Abstract
Efficacy of Continuous Ambulatory Peritoneal Dialysis in E Hospital, Hanoi, Vietnam
Aim: In E Hospital, Hanoi, Vietnam, we started to use peritoneal dialysis (PD) for kidney failure patients in 2005. Following the patients for 6 months, we evaluated the quality of technique and the efficacy of the treatment.
Methods: The study included 16 patients (9 men, 7 women; average age: 50.4 ± 12 years). The main causes of renal failure were chronic glomerulonephritis (81%), hypertension (12%), and diabetes mellitus (6%). Clinical symptoms improved after continuous ambulatory PD (CAPD). Anemia and nutrition were ameliorated, and the patients feel well. Hypertension is 34% controlled.
Results: Laboratory results before and 6 months after dialysis were blood urea nitrogen, 15.1 ± 12 mg/dL and 16.8 ± 5.8 mg/dL; creatinine, 830 ± 197 μg/dL and 790 ± 162 μg/dL; potassium, 4.0 ± 0.7 mEq/L and 4.0 ± 0.6 mEq/L; hemoglobin, 90.2 ± 12 g/L and 99 ± 17.9 g/L; protid 68.4 ± 5.6 and 66.6 ± 7.4; and albumin, 38.9 ± 5.5 g/L and 37.7 ± 5.5 g/L. Complications included pleural effusion (1 patient), umbilical hernia (2 patients), peritonitis (1 episode/12 patient–months), migration and obstruction of peritoneal catheter (3 patients, 18.8%). Two patients (12.5%) dropped out from CAPD therapy (because of pleural effusion and catheter obstruction). Two patients died from myocardial infarction.
Is There Any Difference in Patient Outcome between Patients Using and Not Using Automated Peritoneal Dialysis
Aim: To find out the influence on patient mortality, residual kidney function, and peritonitis episodes of using an automated peritoneal dialysis (PD) system.
Methods: We retrospectively analyzed outcome for all patients who started PD in two centers during 2002 – 2008: n = 247, including 131 patients on continuous ambulatory PD (CAPD) or intermittent PD (IPD) or both, and 87 patients on automated PD (APD) or continuous cycling PD (CCPD) or both. There was no significant difference in the background of the patients in the two centers. Patients who transferred to another dialysis modality were excluded.
Results: We analyzed PD technique survival and mortality by log-rank test, the number of cardiovascular events and peritonitis episodes by chi-square test, and residual kidney function by t-test. There was no significant difference between the groups in technique survival (p = 0.339), mortality (p = 0.617), or residual kidney function (p = 0.963).
Conclusions: We found no difference in technique survival, mortality, residual kidney function, or peritonitis episodes between APD and CAPD.
Short-Term Outcomes of Transfer-Set Connection Techniques in Continuous Ambulatory Peritoneal Dialysis Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) and made it effective 1 January 2008. Currently, more than 3000 new PD patients have received treatment.
Objectives: To study transfer-set (TS) connection techniques in PD exchanges and the correlation between the peritonitis rate and TS connection techniques in continuous ambulatory PD (CAPD) patients.
Methods: A descriptive study with an analytical portion was performed. Subjects were 95 CAPD nurses from 30 hospitals in Thailand, selected by simple sampling. Instruments used were forms for collecting demographic data, peritonitis rates, and TS connection technique data.
Results: The study obtained data on 2254 transfer-set changes in 1 year. The connection techniques were similar, but differed in some procedures such as using 1 or 2 pairs of gloves, flushing the Tenckhoff catheter with 5 – 100 mL PD fluid before connecting a new TS, and changing to a new disinfection cap. The time for the procedure ranged from 20 minutes to 45 minutes. The disinfectant solution used was povidone iodine, and the procedure cost was US$33. Problems included TS obstruction (18%), tear scar of TS (15%), incomplete lock of catheter adapter and TS (14%), Unknown foreign matter in Tenckhoff catheter and TS (13%), and TS changed in color to red, yellow, or black (9%). There was no evidence of peritonitis within 3 days after the procedure. There was no statistically significant relationship between the rate of peritonitis and TS connection.
Conclusions: Flushing the Tenckhoff catheter with 5 – 100 mL PD fluid before connecting a new TS may be useful for eliminating any residual disinfectant or contaminants. The technique of TS connection is an important procedure for CAPD nurses and should be safe, simple, and cost-effective.
Causes of Modality Shift from Peritoneal Dialysis (PD) to Hemodialysis in Continuous Ambulatory PD Patients Covered by the “PD First” Policy Project in Thailand
In 2002, the Thai government launched a health care scheme in Thailand to cover 48 million people who are not government-related and not private employees. This scheme is “universal coverage” health care. In October 2007, the Thai government officially announced a “peritoneal dialysis (PD) first” policy for people with end-stage renal disease (ESRD) 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 (so-called Phase I CAPD hospitals) that had experience with PD before the policy.
Objectives: To study the causes of modality shift from PD to hemodialysis (HD) in CAPD patients.
Methods: This descriptive study collected data from 23 PD pilot project hospitals in Thailand from October 2007 to April 2009.
Results: The study enrolled 1320 patients. During the study, 225 patients (17%) dropped out, 126 patients (9.5%) died, and 68 patients switched to HD (5.1%), received a kidney graft (1%), or otherwise changed treatment (0.4%). The main causes of modality shift were severe peritoneal fibrosis from PD-related peritonitis (n = 39, 57%), PD fluid leakage (n = 8, 12%), and no caregiver (n = 6, 8%). Other causes included intractable peritoneal malposition (n = 4, 6%), hernia (n = 2, 3%), severe depression, ultrafiltration failure because of high transport, bowel perforation, and BMI more than 35 kg/m2.
Conclusions: The results indicate that the major cause of modality change from PD to HD in our series was severe peritoneal fibrosis from PD-related peritonitis. Prevention and aggressive treatment of PD-related peritonitis should be encouraged.
Summary Report of 608 Cases Using a Trocar to Insert a Chronic Dual-Cuff Catheter into Peritoneal Dialysis Patients
Objectives: To explore a new surgical method to insert chronic dual-cuff catheters into peritoneal dialysis (PD) patients.
Methods: At 11.5 cm from the upper margin of the pubic bone, make a transrectus incision at the left side as the catheter insertion position. Cut the skin, subcutaneous tissue, and anterior sheath of the rectus abdominis, and then separate the rectus abdominis. Puncture the posterior rectus abdominis with a trocar and cross the peritoneum less than 0.5 cm, about <0.4 cm. Remove the core needle, and thread the guidewire along with trocar. Place the catheter into the vesicorectal pouch or rectouterine pouch. Fix one cuff at the posterior rectus abdominis, and then make sure that the PD solution inflow and outflow are successful. Suture the rectus sheath, fix the second cuff, and then suture the skin. For the last 20 years, we have used this technique to insert a chronic dual-cuff catheter into 608 PD patients, with every case being successful. From 2006 to 2008, we randomly chose patients to undergo the ordinary surgical method (n = 60) or the new technique (n = 60).
Results: In the ordinary surgery group, 3 cases experienced leakage and 24 had bloody effluent, including 9 cases that had bloody effluent for 3 days. On the other hand, patients who underwent the new technique could carry out PD immediately after the operation was finished, and the operation time was just 20 minutes. There was no bleeding, leakage, or other complications.
Conclusions: The trocar developed by our department received a national patent and the clinical research into the technique received the second prize of Jilin Technical Progress. Compared with ordinary surgery, the trocar technique is safe, easy, reliable, and less painful, and the surgical time is short. It can be introduced to other hospitals so that more uremia patients can receive CAPD.
Application and Impact Assessment of Hydrofilm in Catheter Care in Peritoneal Dialysis Patients
Objectives: To study the effect of hydrofilm in the care of the peritoneal dialysis (PD) drainage tunnel, so as to avoid frequent touching or moving of the catheter during exchanges or daily activities, and ensuring natural drainage of the tunnel to maintain the catheter and the sterile state of the tunnel output to prevent exit-site infection.
Methods: We randomly assigned 100 PD patients to and experimental and a control group. In the experimental group, the patients used hydrofilm to cover the exit and PD catheter. The exit portion of the catheter was about 8 cm, and it was fixed to the abdomen. In the control group, the patients used conventional sterile gauze to cover the exit and PD catheter, and the catheter was not fixed. In the absence of exceptional circumstances, dressings were replaced every 7 days in both groups, and the groups were observed for 1 – 6 weeks after catheter insertion.
Results: There was no significant difference between the two groups of patients in fluid exit (p > 0.05). In 8 control cases, the exit appeared red and swollen; 12 cases experienced pain; and 16 cases experienced skin excision. In the experimental group, 2 cases had inflammation, 5 had pain, and 2 had skin excision. All the results between the groups were statistically significant (p < 0.05). In the control group, dressing fixed-time was 3.8 days on average; in the experimental group, it was 6.7 days on average.
Conclusions: The application of hydrofilm to cover the PD drainage tunnel exit can permitted natural drainage of the tunnel and maintained a state of partial sterility. Using the film, the drainage tunnel can be better fixed so as to reduce mechanical traction during PD exchanges and daily activities, which also can promote early healing of the tunnel exit and provide more comfort to PD patients.
A Better Catheter Insertion Method for Peritoneal Dialysis Patients, with Clinical Observations
Objectives: To evaluate the advantage of using the upper margin of the pubic bone as the mark for catheter insertion. To explore a better catheter insertion method. To assess clinical outcomes and complications in continuous ambulatory peritoneal dialysis (CAPD) patients.
Methods: The study enrolled 309 patients (203 men, 106 women; age range: 8 – 79 years; mean age: 39 years) on CAPD. An area 8 cm from the upper margin of the pubic bone was used as the catheter insertion position, evaluating the distance between the upper margin of the pubic bone and the umbilicus, and analyzing the relationship between the distance and the patient's height and weight. The incidence of catheter obstruction and long-term complications after catheter insertion were analyzed. Blood pressure and hemoglobin in the patients before and after PD were compared, and we analyzed the reasons that patients withdrew from PD.
Results: The catheter insertion position using the upper margin of the pubic bone as the mark is stable. The incidence of catheter obstruction was 2.6%. Other complications of PD included bloody effluent, exit-site or tunnel infection, and peritonitis (which was the most common long-term complication). After PD, blood pressures in the patients was controlled very well, and hemoglobin increased significantly. The primary reason that patients withdrew from PD was death caused by long-term complications of PD.
Conclusions: The upper margin of the pubic bone is useful as the mark for catheter insertion. PD is efficient and safe, and as a renal replacement therapy, can improve the patients’ quality of life.
The Experience of Applying a Minimally Invasive Method to Correct the Catheter in Peritoneal Dialysis
Objectives: Catheter (cath) migration is a common complication of peritoneal dialysis (PD). This study analyzed the causes of poor cath drainage or cath migration in PD patients (pts) and evaluated the efficacy of using a disinfected gastroscope brush to correct cath drift with poor drainage after implantation.
Methods: From June 2008 to April 2009, the study enrolled 10 PD pts [7 men, 3 women; mean age: 57.4 ± 13.4 years (range: 22 – 88 years)] with cath migration in our department. Tenckhoff caths were used by all pts (3 straight, 5 coiled, and 2 swan-neck), and all experienced poor drainage, confirmed by abdominal X-ray. The type of PD cath was determined, and the depth of the PD cath was marked for gastroscope distance (straight cath: 38 – 40 cm; swan-neck cath: 45 cm; coiled tube: 60 cm plus 2 cm buffer distance). The exit of the PD cath was disinfected, and the gastroscope brush was inserted into the exit end of the cath and then slowly pushed and pulled. The guide wire was removed to let the cath clear. The titanium joint and short tube were then connected, and the lumen was filled with heparin and antibiotic (gentamicin or piperacillin). The surgical field was then disinfected, covered, and fixed with sterile gauze. All pts underwent another abdominal X-ray examination and took anti-inflammatory treatment with a conventional antibiotic for 3 days.
Results: The causes of end-stage renal disease in the pts included chronic nephritis (4 cases), chronic obstructive nephropathy (3 cases), diabetic nephropathy (2 cases), and hypertensive nephropathy (1 case). In 7 cases, cath removal occurred on the 14th day after surgery; in 2 cases, after less than 2 months; and in 2 cases, after 2 months. Cath replacement operations were successful in 9 cases. However, 1 case with a coiled cath failed, and during correction by laparoscopic surgery, peritoneum could be seen to be extensively wrapping the PD cath, with some peritoneal tissue entering the lumen. Anesthesia is unnecessary during correction surgery: 9 pts had no discomfort, and 1 pt had mild abdominal pain and recovered after a rest.
Conclusions: Disinfected gastroscope brush is efficatious in cath correction. It can reduce the financial and psychological burden of pts and improve their quality of their life.