Continuous ambulatory peritoneal dialysis: one year's experience in a UK dialysis unit.

Thirty-two patients aged 8-63 years trained to manage themselves by continuous ambulatory peritoneal dialysis for end-stage renal failure achieved better steady-state serum biochemistry and much higher haemoglobin and lower serum phosphate concentrations than during treatment with haemodialysis up to one year before. Two patients, however, returned to intermittent haemodialysis because of recurrent peritonitis. Costs of the technique during the first year were less than half those incurred in the first year of home haemodialysis. Nevertheless, the major advantage was the ease with which patient independence and rehabilitation could be achieved. This technique is an appreciable advance over other forms of management for end-stage renal failure. Nevertheless, until it is more refined and long-term problems have been assessed it should probably be used only in established renal units where back-up treatments are available.     

Continuous ambulatory peritoneal dialysis and renal transplantation: a five year experience.

Continuous ambulatory peritoneal dialysis is a new and increasingly popular method of routine dialysis, but its effect on renal transplantation is uncertain. A non-randomised comparison was made of the outcome of grafting in patients who had been treated before transplantation with continuous ambulatory peritoneal dialysis with that in patients treated with haemodialysis. During the five years, 1979-84, after continuous ambulatory peritoneal dialysis was introduced to Newcastle upon Tyne 220 patients have received transplants after either continuous ambulatory peritoneal dialysis (61 patients) or haemodialysis (159 patients). During follow up no significant differences occurred in survival of patients or grafts between the two treatment groups. One year after transplantation the percentages of survivors who had received continuous ambulatory peritoneal dialysis and haemodialysis were 88% and 91% respectively, and overall graft survival was 66% and 72%, respectively. A multiple regression model was used to allow for differences among patients--for example, duration of dialysis and number of preoperative transfusions--on the survival of grafts. When only first cadaver grafts were considered (in 152 patients) graft survival (non-immunological failures excluded) was not significantly different between the patients treated with continuous ambulatory peritoneal dialysis and haemodialysis. Continuous ambulatory peritoneal dialysis is not a risk factor in renal transplantation, and its continued use in treatment of potential renal graft recipients is recommended.     

Continuous ambulatory peritoneal dialysis: experience with 22 unselected patients with renal failure.

The present study describes our experience with CAPD in an unselected group of patients presenting with endstage renal failure. Twenty-three consecutive patients were offered CAPD, in-center, and home hemodialysis. Twenty-two patients selected CAPD, including 14 patients more than 60 years of age, four patients with diabetes, and one with multiple myeloma. CAPD training was performed in an out-of-hospital office facility. One patient returned to hemodialysis following the development of resistant Pseudomonas peritonitis, two patients died of a myocardial infarction, and one patient died with a GI bleed. The other 18 patients are doing well. Assessment of 17 patients maintained on therapy for four months or more revealed that the patients are less depressed, less organic, and have fewer physical symptoms than previously reported for a comparable group of patients maintained on hemodialysis for a similar period of time. In conclusion, CAPD can be successfully employed, at least for the initial months of therapy, to treat the vast majority of patients with endstage renal disease. CAPD training and follow-up care can be provided in an out-of-hospital office facility.     

Continuous ambulatory peritoneal dialysis after the honeymoon: review of experience in Newcastle 1979-84.

Two hundred and twenty nine consecutive patients (129 men, mean age 45) were reviewed 12 to 65 months after starting treatment with continuous ambulatory peritoneal dialysis (CAPD) from January 1979 to December 1983. They received CAPD for a mean of 19.8 (range 0.5-62) months. Actuarial patient survival was 79% at 24 months and 72% at 36 months. Half of the 46 deaths were related to cardiovascular disease, while eight patients died of abdominal complications, including three patients with peritonitis. Peritonitis occurred at a rate of one episode per 35 patient weeks, and 88% of episodes were cleared by one or more courses of antibiotics. This still left peritonitis as the commonest cause of failure of CAPD, leading to a permanent change of treatment in 44 patients and temporary interruption in a further 25. CAPD remains a reasonable medium term treatment in chronic renal failure. Despite the persisting problem of peritonitis the results are comparable with those achieved by haemodialysis, and CAPD has become the treatment of first choice for end stage renal failure in Newcastle. In younger patients judged unsuitable for transplantation and facing long term dialysis, however, haemodialysis is preferred.     

Peritonitis during continuous ambulatory peritoneal dialysis in children.

The use of continuous ambulatory peritoneal dialysis (CAPD) in children has proved beneficial. However, peritonitis remains the major complication. A review of the incidence of peritonitis in 55 children (mean age 9.6 years) who underwent CAPD between 1978 and 1984 showed that there were 67 episodes of peritonitis (1 per 9.4 patient-months) in 33 of the 55. Three patients accounted for 22 of the episodes. In all cases, treatment with antibiotics, given intraperitoneally, was successful. Cephalothin was routinely given for infections due to gram-positive organisms, tobramycin for infections due to gram-negative organisms. Peritonitis recurred in seven patients, of whom five had to have their catheters replaced because of associated chronic infections of the deep peritoneal cuff, the exit site or the catheter tunnel. Although peritonitis was a common complication of CAPD in this population, it did not affect the success of the technique.     

Factors affecting development of peritonitis in continuous ambulatory peritoneal dialysis.

A questionnaire based survey in patients receiving continuous ambulatory peritoneal dialysis showed that there was an increased incidence of upper respiratory tract symptoms (suggestive of viral illness) in the 14 days before the development of peritonitis. No other factors were identified that might distinguish patients who develop peritonitis. The possibility that viral infections predispose to peritonitis by altering host defence mechanisms in patients receiving this form of renal replacement therapy warrants further study.     

Cytology of peritoneal fluid from patients on continuous ambulatory peritoneal dialysis

Peritoneal fluids from 41 patients on continuous ambulatory peritoneal dialysis (CAPD) were examined. The patients were divided into a short-term group (18 patients with CAPD up to one year) and a long-term group (23 patients with CAPD for one to seven years). Peritoneal fluids from a control group, consisting of ten nondialysis patients with ascites, were also examined. The cellular background of the peritoneal fluids and, in particular, the morphology of the mesothelial cells were studied. The following were found to be significantly increased in the CAPD groups: background lymphocytes, mesothelial exfoliation in three-dimensional clusters, mesothelial nuclear size and the number of mesothelial nucleoli. All of these features increased slightly with an increased duration of the dialysis. These findings emphasize that peritoneal dialysis of any duration can induce significantly atypical changes in mesothelial cells.     

Intraperitoneal insulin in uraemic diabetics undergoing continuous ambulatory peritoneal dialysis.

The kinetics of absorption of intraperitoneally administered insulin were studied in nine uraemic insulin-dependent diabetics undergoing continuous ambulatory peritoneal dialysis (CAPD). In each of three studies 20 U of regular insulin was directly injected as a bolus into the peritoneal cavity through an indwelling Tenckhoff catheter. In two procedures the insulin injection was followed by the instillation of either 2 litres of 1.5% dextrose dialysates or 2 litres of 4.5% dextrose dialysate. In the third 20 ml of saline was used to flush the tubing. Plasma free insulin values rose more rapidly and reached significantly higher concentrations (55.6 +/- 18.8 mU/l) when the insulin had been injected into an empty peritoneal cavity than when it was followed by dialysate. These differences were observed despite the fact that most of the insulin injected was retained by the patients. Since the plasma insulin values did not differ after instillations of dialysate containing 1.5% and 4.5% dextrose, the osmolality of the dialysate seemed not to affect insulin absorption, and the dilution of the insulin probably delayed its transfer through the peritoneum. These findings suggest that insulin given intraperitoneally to patients undergoing CAPD will be most effective if it is given into an empty peritoneal cavity at least 30 minutes before the dialysate is instilled.