| Abstract|| |
CAPD is not as popular mode of renal replacement therapy (RRT) in this country as it is in the west and hence the experience with CAPD is limited. At our center 16 patients (8 Males, 8 Females) with ESRD with a mean age of 46.3 ± 15.6 years were managed by CAPD during 1990-1994. CAPD was the first option as a renal replacement therapy (RRT) in seven (44%) and second option in nine (56%) patients. Indications for CAPD were: Vascular access problems in 10 (62.5%), cardiovascular instability in three (19%), patient preference in two (12.5%) and non-availability of nearby HD center in one (6%) patient. Standard safe leur-lock system was used for dialysis. All patients were well dialyzed with good quality of life. Peritonitis was the main complication encountered (one episode/eight patient months), cause of hospital admission and reason for returning back to hemodialysis (HD). Other complications encountered were intraperitoneal bleeding in three, accidental cutting of outline in two, leakage in one and exit site infection in one. Average survival of this method was 15 + 10.5 months (range 1-37 months). At the time of reporting this study seven patients continued to be on CAPD, six were transferred back to hemodialysis, one was transplanted and two died due to other reasons. We conclude that CAPD is an acceptable mode of RRT in this part of the world.
Keywords: CAPD, RRT, Peritonitis.
|How to cite this article:|
Abbade MA, Bernieh B, Sirwal IA, Mohamed AO, Ashfaquddin M. CAPD: Experience at Al Madinah Al Munawarah. Saudi J Kidney Dis Transpl 1997;8:127-30
|How to cite this URL:|
Abbade MA, Bernieh B, Sirwal IA, Mohamed AO, Ashfaquddin M. CAPD: Experience at Al Madinah Al Munawarah. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Jun 5];8:127-30. Available from: http://www.sjkdt.org/text.asp?1997/8/2/127/39384
| Introduction|| |
Continuous ambulatory peritoneal dialysis (CAPD), developed in the late 70's by Popovich et al , and later modified by better Oreopoulos  , is an established method for renal replacement therapy (RRT) in end-stage renal disease (ESRD) patients. Advantages of CAPD compared to hemodialysis include continuous removal of waste products, steady cardiovascular state, control of hypertension and anemia, lesser dietary restrictions, no involvement of anticoagulation, and independence of dialysis machines. Inspite of these advantages, the number of ESRD patients all over the world treated by this method is relatively small, (14% of all ESRD patients) and varies from country to country (91% in Mexico to 5% in Japan) , . In Saudi Arabia, only 3% of ESRD patients are being treated by CAPD  , which means that this method is still unpopular. In this study we report our experience in CAPD at a Kidney Unit in a community hospital and discuss the problems encountered.
| Patients and Methods|| |
All patients managed by CAPD at King Fahad Hospital-Al-Madinah Al Munawarah, during the period from August 1990 till December 1994 were included in this study. There were 16 patients, eight males, and eight females. The mean age was 46.3 ± 15.6 years (range 19-75 years). Etiology of ESRD in these patients is shown in [Table - 1]. CAPD was the first choice of renal replacement therapy (RRT) in seven (44%) and as the second choice in nine (56%) patients. Indications for selecting CAPD as RRT are shown in [Table - 2]. Vascular access problem was the most frequent indication for this selection.
In all patients, safe Leur-Lock standard fresenius system of CAPD was used with daily four exchanges of 2L fluid of 1.5% Dextrose concentration. In addition, 4.25% was used when extra-ultrafiltration was required. All these patients were regularly followed up as out-patients, on monthly basis. Peritonitis was defined by the presence of turbid dialysate fluid with white blood cells count of more than 100/µl, with or without positive cultures of peritoneal drainage fluid  . All patients with peritonitis received antibiotics (Third generation Cephalosporin and Aminoglycosides) for 7-10 days.
| Results|| |
All patients had reasonably good quality of life while on CAPD. The mean values of the laboratory parameters of the study patients are shown in [Table - 3]. None of these patients required erythropoietin during this study. Peritonitis was the main complication of CAPD in the study patients. The overall incidence of peritonitis was one episode per eight patient months (31 episodes in 16 patients in 252 months of treatment by CAPD). Microbial agents could be isolated only on five occasions, Staphylococcus epidermidis in three cases and pseudomonas in two; and 84% of the episodes were culture negative. Recurrent peritonitis was observed in seven patients, two of these had 11 episodes. A total of five cases needed catheter removal owing to resistant or recurrent peritonitis.
Other complications encountered are shown in [Table - 4]. The average survival of the technique was 15 + 10.5 months (range 1-37 months). Seven patients continued to have CAPD, six were transferred to hemodialysis and one had renal transplant. Two patients died, one because of CVA and the other because of cardiac disease.
| Discussion|| |
Peritoneal dialysis, although a well established method of RRT in ESRD patients, is not as popular as hemodialysis. The percentage of patients on CAPD in our study was 4% of total ESRD patients, slightly higher than the national average in Saudi Arabia  , although still less as compared to international figures. This may reflect the reluctance of patients and doctors to choose CAPD as a mode of therapy for end-stage renal disease.
CAPD was the first choice of treatment in 44% patients in this study and only two patients chose to have CAPD for RRT. As CAPD is usually offered second to HD, patients consider it inferior to HD. This is one of the reasons for lower percentage of CAPD patients in this country, in addition to other factors previously well discussed by Abu-Aisha et al  . Vascular access problems constituted the major indication for CAPD (62.5%) in our study. Many of these patients were on HD earlier, exhausted their vascular access sites, and had a long waiting time for transplantation.
Peritonitis was the main complication encountered in our study patients (one episode/eight patient months). It was also the main reason for abandoning this modality of treatment. The rate of peritonitis in the international literature by using same CAPD system as ours is one episode/12-16 patient months , . Recently, the rate of peritonitis declined further by the use of Y connection tubing system in CAPD.  El-Shahat et al from UAE  reported a lower rate of peritonitis (one episode/32.3 patient months). The high rate of peritonitis among our patients was due mainly to the fact that most of our patients were not motivated enough to abide by the usual precautions to prevent sepsis. Furthermore, the patients were reluctant to come to hospital early when they had peritonitis.
We could isolate the micro-organism responsible for peritonitis in only five cases (84% were culture negative) as compared to other reports , . The reasons for this unusually high false negative results are unclear.
Intraperitoneal bleeding in patients on CAPD is a serious complication, especially in men. One of our patients with intraperitoneal bleeding, who was a man, was diabetic with a concomitant urinary retention. The cause of the bleeding was not clear but resolved within 48 hours after bladder catheterization.
The overall results in these patients as regards general well being, control of hypertension, hemoglobin level and biochemical indices were quite satisfactory and comparable to results from other centers  .
Patients on CAPD require less erythropoietin as compared to HD patients  , however, none of our patients needed it. This shows that CAPD is as effective in our patients population as in the developed countries.
The fact that 7/16 patients (44%) continued CAPD at the time of concluding the study shows that this mode of RRT can be offered to many other patients in this country. Some measures need to be taken to make the program successful nation-wide. Publicity regarding this mode of RRT, increasing awareness and motivation of nephrologists, regular education program for doctors and nurses, patients education, utilizing patients on CAPD to motivate new patients, and using the new technique to prevent peritonitis are some of the ways to make the CPAD program a success.
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Head of Nephrology Department, King Fahd Hospital, Al Madinah Al Munawarah
[Table - 1], [Table - 2], [Table - 3], [Table - 4]