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15 February 1994 | Volume 120 Issue 4 | Pages 264-271
Objective: To assess the clinical efficacy and morbidity of continuous cyclic peritoneal dialysis compared with continuous ambulatory peritoneal dialysis with a Y-connector as renal replacement therapy.
Design: Prospective, randomized study.
Setting: University hospital.
Patients: All new patients with end-stage renal failure consecutively entering the dialysis program from January 1988 through July 1991 were randomly assigned to receive continuous ambulatory peritoneal dialysis with a Y-connector or continuous cyclic peritoneal dialysis and were followed prospectively.
Measurements: Patient and technique survival, dialysis adequacy, and (infectious) morbidity.
Results: Forty-one patients (median age, 56 years; range, 18 to 86 years) started continuous ambulatory peritoneal dialysis with a Y-connector (follow-up, 688 patient-months), and 41 patients (median age, 54 years; range 21 to 76 years) started continuous cyclic peritoneal dialysis (follow-up, 723 patient-months). The two groups showed no significant differences in adequacy of dialysis (as assessed by blood pressure control and laboratory and neurologic variables) and patient or technique survival. Renal transplant was the primary reason for discontinuing the assigned dialysis technique in both groups. The average number of hospitalizations per patient-year was 1.0 using continuous ambulatory peritoneal dialysis with a Y-connector and 0.6 per patient-year using continuous cyclic peritoneal dialysis (P = 0.02), with a mean duration of 10.8 and 9.6 days per admission, respectively (not significant). Peritonitis occurred significantly less often in those receiving continuous cyclic peritoneal dialysis (0.94 compared with 0.51 episodes per patient-year; P = 0.03). No difference in causative pathogens was observed. Exit site infection rate was 0.38 episodes per patient-year in both groups.
Conclusion: In an unselected patient group, continuous cyclic peritoneal dialysis was accompanied by significantly lower rates of peritonitis and dialysis-related hospital admission, whereas it was as effective as continuous ambulatory peritoneal dialysis with a Y-connector for patient and technique survival.
Because no prospective study has compared continuous ambulatory peritoneal dialysis with a Y-connector and continuous cyclic peritoneal dialysis, we began such a study in 1988. Our goals were to determine the treatment outcomes of new patients with end-stage renal failure randomly assigned to receive continuous ambulatory peritoneal dialysis with a Y-connector or continuous cyclic peritoneal dialysis.
All new patients with end-stage renal failure entering the dialysis program of the Free University Hospital from January 1988 until August 1991 were directed to peritoneal dialysis. Patients were randomly assigned to receive either continuous ambulatory peritoneal dialysis with a Y-connector or continuous cyclic peritoneal dialysis after stratification for age and sex. After the patients were given information about the treatment methods, the goals of the study, and the need for randomization, a physician who was not involved in dialysis patient care and who was objective about the treatment methods being studied assigned the patients to the two treatment plans. Absolute contraindications to peritoneal dialysis (such as previous serious abdominal inflammation with adhesions and ostomies including colostomies, ileostomies, and nephrostomies) were the only criteria for exclusion.
Standardized training for home peritoneal dialysis (on an outpatient basis) usually began within 2 weeks after insertion of the peritoneal catheter. Comorbid factors at the start of dialysis were registered using a predetermined list. To determine outcome in relation to treatment, we followed patients prospectively for these end points: blood pressure, body weight, ultrafiltration (calculated daily from the difference between inflow and outflow volumes), routine laboratory assessments, neurologic variables (nerve conduction velocities, which were measured every 6 months), Karnofsky score (a measure of patients' performance status, using a scale from 0 [death] to 100 [normal, no complaints, no evidence of disease]), complications, and hospital admissions. We calculated peritoneal and residual renal clearances of urea and creatinine every 6 months by measuring these solutes in the 24-hour dialysate and urine, respectively; as well as simultaneous serum concentrations. In addition, we estimated KT/V (urea) by dividing peritoneal urea clearance (KT) by the distribution volume of urea (Vurea), as previously described [23]. We considered urea volume of distribution and total body water synonymous and calculated them from body surface area [24]. The minimum target weekly KT/Vurea measurement was 2.1. We modified the dialysis prescription to achieve the desired KT/V by changing either the fill volume per cycle or the number of exchanges, depending on the individual peritoneal permeability characteristics.
We defined exit site infection as pericatheter erythema, discharge, tenderness, or any combination of these symptoms. We based diagnosis of peritonitis on the presence of two of the following findings: abdominal signs or symptoms; a dialysate leukocyte count
The Ethical and Research Committee of the Free University Hospital approved the study and all patients gave informed consent.
Data Analysis
Data are expressed as mean ±SD. We compared biochemical results for the two groups using the Wilcoxon rank-sum test. To compare changes over time between the two groups, we used analysis of variance for repeated measures. However, because the size of the study sample decreased with time as a result of patient dropout, we based the means ±SD as observed at the start of follow-up and at 6, 12, 18, and 24 months on different subsets of patients. Therefore, we replaced observed means ±SD by so-called predicted means and standard deviations according to the method of Little and Rubin [25]. To compare duration of antibiotic therapy and hospitalization, we computed an average duration for each patient separately and compared these averages for the groups using the Wilcoxon rank-sum test.
We estimated patient and technique survival curves and time to first and time to second peritonitis curves using the Kaplan-Meier method [26]. We used the generalized Wilcoxon test to compare curves of the two groups [27]. To compare average rates of peritonitis, hospital admission, and catheter removal, we computed the respective rate for each patient separately. We compared these rates for the two groups using a weighted t-test and durations of follow-up as weights [28]. All null hypotheses were tested for two sides at the 0.05 significance level.
From January 1988 until 1 August 1991, 98 previously untreated patients with end-stage renal failure entered our dialysis program, and 97 were randomly assigned to two dialysis programs. One patient refused to participate because he spent winters in an area with frequent interruptions in electric service. Thus, no new patients had absolute contraindications for peritoneal dialysis. Fifty patients were allocated to receive continuous ambulatory peritoneal dialysis with a Y-connector and 47, to receive continuous cyclic peritoneal dialysis.
Before starting dialysis, seven patients who were to receive continuous ambulatory peritoneal dialysis with a Y-connector dropped out because of death (n = 3), renal transplant (n = 1), hydrothorax (n = 1), and, despite informed consent, a preference for hemodialysis (n = 2). Six patients who were to receive continuous cyclic peritoneal dialysis dropped out because of death (n = 3), renal transplant (n = 2), and inadequate housing (n = 1). Two patients receiving continuous ambulatory peritoneal dialysis with a Y-connector regained sufficient residual renal function after randomization and did not depend on dialysis before 1 August 1992.
Thus, we scheduled 41 patients to receive continuous ambulatory peritoneal dialysis with a Y-connector and 41 patients to receive continuous cyclic peritoneal dialysis. Patient characteristics, including cause of end-stage renal failure, are listed in Table 1. Comorbid factors present at the start of therapy (cerebrovascular or cardiovascular disease, diabetes, dyslipidemia, chronic respiratory disorders, multisystem disease, and malignancy) were distributed equally among the two groups. All patients receiving continuous ambulatory peritoneal dialysis used the Y set without disinfectant and performed three to five daily 2-L exchanges. Patients receiving continuous cyclic peritoneal dialysis were trained to use an automated cycler (PAC-X, Baxter, Deerfield, Illinois) that provided four or five nocturnal cycles and one diurnal cycle (2-L fill volume per cycle). The median duration of training was 8 days for continuous ambulatory peritoneal dialysis with a Y-connector (range, 3 to 15 days) and 9 days for continuous cyclic peritoneal dialysis (range, 3 to 26 days) (P > 0.1). ARTICLE
Clinical Efficacy and Morbidity Associated with Continuous Cyclic Compared with Continuous Ambulatory Peritoneal Dialysis
Peritoneal dialysis has been used to treat chronic renal failure since 1962 [1], but it was not until the introduction of continuous ambulatory peritoneal dialysis by Popovich and associates [2] in 1976 that peritoneal dialysis was recognized as an important treatment for end-stage renal failure. However, since the inception of continuous ambulatory peritoneal dialysis as a renal replacement therapy, peritonitis has been its most frequent and limiting complication. Peritonitis may strike these patients repeatedly. It leads to considerable morbidity, and may require a change to hemodialysis therapy [3-5]. Continuous cyclic peritoneal dialysis was developed as an alternative to continuous ambulatory peritoneal dialysis for patients who were incapable of or unwilling to perform manual dialysate exchanges [6]. Whereas in continuous ambulatory peritoneal dialysis fluid is instilled manually (by gravity) into the peritoneal cavity through a permanent catheter and drained after a dwelling period of several hours, continuous cyclic peritoneal dialysis incorporates a cycler that automatically provides short nocturnal dialysate exchanges and a long diurnal exchange that is cycler-free. Investigators who did an uncontrolled study claimed that continuous cyclic peritoneal dialysis was superior to continuous ambulatory peritoneal dialysis [7]. Since its introduction in 1981, substantially lower infection rates have been reported with continuous cyclic peritoneal dialysis than with continuous ambulatory peritoneal dialysis [7-12]. However, lower infection rates have not been found universally [13-16]. Moreover, continuous cyclic peritoneal dialysis has only been used with a small number of selected patients. Further, these early reports compared continuous cyclic peritoneal dialysis with conventional continuous ambulatory peritoneal dialysis, whereas the recent introduction of various Y-set ambulatory dialysis systems has resulted in a universal reduction in peritonitis rates [17-22]. If continuous cyclic peritoneal dialysis is at least as effective as continuous ambulatory peritoneal dialysis and if it can decrease the dropout rate from peritoneal dialysis to hemodialysis, then continuous cyclic peritoneal dialysis may offer a treatment option that does not increase overall costs because continuous cyclic peritoneal dialysis, although more costly than continuous ambulatory peritoneal dialysis, is less expensive than hemodialysis.
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108/L, 50% or more granulocytes in the differentiation, or both; and presence of microorganisms using Gram stain or dialysate cultures. We defined relapse as a recurrence of cloudy effluent within 15 days after antibiotic treatment and culture of the same organism or no growth. We considered definite change in mode of dialysis as transfer to another method of dialysis for more than 1 month; this included renal transplant. We defined hospital admission as inpatient care for any reason once patients had begun dialysis at home. All data were collected every 6 to 8 weeks from the time of catheter insertion. Follow-up was discontinued on 1 August 1992 or earlier in cases of definitive change of treatment (including transplant), death, or recovery of renal function. No patients were transferred to other renal units.
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Survival of Patients and Techniques
Overall follow-up was 688 patient-months in the patients using continuous ambulatory peritoneal dialysis with a Y-connector and 723 patient-months in those using continuous cyclic peritoneal dialysis. On 1 August 1992, 11 patients were still using continuous ambulatory peritoneal dialysis with a Y-connector and 16 patients were still using continuous cyclic peritoneal dialysis (Table 2). The primary reason for dropout was renal transplant. Among the patients using continuous cyclic peritoneal dialysis, four patients died (three of preexisting cardiovascular problems and one of rapid progressive scleroderma), whereas two patients using continuous ambulatory peritoneal dialysis with a Y-connector died of cardiovascular complications. One patient using continuous ambulatory peritoneal dialysis with a Y-connector regained renal function (creatinine clearance, 20 mL/min). Of the 41 patients using continuous ambulatory peritoneal dialysis with a Y-connector, 14 changed methods of dialysis and 8 patients using continuous cyclic peritoneal dialysis switched to another method. The reasons for definitive change were fecal peritonitis (4 using continuous ambulatory peritoneal dialysis with a Y-connector and 2 using continuous cyclic peritoneal dialysis; all switched to hemodialysis); relapsing peritonitis (2 using continuous ambulatory peritoneal dialysis with a Y-connector; both switched to hemodialysis); cerebrovascular accident (2 using continuous ambulatory peritoneal dialysis with a Y-connector and 3 using continuous cyclic peritoneal dialysis; 4 switched to continuous ambulatory dialysis in a nursing home, and 1 using continuous cyclic peritoneal dialysis switched to continuous ambulatory peritoneal dialysis UVX-Flash); poor ultrafiltration (3 using continuous ambulatory peritoneal dialysis with a Y-connector switched to continuous cyclic peritoneal dialysis); major abdominothoracic surgery (1 using continuous cyclic peritoneal dialysis switched to hemodialysis); pleuroperitoneal communication (1 using continuous cyclic peritoneal dialysis switched to hemodialysis); and psychosocial (2 using continuous ambulatory peritoneal dialysis with a Y-connector switched to hemodialysis, and 1 using continuous cyclic peritoneal dialysis switched to continuous ambulatory peritoneal dialysis).
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When we considered patients who received a transplant and those who recovered renal function as being lost to follow-up, the median time to therapy failure was 26 months in the patients using continuous ambulatory peritoneal dialysis; it exceeded 30 months in the patients using continuous cyclic peritoneal dialysis (P = 0.83). The difference between the two therapy survival curves was not statistically significant (P = 0.14).
Adequacy of Dialysis
As shown in Table 3 and Figure 1, no significant differences were observed between the patients using continuous ambulatory peritoneal dialysis with a Y-connector and those using continuous cyclic peritoneal dialysis with regard to the adequacy of the method of dialysis. Antihypertensive medication was used by 60.9% of the patients receiving continuous ambulatory peritoneal dialysis with a Y-connector and by 73.5% of those receiving continuous cyclic peritoneal dialysis when treatment began. In 44% (continuous ambulatory peritoneal dialysis with a Y-connector) and 56% (continuous cyclic peritoneal dialysis) of the patients, this medication could be diminished or stopped. We observed no difference in the number of patients requiring erythropoietin or in the amount of phosphate binders prescribed for the two groups. The average Karnofsky score increased significantly in the first 6 months in both groups and subsequently remained at the same level (Table 3).
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Clinical Complications
Of the patients using continuous ambulatory peritoneal dialysis with a Y-connector, 14 (34%) were never admitted to the hospital during the study; of the patients using continuous cyclic peritoneal dialysis, 21 (51%) were never admitted. Overall, there were 1.0 and 0.6 hospital admissions per patient-year of therapy when comparing the continuous ambulatory peritoneal dialysis with a Y-connector and the continuous cyclic peritoneal dialysis groups, respectively (P = 0.02). The average hospital stay was 10.8 days for patients using continuous ambulatory peritoneal dialysis with a Y-connector and 9.9 days for patients using continuous cyclic peritoneal dialysis (P > 0.1). Dialysis-related problems accounted for 0.6 and 0.2 admissions per patient-year (P = 0.006) for patients using continuous ambulatory peritoneal dialysis with a Y-connector and for those using continuous cyclic peritoneal dialysis, respectively. More admissions were required for peritonitis in the patients using continuous ambulatory peritoneal dialysis with a Y-connector than in those using continuous cyclic peritoneal dialysis (0.3 compared with 0.1 admissions per patient year, respectively; P = 0.14). Non-dialysis-related causes of hospitalization (either medical, surgical, or social) were comparable at 0.4 admissions per patient-year in both groups.
Infectious Complications
The overall rate of peritonitis was 0.94 compared with 0.51 episodes per patient-year for patients using continuous ambulatory peritoneal dialysis with a Y-connector and those using continuous cyclic peritoneal dialysis, respectively. Thus, the observed difference in average rate of peritonitis was 0.43 episodes per patient-year (95% CI, 0.1 to 0.8; P = 0.03). In the patients using continuous ambulatory peritoneal dialysis with a Y-connector, 54 episodes of peritonitis were recorded in 25 patients, whereas 31 episodes were recorded in 19 patients using continuous cyclic peritoneal dialysis. Thus, 39% of the patients using continuous ambulatory peritoneal dialysis with a Y-connector and 53.7% of those using continuous cyclic peritoneal dialysis remained free of peritonitis. One, two, and three or more infectious episodes occurred in 31.7%, 4.9%, and 24.4% of patients using continuous ambulatory peritoneal dialysis with a Y-connector compared with 26.8%, 9.8%, and 9.8% of patients using continuous cyclic peritoneal dialysis. Kaplan-Meier estimates of the probability of remaining free of peritonitis showed a median time to a first episode of 11 months (continuous ambulatory peritoneal dialysis with a Y-connector) compared with 18 months (continuous cyclic peritoneal dialysis) (P = 0.06; see Figure 2. The median time to a second episode of peritonitis was 6 months [continuous ambulatory peritoneal dialysis with a Y-connector] compared with 25 months (continuous cyclic peritoneal dialysis) (P = 0.18). Patients with diabetes and those without had similar risks for developing peritonitis, but the number of patients with diabetes was small.
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The spectrum of microorganisms causing peritonitis was comparable in both patient groups. Gram-positive organisms were the most common agents (Table 4). All episodes of peritonitis were treated initially with intraperitoneally administered gentamicin and rifampin; the regimen was subsequently modified according to culture and sensitivity results. The mean ±SD duration of antibiotic therapy per patient was 11.8 ±2.6 days in episodes related to continuous ambulatory dialysis and 10.7 ±2.1 days in those related to continuous cyclic peritoneal dialysis (P > 0.1). Peritonitis was cured in 87% of episodes related to continuous ambulatory peritoneal dialysis with a Y-connector and in 83.7% of those related to continuous cyclic peritoneal dialysis (P > 0.1); a relapse occurred in 5.6% and 6.4% of cases, respectively. In four episodes (in patients using continuous ambulatory peritoneal dialysis with a Y-connector) and three episodes (in patients using continuous cyclic peritoneal dialysis) of peritonitis (six of intestinal origin and one due to Staphylococcus aureus), the catheter had to be removed for cure. In two patients using continuous ambulatory peritoneal dialysis with a Y-connector, catheter removal followed episodes of relapsing peritonitis, one due to S. epidermidis and one to diphtheroids. Exit site infections occurred in 11 patients using continuous ambulatory peritoneal dialysis with a Y-connector (22 episodes) and in 12 patients using continuous cyclic peritoneal dialysis (23 episodes), with a mean incidence of 0.38 infections per patient-year in both groups. No catheter had to be removed because of exit site infection; however, in three cases with tunnel-track infection (two using continuous ambulatory peritoneal dialysis with a Y-connector and one using continuous cyclic peritoneal dialysis), extensive intravenous antibiotic therapy was required for cure. Staphylococcus aureus was the most common cause of exit site infections: It caused 81.8% of the episodes in patients using continuous ambulatory peritoneal dialysis with a Y-connector and 95.7% of the episodes in patients using continuous cyclic peritoneal dialysis.
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Other Complications
Catheter-related complications occurred at a rate of 0.32 (in patients using continuous ambulatory peritoneal dialysis with a Y-connector) compared with 0.19 (for patients using continuous cyclic peritoneal dialysis) per patient-year (P > 0.1). In the patients using continuous ambulatory peritoneal dialysis with a Y-connector, 11 catheters were removed for the following reasons: fecal peritonitis (n = 4), relapsing peritonitis (n = 2), leakage (n = 1), inflow-outflow obstruction (n = 3), and dislocation (n = 1). In the patients using continuous cyclic peritoneal dialysis, seven catheters were removed, three because of fecal peritonitis, two because of inflow-outflow obstruction, and two because of dislocation. Infections led to 0.1 (continuous ambulatory peritoneal dialysis with a Y-connector) and 0.05 (continuous cyclic peritoneal dialysis) catheter replacements per patient-year (P = 0.26), whereas noninfectious causes resulted in a comparable number of new catheter insertions per patient-year (0.12 and 0.07, respectively).
Other peritoneal dialysis-related complications encountered were umbilical and inguinal hernias, which occurred in three patients using continuous ambulatory peritoneal dialysis with a Y-connector and in three using continuous cyclic peritoneal dialysis. These complications also necessitated temporary method changes in all six patients. We observed hydrothorax in one patient after the first continuous ambulatory peritoneal dialysis exchange (dropout before start of the study) and in one patient after 4 months of continuous cyclic peritoneal dialysis; both were switched to hemodialysis.
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The advantages anticipated using continuous cyclic peritoneal dialysis were a reduction in the incidence of peritonitis, brought about by a reduction in the number of manual connections required, and improved patient convenience [6]. Despite the fact that this method did not assume such large proportions as continuous ambulatory peritoneal dialysis, it continued to evolve; in 1985, researchers claimed that it was even better than continuous ambulatory peritoneal dialysis [7]. However, because both methods had not been previously compared in a controlled setting, a prospective study of the clinical and biochemical effects and complications of the two forms of treatment was warranted.
Our study showed that biochemical profiles, hematologic parameters, control of hypertension, and maintenance of adequate hydration with continuous cyclic peritoneal dialysis were similar to those achieved with continuous ambulatory peritoneal dialysis with a Y-connector, which corroborates previous findings from uncontrolled studies [6-9, 12, 15]. Dialysis adequacy in continuous cyclic peritoneal dialysis, as assessed by weekly creatinine and urea clearance measurements, paralleled that of continuous ambulatory peritoneal dialysis with a Y-connector, although an additional compensatory exchange was required in continuous cyclic peritoneal dialysis, because cycles lasting less than 4 hours reduce the efficiency of small solute clearances.
Hospital admission for peritoneal dialysis-related causes occurred significantly more often in the patients using continuous ambulatory peritoneal dialysis with a Y-connector; generally, this difference could be ascribed to infectious complications. Hospital admission for other causes (medical, surgical, or social) was equally distributed among the groups. The hospital admission rate in the patients using continuous ambulatory peritoneal dialysis with a Y-connector was comparable to that reported in the literature [21, 30]. No significant difference was observed in patient and technique survival for the patients using continuous cyclic peritoneal dialysis and those using continuous ambulatory peritoneal dialysis with a Y-connector.
A significantly lower incidence of peritonitis was observed in patients receiving continuous cyclic peritoneal dialysis compared with those receiving continuous ambulatory peritoneal dialysis with a Y-connector. The study is unique because the patient group studied was unselected and included all new dialysis patients treated at a single center. Therefore, factors inherent in the applied dialysis techniques remain the most probable explanation for the observed difference in the incidence of peritonitis for patients using continuous ambulatory peritoneal dialysis with a Y-connector and those using continuous cyclic peritoneal dialysis. The "flush before fill" technique (that is, the initial event after each connection is dialysate outflow, and the inflow line is also flushed before dialysate inflow), which has been shown to be efficient in preventing peritonitis [31, 32], is inherent to both continuous cyclic peritoneal dialysis and continuous ambulatory peritoneal dialysis with a Y-connector. However, continuous cyclic peritoneal dialysis requires fewer (dis)connections and is always done at home, allowing hygienic control of the environment [7, 12]. In addition, a long diurnal cycle of continuous cyclic peritoneal dialysis precedes each daily contamination-prone (dis)connection procedure, which takes place at a time when the patient's resistance to peritonitis is highest [12, 33].
Whereas the incidence of peritonitis in our patients using continuous cyclic peritoneal dialysis was comparable to that reported in literature [12, 18], a relatively high incidence of peritonitis was seen in the patients using continuous ambulatory peritoneal dialysis with a Y-connector, especially when compared with that reported by Italian investigators [17, 34, 35]. This difference may be due, in part, to the fact that we used the Y set without disinfectant [21] and did not advise patients to spike dialysis bags in advance [36]. However, differences in patient selection, definitions, and policies regarding transfer to another dialysis method may also have a significant effect on the varying results reported. Nevertheless, our results in the patients using continuous ambulatory peritoneal dialysis with a Y-connector closely match those of patients in a neighboring renal unit, which recently reported an incidence of peritonitis of one episode per year using the Twinbag Y system (Baxter, Deerfield, Illinois) [37], and those of a larger study done in the same time span [22].
Another infectious complication that might result in discontinuation of peritoneal dialysis is exit site infection. Although a difference was reported in the exit site infection rate between patients using continuous ambulatory peritoneal dialysis with a Y-connector and those using continuous cyclic peritoneal dialysis [38], we did not observe one. This may not be surprising because both are disconnection techniques, and immobilizers were used to diminish trauma after catheter manipulation. Our exit site infection rate compares favorably with that reported elsewhere [16, 21, 38, 39]. Staphylococcus aureus was the most prevalent pathogen associated with this complication, which also correlates with data reported by others [38, 39]. The incidence of relapsing peritonitis was low, leaving fecal peritonitis as the primary reason for catheter removal.
Other peritoneal dialysis-related complications, abdominal hernias (7.3%) and hydrothorax (2.4%), occurred as frequently in the patients using continuous cyclic peritoneal dialysis as in those using continuous ambulatory peritoneal dialysis with a Y-connector; further, they occurred in percentages comparable to those reported in the literature [7, 40, 41].
Use of continuous ambulatory peritoneal dialysis increased rapidly during the past years; approximately 13% of the world dialysis population used this method in early 1990, and the other 87% used hemodialysis [5]. Continuous cyclic peritoneal dialysis is more expensive than continuous ambulatory peritoneal dialysis with a Y-connector: Yearly costs per patient, excluding training, laboratory tests, drugs, and hospital costs, were $17 764 for continuous ambulatory peritoneal dialysis with a Y-connector and $23 934 for continuous cyclic peritoneal dialysis; the difference is primarily due to costs to lease ($4605) the continuous cyclic peritoneal dialysis cycler. The extra costs for the larger amount of dialysis fluid used per 24 hours in continuous cyclic peritoneal dialysis were offset almost completely by using large-volume containers in this setting. However, the costs of continuous cyclic peritoneal dialysis are lower than those of hemodialysis. During our study, all new patients were scheduled to receive peritoneal dialysis. The outcome for these patients was comparable to that of the selected patient groups reported in the literature [16, 21, 22], and the dropout rate to hemodialysis was only 20% (8 of 41 patients) in the group using continuous ambulatory peritoneal dialysis with a Y-connector and 12% (5 of 41 patients) in the group using continuous cyclic peritoneal dialysis. The lower rates of peritonitis and hospital admission in the patients using continuous cyclic peritoneal dialysis are important economic considerations. During our study, the mean cost of a patient-year of continuous ambulatory peritoneal dialysis, including hospital stay and peritonitis treatment, was $25 065, compared with $27 428 for continuous cyclic peritoneal dialysis. Further, offering continuous cyclic peritoneal dialysis as a treatment option potentially increases the number of patients to be managed by peritoneal dialysis and, therefore, would not increase overall dialysis costs.
Continuous cyclic peritoneal dialysis was at least as effective as continuous ambulatory peritoneal dialysis with a Y-connector and was accompanied by significantly lower rates of peritonitis- and dialysis-related hospital admission. The relative merits of both treatment methods must be weighed for individual patients. Continuous cyclic peritoneal dialysis is an important alternative to hemodialysis and continuous ambulatory peritoneal dialysis.
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1. Boen ST, Mulinari AS, Dillard DH, Scribner BH. Periodic peritoneal dialysis in the management of chronic uremia. ASAIO Trans. 1962; 8:256-62.
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33. de Fijter CW, Verbrugh HA, Oe PL, Peters ED, van der Meulen J, Donker AJ, et al. Peritoneal defense in continuous ambulatory versus continuous cyclic peritoneal dialysis. Kidney Int. 1992; 42:947-50.
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