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A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Medicine in Paediatrics (MMed) Johannesburg, 2017 / Children with end-stage renal disease are commonly placed onto chronic peritoneal dialysis (PD) while awaiting transplant. Mechanical, infectious and metabolic complications of PD may lead to technique failure, morbidity or mortality. This study aims to describe the complications and associated risk factors in children on chronic PD. It consists of a retrospective record review of patients less than 18 years old enrolled on the chronic PD program between 1 January 2009 and 31 December 2013. Seventy one percent of the patients had one or more complications while on PD. The most common complication was peritonitis (54%) followed by catheter obstruction in 29%. Patients on automated peritoneal dialysis (APD) were significantly less likely to develop peritonitis than those on continuous ambulatory PD (OR 23.14, 95% CI 2.45 – 218.0, p = 0.002). We therefore recommend that PD patients be preferentially placed on APD. / MT2017

Dissertation in fufillment of the degree of MSc(Med), Faculty of Health Sciences, University of the Witwatersrand / Introduction: Measurement of small solute clearance is the objective means of quantifying dose of peritoneal dialysis (PD) and various organisations have issued guidelines on target values. Assessment of PD adequacy involves other factors such as blood pressure control, anaemia management, mineral metabolism, nutritional status and ultrafiltration. Membrane transport characteristic is important for PD prescription on an individual patient basis and is related to patient outcome. In this study the adequacy of PD, using small solute clearance measurement as well as other factors, and membrane characteristics have been assessed and classification of patients using our own reference values is reported for the first time. Nutritional status has been studied and the use of simple tools such as the subjective global assessment has been validated for use in our patients. Materials and Methods: A cross sectional study involving 80 adult continuous ambulatory peritoneal dialysis (CAPD) patients. Peritoneal equilibration test (PET) was performed to assess the membrane characteristics; 24 hour dialysate fluid and urine samples were collected and used for the measurement of solute clearance, while nutritional status was assessed using the subjective global assessment (SGA) instrument, anthropometric measurements and serum albumin estimation. Results: The mean age was 38 ± 12.43 years, 42.3% were females and 86% were blacks. Mean duration on CAPD was 19.8 ± 20.67 months. The mean of 4 hour D/P creatinine was 0.74 ± 0.13 and based on this, 18% were high transporters, 33.8% high average, 36.9% low average and 12% low transporters. Mean kt/v urea was 1.72± 0.32, and the recommended level of 1.7 was achieved by 62.8% of the patients. Mean haemoglobin was 10.99 ± 2.14 g/dl and the recommended target value of 11-12g/dl was reached by 55.8% of the patients. The mean BMI vi was 24.76 ± 3.50, mean Mid Upper Arm Circumference (MUAC) was 28.53±3.89 cm and mean serum albumin was 37.10 ± 7.6 g/l. Based on SGA scores, 42% of our patients were well nourished, 50% moderately undernourished while 8% were severely malnourished. We noted significant correlations between SGA score and BMI and MUAC while there was none with serum albumin level. The mean serum calcium and phosphate levels were within normal though the mean PTH level was higher. Conclusion: The D/P creatinine at 4 hours was higher than those reported in the literature, though the distribution of the transport types was similar. The recommended targets of kt/v and haemoglobin were achieved by the majority of our patients. Mineral metabolism parameters were within normal range. Malnutrition is common and SGA is a reliable method for nutritional assessment in our patients.

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Cardiovascular disease is responsible for at least half of all deaths in end-stage renal disease patients on maintenance dialysis and is attributed to the very high prevalence of left ventricular hypertrophy and dysfunction, cardiac failure, coronary artery disease and other atherosclerotic complications. Apart from traditional risk factors such as smoking, hypertension, diabetes and dyslipidemia, these patients are at risk of accelerated atherosclerosis and other cardiovascular complications as a result of non-traditional risk factors such as inflammation, anemia, increased oxidative stress, hyperparathyroidism and excessive calcium phosphorus load. In recent years, there is an increasing recognition of calcification complications in patients on dialysis. However, the importance and prognostic value of calcification in patients on peritoneal dialysis is not known. Residual renal function has a significant contribution to the overall survival in patients on peritoneal dialysis but whether it is in any way related to cardiovascular death and complications in patients on peritoneal dialysis is not known. Inflammation is highly prevalent in dialysis patients and is considered to play a pathogenic role in cardiovascular disease. In this thesis, we evaluated some of these relatively novel factors that may predispose peritoneal dialysis patients to an increased risk of cardiovascular complications and mortality, including calcification, loss of residual renal function and inflammation. A number of important conclusions were drawn from these studies. First, valvular calcification is a marker of atherosclerosis and shows important associations with malnutrition and inflammation and is an important predictor of mortality and cardiovascular deaths in peritoneal dialysis patients. Second, inflammation, as denoted by either C-reactive protein or vascular cell adhesion molecule-1 shows an important association with residual renal function and cardiac hypertrophy and is associated with mortality and cardiovascular risk in peritoneal dialysis patients. Third, loss of residual renal function is an important cardiovascular risk and combines adversely with C-reactive protein and cardiac hypertrophy to increase cardiovascular mortality in peritoneal dialysis patients. Fourth, resting hypermetabolism and the malnutrition, inflammation and atherosclerosis syndrome are associated phenomena that parallel the decline of residual renal function and predict an increased mortality and cardiovascular death in peritoneal dialysis patients.

<p>Fatigue is a common and debilitating symptom for adult patients with end-stage renal disease on hemodialysis and has been associated with decreased survival and quality of life. Patients on hemodialysis must find ways to manage their fatigue and mitigate its effects on their lives. Currently, there is no description of the experience of fatigue for American hemodialysis patients, nor is there any description of the ways in which they manage their fatigue. The purpose of this qualitative descriptive work was to describe the experience and self-management of fatigue as well as how fatigue changes over time from one dialysis session to the next. Several themes were identified which included: the nature of fatigue, cycles of fatigue, management of fatigue, consequences of fatigue, and correlates of fatigue. Further, hemodialysis patients experience two types of fatigue, post-dialysis fatigue, fatigue that occurs acutely after the dialysis session and resolves after sleep or rest, and constant fatigue, a persistent, underlying fatigue that patients experience at all times and worsens after the dialysis session usually requiring a prolonged period of recovery.</p> / Dissertation

Background: End Stage Renal Disease (ESRD) is one of the commonest diseases in Hong Kong. Patient with ESRD needs to start dialysis for life maintenance. Peritoneal dialysis (PD) is the predominant dialysis modality for home dialysis patients. More than 80% of dialysis patients in Hong Kong receive PD. However, it also brings out some PD-related infectious complication such as tenckhoff exit-site infection, tenckhoff tunnel infection and PD peritonitis. These complications markedly contribute to treatment failure in PD patients. Especially PD peritonitis, it remains a leading complication of PD. Also it is a main cause of patients switch to haemodialysis (HD)and discontinue PD. Nevertheless, if the primary prevention of PD education do better, research evidences have shown that peritonitis infection rate of PD patients can be effectively reduced. It can be achieve by the utilization of effective education strategies and advanced training skills to enhance patients’ knowledge and skills of peritoneal dialysis. Purpose: This written proposal aims to identify the best evidence of PD education and to develop a guideline for this health education programme. The goal of the programme is to reduce the rate of PD-related infection for patients who started PD treatment at home after first CAPD training and education. Method: A total of 12 studies which focused on PD education and strategies for reducing PD-related infections were searched from electronic databases. Data extraction and critical appraisal were performed on these 12 studies. After the integrative review, the implementation potential was assessed. The results shown that the transferability of finding is high and it is feasible to conduct the proposed innovation. Then, the evidence-based guideline for PD education programme were developed and based on the high and medium level of evidence with grades of recommendation stated. Before implementing the proposed innovation, a communication plan was developed and targeted the various stakeholders (the administrators, nurses, patients and their relatives). The proposer would initiate the change and the programme leading group would guide and sustain the proposed innovation. The next process was planning a pilot study to examine the feasibility of the proposed innovation before implementation. Finally, different outcomes of the programme has been identified and evaluated in the evaluation plan. The methods for data analysis were formulated. Conclusion: The proposed peritoneal dialysis education programme with best evidences support is worthy to be adopted in the clinical setting for the beneficial of PD patients to reduce their PD-related infectious complications. / published_or_final_version / Nursing Studies / Master / Master of Nursing

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