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.

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.

Ultrasound-guided femoral dialysis access placement: a single-center randomized trial.

BACKGROUND AND OBJECTIVES: Insertion of dialysis catheters (DCs) is a prerequisite for successful initiation of hemodialysis. We attempted to determine if ultrasonography-guided (USG) insertion was superior and safer than the anatomical landmark-guided technique (ALT) for the femoral vein (FV). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a randomized prospective study on 110 patients requiring FV DCs in a tertiary care hospital. Patients were randomized into two groups: USG and ALT. Data were collected on demography, operator experience, and side of insertion. The USG group had their catheters inserted under USG guidance, whereas the ALT group had their DC inserted by ALT. Outcome measures included successful insertion of DC, number of attempts, and complications. RESULTS: Both groups were comparable regarding age and gender of patients, operator experience, and the side of catheterization. The overall success rate was 89.1%, with 80% using ALT and 98.2% under USG guidance (P = 0.002). First attempt success rate was 54.5% in the ALT group as compared with 85.5% in the USG group (P = 0.000). The complication rate was 18.2% in the ALT group and 5.5% in the USG group (P = 0.039). The odds ratio (OR) for complications with two or more attempts was 10.73 with a relative risk (RR) of 3.2. The OR for successful insertion using USG was 13.5 (95% CI: 1.7 to 108.7). CONCLUSIONS: USG significantly improves success rate, reduces number of attempts, and decreases the incidence of complications related to FV DC insertion.

Chronic peritoneal dialysis in South Asia - challenges and future.

Chronic peritoneal dialysis (PD), especially continuous ambulatory PD (CAPD), is being increasingly utilized in South Asian countries (population of 1.4 billion). There are divergent geopolitical and socioeconomic factors that influence the growth and expansion of CAPD in this region. The majority of the countries in South Asia are lacking in government healthcare system for reimbursing renal replacement therapy. The largest utilization of chronic PD is in India, with nearly 6500 patients on this treatment by the end of 2006. A large majority of patients are doing 2 L exchanges 3 times per day, using glucose-based dialysis solution manufactured in India. Chronic PD is not being utilized in Myanmar, Bhutan, or Seychelles. Affirmative action by the manufacturing industry, medical professionals, government policy makers, and nongovernmental organizations for reducing the cost of chronic PD will enable the growth and utilization of this life-saving therapy.