Habilidad de cuidado del cuidador principal del adulto mayor con diálisis peritoneal / Caregiver skills of the main caregiver of the older adult with peritoneal dialysis

Introducción: la enfermedad renal crónica tiene consecuencias graves para los adultos mayores. La diálisis peritoneal continua ambulatoria es una alternativa de tratamiento, pero afecta la calidad de vida del paciente, la familia y el cuidador primario, por lo que se requiere un cuidador con habilidades que ofrezca apoyo en algunas actividades elementales y, además, apoye emocional y espiritualmente al paciente. Objetivo: identificar el nivel de la habilidad del cuidador primario del adulto mayor con diálisis peritoneal. Metodología: estudio descriptivo en 80 cuidadores familiares de adultos mayores con diálisis peritoneal continua ambulatoria. Se utilizó el instrumento Habilidad de cuidado del cuidador familiar, que consta de 55 reactivos y se divide en tres dimensiones: relación, 27 reactivos; comprensión, 18 reactivos; y modificación de la vida, 10 reactivos. El instrumento incluye variables sociodemográficas, de parentesco y tiempo dedicado al cuidado. Se elaboró una base de datos y éstos se analizaron mediante estadística descriptiva. Resultados: la habilidad de cuidado fue alta en 65%; la dimensión de relación resultó alta en 38.8% y media en 61.3%, con una comprensión alta en 86.2% y modificación de la vida alta en 68.8%. Los cuidadoras fueron mujeres en 85%; 46.3% cuidó > 37 meses; 50% cuidó > 24 h, y padres y esposa(o) apoyaron en 91.3%. Conclusión: estos hallazgos muestran que las habilidades de los cuidadores primarios fueron en general buenas, con la notoria participación del personal de enfermería en la capacitación y el apoyo recibido.

Introduction: Chronic kidney disease has severe consequences for older adults, and continuous ambulatory peritoneal dialysis is an alternative treatment, but it affects the quality of life of patient, family, and primary caregiver. It requires a caregiver with caregiving skills to provide support in some elemental activities, as well as emotional and spiritual support to the patient. Objective: To identify the level of caregiving skills of the primary caregiver of the older adult on peritoneal dialysis. Methodology: Descriptive study in 80 family caregivers of older adults with continuous ambulatory peritoneal dialysis. It was used the Caregiving skill of the family caregiver instrument, which consists of 55 items, divided into three dimensions: relationship, 27 items; understanding, 18 items; and life modification, 10 items. The instrument includes sociodemographic, relationship and time spent variables. A database was created and it was used descriptive statistics analysis. Results: Caregiving skills were high in 65%; relationship dimension high in 38.8%, and medium in 61.3%; understanding high in 86.2%; life modification high in 68.8%. 85% were female caregivers; 46.3% spent > 37 months providing care, 50% provided care > 24 hours; parents and wife/husband supported in 91.3%. Conclusion: Our findings show that caregiving skills of pri- mary caregivers were generally good with the significant involvement of the nursing staff in the training and support received.

Knowledge and Practice of Hemodialysis Amongst Dialysis Nurses.

INTRODUCTION: Dialysis nurses should have a good knowledge regarding hemodialysis treatment. The status of Nepalese dialysis nurses on this aspect is unknown. This study was done to assess the knowledge and practice on different aspects of the hemodialysis treatment. METHODS: We distributed validated questionnaires to the participants in a biannual conference in Kathmandu on 24th September as most of the dialysis nurses attend the event. We calculated mean and standard deviation for continuous variables and frequencies and percentage for the responses and compared counseling with different parameters. RESULTS: Total 94 out of 116 participants who were giving care to dialysis patients were in the study. Total 39 (42%) received formal nursing training in hemodialysis and 71 (78%) respondents always counseled patients regarding fluid intake. A total of 37 (96%) trained nurses always counseled the importance of regular dialysis. Seventy-six (81.7%) respondents did counseling on vaccination against Hepatitis B. Counseling on vaccination against influenza and pneumococcus was 47 (50%). When comparing educational status, respondents below bachelor level did more frequent counseling than level above (P=0.03). All the respondents knew the importance of hand washing and BP monitoring during hemodialysis. Ninety-one (96.7%) respondents knew how to deal with BP changes during hemodialysis. Seventy-three (77.6%) respondents were very confident on managing complications. Only 31 (33%) respondents knew how to deal with patients on continuous ambulatory peritoneal dialysis. CONCLUSIONS: Dialysis nurses have knowledge on basic procedures of hemodialysis but there is a space for improvement in dealing with complications to provide quality service to hemodialysis patients.

Calidad de vida relacionada con la salud en pacientes con diálisis peritoneal continua ambulatoria. Eje cafetero colombiano 2015 / Quality of life related to health in patients with continuous ambulatory peritoneal dialysis. Colombian coffee axis, 2015 / Qualidade de vida relacionada à saúde em pacientes contínuos peritoneal ambulatorial Com diálise. Eixo de café colombiano, 2015

ResumenIntroducción. El objetivo de esta investigación fue evaluar la calidad de vida relacionada con la salud (CVRS) en pacientes con diálisis peritoneal continua ambulatoria (DPCA), en tres unidades renales del eje cafetero de Colombia, en 2015.Método. La metodología de este trabajo está sustentada en un diseño descriptivo transversal. Participaron voluntariamente 185 personas del Programa de DPCA. Se aplicó encuesta y cuestionario SF-36, [Alfa de Cronbach >0,7] y análisis binominal y multinominal. En escalas de 0 a 100 puntos de peor a mejor CVRS, se calculó medias por dimensión. Se utilizó el software SPSS-v21.Resultados. Población con alta vulnerabilidad socioeconómica. Comorbilidad con hipertensión y diabetes.Percepción de mejor CVRS en dolor corporal (Me=87,2) y función social, (Me=76,8). Peor CVRS en Rol físico (Me=52,1) y Rol emocional (Me= 57,3). Sin diferencias por género, la CVRS empeora con la edad.Conclusión.El cuidado de pacientes con DPCA requiere más investigación por enfermería. Intervenciones y evaluaciones de seguimiento en autocuidado domiciliario y apoyo social en roles físico y emocional. Se deben controlar eventos precursores de ERC.

AbstractIntroduction.The objective of this research was to evaluate the quality of life related to health (HRQOL) in patients with Continuous Ambulatory Peritoneal Dialysis (CAPD), in three renal units of the Colombian coffee industry, in 2015.Method.The methodology of this work is based on a descriptive cross - sectional design. 185 volunteers from the DPCA Program participated voluntarily. A SF-36 questionnaire, [Cronbach's alpha> 0.7] and binominal and multinominal analysis were applied. In scales of 0 to 100 points from worse to better HRQoL, we calculated means by dimension. SPSS-v21 software was used.Results.Population with high socioeconomic vulnerability. Comorbidity with hypertension and diabetes.Perception of best HRQOL in Body pain (Me = 87.2) and Social function, (Me = 76.8). HRQL in Physical role (Me = 52.1) and Emotional role (Me = 57.3). Without gender differences, HRQL worsens with age.Conclusion.Caring for patients with CAPD requires more research per nursing. Interventions and follow-up evaluations in home self-care and social support in physical and emotional roles. ERC precursor events should be controlled.

ResumoIntrodução. A grande quantidade de pacientes atendidos nas consultas externas hospitalárias e conhecer a importância de suas opiniões sobre o atendimento recebido neste serviço motiva o desenvolvimento do presente estudo, o qual busca conhecer a opinião de um grupo de usuários sobre as consultas externas de três hospitais públicos da cidade de Madrid e identificar fatores que influem na satisfação global destas pessoas.Método. Realizou-se um estudo descritivo transversal no qual se entrevistaram a 150 usuários de consultas externas mediante um questionário auto-administrado, previamente validado que constava de 12 ítens, englobados em duas dimensões com uma escala tipo Likert de 1 a 10 em função ao grau de satisfação, dos quais se obteve resultados sociodemográficos e de tipo descritivo. Por outra parte, se realizou uma análise bivariante na que se detectaram diferenças significativas em función do sexo, do nível acadêmico, da nacionalidade e da idade.Resultados. Na análise descritiva do questionário merece atenção que a qualidade administrativa é valorada abaixo de 5 pontos, enquanto que para a clínica, a valoração é de 6 pontos aproximadamente, da que resulta uma valoração do questionário total um pouco superior a 5. O tempo de espera em consultas foi o ítem que obteve a valoração média mais baixa de todo o questionário, com algo mais de 3,5 sobre 10, enquanto que a mais alta foi a obtida para o ítem referido ao atendimento por parte do pessoal de enfermagem, com uma nota de quase 7.Conclusão.Pode-se afirmar que na amostra estudada somente existem dois fatores que se relacionam com o incremento da satisfação dos usuários nas consultas externas: sexo masculino e haver cursado estudos universitários.

Educational strategies and challenges in peritoneal dialysis: a qualitative study of renal nurses' experiences.

AIMS AND OBJECTIVES: The aim of the study was to explore renal nurses' experiences, strategies and challenges with regard to the patient education process in peritoneal dialysis. BACKGROUND: Patient education in peritoneal dialysis is essential to developing a successful home-based peritoneal dialysis program. In this area research is scarce and there is a particular lack of focus on the perspective of the renal nurse. DESIGN: Qualitative design formed by thematic qualitative text analysis. METHODS: Five group interviews (n = 20) were used to explore the challenges peritoneal dialysis nurses face and the training strategies they use. The interviews were analyzed with thematic qualitative content analysis using deductive and inductive subcategory application. RESULTS: The findings revealed the education barriers perceived by nurses that patients may face. They also showed that using assessment tools is important in peritoneal dialysis patient education, as is developing strategies to promote patient self-management. There is a need for a deeper understanding of affective learning objectives, and existing teaching activities and materials should be revised to incorporate the patient's perspective. Patients usually begin having questions about peritoneal dialysis when they return home and are described as feeling overwhelmed. Adapting existing conditions is considered a major challenge for patients and nurses. CONCLUSIONS: The results provided useful insights into the best approaches to educating peritoneal dialysis patients and served to raise awareness of challenges experienced by renal nurses. Findings underline the need for nosogogy - an approach of teaching adults (andragogy) with a chronic disease. Flexibility and cooperation are competencies that renal nurses must possess. RELEVANCE TO CLINICAL PRACTICE: Still psychomotor skills dominate peritoneal dialysis patient training, there is a need of both a deeper understanding of affective learning objectives and the accurate use of (self-)assessment tools, particularly for health literacy.

Effect of assistance on peritonitis risk in diabetic patients treated by peritoneal dialysis: report from the French Language Peritoneal Dialysis Registry.

BACKGROUND: Diabetic patients treated by peritoneal dialysis (PD) have been reported to be at an increased risk of peritonitis. This has been attributed to impairment in host defense, visual impairment, disability and muscle wasting, which could compromise ability to safely perform catheter connections. This study aimed to evaluate whether assisted PD is associated with a lower risk of peritonitis in diabetic patients. METHODS: This was a retrospective study based on data from the French Language Peritoneal Dialysis Registry. We included diabetic patients starting PD between 1 January 2002 and 31 December 2012. The end of the observation period was 31 December 2013. Using complementary regression analysis (Fine and Gray, Hurdle models), we assessed the relationship between peritonitis occurrence, peritonitis number over time and the type of assisted PD. RESULTS: Of the 3598 diabetic patients, there were 2040 patients on nurse-assisted PD. These patients were older, more comorbid and more frequently on continuous ambulatory peritoneal dialysis (CAPD). In the multivariate analysis, nurse assistance was associated with a reduced risk of peritonitis in the Fine and Gray [subdistribution hazard ratio: 0.78 (95% confidence interval, CI, 0.68-0.89)] and in the first component of the Hurdle models [rate ratio: 0.82 (95% CI 0.71-0.93)], but not a lower incidence of peritonitis after an initial episode [rate ratio: 0.82 (95% CI 0.95-1.38)]. Transplant failure, glomerulonephritis and CAPD were associated with an increased risk. CONCLUSIONS: In France, nurse-assisted PD is associated with a lower risk of peritonitis in diabetic patients treated by PD but not a lower incidence of peritonitis.

Tratamento com diálise peritoneal: a prática do autocuidado no contexto familiar / Peritoneal dialysis treatment: self-care practice in the family context / Tratamiento con diálisis peritoneal: la práctica del autocuidado en el contexto familiar

Os objetivos do estudo foram identificar as dificuldades enfrentadas pelos clientes ao realizar a diálise peritoneal ambulatorial contínua (DPAC) no domicílio e analisar as soluções por eles adotadas para lidar com elas. Recorte de dissertação aprovada em 2010, sendo um estudo descritivo, qualitativo, que utilizou o método da Pesquisa Convergente-Assistencial, cujo cenário foi um hospital estadual do Rio de Janeiro. Realizaram-se três grupos de encontros com nove sujeitos. A técnica da entrevista semiestruturada originou temas que resultaram na categoria convivência com o tratamento - pontos dificulta dores na realização da DPAC no domicílio. Os participantes afirmaram que dificuldades do tratamento podem ser superadas mediante adaptação individual com auxílio da equipe de enfermagem, de redes de apoio e de familiares. Demonstrou-se a necessidade de que o modelo pedagógico utilizado para o processo educativo dos clientes seja repensado, intermediando os saberes científicos com os saberes populares.

The study objectives were to identify the difficulties faced by clients in performing continuous ambulatory peritoneal dialysis (CAPD) at home, and to analyze the solutions they encountered. Drawn from a dissertation approved in 2010, article reports a descriptive, qualitative study using the Convergent-Care Research method. With a state hospital in Rio de Janeiro as scenario, three groups of meetings were held with nine subjects. The semi-structured interview technique yielded themes that resulted in the category coexisting with the treatment – difficult points in carrying out CAPD at home. The participants noted that difficulties in the treatment can be overcome by individual adaptation with the help of nursing staff, support networks and family. It was demonstrated that the teaching model used for client education needs to be rethought soas to mediate between scientific knowledge and popular knowledge.

El objetivo del estudio consistió en identificar las dificultades enfrentadas por los clientes al realizar diálisis peritoneal continua ambulatoria (DPCA) en casa y analizar las soluciones adoptadas para hacerles frente. Parte de disertación aprobada en 2010, consistiendo en un estudio descriptivo y cualitativo que utiliza el método de Investigación Convergente Asistencial. En el escenario, un hospital del estado de Río de Janeiro, tuvieron lugar tres grupos de encuentros con nueve individuos. La técnica de entrevista semiestructurada originó temas resultaron en la categoría Convivencia con el tratamiento - puntos que dificultan la realización de la DPCA en casa. Los participantes señalar on que las dificultades del tratamiento se pueden superar mediante la adaptación individual con ayuda del personal de enfermería, de redes de apoyo y de la familia. Se ha demostrado la necesidad de que el modelo pedagógico utilizado para el proceso educacional de los clientes se a repensado, intermediando el conocimiento científico con los saberes populares.

Continuous ambulatory peritoneal dialysis: nurses' experiences of teaching patients.

Nine nurses were interviewed to determine nurses' experiences of teaching patients to use continuous ambulatory peritoneal dialysis (CAPD). The material was analyzed using content analysis. Data were sorted into four themes and ten subthemes. The themes were presented as follows: Importance of language, individualized teaching, teaching needs and structure of care in teaching. The findings highlighted important insights into how nurses experience teaching patients to perform CAPD. The study revealed some barriers for the nurses during teaching. The major barrier was shortage of Arabic speaking nursing staff. Incidental findings involved two factors that played an important role in teaching, retraining and a special team to perform pre-assessments, including home visits. In conclusion, the findings of this study showed several factors that are considered as barriers for the nurses during teaching the CAPD patients and the need to improve the communication and teaching in the peritoneal dialysis units, including the importance of individualized teaching.

A patient perspective on the barriers to home dialysis.

INTRODUCTION: People with End Stage Renal Disease rarely choose home dialysis therapies even though they can offer a range of Quality-of-Life (QOL) benefits such as improved convenience, mental health well-being, employment, reduced mortality and cost effectiveness. Attempts to increase usage of such self-caring modalities, have met with limited success, in part due to a lack of understanding of patient decision making and patient perceived barriers to such therapies. OBJECTIVE: To explore the patient perspective on the main barriers to a range of self-care or home dialysis therapies, including Continuous Ambulatory Peritoneal Dialysis, Home Haemodialysis and Extended Home Haemodialysis. MATERIALS AND METHODS: A longitudinal patient narrative approach is adopted. RESULTS: There are significant barriers to all aspects of informed decision making around home therapies, but many are based on perception. Creating decision aids and education programmes to tackle these perceived barriers, actively encouraging home therapy take up, focusing on QOL in clinical decision making, offering peer support and expanded in-centre self-care treatment options may increase awareness and uptake of self-care therapies.

Shared decision making and patient involvement in choosing home therapies.

BACKGROUND: Patient involvement through shared decision making is advocated to support patients deciding on a dialysis treatment suitable to their clinical condition, lifestyle and social circumstances. Evidence to date, however, suggests that shared decision making is far from routine practice. Not all physicians or patients are willing to participate in shared decision making. Equally, modality education does not always meet the needs of patients and their families, resulting in a significant proportion of patients remaining unaware of the existence of home therapies. The selection of home therapies appears to be tightly associated with the quality of the modality education. This paper considers several ways in which patient involvement in their dialysis modality decision can be improved, with particular reference to information provision. Information needs to be balanced, explore the medical as well as the psychosocial aspects of each treatment, be tailored to the needs of the individual patient and be delivered in a timely fashion. CONCLUSION: Optimising modality education will optimise patient's ability to participate in shared decision making, thereby improving uptake of home therapies.

Almost anyone can have home therapy but can we overcome the barriers?

BACKGROUND: Home dialysis, including both peritoneal and haemodialysis, has been shown to improve patient wellbeing as well as being an economically beneficial alternative to hospital-based therapies. OBJECTIVES: This paper discusses the major barriers to home therapies, particularly in relation to home haemodialysis (HHD) and systems that can be used to overcome them. RESULTS: The use of HHD varies considerably between and within countries. The major limitation is lack of experience and education. A well-planned pre-dialysis education programme seems to be one essential key to the growth of home therapies. CONCLUSIONS: Key points in providing a successful home therapy programme are a highly motivated multidisciplinary team including a dedicated nephrologist and high-level nursing expertise. In addition, an effective pre-dialysis education programme for identifying suitable patients is required.

Home haemodialysis dose: how much of a good thing?

BACKGROUND: Home dialysis (peritoneal or haemodialysis) in any reasonable guise offers potential benefits compared with in-centre dialysis. Benefits may be overtly patient centred (independence, quality of life), outcome oriented (survival, resolution of left ventricular hypertrophy) or resource friendly (savings on staff costs). The priority placed on each of these areas is likely to vary from patient to patient, and possibly provider to provider. This is the one strength of home haemodialysis (HHD) rather than being viewed as a weakness, as it can offer different benefits to different people. Intuitively, more haemodialysis is better than less, and this is most realistically achieved at home. Indications are that both long nocturnal dialysis and short daily dialysis can offer real objective benefits. LITERATURE REVIEW: Critics argue correctly that there is a paucity of robust randomised controlled study data. The complexity of HHD regimens and practice and in-homogeneity of patients means such firm data are unlikely to be forthcoming. However, the positive reports both subjective and objective of patients dialysing at home, and results from the available research suggest that advantages may be seen purely with changing the location of dialysis to home, and independently with enhancing dialysis schedules. CONCLUSION: The logical conclusion is that patients undertaking haemodialysis at home should have at least the recommended minimum of four hours three times per week (or equivalent), preferably avoiding the long inter-dialytic interval, but beyond that rigid adherence to a schedule as dogma should be subjugated to patient choice and flexibility, albeit by prior agreement with supervising medical and nursing staff.

The HOME network: an Australian national initiative for home therapies.

BACKGROUND: Longer, more frequent dialysis at home can improve life expectancy for patients with chronic kidney disease. Increased use of home dialysis therapies also benefits the hospital system, allowing for more efficient allocation of clinic resources. However, the Australian and New Zealand Data Registry statistics highlight the low uptake of home haemodialysis and peritoneal dialysis across Australia. OBJECTIVE: In August 2009, the Australia's HOME Network was established as a national initiative to engage and empower healthcare professionals working in the home dialysis specialty. The aim was to develop solutions to advocate for and ultimately increase the use of home therapies. This paper describes the development, achievement and future plan of the Australian HOME Network. ACHIEVEMENTS: Achievements to date include: a survey of HOME Network members to assess the current state of patient and healthcare professional-targeted education resources; development of two patient case studies and activities addressing how to overcome the financial burden experienced by patients on home dialysis. Future projects aim to improve patient and healthcare professional education, and advocacy for home dialysis therapies. CONCLUSION: The HOME Network is supporting healthcare professionals working in the home dialysis specialty to develop solutions and tools that will help to facilitate greater utilisation of home dialysis therapies.

Role of nurses in a continuous ambulatory peritoneal diagnosis outpatient clinic.

The relationship between nurses and peritoneal dialysis (PD) patients begins from the time of the selection of medical treatment for renal replacement therapy. There are various roles in this field that involve nurses, not only in providing technical guidance to patients but also in relaying dietary restrictions including those on fluid and diet, in providing information on public welfare for dialysis patients and in fostering interactions between the patient and doctors, nutritionists, social workers and medical support staff. The nurse plays an important role in the success of a PD training program. Only highly trained nurses should carry out PD training. The nurse trains the patient or a family member as a helper to perform PD. The ultimate goal is to make a plan to help the patient maintain his or her general condition and expand the quality of life by self-care. However, the most important role of nurses is to display empathy to the patient, that is, to put themselves in the patient's position, to foster an ongoing interaction between themselves and the patient and to listen to the patient and understand what is in the mind of the patient.

Nurse-patient communication while performing home dialysis: the patients' perceptions.

This study aimed at describing patients' perception of their communication with nurses when performing home dialysis. Data were collected from interviews guided by the question: "What is communication like, between you and nurses, during home dialysis treatment?" Results show participants' perception of treatment during home peritoneal dialysis [Continuous ambulatory peritoneal dialysis (CAPD)]; relationship with nurses and family and the effects of treatment on one's existence. Patients can be self-caring and they learn to value the autonomy in their own care. However, some are unable to assume the responsibility for self-care. It was discovered that the connotation of "inspection" that some participants attributed to the nurse's visits, led to an alienation from the education process in the CAPD education. Findings suggest that effective communication and the development of the relationship of a working partnership with patients is crucial. Improvement in the nurses' communication, aiming at adapting it to the characteristics, limitations and specific needs of each patient, is significant for achieving better outcomes.

Evaluation of a nurse-led disease management programme for chronic kidney disease: a randomized controlled trial.

BACKGROUND: Patients with end stage renal failure require dialysis and strict adherence to treatment plans to sustain life. However, non-adherence is a common and serious problem among patients with chronic kidney disease. There is a scarcity of studies in examining the effects of disease management programmes on patients with chronic kidney disease. OBJECTIVES: This paper examines whether the study group receiving the disease management programme have better improvement than the control group, comparing outcomes at baseline (O1), at 7 weeks at the completion of the programme (O2) and at 13 weeks (O3). METHODS: This is a randomized controlled trial. The outcome measures were non-adherence in diet, fluid, dialysis and medication, quality of life, satisfaction, symptom control, complication control and health service utilisation. RESULTS: There was no significant difference between the control and study group for the baseline measures, except for sleep. Significant differences (p<0.05) were found between the control and study group at O2 in the outcome measures of diet degree non-adherence, sleep, symptom, staff encouragement, overall health and satisfaction. Sustained effects at O3 were noted in the outcome measures of continuous ambulatory peritoneal dialysis (CAPD) non-adherence degree, sleep, symptom, and effect of kidney disease. CONCLUSIONS: Many studies exploring chronic disease management have neglected the group with end stage renal failure and this study fills this gap. This study has employed an innovative model of skill mix using specialist and general nurses and demonstrated patient improvement in diet non-adherence, CAPD non-adherence, aspects of quality of life and satisfaction with care. Redesigning chronic disease management programmes helps to optimize the use of different levels of skills and resources to bring about positive outcomes.

Can using a questionnaire for assessment of home visits to peritoneal dialysis patients make a difference to the treatment outcome?

Training provided by dialysis nurses to the patients is of great importance in peritoneal dialysis (PD). This study aimed to examine how PD patients continue with the training and practice taught in this unit and correlate these data with the incidence of peritonitis. Home visits were paid to 32 patients. A form including questions about 'knowledge and skill' and dialysis environment was filled in for each patient. Answers were graded out of 100 points and were reported as average, percentage and minimum-maximum values. The mean 'knowledge and skill' criterion scoring was 79.8 +/-14.0, and the mean score for the dialysis environment was 87.7 +/-10.9. There was a significant correlation between the 'knowledge and skill' and environmental scores. Meaningful correlations were detected between the 'knowledge and skill' score as well as the environmental score with the rate of peritonitis. Training is of vital importance in PD practice, but results show that the dialysis environment is as important as the patient's knowledge or skill in exchanges.