| Abstract|| |
To evaluate the complications of CAPD and their contributing factors in order to improve the patients' survival and reduce morbidity and mortality, we studied records of 65 CAPD patients treated at our hospital from October 1996 to January 2002. There were 32 (49%) males and the mean age of the patients was 48 ± 16 years. All the patients were on the
twin bag CAPD system. The mean duration of follow-up on CAPD was 29 ± 20 months. There were 75 episodes of complications occurring in the patients with a rate of 0.41 episodes/patient years. Peritonitis was the most frequent and serious complication accounting for 55 episodes with a rate of 0.35 episodes/patient years. Only 51% of the episodes showed positive culture; the organisms included Staphylococcus epidermidis (18.2%), Staphylococcus aureus (3.6%), Pseudomonas (16.4%), E. coli (1.8%), Azadobacter (5.45%) and Serratia (3.6%). All the episodes of infection, except one, responded to treatment but 10 patients had recurrent infection; one patient was cured only after removal of the catheter. There were 12 exit site infection episodes and five catheters were removed due to mechanical and infectious reasons. Three patients were switched to hemodialysis (HD), nine patients were transplanted and 11 patients expired; none died due to peritonitis. We conclude that the mortality rate of the complications on CAPD has declined in the present study compared to our previous report early in the 1990s due mostly to the adoption of the twin bag CAPD system.
Keywords: CAPD, Peritonitis, Chronic Renal Failure, Complications, Infection.
|How to cite this article:|
Al Wakeel JS, Mitwalli AH, Tarif N, Hammad D, Abu-Aisha H, Memon N, Alam A, Suliman F, Askar A, Qudsi A. Complications of CAPD: A Single Center Experience. Saudi J Kidney Dis Transpl 2005;16:29-32
|How to cite this URL:|
Al Wakeel JS, Mitwalli AH, Tarif N, Hammad D, Abu-Aisha H, Memon N, Alam A, Suliman F, Askar A, Qudsi A. Complications of CAPD: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2021 Jan 26];16:29-32. Available from: https://www.sjkdt.org/text.asp?2005/16/1/29/32948
| Introduction|| |
Continuous Ambulatory Peritoneal Dialysis (CAPD) has gained popularity in the recent years due to the overall improvement in the patients well being, technique survival, better hemodynamic stability, better blood chemistry profiles, absence of the need to vascular access and decline in peritonitis. ,,,, These observations have made CAPD an increasingly opted modality of renal replacement therapy worldwide. ,, In the United Kingdom, 50% of dialysis patients are on CAPD.  Furthermore, it is a better option for elderly patients.  Peritonitis is however a serious complication causing increased mortality and morbidity.  However, the incidence of peritonitis has declined after the introduction of the CAPD "Y" system. 
In this study, we attempt to evaluate the complications of CAPD and the contributing factors in order to improve the patients' survival and reduce morbidity and mortality.
| Material and Methods|| |
We retrospectively reviewed the medical records of 65 incident CAPD patients presented at King Khalid University Hospital, Riyadh, Saudi Arabia from October 1996 to January 2002. There were 32 (49%) males and the mean age of the patients was 48 ± 16 years. All the patients were on the twin bag CAPD system. The mean duration of followup on CAPD was 29 ± 20 months (range from 17-79 years). The etiology of ESRD comprised hypertension, diabetes mellitus, glomerulonephritis, pyelonephritis, recurrent renal stones, polycystic kidney disease, lupus nephritis and unknown etiology.
Data collected included the confirmed diagnosis of the complications such as the mechanical and infectious complications. The laboratory parameters were recorded including the results of the peritoneal dialysis (PD) fluid cell count, and culture and sensitivity. All the samples of the PD fluids and antibiotic coverage were handled according to a described protocol. 
| Results|| |
There were 75 episodes of different complications that occurred during the study period with a rate of 0.41 episodes/patient years. There were 55 episodes of peritonitis including 10 recurrences of peritonitis in five patients, 12 catheter site infections, one catheter displacement, one catheter leakage, three failures of drainage, two episodes of blood stained discharge and one mortality due to fluid overload, [Table - 1].
The peritonitis was due to Staphylococcus epidermidis in 10 episodes (18.2%), Staphylococcus aureus in two (3.6%), Pseudomonas sp. in nine (16.36%), E. Coli in one (1.8%), Azadobacter in three (5.45%), fungal in one (1.8%) and Serratia in two episodes (3.6%) while no organisms on culture were found in the rest of the 27 (49%) episodes, [Table - 2]. There were 10 recurrent episodes of peritonitis. All the patients responded well to the antibiotics. No resistant strain was found and no mortality due to peritonitis occurred during the study period. Out of the 12 catheter site infections, four were followed by peritonitis and Pseudomonas sp. was found in all of them.
A total of five catheters were removed; one was due to recurrent Pseudomonas infection, one was due to fungal infection and three were due to mechanical dysfunction. The outcome of the patients included switch to hemodialysis in three patients and renal transplantation in nine (13.8%) patients. The overall mortality was 11 (16.9%) patients. However, mortality related to CAPD was only in one (1.53%) patient, while the rest were due to non CAPD reasons; road traffic accident, myocardial infarction, surgery, death at home and unknown.
| Discussion|| |
Peritonitis and exit site infections are the most frequent complications of CAPD.  In our study they were also the most frequently encountered complications. Furthermore, peritonitis is the major cause of failure of the technique and return to hemodialysis. ,,
The organisms responsible for peritonitis and exit site infection were Staphylococcus epidermidis and S. aureus followed by the Gram-negative organisms. A similar profile was reported by previous workers also ,, Staphylococcus epidermidis is part of the skin flora and can adhere and proliferate on the smooth surface of the PD catheter and connections and may cause subsequent peritonitis through the catheter lumen. ,,,
In our study, two episodes of peritonitis were preceded by exit site infection with a similar organism (Pseudomonas). A similar episode of peritonitis acquired through exit site or tunnel infection is reported by others. , In our study, peritonitis was controlled well with the appropriate 3 rd generation antibiotics. Two catheters were removed due to peritonitis; however, no mortality was accounted due to peritonitis. There were 10 episodes of recurrence of peritonitis, being common in males, diabetics and in patients with hyperlipidemia. There was one episode of fungal peritonitis, which required catheter removal. A prophylactic course of antibiotic locally at exit site and parenterally may reduce the spread of infection and the incidence of peritonitis. 
In our study, there were other less frequent complications related to the PD catheter such as catheter displacement, leakage, failure of drainage and blood stained drainage. Moreover, there were some other manageable complications that included blood pressure fluctuations, dizziness, shortness of breath and increase in the lipid level.
Overall the complications of CAPD especially peritonitis are reduced currently to 0.41 episodes/ patient years compared to 0.5 episode/patient years in 1994. 
We conclude that the mortality rate of the complications on CAPD has declined in the present study compared to our previous report early in the 1990s due most likely to the adoption of the twin bag CAPD system.
| References|| |
|1.||Geerlings W, Tufveson G, Ehrich JH, et al. Report on management of renal failure in Europe, XXIII. Nephrol Dial Transplant 1994;9(Suppl 1):6-25. [PUBMED] |
|2.||Al Wakeel JS, Abu-Aisha H, Mitwalli AH, et al. Peritonitis in patients on CAPD at King Khalid University Hospital: Less infectionrates with more center-epxerience. Saudi J Kidney Dis Transplant 1998;9(1): 12-7. |
|3.||Mitwali AH, Malik GH, Al Wakeel JS, et al. Intermittent peritoneal dialysis (IPD) in the elderly. Experience at Security Forces Hospital Riyadh, Saudi Arabia. Geriatric Nephrol Urol 1996;00:1-5. |
|4.||Serkes KD, Blagg CR, Nolph KD, Vonesh EF, Shapiro F. Comparison of patient and technique survival in continuous ambulatory peritoneal dialysis, CAPD and hemodialysis: a multicenter study. Perit Dial Int 1990; 10(1):15-9. |
|5.||Maiorca R, Vonesh EF, Cavalli P, et al. A multicenter, selection-adjusted comparison of patient and technique survivals on CAPD and hemodialysis. Perit Dial Int 1991;11: 118-27. [PUBMED] [FULLTEXT]|
|6.||Nolph KD. Continuous ambulatory peritoneal dialysis as long-term treatment for end stage renal disease. Am J Kidney Dis 1991;17:154-7. [PUBMED] |
|7.||Nissenson AR, Diaz-Buxo JA, Adcock A, Nelms M. Peritoneal dialysis in the geriatric patient. Am J Kidney Dis 1990;16:335-8. [PUBMED] |
|8.||Smith WG, Tsakiris DJ, Junor BJ, et al. Peritonitis in continuous ambulatory peritoneal dialysis. Scott Med J 1986;31(2):85-9. |
|9.||Canadian CAPD clinical trials group: peritonitis in continuous peritoneal dialysis: a multi-centre randomized clinical trial comparing the Y-connector disinfectant system to standard systems. Perit Dial Int 1989;9(30):165-8. |
|10.||Saklayen MG. CAPD peritonitis. Incidence, pathogenesis, diagnosis, and management. Med Clin North Am 1990;74-997-1010. |
|11.||Report of a working party of The British Society for Antimicrobial Chemotherapy. Diagnosis and management of peritonitis in continuous ambulatory peritoneal dialysis. Lancet 1987;1:845-9. [PUBMED] |
|12.||Peterson PK, Matzke G, Keane WF. Current concepts in the management of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Rev Infect Dis 1987;9(3):604-12. |
|13.||Solis GL, Memon N, Abu-Aisha H. Peritonitis in chronic peritoneal dialysis: analysis of 4 year experience at King Khalid University Hospital. Ann Saudi Med 1989;9(1):27-31. |
|14.||Continuous ambulatory peritoneal dialysis (CAPD) peritonitis treatment recommendations: 1989 update. The Ad Hoc Advisory Committee on Peritonitis Management. |
|15.||Keane WF, Everett ED, Golper TA, et al. Peritoneal dialysis related peritonitis treatment recommendations. 1993 update. Perit Dial Int 1993;13:14-28. |
|16.||Zimakoff J, Bangsgaard Pederson F, Bergen L, et al. Staphylococcus aureus carriage and infections among patients in four haemoand peritoneal dialysis centres in Denmark. J Hosp Infect 1996;33: 289-300. |
|17.||Korbet SM, Vonesh EF, Firanek CA. Peritonitis in an urban peritoneal dialysis program: An analysis of infecting pathogens. Am J Kidney Dis 1995;26:47-53. [PUBMED] |
|18.||Gupta B, Bernardini J, Piraino B. Peritonitis associated with exit-site and tunnel infections. Am J Kidney Dis 1996;28:415-9. [PUBMED] |
|19.||Scalamogna A, Castelnovo C, De Vecchi A, Ponticelli C. Exit-site and tunnel infections in continuous ambulatory peritoneal dialysis patients. Am J Kidney Dis 1991;18:674-7. [PUBMED] |
Jamal S Al Wakeel
Department of Medicine, King Khalid University Hospital, P. O. Box 2925, Riyadh 11461
[Table - 1], [Table - 2]