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   Table of Contents - Current issue
January-June 2020
Volume 38 | Issue 1
Page Nos. 1-41

Online since Thursday, December 31, 2020

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History of peritoneal dialysis p. 1
Sabina Yusuf
>Peritoneal Dialysis is now an accepted mode of renal replacement therapy. The story of its development is a fascinating scientific journey of pioneers who have worked tirelessly to develop and extend the application of this technique which now plays such an important part in the treatment of patients with ESKD. This article reviews the milestones in the history of innovation of this life saving treatment in an attempt to understand to the hopes and ideas of our predecessors and build on them into the future to make peritoneal dialysis a more effective, safer, and inexpensive therapy for ESKD.
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Valacyclovir toxicity in peritoneal dialysis p. 6
P Ravi Kumar
Valacyclovir (Prodrug) an antiviral agent is not well cleared by peritoneal dialysis and can cause neuropsychiatric manifestations in patient with renal failure on peritoneal dialysis and having Herpes Zoster infection being treated with this drug. Methodology followed for the collection of data and literature review was by using a medline search using the terms Acyclovir, nervous system effects, Valacyclovir, neurotoxicity and peritoneal dialysis. The representative case discussed is about an elderly gentleman with chronic renal failure on CCPD presenting with hallucinations, altered sensorium and restlessness following treatment with Valacyclovir 1000 mg three times per oral daily who was admitted and evaluated. It is of vital importance to consider the differential diagnosis of Herpes zoster encephalitis in the differential diagnosis of these patients as it is difficult to rule it out. The mechanism of this drug induced neurotoxicity is thought to be probably, the accumulation of serum carboxymethoxymethyl guanidine (CMMG), a toxic metabolite of valacyclovir.As peritoneal dialysis is not very effective in removal of this drug, it is thought to be beneficial to change to Hemodialysis for short duration so as to clear the drug from the system as shown in the case and in the discussion. Safe doses in peritoneal dialysis are not clearly delineated. Extreme precaution must be exercised while prescribing these group of anti-viral drugs in patients with CKD and especially those on peritoneal dialysis. If such a patient does manifest neuropsychiatric symptoms it is necessary to immediately stop the drug concerned. Methods to increase the excretion of the drug must be employed immediately or to remove it by intensification of PD or ideally to aggressively remove it by means of hemodialysis. Moreover there is a paucity of similar reports in the literature.
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Peritoneal dialysis – ideal renal replacement therapy during coronavirus (COVID-19) pandemic p. 11
Jeethu Joseph Eapen
Peritoneal dialysis has an important role to play in the ongoing coronavirus pandemic. It can help in maintaining social distancing goals in dialysis patients and hence should be considered as first line renal replacement therapy (RRT) in all incident ESRD patients. There is emerging interest in the role of PD for the treatment of Acute Kidney Injury especially in the setting of overburdened hemodialysis/CRRT services in the ICU. This article discusses the role of PD in managing critically ill COVID patients.
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Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme p. 13
Mayoor V Prabhu, KN Sanman, Ranjit Shetty, GG Laxman Prabhu, BH Santhosh Pai
Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. Coagulase-Negative Staphylococcus (CoNS) was the most common pathogen isolated , accounting for 60% of the episodes. Technique survival was 15% and patient survival was 20% at 5 years. Cardiovascular disease, sepsis, and malignancy accounted for majority of the deaths. Conclusions: Patients with background of extreme poverty had peritonitis rates comparable to good centres, however patient survival at 5 years was lower. Educational or economic considerations did not seem to be an impediment to successful CAPD.
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Randomized controlled trial to compare the tolerability and efficacy of treatment with Icodextrin 7.5% versus Dextrose 2.5% in chronic peritoneal dialysis patients with high/high average solute transport characteristics and low residual renal function p. 16
Vivek Sood, Rahul Grover, Vivek Kumar, Shravan Kumar Singh, Krishan Lal Gupta
Aim: Comparison of tolerability and efficacy of treatment with icodextrin vs. dextrose 2.5% amongst high risk cohort of chronic peritoneal dialysis patients (high/high average solute transport characteristics and low residual renal function) over 3 months. Study Design and Methodology: The study was an open-label, comparative, prospective, randomized controlled trial, conducted at department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. A total of 349 end stage renal disease patients on chronic peritoneal dialysis were screened for eligibility over a period of 6 months and 41 patients with high / high average solute transport characteristics and low residual renal function were randomized to receive either icodextrin 7.5% solution or 2.5% dextrose solution in long dwell. Patients were assessed for adequacy of peritoneal dialysis (creatinine & urea clearance), peritoneal membrane transport characteristics including solute clearance (standard peritoneal equilibration test), body composition, total body water, fat mass and fat free mass (using whole body tetrapolar bioimpedance analyzer) at baseline and at the end of 3 months. Statistical Analysis: Continuous variables were compared with independent samples paired t test if normally distributed, or with Mann–Whitney U test if the distribution was skewed. Categorical variables were analyzed with Chi-square test or Fisher exact test as appropriate. Pearson's correlation coefficient was calculated between different quantitative variables. Paired t test and Wilcoxon signed-rank test were used for within-group comparisons. Repeated measure ANOVA was used to compare bioelectrical impedance between intervention groups. Results: The study has shown that use of icodextrin based continuous ambulatory peritoneal dialysis resulted in better ultrafiltration and improved solute clearance when compared to 2.5% dextrose based peritoneal dialysis in a select cohort of patients having high/high average transporter characteristics with poor residual renal function, however, it didn't significantly alter total body water and failed to translate into improvements in either patient's or physician's assessment of global health of response to therapy atleast at 3 months. Conclusions: Although use of icodextrin based peritoneal dialysis solution for long dwell resulted in significant improvement in solute clearance and ultrafiltration nevertheless failed to translate into better hydration status or subjective improvement scores atleast at 3 months.
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Life threatening hyperkalemia necessitating temporary cardiac pacing and dialysis in elderly patients p. 25
Ajaz A Lone, Tariq A Bhat, Khalid P Sofi, Imtiyaz A Wani, Muzafar M Wani, Mohd Ashraf Bhat
Background Many elderly hypertensive patients are on cardio/reno protective medications (ACEIs, ARBs, β blockers & K sparing diuretics), which may precipitate or worsen hyperkalemia in them. Given its potential life threatening nature, identifying such patients is imperative. Rarely emergency temporary cardiac pacing may be required to thwart cardiac arrest while K is being lowered by extracorporeal removal. In many resource-constrained settings HD to lower K quickly is not always available. Materials and Methods We describe the profile of 26 patients over a three year period who besides medications & dialysis needed temporary cardiac pacing because of severe hyperkalemia. Results: The mean age of these 26 patients (17 males, 9 females) was 64+/-11 years. 12 (46%) had diabetes mellitus. On admission, the mean serum K was 6.7 ± 1.4 mmol/L, mean serum creatinine was 2.8 ± 1.6 mg/dL, mean arterial pH was 7.1 ± 0.5 and the mean plasma bicarbonate was 12 ± 4 mmol/L. The main causes for acute kidney injury (AKI) and hyperkalemia were dehydration (n = 14) and worsening heart failure (n = 7) with concomitant use of ACEIs, ARBs, β blockers, K sparing diuretics either alone or in combination. 22 patients received PD, two HD, while two received both. Six patients were admitted to the ICU, two of whom died. The duration of hospitalization ranged from 1-12 with a mean of 7 days. The patients in the drug induced hyperkalemia group who required pacing were elderly, had been on a combination of K elevating medications, were more likely to have DM and had a longer hospital stay compared to those who had hyperkalemia but did not require cardiac pacing. Conclusion: A combination of ACEIs, ARBs, β blockers & K sparing diuretics should be used with caution in patients who are elderly, have renal insufficiency, DM or heart failure or are at risk for dehydration. In places with limited availability of emergency HD, PD is an effective alternative for lowering serum K.
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Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis p. 30
SankaraKumar GaneshAravind, Anusha Rohit, N Gopalakrishnan, J Dhanapriya, T Dineshkumar, R Sakthirajan, N Malathy, T Balasubramaniyan, AT Maasila
Peritonitis is an important cause for morbidity and mortality in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. There is an emerging trend towards unusual organism causing CAPD peritonitis. We report our experience with unusual organisms and its impact on survival. We had 43 CAPD peritonitis episodes, out of which, six were due to unusual organisms. Although five patients responded to antibiotic therapy, one lost her CAPD access (catheter). Clinically, peritonitis caused by unusual organism is similar to that caused by other pathogens. Adherence to diligent hygienic practices while handling catheter and bag is most important in avoiding such peritonitis episodes.
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An unusual complication of CAPD technique: Lesson to be learnt p. 34
Muzamil Ahmed, Manjusha Yadla
Continuous Ambulatory Peritoneal Dialysis is a recommended mode of renal replacement therapy in those with vascular access failures. Complications of Surgical placement of catheter and Percutaneous technique by Nephrologist are well described. Complications may occur during the procedure or after the procedure. During the placement of the catheter, hollow viscus perforation is known to occur. Patients are given instructions of using laxative , emptying bladder before surgery in order to avoid bladder or bowel injury. Bladder perforation is one of the rare complication of CAPD technique.It is expected to occur commonly with rigid catheters than the soft catheters used in CAPD. Herein we report a case of bladder perforation during the procedure of placement of percutaneous CAPD catheterization.
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A rare case of early Burkholderia cepacia peritonitis in a chronic ambulatory peritoneal dialysis patient p. 36
Sambit Sahoo, Arvind Achra, B Muthukumar, Shiwangi Sharma
Continuous ambulatory peritoneal dialysis (CAPD) is one of the preferred forms of renal replacement therapy. However, peritonitis is the leading cause of morbidity and mortality associated with CAPD. Here, we report a case of Burkholderia cepacia peritonitis which required combination of antibiotics and catheter removal for its treatment.
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Literature Review p. 39

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