Peritonitis in peritoneal dialysis

The impact of shortening patient-doctor contact duration on early peritoneal dialysis-related infections

Early peritoneal dialysis (PD)-related infection is a severe complication. This study investigated the relationship between patient-doctor contact (PDC) duration and early PD-related infection. In the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) Korea, incident dialysis patients receiving PD were divided into two groups based on PDC duration (< 15 min versus ≥ 15 min), which was defined as the duration a nephrologist typically spends with a patient receiving PD during each visit according to the facility practice pattern. Early risks of PD-related infections, such as peritonitis and catheter-related infection (onset within 3 and 12 months of PD), were compared to the PDC duration using Cox regression. The study included 276 patients (184 [66.7%] in the shorter PDC group [< 15 min] and 92 [33.3%] in the longer PDC group [≥ 15 min]). The average age did not differ between the groups. The incidences of 3- and 12-month PD-related infections were significantly lower in the longer PDC group than in the shorter PDC group (3 months: 1.1% versus 9.8%, P = 0.007; 12 months: 9.8% versus 23.4%, P = 0.007). Longer PDC was independently associated with a lower risk of PD-related infections at 3 and 12 months (3 months: adjusted hazard ratio [aHR], 0.11; 95% confidence interval [CI], 0.02-0.85, P = 0.034; 12 months: aHR, 0.43; 95% CI 0.19-0.99, P = 0.048). Overall, a longer PDC duration was associated with a significantly lower risk of early PD-related infection.

Streptococcus mitis Peritonitis in a Peritoneal Dialysis Patient: A Case Report Highlighting the Importance of Dental Hygiene

Viridans-group streptococci, including the Streptococcus mitis/oralis subgroup, can cause peritoneal dialysis (PD)-related peritonitis. The link between dental pathology and PD-related peritonitis remains to be fully elucidated. We report a case of an 83-year-old man undergoing nocturnal intermittent PD due to kidney failure from diabetic nephropathy who developed S. mitis peritonitis and septicemia traced back to a periodontal abscess. Despite having no prior history of peritonitis and maintaining good nutritional status, the patient presented with generalized abdominal pain and a low-grade fever. The initial treatment included intraperitoneal antibiotics. Root cause analysis identified multiple periodontitis and dental abscesses as the primary source of infection, confirmed by DNA sequencing of cultures from the abscesses and blood, which matched S. mitis. This case highlights the critical role of oral flora in causing invasive diseases in immunocompromised individuals, including PD patients, and illustrates how dental infections can lead to PD-related peritonitis through hematogenous spread. Our case also stresses the importance of meticulous dental care and regular dental examinations to prevent such infections in PD patients.

Peritoneal dialysis in Herzegovina, Federation of Bosnia and Herzegovina: 18 years of experience from our center

INTRODUCTION

Due to treatment of end-stage-renal-disease (ESRD), continuous peritoneal dialysis (CAPD) is used in 11% of cases and is associated with several PD-associated infections.

METHODS

Clinical data on 71 patients with CAPD were evaluated in addition to exit site infections and episodes of acute peritonitis (AP).

RESULTS

There were 39 men and 32 women. Average age was 61 years when we began CAPD and average time spent on CAPD program was 3.35 years. Illness that dominantly caused ESRD was diabetes (23 patients). Exit site infection was mostly caused by S epidermidis-MRSE and AP was most commonly caused by Staphylococcus sp. group. Most common cause of death was cardiovascular disease. At the end of this study, 9 patients were alive and still on CAPD, 10 were transplanted, 15 switched to HD and 36 died.

CONCLUSION

Optimal prevention measures and treatment of infectious complications in CAPD is necessary for better treatment possibilities.

Dialysate cyclophilin A as a predictive marker for historical peritonitis in patients undergoing peritoneal dialysis

Introduction

No markers have been used to diagnose historical peritoneal dialysis (PD)-related peritonitis. Cyclophilin A (CypA) is associated with glucose toxicity and inflammation. We hypothesize that dialysate CypA can be a marker for historical peritonitis (at least 3 months free from peritonitis).

Method

An enzyme-linked immunosorbent assay kit was used to measure the concentration of dialysate CypA. Clinical and laboratory data were collected to correlate with historical peritonitis. Mann-Whitney U test and Chi-square test were used for analysis. Receiver operating characteristic (ROC) analysis was used to evaluate predictive power.

Results

Out of a total of 31 patients who had undergone PD for at least 2 years, 18 had no history of PD-related peritonitis, while 13 had experienced PD-related peritonitis at least once. Overall, the patients in this population were in good health (normal white blood cell count, no anemia, normal electrolyte and serum albumin levels). There were no significant differences between patients with and without a history of peritonitis, except for blood white blood cell count (5650.6 ± 1848.4 vs. 7154.6 ± 2056.8, p = 0.032) and dialysate CypA value (24.27 ± 22.715 vs. 54.41 ± 45.63, p = 0.020). In the univariate analysis, only the dialysate CypA level showed a statistically significant association with historical peritonitis (HR = 1.030, 95 % CI = 1.010-1.062, p = 0.046). The AUC for dialysate CypA (>34.83 ng/mL) was 0.748, with a sensitivity of 0.615 and specificity of 0.833.

Conclusion

PD peritonitis poses a significant threat to the long-term use of peritoneal dialysis. Based on our study, even in the absence of concurrent infection, dialysate CypA can serve as a predictive marker for historical peritonitis, demonstrating high predictive power along with fair sensitivity and good specificity.

Peritoneal dialysis in Dalmatian County, Croatia: 21 years of a single-center experience

INTRODUCTION

With end-stage renal disease becoming more prevalent, the importance of continuous ambulatory peritoneal dialysis (CAPD) is expected to rise even more. However, CAPD is associated with several infections with peritonitis being of the biggest importance.

METHODS

We collected data regarding acute peritonitis episodes (APEs), date of birth and CAPD start, BMI, diabetes mellitus (DM) prevalence, year of renal disease discovery, and details about renal replacement therapies. Primary outcomes included death, transplantation, and a switch to hemodialysis (HD).

RESULTS

Hundred and twenty-nine men and 123 women were analyzed. 63 patients had DM. The median age at the start of CAPD was 56. The median length of CAPD treatment was 24 months. In the end, 147 patients were still alive of which 97 were transplanted, 33 were on CAPD, and 26 were switched to HD. A total of 327 APE were observed.

CONCLUSION

Although the incidence is decreasing, efforts are required to enhance the prevention and treatment of APE.

Proton pump inhibitor use and the risk of peritoneal dialysis associated peritonitis

BACKGROUND

The use of proton-pump inhibitors (PPI) has been associated with an increased risk of developing spontaneous bacterial peritonitis in patients with cirrhosis. Whether PPI use confers a similar risk in developing peritonitis in peritoneal dialysis (PD) patients remains unclear.

METHODS

Patients on PD were retrospectively identified. Data such as PPI use during PD, underlying diagnoses, comorbidities, and baseline serum tests were collected. Univariable and multivariable analysis was conducted using logistic regression to assess whether PPI use and other factors were associated with PD peritonitis.

RESULTS

57 patients were identified with a median(interquartile range(IQR)) age of 65.0(51.5-74.0) years. The median(IQR) time on PD was 29.0(17.5-45.0) months. 28 patients were on a PPI during PD. 57% of the PPI group went on to develop peritonitis, compared to 31% of patients without PPI exposure (OR=2.96, 95% CI:[1.00, 8.78], p=0.050). Months on PD (OR=1.03, 95% CI:[1.00, 1.06], p=0.026), serum urea (OR=0.88, 95% CI:[0.80, 0.97], p=0.017), congestive cardiac failure (OR=5.44, 95% CI:[1.29, 23.00], p=0.021) and renovascular disease (OR=14.59, 95% CI:[1.68, 126.67], p=0.015) were identified as possible risk factors for peritonitis on univariable analysis. Following adjustment for covariates, serum urea, but not PPI use, was associated with PD peritonitis (OR=0.87, 95% CI:[0.78,0.98], p=0.020).

CONCLUSION

PPI use during PD was not associated with peritonitis. Due to the small number of patients and the limited number of studies investigating the effect of PPI use on PD peritonitis, further research is needed. This article is protected by copyright. All rights reserved.

Association between the use of exchange devices for peritoneal dialysis fluids and peritonitis incidence: A nationwide cohort study

BACKGROUND

The use of exchange devices for peritoneal dialysis (PD) fluids is a common practice in Japan. Evidence on the effectiveness of exchange devices in preventing PD-related peritonitis is scarce. We evaluated the association between the use of exchange devices for PD fluids and peritonitis incidence.

METHODS

We retrospectively enrolled 3845 patients, aged ≥20 years, receiving PD for ≥3 months, with available data on the exchange procedure for PD fluids and peritonitis incidence that was obtained from the Japan Renal Data Registry, a nationwide annual survey. The patients were grouped according to whether the manual or device PD fluid exchange method was used. The onset of peritonitis was defined as a leukocyte count of >100/µL (neutrophils ≥50%) in PD effluents. We applied quasi-Poisson regression analyses to estimate the incidence rate ratio (IRR). Age, sex, PD vintage, body mass index, automated PD use, residual kidney function, comorbidities, haemoglobin and serum albumin were adjusted as potential confounders.

RESULTS

Older age, automated PD use, diabetes as comorbidity and lower haemoglobin levels were associated with the use of exchange devices for PD fluids. Patients using devices for PD fluid exchange (69.2%) had an increased risk of peritonitis of 37% (IRR: 1.37, 95% confidence interval (CI): 1.07-1.75) and 28% (IRR: 1.28, 95% CI: 1.00-1.63) in the crude and multivariate adjustment models, respectively.

CONCLUSIONS

The use of exchange devices for PD fluids and peritonitis incidence showed no favourable association. There may remain possible residual confounding by indication.

Successful Treatment of Bacillus licheniformis Peritonitis in Peritoneal Dialysis Patient with Intraperitoneal Vancomycin: A Case Report

Bacillus licheniformis is a rare pathogen causing peritonitis in peritoneal dialysis (PD) patients, and it is usually recognized among immunosuppressed or traumatized patients. A 24-year-old lady was treated for peritonitis as an outpatient with empirical therapy. PD culture grew Bacillus licheniformis after 48 hours, and she continued receiving intraperitoneal (IP) vancomycin for a total of three weeks. The patient was clinically stable throughout the course of therapy and showed complete resolution of her symptoms. This was the first case of reported Bacillus peritonitis in an automated peritoneal dialysis (APD) patient with rapid clinical and biochemical improvement without evidence of relapse or recurrence.

Ciprofloxacin and Cefazolin as a Combination for Empirical Initial Therapy of Peritoneal Dialysis-Related Peritonitis: Five-year Follow-up

The treatment of peritoneal dialysis (PD)-related peritonitis has been a matter of extensive investigation, frequently generating therapeutic trials. Several combinations of antibiotics have served as newer protocols and tended to be efficacious, comfortable, and cost-effective. According to the more recent recommendations from the International Society for Peritoneal Dialysis, the rationale for empirical initial therapy of clinically detected peritonitis in PD patients has been to follow the bacterial profile derived from cultured specimens of PD effluents.

The current study describes 5 year's experience with the use of a new antibiotic regimen for the treatment of peritonitis. We herein analyze the outcome of 95 episodes of peritonitis in 54 patients on either automated PD or continuous ambulatory PD at the dialysis unit of the Federal University of Rio de Janeiro. Peritoneal dialysis-related peritonitis was treated with the combination of oral ciprofloxacin and intraperitoneal cefazolin. The observed cure rate was 85.2% and the sensitivity test was observed to be positive for this combination of antibiotics in 88.9% of positive cultures. Of the 14 unsuccessful episodes, 7 were due to catheter colonization and the rest did not respond to the proposed therapy within 48 hours. These 7 cases were also related to peritoneal fluid cultures that were resistant to both ciprofloxacin and cefazolin.

From this study, we propose this combination of oral ciprofloxacin and intraperitoneal cefazolin as a first choice for empirical initial therapy of PD-related peritonitis, given its efficacy and low cost. However, in order to apply the most adequate cost-effective therapy, careful examination of the bacterial profile and sensitivities to antibiotics used in each unit is strongly recommended.

Proton pump inhibitor use increases the risk of peritonitis in peritoneal dialysis patients

Peritonitis is a major and the most significant complication of peritoneal dialysis (PD). Although some predictors of peritonitis in PD patients are known, the association between proton pump inhibitor (PPI) use and peritonitis has not been characterized. Here, we examined whether PPI use is a risk factor for the development of peritonitis, based on a single-center retrospective analysis of 230 consecutive Japanese PD patients at Narita Memorial Hospital. We assessed the association between PPI use and subsequent first episode of peritonitis using multivariate Cox proportional hazards models, following adjustment for clinically relevant factors. The median follow-up period was 36 months (interquartile range, 19–57 months). In total, 86 patients (37.4%) developed peritonitis. Analysis with multivariate Cox proportional hazards models revealed the following significant predictors of peritonitis: PPI use (adjusted hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.11–2.66; P = 0.016) and low serum albumin level (per g/dl adjusted HR = 0.59, 95% CI: 0.39–0.90; P = 0.014). Thus, PPI use was independently associated with PD-related peritonitis. The results suggest that nephrology physicians should exercise caution when prescribing PPIs for PD patients.

Microbiology of peritoneal dialysis-related infection and factors of refractory peritoneal dialysis related peritonitis: A ten-year single-center study in Taiwan

BACKGROUND

Peritoneal dialysis (PD)-related infection is a serious complication of patients with PD. Refractory peritonitis may lead to failure of PD, shift to hemodialysis (HD) or death. Besides, microbiologic resistance increased worldwide that might impact the treatment choice for such infections. Investigating the causative pathogens and risk factors of PD-related infections in Taiwan was warranted.

METHODS

This is a retrospective study involving patients with PD from 2007 to 2016 in a southern Taiwan hospital. Patient characteristics, microbiological data, outcomes, and factors associated with refractory peritonitis were analyzed.

RESULTS

There were 190 episodes of PD-related peritonitis in 110 patients from this cohort. Gram-positive organisms were the leading cause of PD-related peritonitis, but gram-negative organisms, esp. Pseudomonas aeruginosa, were predominant for exit site infection and tunnel infection. The incidence of peritonitis was 0.25 episode per patient-year (1 episode per 47.69 months). The refractory rate was 14.2% (27/190). Methicillin resistance was noted in 2 (13.3%) of 15 Staphylococcus aureus isolates. Of 114 isolates, 72.8% (83) were susceptible to either cefazolin or gentamicin. Staphylococcus spp. and Escherichia coli infections were significantly associated with refractory peritonitis. Baseline hyponatremia (<130 mmol/L) was independently associated with refractory peritonitis.

CONCLUSION

Gram-positive organisms remained major cause of PD-related peritonitis. About three quarters of causative pathogens were susceptible to the recommended empirical treatment for PD-related peritonitis. Baseline hyponatremia (<130 mmol/L) was independently associated with refractory peritonitis. Staphylococcus spp. and E. coli infections had important roles for refractory peritonitis.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH METHODS

For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal.

DATA COLLECTION AND ANALYSIS

Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes.

MAIN RESULTS

We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent.

AUTHORS' CONCLUSIONS

Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Microbiology and outcomes of peritonitis in northern India

BACKGROUND

Peritoneal dialysis (PD) is an established treatment modality for end-stage renal disease (ESRD). Peritonitis remains a serious complication in PD patients and an important cause of drop-out from the program. Types of pathogens and their drug resistance patterns may determine the outcome of peritonitis. The present study was undertaken to determine the microbiology of peritonitis in PD patients, antibiotic resistance in commonly isolated bacterial pathogens and clinical outcomes.

METHOD

We enrolled 211 patients with ESRD undergoing PD who developed peritonitis during 2002 to 2011. PD fluids were cultured and antibiotic susceptibility test of the bacterial isolates was performed.

RESULT

A total of 303 peritonitis episodes with an overall incidence of 0.41 episodes per patient-year were recorded. Gram-positive, gram-negative, fungi, Mycobacterium tuberculosis and ≥ 2 organisms were isolated from 102 (33.7%), 89 (29.4%), 41 (13.5%), 11 (3.6%) and five (1.6%) episodes respectively; 55 (18.2%) episodes were culture negative. Coagulase-negative Staphylococcus spp. (CONS) was the most common isolate. Catheter loss and hospital admission in gram-negative peritonitis were significantly higher than in gram-positive peritonitis (36/89 (40.4%) vs 20/102 (19.6%), p < 0.001; and 56/89 (62.9%) vs 42/102 (41.2%), p = 0.004 respectively). Antibiotic susceptibility tests showed 54.3% of Enterobacteriaceae isolates were extended spectrum β-lactamase (ESBL) producers, 23.5% of Acinetobacter species and 11.5% of Pseudomonas aeruginosa were metallo-β-lactamase (MBL) producers; 15.4% of enterococci and 28.6% of staphylococci were resistant to vancomycin and methicillin respectively. Mortality was significantly higher in patients having peritonitis due to vancomycin-resistant enterococci, ESBL- and MBL-producing bacteria.

CONCLUSION

Emerging antimicrobial resistance calls for prompt diagnosis and aggressive empiric therapy based on the local sensitivity data.

Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center

PURPOSE

Peritonitis continues to be a major cause of dropout in peritoneal dialysis (PD) patients. Changes in the prevalence of peritonitis etiologies and an increase in the frequency of methicillin-resistant coagulase-negative staphylococci (CoNS) and Gram-negative species resistant to commonly used antibiotics have been reported. As a consequence, the current clinical presentation and patient outcome may differ from classical descriptions. The objectives of this study were to describe the clinical and microbiological characteristics of PD-related peritonitis episodes that occurred over a period of 6 years at a single Brazilian dialysis center and to identify predictors of outcome.

METHODS

A total of 170 peritonitis episodes that occurred in 92 PD patients between January 2004 and December 2009 were reviewed. Multivariate analysis was used to identify demographic, clinical, and microbiological factors predicting endpoints (resolution and peritonitis-related death). Patients' characteristics and peritonitis incidence, etiology and outcomes were compared with a series of 232 episodes that occurred in the first 6 years (1995-2000) of the PD program at the same center.

RESULTS

The overall peritonitis rate was 0.65 episodes/patient-year. Gram-positive cocci were identified in 79 (46.5%) episodes, whereas Gram-negative bacilli were isolated from 48 (28.2%). CoNS were the main Gram-positive species identified in 48 episodes. Of these, 56.3% were resistant to methicillin. Among Gram-negative species, amikacin resistance was observed in 60% of non-fermentative Gram-negative bacilli (NFGNB) and in only 3.6% of Enterobacteriaceae. The overall resolution rate was 44.1%. Oxacillin resistance and NFGNB etiology were strong predictors of non-resolution, whereas older age was the only predictor of death. Antibiotic protocols did not influence outcome. Comparison with the results obtained for the 1990-1995 period showed a lower peritonitis rate, a strong decline in the proportion of Staphylococcus aureus episodes, a significant increase in the frequency of oxacillin-resistant CoNS and amikacin-resistant NFGNB, and a significantly lower resolution and higher death rate.

CONCLUSIONS

The current clinical characteristics and outcome suggest a greater severity of peritonitis episodes and higher risk of death, possibly due to bacterial resistance. Older age is a risk factor for death.

Protective measures against ultrafiltration failure in peritoneal dialysis patients

Ultrafiltration failure in patients undergoing peritoneal dialysis is a condition with an incidence that increases over time. It is related to increased cardiovascular morbidity and mortality and is a major cause of the abandonment of the treatment technique. Because the number of patients undergoing renal replacement therapy is increasing with society aging and because approximately 10% of this population is treated with peritoneal dialysis, this matter is becoming more common in everyday practice for clinicians involved in the care of patients with chronic renal failure. In this review, we summarize the available measures used to prevent and treat ultrafiltration failure and the current state of research in the field, both in the experimental and clinical settings, focusing on the possible clinical applications of recent findings.

Description of an outbreak of acute sterile peritonitis in Iran

BACKGROUND

Outbreaks of sterile or chemical peritonitis are uncommon and often not well documented. It is therefore important to describe the characteristics of sterile peritonitis in continuous peritoneal dialysis (PD) patients.

METHODS

Characteristics of acute chemical peritonitis (ACP) are described in 20 patients (5 males, 15 females; mean age 50 +/- 15 years; range 29 - 72 years). Cultures and Gram stains were negative for micro-organisms. All patients with symptoms of peritonitis were using glucose bags with the same lot number and resolution of peritonitis occurred only after changing the suspicious bags. The first measurements of dialysate-to-plasma creatinine (D/P creat) and glomerular filtration rate (GFR) before and after ACP were compared in 14 patients with no separate episode of bacterial peritonitis during that time.

RESULTS

Cloudy dialysate was observed in 19 patients and 13 experienced abdominal pain. Mean dialysate white blood cell count and percentage neutrophils were 520/mm(3) (range 100 - 1600/mm(3)) and 65% (range 14% - 98%) respectively. Analysis of the unused PD solution showed that endotoxin (0.06 endotoxin unit/mL), 5-hydroxymethyl furaldehyde (8 microg/mL), and acetaldehyde (0.4 microg/mL) concentrations were within acceptable ranges. In 14 patients without episodes of bacterial peritonitis, D/P creat was significantly higher after than before ACP (0.77 +/- 0.07 vs 0.55 +/- 0.1, p = 0.036), whereas GFR was not (4.5 +/- 2.9 vs 4.9 +/- 2.53 mL/minute, p = 0.62).

CONCLUSION

Although chemical peritonitis in glucose-based PD solution is uncommon, it should be distinguished from bacterial peritonitis in outbreaks of peritonitis. Facilities to measure glucose degradation products are required, especially in developing countries. Acute chemical peritonitis increases small-molecule transport in the short term.

Impaired TGF-beta signalling enhances peritoneal inflammation induced by E. coli in rats

BACKGROUND

Peritonitis is a common and severe complication of peritoneal dialysis (PD). Although TGF-beta is a key mediator in peritoneal fibrosis with chronic PD, its role in acute peritoneal inflammation remains unclear.

METHODS

Potential role of TGF-beta signalling in acute peritonitis was investigated in a rat model by infecting peritoneum with E. coli and in primary culture of peritoneal mesothelial cells (PMC) by LPS.

RESULTS

We found that a single infection of E. coli caused an acute, but transient peritonitis by a significant increase in ascites white blood cells (WBC), peritoneal CD45+ leukocytes, upregulation of TNFalpha, activation of NF-kappaB/p65 and impaired peritoneal function (all P < 0.01). Interestingly, spontaneous recovery of acute peritonitis occurred with upregulation of TGF-beta1 and activation of Smad2/3, suggesting a protective role of TGF-beta signalling in acute peritonitis. This was demonstrated by the finding that blockade of the TGF-beta signalling pathway with gene transfer of Smad7 inactivated peritoneal Smad2/3 but worsened E. coli-induced, NF-kappaB-dependent peritoneal inflammation and peritoneal dysfunction (all P < 0.01). Furthermore, studies in vitro also found that impaired TGF-beta signalling by overexpressing Smad7 in PMC were able to overcome the inhibitory effect of TGF-beta on LPS-induced, NF-kappaB-mediated peritoneal inflammation.

CONCLUSION

Results from this study demonstrate that TGF-beta signalling is essential in protection against acute peritoneal inflammation induced by bacterial infection.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH STRATEGY

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction. Date of search: February 2005

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI.

MAIN RESULTS

We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal.

AUTHORS' CONCLUSIONS

Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm.

Treatment of peritoneal dialysis-associated peritonitis: a systematic review of randomized controlled trials

BACKGROUND

Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated.

SELECTION CRITERIA FOR STUDIES

The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis.

INTERVENTIONS

Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin.

OUTCOMES

Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions.

RESULTS

36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and first-generation cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy.

LIMITATIONS

The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated.

CONCLUSIONS

Trials did not identify superior antibiotic regimens. Intermittent and continuous antibiotic dosing are equivalent treatment strategies.

[Daily problems involving contact with terminally ill patients with renal failure]

Practitioners and physicians working in emergency rooms are often confronted with dialysis patients or patients who have received a kidney transplant. For dialysis patients, the mode of dialysis treatment needs to be assessed and dialysis access should be secured. Furthermore, the indications for the next dialysis treatment need to be determined. Dialysis patients often present themselves because of fluid overload, hypo- or hypertensive episodes, electrolyte disturbances, fever or cardiovascular events. Patients undergoing continuous peritoneal dialysis are at an increased risk of infection of the catheter or of peritonitis. Patients with a renal transplant require continuation of their immunosuppression and the function of the transplant should be monitored. These patients often present with infections in which case the degree of immunosuppression may need to be reduced. Vaccinations as well as an increased risk for malignancies require special attention in these patients.

Risk factors for peritoneal dialysis-related peritonitis: Can we reduce the incidence and improve patient selection?

BACKGROUND

Peritonitis is a serious complication of peritoneal dialysis (PD) and a major cause of hospitalization, catheter loss, transfer to haemodialysis and death. Thus, it is important to identify risk factors for PD-related peritonitis in order to reduce the incidence and improve patient selection.

METHODS

This study is a prospective cohort review (1992-2003) with data consisting of 12,844 patient months, 506 PD patients and 623 episodes of peritonitis. Comorbidities and patient demographics were provided by the Australian and New Zealand Dialysis and Transplant Registry and these were merged with the hospital combined clinical and microbiology laboratory peritonitis database.

RESULTS

Variables identified to be associated with an increased likelihood of peritonitis were: age (every 10 years; OR, 1.26; 95% CI, 1.07-1.48), gender (female; OR, 1.91; 95% CI, 1.2-3.01), current smoker at entry to dialysis (OR, 1.71; 95% CI, 1.04-2.82) and the pre twin bag connection system (OR, 2.07; 95% CI, 1.22-3.52).

CONCLUSION

Increasing age, female gender and smoking increased the risk of peritonitis. Identifying these risk factors will assist in the selection, training and monitoring of our PD population.

Care of the end-stage renal disease patient on dialysis in the ED

End-stage renal disease is a major public health problem. In the United States, more than 350,000 patients are being treated with either hemodialysis or continuous ambulatory peritoneal dialysis. Given the high burden of comorbidities in these patients, it is imperative that emergency physicians be aware of the complexities of caring for acute illnesses in this population. This article reviews the common medical problems that bring patients with end-stage renal disease to the emergency department, and their evaluation and management.

Aspergillus peritonitis in a lupus patient on chronic peritoneal dialysis

A woman on continuous ambulatory peritoneal dialysis (CAPD) due to renal failure in systemic lupus erythematosus (SLE) developed fungal peritonitis and survived following treatment with amphotericin B and removal of the dialysis catheter. The causative organism, Aspergillus fumigatus is very rare in fungal peritonitis and may be related in this case to the combination of SLE, end-stage renal disease (ESRD) and their treatment.

Regulation of complement C3 and C4 synthesis in human peritoneal mesothelial cells by peritoneal dialysis fluid

Although complement is activated in the peritoneal cavity during chronic peritoneal dialysis (PD), little is known about its role in peritoneal defence and injury related to long-term PD. We examined the impact of glucose and commercial peritoneal dialysis solutions on complement expression in HPMCs obtained by primary culture from omental tissues of consented patients undergoing elective abdominal surgery. Constitutive expression of C3 and C4 mRNA in HPMCs was up-regulated upon exposure to 75 mm glucose in a time-dependent manner. C3 and C4 protein was secreted in both apical and basolateral directions. Glucose doses beyond 100 mm markedly down-regulated C3 and C4 expression, and stimulated LDH release dose-dependently. Such cytotoxic effects were attenuated using equivalent doses of mannitol instead of glucose. Treatment with conventional lactate-buffered dialysis solution gave rise to down-regulation of C3 and C4 expression, and heightened LDH release in HPMCs. These effects correlated with the glucose strength of the solution, persisted despite replacement with a bicarbonate-buffered solution, aggravated by glycated albumin, and were partially abrogated by supplementation with 10% fetal bovine serum in the culture system. Our findings suggest that the artificial conditions imposed by PD lead to alterations in local complement synthesis that have implications for the role of the peritoneal mesothelium in both inflammation and defence.