Continuous ambulatory peritoneal dialysis versus automated peritoneal dialysis and peritonitis in the short and very long term at risk.

Peritonitis (P) is the most important infectious complication in peritoneal dialysis (PD), but disagreement remains about the impact of PD modality on the frequency of P episodes. We compared indices linked to P between patients on continuous ambulatory PD (CAPD) and those on automated PD (APD) in the short and very long term. The study included 9 prevalent and 72 incident patients on CAPD (twin-bag system) and 37 incident patients on APD from 4 August 1995 to 31 March 2011. Data were collected prospectively from our database. The cumulative P rate (CPR) by weighted Student t-test (p < 0.05) expressed as the probabilities of remaining free of a first P episode and remaining free of all P episodes were compared by the Kaplan-Meier method (log rank p < 0.05). The proportion of patients with P (PPP) per group (chi2 p < 0.05) and the relative risk (RR) of P were also calculated. The CAPD patients included 51 women and 30 men [mean age.: 50.2 +/- 14.21 years (range: 15-82 years); duration of treatment: 3579 patient-months (mean: 44.2 +/- 34.2 patient-months); P episodes: 111] had a CPR of 0.38 episodes (1 episode in 31.35 patient-months) and a P rate per year (PRY) in the range 0.08-0.89 episodes. The APD patients [23 women and 14 men; mean age: 53.62 +/- 13.61 years (range: 26-78 years); duration of treatment: 1718 patient-months (mean: 46.4-38.3 patient-months); P episodes: 46] had a CPR of 0.32 episodes (1 episode in 373 patient--months) and a PRY in the range 0-1.12 episodes. At 1, 3, 5, and 10 years respectively, a first P episode occurred in 73%, 36%, 23%, and 8% of CAPD and 72%, 59%, 35%, and 23% ofAPD patients (log-rank p = 0. 056; CPR: p = 0.01; PPP: chi2 p = 0.39), for a RR of 0.83 linked to CAPD compared with APD. A lower P frequency and a trend of less time to first P was observed for APD compared with CAPD. The CAPD patients did not show a higher risk of developing P than did the APD patients. For comparisons between the modalities, CPR is a reliable index in the very long term at risk. Depending on the size of the population and the time at risk, the PRYobtained on short follow-up could result in a misinterpretation of the performance of each treatment modality.

The importance of the Patient's training in chronic peritoneal dialysis and peritonitis.

In a chronic disease, traineeship in the methodology to be used to treat oneself is a key part of success from the beginning and during long-term treatment. In chronic peritoneal dialysis (PD), peritonitis emphasizes, in a certain way, the result of the apprenticeship. We set out to evaluate the relationship between the number of PD training lessons and the frequency of peritonitis. According to the number of lessons, we established three groups: A, up to 8 lessons; B, 9-13 lessons; and C, 14 or more lessons. We evaluated peritonitis rates and micro-organisms, and for the three groups, we compared (Kaplan-Meier method) peritonitis-free survival (PFS) at 1 year of treatment, with significance set at (log rank) p < 0.05. The study enrolled 90 patients (mean age: 51.5 +/- 15.33 years; 37 men). Respectively, groups A, B, and C included 27, 46, and 17 patients with an at-risk duration of 1535, 2879, and 665 patient-months (mean: 56.9 +/- 44, 62.6 +/- 47, and 39.1 +/- 37.8 patient--months), of whom 35%, 37%, and 24% experienced no peritonitis, for peritonitis rates of 0.31, 0.37, and 0.47, with coagulase-negative Staphylococcus (CNS) peritonitis rates of 0.125, 0.12, and 0.235, and PFS rates of 76.9%, 80.4%, and 70.6%. The PFS was not significantly different between the groups (p > 0.05). During 1 year of treatment, all three groups experienced a satisfactory PFS. More frequent retraining should be considered in patients who needed more training lessons at the start of PD.

Body surface area, adequacy, and technique failure in chronic peritoneal dialysis.

Large body surface area (BSA) could be a pitfall in long-term peritoneal dialysis. We analyzed the viability of the peritoneum in terms of adequacy and technique survival in patients of varying BSA. We grouped our PD patients into three categories (BSA < or = 1.59 m2, BSA 1.60 - 1.79 m2, and BSA > or = 1.80 m2) and used the Student t-test to compare the mean weekly Kt/V urea between the groups (significance set at p < 0.05). We also measured and used Kaplan-Meier analysis to compare technique survival overall and in anuric patients from the onset of PD to the endpoints of transfer to hemodialysis or death linked to dialysis technique (log-rank test, p < 0.05). Group A consisted of 24 patients [2 men, 22 women; age: 41.9 +/- 12 years; BSA: 1.49 +/- 0.07 m2; total treatment duration: 1703.4 patient-months (mean: 71 +/- 50.6 months); diabetic: 8.33%; anuric: 62%; weekly Kt/V urea: 2.36 +/- 0.45; technique survival: 100%, 89%, 89%, 53%, and 53% at 1, 3, 5, 8, and 15 years]. Group B consisted of 35 patients [12 men, 23 women; age: 57.19 +/- 18 years; BSA: 1.69 +/- 0.05 m2; total treatment duration: 1870 patient-months (mean: 53.4 +/- 462 months); diabetic: 17.14%; anuric: 37.14%; weekly Kt/V urea: 2.28 +/- 0.41; technique survival: 97%, 93%, 87%, 78%, and 19% at 1, 3, 5, 8, and 14 years]. Group C consisted of 34 patients [24 men, 10 women; age: 56.2 +/- 13 years; BSA: 1.90 +/- 0.09 m2; total treatment duration: 1557.5 patient-months (mean: 45.8 +/- 34.4 months); diabetic: 20.6%; anuric: 41%; weekly Kt/V urea: 1.98 +/- 0.38; technique survival: 97%, 79%, 67.6%, 56%, and 28% at 1, 3, 5, 8, and 12 years]. Using the log-rank test, comparisons of technique survival overall and in anuric patients showed for A vs. B, p = 0.49 and p = 0.58 respectively; for A vs. C, p = 0.45 and p = 0.06; for B vs. C, p = 0.56 and p = 0.10. No significant differences in weekly Kt/V urea were observed between the groups (all p > 0.05). Peritoneal dialysis is viable for patients with a high BSA. There is a tendency toward worse technique survival in anuric patients with a high BSA.

Peritoneum: a noble membrane in long-term dialysis treatment.

The durability of the peritoneum as a dialysis membrane is as yet an unanswered question. Peritonitis episodes have an important effect in long-term treatment. To evaluate survival of the peritoneum for dialysis, we analyzed peritoneal failure related to technique dropout because of peritonitis, inadequate dialysis, and ultrafiltration disorders. We retrospectively analyzed data for 89 peritoneal dialysis patients who had been treated for at least 3 months [52 women, 37 men; mean age: 50.91 +/- 13.72 years (range: 22 - 81 years)] from August 4, 1993, to July 1, 2008. The Kaplan-Meier method was used to measure peritoneum survival, with only a definitive switch to hemodialysis or death from peritonitis, ultrafiltration failure, or inadequate dialysis as endpoints. Total treatment time was 5008 patient-months (mean: 55 +/- 44 patient-months), and the historical annual rate of peritonitis was 0.37 per year at risk (1 episode in 32.52 patient-months). Of the 89 patients, 19 dropped treatment because of peritonitis and 1 because of ultrafiltration failure. Peritoneum survival was 98.8%, 93.7%, 87.6%, 66.9%, 46.4%, and 33.8% at 1, 3, 5, 8, 10, and 14 years. In the 15 years of our program, peritoneum failure represented less than 1.5% of drop-out causes annually. The peritoneum is a reliable membrane to reach dialysis targets in long-term therapy.