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Table of Contents
Year : 2020  |  Volume : 38  |  Issue : 1  |  Page : 13-15

Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme

1 Department of Nephrology, Kasturba Medical College, Mangalore; Manipal Academy of Higher Education, Manipal, India
2 Manipal Academy of Higher Education, Manipal; Department of Urology, Kasturba Medical College, Mangalore, India
3 Department of Nephrology, Yenepoya Medical College, (Yenepoya Deemed to be University), Mangalore, India

Date of Submission14-Apr-2020
Date of Decision16-May-2020
Date of Acceptance23-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. B H Santhosh Pai
Department of Nephrology, Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IOPD.IOPD_3_20

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Introduction Limitations in finance and education is thought to translate into poor technique , understanding and thereby into higher incidence of peritonitis and ultimately poor patient and technique survival. This notion sometimes leads to such patients being denied Continuous Ambulatory Peritoneal Dialysis (CAPD). Methods: In 2013, 20 patients were initiated on CAPD under a Public Private Partnership (PPP) model project in Karnataka province, India. By regulation, they were required to belong to Below Poverty Line (BPL ) category which is a measure of extreme poverty. BPL is the equivalent of earning less than a dollar per day. They were followed up for peritonitis, technique and patient survival besides overall performance. Results: 20 patients were included ( Male: 60%, Mean age 56.7 years, Diabetic Nephropathy 48%). Peritonitis rate was 1 in 33.8 patient –months, with 3 episodes of Fungal Peritonitis (FP) including one of Candida Hemolunii. All FP led to termination of CAPD. Coagulase-Negative Staphylococcus (CoNS) was the most common pathogen isolated , accounting for 60% of the episodes. Technique survival was 15% and patient survival was 20% at 5 years. Cardiovascular disease, sepsis, and malignancy accounted for majority of the deaths. Conclusions: Patients with background of extreme poverty had peritonitis rates comparable to good centres, however patient survival at 5 years was lower. Educational or economic considerations did not seem to be an impediment to successful CAPD.

Keywords: Continuous ambulatory peritoneal dialysis, peritonitis, poverty, public private partnership model, RRT, social deprivation

How to cite this article:
Prabhu MV, Sanman K N, Shetty R, Laxman Prabhu G G, Santhosh Pai B H. Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme. Indian J Perit Dial 2020;38:13-5

How to cite this URL:
Prabhu MV, Sanman K N, Shetty R, Laxman Prabhu G G, Santhosh Pai B H. Peritonitis profile in a cohort of extreme poverty patients on continuous ambulatory peritoneal dialysis-5 year experience from a South Indian public private partnership model PD programme. Indian J Perit Dial [serial online] 2020 [cited 2023 May 29];38:13-5. Available from: http://www.ijpd.org.in/text.asp?2020/38/1/13/305752

  Introduction Top

CKD is a burgeoning health problem in India which impacts the financial and overall well being of numerous patients. It also places a heavy strain on public and private health facilities and stretches already limited healthcare budgets. In India, varying estimates assume a prevalence of CKD in the range of 152 per million population.[1] With a largely rural based population and also hindered by poverty, illiteracy and poor infrastructure, access to high end renal healthcare is also limited. In fact, it is estimated that 90% of Indian patients who require dialysis do not get access to it.[2],[3] Among those who do manage initiation of dialysis, a further 60% of the patients end up discontinuing it within 3-6 months for mostly financial considerations.[4]

Competing priorities of preventive programmes and other healthcare programmes, staff salaries and other expenses further limit funding to renal care. India spends a low percentage (<2%) of its GDP on healthcare. The figures for both HD and CAPD suggest that the cash strapped Govt sector will always struggle to prioritise every healthcare dollar when allocating resources to a RRT programme. Hence partnership with the private sector seems the only viable way to make RRT available and affordable for the lowest income bracket of the populations. With these considerations in mind, the Govt of Karnataka South India (population of 64 million with a per capita GDP of $ 1400) embarked on a PPP model project to evaluate CAPD as a modality of RRT for its ESRD population, based on Thailand's much acclaimed PD first policy.[5] This project was unique in that it only included patients of low socioeconomic status (extreme poverty), defined as belonging to BPL/APL category , with an average income of less than $1 per day. This was an extremely challenging programme, as it presented unique obstacles to surmount like illiteracy, doubtful skills and compliance, and adherence to the hygienic techniques required to protect from peritonitis. Peritonitis remains the Achilles Heel of any PD programme. Achieving low peritonitis rates is one of the critical parts of long term success. Though decreasing in number over the past many years around the world due to better technique, it remains a major cause of technique failure and even possibly death.[6],[7],[8] We evaluated data from this select cohort of patients with extreme poverty, for peritonitis episodes, peritonitis rates, culture patterns, technique and patient survival at 5 years from initiation. This would provide some insight into whether extreme poverty was a factor for overall poor performance on CAPD.

  Methods Top

Baseline demographic details of the initiated patients were recorded on admission and documented. Clinical characteristics were noted .From case records, episodes of peritonitis were noted, collated, and peritonitis rates were calculated in patient- months. Details of peritonitis like-time taken for developing the current peritonitis, catheter implantation technique , pre- and post-catheter exit site care protocol, break-in period etc., were noted where available. Culture reports were traced to document causative organisms and culture positivity rates. Laboratory data (cell count and differential count of dialysate effluent, Gram-stain, culture and sensitivity of dialysate effluent, complete blood count and serum albumin) was recorded where available. Treatment given was retrieved from case records. Episodes of bacterial and fungal peritonitis were noted. Technique and patient survival was calculated.

  Results Top

Baseline demographic details of the patients is described in [Table 1].
Table 1: Demographic details

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A vast majority of the initiated patients were male and diabetes was the main cause of ESRD in these patients. [Table 2] lists the details of socio economic status, PD initiation, peritonitis rates and other details
Table 2: Patient socioeconomic characteristics, peritonitis rates and patient/technique survival

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Details of peritonitis episodes and isolates is given in [Table 3].
Table 3: Peritonitis profile with predominant isolates

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There were 3 episodes of FP including one with Candida Hemolunii. All patients received therapy with anti fungal drugs and catheter removal. All 3 patients were unable to resume PD. As standard practice each episode of bacterial peritonitis was followed by antifungal prophylaxis with Fluconazole.

  Discussion Top

At 5 years, despite a disadvantaged patient sample, we were able to achieve respectable PD peritonitis rates, comparable to other larger centres in our country.[9],[10],[11] The peritonitis rate in the major centers in India is one episode in 22-26 patient-months.[12] Meticulous attention to training and technique, and aggressive home visit protocols were central to this particular result. Peritonitis pattern was also mostly in line with major centres of India, with predominantly Gram positive infections.[13],[14],[15] Gram negative infections were comparatively lower, and rates of culture negative peritonitis were very low. In gram-negative peritonitis episodes, the proportion of catheter loss and hospitalization were similar to gram-positive episodes. Most episodes of peritonitis required hospitalisation, as it was difficult to manage predominantly rural patients at their hometowns in the absence of facilities for culture and sensitivity there, and the unreliability of prompt initiation of antibiotics. Patients were aggressively trained to recognise signs of peritonitis early and to communicate such a development to the PD Centre at the earliest. Such training was positively reinforced at home visits. Antibiotic therapy followed the ISPD guidelines and was mostly intraperitoneally administered. No particular organism correlated with more severe manifestations/mortality. Fungal peritonitis usually constitutes 2-15% of the episodes and it is a serious complication of PD with mortality ranging between 25-53%.[16] We had a very low rate of FP , but all 3 patients lost the catheter and had to be moved to HD. We followed standard practice of antifungal prophylaxis following every episode of bacterial peritonitis.[17] We did not observe any incidence of mycobacterial peritonitis. Technique survival three years and longer on maintenance PD is considered rare in South Asian regions.[18] Our technique survival was mostly on similar lines. Main cause of mortality was cardiovascular disease. Diabetic Nephropathy was the main cause of ESRD in our cohort. In our study, the survival was inferior and mortality was higher in diabetics compared to non-diabetics, however the small sample size precludes any firm conclusions from the same. Indeed, DM has not been considered a contraindication to successful PD. Overall, we conclude that poverty, lower socio economic and educational status should not be considered a hindrance to successful PD- meticulous attention to patient selection, training, home visit and follow up protocols can ensure a reasonable performance on CAPD.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Modi GK, Jha V. The incidence of end-stage renal disease in India: A population-based study. Kidney Int 2006;70:2131-3.  Back to cited text no. 1
Agarwal SK, Srivastava RK. Chronic kidney disease in India: Challenges and solutions. Nephron Clin Pract 2009;111:c197-203.  Back to cited text no. 2
Kher V. End-stage renal disease in developing countries. Kidney Int 2002;62:350-62.  Back to cited text no. 3
Jeloka TK, Upase S, Chitikeshi S. Monthly cost of three exchanges a day peritoneal dialysis is same as of thrice a week hemodialysis in self-paying Indian patients. Indian J Nephrol 2012;22:39-41.  Back to cited text no. 4
[PUBMED]  [Full text]  
Prabhu MV, Shetty R, Devi R, Raju N, Prabhu GG, Sanman KN,et al. Public-private partnership in RRT: Single centre experience from Karnataka State CAPD Pilot Project. Indian J Peritoneal Dialysis 2015;29:17-21.  Back to cited text no. 5
Krishnan M, Thodis E, Ikonomopoulos D, Vidgen E, Chu M, Bargman JM, et al. Predictors of outcome following bacterial peritonitis in peritoneal dialysis. Perit Dial Int 2002;22:573-81.  Back to cited text no. 6
Barretti P, Bastos KA, Dominguez J, Caramori JC. Peritonitis in Latin America. Perit Dial Int 2007;27:332-9.  Back to cited text no. 7
Stinghen AE, Barretti P, Pecoits-Filho R. Factors contributing to the differences in peritonitis rates between centers and regions. Perit Dial Int 2007;27 Suppl 2:S281-5.  Back to cited text no. 8
Vikrant S. Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single center from north India. Perit Dial Int 2014;34:426-33.  Back to cited text no. 9
Prasad N, Gupta A, Sinha A, Singh A, Sharma RK, Kumar A, et al. A comparison of outcomes between diabetic and nondiabetic CAPD patients in India. Perit Dial Int 2008;28:468-76.  Back to cited text no. 10
Abraham G, Kumar V, Nayak KS, Ravichandran R, Srinivasan G, Krishnamurthy M, et al. Predictors of long-term survival on peritoneal dialysis in South India: A multicenter study. Perit Dial Int 2010;30:29-34.  Back to cited text no. 11
Abraham G. Asian PD Perspective. An Update on PD in the Indian Subcontinent. ISPD Asian Chapter Newsletter 2004;p.2. Available from: http://www.ispd.org.  Back to cited text no. 12
von Graevenitz A, Amsterdam D. Microbiological aspects of peritonitis associated with continuous ambulatory peritoneal dialysis. Clin Microbiol Rev 1992;5:36-48.  Back to cited text no. 13
Troidle L, Finkelstein F. Treatment and outcome of CPD-associated peritonitis. Ann Clin Microbiol Antimicrob 2006;5:6.  Back to cited text no. 14
Keithi-Reddy SR, Gupta KL, Jha V, Sud K, Singh SK, Kohli HS, et al. Spectrum and sensitivity pattern of gram-negative organisms causing CAPD peritonitis in India. Perit Dial Int 2007;27:205-7.  Back to cited text no. 15
Prasad KN, Prasad N, Gupta A, Sharma RK, Verma AK, Ayyagari A. Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: A single centre Indian experience. J Infect 2004;48:96-101.  Back to cited text no. 16
Prabhu MV, Subhramanyam SV, Gandhe S, Antony SK, Nayak KS. Prophylaxis against fungal peritonitis in CAPD-a single center experience with low-dose fluconazole. Ren Fail 2010;32:802-5.  Back to cited text no. 17
Abraham G, Pratap B, Sankarasubbaiyan S, Govindan P, Nayak KS, Sheriff R, et al. Chronic peritoneal dialysis in South Asia challenges and future. Perit Dial Int 2008;28:13-9.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


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