Complications Of Peritoneal Dialysis

BackgroundWith the increasing aging population and prevalence of diabetes mellitus, patients with chronic renal disease are growing with each passing day. A large cross-sectional study by Beijing university first affiliated hospital showed that chronic kidney disease occupied 10.8% of Chinese adults. As the national chronic kidney disease situation continues to deteriotating, chronic kidney disease have become an important public healthy issues and social problems.Chronic kidney disease includes the entire process of kidney disease——CKD1 to CKD5. The glomerular filtration rate of some patients continue to falling until it reaches the diagnostic criteria of chronic renal failure. Chronic renal failure patients’ GFR have run down to CKD4, even CKD5. End stage renal disease patients are those people who need renal replacement therapies. According to the Chinese Society of Blood Purification, which is in 2008 only 71.8 per million population went on dialysis in China, while 2584 per million population in Taiwan (2010),1106 per million population in Hong Kong(2010),1870 per million population in the United States (2010),2470 per million population in Japan (2013). So we could see that it is under enormous pressure on this issue of health care in our country.Primary causes of end stage renal disease differ with economic condition, geographical enviroment. race and time. The primary causes of end stage renal disease in less developed countries and areas are different from those in developed and developing countries and areas. For example, the major primary causes of ESRD is glomerulonephritis, interstitial nephritis and hypertensive nephropathy in a large number of African countries. While it is chronic glomerulonephritis(49.81%), diabetic nephropathy (16.76%), hypertensive nephropathy (8.79%) among new dialysis patients in Shen Zhen city from January 1,2006 to December 31,2010.Diabetic nephropathy (43.8%) was also the most common primary disease among the new dialysis patients in 2013 Japan, followed by chronic glomerulonephritis (18.8%) and nephrosclerosis (13.1%).Renal replacement therapy conclude hemodialysis, peritoneal dialysis and kidney transplant. Objectively, it is infeasible to doing kidney transplant on the whole patients since the limited organ resourses——it is banned to get organs from the criminal sentenced to death unless donation from citizens in China. With the improving of medical insurance policy and the balancing of medical resourses, more and more patients would be access to dialysis therapies.Peritoneal dialysis is one of renal replacement therapies, which is used to remove extra fluid and metabolin from patient’s blood to dialysate through peritoneum. Peritoneum is a biofilm lining the abdomical cavity which is 1 to 2 square metres. Peritoneal dialysis principles include, there are three, dispersion, ultra-filtration and absorbtion.It is controversial whether peritoneal dialysis is better than hemodialysis to this day. Many domestic and international researches showed that peritoneal dialysis is superior than hemodialysis on protecting residual renal function. RRF is an important determinant of mortality in patients undergoing dialysis. Conserving more function of kidney is beneficial to eliminate excess fluid and salts (electrolytes) as well as small and middle molecular substances from blood and it also means restoring more metabolic and endocrine function. Thus a more steady internal environment in ESRD patient lead to a better prognosis. Besides, it can also be considered from other aspects, namely, signs, symptoms, economic condition, living environment, local medical level and so on. Peritoneal dialysis will be a better choice in these condition:(1) the infants and children, (2) the patients who cannot be constructed good and efficient blood access, (3) the patients like home dialysis, (4) the patients who like moving about freely, (5) the patients who has poor cardiac function and ischemic heart diseases or the hemodialysis patients who are liable to become hypotensive, hypertensive or bleeding, (6) the diabetics.Anyway, peritoneal dialysis is simpler, more convenient, better at recerving RRF and cheaper relatively. But any kind of therapy contains the advantages with the shortages. The complications of peritoneal dialysis include infective complications (peritoneal dialysis associated peritonitis, exit site infection, etc.), mechanical complications (hernia, obstructed drainage, leakage, bleeding, etc.) and metabolic complication (disturbance of electrolyte, protein, lipid, etc). Peritoneal dialysis associated peritonitis is a main complication.The incidence of peritoneal dialysis associated peritonitis reduced graducally with the improvement of peritoneal dialysis equipment and asepsis. PDAP is a kind of serious complication and even the most common cause of technique failure. A study in Hong Kong investigated that PDAP was the reason for 16% of PD patients death. In a single-center cohort study of a dacade-long in Taiwan, the investigators discovered that PDAP was an independent predictor of PD technical failure. The date from Australia and new Zealand dialysis and transplant registry showed that PDAP accounted for 42%of unexpected reasons which led to the transfer from PD to HD. Relapse and recurrent PDAP lengthened the hospital duration, increased the risk of transferring to hemodialysis, that date also showed. When compared with the common peritonitis, relapse and recurrent PDAP is more harmful. A study by Hong Kong in 2013 found that bacteria-derived DNA fragment might be a predictor of relapse peritonitis. But it cannot be popularized and performed in Mainland China temporarily.There are many kinds of complications of peritoneal dialysis, this article reviews the occurrence rate, risk factors, preventations, therapies of the complications. To preidict the relapse and recurrent peritonitis by simple and feasible approaches and to treat it effectively, dates from 101 patients on continuous ambulatory peritoneal dialysis with at least 1 episode of peritonitis were collected. This study makes two groups of contrastive analysis depending on these dates so as to provide evidences for treatment and prevention.Objective1. To provide a reference for clinical practice of complications of peritoneal dialysis.2. To provide evidences for treatment and prevention by investigating the risk factors and characteristics of pathogenic bacterias of relapse and recurrent PDAP.Methods1 Patients and Exclusion criteriaCAPD patients with at least 1 episodes of peritonitis in Department of Nephrology of Zhu Jiang hospital were included. Exclusion criteria:(1) children under 18, (2) intervals less than 3 months between PD initiation and PDAP occurrence, (3) mixed infection, (4) repeated peritonitis, (5) operation done in other hospital, (6) transfered to other centres, (7) cancer patients or patients with active stage of autoimmune diseases. (8) have been infected within 3 months.2 GroupThe patients was divided into two groups depending on the peritonitis stype:the observation group (34 CAPD patients with 114 samples of relapse and recurrent peritonitis) and the control group (67 CAPD patients with 98 samples of common peritonitis).3 Demographic and Clinical DataPatients’ demographic profiles (sex, age, intervals between PD initiation and peritonitis occurrence, education level, body mass index, residual renal function, primary disease, systolic and diastolic blood pressure), biochemistry dates (Dialysate /Plasma creatinine, hemoglobin, serum kalium, natrium, calcium, phosphorus, creatinine, urea, glucose, uric acid, cholesterin, triglyceride, albumin, parathyrin) and the results of bacterial culture and drug-sensitive test were analyzed. Nurse was responsible for the retention and management of the follow-up dates. The department of laboratory provided the blood biochemical test and bacterial culture report.4 Statistical AnalysisSPSS 20.0 statistical software was used for statistical analysis. The difference of measurement dates was compared with t test between the two groups, while the enumeration dates was chi-square test or Fisher exact probabilities. A P-value<0.05 was considered statistically significant.ResultsCompared with those in the control group, patients in the observation group had higher systolic and diastolic blood pressure (P<0.05), but younger age and lower plasma albumin (P<0.05), with higher rate of multi-drug resistant bacteria and drug resistance (P<0.05). No fungi was isolated from the observation group. No significant differences were found between the two groups in gender, body mass index, intervals between dialysis peritoneal initiation and the first peritonitis occurrence, residual renal function, primary diseases, pathogenic bacteria spectra, positive rate of bacteria culture, the level of hemoglobin, potassium, calcium, phosphate, serum creatinine, urea, uric acid, blood glucose, blood lipids, parathyroid hormone and the pathogenic bacteria(P>0.05). Pathogen isolation rate was 66.51% (141/212) in this dialysis centre. Among them, gram-positive bacteria constituted 66.7% (94/141), gram-negative bacteria 30.5% (43/141) and fungus 2.8%(4/141). The drug resistance rate of gram-positive bacteria to glycopeptides was the highest (99%). Above 97% of gram-negative bacteria were sensitive to imipenem, amicacin and meropenem. Some drug resistant rates in the observation group were higher than those in the control group (P>0.05).ConclusionThere are many kinds of complications during dialysis, some of them are very insidious. Thus, clinicians need to observe carefully and gather experience. The incidence of peritoneal dialysis-related peritonitis is closely related with younger age, increased fluid overload, lower level of serum albumin. The risk factors should be corrected by effective treatments to prevent the occurrence of relapse and recurrent peritoneal dialysis-related peritonitis, In cases of relapse and recurrent peritoneal dialysis-related peritonitis, clinician may need to consider increasing the duration of treatment. The Patients with fungal peritonitis need to be removed dialysis catheters as soon as possible.