More Than 17 Years of Peritoneal Dialysis : A Case Report
Mohamed Shariful Islam, Claude Briat, Claude Soutif, Fran~oise Bamouin, Joseph PoIlini
Very few patients have undergone long-term peritoneal dialysis (PD). We report a case of a female patient on PD since 26 May 1979. Suffering from malignant hypertension, she developed renal failure in Apri11979. The renal biopsy showed a severe vascular nephropathy. She was 5 O years old, her body weight (BW) was 45 kg, and her height was i. 49 m. She refused hemodialysis. A Tenckhoff catheter was installed, and i 2-hour intermittent PD (iPD), three times a week, was started in the dialysis cente1: Ten months latel; she began nightly home IPD. In March i 985 she started continuous ambulatory PD (CAPD); she was nearly an uric. During the following years, she developed renal osteodystrophy and suffered from repeated hyperparathyroidism requiring multiple surgical interventions, osteomalacia, pseudotumoral calcinosis, and, finally, adynamic bone disease. She is now 67.5 years old, her BW is 34 kg, and she is still using CAPD.
This patient has the same Tenckhoffcathete1: She never developed peritonitis or an exit-site or tunnel infection. She used acetate dialysis solutionfor nearly six years and then lactate solution. Presently her peritoneal permeability is of the high-average type; dialysis adequacy (weekly Kt/V: 2. i 5, weekly peritoneal clearance: 58 L/1. 73 m2) as well as nutritional parameters are satisfactory. She has moderate anemia without erythropoietin treatment. She maintains a good quality of life.
Although the patient lost 1 i kg in i 7 years, she has maintained good nutritional status. Dialysis adequacy could be achieved despite anuria for more than ii years. Small body size, absence ofinfection and catheter-related problems, healthy peritoneal membrane, good acceptance of the technique, and vigilance towards dietary habits may be the keysfor satisfactory long-term PD.
Key wordsIntermittent peritoneal dialysis, long-term survival
From:Service de Nephrologie-hemodialyse, Hopital Henri Duffaut, Avignon, France.
IntroductionVery few reports are available regarding long-term peritoneal dialysis (PD) (1-5). Still, PD is one of the oldest dialysis techniques used in experimental animals and in human beings. This technique has encountered many difficulties due to setbacks, such as high peritonitis rates and limitations regarding ultrafiltration and dialysis adequacy. Thus it has long been marginalized with respect to hemodialysis (HD).
During the previous decades, we saw improvements in PD connecting systems, which reduced the rates ofperitonitis to acceptable levels. PD clinicians are much keener to do minute clinical and nutritional assessment. Recent developments in PD offer several treatment options (6), allowing adequate dialysis with individualization of the treatment. Such home dialysis provides an improved quality of life, better socio-professional rehabilitation, better acceptance of the method, and dialysis efficacy at a low cost.
We report a case of a female patient undergoing PD for more than 17 years. We try to determine the keys to such successfullong-term PD.
Clinical historyThis patient, a 50-year-old female, had been suffering from malignant hypertension (MHT) since 1978. An intravenous pyelography showed small kidneys. The creatinine level was 105 ~mol/L, but no creatinine clearance was available. She was rehospitalized in April 1979 with rebound MHT with headache, epistaxis, hypertensive retinopathy, convulsion, left ventricular hypertrophy, and severe renal failure (serum creatinine 440 ~moUL). Due to an unexplained oscillating fever, glomerular inflammatory syndrome, and abnormal immunological parameters (increased immunoglobulin G, presence of circulating immune complex and antinuclear antibodies, and a low C3 complement level), a renal biopsy was done on 19 May 1979, showing severe vascular nephropathy. However, she received corticoid treatment for several years and showed some clinical improvement. MHT could be controlled without recovery of renal function.
Since she developed severe renal failure and refused to accept HD due to her religious beliefs (Jehovah's Witness), it was decided to put a two-cuff Tenckhoff PD catheter by surgical paramedian incision on 26 May 1979. First, she started IPD in the hospital center. Ten months later, she began home IPD and a few years later CAPD.
During more than 17 years of PD treatment, she developed repeated symptomatic hyperparathyroidism requiring multiple surgical interventions (Figure 1 ). A left inferior parathyroid adenoma and a multinodular hyperplasia of the right inferior parathyroid gland were removed in 1985 and 1989, respectively. In 1994, she again developed an adenoma of left inferior parathyroid gland (a fifth gland) which was also removed. In 1993, she was operated on for pseudotumoral calcinosis of the left hip muscle. She is now suffering from suspected adynamic bone disease with a low blood parathyroid hormone level (2 20 pg/mL). She had two bone biopsies: one in November 1980, showing severe osteocondensation with signs of severe osteomalacia and hyperparathyroidism, the other in 1991, showing improvement of the bone histology with normalization of resorption surface and disappearance of signs of osteocondensation and osteomalacia, but presence of osteoporosis. There is no evidence of amyloidosis or carpal tunnel syndrome.
She also suffered from gastroduodenal ulcers, ulcerative colitis, and chronic cholestasis due to gall bladder microlithiasis. She was immunized against hepatitis B virus of unknown origin (no blood transfusion) with absence ofHBs antigen and presence of anti-HBs and anti-HBc antibodies from the beginning ofPD, but absence of the hepatitis C virus antibody. She has no cardiovascular or neurological complications related to long-term dialysis.
Material and methodsThis female patient is the second PD patient of our center and has always been treated and followed up here. She has been neither hemodialyzed nor transplanted. She is now 67.5 years old. Her height is 1.49 m. In 1979 her BW was 45 kg, but since 1985 her BW has been stable, at about 34 kg. She performed 12-hour IPD (30 40 L) three times a week with a Physiocontrol "PDS" generator in the outpatient hospital clinic from May 1979 to March 1980 (Figure 1 ). Then she began 10-hour IPD three times a week at home with the same generator, which was replaced by a Drake Willock generator in May 1982.
Until 1985 she was doing IPD with acetate solution. She became oliguric and then anuric, and developed fluid retention, pericardial effusion, severe anemia, and malnutrition, suggesting inadequate dialysis. So in March 1985 it was decided to start CAPD with four l-L exchanges per day with 35 mmol/L lactate solution. During the following years the volume of dialysis bags had to be increased regularly (Figure 1) in order to meet adequacy requirements. She now performs five exchanges (9 L) per day: one 1.5-L hypertonic bag, three 2-L and one 1.5-L isotonic bags.
She used a straight connection from March 1985 to July 1986 and then an O-connection until February 1990. Afterwards, she started using the twin-bag system, which she continues today without any difficulty. She also tried cycler PD for few months, but abandoned this rapidly due to poor adaptation. Because ofher meticulous nature, it was often difficult to ask her to change her habits while treatment change was required. But once convinced, she followed medical prescriptions quite rigorously. She takes care ofher exit site twice a week and after her shower by herself. She applies povidone iodine and cleans the site with sterile water, followed by a sterile dry dressing.
To determine peritoneal permeability, we regularly use the accelerated peritoneal equilibration examination (APEX) time according to Verger (Pontoise, France) and recently began using the peritoneal equilibration test (PET) according to Twardowski (Columbia, USA). Blood chemistry and hematological parameters were measured using the standard laboratory techniques. Dialysate creatinine levels were measured by the enzymatic method. Serum albumin, prealbumin, and transferrin were measured by nephelometer (Behring second generation). The patient's dietary habits consist of several small meals during 24 hours.
ResultsThis patient has never had any catheter problems and is still using the same two-cuffTenckhoff catheter inserted on 26 May 1979. We have no report of tunnel or exit-site infection (ESI), except for a few inflammatory lesions without infection. She never developed peritonitis, except one doubtful turbid dialysate solution with sterile culture in 1987, from which she recovered without treatment. In the last seven years, ESI and overall peritonitis rates of our center were 0.73 and 0.45 episode per patient-year of exposure, respectively.
Since 1979, 13 patients have performed PD for more than 5 years in our center. Overall 5-year actuarial technique and patient survival rates are 18.5% and 26.2%, respectively, with data censored for death, recovered, transferred, and transplant patients.
Concerning permeability tests, APEX time done since 1992 showed normal peritoneal permeability (68 88 minutes). The PET showed her peritoneal permeability to be of the high-average type (DIP creatinine at hour 4 = 0.79, DIP urea = 0.75, and DIDo glucose = 0.32).
Dialysis adequacy has been achieved regularly by increasing the PD solution and then the number ofbags. Figure 2a shows the last two years of dialysis adequacy. Mean total serum protein and albumin levels show an overall satisfactory nutritional status except in 1984 and 1985 before starting CAPD (Figure 2b). Blood cholesterol levels remained relatively high without treatment. Latest nutritional parameters are as follows: body mass index = 15, total protein = 78 glL (N = 60 -81 ), serum albumin = 35.8 glL (N = 35 -52), prealbumin = 0.48 glL (N = 0.23 0.36), transferrin = 1.76 g/L (N = 1.85 3.45), total cholesterol = 7 mmollL (N = 3.6 6.5), normalized protein catabolic rate (Randerson) = 0.81, and protein intake = 1 glkglday. She has moderate anemia (hemoglobin level: 11.9 gldL and hematocrit: 38.3%) without erythropoietin treatment. Subjective global assessment suggests a well-nourished state.
We report very little general and physical health problems except occasional fatigue and bone pains. The last hospitalization for a health problem was in May 1995. In 17.5 years, the morbidity rate for different health problems including initial long hospitalization is 23 hospital days per year. She is divorced and has six children. She always dresses attractively, attends all the family occasions, and goes dancing. She also enjoys short vacations, for 10 -15 days, during which she carries her PD bags with her. She seems to be quite happy and maintains satisfactory social and mental health.
DiscussionLong-term CAPD treatment in end-stage renal failure is rare and still debatable (7). The 10-year survival rate in CAPD is comparable to HD in adult and elderly patients (4). Overall, the 5-year survival rate in adult CAPD patient varies in the literature from 34% to 67% (2,8,9); it is lower (26.2%) in our center. For an individual PD patient, maximum survival period, cited in the literature, is 17 years (5), which is comparable to our patient. But reports are available for a good number of patients who are performing 5 to 10 years ofPD (1,2,10).
Our 50-year-old patient falls in the age group (45 -64 years) where the CAPD dropout rate is high (4,9). She is now reaching the elderly age group (more than 75 years ), where better technique survival is observed (II). In addition, she showed no catheter-related mechanical (leak or bad drainage) or infectious (exit-site infection or peritonitis) problems that provide chances of improved technical survival (12). Although she used acetate dialysate solution for 6 years in IPD, she did not show evidence of sclerosing peritonitis as described in the literature (13). Her peritoneal permeability is good. A healthy peritoneum with a well-functioning catheter is of utmost importance for successfullong-term PD.
Limitations related to dialysis adequacy (6) could be overcome first by changing from IPD to CAPD and then progressively increasing dialysate volume from 4 to 7.5 L/day. Now, she accepts 5 bags/day with 9 L/day ofdialysate, which clearly demonstrates good patient compliance. Small body size requiring small dialysis dose may be an important determining factor.
Her morbidity rate (23 hospital days per year) is higher than that mentioned in the literature, 10 days for a nondiabetic patient (14). She has not been hospitalized since May 1995. She showed problems related to long-term dialysis, notably renal osteodystrophy and gastrointestinal problems, but there is no evidence of amyloidosis or carpal tunnel syndrome. She has moderate anemia without erythropoietin and no cardiovascular or neurological complications, suggesting optimal adequacy achievement.
Reasonable dietary habits helped her to overcome ultrafiltration limitations. Even if she lost II kg during her IPD period, she could maintain stable body weight with satisfactory nutritional status in CAPD for II years despite her anuric state.
Strong motivation and high adaptability helped this patient to be happy and maintain a satisfactory social life and nearly normal lifestyle.
ConclusionThis patient seems to be one of the longest continuous PD-practicing patients. She seems to lead an acceptable lifestyle despite increasing volume and number of bags. This could only happen due to her willingness to adapt to different situations of her disease state. Small body size, absence of infection and catheter-related problems, healthy peritoneal membrane, and seriousness of the dietary follow-up certainly helped her to achieve a long-term adequate dialysis with an improved quality of life.
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Mohamed Shariful Islam, Service de Nephrologiehemodialyse, Hopital Henri Duffaut, 305, Rue Raoul Follereau, 84902 Avignon cedex 9, France.