Continuous ambulatory peritoneal dialysis - medIND

Indian Journal of Nephrology OfÞcal Publication of the Indian Society of Nephrology October - December 2007 ! Volume 17 ! Number 4

Table of Contents NEWS The third World Kidney Day: Looking back and thinking forward S. V. Shah, J. Feehally

147

REVIEW ARTICLE Pathogenesis and management of renal osteodystrophy A. S. Narula, A. Jairam, K. V. Baliga, K. J. Singh

150

ORIGINAL ARTICLES Subtle renal dysfunction after radiocontrast administration in prospective renal donors: Does N-acetylcysteine have a role in its prevention? K. Gohel, M. Khanpete, B. Mukhopadhyaya, U. Hegde, S. Gang, M. Rajapurkar

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Continuous ambulatory peritoneal dialysis: A viable modality of renal replacement therapy in a hilly state of India S. Vikrant

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CASE REPORTS Immunoglobulin M nephropathy in familial Mediterranean fever O. Yavascan, N. Aksu, K. Demir, S. Sarioglu, O. D. Kara, A. Bal

170

Hereditary spherocytosis with nephrotic syndrome A. Mathew, J. Varghese, G. Kurian, V. N. Unni

174

A sinister presentation of typhoid fever P. George, B. Pawar

176

Epidermolysis bullosa dystrophica with renal failure due to secondary amyloidosis F. Mutlubas, S. Mir, C. Kabasakal, O. Yavascan, B. Sarsik

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Growth hormone therapy in chronic kidney disease J. Muthukrishnan, R. Jha, J. Kumar, K. D. Modi

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IMAGES IN NEPHROLOGY Reversible cause of blindness in end stage renal disease on dialysis M. Singh Jhawar, P. Pawar, U. George, P. George, B. Pawar, Yashpal Singh

185

LETTER TO EDITOR Vitamin D replacement in tertiary hyperparathyroidism with vitamin D deficiency: Is there any reason for being overcautious? J. Muthukrishnan, R. Jha, K. D. Modi, J. P. Kumar

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RENAL PHYSIOLOGY Role of non-transferrin-bound iron in chronic renal failure and other disease conditions M. Prakash

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Author Index, 2007

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Title Index, 2007

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Original Article

Continuous ambulatory peritoneal dialysis: A viable modality of renal replacement therapy in a hilly state of India S. Vikrant Department of Nephrology, Indira Gandhi Medical College, Shimla (Himachal Pradesh) - 171 001, India

ABSTRACT Objective: Chronic ambulatory peritoneal dialysis (CAPD) has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade and has emerged as accepted form of renal replacement therapy in urban areas. The objective of this paper is to report the experience with CAPD as a modality of renal replacement therapy from a tertiary care hospital in a hilly state of India with predominant rural population. Design: Retrospective study. Setting: A government-owned tertiary care hospital in Himachal Pradesh, a state with a population of 6 million. Materials and Methods: This study involved the patients who were initiated on CAPD between October 2002 and December 2006 and who survived and/or had more than 6 months follow up on this treatment with last follow up till June 30, 2007. Results: A total of 25 patients were included in the analysis. The mean age of the patients was 61 ± 10.2 years. 13 (52%) patients were female. 18 (72%) patients out of these lived in rural areas. The total follow up was 553.1 patient-months with a mean follow up of 22.1 ± 12.4 months. The total duration on peritoneal dialysis treatment was 541.1 patient-months with a mean duration of 21.6 ± 12.2 months and median duration of 19 patient-months (range: 6–56.3 patient-months). No patient had exit-site infection. There were 26 episodes of peritonitis. The rate of peritonitis was 1 episode per 21 patient-months or 0.6 per patient-year during the treatment period. The main cause of death was cardiovascular complications. Patient and technique survival at 1, 2 and 3 years was 80, 36 and 12%, respectively. Conclusion: Chronic ambulatory peritoneal dialysis (CAPD) is a safe and viable mode of renal replacement in remote and rural places. It can emerge as a revolutionized procedure for ESRD patients dwelling in remote and geographically difÞcult regions in developing countries such as India. Key words: Chronic ambulatory peritoneal dialysis, catheter-related infections, developing countries, exit-site infection, India, peritonitis, rural, tropical country

Introduction In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, only 5–10% of all patients with ESRD in India obtain some form of renal replacement therapy.1,2 Most hemodialysis units are situated in cities and are not accessible to patients living in rural areas. In the early 1980s, the combined financial burden and considerable patient morbidity and mortality associated with peritonitis limited the appeal of continuous ambulatory peritoneal dialysis (CAPD) as a dialysis modality in ESRD patients.3 However, technical advances in connecting system, flushbefore-fill technique and use of UltraBag have recently decreased the peritonitis rate, thereby making CAPD a feasible alternative to hemodialysis (HD) in India.3

Address for correspondence: Dr. Sanjay Vikrant, Department of Nephrology, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh, India. E-mail: [email protected] Indian Journal of Nephrology

Although CAPD has been an established form of therapy in adult patients with end-stage renal failure in India for more than a decade, less than 10% of patients are started on peritoneal dialysis (PD) to date because the cost of PD is two times higher than that of HD. Majority of the patients on this therapy are from urban areas.3-6 Himachal Pradesh is a mountainous state with altitudes ranging from 350 to 7000 m above the sea level in the northern part of India. There is great diversification in the climatic conditions of Himachal Pradesh due to variation in elevation. The state is inhabited by over 6 million people with majority of the population (90.2%) living in rural areas as compared to the national average of 72.2% (2001 Census).7 Indira Gandhi Medical College Hospital, Shimla, is the only tertiary care hospital in the state of Himachal Pradesh providing dialysis services. There is no other dialysis center in this state that offers acute or maintenance HD. Therefore, chronic PD was started as a modality of renal replacement therapy for ESRD patients. Oct 2007 / Vol 17 / Issue 4

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Vikrant: CAPD – A viable modality in a hilly state of India

Materials and Methods

Table 1: Demographic and clinical characteristics of patients on chronic ambulatory peritoneal dialysis - total 25

It was a retrospective analysis of the patients who were initiated on CAPD at Indira Gandhi Medical College Hospital, Shimla, between October 2002 and December 2006. All patients had surgical implantation under local anesthesia of two-cuff straight Tenckhoff catheters. After the break-in period, the patients were initiated on manual exchanges using twin-bag system; however, later on, two patients switched to automated peritoneal dialysis (APD). For the first 10 patients, the treating nephrologist gave education and training in PD and was helped in this job by the corporate colleagues in the rest of the patients. All patients were taught to apply 2% mupirocin cream to the exit site with a cotton bud, following daily exit-site care. Patients were advised to immediately contact telephonically the treating nephrologist for any assistance and advice. Patients with suspected peritonitis were advised to come to the hospital for microbiological analysis of the cloudy peritoneal effluent and treatment. Patients who were likely to have delay in reporting to hospital were advised to immediately start the empiric antibiotics covering both gram-positive and gramnegative organisms through the intraperitoneal route. Peritonitis was defined as cloudy fluid and/or abdominal pain associated with a white blood cell count >100 (with >50% neutrophils). All patients with peritonitis were treated as per the International Society for Peritoneal Dialysis protocol.8 All patients who survived and/or had more than 6 months follow up on this treatment with last follow up till June 30, 2007 were included. The comorbid illnesses, survival and complications related or unrelated to peritoneal dialysis were reviewed.

Age (year)

Results Out of a total of 33 patients, 25 patients were included in the analysis. Demographic and clinical characteristics of the patients are shown in Table 1. The mean age of the patients was 61 ± 10.2 years. Fifteen (60%) patients were elderly. Thirteen (52%) patients were female. The location of residence was – 8 (32%) patients within 50 km, 12 (48%) patients within 50–150 km and 5 (20%) patients were located at a distance greater than 150–300 km. Eighteen (72%) patients out of the total lived in rural areas. The causes of ESRD were as follows: diabetic nephropathy 8 (32%), chronic tubulointerstitial nephritis 9 (36%), hypertension 5 (20%), chronic glomerulonephritis 2 (8%) patients and autosomal dominant polycystic kidney disease 1 (4%) patient. Comorbid conditions were as follows: hypertension 25 (100%), diabetes 9 (36%), coronary 166

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61 ± 10.2

Female gender n (%) Cause of ESRD n (%) Diabetic nephropathy Hypertensive renal disease Chronic glomerulonephritis Chronic tubulointerstitial nephritis Polycystic kidney disease Comorbidity n (%) Diabetes Hypertension Coronary artery disease Stroke and peripheral vascular disease Chronic lung disease Residence location n (%) 150–300 km Residence in rural location n (%) Follow up in patient-months Total Mean ± SD Patient and technique survival in months Mean ± SD Peritonitis rate Episode in patient-months Episode per patient-year Exit site infection

13 (52) 8 (32) 5 (20) 2 (8) 9 (36) 1 (4) 9 (36) 25 (100) 4 (16) 2 (8) 4 (16) 8 (32) 12 (48) 5 (20) 18 (72) 553.1 22.1 ± 12.4 21.6 ± 12.2 21 0.6 0

artery disease 4 (16%) patients. The mean break-in period was 12 ± 3 days. The standard prescription for all patients consisted of three daily exchanges with 1.36% glucose solution for non-anuric and four exchanges in anuric patients. Some patients utilized 2.27% and 3.86% strengths for the night dwell to aid the achievement of better ultrafiltration. Patients on APD cycled 10 L of dialysate over 8 h during night. Fifteen patients used dialysis fluid of Baxter India (Gurgaon) and other 10 patients used dialysis fluid manufactured by indigenous companies (Mitra Industries, New Delhi) and Claris (Ahmedabad). The total follow up was 553.1 patient-months with a mean follow up of 22.1 ± 12.4 months. The total duration of PD treatment was 541.1 patient-months with a mean duration 21.6 ± 12.2 months and median duration of 19 patient-months (range: 6–56.3 patient-months). At the last follow up, the mean values of urine output and ultrafiltration were 716 and 812 ml, respectively. Five (20%) patients were anuric. All patients were treated with parenteral iron and erythropoietin. The latest value of hemoglobin was 10.5 ± 1.5 g/dl; albumin, 3.4 ± 0.5 g/dl; calcium, 9.1 ± 0.5mg/dl; phosphorous, 4.8 ± 0.8 mg/dl; total cholesterol, 184 ± 43.3 mg/dl; and triglyceride, 137.6 ± 39.3 mg/dl. All patients used mupirocin cream daily at the catheter Indian Journal of Nephrology


exit site. No patient had exit-site infection (ESI). There were 26 episodes of peritonitis. None was associated with exit site or tunnel infection. Out of these, 9 episodes occurred in months of June to August and 9 episodes occurred in months of November to January. Touch contamination was incriminated in 46.2% of peritonitis episodes. Touch contamination is defined as a break in the sterile technique by which dialysis is supposed to be performed. Examples encountered were failure to wash or dry hands appropriately before performing the procedure, especially during winter months, and inattention to avoiding connector tip contamination when connecting and disconnecting the transfer set and the twin bag. In many patients, problems observed included the execution of dialysis by inadequately trained helpers such as family members and in general less meticulous adherence to hygienic technique. The culture report available in 20 patients showed the growth of microorganisms in 10 patients, gram-positive in 4 patients and gram-negative in 6 patients. The rate of peritonitis was 1 episode per 21 patient-months or 0.6 episode per patient-year during the treatment period. Three patients with severe peritonitis required catheter removal after a mean duration of 19.7 ± 9.8 months on PD. One patient had successful reinsertion of catheter and the other two patients were transferred to hemodialysis. Three patients developed tuberculosis; 4 patients, herpes zoster; and 2 patients, hypothyroidism. Quality of life improved in 23 (92%) patients and remained unchanged in 2 (8.7%) patients who were suffering from a depressive disorder. Fifteen (60%) patients were alive. Ten (40%) patients had died after a mean duration 19.7 ± 10.1 months on dialysis. The cause of death was cardiac in 4 patients, stroke in 1 patient, infection and malnutrition in 3 patients each. Patient and technique survival at 1, 2 and 3 years was 80, 36 and 12%, respectively [Fig. 1].

Fig. 1: Patient and technique survival in patient-months on PD

Indian Journal of Nephrology

Discussion Our study demonstrates that CAPD is a safe and viable mode of renal replacement in remote and rural places. It is the first study from India reporting a reasonably good survival on dialysis treatment in ESRD patients, majority of them were elderly with a lot of comorbid conditions. Although the demographic profile and pattern of comorbidities of our patients was comparable to other studies in the urban setup,3-6 only one-third of the patients under our study were diabetic, whereas the other studies have reported a higher proportion of diabetic patients. Patients on dialysis require ongoing supervision by nephrologists to adjust the dialysis prescription and manage complications. Since PD patients typically perform the treatment themselves in their own homes, they tend to have more autonomy than those treated with hemodialysis, which typically must travel to a health-care facility at least three times weekly to receive their dialysis treatment. Remote residence location might act as a geographical barrier to proper care once established on PD. Thus, it is plausible that patients who live further away from nephrology services may be more likely to initiate renal replacement on PD – allowing them to avoid relocation at the expense of adverse clinical outcomes.9 Our study found comparable clinical outcomes to previous studies of CAPD from major urban centers from this country. Catheter-related infections (CRIs) have become a prominent morbidity factor in CAPD. Staphylococcus aureus (S. aureus)-associated peritonitis and catheter exit-site infections (ESIs) are important causes of hospitalization and catheter loss in patients undergoing chronic peritoneal dialysis. Several controlled studies have shown that prophylactic use of mupirocin, either intranasally or at the exit site, in S. aureus carriers reduces the incidence of both ESI and peritonitis.10,11 Recent studies have shown that when prophylactic mupirocin is used at the exit site in patients on PD, even when their carrier status is not known; there is still a significant reduction in the incidence of ESI and peritonitis in comparison to historical controls.12,13 All our patients used mupirocin cream daily at the catheter exit site. No patient had exit-site infection. None of the peritonitis was associated with exit site or tunnel infection. Our study demonstrates that the daily application of mupirocin at the exit site is an effective strategy in reducing the incidence of ESI and peritonitis which may thus have important benefits in reducing the rate of technique failure, thereby maintaining a greater number of patients on PD for longer periods, even in tropical countries such as India. Oct 2007 / Vol 17 / Issue 4

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The peritonitis remains a major cause of technique failure, morbidity and mortality in CAPD patients. The peritonitis rate in the major centers in India is one episode in 22–26 patient-months.14 The rate of peritonitis in our patients was 1 episode per 21 patient-months or 0.6 episodes per patient-year during the treatment period. The peritonitis episodes are well within the accepted ISPD 2005 Guidelines –1 episode every 18 patient-months (0.67 per year at risk).15 It has been found that climatic factors affect the incidence of peritoneal dialysis-related peritonitis. There is substantial seasonal variation in the incidence of dialysis-related peritonitis. CAPD peritonitis increases in the season of high temperature and high humidity.16-18 Most of the peritonitis in our patients occurred in hot and humid months (June to August) and period of extreme cold (November to January). More extensive training and retraining and meticulous adherence to hygienic technique need to be pursued for all patients. Proper hand hygiene techniques need to be well taught and persistently respected by patients and medical staff. In our peritonitis patients, the culture could be carried out in only 20 patients – growth of microorganisms was observed in 10 of them. Thus, the culture-negative infection rate was greater than 50%, that is, higher than the maximum of 20% recommended by the ISPD. Deficiencies in culture techniques, culture done after the institution of antibiotics, late processing and poor preservation of PD fluid could account for this large number of culture-negative peritonitis episodes. Several difficulties impede the implementation of the appropriate processing technique in our setting as advised by the ISPD guidelines. Large-volume centrifuging devices are not available. Blood culture bottles are expensive and not uniformly available. The culture procedure followed many circumstances is injection of a few milliliters of the dialysate directly into solid culture media and checking daily for growth. However, certainly there is a need to improve the results of our microbial cultures.

There are certain limitations for PD practice in our setting. The treatment of ESRD is a low priority for the cash-strapped public hospitals. Continuous ambulatory peritoneal dialysis (CAPD) seems to be the ideal dialysis option for patients living in remote areas, but high costs preclude its widespread usage. Hospitals are unwilling to invest in PD program as the in-center HD is more visible than in home PD. As our PD program is relatively small, the PD training support team such as trained healthcare staff and a regular clinical coordinator (CC) are not available. Due to lack of laboratory facilities, adequacy studies are not possible. The local manufacture of PD solution either by major international companies or by their local competitors avoids onerous tariffs and transport costs, and it is beginning to turn the economics in favor of PD. Increasing the affordability, PD attaining critical mass and gaining acceptance, increasing patient awareness and understanding the realistic therapy price difference in PD vs HD will facilitate the widespread use of PD. As the output and use of PD solution manufactured by indigenous companies increase and numbers of PD patients treated rise, one hopes the economies of scale will further decrease PD costs. In conclusion, CAPD is a revolutionized procedure for ESRD patients in remote and rural places. It is an excellent alternative suitable for patients who are living in far flung areas where facility of hemodialysis is not available. Good results can be achieved by carefully selecting patients who have sufficient resources and can strictly adhere to the basic principles of asepsis. It can emerge as a safe, viable mode of renal replacement therapy for ESRD patients dwelling in remote and geographically difficult regions in developing countries such as India.

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In developing countries, infections are the leading causes of morbidity and the second commonest cause of mortality in the dialysis population. Tuberculosis is endemic in several developing countries and impaired cell-mediated immunity increases the susceptibility among the dialysis population. The reported incidence of tuberculosis in dialysis patients varies from 10 to 15% in India. Further, the infection rate is higher in governmentfunded hospitals that cater to patients from the lower socioeconomic groups. The principal causes of death are cardiovascular (40−51%) and infections (15−23%).19 A similar morbidity and mortality figures were observed in our patients. 168


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CJ, et al. Adult peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000;20:396-411. Tonelli M, Hemmelgarn B, Culleton B, Klarenbach S, Gill JS, Wiebe N, et al. Mortality of Canadians treated by peritoneal dialysis in remote locations. Kidney Int 2007;72:1023-8. Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: A meta analysis. Clin Infect Dis 2003;37:1629-38. Thodis E, Bhaskaran S, Pasadakis P, Bargman JM, Vas S, Oreopoulos DG. Decrease in Staphylococcus aureus exit site infections and peritonitis in CAPD patients by local application of mupirocin ointment at the catheter exit site. Perit Dial Int 1998;18:261-70. Casey M, Taylor J, Clinard P, Graham A, Mauck V, Spainhour L, et al. Application of mupirocin cream at the catheter exit site reduces exit-site infections and peritonitis in peritoneal dialysis patients. Perit Dial Int 2000;20:566-8. Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, et al. Effect of local mupirocin application on exit-site infection and peritonitis in an Indian peritoneal dialysis population. Perit Dial

Int 2005;25:473-7. 14. Abraham G. Asian PD perspective: An update on PD in the Indian subcontinent. ISPD Asian Chapter Newsletter 2004;2. Available from: http://www.ispd.org. 15. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005;25:107-31. 16. Alves FR, Dantas RC, Lugon JR. Higher incidence of catheter-related infections in a tropical climate. Adv Perit Dial 1993;9:244-7. 17. Kim MJ, Song JH, Park YJ, Kim GA, Lee SW. The influence of seasonal factors on the incidence of peritonitis in continuous ambulatory peritoneal dialysis in the temperate zone. Adv Perit Dial 2000;16:243-7. 18. Szeto CC, Chow KM, Wong TY, Leung CB, Li PK. Influence of climate on the incidence of peritoneal dialysis-related peritonitis. Perit Dial Int 2003;23:580-6. 19. Jha V, Chugh KS. The practice of dialysis in the developing countries. Hemodial Int 2003;7:239. Source of Support: Nil, Conflict of Interest: None declared.

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