Year : 1996 | Volume
: 7 | Issue : 1 | Page : 15--19
Is Peritonitis a Limiting Factor in the Widespread Use of CAPD in the Developing Countries?
Yassin I El-Shahat, Shakuntala Varma, Avinash Pingle, AK Hadi, Shah Nawaz, M Zahir Bari
Department of Nephrology, Al Jazierah and Central Hospitals, Abu-Dhabi, United Arab Emirates
Yassin I El-Shahat
Consultant Nephrologist, Al Jazierah and Central Hospitals, P.O. Box 233, hu-Dhahi
United Arab Emirates
Although continuous ambulatory peritoneal dialysis (CAPD) is now an established form of treatment for patients with end-stage renal failure (ESRF), it is not being used on a large scale in developing countries (DC). One of the limiting factors in this regard is peritonitis which is the most common complication of CAPD. Data on 70 patients on CAPD in our center were analyzed to study the impact of peritonitis on long-term outcome of this treatment. The mean age of the study patients was 37.2 years and the mean follow-up was 32.8 months per patient. A total of 41 patients (58.6%) received CAPD as first choice, 27 (38.6%) were started on CAPD after being on hemodialysis earlier and two (2.8%) were started on CAPD after a failed renal transplantation. Thirty three patients (47.1%) used safe-leur lock system, 23 (32.9%) used the spike system and 14 (20%) used safe-leur system initially and subsequently were changed to spike system. The overall incidence of peritonitis encountered was one episode per 32.3 patients months and was higher among patients who started CAPD as second choice. The incidence of peritonitis was not influenced by sex, age, profession or presence of diabetes mellitus or cardiovascular disease. This study shows that peritonitis rate in CAPD patients in our hospital is low and compares favorably with results from established centers in the developed countries. Thus, worries about recerrent peritonitis should not hinder CAPD programs in DC.
|How to cite this article:|
El-Shahat YI, Varma S, Pingle A, Hadi A K, Nawaz S, Bari M Z. Is Peritonitis a Limiting Factor in the Widespread Use of CAPD in the Developing Countries?.Saudi J Kidney Dis Transpl 1996;7:15-19
|How to cite this URL:|
El-Shahat YI, Varma S, Pingle A, Hadi A K, Nawaz S, Bari M Z. Is Peritonitis a Limiting Factor in the Widespread Use of CAPD in the Developing Countries?. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Oct 26 ];7:15-19
Available from: https://www.sjkdt.org/text.asp?1996/7/1/15/39533
Continuous ambulatory peritoneal dialysis (CAPD) is now an established method of treatment for patients with end-stage renal failure (ESRF). Patients managed well on CAPD enjoy a good quality of life. There are important geographical differences in the implementation of this treatment. This is more due to socioeconomic factors than to medical reasons. The number of ESRF patients treated by CAPD is increasing in the developed countries, but in most of the developing countries (DC) it is not yet widely used as an alternative form of renal replacement therapy. One of the limiting factors in DC is perhaps, peritonitis which still represents the most frequent complication of CAPD. Peritonitis is also the single most common cause of morbidity and treatment failure in patients on CAPD. Although the overall incidence of peritonitis is on the decline, the risk and consequences to the individual patient have always to be taken into account. Also, consideration must be given to the cost incurred in the treatment of peritonitis and its impact on the budget allotment for health care systems in DC.
This study was undertaken to evaluate the incidence of peritonitis in patients on CAPD in our unit, and the impact of this complication on patient survival and morbidity as well as on long-term results.
Patients and Methods
Data on 70 patients with ESRF on CAPD during the period between June 1987 and June 1994 was analyzed. The mean age of the study patients was 37.2 years (range 1275 years) and more than half the patients (67%) were between the ages 30-45 years. Males predominated (74%). The overall observation period was 191.3 patient years (mean 32.8 months per patient). CAPD was the first choice dialysis treatment for 41 patients (58.6%). Of the remaining 29 patients, 27 (38.6%) were started on CAPD after varying periods on hemodialysis (HD) and two (2.8%) were started on CAPD after a failed renal transplantation. The most frequent co-morbid conditions among CAPD patients were cardiovascular disease seen in 38 patients (54.3%) and diabetes mellitus seen in 11 patients (15.7%).
The mean period of training was seven days. A total of 33 patients (47.1%) used safe-leur lock system, 23 (32.9%) the spike system and 14 (20%) initially used the safeleur lock system but were subsequently changed to the spike system. All patients performed four exchanges per day (3 of 1.36 g/dl and 1 of 2.27 g/dl of dextrose). The sample size calculation assumed an expected peritonitis rate of 1 in 12 patientmonths (annual probability of peritonitis = 0.39) and defined a clinically important decrease in the peritonitis rate as 1 in 24 patient-months (annual probability of peritonitis = 0.63) and as 1 in 36 patientmonths (annual probability of peritonitis = 0.24). Detailed assessment was made with regard to patient survival, technique survival and peritonitis. Peritonitis was defined as a cloudy dialysate containing > 100 white blood cells per ml of the dialysate of which > 50% are neutrophils, and a positive growth of microorganisms on culture.
Prognostic factors recorded were age, sex and profession of the patient, diabetic status, presence of cardiovascular complications and whether CAPD was first choice or not. The peritonitis rate was calculated in two ways: first, the initial peritonitis event was evaluated by constructing a survival curve for each treatment group using the Kaplan-Meier method and, secondly, the total period of treatment was divided by the total number of episodes of peritonitis to obtain the mean incidence per patientmonth. Peritonitis episodes were treated as per the standard protocol  .
Peritonitis: incidence and risk factors
The overall incidence of peritonitis episodes was one episode per 32.3 patientmonths. The probability of developing the first episode of peritonitis was higher in patients who were started on CAPD as a second choice, and not influenced by sex, age, profession, presence or absence of diabetes mellitus or cardiovascular disease at the beginning of treatment.
Peritonitis: etiology and infecting microorganism
Staphylococcus aureus was the most frequent organism, accounting for 70% of episodes of peritonitis. Pseudomonas was isolated in 13% of episodes and coliforms and fungi were each isolated in 8.5% of episodes. A total of three cases with peritonitis necessitated catheter removal including two with fungal infection and one with accompanying exit-site and tunnel infections.
Peritonitis: morbidity and mortality
Our protocol required the hospitalization of any patient with peritonitis till obtaining relief of symptoms and a negative culture from the peritoneal dialysis fluid. Peritonitis required a mean hospital stay of 5 + 2 days. Recurrent peritonitis was the major causes of drop-out from the CAPD program. It also accounted for 7.2% of all causes of death in these patients, while 2.1% of peritonitis episodes resulted in death. Of our study patients, seven died. Cerebrovascular and cardiac disease were the most frequent causes of death [Table 1].
Peritonitis: technique and patient survival and rehabilitation
The overall technique survival was 93% at one year [Figure 1] and was lower in patients who received CAPD as a second choice treatment. Peritonitis was the most important factor for technique failure and dropout. The probability of technique failure due to peritonitis was not higher in diabetics and elderly patients.
The actuarial survival rate calculated in our patients was 93% at one year and 72% at five years [Figure 2]. Rehabilitation was excellent generally with only two patients being totally dependent on other people for day to day existence [Table 2].
CAPD offers a number of theoretical advantages over conventional hemodialysis. It offers a good quality of life with less severe dietary restrictions, results in higher mean hemoglobin levels and offers greater flexibility with regard to movement and travel. Also, the initial cost of establishing a CAPD program is lower when compared to establishing independent community-based HD. With all these advantages, one is forced to ask why CAPD has not become the universal mode of dialysis for ESRF patients, particularly in DC. Use of CAPD on a widespread basis in DC is perhaps limited by the high risk of peritonitis which has social and financial implications; it increases the cost of treatment, influences the well-being of patients, prevents proper rehabilitation and sometimes causes death. In the last few years, development and proliferation of connectology devices, techniques and catheter design, have led to marked decrease in the rate of peritonitis. However, the higher cost of these new devices has lessened the financial benefits of CAPD.
Our experience in treating ESRF patients with CAPD and overcoming the high incidence of peritonitis is a positive one. The overall rate of peritonitis in our group of patients was much lower than that reported by other groups using the same connecting system as ours ,,,, and can be favorably compared with the rate reported by other groups using the Y-set or other sophisticated systems ,,,, . This low rate of peritonitis could be attributed to the high motivation of the medical team and nursing staff, and the patients as well as the excellent educational program adopted by our unit.
The risk of peritonitis was significantly lower in patients undergoing CAPD as a first choice treatment. Data reported by other authors confirm that patient selection represents an important factor in reducing the incidence of peritonitis , . In our study age, sex, profession, presence of cardiovascular disease and diabetes mellitus did not increase the risk of peritonitis, contrary to the report by Nolph, et al  .
Staphylococcus aureus was the most frequent micro-organism causing peritonitis in our study patients. The organism is thought to be transmitted transluminally from exit-site or tunnel infections as also from touch contamination during connection-disconnection techniques.
The incidence of death and drop-out due to peritonitis was low in our study patients and this may be due to the low incidence of this complication as a whole. Maiorca, et al have reported that if patients who die of other complications before the onset of peritonitis are excluded, the risk of death becomes higher as the number of episodes of peritonitis increases  . Also, the risk of technique failure increases with increase in rates of peritonitis  . It has been observed that, if peritonitis is excluded as a cause of drop-out, the risk of discontinuing CAPD is similar to that of HD. Contrary to other reports  , a higher drop-out due to peritonitis in diabetics and elderly patients was not observed by us. Rehabilitation was excellent in our CAPD treated patients and was better than that obtained with HD patients, confirming the finding of Gokal.
The economic aspects of dialysis therapy still play an important role in the choice of available dialysis modalities in DC. The final place of CAPD in the treatment of ESRF in DC will depend largely on successful control of peritonitis and prevention of other complications which result is increased cost and affect patient outcome. Prevention of peritonitis appears to be the cornerstone for extension of CAPD as treatment of first choice for a large number of ESRF patients in DC. Appropriate technology and careful selection and training of patients are the mainstay in this regard. Our study shows that these measures, if adopted stringently, will help in decreasing the incidence of peritonitis and make CAPD feasible in DC.
|1||Peritoneal dialysis-related peritonitis treatment recommendations. 1993 update. The Ad Hoc Advisory Committee on Peritonitis Management. Perit Dial Int 1993;13:14-28.|
|2||Tranaeus A, Heinburger O, Lindholm B. Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): diagnostic findings, therapeutic outcome and complications. Perit Dial Int 1989;9:179-90.|
|3||Ota K, Kawagnchi Y. Peritoneal dialysis in Japan. Current concepts in peritoneal dialysis. Ota K, et al. (eds), Elsevier Science Publishers B.V. 1992;848-53.|
|4||Lee HB, Han DC, Park MS, et al. CAPD in Korea 1981-1989. Current concepts of peritoneal dialysis Ota K, et al. (eds) Elsevier Science Publishers 1992;854-60.|
|5||Faller B, Brignon P, Boses G, et al. Bvoluation of peritonitis over time: a restrospective analysis of 12 years of CAPD in Colmer, France. Current concepts in peritoneal dialysis. Ota K, et al. (eds), Elsevier Science Publishers B.V. 315-19.|
|6||Liao LT. CAPD in China. Current concepts in peritoneal dialysis, Ota K, et al. (eds). Elsevier Science Publishers B.V. 1992;861-3.|
|7||Port FK, Held PJ, Nolph KD, Turenne MN, Wolfe RA. Risk of peritonitis and technique failure by CAPD connection technique: a national study. Kidney Int 1992;42:967-74.|
|8||Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): a multi-centre randomized clinical trial comparing the Yconnector disinfectant system to standard systems. Canadian CAPD Clinical Trial Group. Perit Dial Int 1989;9:159-63.|
|9||Lewis J, Abbott J, Crompton K, Fowler I, Smith B. CAPD disconnect systems: UK eritonitis experience. Adv Perit Dial 1992;8:306-12.|
|10||Feelin G, Gentile MG, Cancarini G, et al. Peritonitis in CAPD: role of patients and staff. A report from the Italian CAPD study group. In: Khanna R, Nolph KD, Prowant B, Towardowski ZJ, Orepoulos DG, (eds) Perit Dial Bui Inc, Toronto 1988;165-8.|
|11||Coward RA, Uttley L, Murray Y, et al. The importance of patient selection for CAPD. Perit Dial Bull 1982;2(l):8-10.|
|12||Nolph KD, Cutler SJ, Steinberg SM, Novak JW, Hirschman GH. Factors associated with morbidity and mortality among patients on CAPD. ASAIO Trans 1987;33:57-65.|
|13||Maiorca R, Cancarini GC, Manili L, et al. Peritonitis rate and CAPD results. In: La Greca, Ronco C, Feriani M, Chairomonte S, Conz P, (eds). Peritoneal Dialysis, Milano, Wichtig Editore 1991;223-31.|
|14||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.|
|15||Gokal R. Quality of life and effectiveness of renal replacement therapy for end-stage renal failure. In: Bunmch C, (ed) Horizons in Medicine, London Balliere Tindall 1989;279-86.|