A Retrospective Analysis Of The Six-year Data Of Peritoneal Dialysis In A Single Center

BackgroundIn recent years, with the development of society and science and technology, the extension of human life expectancy, end-stage renal disease (ESRD) rates showed a trend of growing throughout the world.Restricted by kidney, peritoneal dialysis (PD) and hemodialysis (HD) have been the major mode of renal replacement therapy (RRT). PD was gradually accepted by ESRD patients, based on simple equipment, strong autonomy, hemodynamic stability and residual renal function protection, high early-stage survival rate, lower cost and lower cross infection risk. PD was widely used all over the world, and has become the main RRT method in developed areas like Hong Kong and Singapore over the past30years.PD was one of the main RRT methods for ESRD patients. PD technique had been given series innovation since the German doctor Ganter applied PD to the human body for the first time in1923. The development of continuous ambulatory peritoneal dialysis (CAPD), continuous cycling peritoneal dialysis (CCPD), nocturnal intermittent peritoneal dialysis (NIPD), tidal peritoneal dialysis (TPD) and automated peritoneal dialysis (APD) significantly improved the ease and efficiency of PD. As the improvement of PD tube connection technique and nursing measures for the tunnel exit, the incidence of PD correlated peritonitis had obviously decreased. At the same time, the concept that PD was good at protection for residual renal function and removal for middle molecules got common understanding. The number of PD patients continuously increased. Currently patients on CAPD and APD have accounted for about15%of dialysis patients of around the world. PD patients accounted for95%of all dialysis patients in Mexico,78%in Hong Kong,30%～45%in North America,25%～40%in Europe, about10%in mainland China.PD related peritonitis and PD catheter dysfunction were the two main complications of PD. PD correlated peritonitis is still the most common infectious complication of PD. Peritonitis caused the loss of protein, intraperitoneal abscess, sepsis, peritoneal adhesion and even death in severe cases. Hence the prevention and treatment of PD correlated peritonitis has become the important subject. In addition, the PD catheter dysfunction was the most common non-infectious complication of CAPD, also was the leading cause of CAPD technical failure. It mainly included PD catheter displacement, loss of dialysate drainage, etc. Greater omentum wrapping up was closely related to PD catheter shifting and loss of dialysate drainag.The trend of PD development in our country had something in common with international. PD was started to use in the1960s. CAPD had been used from70s. CAPD in China is taking shape in the80s, especially after90s, due to the improvement of double "O" dialysis tube. PD was further promoted with the improvement of dialysate biocompatibility. Since the new century, patients with RRT had risen at an annual rate of more than11%, and reached60000people in2005. The increase rate of PD patients was20%, far more than the world average of7%. However, compared with other developed countries or regions, the problem such as uneven allocation of resources between different areas and inperfect registration system still existed in our country due to the influence of economic, cultural background and the people’s education level. Although the Chinese Nephrology Society established the first National Kidney Disease Data System in2010and collected data of270000patients with kidney disease, so far there was no accurate statistical data and the domestic publication of a single large PD center data is also very little.Based on the above research background and the large difference among different PD centre, patients with ESRD undergoing PD from January,2004to November,2009in our center were studied. Data of these patients were retrospectively collected and analyzed. Studies were as followings:1. clinical characteristics and risk factors of frequent peritoneal dialysis-related peritonitis;2. effect of preventive partial omentum resection on peritoneal dialysis catheter malfunction;3. comparison of peritoneal dialysis data in recent6years with other relatively developed countries or areas.Objectives1. To know the clinical features and risk factors of frequent PD correlated peritonitis.2. Choose between April2008and July2008in our line of peritoneal dialysis catheter, CAPD patients with end-stage renal failure and30patients with greater omentum resection for the observation group, at the same time line of the peritoneal dialysis catheter in33patients as control group. To observe the effects of prophylactic partial removal of greater omentum on PD catheter dysfunction, postoperative intraperitoneal hemorrhage, PD liquid leakage, PD efficiency and PD-related peritonitis.3. To realize current status of PD and to improve treatment and management of PD in our hospital, via comparison with PD centers in the more developed countries or regions.MethodsFrom January1,2004to November30,2009,236cases (male137, female99cases) patients with end-stage kidney disease (CKD) taking CAPD treatment in our center for6years are analyzed. First, retrospectively collect patients information including name, gender, the age of tube graft, address, contact information, category of payment of medical expenses, primary disease cause of ESRD, pipe time, means, way of anesthesia, dialysis tube type, complication, exit PD time, then register these data item by item, and enter them into the Microsoft Excel to do data processing.(1) Investigate retrospectively peritonitis patients undergoing CAPD in our hospital during1/2004to7/2009. Define the patients who suffering from peritonitis twice or more in one year as frequent PD related peritonitis (group1), and those who have peritonitis only once a year as comparison group (group2). Compare clinical and laboratory data of the two groups and analyze risk factors of PD related peritonitis.(2) Choose between April2008and November2008in our line of peritoneal dialysis catheter, CAPD patients with end-stage renal failure and30patients with greater omentum resection for the observation group, at the same time line of the peritoneal dialysis catheter in33patients as control group. Patients investigated were divided into two groups:partial omentum resection group and control group. Patients in partial omentum resection group underwent partial greater omentum resection during PD catheter placement surgery. Patients in control group underwent routine surgical placement of PD catheters. The incidences of PD catheter malfunctions, haemic dialysates, PD fluid leakage and PD related peritonitis were compared between the two groups. Serum creatinin, urea and CO2CP were also compared before placement of PD catheters and PD3-6months later.(3)Retrospectively collected patients information including name, gender, the age of tube graft, address, contact information, category of payment of medical expenses, primary disease cause of ESRD, pipe time, means, way of anesthesia, dialysis tube type, complication, exit PD time, and calculated rate of drift tube, incidence of peritonitis, drop rate(DOR), incidence of peritoneal dialysis treatment time (TOT) and survival rate etc., and compared peritoneal dialysis centers with other more developed countries or regions.3. Results (1)Group one has16cases with44times of infectious peritonitis, and groups two has45cases with53times of infectious peritonitis. Compared with group two, in group one patients’blood pressure increased significantly (P<0.05), edema proportion increased significantly (P<0.01), hemoglobin (P<0.05) and plasma albumin (P≤0.01)significantly lowered, and etiology check showed the proportion of gram-negative bacilli and fungi increased significantly (P<0.05), invalid cases of extubation increased significantly (P<0.05). Ages between the two groups, the catheter surgery way, peritonitis occurred from the time peritoneal dialysis started, inducement of peritonitis, occurred times accompanied by shortness of breath symptoms, serum creatinine, urea, calcium, phosphorus, peripheral blood white cells and peritoneal fluid of high white blood cells all have no obvious difference (P>0.05). Logistic regression analysis showed that when placing tube, hemoglobin<70g/L (OR0.135, P<0.01) and plasma albumin<30g/L (OR0.181, P<0.05) are the risk factors and predictors of frequent peritoneal dialysis related peritonitis.(2) The incidence of catheter dysfunction of greater omentum resection group was obviously lower than the control group (P=0.041), hemorrhagic high fluid (P=0.869) and drain fluid leakage (P=0.336) and peritonitis (P=0.224)of two groups had no obvious difference. Before catheter, observation group of Cr (P=0.011) and BUN (P=0.012) are significantly higher than the control group, while TCO2had no obvious difference between two groups (P=0.096); after dialysis, two groups of Cr (P=0.995), BUN(P=0.226) and CO2CP had no obvious difference (P=0.395); after dialysis Scr and urea and TCO2of the two groups were significantly improved (P<0.01) before peritoneal dialysis.(3) The number of new PD patients is rising year by year; the new patients were47±16ages,77.96%of them were under the age of60;67.37%were patients at their own expense,and the rate of this kind patient declines year by year; Chronic glomerulonephritis (54.66%) is the main cause of ESRD, diabetic nephropathy (12.29%) is the second, similar to most of the center in the Asia-pacific region.But the rates of obstructive nephropathy (11.02%) and chronic nephritis are high, while the rates of diabetic nephropathy and hypertension benign nephrosclerosis (10.17%)are low; Catheter displacement rate (8.05%) and the incidence of peritonitis rates (1month:44.22patients) are low; Patients in1year,2years and3years overall survival rates were83.65%,51.59%and29.81%, lower than other developed countries and regions, but higher than the national average; DOR is declining year by year, TOT is an upward trend,and in2009the two were11.56%and23.61%respectively.4. Conclusion(1)Compared with single peritonitis in peritoneal dialysis patients, frequent peritoneal dialysis related peritonitis in patients with gram-negative bacteria and fungi infection rate is higher, the condition of malnutrition and overload capacity deteriorates further, and these factors may be related to the high rate of decannulation and poor prognosis in patients. Severe anemia and proteinemia are risk factors and predictive factors of frequent PD related peritonitis. To ameliorate anemia and proteinemia may be helpful to prevent and conrol frequent PD related peritonitis.(2) Preventive partial omentum resection can significantly decrease the incidence of PD catheter malfunction, but not decrease PD efficiency and increase the incidence of celiac hemorrhage, PD fluid leakage and PD related peritonitis.(3) Our center’new PD patients are rising year by year; the new peritoneal dialysis patients are younger;drift rate and peritonitis rates are low;chronic glomerulonephritis is the major cause of ESRD, diabetic nephropathy was the second, and obstructive nephropathy is the third; Overall survival (patient survival) is much lower than other economic developed countries and regions, but still higher than the national average; TOT is roughly rising year by year, DOR is gradually declining. Above characteristics are related with the principle of "PD priority" in our center, patients from main source area of high incidence of urinary system calculus,some patients in placing tube after taking the greater omentum resection, paying attention to patient education and follow-ups, and coverage of health insurance and increased financing dynamics year by year. But on the whole, Quality of treatment and management of PD in our hospital still need to be improved.