Changing the trend: a prospective study on factors contributing to the growth rate of peritoneal dialysis programs.

Compared with countries worldwide, the United States currently has one of the lowest peritoneal dialysis (PD) populations as compared with its hemodialysis (HD) population. Approximately 12% of the total dialysis population in the United State is on PD. This figure correlates with the take-on rate [percentage of end-stage renal disease (ESRD) patients enrolling in PD programs] of about 12%-15% in the United States. Over a two-year period, we prospectively examined the role that developing a comprehensive infrastructure and support system had on expanding our PD program. The changes made included these: nephrologists placing PD catheters using the laparoscopic method; active identification of, and training for, family members and personnel in nursing homes and daycare centers to perform PD; improvements in home conditions through support by social workers; early ESRD patient education; and provision of in-center intermittent PD (IPD) for selected patients. We then compared the results from the two years after commencement of the changes against the two years before the changes were made. Training of personnel in nursing homes increased enrollment from 3 to 11 patients (p = 0.01); training of personnel in daycare centers increased enrollment from 0 to 5 patients (p = 0.05); training family members and providing family support increased enrollment from 4 to 15 patients (p = 0.03); early patient and family education increased enrollment from 4 to 24 patients (p = 0.008); improving home conditions increased enrollment from 1 to 14 patients (p = 0.01); and providing an IPD program for selected patients added 6 patients (p = 0.05). Introducing a program for nephrologists to place PD catheters by the laparoscopic technique decreased catheter mechanical failure (and subsequent transfer to HD), from 22 to 3 patients (p = 0.005). Our PD take-on rate (percentage of ESRD patients choosing PD modality) increased from 19% to 76% (p = 0.002). The total number of patients in the PD program over the two years after initiation of the changes increased from 33 to 93 (p = 0.01), while the number of HD patients decreased from 168 to 142 (p = 0.05). Developing a comprehensive infrastructure and support system for PD programs permits enrollment of patients who otherwise would have been excluded as PD candidates and eliminates loss of PD patients to HD. Implementation of such programs can contribute considerably to enhancing the PD population growth rate.

Relationship between intraperitoneal bleeding, adhesions, and peritoneal dialysis catheter failure: a method of prevention.

Intraperitoneal (i.p.) bleeding causes intense inflammatory reactions and extensive adhesions. The relationship between i.p. bleeding and adhesions is well documented in both animal and human studies. Over an 8-year period, we performed 362 permanent peritoneal dialysis (PD) catheter placements in 317 patients, using the laparoscopic technique. In the first 203 procedures (group I), we observed intra-operative bleeding in 12 patients (intra-operative i.p. bleeding seen laparoscopically, and significant blood-tinged dialysate irrigation). Patients were left dry for 3-5 days before dialysate instillation during the break-in period. During the break-in period, 7 of the 12 patients (58%) developed primary catheter failure requiring catheter removal (p = 0.03). All 7 patients underwent repeat laparoscopy for placement of a new catheter. In all 7 patients, laparoscopy showed significant adhesions. In the subsequent 159 procedures (group II), we observed intra-operative bleeding in 10 patients. We irrigated the peritoneal cavity repeatedly, until clear dialysate was obtained, then instilled 500-1000 mL 1.5% Dianeal solution (Baxter Healthcare Corporation, Deerfield, IL, U.S.A.) and capped the catheter. These patients were then placed on low-volume continuous cycling peritoneal dialysis [(CCPD) 700-1200 mL, based on the patient's size, every 2 hours, until the effluent became clear]. Following this, patients underwent daily irrigation and PD fluid cell count, and were left with 700-1200 mL dialysate to dwell. The process was continued until PD fluid drainage showed no red blood cells or until the patient was started on routine peritoneal dialysis. None of these patients were drained dry. Compared with group I, no patient among the 10 in group II developed catheter failure (p = 0.001), and mean catheter survival was 31 +/- 7 months. Of the 10 patients, 2 developed exist-site leaks, both after clearance of red blood cells from the drained dialysate. None developed peritonitis. We conclude that intra-operative i.p. bleeding associated with significant blood-tinged dialysate irrigation may lead to local adhesions if the peritoneum is drained dry. The result may be loss of the PD catheter in about 60% of cases. Continuous irrigation, combined with a moderate amount of Dianeal solution left to dwell, or early initiation of low-volume PD, or both, prevents this complication.

Intestinal lipid absorption in the nephrotic rat.

There is limited data on intestinal lipid absorption in the nephrotic syndrome. This study investigated whether the efficiency of intestinal lipid absorption is altered in nephrotic lymph-fistula rats. The nephrotic syndrome was induced in nine Sprague-Dawley rats by an i.v. injection of puromycin aminonucleoside in saline; seven control rats received saline only. At 10 to 14 days after injection, the main intestinal lymph duct was cannulated for collection of lymph. The duodenum was also cannulated and a fasting saline-glucose solution was infused overnight at 3 mL/h. The next day, the infusate was changed to a lipid emulsion that contained (14C) cholesterol and (3H)triglyceride (triolein) that was infused at 3 mL/h for 8 h. During the last hour of fasting and during the lipid infusion, lymph flow in the Nephrotic group averaged 0.6 mL/h higher than the Control group (P = 0.02). No significant differences were found between the two groups in recovery of infused radioactive cholesterol (P = 0.37) or triglyceride (P = 0.38) from the gastrointestinal lumen, small intestinal mucosa, or lymph. Lymphatic output of chemically measured cholesterol was also similar (P = 0.96). These results suggest that mucosal uptake and lymphatic output of cholesterol and triglyceride are not altered in the nephrotic syndrome.