Stephen Vas

Continuous Ambulatory Peritoneal Dialysis in Diabetics with End-Stage Renal Disease

Twenty diabetics with end-stage renal disease who had never previously received dialysis treatment were treated with continuous ambulatory peritoneal dialysis for periods of two to 36 months (average, 14.5). Intraperitoneal administration of insulin achieved good control of blood sugar. Even though creatinine clearance decreased significantly (P = 0.001), control of blood urea nitrogen and serum creatinine was adequate. Hemoglobin and serum albumin levels increased significantly (P = 0.005 and 0.04, respectively). Similarly, there was a significant increase in serum triglycerides and alkaline phosphatase (P = 0.02 and 0.05). Blood pressure became normal without medications in all but one of the patients. Retinopathy, neuropathy, and osteodystrophy remained unchanged. Peritonitis developed once in every 20.6 patient-months--a rate similar to that observed in nondiabetics. The calculated survival rate was 93 per cent at one year; the calculated rate of continuation on ambulatory peritoneal dialysis was 87 per cent. We conclude that continuous ambulatory dialysis with intraperitoneal administration of insulin is a good alternative treatment for diabetics with end-stage renal disease.

Infections in patients undergoing peritoneal dialysis.

Considering experience acquired in the past years, it seems as though physicians have reached a plateau in the frequency of peritonitis. A peritonitis rate of 1 every 2 patient years may be acceptable. Further reduction of this peritonitis rate will require inordinately large efforts on all fronts. One will have to consider what are the acceptable costs and risks of peritonitis in patients on peritoneal dialysis. New developments in catheter technology, improved connections, better understanding of patient selection and training programs, improved diagnostic and therapeutic methods in the management of peritonitis, and understanding of the infectious and immune processes are eagerly awaited developments.

Update on continuous ambulatory peritoneal dialysis

SummaryBy now many patients have been successfully maintained on CAPD for five years or more, thus demonstrating that CAPD is a viable long-term treatment for end-stage renal disease. Peritonitis—the main concern of the earlier years—is now a less frightening complication. We know better how to treat peritonitis and its incidence has decreased from one episode every 8 months initially to one episode every 18 months now. In addition, several innovations, which have been or soon will be introduced, promise to decrease the frequency of peritonitis to an even lower rate. The problem of peritonitis is now being replaced by the chronic complications of CAPD, predominantly malnutrition and decrease in peritoneal ultrafiltration. CAPD has become an important adjunct in the treatment of children with ESRD, especially the very young. Even though not normal, their growth on CAPD is better than that of children on hemodialysis and as good as that after a successful transplant. CAPD has become a promising treatment for the diabetic with ESRD. This experience has stimulated interest and research in the role of intraperitoneal administration of insulin for blood glucose control. With the present worldwide experience of CAPD, this treatment has ceased to be experimental. A percentage of patients requiring dialysis will be better off on CAPD than on hemodialysis. Even though this percentage will vary among various countries, the nephrologist who wants to provide the best treatment for each patient must be well experienced in and have all treatments at his disposal including CAPD.