Perit Dial Int
29(Supplement_2):
74-77
2009
© 2009 International Society for Peritoneal Dialysis
Part 3: Clinical Experiences |
IMPROVING TECHNIQUE SURVIVAL IN PERITONEAL DIALYSIS: WHAT IS MODIFIABLE?
F. Fevzi Ersoy
Akdeniz University Medical School, Department of Medicine, Division of
Nephrology, Antalya, Turkey
Correspondence to: F.F. Ersoy, Akdeniz University Medical School, Department
of Medicine, Division of Nephrology, Dumlupinar Bulvari, Akdeniz University
Campus, 07070 Antalya, Turkey.
ersoy{at}akdeniz.edu.tr
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ABSTRACT
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The continuous quality improvement approach in peritoneal dialysis
practice necessitates definition of the factors and the procedures that may
possibly be contributing to the final success of peritoneal dialysis. The
philosophy of continuous quality improvement uses the Plan, Do, Check, Act
(PDCA) cycle. To improve the procedures used during peritoneal dialysis, the
first step is to create a plan, then to carry out the plan, to check it, and
after the collection of satisfactory information, to execute the chosen
improvement action.
Several studies have identified the most frequent causes of transfer
from PD to HD as infection, catheter problems, inadequate dialysis, and
psychosocial factors, among others. According to training guidelines from the
International Society for Peritoneal Dialysis, seven points are of major
importance to decrease infection risks: exit-site care, catheter placement,
antibiotic prophylaxis for procedures, prevention of bowel-source peritonitis,
prevention of fungal peritonitis, and connection methods. On the other hand,
other factors such as hypoalbuminemia, depression, and obesity should also be
taken into consideration for better technique survival in peritoneal dialysis
patients.
KEY WORDS: Technique survival; peritonitis.
In the 1950s, W. Edwards Deming proposed that, to improve any process, that
process should be placed in a continuous feedback loop so that the parts that
need improvement can be identified and changed. Deming used a circle to
illustrate this continuous improvement action, commonly known as the PDCA
cycle (for Plan, Do, Check, Act; Figure
1).
The Deming circle is the foundation of the modern concept of
improvement:
- Plan: To manage any improvement activity, the first requirement is
a definition of the components (procedures) and the targets of the operation.
In our case, the operation is peritoneal dialysis (PD). For instance,
exit-site care technique may be a good example of a procedure used during PD
treatment.
- Do: A new, well-defined exit-site care procedure needs to be
introduced into our operation. The nurses and patients or other caregivers
need to be trained and motivated for the new technique.
- Check: There has to be some assurance that the new exit-site care
technique is being carefully followed by the patients and the other trainees.
Gathering accurate and reliable data and other measurements during the
observation is vital. To "check" correctly, only objective,
carefully measured data can be used. In our case, during the observation
period for the new exitsite care technique, data may need to be collected
concerning exit-site infection rates, infecting organisms, the peritonitis
rate, patient compliance, and other factors that may affect the success of the
new procedure.
- Act: Using the information collected, changes to improve
performance must be identified and prioritized. In our exit-site care model,
if Pseudomonas infections rise, adding gentamicin ointment to the
daily care procedure may be a good example of an "act" that may be
expected to improve the technique.
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PROCEDURAL MANAGEMENT OF PD
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Using the continuous quality improvement approach to improve the success of
our operation—technique survival in PD—we first need to define the
factors and the procedures that may possibly be contributing to outcome in PD,
which in quality management terms are called "subprocesses." Only
by aiming for and successfully accomplishing an improvement in each of those
subprocesses can a total improvement in PD technique be reached and technique
survival increased for the patient (Figure
2). What are those factors?
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Figure 2 — Improvements in subprocesses make an overall improvement in
peritoneal dialysis (PD) technique possible.
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Kavanagh et al. conducted a study in 10 adult renal units serving
1205 chronic PD patients and tried to identify the factors affecting the
technique failure rate (1).
Table 1 shows factors that,
according to that study, affect technique failure in chronic PD.
What are the other factors that contribute to better technique
survival?
In 4 large cohorts involving more than 40 000 patients initiating PD in the
period 2000 to 2003, the trends in patient outcomes, technique success, and
their predictors were investigated
(2). The authors identified the
main causes for transfer from PD to hemodialysis (HD) as infection (28%),
catheter problems (17%), inadequate dialysis (18%), psychosocial factors
(15%), and other factors (22%). In the same study, younger nondiabetic
patients, patients in larger centers, and patients on automated PD were found
to have better outcomes than were seen in older diabetic patients, patients in
smaller centers, and patients receiving continuous ambulatory PD respectively.
Although age and diabetes status are not modifiable, center size and modality
choice seem to be important modifiable factors in the success of PD.
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PREVENTION OF INFECTION: WHAT CAN WE DO?
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All of the foregoing studies rank infection-related factors as important
contributors to the long-term success or failure of PD. Infections may affect
technique outcome in PD through peritonitis or exit-site infection. Prevention
of peritonitis and exit-site infections is therefore of major importance in
improving technique outcome in PD. The International Society for Peritoneal
Dialysis, in the Society's 2005 guidelines, addresses seven points of interest
in the prevention of peritonitis:
- Training
- Exit-site care
- Catheter placement
- Antibiotic prophylaxis for procedures
- Prevention of bowel-source peritonitis
- Prevention of fungal peritonitis
- Connection methods
In many studies, the contributing role of better patient training
procedures to the success of PD was evident. In centers with a higher
nurse:patient ratio, rates of peritonitis and of technique success in chronic
PD are better (1). In a 2-year
observational study, Hall et al. compared outcomes in two patient
groups. One group was trained in a new, industry-sponsored, professionally
prepared, theory-based curriculum (246 patients); another group was trained in
a previous institutional curriculum (374 patients). The group receiving the
professional curriculum was found to have significantly fewer exit-site
infections, lower peritonitis rates, and fewer hospital admissions
(3). Improvement of patient
training procedure is therefore an important factor in reducing infectious and
noninfectious complications of PD and seems to be of vital importance for the
whole process.
Of course, the availability of well-trained PD nurses in PD clinics is the
main component of patient training, and it may not always be easy to justify
assigning a full-time nurse to a PD program, especially if patient numbers are
small. In that case, it may be good to combine home PD and home HD under the
control of the same nurse, or the PD nurse may provide pre-dialysis patient
education and training, and collection of continuous quality improvement data
for both the PD and the HD program
(4).
The second point is exit-site care. An infected exit site is known to be an
important risk factor for peritonitis. In general, exit-site infections must
be treated aggressively. Antibiotics should be continued until the exit site
appears totally normal. If the infection is refractory or relapsing, the
catheter should be replaced before risking the use of PD in that particular
patient.
Methods for daily care of exit sites may vary from one center to another.
Since the late 1990s, the introduction of new concepts in exit-site care have
resulted in considerable improvement in PD technique survival. One of these
concepts is the recognition of nasal Staphylococcus aureus carriage
as an important risk factor for both exit-site infection and peritonitis
(5). Exit-site infections,
peritonitis episodes, and catheter loss are almost tripled in nasal carriers
of S. aureus as compared with non-carriers. Use of nasal mupirocin
and treatment of nasal carriage therefore improves infection rates and
catheter-related problems, improving technique success in PD
(6). In the Kavanagh study
mentioned earlier, centers using mupirocin in exit-site care were shown to
have significantly lower (18.3% vs 21.9%) S. aureus–related
peritonitis rates (1).
On the other hand, in recent years, in centers using regular mupirocin in
exit-site care, Pseudomonas-related exit-site infection and
peritonitis rates have remained unchanged, resulting in considerable
continuing losses in technique survival. Topical use of an antibiotic
effective against P. aeruginosa, namely gentamicin, seems to be
promising for decreasing Pseudomonas-related infectious complications
of PD and further improving technique success. In a study by Bernardini et
al., use of gentamicin was found to significantly increase time to a
first peritonitis episode
(7).
Another preventable risk for peritonitis is the exit-site infection and
early postoperative peritonitis episodes following the catheter placement
procedure. Use of prophylactic antibiotics before catheter placement was found
to be effective in reducing postoperative early peritonitis episodes. The use
of prophylactic antibiotics may therefore contribute to technique success in
PD (8).
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OTHER MODIFIABLE FACTORS CONTRIBUTING TO TECHNIQUE FAILURE
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Are there other modifiable risk factors?
One of the other identified risk factors for the development of peritonitis
is hypoalbuminemia. Initial serum albumin was found to be an independent risk
factor for development of peritonitis, at 0.74 for every 1 g/dL drop in serum
albumin (9). A low dietary
protein intake is also a risk factor for technique failure
(10). Better dietary
management of a PD patient may therefore be an important tool for reducing
technique failure.
In another study with a group of 162 patients screened for depression using
the Beck Depression Inventory at PD start and every 6 months thereafter,
depressive patients were found to experience significantly more peritonitis
episodes than did the patients with no evidence of depression
(11). A large Australia and
New Zealand Dialysis and Transplant Registry study of 10 709 chronic PD
patients showed that a higher body mass index was associated with a shorter
time to first peritonitis, independent of other risk factors
(12). Therefore, as a
preventable cause of technique failure, obesity seems to be an another
modifiable risk factor. In the Netherlands Cooperative Study on the Adequacy
of Dialysis, urine volume, peritoneal ultrafiltration, and systolic blood
pressure were also found to be independent predictors for technique failure
(10,13).
All of the foregoing factors can be considered at least partly modifiable, and
their management may contribute to technique success in PD.
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PREVENTION OF CATHETER RELATED PROBLEMS
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Data from more than 30000 chronic PD patients in the United States have
shown that catheter problems rank second, right after infectious
complications, as a cause of technique failure in PD
(14). What are the general
rules for avoiding catheter-related complications and optimizing catheter use
in PD?
A standard 2-cuff coiled Tenckhoff catheter is a practical, inexpensive,
and optimal choice. The most appropriate catheter dimension is the one that
produces a deep pelvic tip position. The exit site should be easily visible to
the patient, free of the belt line and of skin creases and folds. Downward and
lateral exit sites both function well. Exit-site location should be
individualized, depending on patient needs. In most women, and in some men,
the belt line is located above the level of the umbilicus; the exit site
should be located above the umbilicus. In obese individuals with floppy
abdominal skin folds, and in patients with stomas or incontinence or a desire
to take deep tub baths, the exit site should be in the upper abdomen or chest
(15).
Laparoscopic catheter implantation techniques such as the embedded catheter
technique, rectus sheet tunneling, and omentopexy may assure greater patient
acceptance, reduce the risks of leakage and catheter tip migration, and create
a possibility of diagnosing and repairing missed hernias
(15,16).
A contribution from the new dialysis solutions to the improvement of
technique survival (especially by preventing the long-term notorious effects
of glucose, lactate, glucose degradation products, and advanced glycation
end-products on the peritoneum and patient metabolism in general) may also be
expected. However, further clinical studies in that area are needed before a
final decision is made.
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REFERENCES
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ABSTRACT
PROCEDURAL MANAGEMENT OF PD
