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

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.

Dialysis at Home in the West of Scotland: A Comparison of Hemodialysis and Continuous Ambulatory Peritoneal Dialysis in Age and Sex-Matched Controls

Objective

To audit the outcome of patients treated at home by hemodialysis and continuous ambulatory peritoneal dialysis (CAPD).

Design

Retrospective comparison of nondiabetic hemodialysis patients with age and sex-matched nondiabetic patients treated by CAPD.

Setting

Renal Units, Stobhill General Hospital and Western Infirmary, Glasgow, providing the home dialysis service for the West of Scotland.

Patients

Between 1982 and 1988, 139 hemodialysis patients starting treatment at home, compared with 139 matched patients starting CAPD over the same time period.

Main Outcome Measures

Patient characteristics and cardiovascular risk factors at the start of home treatment. Patient and technique survival with both forms of dialysis.

Results

Patients selected for home hemodialysis were less likely to be smokers (p<0.02) and to have electrocardiographic evidence of ischemia or left ventricular hypertrophy (p<0.05) than patients treated by CAPD. Patient survival and technique survival (excluding death and renal transplantation) at 3 years were 93.8% versus 86.2% (p<0.05) and 94.2% versus 80.8% (p<0.04) for hemodialysis and CAPD, respectively. Cardiovascular events were responsible for the majority of deaths in both groups, but there was a greater proportion of deaths from other causes in patients treated by CAPD. There was no significant difference in the transplantation rate between the two treatment groups.

Conclusions

Home dialysis is an effective method of renal replacement treatment for patients with end-stage renal disease. The results of hemodialysis are superior to CAPD, but this may be partly due to selection bias.

The Role of Omentectomy in Continuous Ambulatory Peritoneal Dialysis

Long-term survival of the peritoneal catheter is essential for successful CAPD. In our unit, all CAPD catheters are now placed by an open surgical technique, which in some cases has included performing a partial omentectomy. The aim of this study was to assess the influence of omentectomy on CAPD catheter survival. Three hundred consecutive CAPD catheters inserted over a 5-year period were analyzed. Omentectomy was performed in 113 cases (38%). Data relating to a number of potentially significant risk/benefit factors were analyzed using multiple regression analysis (proportional hazards method of Cox). Performing a partial omentectomy at the time of catheter insertion was found to significantly improve CAPD catheter survival (p=0.0002).

Characterisation and Evaluation of a New Double Lumen Central Venous Catheter

The performance of a new double lumen central venous haemodialysis catheter was tested in two laboratory models. In a bench model the patient's venous system was simulated by a reservoir from which water or glycerol was drawn through a fixed tube. A double lumen silastic catheter was then inserted into the tube, as it would in a major vein, with the tip directed away from the direction of flow. The catheter was linked to a dialysis circuit incorporating pressure sensors and dye was infused at constant rate so that recirculation at the tip could be measured and found to be less than 5%. The same catheters were inserted operatively into the superior vena cava via the external jugular vein of three pigs (weight 27-31 kg). The catheters remained patent for four weeks and when connected to an extracorporeal circuit had recirculation and pressure flow characteristics comparable to the bench model in the range 50-400 ml/min. The new double lumen catheter is worthy of clinical evaluation.

Bacterial peritonitis in continuous ambulatory peritoneal dialysis: effect on dialysis on host defense mechanisms

We have used an experimental model of continuous ambulatory peritoneal dialysis (CAPD) to investigate the effect of dialysis on host defense mechanisms in the peritoneal cavity. Laboratory rats undergoing regular dialysis were challenged with a single bolus of Staphylococcus epidermidis, Staphylococcus aureus, Candida albicans, and Pseudomonas aeruginosa. Intraperitoneal challenges with all four microbial strains underwent a rapid clearance during the first 4 hours, irrespective of whether the host was undergoing dialysis. Studies using S epidermidis showed that the rapid clearance was not mediated by the diaphragmatic stomata as might have been expected. Dialysis did, however, cause delays over the following 48 hours with all of the pathogens except C albicans. Bacterial clearance over a 10-day period was strain dependant, and microbial persistence was related to adhesion formation around the cannula. Again C albicans was an exception. Our conclusions are that dialysis does not affect the innate defense mechanisms involved in the early clearance of a bolus challenge to the peritoneal cavity but can cause delays in eradicating microorganisms that survive this phase. Because these experiments were carried out using a bolus inoculum, it may be necessary to reevaluate the effect of dialysis on host defenses in the peritoneal cavity under conditions in which the challenge more closely approximates a touch contamination event.

The influence of continuous ambulatory peritoneal dialysis connection technique on peritonitis rate and technique survival

Peritonitis is still the most common complication of continuous ambulatory peritoneal dialysis (CAPD). Several measures have been used to prevent peritonitis, including prophylactic antibiotics and a variety of connection techniques. This study was designed to evaluate the effects of different connection techniques, age at the start of CAPD, sex, and diabetic status on peritonitis rate and technique survival. Three hundred twenty-seven patients treated with CAPD and followed for 8,804.4 patient-months at the Vancouver General Hospital between February 13, 1978, and August 31, 1992, were reviewed. The mean age of the patients was 57.1 +/- 16.3 years. The overall peritonitis rate was 16.6 patient-months per episode. The overall technique survival was 79.6%, 60.2%, and 41.8%, at 1, 2, and 3 years, respectively. Patients using "standard" spike technique (group A, n = 87), Luer lock connector (group B, n = 77), and Luer lock with iodine instillation at the dialysis bag connection site (group C, n = 120) had peritonitis rates of 10.4, 14.7, and 33.3 patient-months per episode, respectively. The relative risk (RR) of peritonitis was 3.5 for group A (95% confidence interval, 2.1 to 4.5) and 2.6 for group B (95% confidence interval, 1.7 to 3.9) compared with group C. Patient age at the start of CAPD, sex, and diabetic status had no effect on the RR of peritonitis. None of the variables studied, except patient age, affected technique survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous ambulatory peritoneal dialysis: a review of its mechanics, advantages, complications, and areas of controversy

OBJECTIVE

The primary objective of this article is to review the mechanics, advantages, complications, pharmacokinetics, and future trends of continuous ambulatory peritoneal dialysis (CAPD) as they pertain to pharmacotherapy.

DATA SOURCES

Pertinent articles were obtained from an English-language literature search using MEDLINE (1980-1991), Index Medicus (1987-1990), and bibliographic reviews of review articles. Indexing terms included peritoneal dialysis, pharmacokinetics, peritonitis, vancomycin, and fluoroquinolones.

DATA SYNTHESIS

All clinical studies comparing organism recovery methods and treatment of peritonitis have methodologic limitations (e.g., comparison of disparate patient groups, different definitions of peritonitis, lack of follow-up, lack of control for sterile cultures) that may affect the reported results.

CONCLUSIONS

CAPD is an alternative to hemodialysis for the treatment of endstage renal disease and has many complications, leading to significant morbidity. This indicates that CAPD is not appropriate for all patients. Using blood-culturing techniques to culture for dialysate is most productive, but also the most costly. There are few data to indicate exactly the drugs, doses, and durations of choice for peritonitis. Both intraperitoneal and oral administration appear to be appropriate.

Surgical complications of continuous ambulatory peritoneal dialysis

Surgical experience with 260 consecutive patients with chronic renal failure receiving continuous ambulatory peritoneal dialysis (CAPD) at one medical center from 1980 to 1989 is reviewed. Patients received CAPD for a mean of 24.2 months (range: 3 days to 91 months). Catheter longevity consistently improved in all but 1 year from 1984 to 1989, as did exit-site and tunnel infections. Of 311 catheters inserted, 151 (49%) required removal, of which 111 (74%) were attributed to peritonitis. Cumulative patient survival was 80%, 60%, and 53% at 1, 2, and 3 years, respectively. Diabetic patients had statistically significant lower survival rates. Additional complications including catheter leakage, catheter malposition, catheter obstruction, and abdominal wall hernias were negligible. Although CAPD is not free from serious complications, our data show remarkable improvement since 1980 in catheter longevity, hospital stay, and infection rates.

Factors influencing peritoneal catheter survival in continuous ambulatory peritoneal dialysis

The success of continuous ambulatory peritoneal dialysis (CAPD) is to a great extent determined by the survival of the peritoneal catheter. The aim of this study was to identify technical factors which influence CAPD catheter survival. A total of 453 CAPD catheters inserted into 310 patients over an 8-year period were analysed. Access to the peritoneum was gained either by an open surgical technique (n = 290) or by a closed technique using a trocar and introducer (n = 163). Data relating to a number of potentially significant risk/benefit factors were analysed using multiple regression analysis (proportional hazards method of Cox). Three factors were found to be independently associated with improved catheter survival. They were: using an open surgical insertion technique, performing a partial omentectomy at the time of catheter insertion and the procedure being performed by a consultant.

Renal replacement treatment for diabetic patients in Newcastle upon Tyne and the Northern region, 1964-88

OBJECTIVES

To review the experience of renal replacement treatment in diabetic patients treated in Newcastle upon Tyne and the Northern region from 1964 to 1988, and to compare the morbidity and mortality of diabetic patients treated with dialysis or transplantation with those of matched controls of non-diabetic patients.

DESIGN

Retrospective study of clinical case notes.

SETTING

Renal units of the Northern region, particularly that in Newcastle upon Tyne.

PATIENTS

All 65 diabetic patients treated by renal replacement treatment in Newcastle upon Tyne from 1964 to 1987; 42 diabetic patients were matched with 42 non-diabetic patients according to age, sex, year of starting treatment, and type of treatment (dialysis or transplantation).

MAIN OUTCOME MEASURES

Sex, age, renal biopsy findings, blood pressure, history of diabetic treatment, and plasma creatinine concentration at the start of renal replacement treatment. History of renal replacement treatments, suitability for transplantation, history of transplantation, cumulative survival, and cause of death during follow up. Survival of technique, cumulative survival of the first peritoneal catheter and history of peritonitis in patients treated with continuous ambulatory peritoneal dialysis; source of graft, histocompatibility antigens, duration of associated stay in hospital, and graft survival in patients receiving renal or pancreatic transplant.

RESULTS

1259 Patients with chronic renal failure were accepted for renal replacement treatment in Newcastle upon Tyne, of whom 65 (5%) had diabetes. The first was accepted in 1974, and between 1974 and 1980 another 15 were treated (mean age 42 years; 4% of new patients). From 1981 to 1987, 49 diabetic patients (mean age 44; 9% of new patients) were treated. Fifty patients (77%) had insulin dependent diabetes and the remaining 15 (23%) non-insulin dependent diabetes. On average, the patients were aged 25 (range 5-57) when diabetes was first diagnosed and 44 (range 24-70) at the start of renal replacement treatment. The mean age at the start of treatment was 40 for patients with non-insulin dependent diabetes and 58 for patients with non-insulin dependent diabetes. Transplantation was performed in 33 of the diabetic patients, whose mean age was lower than that of those who did not receive a transplant (41 v 48 respectively, p less than 0.05). Comparison between the 42 diabetic patients and matched controls showed that the overall survival at five years was 46% and 77% respectively. The three year survival of the diabetic patients who did not receive a transplant was poor (41% v 79% respectively). Of patients transplanted, survival at five years was 73% in the diabetic patients and 90% in the controls. However, there was no significant difference in the five year graft survival (64% v 46% respectively).

CONCLUSIONS

Diabetes adversely affects morbidity and mortality in patients having renal replacement treatment, but renal transplantation seems to be the best option for treating diabetic patients with end stage renal failure.

Intramural and extramural health care in the United Kingdom

In this article the factors which determine whether health care in the United Kingdom is provided in hospital, at home or through intermediate or shared care arrangements are considered. The following aspects of home health care in the United Kingdom are discussed: continuous ambulatory peritoneal dialysis; parenteral nutrition; cytotoxic therapy; terminal care/pain control; intravenous antibiotics. Pharmaceutical implications of the transfer of the long-term care of the mentally ill, mentally handicapped and elderly from hospital to community settings are also considered. Key changes in the development of pharmacy in the United Kingdom are mentioned and the emergence of a new group, community service pharmacists, is identified.

A selection adjusted comparison of hospitalization on continuous ambulatory peritoneal dialysis and haemodialysis

A retrospective study was made of the rate of hospitalization (days/annum) in 227 patients established on either continuous ambulatory peritoneal dialysis (CAPD) or haemodialysis (HD) between 1 January 1980 and 31 July 1985. In order to address the biases which may confound simple comparisons of morbidity when treatment allocation is non-random, multiple regression was used to identify and adjust for the effect of pre-treatment variables significantly (p less than 0.01) influencing hospitalization rate. Six significant variables were identified out of 86 studied. Adverse factors were (i) diabetes and (ii) atherosclerotic disease. Beneficial parameters were (iii) a living spouse and (iv) a controlled presentation via outpatients. The relationship (v) between age and hospitalization rate was U-shaped; the rate increasing above the age of 60 years and below the age 20. (vi) Date of commencement of dialysis exhibited a complex relationship with hospitalization rate implying that whilst the rate on HD remained relatively stable over the course of the study, that on CAPD markedly diminished. As a result, the hospitalization ratio (CAPD:HD) fell consistently throughout the study period, at an estimated annual rate of 28.3% (95% confidence limits 15.6-39.1%). For a patient starting therapy on 1 January 1980 the predicted hospitalization rate on CAPD was 7.8 times greater than that on HD (4.4-13.9) but by 1 May 1985 the estimated ratio had fallen to 1.33 (0.85-2.09). Having adjusted for important confounding, it would appear that with growing experience, hospitalization rates on CAPD fall close to those on HD.

Renal replacement therapy in patients aged over 60 years

The availability of dialysis for patients with end-stage renal failure in the United Kingdom has lagged behind that in most of the rest of Europe and USA, although there has been considerable improvement over recent years. Concern about prognosis and quality of life on renal replacement therapy, together with shortage of facilities has meant that some elderly people have been denied treatment. A retrospective study of all patients commencing renal replacement therapy in Newcastle between 1974 and 1985 was performed. The five year survival of patients aged more than 60 years at the start of treatment (n = 122) was 53%, compared with 68% for a cohort of individuals aged less than 60 years (n = 632). A questionnaire sent to the 62 elderly patients surviving at the end of the follow-up period revealed that most were married, independent, active and lived in their own home. They were not lonely, generally enjoyed life and were happy with their mode of renal replacement therapy. These results show that elderly patients make good dialysis candidates and they should not be denied treatment on the basis of age alone. Greater funding of renal services is necessary to accommodate these patients.

Outcome in patients on continuous ambulatory peritoneal dialysis and haemodialysis: 4-year analysis of a prospective multicentre study

In a study in seven large renal units in England, the morbidity and mortality of all patients starting continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis during 1983-85 were monitored prospectively over a 4-year period and related to reasons for choice of therapy and potential risk factors. 610 new patients (median age 52 years, range 3-80 years) started CAPD; 16% had diabetes mellitus and 21% cerebrovascular or cardiovascular disease. 329 patients (median age 48 years, range 5-77 years) started haemodialysis; 7% had diabetes mellitus and 17% cerebrovascular or cardiovascular disease. The Kaplan-Meier patient survival estimates at 4 years were 74% for haemodialysis and 62% for CAPD; technique survival figures for the same period were 91% for haemodialysis and 61% for CAPD. Cox's proportional hazards regression analysis showed that cerebrovascular/cardiovascular disease, age over 60 years, and diabetes mellitus were important predictors for survival in CAPD patients; there were no risk factors associated with permanent change to haemodialysis. In the haemodialysis group early change to CAPD was associated with presence of cerebrovascular or cardiovascular disease. The major cause of drop-out in both groups was transplantation. The mean length of hospital admission was 14.8 days per patient-year for CAPD and 12.4 days per patient-year for haemodialysis.

Selection-adjusted comparison of life-expectancy of patients on continuous ambulatory peritoneal dialysis, haemodialysis, and renal transplantation

To investigate the controversy surrounding the life-expectancy of patients on continuous ambulatory peritoneal dialysis (CAPD) compared with that of patients on haemodialysis or transplantation mortality data from 389 patients accepted for renal replacement therapy in Leicester between July, 1974, and July, 1985, were retrospectively analysed with respect to a wide range of pre-treatment variables (6 scales and 115 binary variables), by a method (Cox's) that adjusts for the distorting influence of selection bias. 9 independent variables were identified as having a significant influence on survival. Adverse factors were age, amyloidosis, ischaemic heart disease, convulsions, and acute presentation. Beneficial variables were male sex, parenthood, pyelonephritis, and residence in Leicestershire. By correcting for the influence of these variables and using time-dependent treatment co-variates, the bias adjusted estimates of the relative risk of death were 1 for patients on CAPD, 1.30 for those on haemodialysis, and 1.09 for patients who received transplants. These risks do not differ significantly from one another and suggest that CAPD is at least as effective as haemodialysis or transplantation at preserving life.