CASE PRESENTATION: We report a successful elderly multigravid pregnancy, in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). Her pregnancy was detected early and she was closely managed by the nephrologist and obstetrician. She tolerated the same PD prescription throughout 36 weeks of pregnancy with daily ultrafiltration of 500-1500mls. Her blood pressure remained well controlled without the need of any antihypertensive medication. Her total Kt/V ranged from 1.93 to 2.73. Her blood parameters remained stable and she was electively admitted at 36 weeks for a trans-peritoneal lower segment caesarian section and bilateral tubal ligation.
CONCLUSIONS: At the age of 42, our case is the oldest reported successful pregnancy in a patient on peritoneal dialysis. With careful counselling and meticulous follow up, we have shown that woman in the early stage of end stage renal failure can successfully deliver a full term baby without any complications. Therefore, these women should not be discourage from conceiving even if they are in advanced maternal age for pregnancy.
SUMMARY: Nephrologist-initiated peritoneoscopic PD access programs have had a positive impact on PD penetration. The technique has been associated with a better primary success rate, superior catheter survival, less postoperative pain, shorter hospital stay, and shorter catheter break-in time compared with the conventional surgical technique. The role of interventional nephrologists in peritoneoscope Tenckhoff catheter placement is still perceived to be a relatively new advance, investigational by some, and many nephrologists and surgeons alike remain sceptical of the value of this recent option. Crucial questions often raised are how many procedures one needs to perform before being considered competent and who should be credentialed to perform the procedure or supervise trainees performing it. The evaluation of technical proficiency in a specific operation is difficult and complex. Cumulative summation (CUSUM) analysis is one option for tracking the success and failure of technical skill and examining trends over time. Key Messages: The author's facility has had good outcomes with a nephrologist-initiated peritoneoscopic PD access programme. Quality control of PD catheter insertion can be performed using CUSUM charting to monitor for primary catheter dysfunction, primary leak, and primary peritonitis.
METHODS: Between November 2005 and November 2006, the technique was applied in 18 patients (6 female, 12 male; median age 50 years, range 16 - 73 years) on continuous ambulatory peritoneal dialysis with catheter malfunction secondary to omental wrap. Pneumoperitoneum was induced under general anesthesia. Three ports were inserted. The catheter was released from the omentum and repositioned in the pelvis. The omentum was then folded onto itself in a cephalad direction using silk sutures. This shortened the omentum. The risk of catheter migration was minimized with a polypropylene sling passed through the abdominal wall and around the catheter, then knotted subcutaneously. The sling allowed catheter removal without a new laparoscopy. The outcomes were prospectively evaluated.
RESULTS: Median operating time was 90 minutes (range 35 - 160 minutes). Adhesiolysis was performed in 4 patients: 1 patient had port-site leakage of dialysate, which settled with abdominal rest; 1 patient had bleeding during adhesiolysis and laparoscopic hemostasis was successful; 1 patient had recurrent catheter obstruction 2 weeks post-operatively and was converted to hemodialysis; and 1 patient had recurrent malfunction secondary to small bowel wrap after 5.5 months; re-salvage was successful. The success rate of the first salvage procedure was 89%(16/18). The catheters were still functioning after a mean follow-up of 16.5 +/- 6.3 months (range 0.5 - 24 months). The 1-year catheter survival rate was 83.3%.
CONCLUSIONS: Omental folding is a safe and effective technique for salvaging peritoneal dialysis catheters.
PATIENTS AND METHODS: The open, paramedian approach is the commonest technique to insert the 62-cm coiled double-cuffed Tenckhoff peritoneal catheter. All patients with catheters inserted between January 2004 and November 2007 were retrospectively analyzed for demographics and followed for up to 1 month for complications. We excluded patients whose catheters had been anchored to the bladder wall and who underwent concurrent omentectomy or readjustment without removal of a malfunctioning catheter (n = 7). Intravenous cloxacillin was the standard preoperative antibiotic prophylaxis. ♢
RESULTS: Over the 4-year study period, 384 catheters were inserted under local anesthetic into 319 patients [201 women (62.8%); mean age: 49.4 ± 16.7 years (range: 13 - 89 years); 167 (52.2%) with diabetes; 303 (95%) with end-stage renal disease] by 22 different operators. All Tenckhoff catheters were inserted by the general surgical (n = 223) or urology (n = 161) team. There were 29 cases (7.6%) of catheter migration, 22 (5.7%) of catheter obstruction without migration, 24 (6.3%) of exit-site infection, 12 (3.1%) of leak from the main incision, 14 (3.6%) of culture-proven wound infection, 11 (2.9%) post-insertion peritonitis, and 1 (0.3%) hemoperitoneum. No deaths were attributed to surgical mishap. ♢
CONCLUSIONS: The most common complication was catheter migration. The paramedian insertion technique was safe, with low complication rates.
METHODS AND ANALYSIS: The study is an open-label randomised controlled trial. A total of 434 patients with end-stage renal disease undergoing CAPD will be enrolled and randomised to either the intervention group, Stay Safe Link, or the control group, Stay Safe. All study subjects will be followed up and monitored for 1 year. The primary safety outcome is the rate of peritonitis while the primary efficacy outcomes are the delivered dialysis dose and ultrafiltration volume.
ETHICS AND DISSEMINATION: The study was approved by the Medical Research Ethics Committee, National Institute of Health Malaysia. A written informed consent will be obtained from all participating subjects prior to any trial-related procedure and the study conduct will adhere strictly to Good Clinical Practice. The findings will be disseminated in a peer-reviewed journal.
TRIAL REGISTRATION NUMBER: NCT03177031; Pre-results.
METHOD: A multicentre, parallel, randomised, controlled, open-label, non-inferiority trial was conducted. Adult patients receiving CAPD were randomised in a 1:1 ratio to SSL or STS. The primary outcome was the rate of peritonitis after 1 year of follow-up.
RESULTS: A total of 472 subjects were randomised (SSL, n = 233; STS, n = 239). One subject in each group was excluded from the analysis as they withdrew consent before the first dialysis dose. Four hundred and seventy subjects (SSL, n = 232; STS, n = 238) were included in the modified intention-to-treat analysis. Non-inferiority between two groups was established as no significant difference was found in peritonitis rate (incident rate ratio: 0.91, 95% CI: 0.65-1.28). No significant difference was detected in weekly Kt/V (p = 0.58) and creatinine clearance (p = 0.55). However, the average ultrafiltration volume was significantly lower in SSL, with a mean difference of 93 ml (p < 0.01). SSL also demonstrated a 2.57-times higher risk of device defect than STS (95% CI: 1.77-3.75).
CONCLUSION: SSL was non-inferior in peritonitis rate compared to plastic-free STS over 1 year in patients requiring CAPD. There was no difference in the delivered dialysis dose, but there was a higher rate of device defects with SSL.
OBJECTIVE: Peritoneal dialysis (PD)-related infection is a common cause of catheter loss and the main reason for PD drop-out. Exit-site infection (ESI) is a pathway to developing tunnel infection and peritonitis, hence rigorous exit-site care has always been emphasized in PD therapy. The aim of this study was to evaluate the effect of exit-site dressing vs non-dressing on the rate of PD-related infection. ♦
METHODS: A prospective randomized controlled study was conducted in prevalent PD patients at the Hospital Tuanku Jaafar Seremban, Negeri Sembilan, Malaysia, from April 2011 until April 2013. All patients were required to perform daily washing of the exit site with antibacterial soap during a shower. In the dressing group (n = 54), patients were required to clean their exit site using povidone-iodine after drying, followed by topical mupirocin antibiotic application to the exit site. The exit site was then covered with a sterile gauze dressing and the catheter immobilized with tape. In the non-dressing group (n = 54), patients were not required to do any further dressing after drying. They were only required to apply mupirocin cream to the exit site and then left the exit site uncovered. The catheter was immobilized with tape. The primary outcome was ESI. The secondary outcomes were evidence of tunnel infection or peritonitis. ♦
RESULTS: A total of 97 patients completed the study. There were a total of 12 ESI episodes: 4 episodes in 4 patients in the dressing group vs 8 episodes in 4 patients in the non-dressing group. This corresponds to 1 episode per 241.3 patient-months vs 1 episode per 111.1 patient-months in the dressing and non-dressing groups respectively. Median time to first ESI episode was shorter in the non-dressing than in the dressing group, but not significant (p = 0.25). The incidence of gram-positive ESI in both groups was similar. There were no gram-negative ESI in the non-dressing group compared with 2 in the dressing group. The peritonitis rate was 1 per 37.1 patient-month in the dressing group and 1 per 44.4 patient-months in the non-dressing group. Median time to first peritonitis episode was significantly shorter in the dressing group compared to non-dressing (p = 0.03). There was no impact of dressing disruptions in the occurrence of major PD catheter-related infection. ♦
CONCLUSION: Use of a non-dressing technique with only prophylactic topical mupirocin cream application is effective in preventing PD-related infection. The non-dressing technique is more cost-effective and convenient for PD patients, with fewer disposables.
METHODS: A retrospective record review of all CAPD patients on follow-up at the Miri Hospital, Sarawak, Malaysia from 2014 until 2017 was done.
RESULTS AND DISCUSSION: During the 4-year period, the overall peritonitis rate was 0.184 episodes per patient-year. Gram-positive and gram-negative bacteria each constituted one-third of the peritonitis; fungi (2.6%), Mycobacterium tuberculosis (MTB) (5.3%), polymicrobial (2.6%) and sterile culture (26.3%). The most commonly isolated gram-positive bacteria were coagulase-negative Staphylococcus. Our peritonitis rate is comparable to that of other centres i.e., Japan 0.195 and Indonesia 0.25. In comparison, countries like India (0.41), Korea (0.40) and Singapore (0.59) had relatively higher rate of PD-associated peritonitis. Two tuberculosis peritonitis patients died. The rate of catheter removal was approximately 20%. Gram-negative bacteria and MTB have a higher risk of catheter loss. About one-fifth used rainwater to clean their CAPD exit site. Out of this group, 33% did not boil the rainwater prior to usage.
CONCLUSION: Patient's characteristics and microbial susceptibility vary in different places of practice. The high rates of culture-negative peritonitis and high mortality risks associated with TB peritonitis warrant special attention. In patients with refractory peritonitis, early catheter removal is warranted in order to reduce mortality and minimize damage to peritoneal membrane.
DESIGN: This multicenter, parallel group, randomized controlled trial involved 363 prevalent CAPD patients from 8 centers. The primary endpoint was peritonitis rate; secondary endpoints were technique failure and technical problems encountered. The duration of the evaluation was 1 year.
RESULTS: The risk of peritonitis on Carex varied between the centers. We found a significant treatment-center interaction effect (likelihood ratio test: p = 0.03). The incidence rate ratio (IRR) of peritonitis on Carex as compared with Ultra ranged from 0.4 to 7.2. In two centers, Carex was inferior to Ultra with regard to peritonitis; but, in five centers, the results were inconclusive. Equivalence was not demonstrated in any center. The overall rate of peritonitis in the Carex group was twice that in the Ultra group [IRR: 2.18; 95% confidence interval (CI): 1.51 to 3.14]. Technique failure and technical problems were more common with the Carex system. Technique failure rate at 1 year was 44% in the Carex group and 22% in the Ultra group.
CONCLUSIONS: Equivalence between the Carex disconnect system and the Ultra disconnect system could not be demonstrated. The risk of peritonitis on Carex varied significantly between centers.
METHODS: Incident HD patients without permanent vascular access encountered from January to December 2014 were included in this study. Patients were divided into 2 groups: Group 1 were encountered within 6 months prior to introduction of in-patient IPD bridging therapy in substitution of noncuffed catheter (NCC) insertion while awaiting maturation of permanent vascular access. Group 2 were encountered within 6 months after the introduction of this policy. The number of NCC and peritoneal dialysiscatheter insertion, along with catheter-related infections were evaluated during this period.
RESULTS: Approximately 450 patients were distributed in each group. We achieved 45% reduction in internal jugular catheter insertion from 322 to 180 catheters after policy change. This led to a significant drop in catheter-related blood stream infection (53%, P <0.001). On the other hand, 30% more peritoneal dialysiscatheter were inserted to accommodate our IPD bridging therapy.
CONCLUSIONS: The introduction of IPD as bridging therapy while awaiting maturation of permanent vascular access significantly reduced the utilization of NCC in incident HD patients and catherter-related blodstream infection. With this, it is our hope that it will contribute to the preservation of central vein patency.
METHODS: An Excel-based budget impact model was constructed to assess dialysis-associated costs when changing dialysis modalities between PD and ICHD. The model incorporates the current modality distribution and accounts for Malaysian government dialysis payments and erythropoiesis-stimulating agent costs. Epidemiological data including dialysis prevalence, incidence, mortality, and transplant rates from the Malaysian renal registry reports were used to estimate the dialysis patient population for the next 5 years. The baseline scenario assumed a stable distribution of PD (8%) and ICHD (92%) over 5 years. Alternative scenarios included the prevalence of PD increasing by 2.5%, 5.0%, and 7.5% or decreasing 1% yearly over 5 years. All four scenarios were accompanied with commensurate changes in ICHD.
RESULTS: Under the current best available cost information, an increase in the prevalent PD population from 8% in 2014 to 18%, 28%, or 38% in 2018 is predicted to result in 5-year cumulative savings of Ringgit Malaysia (RM) 7.98 million, RM15.96 million, and RM23.93 million, respectively, for the Malaysian government. If the prevalent PD population were to decrease from 8% in 2014 to 4.0% by 2018, the total expenditure for dialysis treatments would increase by RM3.19 million over the next 5 years.
CONCLUSIONS: Under the current cost information associated with PD and HD paid by the Malaysian government, increasing the proportion of patients on PD could potentially reduce dialysis-associated costs in Malaysia.