Borg Diane, Shetty Anupkumar, Williams Deborah, Faber Mark D
Division of Nephrology and Hypertension, Henry Ford Hospital, Greenfield Health Systems, Detroit, Michigan, USA.
Adv Perit Dial. 2003;19:202-5.
Despite recent advances in peritoneal dialysis (PD) systems, peritonitis is a significant clinical problem in patients on PD. Risk factors for peritonitis are identifiable and modifiable and require focused intervention. During a baseline period in 1998, we observed consistent differences in peritonitis rates among patients using various PD connection systems. In January 1999, motivated by a need to reduce peritonitis, we initiated a multifaceted continuous quality initiative (CQI) program that included retraining all current patients and all new patients 6 months after initiation and then annually; changing from plastic to titanium adapters between the catheter and the transfer set; and using equipment from a single PD manufacturer for all new patients and for current patients with high peritonitis rates. Furthermore, all patients using HomeChoice cyclers (Baxter Healthcare Corporation, McGaw Park, IL, U.S.A.) were taught to use the Compact Exchange Device II to avoid contamination when spiking solution bags. Peritonitis rates improved from 1 episode per 7.5 patient-months (over 512 patient-months) in 1998 to 1 episode per 36.5 patient-months (over 292 patient-months) as of September 2002. Further analysis also showed a significant difference in peritonitis rates between equipment produced by various manufacturers. There was a statistically significant difference in peritonitis for automated peritoneal dialysis systems. Patients using the Freedom Cycler PD+ (Fresenius Medical Care, Frankfurt, Germany) had an average peritonitis rate of 1 episode per 6.9 patient-months as compared with patients using the HomeChoice cycler (Baxter Healthcare), who experienced 1 episode of peritonitis per 23.9 patient-months on average (p < 0.0001). For continuous ambulatory peritoneal dialysis patients using UltraBag (Baxter Healthcare), the peritonitis rate was 1 episode per 26 patient-months as compared with the Premier Double Bag (Fresenius Medical Care), for which a peritonitis rate of 1 episode per 6.3 patient-months was seen (p < 0.0001). Comparison of the UltraBag (1 episode per 26.0 patient-months) with the Disposable Freedom Set, a single-bag "Y" system (Fresenius Medical Care; 1 episode per 7.5 patient-months) yielded similar results (p < 0.0001). We conclude that ongoing CQI efforts can significantly reduce peritonitis rates. Our efforts included aggressive patient retraining, protocol changes, use of a titanium adapter between the catheter and the transfer set, and careful choice of connectology systems (possible supplier-dependent effect).
尽管腹膜透析（PD）系统最近取得了进展，但腹膜炎仍是接受PD治疗患者的一个重大临床问题。腹膜炎的危险因素是可识别和可改变的，需要有针对性的干预。在1998年的基线期，我们观察到使用各种PD连接系统的患者在腹膜炎发生率上存在持续差异。1999年1月，出于降低腹膜炎发生率的需要，我们启动了一项多方面的持续质量改进（CQI）计划，包括对所有现有患者以及计划启动6个月后及之后每年的所有新患者进行再培训；将导管与转接器之间的塑料转接器更换为钛制转接器；对所有新患者以及腹膜炎发生率高的现有患者使用单一PD制造商的设备。此外，所有使用HomeChoice循环器（美国伊利诺伊州麦加公园市百特医疗保健公司）的患者都学会了使用Compact Exchange Device II，以避免在穿刺溶液袋时发生污染。腹膜炎发生率从1998年的每7.5患者月1次发作（超过512患者月）降至截至2002年9月的每36.5患者月1次发作（超过292患者月）。进一步分析还显示，不同制造商生产的设备在腹膜炎发生率上存在显著差异。自动腹膜透析系统的腹膜炎发生率存在统计学显著差异。使用Freedom Cycler PD+（德国法兰克福费森尤斯医疗集团）的患者平均腹膜炎发生率为每6.9患者月1次发作，而使用HomeChoice循环器（百特医疗保健公司）的患者平均每23.9患者月发生1次腹膜炎发作（p<0.0001）。对于使用UltraBag（百特医疗保健公司）的持续非卧床腹膜透析患者，腹膜炎发生率为每26患者月1次发作，而使用Premier Double Bag（费森尤斯医疗集团）的患者腹膜炎发生率为每6.3患者月1次发作（p<0.0001）。将UltraBag（每26.0患者月1次发作）与一次性Freedom Set（一种单袋“Y”系统，费森尤斯医疗集团；每7.5患者月1次发作）进行比较，结果相似（p<0.0001）。我们得出结论，持续的CQI努力可以显著降低腹膜炎发生率。我们的努力包括积极的患者再培训、方案变更、在导管与转接器之间使用钛制转接器以及仔细选择连接系统（可能存在供应商相关效应）。
