Prospective controlled trial of a Y-connector and disinfectant to prevent peritonitis in continuous ambulatory peritoneal dialysis

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

A systematic review of peritoneal dialysis-related peritonitis rates over time from national or regional population-based registries and databases

Peritoneal dialysis (PD)-related peritonitis is one of the top priorities for care and research among PD stakeholders. This study summarizes PD peritonitis rates from available population-based national or regional registries around the world, examining trends over time. This is a systematic review of PD peritonitis rates in patients treated with PD for kidney failure, from census-based national or provincial/statewide/provider registries or databases. MEDLINE (via PubMed) was searched from inception to August 2020, and inquiries made to national registry personnel using the International Comparisons section of the 2018 United States Renal Data System Annual Data Report as a contact list. Quantitative synthesis was done using weighted random-effects Poisson regression. Of 81 countries that reported utilization of PD, 19 did not have a traditional dialysis registry (governed by either professional societies or government entities), and only 33 monitored PD peritonitis rates correctly and accessibly. There is wide variation in PD peritonitis rates between countries, although the global average has been decreasing over time, from 0.600 episodes/patient-year in 1992 to 0.303 in 2019. Other sources of variability include the continent in which the country is nested and the size of its PD population. PD peritonitis, despite its importance for PD stakeholders, is under-monitored. While the global rate is decreasing over time, the presence and extent of this improvement varies from country to country. There is an opportunity for better monitoring, research into underachieving and overachieving nations and development of international clinical support networks.

Optimizing Peritoneal Dialysis-Associated Peritonitis Prevention in the United States: From Standardized Peritoneal Dialysis-Associated Peritonitis Reporting and Beyond

Peritoneal dialysis (PD)-associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.

Long-Term Clinical Outcomes of Peritoneal Dialysis Patients: Single Center Experience from Korea

Of a large body of literature reporting clinical outcomes for patients maintained on peritoneal dialysis (PD), most publications have focused on relatively short-term results. Few reports have focused on long-term survival in PD patients. Here, we present our experience with long-term patient outcomes and further analyses of the trends in demographics and clinical outcomes of 2301 end-stage renal disease (ESRD) patients treated with continuous ambulatory PD (CAPD) during a 25-year period (1981 – 2005) at our institute. Outcomes were analyzed for 1656 patients, excluding those younger than 15 years of age at initiation of CAPD, those having less than 3 months’ follow-up, or those who had been on hemodialysis or who received a kidney graft before starting CAPD.

In the study patients, technique survival at 5 and 10 years was 71.9% and 48.1% respectively. Patient survival was 69.8% and 51.8%. Mean age at the start of PD (50.4 ± 13.9 years vs. 44.2 ± 13.9 years, p < 0.01), ESRD incidence as a result of diabetic nephropathy (30.5% vs. 19.5%, p < 0.01), and incidence of cardiovascular comorbidities (26.6% vs. 20.5%, p < 0.01) were all significantly greater in patients who started PD during the second half of the study period (1993 – 2005) as compared with the first half (1981 – 1992). A multivariate analysis adjusting for these changes in demographics and comorbid conditions revealed that PD therapy starting in 1993 – 2005 was associated with a significant reduction in technique failure [hazard ratio (HR): 0.65; p < 0.01] and mortality (HR: 0.68; p < 0.01) as compared with the earlier period. However, in subgroup analyses, technique survival was not observed to be significantly improved in patients with diabetes.

In summary, technique and patient survival have significantly improved despite increases in patient age, cardiovascular comorbidity, and ESRD caused by diabetes. Although diabetes, older age, and cardiovascular comorbidities are not factors that are easily modifiable to improve PD outcomes, results at our institution are encouraging in an era of declining PD utilization.

30 Years of Peritoneal Dialysis Development: The past and the Future

A review is given of 30 years of development in peritoneal dialysis (PD). After a short description of the first 20 years, the main emphasis is put on the last 10 years. Subjects discussed are the increasing use of PD in high-risk populations, peritonitis and other catheter-related problems, adequacy of dialysis and nutrition, patient outcomes in comparison with hemodialysis, and peritoneal membrane changes with time on PD. Topics that have emerged during the last decade and the challenges for the next decennium are discussed. The great importance of quality assurance in fast-growing PD populations and of prevention of long-term membrane alterations are emphasized.

Long-Term Capd Survival and Analysis of Mortality Risk Factors: 12-Year Experience of a Single Mexican Center

Objective

To evaluate patient and technique survival, and to analyze mortality risk factors in a large Mexican single-center continuous ambulatory peritoneal dialysis (CAPD) program.

Design

Cohort study.

Setting

Tertiary care, teaching hospital located in Mexico City.

Patients

All patients from our CAPD program (1985 – 1997) were retrospectively studied.

Interventions

Clinical and biochemical variables at the start of dialysis were recorded and considered in the analysis of risk factors.

Main Outcome Measures

End points were patient (alive, dead, or lost to follow-up) and technique status at the end of the study (December 1997).

Results

627 patients, 37% with diabetes mellitus (DM), were included. Median patient survival (± SE) was 5.1 ± 0.6 years. In the univariate analysis, the following variables were associated ( p < 0.05) with mortality: DM, old age, hypoalbuminemia, low serum creatinine, low serum phosphate, and lymphopenia. In the multivariate analysis, the only significant mortality risk factors were DM (RR 2.56, p < 0.0001), old age (RR 1.01, p = 0.01), hypoalbuminemia (RR 0.77, p = 0.04), and lymphopenia (RR 0.98, p = 0.05). Median technique survival was 4.0 ± 0.2 years. Peritonitis, hypoalbuminemia, lymphopenia, old age, and DM were all significantly associated ( p < 0.05) with technique failure in the univariate analysis, while in the multivariate analysis, only DM (RR 1.78, p = 0.001), peritonitis (RR 1.13, p = 0.004), lymphopenia (0.98, p = 0.04), and hypoalbuminemia (RR 0.80, p = 0.06) were technique failure predictors.

Conclusions

Patient survival in our setting is similar to that reported in other series. Diabetes mellitus, lymphopenia, and hypoalbuminemia were the strongest predictive factors for mortality and technique failure on CAPD. Our 12-year CAPD program is one of the largest single-centers reported in CAPD literature.

Peritonitis Prevention in Continuous Ambulatory Peritoneal Dialysis: Long Term Efficacy of a Y-Connector and Disinfectant

We have already described (Lancet 1983, ii, 642) the results of a controlled study in two centres showing the efficacy of a Y-shaped connector, filled with sodium hypochlorite during the dwelling time, for the reduction of peritonitis: one episode every 33 patient-months in the treated group versus one episode every 11.3 patient-months in the control group using the standard method.

During the past 2.5 years we have continued to use the Y-connector. All new patients referred to our hospital for initiation of CAPD program were trained to use the Y-connector, while those patients already on the standard Y-connector continued on it.

From January 1983 to June 1985, among 18 non-diabetic patients using the standard bag-exchange method, there were 23 peritonitis episodes in 14 patients (78%) over a cumulative period of 257 months -one episode every 11.2 patient-months. In contrast, among the 92 patients using the Y-connector, there were 30 peritonitis episodes in 21 patients (22.8%) during 1354 months -one episode every 45.1 patient-months. When we exclude from this group the 10 diabetic patients adding insulin to the bags, the incidence of peritonitis fell to one episode every 92.2 patientmonths.

These results confirm that the Y-connector is extremely effective in reducing the rate of peritonitis in patients on CAPD.

The most widely accepted technique for prevention of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) is that described by Oreopoulos et al (I). However, to reduce further the risk of dialysis-fluid

Comparison of Exit -Site Infections in Disconnect versus Nondisconnect Systems for Peritoneal Dialysis

Objective

To determine if disconnect systems reduce the incidence of exit-site infections when compared to nondisconnect systems.

Design

We prospectively monitored exit-site infections and peritonitis rates in 96 disconnect patients (Yset, automated peritoneal dialysis (APD)) and 60 nondisconnect patients (spike, ultraviolet connection device (UVXD)).

Setting

A freestanding chronic peritoneal dialysis unit staffed by physicians from both a medical school and a private setting.

Patients

All patients who began peritoneal dialysis at our unit were monitored, regardless of cause of endstage renal disease (ESRD) or age.

Intervention

Patients were dialyzed using the system (Y-set, spike, etc.) most appropriate for their life-style and their ability to administer self-care.

Main Outcome

We attempted to follow disconnect and nondisconnect patients for a similar median time on dialysis and compared differences in exit-site infections.

Results

Peritonitis rates (episodes/pt year) were reduced for disconnect (0.60) versus nondisconnect (0.99) systems (p=0.0006). Despite the marked reduction in peritonitis rates, there was no difference in exit-site infection rates (0.35 vs 0.38), the time to the first exit -site infection, or the time to the first catheter removal for disconnect versus nondisconnect groups. When individual systems were compared, differences in exit-site infection rates (episodes/pt years) were noted (0.62, spike; 0.26,UVXD; 0.32,Y-set; 0.41,APD).

Conclusion

We found no overall difference in exit site infection rates for disconnect versus nondisconnect systems, despite a reduction in peritonitis rates for disconnect systems.

A Multicenter, Selection-Adjusted Comparison of Patient and Technique Survivals on CAPD and Hemodialysis

Four hundred and eighty CAPD and 373 HD patients started regular dialysis treatment between 1981 and 1987 in 6 dialysis centers. The CAPD patients were 6 years older, on average, than the HD patients and had more complicating conditions (43.3% with 3 or more coexisting risk factors versus 28.9% with coexisting complications). The 7-year patient survival rate was not significantly different. Cox's proportional hazards regression showed that age, cardiovascular disease, cerebrovasculardisease, peripheral vasculardisease, diabetes, malignancy and multisystem disease had significant adverse effects on patient survival. After correcting for the influence of these factors, no significant differences in patient survival were seen. However, after 53.5 years of age, the increase in the risk of death was significantly higher in HD than in CAPD patients. Technique survival was significantly different in the 6 centers and was better for HD than for CAPD. There was no statistically significant difference between CAPD and HD technique survival when peritonitis was eliminated as a cause of failure. Based on this 7 year analysis, CAPD would appear to be an excellent alternative to HD.

Oral versus Intraperitoneal Application of Clindamycin in Tunnel Infections: A Prospective, Randomized Study in Capd Patients

Objective

To evaluate the potential superiority of either oral or intraperitoneal treatment of catheter tunnel infections (TI), using clindamycin as a first-Iine antibiotic and ultrasound as a diagnostic tool.

Design

This was a prospective, randomized study in continuous ambulatory peritoneal dialysis patients. From August 1993 until August 1995, 16 clinically and ultrasound-proven episodes of TI were randomly assigned to either an oral or an intraperitoneal (IP) treatment (100 patients, 1414 patient-months). Main criteria for TI diagnosis were purulent drainage from the exit site and/or a positive ultrasound (pericatheter fluid collection of at least 2 mm, 7.5 MHz transducer). Initially, clindamycin (20 mg/kg body weight) was given via the oral (three times per day) or intraperitoneal route (four times per day). In the case of incompatibility or resistance to clindamycin, either oxacillin orciprofloxacin were used orally or IP.

Results

Based on ultrasound criteria, the mean time until a ≥50% reduction of pericatheter abscess diameter was 26 days (median) (range: 8 28 days) in the oral, and 15 days (8 27 days) in the IP group (p ≤ 0.05). Showing no significant difference of pericatheter fluid at study entry with 4 mm (median) (range: 2 -6 mm) in the oral group and 4 mm (2 -4 mm) in the IP group, the IP treatment resulted in a decrease to 0 mm (0 2 mm) after 28 days (p < 0.05), while the diameter was still 2 mm (0 10 mm) (NS) in the oral group. Disappearance of exit-site infection was also somewhat earlier in the intraperitoneal group (51 vs 15 days, NS). Catheter removal had to be done once in the IP group and twice in the oral group within 6 months after study entry.

Conclusions

The results give evidence for greater efficacy of the IP application of clindamycin as a first -Iine antibiotic compared to the oral route for the treatment of tunnel infections.

Generation of TNFα and Interleukin-6 by Peritoneal Macrophages after Overnight Dwells with Bicarbonate- or Lactate-Buffered Dialysis Fluid

Objective

In order to evaluate the biocompatibility profile of a newly designed peritoneal dialysis fluid (PDF), we evaluated peritoneal leukocyte (PMΦ) cytokine release following overnight in vivo dwells using standard, lactate-buffered, single-chamber bag PDF (Lac-PDF) and purely bicarbonate-buffered, double-chamber bag PDF containing 34 (Bic-PDF) or 39 (Bic Hi-PDF) mmol/L bicarbonate.

Design

A randomized, open, crossover clinical trial with single weekly test dwells was performed in stable, long-term continuous ambulatory PD patients ( n = 8). During 8-hour overnight dwells, PMΦ were exposed to different PDF containing 1.5% glucose. After drainage, peritoneal cells were isolated and incubated with RPMI 1640 medium for 2 or 3 hours, with and without stimulation by lipopolysaccharide (LPS). Ex vivo release of tumor necrosis factor (TNF)-α and interleukin (IL)-6 was measured by specific ELISA technique.

Results

After pre-exposure to Lac-PDF, PMΦ generated 242 ± 279 pg TNFα/106 cells and 157 ± 105 pg IL-6/106 cells. When pre-exposed to Bic-PDF and Bic Hi-PDF, TNFα and IL-6 production of PMΦ was not significantly different from Lac-PDF. After LPS stimulation (100 ng/mL), PMΦ secretion of TNFα and IL-6 pre-exposed to three PDF revealed no significant differences between groups: TNFα was 2864 ± 1216, 2910 ± 1202, and 3291 ± 558 pg/106 cells after overnight dwells with Lac-PDF, Bic-PDF, and Bic Hi-PDF, respectively. Comparably, LPS-stimulated (100 pg/mL) PMΦ showed IL-6 secretion of 891 ± 335, 1380 ± 1149, and 1442 ± 966 pg/106 cells for Lac-PDF, Bic-PDF, and Bic Hi-PDF.

Conclusion

After long-term overnight dwells, initial pH, the different buffers, and varying glucose degradation product levels of PDF do not strongly affect PMΦ function with respect to cytokine release. The lack of significant differences between fluids may result from the complete dialysate equilibration achieved during the overnight intraperitoneal dwell.

Disconnect during Continuous Ambulatory Peritoneal Dialysis (CAPD): Retrospective Experience with Three Different Systems

Disadvantages of continuous ambulatory peritoneal dialysis (CAPD), such as inconvenience and bulkiness of the apparatus, inflexibility of infusion volume, and predictable peritonitis incidence may be altered by using systems which allow disconnection from the tubing and bag after each exchange. At University of Michigan we have followed 35 patients using the O set@ with sodium hypochlorite (Baxter Healthcare Corp.) for 15.5 ± 10 months, 16 patients using the Y configuration Ultraset® (Baxter Healthcare Corp.) for 8.1 ± 5 months, and 6 patients using a universal adapter (Delmed Corp.) for 14.3 ± 7 months. Failure occurred in 7 cases (18%) at 12 ± 8 months using the O set (3 elective, 3 related to peritonitis, 1 ultrafiltration difficulty), and 1 (7%) at 3 months using the Ultraset (related to peritonitis). Accidental sodium hypochlorite infusion occurred 8 times in 6 patients, 4 patients still on CAPD without residual effect and 2 in whom infusion contributed to failure but not to ultrafiltration difficulty. Cumulative per-patient-year (episode/ months) peritonitis rates of 0.75 (1/16.4), 0.65 (1/18.4) and 0.88 (1/14.3), respectively, compare favorably with the overall center experience of 0.96 (1/12.2) (NIH-CAPD Registry). Peritonitis rates did not differ during use of any of the disconnect systems between patients with prior CAPD experience compared to patients without prior CAPD experience. More important, however, in patients with prior CAPD experience, peritonitis rates after initiation of the disconnect system tended to be lower than rates before disconnect with both the O set, 0.66 (1/18.1) vs. 1.18 (1/10.2) (n = 16, p < 0.09) and Ultraset, 0.46 (1/26.1) vs. 1.54 (1/7.9) (n = 6, p < 0.03), with insufficient data (n = 2) for the universal set. In conclusion, disconnect systems favorably influence not only patient preference for CAPD and ability to vary CAPD infusion volume, but also the frequency of peritonitis during long term use.

Continuous Ambulatory Peritoneal Dialysis (CAPD) or Center Hemodialysis? Retrospective Evaluation of the Success of Both Methods

In a retrospective study, the authors analysed the dialysis-technique success rate in 276 chronic renal patients. Of these, 137 patients have been treated with in center hemodialysis (CHD) from 1972 to 1989 and 139 with continuous ambulatory peritoneal dialysis (CAPD) from 1978 to 1989. The six-year technique success rate was 28% in CAPD and 31% in CHD (statistically not significantly different). Various risk factors influence the technique-success rate of both methods in the same way. The results suggest that in our center CAPD is as effective as CHD in the treatment of patients with endstage renal failure.

A Randomized Multicenter Clinical Trial to Evaluate the Effects of An Ultraviolet Germicidal System on Peritonitis Rate in Continuous Ambulatory Peritoneal Dialysis

In continuous ambulatory peritoneal dialysis (CAPD), peritonitis frequently is assumed to result from spike contamination during bag exchanges. An ultraviolet germicidal chamber has been developed, which disinfects the spike and the solution-bag outlet before spike insertion. This report summarizes the results of a multicenter trial carried out to determine if this device reduces the incidence of peritonitis in patients on CAPD. Ten centers contributed 167 patients who were followed during a base-line historical control period for a minimum of four months. Thereafter, 93 patients were randomized to a control group, and 74 to the test group. After an interim period for retraining (both groups) and change over (test group), a trial period of nine months was undertaken. Peritonitis rates and actuarial analyses of time-to-peritonitis showed no significant differences between historical and trial periods in either group, or between groups during either period. In both groups, rates of peritonitis were consistently lower than rates reported in the National Registry. The results suggest that, in the patients participating in these studies, spike contamination may have been an infrequent cause of peritonitis.

In the U.S.A. over 9000 patients with end-stage renal disease are maintained on continuous ambulatory peritoneal dialysis (CAPD) (I). A peritonitis rate of 1.6 episodes per patient year represents the national average in the latest report of the U.S.A. CAPD Registry (2). Most clinicians assume that spike contaminations during bag exchanges are responsible for some portion of these episodes. Popovich, Moncrief and colleagues have described preliminary experiences with an ultraviolet germicidal system shown to disinfect intraspike contaminations with solutions containing 200,000 organisms per ml (3–4). An integrated dose of ultraviolet light within the germicidal chamber kills microorganisms before spike insertion into a fresh bag of solution. An improved chamber has been made available for clinical trials by Travenol Laboratories Inc (Deerfield, Illinois) (5).

This study summarizes the results of a multicenter trial designed to test the effects of this germicidal chamber on the frequency of peritonitis in a population of patients maintained on CAPD.

Prospected Randomized Study of Two Y Devices in Continuous Ambulatory Peritoneal Dialysis (CAPD)

To evaluate acceptability, safety, and efficacy of a y set with two short branches (TAs) filled with electrolytic chloroxidizer solution during the dwell time, 60 patients were randomly allocated to be treated with the traditional y set (TCs) or with the T AS. Twenty-three were new patients whereas the remaining 37 were patients already on continuous ambulatory peritoneal dialysis (CAPD) with the TCs. The follow-up was 416.5 months in the control group and 387.4 months in the test group. During the study period there were 6 peritonitis episodes in each group with an incidence of 1 episode every 69.4 patient-months in the control group and 1 episode every 64.6 patient-months in the test group. Twenty-four patients (80%) in the control group and 27 (90%) in the test group were free from peritonitis. The probability to remain free from peritonitis was respectively 87% and 83% in the test group and in control group after 12 months, 70% and 78% after 21 months. seventy -nine percent of the patients who used both systems preferred the T AS for better handling, lower encumbrance, and major safety. One patient preferred the TCs, three patients did not find any differences between the two devices.

Decrease in Peritonitis Rate by Integrated Disconnect System in Patients on Continuous Ambulatory Peritoneal Dialysis

The prevention of peritonitis is of major concern for successful long-term continuous ambulatory peritoneal dialysis (CAPO) treatment. The effect of a Y-systern on peritonitis Incidence and patient morbidity was observed in a comparative, retrospective single-center analysis over a period of 5 years. The Integrated disconnect system prolonged the peritonitis-free period from 1:11 patient-months, observed with the conventional system, to greater than 1:50 patient-months. The rate of hospitalization was reduced by 45%.

Why the Double-Bag System Still Remains the Best Technique for Peritoneal Fluid Exchange in Continuous Ambulatory Peritoneal Dialysis

Since March 1979 (the Italian-French-Spanlsh meeting in Turin), we have been using the double-bag system for peritoneal fluid exchange in patients on continuous ambulatory peritoneal dialysis (CAPD). This technique, subsequently followed by many others because of the advantages to the patients, still represents the best tool in bag-exchange procedure, because It satisfies the following characteristics: single luer-lock connection; fiush before-fill; simple, safe, and aseptic manipulation; short training period; no carrying bag; good patient acceptance; and low incidence of exogenous peritonitis. In 13 years with 237 patients selected for double-bag treatment, we have observed an incidence of 1 episode of peritonitis every 26.6 patient-months. Few clinical CAPD-related complications like hypotension and alterations of Ca-P metabolism were observed, probably as a result of more personalized peritoneal fluid with high Na+ (136 mEq/L) and Ca2+ (3.5 mEqL) concentrations. In the meantime, we have also had available plasticizer-free bags, which eliminated one of the main risk factors In peritoneal sclerosis. The utilization of the plasticizer-free double-bag system, currently adopted by numerous other centers, still remains the best option from a clinical and psychological viewpoint of the patients on CAPD.

A Randomized, Multicenter, Open-Label Trial to Establish Therapeutic Equivalence between the Carex and Ultra Disconnect Systems in Patients on Continuous Ambulatory Peritoneal Dialysis

Objective

In the present study, we undertook to establish therapeutic equivalence with respect to peritonitis and technique failure between the Carex disconnect system (B. Braun Carex, Mirandola, Italy) and the standard Ultra system (Baxter Healthcare, Tokyo, Japan) in patients on continuous ambulatory peritoneal dialysis (CAPD).

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.

Capd Viability: A Long-Term Comparison with Hemodialysis

Objective

To compare the long-term viability of continuous ambulatory peritoneal dialysis (CAPD) to that of hemodialysis (HD).

Design

Retrospective study of patients of our institution starting dialysis between January 1,1981, and December 31, 1993, and surviving for at least 2 months.

Patients

Five hundred and seventy-eight new patients (51.3% on CAPD and 48.6% on HD).

Main Outcomes Studied

Cox -adjusted assessment of patient and technique survival, and of technique success. Differences in results for two successive periods of time.

Results

Patient survival did not differ between CAPD and HD after adjusting for age and comorbidity, and significantly improved in the second part of the follow-up (1987 -1993). Technique failure was significantly higher on CAPD, in which it was inversely related to age. The probability of a patient continuing on the first method of dialysis (“technique success”) was significantly lower on CAPD than on HD, but the difference decreased progressively with age and disappeared in patients ≥75 years.

Conclusion

CAPD is as effective as HD in preserving life in uremic patients in the long-term, and gives better results in the older elderly. In adults, the lower technique success rate may not be a problem for patients with access to a good transplantation program; for others, this drawback must be weighed against the advantages of home treatment.

Exit-Site Infection in Continuous Ambulatory Peritoneal Dialysis: A Review

Although the ability of CAPD to successfully treat end-stage renal disease is now well established, exitsite infection (ESI) remains a serious cause of morbidity. The objective of this article is to review recent advancements relating to ESI pathogenesis and its reduction. Current definitions of ESI are reviewed, as are comparative studies of etiology. Emphasis is placed on the literature identifying Staphylococcus aureus as the primary cause of ESI in CAPD. The article reviews reported rates of ESI and discusses reasons for variations of this complication's reported frequency. The selection of catheters available in CAPD are discussed, as are studies demonstrating the threat of S. aureus to catheter survival. The pathogenesis of exit-site infection related to S. aureus nasal carriage in CAPD is reviewed in light of recent findings indicating the pre-CAPD nasal carrier as the patient at risk for subsequent ESI. Postoperative and long-term care of the catheter patient are reviewed for various literature protocols. Treatment recommendations for choice of agents are discussed. Future research should include a better understanding of the morphology of the CAPD catheter exit-site in humans and the healing process. ESI epidemiological studies should be encouraged in tandem with well -designed, controlled studies on the value of prophylactic treatment.

Povidone Iodine Sterilization of Contaminated CAPD-Exchange Spikes

Thirty routine CAPD exchange spikes (Travenol) were dipped in a Staphylococcus aureus suspension and then divided into three equal groups. Group I (G1) spikes were advanced from the bacterial suspension to a povidone-iodine solution for a five-minute soak; Group 2 (G2) spikes were advanced into a sterile, non-bacteriostatic, physiologic saline solution for a five-minute soak. Then G1 and G2 spikes were attached in the usual sterile fashion to dialysis bags pretreated with tryptic soy broth to enhance bacterial growth. Group 3 (G3) spikes were advanced immediately to pretreated dialysate bags. Cultures of the dialysis solution were obtained immediately after the spikes were connected to the dialysis bags, 48 hours later, and at weekly intervals for three weeks. All 10 of the G3 bags connected to spikes without soaking grew greater than 10 colony forming units/mi of S. aureus by 48 hours. All 10 of the saline soaked G2 bags also demonstrated growth at 48 hours. Only one of the 10 Gl povidone-iodine soaked spike bags grew detectable colonies of bacteria at 48 hours. We conclude that a five-minute povidone-iodine soaking of spikes contaminated with S. aureus usually will prevent bacterial growth but is not a perfect solution to the problems of spike contamination.

The frequent occurrence of peritonitis remains the limiting factor to the widespread acceptance of CAPD. Oreopoulos et al proposed that 36.5% of episodes of peritonitis are secondary to contaminations at the connection site during the a CAPD bag exchange (1). Although the exact frequency is unknown, we agree that the likelihood is high that contamination at the time of the exchange is a common mode of bacterial access to the peritoneal cavity.

When we established our CAPD programs we instructed our patients to change the tubing if the spike became contaminated. Patients only rarely notified us of this necessity, despite our suspicion that known contamination was occurring. Two of us asked the Bulletin's editors if one could manage spike contamination simply by soaking the spike in povidone-iodine (2). Vas recommended that the tubing be changed because simple soaking would not deal with contamination inside the lumen (3). We decided to study this issue further because we believed that patients would not comply with this recommendation.

Trimethoprim-Sulfamethoxazole Pharmacokinetics during Continuous Ambulatory Peritoneal Dialysis (CAPD)

Ten adult patients on continuous ambulatory peritoneal dialysis (CAPO) received one dose of trimethoprim320 mg (TMP) and sulfamethoxazole 1600 mg (SMX) orally (p.o.), intravenously (i.v.), and intraperitoneally (i.p.) on three separate occasions to characterize the pharmacokinetics of both drugs. Concentrations of both TMP and SMX were measured in serum and dialysate by HPLC to 48 h. Half-life, total body clearance (TBC), and peritoneal clearance (PCI) were determined. The mean half-life of TMP was 28 h, while for SMX it was 12.5 h. Relative to the i.v. dose, the bioavailability following oral administration for TMP was 98% and 87% for SMX. Intraperitoneal bioavailability was 73% for TMP and 65% for SMX after a 4-h dwell.

After 24 h, regardless of the route of administration, less than 3% of TMP and less than 6% of SMX appeared in dialysate.

We conclude that peritoneal losses contribute insignificantly to TMPISMX elimination during CAPO.

A Comparison of Infection Rates among Older and Younger Patients on Continuous Peritoneal Dialysis

Objective

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

Design

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.

Setting

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

Patients

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).

Main Outcome Measures

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.

Results

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).

Conclusions

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.

A Randomized Prospective Study of the Cost -Effectiveness of the Conventional Spike, O-Set, and Uvxd Techniques in Continuous Ambulatory Peritoneal Dialysis

Objective

To compare the clinical outcome and cost-effectiveness of three techniques for continuous ambulatory peritoneal dialysis (CAPD): the conventional spike technique (C), the O-set (0), and UVXD (U, ultraviolet irradiation connection box).

Design

A randomized and prospective comparison of three CAPD techniques.

Setting

A tertiary referral and a satellite dialysis center.. Patients: One hundred patients with end-stage renal failure between 10 and 70 years of age, with good handeye coordination and not anticipated to receive a living related transplant within 6 months.

Interventions

Patients were randomized by referral to a table of random numbers to perform one of the three CAPD techniques.

Main Outcome Measures

Training time, details of peritonitis and exit-site infection (ESI) including the costs of antibiotic treatment, outpatient visits, hospital stays, technique, and patient survival were analyzed after a minimum follow-up period of one year.

Results

There were 38, 31, and 31 patients in groups C, 0, and U, respectively, and the total observation periods were 838,802, and 745 patient-months, respectively. The peritonitis rates for C, 0, and U were 21.5, 30.8, and 29.8 patient-months/episode, respectively. The corresponding ESI rates were 16.4,14.9, and 24 patient-months/ episode, respectively. When the time from the commencement of CAPD to the first infection was expressed using the Kaplan-Meier life table analysis, 39.5%, 67.7%, and 61.3% of patients in Groups C, 0, and U were free from peritonitis at one year (p = 0.088). The corresponding figures for ESI were 52.6%, 48.4%, and 61.3% (p = 0.35). There was no significant difference in technique survival in the three treatment groups. An analysis of the costs related to the use of antibiotics, outpatient visits, and hospital stays necessary for the treatment of peritonitis and ESI and those related to training time, additional equipment, and consumables required for the three CAPD techniques showed that, overall, the cost in 0 was the lowest, followed by U and C (U.S. $158, $170, and $179 per patient-month, respectively).

Conclusion

It was concluded that the O-set is a more cost-effective CAPD technique than UVXD, while both are more cost-effective than the conventional spike technique.

Continuous Ambulatory Peritoneal Dialysis Connection Systems

The history of the various connection systems proposed and tried during the first 15 years of clinlcal application of continuous ambulatory peritoneal dialysis (CAPD) is reviewed.

In order to understand the reasons for their success or lack of success, the main technical and operating characteristics regarding their efficacy In preventing peritonitis are examined in detail, together with a range of other pros and cons (I.e., reliability, simplicity, ease of use, cost, aesthetlcal aspects).

The result Is an updated state-of-the-art review In the field of CAPD connectology, with a look at future trends.

Touch Contamination of Connection Devices in Peritoneal Dialysis-Aquantitative Microbiologic Analysis

Objective

To determine the level of bacterial contamination associated with touch contact of a connector set during peritoneal dialysis (PD).

Design

The experiment utilized a laboratory-based simulation of a bag exchange procedure. Deliberatetouch contamination of the connector set spike was followed by quantitative recovery of micro-organisms from the connector and, in some cases, the dialysis bag.

Subjects

Patients undergoing PD were used as the “test” group. Departmental secretarial and laboratory staff served as the comparative control group.

Setting

The patients were voluntary subjects from a PD outpatients unit and were tested in their own homes.

Outcome

The numbers of micro-organisms contaminating a connector set and entering the dialysis bag during a touch-contamination event were determined. Additionally we identified hand hygiene and, in particular, the care taken to dry the hands after washing as being highly relevant to microbial touch-contamination levels. Patient hand disinfection, as practised in most PD units, effectively reduced touch contamination to low levels.

Results

Touch contamination of a connector set with unprepared hands led to fewer than 100 micro-organisms translocating from fingers to the spike. If the hands were washed but not dried before touch contact was made, up to 4500 micro-organisms trans located to the connector set spike. Air-towel drying of washed hands before touch contact reduced the translocating numbers by 95% -99%. Hand disinfection, as routinely practiced by PD patients, reduced the bacterial numbers reaching the peritoneal cavity after touch contamination to <5. The range of micro-organisms isolated from the fingers of PD patients using hand disinfectants on a regular basis showed considerably more diversity than the control group.

Conclusion

Hand care prior to bag exchange has a major effect on touch-contamination levels. Accidental touch contact of connecting devices by unprepared hands using a PD-bag exchange procedure leads to the translocation of 500 micro-organisms or fewer to the connector device. If the hands are wet at the time of contact the number translocating can be as high as 4500. Hand drying with an air towel before touch contact reduces the numbers translocating by 95% -99%. Hand disinfection procedures carried out prior to bag exchange minimizes touch-contamination levels.

In Vitro and in Vivo Efficacy of a New Connector Device for Continuous Ambulatory Peritoneal Dialysis

The purpose of this study was to evaluate the In vltro and in vivo efficacy of a new connection system for continuous ambulatory peritoneal dialysis (CAPO), called the T-set. With this system the patient wears a 27–cm extension line filled with Amuchina during the dwell time; the bag is made of a fill container linked to a drainage tube with a Y-shaped set. For bag exchange, only one connection is needed and this is subsequently flushed with the entire drainage volume.

The in vitro efficacy of the system was tested with 20 sets filled with 10 mL of Amuchina and inoculated in the distallumen with 2.1x103 colony-forming units (cfu) of S. aureus. After an Incubation of 4–6 hours at 35–37°C, three dialysate samples per set were collected, respectively, at the beginning of drainage and filling. Al1120 samples were negative, whereas two control sets, filled with a phosphate-buffered saline, had positive drainage samples, and at least one positive Infusion sample, Indicating the efficacy of Amuchina in sterilizing the system under conditions simulating touch contamination.

To evaluate the in vivo efficacy, safety, and acceptability of the T-system, a prospective randomized controlled trial was performed In seven centers: a control group (CG) of 56 patients (follow-up: 952.3 months, mean±SO: 17.0±7.8) was treated with a long branch (21 patients) or short branch (35 patients) Y-set and a test group (TG) of 66 patients (follow-up: 898.1 months, mean±SO: 13.6±7.8) with the T-set. The two groups were comparable for patient and dialysis characteristics. The incidence of peritonitis was 1143.3 months in the CG and 1129.0 months In the TG (p=NS). The percentage of patients without peritonitis was 67.8% In the CG and 68.2% In the TG (p=NS); the probability of remaining free from peritonitis was, respectively, 76% and 75% In the CG and in the TG at 1 year, and 66% and 60% at 2 years (p=NS). In the CG 26 patients and In the TG 21 patients were already on CAPO before the trial; among these 21 patients, 10 of 10 with the long Y-set and 4 of 11 with the short Y-set who transferred to the T-set preferred the latter for better handling (52.4%) or for less encumbrance (14.3%).

Clinical Evaluation of a Peritoneal Dialysis Solution with 33 mmol/L Bicarbonate

Objective

To evaluate the efficacy and safety of a new peritoneal dialysis solution with 33 mmol/L bicarbonate.

Design

In an acute, prospective, randomized crossover study, 8 patients were randomized in two groups of 4. On the first study day, the first group performed two consecutive 4-hour exchanges with a dialysis solution containing 35 mmol/L lactate: the first exchange with 13.6 g/L and the second with 38.6 g/L dextrose. On the second study day, the same type of exchanges were performed with bicarbonate. The second group underwent the same treatment, but used bicarbonate solutions on the first day and control solutions on the second study day. Thirty-three patients participated in a 2-month prospective and randomized study. After a 4-week baseline period using solutions containing 40 mmol/L lactate, the patients were dialyzed with either 33 mmol/L bicarbonate solutions or 40 mmol/L lactate solutions.

Setting

Peritoneal dialysis units at the University Hospital of Brescia and the Niguarda Hospital of Milan, Italy.

Results

Acute study: Control and bicarbonate solutions had similar effects on blood chemistries and peritoneal transport. Chronic study: Mean venous bicarbonate concentrations remained unchanged in the control group (26.6 -27.2 mmol/L), but decreased significantly in the bicarbonate group from 28.8 mmol/L at the start of the study to 23.0 mmol/L after 2 months of bicarbonate administration. Other biochemical parameters remained unchanged.

Conclusion

A peritoneal dialysis solution with a bicarbonate level of 33 mmol/L does not adequately correct uremic acidosis.

In Vitro Study of the Flush Effect in Two Reusable Continuous Ambulatory Peritoneal Dialysis (CAPD) Disconnect Systems

Previously published in vitro results, confirmed by clinical studies, indicate that the use of a flush significantly reduces peritonitis in single-use and reusable continuous ambulatory peritoneal dialysis (CAPD) systems. Since reusable systems may use the flush plus inline disinfectant between exchanges, the question remains as to whether or not the flush could be used alone in all disconnect systems. Using an in vitro model, we evaluated the flush in two reusable disconnect systems that use both flush and disinfectant in vivo. In a series of twenty sets per organism per incubation (0 h and 10 h), Y sets were inoculated in the lumen with three pure cultures (103 CFU range). Ability of flush without disinfectant to clear sets of contamination was analyzed by collecting multiple samples at each step of the procedure, enriching with tryptone broth and verifying bacterial growth. When contaminated sets were not incubated, flush efficacy of the systems was consistent with previous data showing 100% removal of Staphylococcus epidermidis, but only partial elimination of Staphylococcus aureus and Pseudomonas aeruginosa. After incubation, simulating reusable systems, the flush was able to eliminate S. epidermidis less than 50% of the time. There was no significant difference in results between the two systems tested. Reusable systems allow more contact time between bacteria and plastic resulting in reduced flush efficacy suggesting that, for safest conditions, they should be used with inline disinfectants.

Randomized Study of Peritonitis with Conventional versus O-Set Techniques in Continuous Ambulatory Peritoneal Dialysis

We performed a prospective randomized trial, comparing the incidence of peritonitis between a flushdisconnect (O-System, Baxter, Deerfield, IL) (OS) and a conventional (System II, Baxter) (CS) continuous ambulatory peritoneal dialysis (CAPD) method.

Sixty consenting patients with no significant physical disabilities who commenced CAPD after May 1987 were entered and followed for a minimum of 12 months. Thirty were placed on the OS system and 30 were placed on CS. Age, gender, and time for training did not differ significantly.

The period of observation for OS was 375 months; CS was observed for 430 months. OS patients experienced 28 episodes of peritonitis (13.4 months/patient/episode) compared with 88 (4.9 months/patient/episode) in CS (p<0.005). By 6 months, 32% of OS patients had had at least one episode of peritonitis, compared with 62% of CS patients; at 12 months, these figures rose to 48% for OS and 91% for CS (p<0.01) patients (Life Table Analysis). The median survival time to first peritonitis episode was 5.1 months in CS and 9.7 months in OS (p<0.01). Exit. site infections occurred in 14/30 (46%) of patients on OS and in 13/30 (43%) of CS patients. We conclude that the OS was associated with a significant reduction in the incidence of peritonitis.

Management of Peritonitis Complicating Continuous Ambulatory Peritoneal Dialysis: An Australian Perspective

In the decade following the introduction of CAPD by Popovich et al (I) substantial improvements have been made in the management of CAPD peritonitis. This review summarizes the significant advances in the prevention, diagnosis and treatment of CAPD peritonitis in the first 10 years of CAPD therapy (1976–1986) and highlights additional areas where management protocols can be improved further.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis {CAPD): A Multi-Centre Randomized Clinical Trial Comparing the Y Connector Disinfectant System to Standard Systems

sixty-one new continuous ambulatory peritoneal dialysis (CAPD) patients were allocated to a Y connector disinfectant (Amuchina, Italy) and 63 to standard systems (Baxter Systems II & III) in a randomized clinical trial addressing peritonitis rates in 8 CAPD programs in 6 Canadian cities. In the Y connector-disinfectant group, 15 patients experienced 21 episodes of peritonitis in 452 patient-months or 1 per 21.53 patient-months. In the standard systems group, 30 patients experienced 47 episodes of peritonitis in 467 patient-months or 1 per 9.93 patient-months ( p = 0.009). The peritonitis risk reduction was 61% (95% confidence limits 27–79%). Exit-site infections occurred in 36% of each group.

Prior to the development of exit -site infection, the monthly risk for peritonitis was 3.12% for the Y connector disinfectant system and 7.37% for the standard system. After an exit -site infection, these probabilities increased to 6.15% and 15.47%, respectively. Skin organisms were responsible for peritonitis in 8/21 (38%) in the Y connector-disinfectant group and 30/47 (64%) in the standard group. There were 75 days hospitalized for peritonitis in the Y connector-disinfectant group compared to 257 days for the standard group. The Y connector disinfectant system decreases the peritonitis rate through its effect on skin organisms. Exit -site infections are a major source of organisms responsible for peritonitis.

Technique Failure in Peritoneal Dialysis and Its Impact on Patient Survival

Objective

To determine the frequency and causes of continuous ambulatory peritoneal dialysis (CAPD) technique failure and its effect on patient outcome.

Design

Retrospective study of CAPD technique and patient outcome.

Setting

Teaching hospital renal unit.

Patients

All 221 patients commencing CAPD over a 14-year period. Outcome measures: Outcomes assessed included patient survival and technique survival (with change to hemodialysis being considered as technique failure).

Results

CAPD failure occurred in 46 patients, with a CAPD technique survival of 93%,73%, and 63% at 1,3, an d 5 years after start of treatment. Peritonitis was the major cause of technique failure. CAPD system had no effect on technique survival, despite the lower peritonitis rate in patients using Y-connection systems. Overall patient survival was 91 %, 72%, and 53% at 1, 3, and 5 years after start of treatment, with increasing age and diabetes being associated with a worse outcome. There was a high early mortality after CAPD failure, with an actuarial survival of only 61% 1 year later.

Conclusion

Failure of CAPD is an important problem, with peritonitis being the major cause, either directly, or indirectly by the later effects of damage to the peritoneal membrane with loss of dialysis adequacy. The high mortality in the period following CAPD failure warrants careful monitoring of patients during this phase, along with efforts to optimize correctable factors such as nutrition, adequacy of the new form of dialysis, and treatment of residual sepsis.

Biofilm on Tenckhoff Catheters: A Negligible Source of Contamination

The authors studied the presence and characterization of biofilm in the lumen of Tenckhoff chronic peritoneal dialysis catheters of 17 CAPD patients to elucidate the role of biofilm as a source of peritonitis.

At the time of investigation, all 17 patients were peritonitis-free. All used a single-use, Y -system without disinfectant. Previously eight had used the conventional system. Seven had experienced II episodes of peritonitis with their present catheter (4 episodes while on conventional systems). Ten patients had no history of peritonitis. Four samples from each catheter were obtained with aseptic technique: swabs from inside the titanium adaptor, a 5 cm proximal segment removed and sectioned longitudinally to obtain luminal scrapings, a nylon brush sample from the entire length of the catheter, and from fluid run through the catheter after introducing the brush. All samples were treated by different microbiological techniques and incubated under various conditions. In vitro control experiments were performed to recover biofilm with the brush technique. Whereas all controls were positive, 100% of the samples demonstrated no bacterial growth after two -weeks’ incubation. Five patients’ catheters (four with previous peritonitis) examined under light microscopy contained amorphous material without viable bacteria as evidenced by both growth experiments and mi croscopy. Ten catheters were examined on scanning electron microscopy: the inner surface of all were covered with a protein-Iike membra nous deposit. Occasional bacteria and various number of macrophages were observed on three catheters. On two other catheters, biofilm looked like bacterial microcolonies but this was not confirmed by gram-staining and cultures. Results suggest that biofilm is not ubiquitous in catheters of CAPD patients and that the catheter does not appear to be a bacterial reservoir that would provoke peritonitis. Biofilm might be secondary to frequent peritonitis and/or frequent asymptomatic intra-luminal catheter contaminations. The low peritonitis rate of the studied patients and the use of Y -line systems could explain the absence of a typical biofilm. Results also suggest there may be two types of biofilm -one made up of adherent bacteria and glycocalyx, and one made up of non-contaminated protein -like deposits. The presence of each type would depend of the efficacy of connectors in avoiding touch contaminations.

A Prospective Randomized Study of the Effect of a Subcutaneously “Buried” Peritoneal Dialysis Catheter Technique versus Standard Technique on the Incidence of Peritonitis and Exit-Site Infection

♦ Objective

A new method for implantation of peritoneal dialysis (PD) catheters was described in 1991. The distal part of the catheter is buried subcutaneously and exteriorized at the start of PD. This study was designed to evaluate the effect of such a subcutaneous rest period on the incidence of peritonitis and exit-site infections (ESI).

♦ Design

Sixty patients were randomized to either the new method (B group; n = 30) or to not having the distal part buried subcutaneously (NB group; n = 30). Sixty-five patients (NS group) were not randomized as they had to start PD within 1 – 2 weeks after implantation. The Moncrief–Popovich catheter was used in the B and NB groups and a standard Tenckhoff catheter was used in the NS group.

♦ Patients

Patients scheduled for PD treatment, judged not in need of PD for at least 6 weeks after implantation.

♦ Results

There was no statistically significant difference in the cumulative probability of not developing peritonitis during the first 6, 12, and 24 months. The incidence of the first episode of peritonitis was 1/40, 1/26, and 1/33 treatment-months in the B, NB, and NS groups, respectively. The incidence of ESI was 1/103 and 1/95 treatment-months in the B and NS groups, respectively. The cumulative probability of not developing ESI was similar in both groups. There were no episodes of ESI in the NB group. The difference in the number of ESI between the NB and NS groups was significant ( p < 0.05).

♦ Conclusions

Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients: A Randomized Clinical Trial of Cotrimoxazole Prophylaxis

A double-blind randomized controlled trial compared the effectiveness of prophylactic oral trimethoprim/sulfamethoxazole (cotrimoxazole) to a placebo in preventing peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. A daily trimethoprim/sulfamethoxazole dose of 160/800 mg gives a steady state dialysate concentration of 1.07/4.35 mg/L in the final dwell of each dosing interval. Identification of a 40% reduction in peritonitis probability with 80% statistical power and a type 1 error probability of 0.05 required 52 subjects per group. With stratification by previous peritonitis, 56 were allocated to cotrimoxazole and 49 to placebo. For cotrimoxazole there were five deaths and seven catheter losses. For placebo there were three deaths and nine catheter losses. There were 20 withdrawals from cotrimoxazole and 9 from the placebo group. With respect to time to peritonitis, there was no statistically significant difference between cotrimoxazole and placebo groups (p = 0.19). At 6 months, 64.1% of cotrimoxazole and 62.5% of placebo were peritonitis free; at 12 months 41.9% of cotrimoxazole and 35% of placebo were peritonitis free. There was no effect (p > 0.05) of age, sex, catheter care technique, spike or luer, or dialysate additives. Previous peritonitis increased the risk of peritonitis by 2.06 (95% CI, 3.61–1.18) while frequent (six weekly) extension tubing changes increased the risk of by 1.79, (95% CI, 3.04–1.02) when compared to six monthly changes. Cotrimoxazole appears ineffective in prevention of CAPD peritonitis.

Is Technique Survival on Peritoneal Dialysis Better in Japan?

Technique failure resulting in transfer to hemodialysis (HD) remains one of the most important challenges in long-term peritoneal dialysis (PD). In general, the proportion of patients transferring from PD to HD is much greater than the proportion transferring from HD to PD. However, technique failure rates differ considerably between and within countries.

The question arises as to how technique failure rates in Japan compare with those in other countries. To address this issue, we reviewed the literature and our experience of 139 incident continuous ambulatory peritoneal dialysis (CAPD) patients from January 1995 to December 1999.

Based on our review, we estimate that the 5-year technique survival rate in Japanese CAPD patients is approximately 70%, and that technique failure rate is around 7% per year. This rate is significantly lower than that in many other countries. The most common reasons for technique failure in Japan are peritoneal membrane failure, ultrafiltration loss, and inadequate dialysis. Another factor contributing to the low technique failure rate in Japan is an extremely low peritonitis rate. This may be related to good sanitation and excellent PD training programs. Peritoneal membrane failure continues to be the major challenge for long-term technique survival on PD in Japan.