Application of new innovations/technology for care of end-stage renal disease in a resource-limited environment.

The costs involved in the management of end-stage renal disease (ESRD) patients are overwhelming the healthcare commitments of countries worldwide and even more so in resource-limited settings. Some countries have intelligently managed to implement universal healthcare coverage for their citizens. Many others, unable to achieve this, have sensibly concentrated on spending their limited resources on less expensive but more important healthcare issues, such as preventive care especially in the areas of waterborne diseases and implementation of universal vaccination. This however leaves a large section of the population with ESRD vulnerable, and it is up to the various stakeholders, including the medical professions, to innovate and partly alleviate their suffering as a social responsibility.

Emergent Start Peritoneal Dialysis for End-Stage Renal Disease: Outcomes and Advantages.

BACKGROUND/AIMS: Initiating renal replacement therapy in late referred patients with central venous catheter (CVC) hemodialysis (HD) causes serious complications. In urgent start peritoneal dialysis, initiating peritoneal dialysis (PD) within 14 days of catheter insertion still needs HD with CVC. We initiated Emergent start PD (ESPD) with Automated PD (APD) at our center within 48 h from the time of presentation. METHODS: A prospective, case-controlled, intention-to-treat study with 56 patients was conducted between March 2016 and August 2017. Group A (24 patients) underwent conventional PD 14 days after catheter insertion. Group B (32 patients), underwent ESPD with APD. Exit site leak (ESL), catheter blockage, and peritonitis at 90 days were primary outcomes. Technique survival was secondary outcome. RESULTS: Baseline characteristics were similar with 3 episodes of ESLs (9.4%) in the study group and none in the control group (p = 0.123). Catheter blockage (16.7%-Group A, 25%-Group B) and peritonitis (none vs. 9.4% in study group) were similar in terms of statistical details just as technique survival (95%-Group A, 88.2%-Group B at 90 days). CONCLUSION: ESPD with APD in the unplanned patient is an appropriate approach.

Remote monitoring of peritoneal dialysis in special locations.

Peritoneal dialysis (PD) as a therapy with all its advantages has not grown as would have been expected except in certain pockets, notably in Asia. In our opinion, from patient and their family interviews, a perception among prospective PD patients of inaccessibility to the referral PD Unit (RPU), usually for patients from rural areas in far flung places, inaccessible due to difficult terrain or long distances, play a strong role against the choice of PD as their modality choice for end-stage renal disease. We decided to address this issue by adopting novel initiatives such as easy access to the RPU through usage of internet and mobile phones from the patient homes especially in addressing the more clinically relevant infectious complications such as peritonitis and exit site infections with immediate treatment management responses from the RPU. In addition, we found that inherently the rural PD patients had several advantages over their urban counterparts and also over their hemodialysis (HD) counterparts in many socioeconomic, emotional support and nutritional parameters. We enhanced these advantages with an intensive home visit program. This two pronged approach has paid dividends in that our rural PD patients do as well, if not better than the urban PD and the HD patients, contrary to prevailing international experience.

Prophylaxis against fungal peritonitis in CAPD--a single center experience with low-dose fluconazole.

BACKGROUND/AIMS: Fungal peritonitis (FP) significantly alters the outcome of patients on peritoneal dialysis (PD). Exposure to antibiotics is a risk factor for subsequent FP. Antifungal prophylaxis has been tried, with varying success, to prevent the occurrence of antibiotic-related fungal peritonitis (AR-FP). We aimed to evaluate the effect of prophylaxis with a low dose of fluconazole, in preventing AR-FP. METHODS: In this retrospective review, we examined the incidence of FP in a cohort of 115 patients, who had received antibiotics for bacterial peritonitis and received a co-prescription of fluconazole, 50 mg/day for the duration of antibiotic therapy. The incidence of bacterial peritonitis and FP for up to 3 months after antibiotic therapy was noted. RESULTS: One hundred and fifteen patients were followed up over a 6-year period, for 2549 patient-months. We observed 82 episodes of bacterial peritonitis and a total of 137 antibiotic prescriptions. The peritonitis rate was 1 episode per 31.08 patient-months (1 per 2.58 patient-year, 0.38 episodes every patient-year). We had six episodes of FP. There were no episodes of AR-FP. CONCLUSION: We observed very low rates of both bacterial peritonitis and FP, and prophylaxis with low-dose fluconazole seemed to confer protection against AR-FP. We did not encounter any adverse effects with its use.