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Clinical |
Institute of Nephrology,1 First Hospital, Peking University, Beijing, China; Divisions of Nephrology,2 The Scarborough Hospital, Toronto, Canada
Correspondence to: T. Wang, Institute of Nephrology, Peking University, 8, Xishiku St., West District, Beijing 100034 China.wangt{at}bjmu.edu.cn
Background: Volume overload is common in diabetic
patients on continuous ambulatory peritoneal dialysis (PD), especially when
the patient's residual renal function decreases with time on PD. Due to the
higher dietary salt and fluid intake, diabetic PD patients tend to use more
hypertonic glucose solution to remove excess fluid, which in turn may lead to
increased membrane permeability. In the present study, we investigated the
effect of negotiated care on fluid status in diabetic PD patients. Methods: All diabetic PD patients who had been on PD
for at least 3 months by the end of year 2002 in the First Hospital of Peking
University were included in the present study. A primary nurse was assigned to
each patient and intensive patient education was implemented, focusing on the
importance of dietary salt and fluid restriction, the detrimental effect of
using more hypertonic glucose solution, and the consequence of fluid overload.
Decisions on dialysis prescriptions were made after extensive discussion among
the primary nurse, nephrologists, patients, and patients' families. A patient
support group was also involved when it was necessary. All the patients were
followed for 1 year and fluid status, compliance to dietary restriction, and
dialysis prescription were evaluated before the start and at the end of the
study. Results: There were 30 diabetic PD patients (age 65.4
± 10.3 years; on PD for 24.5 ± 19.9 months, range 3 – 66
months) included in the study when it was started. During the 1 year of
follow-up, 4 patients died of diabetic complications, 3 patients were
transferred to hemodialysis due to resistant peritonitis, and 2 patients were
transplanted. By the end of follow-up, 21 patients remained on PD, among whom
15 had improved fluid status, 4 did not change, and 2 had worsened fluid
status as assessed by clinical and bioimpedance evaluation. Patient compliance
to dietary salt and fluid restriction had increased from 19.5% to 76.2%.
During the follow-up, 8 patients were anuric at the beginning of the study and
the remaining 22 patients had declining residual renal function. Only 4
patients increased their use of hypertonic solution including 2.5% (3
patients) and 4.25% (1 patient) glucose, whereas 5 patients decreased their
use of 2.5% dialysis solution. By the end of follow-up, only 1 of the 21
patients was using 4.25% glucose solution and all the patients had good blood
glucose control. Conclusions: Our results suggest that negotiated care
can be successfully used in diabetic PD patients. It helps to minimize the use
of hypertonic glucose solution and improves patient compliance to dietary
restriction of salt and fluid intake, and thus improves their fluid
status.
KEY WORDS: Volume control; negotiated care; compliance; nursing.
Received 3 January 2005; accepted 27 May 2005.
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