Patient and technique survival for blind and sighted diabetics on continuous ambulatory peritoneal dialysis: a ten-year analysis.

A retrospective analysis of patient and technique survival over 10 years in a group of 66 diabetics (40 being blind) and 71 non-diabetics was undertaken. Patient survival profiles showed that the blind diabetics lived longer than the sighted, but for a shorter time than the nondiabetics. In technique success, the sighted diabetics out did the blind and the non-diabetics, long term. Short term, the blind performed better than sighted diabetics. The key to success and longer survival on CAPD depended on motivation on the part of the patient, patient's acceptance of given disability, family (social) support, and willingness on the part of renal care personnel to train the disabled diabetic to perform CAPD. With adequate education and support, blind diabetics did CAPD as well as sighted patients. There was no increased frequency of peritonitis in blind diabetics compared to sighted diabetics. Both blind diabetics and non-diabetics had fewer episodes than sighted diabetics. Intraperitoneal route of insulin administration achieved good glycemic control in diabetic population. Refractory congestive cardiac failure and/or fatal arrhythmias was the most common cardiac cause of death in diabetics on CAPD.

Acute abdominal events and their impact on morbidity and mortality in a CAPD program.

A retrospective analysis was done to explore the impact of acute abdominal events other than peritonitis, on morbidity and mortality in a CAPD program over a span of 6 years. Subtlety of clinical manifestations and low yield from investigational attempts (except microbiologic) made decision-making as to whether or not to continue CAPD, hard. An increased prevalence of septicemic shock with its inevitable high risk of morbidity and mortality was striking. Timely termination of CAPD and change over to hemodialysis may help to prevent dissemination of infection in these patients. Among the vascular causes of death in CAPD patients, bowel infarction seemed to be the most common.

Why blind diabetics with renal failure should be offered treatment.

During May 1978 to April 1983 this renal dialysis unit treated 65 patients by continuous ambulatory peritoneal dialysis. Of these, 24 had type I (insulin dependent) diabetes, of whom 20 were blind; eight had type II (non-insulin dependent) diabetes, of whom three were blind; and 33 did not have diabetes and were not blind. The cumulative actuarial survival rates of these patients at five years were 60% for blind diabetics, 40% for sighted diabetics, and 46% for the non-diabetics. Of the 23 blind patients, 22 successfully achieved self care, including the self administration of insulin into the peritoneal dialysis solution. Blind patients had the least peritonitis and fewest complications of continuous ambulatory peritoneal dialysis, and none objected to the treatment or requested to be taken off it or be allowed to die. It was concluded that blind diabetic patients with renal failure showed both the will and the ability to stay alive and that their treatment was worth while.

Long-term continuous ambulatory peritoneal dialysis.

This paper reports experience with 65 patients treated by continuous ambulatory peritoneal dialysis (CAPD) during the past five years. The patients are divided into 33 non-diabetic and 32 diabetic and the latter are subdivided into blind and sighted. Cumulative actuarial survival on CAPD calculated at five years was highest for blind diabetics, intermediate for non-diabetic and lowest for sighted diabetics. Blind diabetics had the lowest rate of drop-out from CAPD. Many patients, especially in the non-diabetic and sighted diabetic groups required temporary haemodialysis which allowed them to return to CAPD.

Percutaneous subclavian vein catheter hemodialysis--impact on vascular access surgery.

The problem of the immediate need for access to the circulation for hemodialysis arises because of an acute renal failure (ARF), the failure of an established access route, or the acute presentation of end-stage renal disease. Prior to 1976 emergent hemodialysis at our center necessitated either surgical placement of an external shunt or intermittent femoral vein cannulization, Since 1976 indwelling percutaneous subclavian vein catheterization (SVC) has been used on a routine basis for emergency hemodialysis. We have evaluated retrospectively the clinical courses of 50 patients with ARF and 48 patients with chronic renal failure (CRF) who underwent SVC dialysis in comparison with the clinical courses of 50 patients with ARF and 35 patients with CRF who had external shunt dialysis. In the ARF group, SVC dialysis resulted in lower incidences of serious infection, hemorrhage, and access thrombosis and reduced the number of replacement access procedures needed. In the CRF group, SVC permitted creation of more autogenous fistulas, rarely failed because of infection or thrombosis, and could therefore be used for extended periods, allowing primary autogenous fistula placement and maturation. Future access sites were also saved. SVC dialysis has become our primary interval angioaccess procedure for acute hemodialysis.

A comparison of continuous ambulatory peritoneal dialysis in diabetic and nondiabetic patients.

Between May of 1978 and December of 1980 we have treated 33 patients with continuous ambulatory peritoneal dialysis (CAPD) for a total of 1209 patient weeks. Thirteen patients were diabetic, 14 nondiabetic but with complications that made CAPD the treatment of choice, and six were nondiabetic without complications. Good control of plasma glucose was obtained n diabetics by the use of intraperitoneal insulin. Overall plasma glucose control, as estimated by glycohemoglobin and fasting plasma glucose levels was the same in both groups. Plasma triglyceride levels were normal in most of the diabetic patients and elevated in most of te nondiabetic patients. Visual difficulties did not prevent self-dialysis in seven diabetic patients who were legally blind, and these patients spent the least time in hospital and had the least peritonitis. Diabetic patients seem at least as able to cope with CAPD as nondiabetic patients and may derive some special advantages from the technique.

Advantages of continuous ambulatory peritoneal dialysis to the diabetic with renal failure.

Among the diabetic patients we have treated with dialysis blood pressure and blood sugar control have been poor and vascular disease progressive. Intermittent peritoneal dialysis did not improve these problems compared with haemodialysis. Continuous ambulatory peritoneal dialysis was undertaken in three patients as a last resort and electively in another two patients. Insulin was given by the intraperitoneal route and none was used systemically. Self-care was taught from the first using the spouse if visual problems were present. Serum creatinine levels fell and haemoglobin levels rose. Blood pressure was controlled without diet or drugs. Blood sugar levels were controlled without symptomatic hypoglycaemia or rebound hyperglycaemia. The procedure had a demoralising effect on helper spouses, and self-care had to be achieved even with severe visual problems. The advantages of continuous ambulatory peritoneal dialysis to the diabetic with renal failure are greatly improved control of blood pressure and blood sugar.

Improvement in lacrimal and salivary secretions after alkali therapy in Sjøgren's syndrome with renal tubular acidosis.

A patient with Sjøgren's syndrome developed renal tubular acidosis which led to systemic acidosis and potassium depletion. Treatment with Shohl's solution and potassium supplements was followed by subjective improvement in tear flow, salivary flow, and by disappearance of bronchitic symptoms. Detailed objective assessments were then made during the next year, twice on treatment and twice without. These confirmed the subjective impression of improvement.