Opinion: Peritoneal Dialysis In Pakistan: An Insider’s View. State of Affairs and Planning?

Pakistan has an estimated population of 212 million while the incidence of end stage renal disease in Pakistan is 100 patients per million; hence approximately 22,000 patients require maintenance dialysis to sustain life in our country. Remarkably peritoneal dialysis (PD) as a form of maintenance renal replacement is utilized in less than one per cent of these patients. In the absence of a formal dialysis registry, we place the total number of chronic ambulatory peritoneal dialysis patients (CAPD) in Pakistan at approximately 76 excluding holiday patients who are visiting from abroad (*This figure was estimated by enquiring the total number of patients each PD units care in Pakistan. This figure was corroborated with the sole distributor of CAPD fluids in Pakistan.).

P1227SURVIVAL OF PATIENTS TRANSFERRED FROM HEMODIALYSIS (HD) TO CHRONIC AMBULATORY PERITONEAL DIALYSIS (CAPD) DUE TO POOR ARTERIOVENOUS (AV) ACCESS

Background and Aims This study was carried out to ascertain the 6 month survival of patients who were transferred from hemodialysis to peritoneal dialysis due to poor vascular access at tertiary care facility in Pakistan. PD remains an under-utilized and unpopular modality of renal replacement therapy. One of the major reasons for its unpopularity remains poor patient selection. Furthermore PD is used as a last resort when AV access for HD becomes impossible in Pakistan. Method This study was carried out over a 4 year period. All patients transferred from hemodialysis onto peritoneal dialysis were included in the study. A total of 23 patients of Pakistani decent were switched to peritoneal dialysis from hemodialysis because of poor AV access. All patients included in the study had undergone venograms and consultation with vascular surgeons to confirm that AV access henceforth was inadequate for hemodialysis to continue. After placement of the peritoneal dialysis catheter a 2 week rest period was given to each patient before CAPD was initiated. The 6 month survival of each patient from the point of being transferred to CAPD was noted. Results The mean age of patients included in the study was 58 years. 80% of the participants were known to have diabetes mellitus. 15 out of the 23 patients included in the study died within 6 months of starting peritoneal dialysis. 12 out of the 23 patients included had difficulties in achieving either required ultrafiltration or KT/V despite ensuring correct catheter placement and following standard CAPD good practices. Conclusion Patients being switched from hemodialysis to CAPD due to poor AV access carry a greater than 50% 6 month mortality rate. In a country where PD struggles to gain popularity, we need to be very selective in starting patients on this modality with a realization that PD cannot be kept as a last resort rather should be advocated as the first choice therapy. Only then can the true benefits of PD be exhibited.

Monomicrobial non-neutrocytic bacterascites caused by aeromonas hydrophila in a patient with liver cirrhosis

Aeromonas peritonitis is a rare, but serious infection, as associated with spontaneous bacterial peritonitis, peritonitis in chronic ambulatory peritoneal dialysis, and intestinal perforation. Here, we reported a case of monomicrobial non-neutrocytic bacterascites caused by Aeromonas hydrophila (A. hydrophila). The patient, a 57-year-old man who had a history of alcoholic liver disease and chronic hepatitis C-related Child- Pugh class C liver cirrhosis, was admitted to our hospital with fever, dyspnea and a localized wound pain over left ankle. Ascitic fluid analysis demonstrated that ascitic polymorphonuclear cell count was 30 cells/ mm3. Empirical antimicrobial treatment with a combination of ceftriaxone and clindamycin were administered. However, the patient died due to fatal septic shock on Day 3. His blood and ascites cultures were positive for A. hydrophila. The case report presents the diagnosis, management, and literature review of Aeromonas monomicrobial non-neutrocytic bacterascites.

A case report of Neisseria mucosa peritonitis in a chronic ambulatory peritoneal dialysis patient

Peritonitis is a leading complication of chronic ambulatory peritoneal dialysis. However, very rarely does <em>Neisseria</em> <em>mucosa</em> cause peritonitis. We describe an unusual case of <em>N</em>. <em>mucosa</em> peritonitis in a chronic ambulatory peritoneal dialysis patient. A 28-year-old Hispanic male presents with diffuse abdominal pain exacerbated during draining of the peritoneal fluid. Peritoneal fluid examination was remarkable for leukocytosis and gramnegative diplococci. Bacterial cultures were positive for <em>N. mucosa</em> growth. The patient was treated with ciprofloxacin with preservation of the dialysis catheter. This case highlights the rarity and importance of <em>Neisseria</em> <em>mucosa</em> causing peritonitis in chronic ambulatory peritoneal dialysis patients’. There seems to be a unique association between <em>N. mucosa</em> peritonitis and chronic ambulatory peritoneal dialysis patients’. The patient was successfully managed with ciprofloxacin along with salvaging of the dialysis catheter.