Abstract
Cause of Death in Continuous Ambulatory Peritoneal Dialysis Patients Covered by the PD-First Policy Project in Thailand
Background: In 2002, the Thai government launched a health care scheme in Thailand to include 48 million people who are not government-related and not private employees. This scheme is called “universal coverage” health care. The Thai government officially announced a “peritoneal dialysis first” (PD-First) policy for people with end-stage renal disease (ESRD) in October 2007 and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment. We studied data from 23 continuous ambulatory PD (CAPD) hospitals, called “phase I CAPD hospitals,” which had experience in PD before the policy.
Objectives: To analyze cause of death in CAPD patients covered by the PD-First policy project in Thailand.
Methods: This descriptive study reports causes of death in CAPD patients covered by the PD-First policy project in Thailand from October 2007 to April 2009.
Results: We reviewed the records of 961 CAPD patients from 15 phase I CAPD hospitals. Deaths totaled 88, for a mortality rate of 9.1%. Causes of death were sepsis in 27.1%; cardiovascular disease in 13.6%; cerebrovascular disease in 9.9% (most being intracerebral hemorrhage); carcinoma (breast and lung) in 2.5%; and unclassified in 47%.
Conclusions: The results show that the most common cause of death in CAPD patients in the hospitals studied is sepsis. However, the major cause should be cardiovascular mortality, because the unclassified group who died at home or outside the hospital may die mainly from heart attack. To reduce the mortality rate, preventive measures therefore have to be applied for both sepsis and cardiovascular disease.
A Novel Intervention for Peritoneal Dialysis–Associated Peritonitis: Laparoscopic-Assisted Removal of Biofilm
Introduction: Peritonitis is a major complication of peritoneal dialysis (PD). Refractory, recurrent, and relapsing peritonitis are major causes of technique failure. Current management guidelines state that removal of the PD catheter is strongly indicated for these forms of PD-associated peritonitis. We describe a new treatment for PD-associated peritonitis: mechanical removal of catheter-associated bacterial biofilm and laparoscopic peritoneal lavage while preserving the catheter.
Methods: Between July 2007 and December 2008, 6 PD patients [5 women, 1 man; mean age: 56.2 ± 15.9 years (range: 24 – 73 years)] with refractory [extended-spectrum beta lactamase bacteria, methicillin-resistant S. aureus (MRSA), E. coli, Acinetobacter] or relapsing (S. aureus, Burkholderia pseudomonas) peritonitis underwent laparoscopic intervention. Clinically septic patients were excluded. Mini-laparoscopic ports were inserted under conscious sedation. Almost the entire length of the catheter was exteriorized via a port site, internally brushed, flushed with povidone iodine, externally scrubbed with gauze, and returned to the pelvic cavity. Laparoscopic release of sequestrations and lavage were performed. After the operation, PD and intraperitoneal antibiotics were continued. Peritoneal fluid cell counts and cultures were repeated.
Results: The peritonitis resolved in all 6 patients after laparoscopic intervention. The PD fluid cleared, and cell counts returned to 0 after a median of 8 days (range: 3 – 10 days). The primary success rate was 100%. Two repeat infections occurred 2 months (Acinetobacter) and 9 months (MRSA) after surgery. The repeat Acinetobacter infection was successfully treated with antibiotics alone. The catheter with repeat MRSA infection was removed. The secondary success rate was 83%. Of the 6 patients, 5 were on regular PD at a median follow-up of 15 months (range: 6 – 23 months).
Conclusions: This pilot study suggests that laparoscopic intervention with eradication of catheter-associated bacterial biofilm is an effective treatment for refractory and relapsing PD peritonitis. Catheter removal is avoided. Larger studies are needed to evaluate the potential reduction in the technique failure rates and overall costs.
Peritoneal Scintigraphy: A Useful Tool in the Diagnosis of Peritoneal Adhesions
Aim: After severe episodes of peritonitis, some patients (pts) are not able to return to continuous ambulatory peritoneal dialysis (PD) because of peritoneal adhesions (PAds). Unfortunately, it is difficult to predict who will have significant PAds causing technique failure. Furthermore, current radiologic investigations [ultrasonography and contrast-enhanced computed tomography (CECT)] have low sensitivity in the diagnosis of PAds. Peritoneal scintigraphy (PS) is useful for evaluation and assessment of chronic PD pts who develop anatomic problems and problems with ultrafiltration or drainage. We used PS to diagnose PAds before catheter reinsertion.
Methods: We performed PS by mixing 2.0 mCi of 99m Tc sulfur colloid in 2 L 2.5% dextrose PD solution and then infusing the dialysate using a 14-gauge intravenous cannula under aseptic conditions. Scintigraphic views were obtained using a large field of view scintillation camera set at the 140-keV photopeak with a 20% window and equipped with a low-energy parallel-hole collimator. Starting at the time of infusion, a dynamic series of 1 minute-per-frame images centered on the diaphragmatic region were obtained for 15 minutes; static anterior, posterior, and lateral views of the abdomen were then obtained at post-infusion phase, post-ambulatory phase, and after the radiolabeled dialysate was drained. A normal scan should demonstrate free flow of dialysate fluid throughout peritoneal cavity, outlining the intraperitoneal recesses. When PAds were present, the scintigram reveals non uniform distribution of the dialysate, with most of it confined to the central part of the abdomen in several loculations. The loculated tracer accumulation persists even after drainage of the dialysate, confirming the presence of PAds. Imaging by CECT is performed for comparison with the scintigram. Six pts underwent these investigations before re-insertion of a Tenckhoff catheter. All pts underwent laparotomy. In all 6 pts, CECT showed no evidence of peritoneal thickening, peritoneal enhancement, and PAds. The scintigram suggested PAds in 4 pts, and no PAds in 2. The PS findings were confirmed on laparotomy.
Conclusions: PS proved useful in the diagnosis of PAds before catheter reinsertion. PS is a simple procedure and minimally invasive. it particularly avoids perforation of intestine that may be immediately adherent to the abdominal wall.
Effect of Continuous Quality Improvement in Preventing Peritoneal Dialysis-Related Peritonitis
Objective: To analyze the causes and factors of continuous ambulatory peritoneal dialysis (CAPD)–related peritonitis and to reduce the incidence of peritoneal dialysis (PD)–related peritonitis through a continuous quality improvement (CQI) process.
Methods: In a 12-month study (December 2007 to December 2008), 145 PD patients dialyzed for more than 3 months were investigated for basic information, primary disease, cultural background, family circumstances, and possible reasons for CAPD-related peritonitis. Nutrition status was evaluated by SGA, and serum albumin and hemoglobin were determined. Using the 4-step problem-solving framework called the Plan–Do–Check–Act (PDCA) cycle, we conducted a CQI program.
Results: During 2007, 33 patients experienced a peritonitis episode. The incidence of PD-related peritonitis was 1 episode in 50.5 patient–months. There were 17 patients (53.1%) who did not adhere strictly to the rules of aseptic technique, which is an important cause of peritonitis. In 10 cases (30.3%), the peritonitis was related to diarrhea and constipation; in 4 cases (12.1%), it was caused by a bad living environment; in 2 cases (6.1%), it was caused by an upper airway infection. Afterward, we followed the patients for 12 months and conducted the CQI program. We intensified patient education, improved the patient's nutrition status, and reduced various infection factors, among other steps. At the end of follow-up, the incidence of PD-related peritonitis decreased significantly to 1 episode in 65.6 patient–months in 2008 from 1 episode in 50.5 patient–months in 2007 (p < 0.05).
Conclusions: Lack of a concept of aseptic technique in patients is a crucial cause of peritonitis. We can successfully use a CQI program to reduce the incidence of peritonitis.