comparing the infectious complications of these modalities is limited. Subjects and methods. Ninety-five patients using APD (the APD group) and 117 patients using TB system (the TB group) were recruited. Among them, 35 patients used both modalities. The two groups' clinical characteristics, incidences of infectious complications, and the time intervals to first PD-related infection were compared. RESULTS: Clinical characteristics, incidence of exit-site infection (ESI), and time intervals to first ESI were similar in the TB and APD groups. The incidence of peritonitis in the APD group (1.22 episodes/100 patient-months) was significantly (P < 0.001) lower than that of the TB group (2.28 episodes/100 patient-months). Using the Cox proportional hazard model, APD was found to have a lower risk of peritonitis relative to TB systems, with marginal significance (RR 0.58, P = 0.051). CONCLUSION: APD was found to have a lower peritonitis rate than the TB system. Since reducing the peritonitis rate helps to maintain technical survival during PD, from this viewpoint, APD may be preferred for patients undergoing PD, unless contraindicated.     

The role of continuous ambulatory peritoneal dialysis in end-stage renal failure due to multiple myeloma

A study in 10 patients (eight male, two female; mean age 61.9 +/- 10.7 years) suffering from multiple myeloma (MM) and end-stage renal failure (ESRF) is detailed. Continuous ambulatory peritoneal dialysis (CAPD) was the preferred mode of chronic dialysis in all the patients. Survival after diagnosis was 32.2 +/- 23.9 months. Survival after starting dialysis was 24.6 +/- 20.6 months. All patients on CAPD were adequately dialyzed and in good fluid control. Peritonitis was the main problem on CAPD (one episode per 5.6 patient-months). The majority of peritonitis episodes responded to intraperitoneal antibiotic therapy. One patient with Staphylococcus aureus peritonitis, septicemia, and neutropenia secondary to chemotherapy, died. Recommendations for prophylaxis and treatment of peritonitis are given. Three patients were transferred to hemodialysis. The use of subclavian vein catheters during hemodialysis was associated with a high incidence of gram-positive septicemia. Alkylating agent-based chemotherapy resulted in hematological responses in five patients. Survival after diagnosis in those responders was 47.4 +/- 25.6 months, compared with 17.0 +/- 7.2 months in the nonresponders (P less than 0.05). All responders subsequently relapsed. Four patients died with progressive myeloma. Bone marrow suppression resulted in a high blood transfusion requirement, neutropenia, and thrombocytopenia associated with bleeding into the gastrointestinal tract and central nervous system. Uremic myeloma patients can be adequately dialyzed using CAPD. Those patients who do not have an initial hematological response have a poor prognosis.     

Successful prophylaxis for fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: six years' experience

Fungal peritonitis as a serious complication of continuous ambulatory peritoneal dialysis (CAPD) is often associated with severe morbidity, CAPD "drop-out" and, occasionally, death. Most episodes of fungal peritonitis occur during or after a period of antibiotic treatment of various bacterial infections, usually bacterial peritonitis. From April 1979 to December 1982 (period I), 10 episodes of fungal peritonitis occurred during 415 patient-months, ie, 10.5% of all peritonitis episodes recorded in our CAPD program. After the introduction of oral prophylaxis with 3 x 500,000 IU [corrected] nystatin during every course of antibiotic treatment, only four episodes of fungal peritonitis occurred during 2,102 patient-months, ie, 3.1% of all peritonitis episodes from January 1983 to March 1989 (period II). This difference between the first and second periods is significant (P less than 0.05). Moreover, none of the four patients who contracted fungal peritonitis in the second period received nystatin prophylaxis. Thus, the simple measure of oral prophylaxis using this nonabsorbable antifungal agent in every case of an antibiotic treatment largely eliminates the risk of fungal peritonitis in patients on CAPD.     

Effects of conventional and new peritoneal dialysis fluids on leukocyte recruitment in the rat peritoneal membrane

Peritonitis remains an important cause of morbidity and technique failure in peritoneal dialysis (PD). Conventional peritoneal dialysate fluids (PDF) inhibit peritoneal leukocyte function in vitro and may thus adversely affect the immune response to peritonitis. New PDF have been designed with neutral pH, low glucose degradation product (GDP) contents, and bicarbonate as buffer. The present intravital microscopy study examined the effects of conventional and new PDF on leukocyte behavior in the peritoneal microcirculation of Wistar rats. The visceral peritoneum was superfused by a control solution (EBSS), a conventional (CAPD), or a new bicarbonate-buffered PDF with neutral pH and low GDP content (CAPD BicaVera). In addition, spent conventional and new PDF were tested. The number of rolling, adhering, and extravasated leukocytes and leukocyte rolling velocity were assessed at different time intervals after exposure to lipopolysaccharide (LPS) or cell-free supernatants of coagulase-negative staphylococci (CNS-CFS). Exposure to LPS or CNS-CFS dissolved in EBSS dramatically increased the number of rolling, adhering and extravasated leukocytes and decreased leukocyte rolling velocity. Superfusion by CAPD abolished the LPS- or CNS-CFS-induced leukocyte recruitment, whereas CAPD BicaVera had significantly fewer depressant effect. Spent PDF affected the leukocyte response in a similar way as fresh PDF. High lactate concentrations, GDP, and hypertonicity appeared to be mainly responsible for the inhibition of leukocyte recruitment. In conclusion, conventional PDF abolish in vivo leukocyte recruitment in response to potent inflammatory stimuli. Bicarbonate-buffered pH-neutral PDF with low GDP contents have fewer depressant effects and may therefore contribute to a better preservation of peritoneal host defense.     

Humoral immunity and frequency of peritonitis in chronic peritoneal dialysis patients

This study was designed to investigate the humoral immune status and immunological abnormalities in relation to the pathogenesis of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). The levels of serum and dialysate total protein, immunoglobulins (IgG, IgA, IgM, and IgG subgroups), and C3 were measured at baseline and at the end of the study in 12 children and 10 adult patients on CAPD. The relationship between the levels of immunoglobulin and C3 and the frequency of peritonitis was investigated. Peritonitis occurred at a frequency of one episode every 3.9 and 6.3 patient-months in children at the beginning and at the end of the study, respectively; however, the respective rates for adult patients were one episode every 5.6 and 9.8 patient-months. The levels of serum immunoglobulin and C3 were normal in adults at the beginning and at the end of the study. However, the levels of serum IgG were low in 4 of 12 pediatric patients. Of the 4 patients with low total IgG, IgA was low in 1 and IgM was low in 2 patients. Of 4 patients with low total IgG, 2 also had low IgG1 and IgG2. However, 3 of the patients with normal IgG had low IgG2 levels at the end of the study. The levels of C3 were low in 6 of 12 and in 3 of 10 pediatric patients at the beginning and at the end of the study, respectively. The protein levels of dialysate were increased at 1-year follow-up in both groups, but the difference was only statistically significant in adult patients (P<0.05). No correlation was found between the levels of serum and dialysate immunoglobulin and the frequency of peritonitis in either group. In this study, hypogammaglobulinemia and hypocomplementemia were determined in pediatric patients undergoing CAPD. Although these immunological deficits are not major factors in the occurrence of CAPD-related peritonitis, they may contribute to the frequency of peritonitis. Received: 19 September 2000 / Revised: 7 February 2001 / Accepted: 24 August 2001     

The comparison in terms of early complications of a new technique and percutaneous method for the placement of CAPD catheters

BACKGROUND: Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. SUBJECTS AND METHOD: Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. RESULTS: In all of the subjects, dialysis was started soon after catheter placement. No peroperative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. CONCLUSION: The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.     

Long-term incidence of peritonitis in CAPD patients treated by the Y set technique: experience in a single center

Our experience of peritonitis in 156 patients over an 8-year period represents 186 episodes of peritonitis and 4,964 patient-months of CAPD. The incidence of peritonitis was significantly greater (1 episode every 8.6 patient-months) when the Oreopoulos technique was used and dropped to 1 episode every 43.3 patient-months when the Y set system was used. Of the 109 patients using the Y set system, 88 (80.7%) never had episodes of peritonitis, whereas only 7 (16.7%) of the 42 patients using the Oreopoulos technique were free of peritonitis. For 23 patients shifted from the Oreopoulos to the Y set technique, the incidence of peritonitis dropped from 1/9.8 to 1/35.2 episodes/patient-months.     

Use of different buffers in peritoneal dialysis

A buffer is included in the peritoneal dialysis solution in order to offset the hydrogen ions normally produced during the metabolic processes. Nowadays, the buffer used is lactate, and its concentration in conventional peritoneal dialysis fluids is 35 or 40 mmol/L. Despite the general thought that peritoneal dialysis adequately corrects uremic acidosis, several studies have demonstrated that more than 50% of patients present mild to moderate acidosis with the solution containing 35 mmol/L of lactate, although with a 40 mmol/L solution this percentage decreases, a substantial number of patients still remain acidotic. This acid-base derangement is characterized by a normal pH and a below-normal plasma bicarbonate concentration, although the external body base balance is in equilibrium. There is evidence that this condition contributes to uremic osteodystrophy and has a detrimental effect on protein metabolism. Conventional solutions also affect mesothelial cell viability and local leukocyte function and have potential systemic effects such as the impairment of cellular redox state. New solutions containing pure bicarbonate or a mixture of bicarbonate and lactate have recently been investigated. A bicarbonate solution containing 34 mmol/L significantly increased plasma bicarbonate levels as compared with the lactate 35 mmol/L solution. It has been demonstrated that bicarbonate solutions have better biocompatibility than the lactate buffered solution and substantially reduce abdominal discomfort experienced by a certain percentage of patients during the solution infusion. These studies demonstrated that the bicarbonate-buffered CAPD solution is safe, well-tolerated, and does not present any, even potential, side effects. Thus, it seems reasonable to consider the bicarbonate buffered solution the standard instead of the alternative, and it might entirely replace lactate as buffer in peritoneal dialysis fluid.     

Continuous Cyclic Peritoneal Dialysis: A Preliminary Report

Continuous cyclic peritoneal dialysis (CCPD) was designed to reduce the high incidence of peritonitis and eliminate the multiple interruptions created by dialysate exchanges during the day needed for CAPD, while maintaining the quality of dialysis. Three nocturnal cycles with 2 liters of dialysate lasting 3 hours each are provided by an automated cycler while the patient sleeps. Two liters are left in the abdomen in the morning. Only one daily connection and one disconnection are required between the peritoneal catheter and the cycler line. Our 84 patient months experience with 14 patients reveals a low incidence of peritonitis (1 per 42 patient months), satisfactory ultrafiltration rates and clearances that compare favorably with those of CAPD (C_urea 67, C_creatinine 58, and C_B12 45 L/wk). Blood pressure control has been excellent while most patients enjoy liberal diets.
This preliminary study suggests that CCPD may indeed reduce the rate of peritonitis, provide excellent clearance and ultrafiltration, allow more free time to the patient and maintain a steady physiological state.