Current practice of peritoneal dialysis in children: results of a longitudinal survey. Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS).
(25/1510)
Since 1993, the Mid European Pediatric Peritoneal Dialysis Study Group (MEPPS) has been accumulating epidemiological data regarding the practice of peritoneal dialysis (PD) in children. More than 200 children have been evaluated to date. While treatment modalities were evenly distributed in 1993, automated peritoneal dialysis (APD) has emerged as the preferred mode of therapy during the last few years. Technique survival was 95% at 2 years, but decreased to 65% after 4 years of treatment, the main reasons for treatment failure being recurrent peritonitis, ultrafiltration failure, or both. Most centers use double-cuff curled Tenckhoff catheters with an upward pointing exit site. The first catheter was still functioning in 82% of patients after 1 year, and in 57% of patients after 4 years of treatment. While the overall peritonitis incidence between 1993 and 1997 was 1 episode per 17 months, it was much higher in children below 6 years of age. Empirical PD prescription resulted in a mean total weekly creatinine clearance of 57 L/1.73 m2/week in both continuous ambulatory peritoneal dialysis (CAPD) and APD patients, while average total weekly Kt/V urea was higher in APD-treated (2.45) than in CAPD-treated children (1.96). Antihypertensive treatment was required in 40%-50% of patients; oral phosphate binders in 75%-80%; bicarbonate substitution in 30%; potassium binders in 7%-14%; and NaCl supplementation in 9%-21% of patients. While growth retardation had a prevalence of 57%, body mass relative to height was in the normal range. After one year of dialysis, 20% of patients received growth hormone treatment. In conclusion, peritoneal dialysis in children, preferably performed as APD, achieves technique survival rates similar to those reported for adults. Young children are at increased risk for peritonitis. The current empirical PD prescription is of limited efficacy in terms of small-solute and fluid removal. (+info)
The 1997 Report of the Japanese National Registry data on pediatric peritoneal dialysis patients.
(26/1510)
OBJECTIVE: We have collected data on pediatric patients less than 16 years of age from the National Registry of Chronic Peritoneal Dialysis (PD). We present our experience with this population. DESIGN: The database details the patient numbers, age, outcome, cause of death, reason for terminating PD therapy, type of PD therapy, peritonitis, and catheter survival. PATIENTS: Of 807 patients, 70 patients (8.7%) were under 1 year of age, and 268 patients (33.2%) were under 6 years of age, clearly indicating that PD was the treatment of choice in young children. The duration on PD was 5 years or more in 200 patients (24.8%), which showed an increase in long-term PD patients from 11% in 1991. Patients on automated PD (APD) increased to 75% in 1997 from 9% in 1991. RESULTS: The outcomes for the total patient population of 807 as of the end of 1997 is: 253 patients (31.4%) were being successfully treated with PD, 87 patients (10.8%) died, 238 patients (29.5%) received a kidney transplant, and 121 (15.0%) were transferred to hemodialysis. The patient survival rate was 91% in 3 years and 86% in 5 years. The technique survival rate was 83% in 3 years and 71% in 5 years. The rate of peritonitis was 1 episode per 30 patient-months. The mean catheter duration was 2.25 years. CONCLUSION: The patient and technique survival rates, the peritonitis rate, and the catheter survival improved recently. However, these data were worse in younger children (less than 6 years of age), indicating that extra-careful management is needed for this young age group. (+info)
The hemodialysis catheter conundrum: hate living with them, but can't live without them.
(27/1510)
BACKGROUND: Hemodialysis requires reliable recurrent access to the circulation. On a chronic basis, this has been best provided by the use of arteriovenous fistulae and arteriovenous grafts. In recent years, hemodialysis catheters have come to play an increasingly important role in the delivery of hemodialysis. The use of both temporary as well as cuffed hemodialysis catheters has emerged as a significant boon for both patients and practicing nephrologists. The complications, however, associated with each of these hemodialysis catheters, both in terms of anatomic, thrombotic, and infectious issues, have emerged as a major problem with their continued use. This significant morbidity and complication rate has forced many nephrologists to face a basic conundrum: they have come to hate having to deal with the problems inherent in catheter usage, but the enormous utility of these devices have forced physicians to accept the fact they cannot live without them in their current practice. METHODS: We used a comprehensive literature review to describe the types, use and dilemmas of hemodialysis catheters. RESULTS: This article provides a comprehensive review of both the benefits inherent with the use of these hemodialysis catheters while cataloging their complications and offering some possible solutions. CONCLUSION: Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines. (+info)
Predictors of adequacy of arteriovenous fistulas in hemodialysis patients.
(28/1510)
BACKGROUND: Dialysis access procedures and complications represent a major cause of morbidity, hospitalization, and cost for chronic dialysis patients. To improve the outcomes of hemodialysis access procedures, recent clinical guidelines have encouraged attempts to place an arteriovenous (A-V) fistula, rather than an A-V graft, whenever possible in hemodialysis patients. There is little information, however, about the success rate of following such an aggressive strategy in the prevalent dialysis population. METHODS: We evaluated the adequacy of all A-V fistulas placed in University of Alabama at Birmingham dialysis patients during a two-year period. A fistula was considered adequate if it supported a blood flow of >/=350 ml/min on at least six dialysis sessions in one month. Fistula adequacy was correlated with clinical and demographic factors. RESULTS: The adequacy could be determined for 101 fistulas; only 47 fistulas (46.5%) developed sufficiently to be used for dialysis. The adequacy rate was lower in older (age >/= 65) versus younger (age < 65) patients (30.0 vs. 53.5%, P = 0.03). It was also marginally lower in diabetics versus nondiabetics (35.0 vs. 54.1%, P = 0.061) and in overweight (BMI >/= 27 kg/m2) versus nonoverweight patients (34.5 vs. 55.2%, P = 0.07). The adequacy rate was not affected by patient race, smoking status, surgeon, serum albumin, or serum parathyroid hormone. The adequacy rate was substantially lower for forearm versus upper arm fistulas (34.0 vs. 58.9%, P = 0.012). The adequacy of forearm fistulas was particularly poor in women (7%), patients age 65 or older (12%), and diabetics (21%). In contrast, upper arm fistulas were adequate in 56% of women, 54% of older patients, and 48% of diabetics. CONCLUSIONS: An aggressive approach to the placement of fistulas in dialysis patients results in a less than 50% early adequacy rate, which is considerably lower than that reported in the past. Moreover, the success rate of fistulas is even lower for certain patient subsets. To achieve an optimal outcome with A-V fistulas, we recommend that they be constructed preferentially in the upper arm in female, diabetic, and older hemodialysis patients. (+info)
Stability of antibiotics used for antibiotic-lock treatment of infections of implantable venous devices (ports).
(29/1510)
Antibiotic-lock is a treatment for catheter-related bloodstream infections in which a solution containing heparin and an antibiotic dwells in the lumen of the catheter or port. We tested the stability of vancomycin, cefazolin, ticarcillin-clavulanic acid, ceftazidime, or ciprofloxacin combined with heparin after incubation in vitro at 25 or 37 degrees C for intervals of up to 10 days by bioassay. All the antibiotic solutions except ceftazidime retained >/=90% activity at both 25 and 37 degrees C. Thus, studies of antibiotic-heparin lock solutions with dwell times of up to 10 days are feasible. (+info)
A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.
(30/1510)
OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD. (+info)
Cure of implantable venous port-associated bloodstream infections in pediatric hematology-oncology patients without catheter removal.
(31/1510)
The efficacy of antibiotic treatment of port-associated bloodstream infection without device removal has not been systematically studied. We analyzed the outcome of 43 consecutive port-associated bloodstream infections in pediatric hematology-oncology patients. Etiologies included Staphylococcus epidermidis (30) and Staphylococcus aureus (6). Antibiotics were given through the port for a median of 11 days. Four ports were removed within 72 hours. In 36 (92%) of the remaining 39 episodes, there was a response to antibiotic therapy (defervescence and negative blood culture). In 78% of episodes in which there was a response (excluding two in which the catheters were removed because of mechanical problems), the infections were cured without port removal. Two of the four relapses were cured with a second course of antibiotics. The cure rate was 92% for S. epidermidis infections and 67% for S. aureus infections. Thus, the majority of port-associated bloodstream infections in pediatric hematology-oncology patients can be cured without device removal. (+info)
Vascular access for haemodialysis--an epidemiological study of the Catalan Renal Registry.
(32/1510)
BACKGROUND: Vascular access (VA) continues to cause problems in a proportion of haemodialysis (HD) patients. VA complications are a major cause of hospitalization, with the resulting financial consequences and human suffering. The purpose of the study was to assess the types and duration of function of different modalities of VA in Catalunya and to relate them to treatment characteristics, to study the characteristics of patients who necessitated more than four VAs and to describe the factors associated with the start of HD using a catheter. METHODS: The Catalan Renal Registry, using a questionnaire, sampled the data of all patients alive on December 31, 1997 (n=3073). Data were analysed using the chi2 test, ANOVA and logistic regression. RESULTS: In 85.8% of HD patients in Catalunya, an AV fistula was used, in 8.5% a vascular graft and in 5.6% a catheter. In 48% of incident HD patients in 1997, a catheter was necessary due to lack of an AV fistula. The use of grafts increases with progressive time on dialysis, reaching > 10% amongst patients on dialysis for >7 years. The average time of function for AV fistula was 4 years, for grafts 2 years and for catheters 9 months. A total of 39.1% of patients required only one VA during the entire time on HD, 29.9% two, 14.4% three, and 16.5% four or more. The duration of VA function decreases with age. In patients with autosomal dominant polycystic kidney disease and glomerulonephritis, the duration of VA function exceeds 4 years; it is 3 years in patients with vascular disease and 25 months in diabetic patients. CONCLUSIONS: The most frequent modality of VA used in Catalunya is the AV fistula. It is used more frequently in male than in female patients. Approximately half of the patients have no VA at the time of start of renal replacement therapy. Age, duration of dialysis treatment and diabetes have an adverse effect on the duration of VA function. Repeated VA failure concerns a minority of patients. (+info)