Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis

To describe our experience with chronic ambulatory peritoneal dialysis in children with the prune belly syndrome (PBS).

From our peritoneal dialysis (PD) program we were able to review the medical records of 6 boys with PBS. Data were collected on potential complications such as infections, hernias, growth, and problems encountered with PD catheter insertion.

The ages of the 6 boys ranged from 10 months 17 years. The dialysis duration was from 9–22 months, with a total of 76 patient-months on PD. There was one death, possibly as a complication of an exit-site infection. Five received a renal transplant, and 4 have functioning grafts. Peritonitis occurred once in every 10.8 patient months, and exit-site or tunnel infection was diagnosed every 7.6 patient-months. Four patients required PD catheter replacement because of tunnel infection in 2, persistent exit-site infection in 1, and fluid leakage in 1. Of a total of nine catheters, three were inserted using a laparoscopic technique. There were no leaks in these three; however, there was one exit-site infection. Two patients had inguinal hernias that required surgery.

Deficiency of abdominal musculature in PBS poses potential problems for the use of PD, in particular, catheter anchorage, exit-site healing, and leakage. In our patients the most serious complications were infections of the exit site or catheter tunnel. Our experience suggests that a laparoscopic technique may provide improved catheter placement. PD offers a potentially successful form of dialysis for patients with PBS.

To report the complications and outcome of 10 newborns affected by acute renal failure (ARF), treated by continuous peritoneal dialysis (CPD).

All newborns admitted for tertiary treatment to the Neonatal Intensive Care Unit of the University of Padova, who underwent CPD between February 1986 and December 1990, were analyzed retrospectively.

Ten newborns (mean weight 2077 g, range 540–4930 g) received CPD, 6 of whom were preterm. All the survivors completed the study.

A number 9,5 French Tenckhoff catheter was used, and a closed circuit was created by means of a modified continuous ambulatory peritoneal dialysis (CAPD) technique. The mean duration of dialytic therapy was 7 days.

At the end of the dialytic period, 7 of the 10 patients had normal serum potassium and sodium values. CPD produced two different types of complications: leakage of the dialytic fluid in very low weight newborns and one episode of peritonitis during a chronic dialysis treatment. Six died of severe respiratory failure (in no case, however, was this attributable to ARF or CPD procedure). All but one of the survivors regained normal renal function. The only exception necessitated a kidney trans plant.

We believe that this technique, although invasive, improves the outcome of both preterm and low birth weight newborns affected by ARF.

To evaluate the ability of tidal peritoneal dialysis to decrease the pain and frequency of hemoperitoneum associated with peritoneal calcification.

Prospective case evaluation.

The Home Peritoneal Dialysis Unit, Children's Mercy Hospital.

Seven-year-old male with diffuse peritoneal calcifications, daily abdominal pain, and recurrent hemoperitoneum.

Tidal peritoneal dialysis was conducted with an initial fill volume of 45 mL/kg and a tidal inflow volume of 23 mL/kg. The patient also maintained a daytime pass volume of 45 mL/kg. Duration of treatment was 7 months.

The patient's abdominal pain resolved 2 days after initiating tidal peritoneal dialysis. No episodes of hemoperitoneum or abdominal pain have occurred for 7 months.

Tidal peritoneal dialysis is a unique approach to the achievement of symptomatic relief in the patient with peritoneal calcification.

Measurement of mass transfer area coefficients (MTAC) in children of different sizes to determine if solute transport varies with age and to compare with published adult values.

Mass transfer area coefficients calculated from prospectively collected data in 28 selected patients.

All children starting maintenance peritoneal dialysis at the Hospital for Sick Children. Selected patients were also studied if hospitalized for unrelated reasons.

Mean MTAC values for creatinine and glucose were 4.0 and 4.5 mL/min, respectively, both considerably lower than adult values. When scaled per 70 kg body weight, these results were greater, and when scaled per 1.73 m2 surface area, they were lower than reported adult values. The MTAC/kg body weight was inversely correlated to age.

Solute transport in children is directly related to age and does not approach adult values until later childhood. However, more rapid transport per unit body weight is observed in children and may reflect an increased effective peritoneal surface area.

To compare the nutritional and biochemical effects of amino acid dialysis to dextrose dialysis in children receiving continuous ambulatory peritoneal dialysis (CAPD).

Prospective randomized crossover study.

Pediatric Nephrology Unit in a tertiary care, teaching hospital of the University of Toronto.

Seven children aged 0.7–16.5 years receiving CAPD. All patients had poor linear growth, with 5 patients showing evidence of energy deficit.

Each patient received either amino acid or dextrose dialysate for 3 months, then crossed over to the alternate regimen for a subsequent 3 months.

Nutritional and biochemical data were obtained on each patient during each dialysis regimen.

Analysis of the patients’ nutritional data showed comparable weight gain with both regimens but no significant improvement in lean body mass with either regimen. Appetite improved in most patients during amino acid dialysis. Biochemical data during amino acid dialysis showed a tendency to higher plasma potassium and urea levels with no clinical side effects or worsening of acidosis; however, there was a reduced anion gap and increased total plasma protein, due mostly to a rise in plasma albumin and a smaller increase in immunoglobulins. With the exception of tryptophan, fasting amino acid levels at the start and end of amino acid dialysis did not show any significant change. An interesting phenomenon of early blunting of the rise in amino acid levels, following a single amino acid dialysate exchange, was noticed at the end of the amino acid dialysis period. This newly described phenomenon could have been due to tolerance or hepatic enzyme induction.

Overall amino acid dialysis was comparable to dextrose dialysis with no additional proven nutritional benefit, was equally effective in ultrafiltration and creatinine clearance, and produced no adverse clinical or biochemical effects.

Previous measurements of peritoneal fluid handling in children treated by continuous ambulatory peritoneal dialysis (CAPD) were performed with human albumin as a fluid marker. A major disadvantage of this substance is that endogenous patient albumin enters the peritoneal cavity during the dwell period. For this reason perito neal fluid kinetics were measured in a group of children on CAPD, using autologous hemoglobin as a volume marker.

Autologous hemoglobin was added to dialysate containing 1.36% glucose as a volume marker. Marker clearance (MC), which is presently the best available approximation of lymphatic absorption in the clinical setting, and transcapillary ultrafiltration (TCUF) were measured during a 4-hour dwell.

University hospital.

Children on CAPD (N=9), with a median age of 8.1 years (range 2.1–13.2 years).

MC was 521±166 mL/4 hour/1.73 m2, which is high compared to the literature data on adult CAPD patients. TCUF was 519±92 mL/4 hour/1.73 m2, which is similar to data concerning adult patients. TCUF reached no maximum during the 4-hour dwell, and the deviation of the TCUF curve from linear was markedly less than usually seen in adult patients.

MC in children treated with CAPD is higher when compared to the literature data on adults. Difficulties to achieve sufficient ultrafiltration in children could be caused by relatively small differences between MC and TCUF from the beginning to the end of the dwell.

To evaluate specified biomedical, socio-economic, and psychosocial criteria as predictors of therapeutic success to optimize patient selection for continuous ambulatory peritoneal dialysis (CAPD) in a developing country.

A restrospective cohort study investigating the relationship between episodes of peritonitis and exitsite infection, and predetermined biomedical, socioeconomic, and psychosocial data.

A CAPD unit in a large tertiary care teaching hospital.

AI1132 patients entering the CAPD program between 1987 and 1991.

Overall mean survival time on CAPD was 17.3 months. Peritonitis rates were high, especially among blacks. Multivariate analysis demonstrated that increased peritonitis rates were associated with age, black race, diabetes, and strongly so with several psychosocial factors. Because being black was strongly linked to poor socioeconomic conditions, repeat analysis excluding blacks showed the same associations with the above variables, but, additionally, several socioeconomic factors were associated with high peritonitis rates. No significant explanatory variables were shown for exit-site infections.

The association of biomedical, socio-economic, and psychosocial variables with high peritonitis rates has important implications for the selection of patients for CAPD in this setting.

To examine features of drainage flow and to determine whether the drainage period could be safely reduced in continuous ambulatory peritoneal dialysis (CAPD) patients.

Open nonrandomized prospective study in CAPD patients.

The kidney center in a tertiary care university hospital.

Fourteen CAPD patients with good catheter function.

Drainage flow pattern was studied using a 2-L dialysate. The drainage period was reduced from 28 minutes (mean) to 10 minutes throughout a short-term, 2-month study period and a long-term, 6-month study period for 10 patients.

Ultrafiltration volume, body weight, and peritoneal clearance.

A kinetics analysis of the drainage period and volume indicated a positive linear correlation with two different slopes: one for rapid drainage for the first 5–7 minutes and one for subsequent slow drainage. The effluent exceded 80% in the former period. Ultrafiltration volume and body weight showed no change due to the reduction. Improved peritoneal clearance of small molecular substances could not be confirmed despite a 5% increase in the effective dialysis period. Nearly all patients were satisfied with the reduction and desired its continuation.

Ten minutes is a sufficient drainage period for most CAPD patients with a 2-L dialysate volume. This may possibly allow an increase in daily activities and an effective peritoneal membrane dialysate contact period.

To investigate the effectiveness of administering relatively high doses of r-HuEPO subcutaneously once a week or once every 2 weeks in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

Multicenter prospective analysis. The trial was divided into two phases: an initial 8-week phase (once a week dosing) followed by a 12-week maintenance phase (once every 2 weeks dosing). A response was defined as a change in hematocrit (Ht) of 3% or more. Results were analyzed using Sheffe's test, Mantel-Haenszel's test, and Dunnett's test.

Eleven renal units in Japan providing a CAPD program.

Forty-one CAPD patients with a Ht of 28% or less.

After the initial 8 weeks, 13 (81.3%) of 16 patients showed a response to 6000 U (106.9±20.0 U/kg) subcutaneously (sc), once a week. Eleven (84.6%) of 13 in the 9000 U (166.5±27.7 U/kg) group and all 12 (100%) in the 12 000 U (210.7 ±42.1 U/kg) group also showed responses. At the end of both phases, that is, at 20 weeks, 7 (53.8%) of 13 patients in the 6000 U group with once every 2 weeks dosing, 7 (63.6%) of 11 in the 9000 U group, and 10(90.9%) of 11 in the 12 000 U group maintained responses with the same dosing interval. There were no significant changes in mean blood pressure during the study period, and only 2 patients developed treatable hypertension with mild headache.

Administration of relatively high doses of r-HuEPO to CAPD patients once a week or once every 2 weeks is safe and potentially an effective regimen for the correction of renal anemia.

To assess the possible effects of peritonitis on peritoneal and systemic acid-base status.

pH, pCO2, lactate, and total leukocyte and differential count were simultaneously determined in the overnight dwell peritoneal dialysis effluent (PDE) and arterial blood in noninfected patients (controls) and on days 1, 3, and 5 from the onset of peritonitis.

University multidisciplinary dialysis program.

Prospective analysis of 63 peritonitis episodes occurring in 30 adult CAPD patients in a single center.

In controls, mean (±SD) acid-base parameters were pH 7.41 ±0.05, pCO2 43.5±2.6 mm Hg, lactate 2.5±1.5 mmol/L in the PDE, and pH 7.43±0.04, PaCO2 36.8±3.8 mm Hg, lactate 1.4±0.7 mmol/L in the blood. In sterile (n=6), gram-positive (n=34), and Staphylococcus aureus (n=9) peritonitis PDE pH's on day 1 were, respectively, 7. 29±0.07, 7. 32±0.07, and 7.30±0.08 (p<0.05 vs control). In gram -negative peritonitis (n=14) PDE pH was 7.21 ±0.08 (p<0.05 vs all other groups). A two-to-threefold increase in PDE lactate was observed in all peritonitis groups, but a rise in pCO2 was only seen in gram -negative peritonitis. Acid-base profile of PDE had returned to control values by day 3 in sterile, gram -positive and Staphylococcus aureus peritonitis and by day 5 in gramnegative peritonitis. Despite a slight increase in plasma lactate on the first day of peritonitis, arterial blood pH was not affected by peritonitis.

PDE pH is decreased in continuous ambulatory peritoneal dialysis (CAPD) peritonitis, even in the absence of bacterial growth. In gram-negative peritonitis, PDE acidosis is more pronounced and prolonged, and pCO2 is markedly increased. Arterial blood pH is not affected by peritonitis.

To determine if peritoneal dialysis -related infection rates are higher in older patients compared with younger patients.

A retrospective review of prospectively collected data. Control adult patients were matched with older study patients for race, sex, insulin dependence, connection device, and time on dialysis.

A university-based peritoneal dialysis program which includes patients from a Veterans Administration Hospital outpatient dialysis program.

Infection rates of 103 patients 60 years of age (older patients) were compared with 103 matched control patients 18–49 years of age (younger patients).

Rates of peritonitis, exit site and tunnel infection expressed as episodes/patient/year (episodes/year) and the infecting organisms for each were examined. Outcomes, including catheter removal and the cause for removal, transfer to another dialysis modality and the reason for such, death and transplantation were also assessed.

Mean time on peritoneal dialysis was the same in each group (20±21 months in the older and 18±17 months in the younger patients). The overall peritonitis rates were the same in the two groups (0.95/year in the older and 0.89/year in the younger patients), but the older patients had a higher rate of S. epidermidis peritonitis (0.28/year vs 0. 13/year, p=0.0001). S. aureus peritonitis rates were similar (0.16/year in older and 0.17/year in younger patients). Older patients had fewer exit-site infections (0.80/year versus 1.2/year, p=0.0001) and, specifically, lower rates of S. aureusexit-site infections (0.23/year vs 0.47/year, p=0.0001). Tunnel infections were also less common in older patients (0.15/year vs 0.23/year, p=0.008), but S. aureustunnel infection rates were similar (0.05/year and 0.09/year). Catheter infection was the most common reason for catheter removal in both patient groups (35% of catheters in the older and 44% of catheters in the younger patients, p=NS). More catheters were removed from older patients because of dementia or the loss of mechanical skills required to perform peritoneal dialysis exchanges (15% vs 5%, p=0.04).

Older age per se is not associated with higher peritonitis rates, but the use of disconnect sys tems should be encouraged in older patients and their mental and physical skills monitored to avoid S. epidermidis peritonitis. The lower rates of S. aureus catheter infection in older patients requires further study.

To examine the impact of peritoneal catheter configuration on mechanical complications, catheter survival, probability of episodes of peritonitis, and probability of exit-site infections associated with the use of catheters for continuous ambulatory peritoneal dialysis (CAPD).

Prospective randomized trial.

CAPD unit in one university hospital.

Forty consecutive patients requiring a dialysis catheter for future CAPD were randomized to receive either a single-cuff straight Tenckhoff catheter or a permanently bent single-cuff Swan neck catheter. The skin exit was upward-directed in the Tenckhoff group and downward-directed in the Swan neck group.

Dialysate leak occurred in one patient and symptomatic catheter tip migration in 3 patients with the Tenckhoff catheter but in none with the single-cuff Swan neckcatheter(p=O.5, p=0.12). No significant differences in catheter survival at 2 years, probability of episodes of peritonitis, or probability of exit-site infections could be demonstrated.

Catheter configuration did not influence the catheter-related mechanical or infectious complications. We were unable to demonstrate any advantage of the newer, permanently bent single-cuff Swan neck catheter over the conventional straight type.

For the normalization of serum magnesium (Mg) concentration, dialysate Mg concentration tends to be reduced in continuous ambulatory peritoneal dialysis (CAPD) patients. The aim of this study was to evaluate the influence of Mg on parathyroid hormone (PTH).

Prospective study of the utilization of Mg-free dialysate for 8 weeks.

Dialysis service, Itabashi Hospital, Nihon University School of Medicine.

Five stable CAPD patients (1 male; 4 female; age 49.7±1.3 years; duration of CAPD 27±9 months).

Serum Mg, serum high sensitive PTH, and Mg content in mononuclear cells were measured at 4-week intervals.

In comparison to baseline, serum Mg concentration was significantly reduced at week 4 (p<0.01) and week 8 (p<0.01), and serum PTH was significantly increased at week 4 (p<0.05) and at week 8 (p<0.05). However, the PTH level at week 8 was lower than that at week 4. Furthermore, the Mg content in mononuclear cells was significantly decreased at week 4 (p<0.01) and at week 8 (p<0.01). Serum -ionized calcium and phosphate concentrations did not change.

The removal of Mg by Mg-free dialysate leads to Mg depletion in CAPD patients. In addition, Mg depletion stimulates PTH synthesis or secretion at 4 weeks, but at 8 weeks PTH synthesis or secretion is also influenced by other factors.