| Abstract|| |
End-stage renal disease (ESRD) associated with pre-existing advanced liver disease (ALD) has increased the risk of morbidity and mortality. The aim of this study is to assess the outcome following the use of continuous ambulatory peritoneal dialysis (CAPD) in ESRD patients with ALD. A retrospective case-controlled study was performed on 16 patients with ALD and ESRD (ESRD-ALD) and 27 control patients with ESRD but without liver disease (ESRD); both groups were started on CAPD during the same period. No major complications were observed in either group in the immediate post-surgical period and, after an average break in period of 11.3 days, the cases and controls were started on regular CAPD. The average duration of follow-up was 8 ± 2.3 months in the ESRD-ALD group compared with 20 ± 1.3 months in the ESRD group. The overall peritonitis rates were 1.26/treatment year in the ESRD-ALD group and 0.63 in the ESRD group. The 6- and 12-month survivals among ESRD-ALD patients were 63.75% and 38.75%, respectively. Patients with ESRD-ALD had significantly lower baseline serum protein and albumin levels at the time of initiation of CAPD. On follow-up, the hemoglobin levels improved in both the groups along with an improvement in the serum protein and albumin levels. Fourteen of the 16 ESRD-ALD patients died at the end of the 3-year follow-up period; deaths were due to terminal liver failure in nine patients and peritonitis in five patients. Patients who died in the ESRD-ALD group had lower serum albumin, lower body mass index (BMI) (median BMI 18.2 vs. 25.6) and higher grades of liver disease [child Pugh grade B (8), grade C (6) vs. grade B (2)] at initiation of CAPD. Our study suggests that CAPD is a safe modality in patients with ESRD-ALD and that it does not carry any major risk for bleeding tendencies, technique failure or worsening of nutritional status. Low serum albumin, lower BMI and higher grade of liver disease at initiation are associated with higher mortality in these patients.
|How to cite this article:|
Kaul A, Sharma R K, Gupta A, Prasad N. The use of continuous ambulatory peritoneal dialysis for patients with end-stage renal disease and pre-existing advanced liver disease. Saudi J Kidney Dis Transpl 2013;24:719-24
|How to cite this URL:|
Kaul A, Sharma R K, Gupta A, Prasad N. The use of continuous ambulatory peritoneal dialysis for patients with end-stage renal disease and pre-existing advanced liver disease. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jun 4];24:719-24. Available from: http://www.sjkdt.org/text.asp?2013/24/4/719/113863
| Introduction|| |
Chronic kidney disease in patients with advanced liver disease (ALD) presents interesting therapeutic challenges. In the presence of advanced liver failure, the signs and symptoms of renal failure are usually misinterpreted and initiation of dialysis may be delayed. Low muscle mass, malnutrition and impaired synthesis of creatine by a cirrhotic liver leads to lower serum creatinine values and, hence, over-estimation of renal functions by predictive formulas. Also, uremia increases the risk of malnutrition and infections in patients with ALD.
Currently, there are no clear guidelines regarding the timing of initiation of dialysis in patients with end-stage renal disease (ESRD) and ALD (ESRD-ALD).
Liver-kidney transplant, the best therapeutic option in this population, is often not feasible and dialysis remains the only therapeutic choice in this sub-group. Hemodialysis (HD) is associated with an increased risk of intra-dialytic hypotension, hemodynamic instability, electrolyte and acid-base abnormalities, worsening encephalopathy and bleeding tendencies.  The use of continuous ambulatory peritoneal dialysis (CAPD) in this sub-group is known to result in slow removal of endotoxins and gradual removal of excess fluids, along with maintaining good caloric replacement. However, it increases the risk of malnutrition, infections and hernias. In developing countries like India, where there are limited dialysis centers for Hepatitis B- and Hepatitis C-positive patients, CAPD stands out as a useful alternative mode of dialysis. The literature on the role of CAPD in ALD is scarce and this study attempts to study the outcome of the use of CAPD in patients with ESRD-ALD.
| Materials and Methods|| |
Retrospective data of all patients with ESRD initiated on CAPD from January 2000 to August 2003 were analyzed and 16 patients with ESRD-ALD were identified as cases. The control group comprised of 27 age- and sex-matched ESRD patients without ALD, who were started on CAPD during the same period. Patients with diabetes, prior use of CAPD, patients on anticoagulants, patients lost to follow-up within one month of initiation of CAPD and post-renal transplant patients were excluded from the study. ALD was diagnosed based on clinical evaluation, biochemical parameters, gastrointestinal endoscopy and abdominal ultrasound.
A double-cuffed Tenckhoff catheter was placed using the open surgical technique in all patients. After an average break-in period of ten to 14 days, these patients were gradually taken up on small volume exchanges and, within a period of one week, were put on an average of 3.2 exchanges a day with gradual drainage of fluid. The ultrafiltration target was 200-500 mL/day in the initial period, which was gradually increased to achieve the desired dry weight. This was performed to avoid sudden decompensation and hypovolemia, which could precipitate hepatic encephalopathy. All patients were on a twin bag system, 2 L each exchange, using 1.5-4.25% strength bags (Baxter Private India Limited, DLF Cyber city, Gurgaon, Haryana, India). Patients were followed-up weekly for one month and monthly thereafter. The diagnosis of peritonitis was based on clinical evaluation, cloudy effluent and cell counts with or without culture positivity. A peritoneal equilibration test (PET) was performed one month after catheter implantation and was repeated after three months.
Data are reported as mean ± SD and statistical comparison was performed using Chi-square test. The Kaplan-Meier method was used for survival analysis. A P-value of <0.05 was considered significant.
| Results|| |
Sixteen patients with ESRD-ALD and 27 controls were compared, and their baseline characteristics are shown in [Table 1]. The cause of ESRD-ALD included Hepatitis B-related in 11 patients, Hepatitis B- and Hepatitis C-related in one patient, Hepatitis C-related in three patients and alcoholic liver disease in one patient. No major complications were observed in either group in the immediate post-surgical period. After an average break-in period of 11.3 days, the cases and controls were on regular CAPD. In comparison with the ESRD group, the ESRD-ALD patients had significantly lower baseline serum protein and albumin levels at the time of initiation of CAPD. The overall peritonitis rate/treatment year was 1.26 in the ESRD-ALD group compared with 0.63 among the ESRD patients. On follow-up, the hemoglobin levels improved in both the groups along with an improvement in the serum protein and albumin levels [Table 2].
|Table 2: Comparison of clinical and biochemical parameters at the end of follow-up.|
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During follow-up, 14 ESRD-ALD patients died, with 63.75% of the patients surviving at six months and 38.75% surviving at one year after starting CAPD. Five patients of the ESRD group died, with 85.1% surviving at six months and 74.01% surviving at one-year of follow-up after starting CAPD. The cause of death among patients with ESRD-ALD included peritonitis in five patients and terminal liver failure in nine patients. Patients who died in the ESRD-ALD group had lower body mass index (BMI) [median BMI (18.2 vs. 25.6)] and higher grades of liver disease [child Pugh grade B (eight), grade C (six) vs. grade B (two)] at initiation of CAPD [Table 3].
|Table 3: Comparison of clinical and biochemical parameters between patients who died and those who survived in the ESRD-ALD group.|
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There were no instances of technique failure and none of the patients were shifted to HD. The average length of follow-up in the ESRD-ALD group was 8 ± 1.3 months and was 20 ± 2.3 months in the ESRD group. Kaplan-Meier analysis comparing the survival rates in the ESRD-ALD group (cases) with the ESRD group (control) is depicted in [Figure 1].
|Figure 1. Kaplan–Meier analysis showing survival outcomes in cases with ESRD-ALD (green line) and ESRD (pink line).|
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| Discussion|| |
The timing of initiation of renal replacement therapy in patients with ESRD-ALD is difficult to determine as the symptomatologies in uremia and liver disease (i.e., loss of appetite, weight loss, etc.) are similar. Besides this, these patients have an increased risk of infections, deranged coagulation profile and increased risk of bleeding. The occurrence of intradialytic hypotension during HD limits ultrafiltration and worsens ascitis. Rapid osmotic and electrolyte shifts during intermittent dialysis are a risk for increased brain water content,  which may worsen the encephalopathy in this group of individuals. CAPD offers better hemodynamic stability than HD. The use of peritoneal dialysis has been beneficial in patients who have ascitis due to other causes like congestive heart failure , and fulminant hepatic failure. 
In our study, patients with ESRD-ALD on CAPD showed an improvement in their serum protein and albumin levels at the end of follow-up. There is always a risk of worsening of malnutrition while on CAPD due to protein loss through the CAPD fluid. However, our patients as well as those in other reports that have studied the ESRD-ALD population have shown no worsening of malnutrition. The possible explanation could be that the patients were feeling better symptomatically with drainage of large ascitis and improvement in appetite. Also, there is possibly a decrease in loss of protein through CAPD over time as reported by Selgas et al, where initial protein loss was high at >30 g/day and decreased to <10 g/day over time.  A similar observation was reported by De Vecchi et al  in their patients. The theoretical explanation could be due to counter pressure exerted by the increased intra-abdominal pressure opposing the portal pressure thus decreasing the formation of ascitis and decreased protein loss. Also, there was no worsening of hepatic encephalopathy in our study population (which is often precipitated by peritonitis).
Fourteen of our 16 ESRD-ALD patients died after a follow-up period of 36 months, with an average length of follow-up of 8 ± 2.3 months. Marcus et al  studied nine ESRD patients having cirrhosis and ascitis. The maximum survival was eight years. Six of the nine patients survived longer than 18 months with good control of uremic symptoms and volume status. In contrast, the possible causes of poor patient outcome in our study could be due to the higher grade of liver disease (eight patients were child Pugh grade B and six were grade C), lower serum albumin and BMI (which suggests a higher degree of malnutrition) at initiation of CAPD.
When patients with ESRD-ALD on CAPD who survived were compared with those who died, patients who died had significantly lower baseline serum albumin and protein levels at the completion of the study. Also, patients who died had a lower BMI at initiation of CAPD and higher incidence of peritonitis. Two prior studies , have shown a trend toward a higher incidence of peritonitis in these patients. The study by Selgas et al  found an increased incidence of peritonitis related mostly to gram-negative organisms. Bajo et al  reported an incidence of one event every nine patient-months, with the average incidence being one event every 24 patient-months. Marcus et al,  in their nine patients, showed one episode of peritonitis every 1.2 patient-year, which is comparable to the peritonitis rates among non-cirrhotic CAPD patients; the serum albumin remained stable in most patients. The overall peritonitis rate in our study group was 1.26/ treatment-years for ESRD-ALD patients and 0.63 for ESRD patients. The reported rates of gram-negative, gram-positive, polymicrobial and fungal peritonitis in our center were 0.17, 0.11, 0.04 and 0.09 episodes per patient-year, respectively.  De Vecchi et al  reported peritonitis rates of one episode/39 months in cir-rhotic patients versus one episode/22 months in patients without cirrhosis. The five-year patient and technique survival rates were similar in both groups. Chow et al  observed that peritonitis-free survival of patients with cirrhosis infected by Hepatitis B virus com-pares favorably with that in patients without cirrhosis. The presence of ALD does not appear to compromise the peritoneal dialysis outcome and could often be life-saving. ,
In conclusion, our study suggests that CAPD is a safe modality in ESRD-ALD patients without any major risk for bleeding tendencies, technique failure or worsening of nutritional status. Low serum albumin, lower BMI and higher grade of liver disease at initiation are associated with higher mortality in these patients.
Our study has the usual disadvantages of all retrospective analyses. Also, the small number of patients studied adds to its limitations. Further large-scale prospective studies are required to establish the benefits of CAPD in patients with ESRD-ALD.
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R K Sharma
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, Uttar Pradesh
[Table 1], [Table 2], [Table 3]