Serum albumin in continuous peritoneal dialysis: its predictors and relationship to urea clearance

We investigated the predictors of serum albumin and the relationship between serum albumin and urea kinetic indices in continuous peritoneal dialysis (CPD). In a training set (TS) of 143 urea kinetic studies performed in 92 CPD patients, stepwise logistic regression identified high/high-average peritoneal solute transport, diabetes, advanced age and high daily drain volume normalized by body water as predictors of low serum albumin (< 35 g/liter). This analysis was then substantiated in a validation set (VS) of 187 kinetic studies performed in another 102 CPD patients. The calculated area under the receiver operating characteristic (ROC) curve by this logistic regression model was 0.782 (95% CI, 0.745 to 0.819). Logistic regression was repeated in the TS using only the first kinetic study from each patient, and it identified high/high-average peritoneal solute transport, diabetes, and advanced age as predictors of low albumin. Using only the first kinetic study from each patient in the VS, the second logistic regression model calculated an area under the ROC curve equal to 0.850 (95% CI, 0.810 to 0.890). The relative risk (RR) of serum albumin < 35 g/liter was computed for all kinetic studies after combining the TS and the VS and using non-diabetic CPD subjects aged < or = 61 years with low/low average peritoneal solute transport as the reference group. The RR with only one risk factor present ranged from 1.076 (age > 61 years) to 6.792 (high/high-average transport). The RR with two risk factors present ranged from 5.200 to 9.729. The RR with all three risk factors present was 9.100 (95% CI, range 3.923 to 21.111). A subset of 37 CPD patients had a second urea kinetic study 8 +/- 5 months after an increase in the amount of dialysis due to low urea clearance and/or uremic symptoms. The weekly KT/V urea increased from 1.40 +/- 0.24 to 2.10 +/- 0.31 after the increase in the CPD dose. With the increase in dialysis, the protein catabolic rate increased substantially; however, the mean serum albumin remained stable (from 33.9 +/- 4.6 to 33.3 +/- 6.2 g/liter; decrease 18; increase 15; same 4). In comparison to the subjects who had a decrease in serum albumin after the increase in KT/V, those with the increase in serum albumin were younger (44.2 +/- 11.2 vs. 54.3 +/- 16.2 years, P = 0.044) and had a higher serum urea after the increase in the dose of CPD (22.4 +/- 7.8 vs. 17.0 +/- 6.0 mmol/liter, P = 0.037). We conclude that the major predictors of low serum albumin in CPD are advanced age, diabetes, and high/high-average peritoneal solute transport, but not urea kinetic studies. An increase in the dose of dialysis does not cause a consistent rise in serum albumin in underdialyzed CPD subjects. However, a subset of younger patients may be able to increase their serum albumin in response to the increase in KT/V.

Culture of dialysate in suspected CAPD associated peritonitis using the BacT/Alert system

The BacT/Alert blood culture system was evaluated as a method of culturing dialysates by comparing inoculation of culture bottles directly (DBTA) or after centrifugation of 50 mL of dialysate (CBTA) with conventional culture. Of the 122 dialysates cultured, 84 were positive by one of the 3 methods. After eliminating contaminants, DBTA and CBTA detected 84% (59 of 70) and 93% (65 of 70) of the positive cultures, respectively, compared to 77% (54 of 70) for conventional culture. CBTA and DBTA detected 87% (82 of 94) and 73% (68 of 94) of the significant organisms isolated, respectively, compared to 61% (57 of 94) by conventional culture. However, 60% of the contaminants occurred with the CBTA method. When a dialysate was positive by all 3 methods, both BacT/ Alert methods detected growth earlier by a mean of almost 19 hours. The BacT/Alert system is a useful alternative method for culturing dialysates with the advantages of an earlier detection of positive cultures and minimal handling for the processing of negative cultures.

Fungal peritonitis in a large chronic peritoneal dialysis population: a report of 55 episodes

Fungal peritonitis (FP) is a rare but serious complication of chronic peritoneal dialysis (CPD) therapy and is associated with high morbidity and CPD drop-out. Risk factors and management of FP remain controversial. We reviewed our experience with FP in an attempt to identify risk factors and to examine outcome in relation to treatment strategies. Between March 1984 and August 1994, 704 patients were maintained on CPD therapy in our unit. A total of 1,712 episodes of peritonitis were identified among these patients. Fungal peritonitis accounted for 55 (3.2%) of these episodes. The patients on CPD therapy who developed FP were similar to those who did not develop FP with regard to age, gender, underlying etiology for end-stage renal disease, and comorbid disease. Prior antibiotic use was noted in 87.3% of episodes of FP. The peritonitis rate in the patients who developed FP was one episode every 5.1 months compared with one episode every 9.9 patient-months in the CPD patients who did not develop this infection. Candida sp caused 74.5% of the episodes of FP. All patients were treated with antifungal drugs. In 85.5% of infections the Tenckhoff catheter was removed within 1 week of the diagnosis of FP; 31.9% of the patients who had the Tenckhoff catheter removed did not have the catheter replaced because of death or transfer to hemodialysis. In the patients who developed FP, 68.1% had the Tenckhoff catheter replaced; of these patients, 90.6% and 59.4% were on CPD therapy 1 and 6 months after catheter replacement, respectively. We conclude that risk factors identified in our population include peritonitis rate and prior antibiotic use. Fungal peritonitis is rare in our CPD population, and although it leads to significant CPD drop-out, it can be managed in many patients with antifungal therapy, early catheter removal, and temporary hemodialysis. Of the catheters replaced between 2 and 8 weeks after the diagnosis of FP, 91% functioned successfully, allowing continuation of CPD.

Nursing interventions related to peritonitis

Effective management of peritonitis in chronic peritoneal dialysis patients requires a multidisciplinary approach. Nursing's role begins with the prevention of peritonitis by the development of sound program policies and procedures and effective patient education. Nursing activities at the time of infection focus on assessment and patient education. Nurses are also responsible for maintaining peritonitis data as well as directing or participating in related quality improvement activities.

Peritonitis in peritoneal dialysis patients: an overview

The incidence of peritonitis in peritoneal dialysis (PD) patients has decreased as a result of improvements in PD technology. Nevertheless, peritonitis remains a major problem in PD, with a substantial percent of patients developing persistent or relapsing infections. Current treatment guidelines emphasize the use of intraperitoneal antibiotics and once-a-day administration of aminoglycosides and provide indications for removal of the peritoneal catheter. Further clinical studies testing these guidelines are needed. In addition, guidelines for patients on PD treatment modalities other than standard continuous ambulatory peritoneal dialysis (CAPD) need to be developed. Peritonitis may lead to extensive adhesion formation, peritoneal fibrosis of varying severity, permanent loss of peritoneal ultrafiltration, severe malnutrition, sepsis, and death. Special forms of peritonitis requiring great care and further study include those caused by fungi, mycobacteria, and multiple microorganisms, and those developing in HIV-positive PD patients.

The team approach to the management of children on chronic peritoneal dialysis

The diagnosis of chronic renal failure has a profound and lasting impact on a child and family, with the potential for impairment of the child's physical, mental, and social development. To achieve an ideal outcome, the peritoneal dialysis (PD) team must focus on preparing the child and family to perform home dialysis, prescribe the dialysis regimen most compatible with the patient's lifestyle and clearance requirements, ensure optimal nutrition, and facilitate psychosocial adaptation to PD. Close follow-up is essential for early detection, prevention, and treatment of potential complications of dialysis. A multidisciplinary team approach encompassing nursing, medicine, nutrition, and social work best suits the needs of the child and family.

Current issues of continuous ambulatory peritoneal dialysis

This paper concerns the overall median technical survival of chronic continuous ambulatory peritoneal dialysis (CAPD) patients and treatment in the 6 years since the commencement of CAPD at the Jikei University Hospital. Diabetic end-stage renal disease (ESRD) patients showed 5 years' survival, apparently shorter than that of nondiabetic ESRD which was 7 years. From this fact, the question of whether CAPD is the best dialytic option in diabetic ESRD should be reevaluated. Although a remarkable reduction in the incidence of peritonitis has been seen, generally ranging from 1 episode/40 patient months to 60 patient months or more in Japan, one serious issue still to be addressed is exit site/skin tunnel infection. The incidence is around 1 episode/30 patient months in our hospital. Discovering how to prevent this infection is a matter of some urgency. Peritoneal dialysis is a limiting dialytic modality as far as the biomembrane used. Although the precise mechanisms deteriorating the peritoneal function are still obscure, the treatment of sclerosing encapsulated peritonitis is also an urgent matter. Regarding bone disease and metastatic calcification, adynamic bone disease is frequently observed in ESRD patients: However, the pathogenesis of this morbidity has not been clarified. Treatment of extraosseous calcification in vessels and periarticular, and visceral organs should be developed. New dialytic alternatives to glucose and/or lactate-based solutions have been under experimental study. Until a new solution is delivered commercially, CAPD will remain a transient therapy. Our large study of CAPD patients revealed that 26% were malnourished. The biochemical parameters, amount of daily protein intake, and KT/V did not show significant differences between those patients identified as well nourished versus malnourished. The causes of malnutrition should be considered from other points of view such as endocrinological circumstances. Newer therapeutic approaches to malnutrition are also required.

Chylous ascites complicating neonatal peritoneal dialysis

We report the development of chylous ascites in a neonate as an uncommon complication during continuous peritoneal dialysis. Cloudy dialysis fluid containing many white blood cells might confuse the diagnosis of chylous ascites with infective peritonitis and result in inappropriate use of antibiotics. Resolution may be critical, since chyle removal during dialysis may result in profound immunosuppression and malnutrition due to lymphocyte and fat losses. After 4 weeks on a modified diet, the chyle leak resolved. The patient returned to breast milk and continues nighttime continuous-cycle peritoneal dialysis without further chyle leak.

Pseudomonas peritonitis in peritoneal dialysis patients: the Network #9 Peritonitis Study

To determine risk factors for the development of Pseudomonas peritonitis (PsP) and outcomes of PsP, the authors compared peritoneal dialysis patients who developed PsP with peritoneal dialysis patients who developed non-Pseudomonas bacterial peritonitis (non-PsP). The authors also sought to determine if there were differences in patients who had resolution of PsP compared with those patients whose PsP did not resolve. The data were derived from the prospective Tristate Renal Network Peritonitis and Catheter Survival Study. Resolution in this study was defined as clearing of peritoneal dialysate on visual inspection, with up to three courses of antibiotic therapy allowed. Catheter removal, switch to hemodialysis, or death were outcomes that were considered separately from resolution because of the study design. There were 31 cases of PsP in 28 patients and 886 cases of non-PsP identified in 667 adult patients. There were no differences in race, gender, age, or incidence of diabetes between the groups. The PsP group had a 25% incidence of previous exposure to immunosuppressive agents, whereas it was 10.6% in the non-PsP group (P = 0.028). PsP infections were more frequently associated with concomitant exit and tunnel infections, higher hospitalization rates, increased incidence of catheter loss, switch to hemodialysis, and a worse rate of resolution when compared with non-PsP (all, P < 0.05). Logistic regression could not identify patients at increased risk of PsP. PsP resolved with antibiotic therapy only in 10 of 31 episodes.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality control in a peritoneal dialysis program

A reliable and effective quality-control program in the peritoneal dialysis (PD) unit requires a team effort. Historically, the nursing staff has been responsible for PD program development, and in some programs the physicians are frankly uninvolved. An enthusiastic, knowledgeable, and committed physician is necessary. In the early days of continuous ambulatory peritoneal dialysis in the United States, lack of physician understanding and commitment tarnished the image of this promising, evolving therapy. After recognizing this problem, Baxter embarked on an intensive effort to upgrade the expertise of the physicians. Concurrently, PD programs were identified with successful outcomes and "best demonstrated practice" techniques were promulgated. The key to quality control is the involvement of all members of the team, including physicians, nurses, dietitians, social workers, technicians, administrators, and patients. A commitment is needed for continuing education, continuing reevaluation of policies and procedures, and the empowerment of all team members to achieve the programmatic goals.

Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.

Infectious and catheter-related complications in pediatric patients treated with peritoneal dialysis at a single institution

Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) are the predominant dialytic modalities for the majority of children while awaiting transplantation. Wide acceptability of peritoneal dialysis is hindered by infectious complications. A retrospective review of 367 pediatric patients treated with CAPD/CCPD for at least 3 months from September 1980 through December 1994 revealed that the peritonitis incidence ranged from 1.7 to 0.78 episodes per patient-year. No differences in peritonitis rates were observed between patients treated with CAPD or CCPD. Gram-positive organisms were responsible for the majority of peritonitis episodes. Age, sex, race, primary renal disease, presence of nephrotic syndrome, and serum albumin level were not associated risk factors. Longer time on treatment and diminished serum IgG level were associated with increased peritonitis incidence. Treatment was successfully completed at home in most cases. Almost half of the catheter losses were caused by Staphylococcus, Pseudomonas, and fungal peritonitis and tunnel/exit-site infections. Infectious complications are still the major causes of morbidity and treatment failure in patients treated with CAPD/CCPD. Thus, controlled studies are needed to assess methods for prevention or improvement of peritonitis rates in this patient population.

Neisseria sicca peritonitis in a patient maintained on chronic peritoneal dialysis

Neisseria sicca, previously classified as a "nonpathogenic" organism, has now been recognized as a cause of many infections, including endocarditis and meningitis. However, it has not been reported as a cause of peritonitis. We present a case of documented N. sicca peritonitis immediately following an episode of Staphylococcus aureus peritonitis in a pediatric chronic peritoneal dialysis (CPD) patient. N. sicca should be considered as a possible pathogen in CPD-associated peritonitis.

Abdominal abscesses complicating peritonitis in continuous ambulatory peritoneal dialysis patients

Ten patients with end-stage renal disease maintained on continuous ambulatory peritoneal dialysis therapy developed abdominal abscesses between 1982 and 1992. During this period, 537 patients cared for in our continuous ambulatory peritoneal dialysis unit developed 1,345 episodes of peritonitis. All abdominal abscesses were attributed to concomitant or antecedent peritonitis, suggesting that abscesses developed in 0.7% of peritonitis episodes. Abdominal pain, tenderness, fever, and nausea and vomiting were the most common presenting symptoms and signs. Radiographic findings that were helpful in establishing the diagnosis included abnormalities on computed tomography (CT) scanning, ultrasound, and Indium scanning. Seven patients developed intraperitoneal abscesses, two developed abdominal wall abscesses, and one developed both abdominal wall and intraperitoneal abscesses. Drainage of the abscesses was performed in all cases either surgically or percutaneously. Two patients died. The remaining eight patients have been maintained on hemodialysis therapy. The present data suggest that abdominal abscesses are uncommon complications of continuous ambulatory peritoneal dialysis-associated peritonitis. Prompt diagnosis by clinical criteria and radiographic techniques is important to permit appropriate drainage of the abscess cavity.

Clinical Pharmacy Care in Continuous Ambulatory Peritoneal Dialysis Patients

Continuous ambulatory peritoneal dialysis (CAPD) continues to grow as a treatment modality for end-stage renal disease (ESRD). The high cost of care, multiplicity of drugs used by each patient, high cost of individual drugs, and high incidence of complications, make this patient population a challenging area for clinical pharmacy input. This article discusses the mechanics of CAPD, together with patient selection criteria, monitoring of the dialysis prescription, and infectious complications. The potential for research involving clinical pharmacists is discussed. Apart from studies on the pharmacokinetic disposition of drugs administered to CAPD patients, there remains a relative lack of information on many aspects of drug therapy. Recommendations for areas of continued study include the optimization of antibiotic therapy for peritonitis and exit-site infections, use of the intraperitoneal route for systemic effects of drugs, quality-of-life investigations, and stability studies of drugs in dialysate.