Exit-site infection (ESI) is still one of the most important technical complications in peritoneal dialysis because it can lead to peritonitis and catheter loss. Catheter choice does not appear to affect exit-site infection in most cases. Early diagnosis is extremely important in reducing such complications. Ultrasound inspection of the exit site and of the subcutaneous tunnel is one of the best practices to prevent technique failure. Surgical technique, peri- and postoperative protocols and care of the exit site are key points. Medical therapy should be selected based on international guidelines and prompt and timely intervention is the basis of successful therapy. A new treatment for exit-site infection is described and discussed in this paper.
Peritoneal dialysis is a method used in Italy from the 70s; starting from the first unsuccesses due to inexperience, today we reached a point in which the technique is safe and supported by a large amount of literature. Nevertheless, the percentage of patients using this method has settled for a long time at 10%, with a negative trend in the recent years. It is not understood why such a simple and yet so effective technique fails to obtain a more respectable space. Much has been written about the so-called “barriers” to its development, among which social, economical, and organizational issues are included. The purpose of this work is to show, using examples, that these barriers are only determined by the inexperience and total lack of will of those who run a nephrology unit.
Automated peritoneal dialysis (APD) is important for the further penetration of PD in the dialysis marketplace. Long dwell, equilibration PD (CAPD) has limited applicability in many patients due to inadequate solute clearance or fast membrane transport characteristics. Providing large volumes of dialysate over circumscribed hours is highly labor intensive without an automated system. Early attempts at APD were crude but effective in reducing labor, which was generally provided by nursing staff. Later evolution of PD technology has been greatly accelerated by the microchip, and by miniaturization of components. Current generation machines allow individualized fill volumes, variable tidal volumes and additional daytime automated exchanges, teledialysis, memorized delivery control, and full portability. The ideal machine should not only be able to perform all treatment schedules, but it should also optimize the performance of a selected treatment strategy. Biocompatible solutions, improved osmotic agents, and sorbent technology are all adaptable to APD. The eventual evolution toward continuous flow PD will resolve many of the current problems with both CAPD and APD.
To perform CFPD, a two way access must be available in order to allow continuous inflow and outflow of the solution. This is most likely achieved with a double lumen peritoneal catheter. To design a double lumen catheter does not necessarily mean to increase the size of the tube or to increase the discomfort of the patient. However, the real challenge is to find a design in which minimal re-circulation is experienced. The two tips of the catheter must be positioned such that a maximal exposure of the peritoneal surface to the fluid is guaranteed during one single passage of the fluid from one lumen to another. Double lumen catheters with one short branch and another long of straight and of spiral shape were originally designed. Ash and coworkers have designed a catheter with a t-shape configuration in order to distantiate to the maximum the tips of the two lumens. Recently we have designed a novel catheter for CFPD equipped with a thin walled silicone diffuser used to gently diffuse the inflow dialysate into the peritoneum. The holes on the round tapered diffuser are positioned to allow dialysate to perpendicularly exit 360 degrees from the diffuser. The diffuser design and hole locations disperse the high-flow dialysate fluid at 360 degrees, reducing trauma to the peritoneal walls and allowing the dialysate to mix into the peritoneum. The dispersed fluid infused into the peritoneal cavity is then drained through the second lumen whose tip is placed into the lower Douglas cavity. The new catheter with diffuser is also equipped with a special removable hub that allows for easy creation of the subcutaneous tunnel without increasing the size of the skin exit site. The results so far achieved seems to offer advantages in terms of high flows, minimal pressure regimes and negligible recirculation.
La dialisi peritoneale è una metodica in uso in Italia dagli anni '70; dalle prime sconfitte dovute all'inesperienza, siamo giunti oggi, se non ieri, a una metodica sicura e con una mole di letteratura favorevole. Malgrado ciò, la percentuale di utilizzo di tale metodica è assestata da molto tempo sul 10% e con un trend in negativo in questi ultimi anni. Non si comprende come una tecnica così semplice e, al tempo stesso, così efficace non riesca ad avere un suo rispettabile spazio. Molto è stato scritto sulle cosiddette “barriere” al suo sviluppo, tra le quali si annoverano cause sociali, economiche e organizzative. Lo scopo di questo lavoro è di dimostrare con degli esempi che, se barriere ci sono, queste sono rappresentate solo dall'inesperienza e dalla mancanza totale di volontà di chi dirige una struttura di nefrologia.
The peritoneal catheter should be a permanent and safe access to the peritoneal cavity. Catheter-related problems are often the cause of permanent transfer to hemodialysis (HD) in up to 20% of peritoneal dialysis (PD) patients; in some cases, these problems require a temporary period on HD. Advances in connectology have reduced the incidence of peritonitis, and so catheter-related complications during PD have become a major concern. In the last few years, novel techniques have emerged in the field of PD: new dialysis solutions, better connectology, and cyclers for automated PD. However, extracorporeal dialysis has continued to improve in terms of methods and patient survival, but PD has failed to do so. The main reason is that peritoneal access has remained problematical. The peritoneal catheter is the major obstacle to widespread use of PD. Overcoming catheter-related problems means giving a real chance to development of the peritoneal technique. Catheters should be as efficient, safe, and acceptable as possible. Since its introduction in the mid-1960s, the Tenckhoff catheter has not become obsolete: dozens of new models have been proposed, but none has significantly reduced the predominance of the first catheter. No convincing prospective data demonstrate the superiority of any peritoneal catheter, and so it seems that factors other than choice of catheter are what affect survival and complication rates. Efforts to improve peritoneal catheter survival and complication rates should probably focus on factors other than the choice of catheter. The present article provides an overview of the characteristics of the best-known peritoneal catheters.
Fluid overload and uncontrolled hypertension may be considered important mortality risk factors in peritoneal dialysis (PD) population. Even malnutrition is highly prevalent in PD patients. It is now well established that lower levels of serum markers of nutrition such as albumin, creatinine, and prealbumin are associated with increased mortality in PD patients [Fein, P.A. et al: Adv Perit Dial 2002;18:195-199]. Moreover cardiovascular disease is a leading cause of death in patients with end-stage renal disease, and hypertension and volume expansion are highly prevalent in long-term PD patients. Many studies in hemodialysis and in PD have demonstrated that phase sensitive bioelectrical impedance analysis is a widely used and proven method for evaluating patient's body composition. The vectorial bioimpedance analysis is a validated system to evaluate the hydration and nutritional state of hemodialysis and PD patients with acceptable sensitivity and specificity. The aim of this study is to evaluate the reliability and accuracy of the new multifrequency BodyComp bioimpedance analyzer as a home based tool versus traditional Bia Vector.
significant difference between both groups.Rate of PD peritonitis was slightly higher in intensive PD dosage group (21.4% vs. 13.3%).CONCLUSIONS: Among AKI patients who required PD, intensive PD dosage was not significant difference in hospital mortality with minimal standard PD dosage.
