A multicenter study of noncompliance with continuous ambulatory peritoneal dialysis exchanges in US and Canadian patients.

Recent evidence suggested that noncompliance (NC) with continuous ambulatory peritoneal dialysis (CAPD) exchanges may be more common in US than in Canadian dialysis centers. This issue was investigated using a questionnaire-based method in 656 CAPD patients at 14 centers in the United States and Canada. NC was defined as missing more than one exchange per week or more than two exchanges per month. Patients were ensured of the confidentiality of their individual results. Mean patient age was 56 +/- 16 years, 52% were women, and 39% had diabetes. The overall admitted rate of NC was 13%, with a rate of 18% in the United States and 7% in Canada (P < 0.001). NC was more common in younger patients (P < 0.0001), those without diabetes (P < 0.001), and employed patients (P < 0.05). It was also more common in black and Hispanic than in Asian and white patients (P < 0.001). NC was more common in patients prescribed more than four exchanges daily (P < 0.0001) but was not affected by dwell volume. On multiple regression analysis, the independent predictors of NC, in order of importance, were being prescribed more than four exchanges per day, black race, being employed, younger age, and not having diabetes. Being treated in a US unit did not quite achieve significance as a multivariate independent predictor. These findings suggest that NC is not uncommon in CAPD patients and is more frequent in US than in Canadian patients. However, country of residence is less powerful as a predictor of NC than a variety of other demographic and prescription factors.

Impact of capitation on free-standing dialysis facilities: can you survive?

Proposed changes in the Medicare reimbursement method for end-stage renal disease (ESRD) patients prompted us to study the total cost of caring for the ESRD patients in northeast Indiana over a 1-year period. We hoped to ascertain the actual cost of caring for patients treated with different modalities, determine if we could compete in a capitated environment, and identify areas in which we might reduce these expenses. Six patients new to dialysis and 29 patients already receiving treatment underwent follow-up evaluation for 1 year. We tracked their cost of care for 1 year in the outpatient setting as well as in the hospital. We found the cost of caring for all patients was $43,044 per year. Patients new to dialysis cost $3,164 more to care for than patients already receiving dialysis treatment. Hospitalization expense was the primary component of that difference. Continuous ambulatory peritoneal dialysis (CAPD) patients were $14,570 less costly per year to care for than hemodialysis patients. This differential primarily related to decreased hospitalization. Vascular access expenses were a major component of both the outpatient and inpatient cost for hemodialysis patients. Our yearly expenditures for all patients compared with suggested capitated Medicare reimbursement rates suggested that our program could be successful in a new reimbursement model. Several areas of possible cost reduction were identified.

Peritoneal dialysis kinetic modeling: validation in a multicenter clinical study.

OBJECTIVE: To clinically validate the use of a computer-based kinetic model for peritoneal dialysis (PD) by assessing the level of agreement between measured and modeled values of urea and creatinine clearances and ultrafiltration (UF). DESIGN: An open multicenter observational study. PATIENTS: There were 111 adult continuous ambulatory peritoneal dialysis (CAPD) patients (47 female, 64 male) in four centers. All patients underwent a four-hour peritoneal equilibration test (PET) using 2.5% dextrose but with variable fill volumes (range: 1-3 L). Patients with a residual renal function greater than 10 mL/min were excluded. MAIN OUTCOME MEASURES: Correlations and limits of agreement between measured and modeled values of total weekly urea KT/V, total weekly normalized creatinine clearance (L/week/1.73 m2), daily drain volume (L), net ultrafiltration (L), daily peritoneal urea clearance (L/day), and daily peritoneal creatinine clearance (L/day). Measured values were obtained from 24-hour urine and dialysate collections while modeled values were based on results from the PET in combination with the PD ADEQUEST kinetic program. RESULTS: The results show there is excellent agreement between measured and modeled urea KT/V and creatinine clearances, with concordance correlations of 0.94 and 0.92, respectively. Given the excessive variation and limited range in ultrafiltration values, the concordance correlation between measured and modeled UF was only 0.50. In terms of daily peritoneal clearances and ultrafiltration, the level of precision (i.e., standard deviation) in the differences between modeled and measured values is +/- 1.05 L/day for urea clearance +/- 1.03 L/day for creatinine clearance, and +/- 0.919 L/day for ultrafiltration. By contrast, the level of precision (i.e., standard deviation) in the differences between two measured values is estimated to be +/- 0.979 L/day for urea clearance, +/- 0.802 L/day for creatinine clearance, and +/- 0.707 L/day for ultrafiltration. Defining the limits of clinical agreement to be +/- 2 standard deviations of the differences between two clinically measured 24-hour clearances (or ultrafiltration), we find that 94% of the modeled urea clearances, 87% of the modeled creatinine clearances, and 86% of the modeled ultrafiltration values fall within the limits of clinical agreement. CONCLUSION: Data for a carefully performed PET and overnight exchange can, in combination with a scientifically validated kinetic model, provide clinicians with a powerful mathematical tool for use in CAPD dialysis prescription management. Although not intended to replace actual measurements, kinetic modeling can prove useful as a means for predicting clearances for various alternative prescriptions and perhaps also as a means for checking certain types of noncompliance.

Clinical experience with erythropoietin in continuous ambulatory peritoneal dialysis.

The purpose of this project was to determine a safe and effective Epogen (EPO) subcutaneous administration schedule for patients who were on continuous ambulatory peritoneal dialysis. To comply with the manufacturer's recommendation to enter a vial only once, a dosing regimen had to be established that used a standard dose of 2,000 or 4,000 units. The goal was to determine the frequency of administration that would achieve and maintain the target hematocrit. Twenty-six patients participated. The starting dose of 4,000 units was administered either two or three times per week. An average 8.3% point increase in hematocrit was seen in 8 weeks. When the target hematocrit of 33% to 35% was reached, the dose and or frequency of administration was decreased. Maintenance doses were established at 2,000 or 4,000 units weekly or biweekly. We were able to meet and maintain the target hematocrit by using 2,000 or 4,000 units per dose and adjusting the frequency.

Was there a retained spinal catheter?

The 28-gauge catheter supplied by Kendall Healthcare Products Company (Mansfield, MA) for continuous spinal anesthesia has two important characteristics. The ink used for the centimeter calibration marks and to identify the tip of the catheter "washes off" while it is inserted in the patient. In addition, the catheter has a tendency to stretch while it is in the patient or being removed. These two characteristics produced a situation in which it was impossible to determine whether a catheter fragment had been left in a patient. This predicament had a serious impact on the postoperative management of the patient. A computerized tomographic scan and spine films were negative, while other evidence suggested that a fragment was left behind. When the patient developed a postdural puncture headache, the authors felt that an epidural blood patch was contraindicated. The patient's headache did resolve with 48 hours of conservative therapy.

Evaluation of dressing protocols that reduce peritoneal dialysis catheter exit site infections.

Exit site infections (ESIs) remain a major complication of peritoneal dialysis (PD). This study was designed to evaluate various catheter care techniques that would decrease ESIs during the 3 months following catheter implantation. Factors that affect wound healing were studied by evaluating preoperative and postoperative variables, skin cleansing agents, and three types of dressings. A 40% reduction in ESIs occurred following implementation of a new protocol that was developed from the knowledge acquired after studying the catheter care protocols.

Prevailing patterns and predictor variables in patients with acute tubular necrosis.

The courses of 276 acute tubular necrosis patients referred for dialysis were reviewed in search for prognostic indicators. Sixty-three percent survived. Of 28 possible predictor variables, a posttoxic cause and nonoliguria were favorable, whereas myocardial infarction and peritonitis affected survival unfavorably. Total pareneral nutrition influenced survival favorably only in those with multiple complications or peritonitis. No single variable or combination predicted a lethal outcome. Since survivors were frequently restored to complete health, we advocate an aggressive therapeutic approach even in the face of multiple complications.

Iatrogenic factors in acute renal failure: can vigilance equal avoidance?

Physicians can aid substantially in reducing morbidity and mortality from acute renal failure by exercising particular care when using potentially nephrotoxic procedures or agents, by identifying patients at high risk before undertaking elective surgical procedures, and by acting promptly to correct predisposing conditions.

Intra-abdominal infection and acute renal failure.

The course of 76 consecutive patients with acute renal failure and severe intra-abdominal infection was reviewed to identify the microorganisms responsible, the factor precipitating reoperation, and prognostic indicators. Peritonitis occurred in 75 patients, 48 of whom had abscesses. Twenty-four patients (32%) survived. Anaerobes and fungi were commonly grown from blood. Gram-negative aerobic blood isolates were associated with the highest mortality. Leukocytosis, physical findings, and fever were factors that prompted reexploration whereas diagnostic procedures played an ancillary role. The finding of specifically correctable conditions at reoperation improved survival (P less than .05). Myocardial infarction and disseminated intravascular coagulation affected survival unfavorably whereas hyperalimentation had a favorable influence (P less than .05). Aggressive medical, nutritional, and surgical management results in improved survival rates in these patients.

The transmission of Candida albicans by cadaveric allografts.

Two transplant patients suffered Candida infections after receiving homografts from a cadaveric donor whose urine culture yielded Candida albicans greater than 100,000 colonies per ml. In both patients the infections became apparent after large doses of methylprednisolone were administered for acute rejection. Flucytosine proved to be inadequate therapy but modified doses of amphotericin B served to eradicate the infection in each case. Donor urine cultures yielding Candida albicans should be interpreted as representing a transmissible infection.

Emphysematous pyelonephritis.

Emphysematous pyelonephritis is a rare complication of urinary tract infection and generally occurs in patients with diabetes mellitus or urinary tract obstruction. We recently treated an 81-year-old diabetic woman with Klebsiella pneumoniae urinary tract infection and septicemia whose abdominal roentgenogram demonstrated a striking left pneumonephrogram as well as intraureteral and perirenal gas. The patient died despite intensive therapeutic efforts. Unfortunately, the prognosis for this severe necrotizing infection process remains unfavorable.