Discussion

In Mexico, CAPD has been the first-choice treatment for the last 25 years. At present time, represents 85% of the dialysis population. Hemodialysis access is very limited, and is offered largely as a second option, mostly to patients with uncontrolled peritonitis or to those who lost their peritoneal membrane to this complication. In most cases, they receive one or two 3-hour sessions per week and some patients are placed on a waiting list, risking death while waiting. This is especially critical among uninsured patients [1]. Therefore, preserving the integrity of the peritoneal cavity becomes crucial in our CAPD patients.

Our study shows a considerable reduction in peritonitis rate with the use of the double-bag system in combination with sodium hypochlorite 50% solution as disinfectant, when compared to the conventional system and the use of povidone-iodine 10% solution. The peritonitis rates with both systems are similar to those previously described in Mexico [3]. However, there are significant differences between the two studies. Firstly, most of the patients in the study reported by Monteon et al. [3] belonged to the Mexican Institute of Social Security (IMSS), which provides medical care only to those who have a salary. Our patients are self-employed or unemployed, lack medical insurance, and are at higher risk because of the widespread of poverty, poor environmental conditions, malnutrition and diabetes. Secondly, patients with previous abdominal surgery, abdominal hernias, and diverticulosis were excluded in the IMSS trial, while this was not the case in our study. Therefore, even in the presence of adverse conditions, the double-bag system is effective in preventing peritonitis in patients on CAPD.

Technique survival was higher than that reported previously in Mexico [2], and this was associated with the significant reduction in peritonitis incidence with the introduction of the double-bag. This finding is particularly important, since peritonitis has been reported as the most important factor for technique failure in developing nations [2, 4, 5]. Indeed, it was responsible for 69% of the cases switching to hemodialysis in a Korean CAPD population [5].

Gram-positive organisms, predominantly of skin origin, were the most common organisms, accounting for 56% of the peritonitis episodes. We did not encounter a significant reduction in the coagulase-negative Staphylococcus infection rate with the use of disconnect systems, as has been reported by others [3, 13-15]. However, similar findings to our study have been described [16, 17].

Although we did not address the issue of the cost of peritonitis, it has been shown by others that the higher purchase cost of disconnecting systems could be offset by the saving resulting from fewer infections and hospitalizations [3, 17, 18]. In addition, in the long-term, the reduction in the peritonitis rates will contribute to the preservation of the functional integrity of the peritoneum, because infections reduce the capacity of the peritoneal membrane for dialysis and may lead to the loss of the peritoneal cavity [19, 20]. This issue is particularly important in countries like Mexico, where the availability of hemodialysis and transplantation for the poor is severely limited, and the preservation of the peritoneum functional integrity in CAPD patients becomes a matter of life or death.

Finally, although from our study we cannot define the direct impact of the use of electrolytically produced sodium hypochlorite solution (ExSept 50%) in peritonitis rates and technique survival, its association is likely, since the efficacy and safety of this disinfectant has been previously documented in peritoneal dialysis patients [21].

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