Rapid, simple, and reliable method for the diagnosis of CAPD peritonitis using the new MMP-9 test kit

The objective of the present study was to evaluate the sensitivity and efficiency of the matrix metalloproteinase-9 (MMP-9) test kit for the diagnosis of bacterial peritonitis in patients undergoing peritoneal dialysis (PD). Peritoneal effluents were collected from seven continuous ambulatory PD (CAPD) patients with peritonitis, four patients with suspected peritonitis, 30 maintenance PD patients without infection, and seven patients at initiation of PD. The MMP-9 test kit was used to analyze 112 peritoneal effluent samples. These peritoneal effluents were also used to count leukocytes and examine microorganisms. MMP expression was measured by gelatin zymography, and activities were measured by an enzyme-linked immunosorbent assay (ELISA). The relationship between the reactivity of the test kit and the number of leukocytes in the samples was examined. There was a significant difference in the number of leukocytes in peritoneal effluents between the negative and positive groups detected by the MMP-9 test kit (P < 0.0001). The results obtained with the MMP-9 test kit were negative for peritoneal effluent samples that did not show increased cell counts. The reactivity of the MMP-9 test kit showed no significant differences among various microorganisms, and remained stable. The MMP-9 test kit appears to be a simple and reliable method for early diagnosis of CAPD peritonitis, and reflects the leukocyte count in peritoneal effluents.

Dialysate Leukocytes, sICAM-1, Hyaluronan and IL-6: Predictors of Outcome of Peritonitis?

BACKGROUND/AIMS

Despite effective antibiotic therapy, peritonitis still remains a major problem in peritoneal dialysis (PD). The aim of the present study was to investigate changes of CRP, dialysate leukocytes and IL-6, hyaluronan (HA) and sICAM-1 in dialysate during and after peritonitis and their association to the outcome of peritonitis.

METHODS

Dialysate IL-6, HA and sICAM-1 were measured at the onset and on day 4, at the end of the treatment and 2 months after onset of peritonitis. Furthermore, CRP and dialysate leukocytes were measured on days 1-4.

RESULTS

All measured soluble factors were higher on the first and fourth day than at the end of the treatment. sICAM-1 and HA were lower at the end of the treatment in patients who later had a relapse/re-infection. IL-6 remained higher 2 months after clinically cured peritonitis. CRP and dialysate leukocytes were higher on day 4 in patients with poor outcome.

CONCLUSIONS

Peritonitis causes increased excretion of soluble factors. Low concentrations of sICAM-1 and HA at the end of the treatment were negative prognostic indicators. Higher IL-6 levels after peritonitis could be a sign of ongoing inflammation in the peritoneal membrane. Delayed decrease in CRP and dialysate leukocytes may indicate poor outcome.

Continuous peritoneal dialysis-associated peritonitis: a review and current concepts

The percentage of end-stage renal disease (ESRD) patients in the United States maintained on continuous peritoneal dialysis (CPD) therapy is decreasing. Complications from CPD therapy, including peritonitis, may be the reason for the decline. Improvements in CPD technology and a better understanding of the risk factors that predispose patients to the development of peritonitis have been responsible for a decline in the rate of peritonitis. Yet peritonitis remains a significant cause of patient morbidity and mortality and the overall outcome of peritonitis is not acceptable. Factors that have limited our ability to lessen the impact of peritonitis include a lack of data on dosing antibiotics in patients on continuous cycling peritoneal dialysis (CCPD) therapy, a lack of knowledge concerning the biology of bacterial biofilm, and the development of resistance to the current prophylactic antibiotic protocols. Further studies are needed concerning the optimal management of the peritoneal catheter and whether it is feasible to resume CPD therapy after catheter removal.

The clinical course of culture-negative peritonitis complicating peritoneal dialysis

BACKGROUND

Culture-negative peritonitis is a serious complication in peritoneal dialysis patients.

METHODS

We studied all consecutive episodes of culture-negative peritonitis in our unit from 1995 to 2001. We identified 1,182 episodes of peritonitis recorded; 212 episodes in 149 patients had negative culture results.

RESULTS

The overall primary response rate was 67.5%, and the complete cure rate was 37.7%. In 95 episodes (44.8%), technical problems during the collection of dialysis effluent were suspected. There was a history of antibiotic therapy within 30 days before the onset in 56 episodes (26.4%). Recent antibiotic therapy was associated with a lower primary response rate (31 of 56 versus 113 of 156 episodes; P = 0.019) and lower complete cure rate (12 of 56 versus 68 of 156 episodes; P = 0.003). Furthermore, a history of peritonitis from 31 to 120 days before the onset also was associated with a lower complete cure rate (P = 0.001). Multivariate analysis showed that recent peritonitis was the only independent predictor of treatment failure (odds ratio, 2.87; 95% confidence interval, 1.56 to 5.29).

CONCLUSION

Most of the culture-negative peritonitis could be explained by recent antibiotic therapy or technical problems during dialysate culture. Recent peritonitis and antibiotic therapy are associated with a poor treatment response. Early Tenckhoff catheter removal is recommended in this group of patients.

Empirical aminoglycosides for peritonitis do not affect residual renal function

BACKGROUND

Aminoglycosides have been proven to be an efficacious treatment for peritonitis in peritoneal dialysis patients for many years. Consequently, they have been recommended in previous guidelines for the empirical treatment of peritonitis. However, with the increasing emphasis on preserving residual renal function (RRF), there has been concern about the nephrotoxic potential of these compounds. The 2000 International Society of Peritoneal Dialysis (ISPD) guidelines recommended that aminoglycosides not be used in patients with RRF, and that ceftazidime be used instead. In 1997, in response to the 1996 ISPD guidelines, we changed our peritonitis regimen from vancomycin and ciprofloxacin to cefazolin and gentamicin. The aim of this study is to compare the change in renal function occurring after treatment of peritonitis with and without gentamicin.

METHODS

Using 6-monthly urine and dialysis clearance measurements, preperitonitis and postperitonitis RRF (mean of 24-hour urea and creatinine clearance) were determined for 70 peritonitis episodes treated with the aminoglycoside-based regimen (group A), 61 episodes treated without aminoglycosides (group B), and 74 control patients without peritonitis (group C).

RESULTS

Group A had mean declines in estimated glomerular filtration rate and urine output of -0.08 +/- 0.50 mL/min/mon and -8.82 +/- 88.09 mL/24 h/mon compared with -0.17 +/- 0.27 mL/min/mon and -34.68 +/- 69.58 mL/24 h/mon in group B and -0.20 +/- 0.39 mL/min/mon and -14.61 +/- 77.33 mL/24 h/mon in group C, respectively. There were no significant differences between groups.

CONCLUSION

In our patients, there was no evidence of an accelerated decline in RRF when using an empirical regimen containing aminoglycosides for peritonitis. Because there are few data to contradict this finding, we recommend the continued use of these drugs in peritonitis regimens, even in patients with significant RRF.

Conservative management of polymicrobial peritonitis complicating peritoneal dialysis--a series of 140 consecutive cases

PURPOSE

Because polymicrobial peritonitis is believed to be caused by bowel perforation in peritoneal dialysis patients, surgical exploration is often recommended. However, there is recent evidence that antibiotic therapy may be a safe alternative.

METHODS

We studied 140 consecutive episodes of dialysis-related polymicrobial peritonitis from January 1995 to June 2001. All episodes were treated primarily with intraperitoneal antibiotics. When there was no response, the Tenckhoff catheter was removed, usually after about 10 days of treatment. Laparotomy was performed only when there was clinical suspicion of surgical pathology.

RESULTS

Ninety patient-episodes (64%) responded to antibiotics alone by day 10; 56 patients (40%) had complete cure with no relapse in 4 months. Nine patients (6%) died within 2 days. Laparotomy was performed in 8 patients who did not respond by day 10, but only 3 had underlying surgical disease (strangulated hernia, ischemic colitis, and colonic cancer). In a multivariate logistic regression analysis, age and the presence of fungus, anaerobes, or Pseudomonas species in the dialysis fluid were independent predictors of poor primary response; and presence of fungus was the only independent predictor of failure to cure in 4 months.

CONCLUSION

Most patients with dialysis-related polymicrobial peritonitis responded to antibiotic therapy, and surgical exploration was needed only in a few patients. A careful examination of isolated organisms may help in identifying patients who need Tenckhoff catheter removal or surgical intervention.

Preventing bacterial infections and antimicrobial resistance in dialysis patients

Antimicrobial use, in concert with patient-to-patient transmission of resistant strains, has caused a rapid increase in the prevalence of antimicrobial resistance in recent years. This increase is a particular threat to dialysis patients, who often have been in the forefront of the epidemic of resistance. In this report, which was written in collaboration between the American Society of Nephrology and the Centers for Disease Control and Prevention and has been endorsed by the Executive Council of the Infectious Diseases Society of America, we review and summarize existing clinical practice guidelines and recommendations concerning the prevention, diagnosis, and treatment of certain bacterial infections in dialysis patients and present four strategies to limit the spread of antimicrobial resistance in dialysis patients. First, preventing infection eliminates the need for antimicrobials, thereby reducing selection pressure for resistant strains. Efforts to prevent infection include avoidance of hemodialysis catheters, when possible, and meticulous care of hemodialysis and peritoneal catheters and other hemodialysis vascular access sites. Second, diagnosing and treating infections appropriately can facilitate the use of narrower spectrum agents, rapidly decrease the number of infecting organisms, and reduce the probability of resistance emerging. This entails the collection of indicated specimens for culture and avoidance of contamination of cultures with common skin microorganisms. Third, optimizing antimicrobial use helps protect the efficacy of such critical agents as vancomycin. Published guidelines for the use of vancomycin should be followed, and alternate agents should be used when infections with beta-lactam-resistant bacteria are unlikely or not documented. Fourth, preventing transmission in health care settings is important to limit the spread of resistant organisms. In this regard, such basic measures as glove use and hand hygiene are most important.

Plasminogen activator inhibitor-1 4G/5G genetic polymorphism does not affect peritoneal transport characteristic

There is evidence that type 1 plasminogen activator inhibitor (PAI-1) may have an important role in peritoneal function. We studied the effect of physiologically relevant PAI-1 promotor polymorphisms on peritoneal permeability. We performed a standard peritoneal equilibration test (PET) in 100 new continuous ambulatory peritoneal dialysis (CAPD) patients. We studied another 48 prevalent CAPD patients who had a baseline PET performed 2 years before; a standard PET was repeated on enrollment. The PAI-1 promotor polymorphism was examined. All patients then were followed up for 16.7 +/- 15.0 months. Prevalences of 4G/4G, 4G/5G, and 5G/5G genotypes were 31.8%, 46.6%, and 21.6%, respectively. Of the 100 new CAPD patients, there was no difference in net ultrafiltration (UF), dialysate-plasma (D/P) creatinine ratio at 4 hours, or mass transfer area coefficient (MTAC) of creatinine among the three genotype groups. D/P creatinine ratios at 4 hours were 0.595 +/- 0.133, 0.607 +/- 0.137, and 0.627 +/- 0.142 for the 4G/4G, 4G/5G, and 5G/5G groups, respectively (one way analysis of variance, P = 0.715). Of the 48 prevalent patients, PAI-1 genotype did not affect the longitudinal change in net UF, D/P creatinine ratio at 4 hours, or MTAC of creatinine. During follow-up, 16 patients developed peritonitis episodes that required Tenckhoff catheter removal. One patient died, 8 patients returned to long-term CAPD therapy after peritonitis resolved, and the other 7 patients developed peritoneal failure and were switched to long-term hemodialysis therapy. PAI-1 promotor genotype did not predict peritoneal failure after an episode of severe peritonitis (chi-square test, P = 0.328). We conclude that PAI-1 promotor polymorphism is not associated with peritoneal transport characteristics in stable peritoneal dialysis patients, longitudinal change in peritoneal transport, or development of peritoneal failure after an episode of severe peritonitis.

Peritonitis in peritoneal dialysis

Peritonitis, an infectious complication of peritoneal dialysis, continues to account for much of the morbidity associated with this techniques. The clinical presentation and laboratory data used in diagnosis the peritonitis, as well as its differential diagnosis will be reviewed in this article. The distribution of pathogens is an important outcome determinant, Gram-negative infections being associated with greater rates of catheter loss and higher death rates. Among the five routes of peritoneal contamination, intraluminal and periluminal contamination account for most of the infections. Due to the two prevention methods implemented in the care of the PD population, the incidence of peritonitis has decreased over the last two decades. The recommendations for empiric treatment of peritonitis have changed over the years, as more was learnt about antibiotic resistance and drug toxicity. Future research to address enteric peritonitis, as well as biocompatible dialysis solution or biocompatible catheter materials is needed to further reduce the incidence of PD peritonitis.

Vancomycin-resistant peritonitis associated with peritoneal dialysis: a cause for concern

BACKGROUND

Peritonitis resulting from peritoneal dialysis (PD) remains a serious cause of morbidity and even mortality among dialysis patients.

AIM

To highlight the danger of antibiotic resistance in patients on dialysis who have received multiple courses of antibiotics.

METHODS

Two cases are reported in which the patients developed peritonitis resistant to vancomycin.

CONCLUSIONS

Multi-drug resistance is a growing danger. It is imperative to use the most appropriate antibiotics in the proper dosage. If infections persist, early removal of the catheters is essential. The use of antibiotics in PD patients needs to be limited. Sensitivity patterns of the cultured organisms must be monitored regularly as the lack of vigilance may help accelerate the development of the so-called 'super bug' resistant to all antibiotics.

Curtailing unnecessary vancomycin usage in a hospital with high rates of methicillin resistant Staphylococcus aureus infections

AIMS

To implement and monitor the effectiveness of a strategy to curb unnecessary use of vancomycin and teicoplanin for inpatients in a teaching hospital/tertiary referral centre where 33% of S. aureus isolates (72% from ICU patients) were methicillin resistant.

METHODS

A sample of 182 vancomycin/teicoplanin inpatient prescriptions surveyed, revealed that only 31 (17%) conformed with Centre for Disease Control (CDC) guidelines. Following education (ward-rounds, bulletins) on appropriate CDC based guidelines for prescribing glycopeptides directed at relevant clinicians, 'Immediate Concurrent Feedback' (ICF) was gradually deployed throughout the hospital. This entailed review of respective inpatient records on the next working day. If the indication was deemed not to conform with our guidelines, the prescriber was issued a memo (copied to the supervising doctor). Each memo detailed the 'errant' incident, listed appropriate indications and explicitly advised desisting from such prescribing and suggested alternative therapy if necessary. Corresponding glycopeptide usage data for our hospital and others in Hong Kong were retrieved and analysed as were samples of records of our inpatients with staphylococcal septicaemia (pre and during ICF).

RESULTS

Compared with baseline values, during 2 years of ICF, inpatient prescribing of vancomycin and teicoplanin deemed to conform increased to 71% (773/1086); difference 54% (P < 0.0001, 95% CIs 47-62%). Corresponding average monthly usage (DDDs/1000 admissions) decreased from 76 (pre-ICF) to 45; mean difference 31 (P < 0.0001, 95% CIs 24, 38). Mortality from staphylococcal bacteraemia remained unchanged. No comparable changes in glycopeptide usage ensued in comparator hospitals.

CONCLUSIONS

ICF can be used safely to curb irrational overuse of vancomycin and teicoplanin in a hospital with high methicillin resistant S. aureus infection rates.

Cefepime versus vancomycin plus netilmicin therapy for continuous ambulatory peritoneal dialysis-associated peritonitis

Cefepime is a cephalosporin with a broad spectrum of activity against most gram-positive and gram-negative pathogens. In this study, we attempted to compare the safety and efficacy of cefepime monotherapy against the potentially more toxic combination of vancomycin and netilmicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD)-associated bacterial peritonitis. Eighty-one consecutive CAPD patients who presented with peritonitis from January 1, 1998, to June 30, 2000, were recruited for study. Patients were randomized to be administered either intraperitoneal (IP) cefepime, 1 g once daily (group A), or intravenous vancomycin and netilmicin at conventional doses (group B) for 10 days. Bacterial growth was obtained in 52 episodes (66%), and pathogens identified included gram-positive organisms (30 episodes; 38%), gram-negative organisms (14 episodes; 18%), mixed organisms (2 episodes; 2.5%), and fungus (6 episodes; 8%). Eight patients were excluded after randomization for various reasons (6 patients, fungal peritonitis; 2 patients, wrong diagnoses). Because of the relatively low peritonitis rate after the use of a disconnect system, the sample size of this study was relatively small, giving a power of 0.45. There were no significant differences in primary response rates and cure rates (no relapse >28 days after completion of antibiotic therapy) between both groups of patients (group A versus group B, 82% [32 of 39 patients] versus 85% [29 of 34 patients] and 72% [28 of 39 patients] versus 76% [26 of 34 patients], respectively; P = not significant). No significant side effect was encountered in either group. Total peritonitis-related hospitalizations were 84 patient-days (1, 7, 8, 11, 20, and 37 patient-days) and 115 patient-days (3, 6, 9, 14, 21, 21, and 41 patient-days), whereas total costs per patient cure were estimated to be US $1,039 and US $1,371 in groups A and B, respectively. We conclude that once-daily 1-g IP cefepime monotherapy is a simple, safe, and cost-effective alternative to vancomycin and netilmicin therapy in the treatment of CAPD-associated bacterial peritonitis.

Infectious complications of the hemodialysis access

Infectious complications of the vascular access are a major source of morbidity and mortality among hemodialysis (HD) patients. Numerous reports implicate the vascular access in up to 48 to 73% of all bacteremias in HD patients. The incidence of vascular access-related infection is highest when central venous dialysis catheters are employed. Native arteriovenous fistulas carry the lowest risk of infection. Unfortunately, prosthetic arteriovenous grafts, which represent the most common type of HD access in the United States, have been repeatedly shown to be a risk factor for bacteremic and nonbacteremic infections. Silent infection in old nonfunctional clotted prosthetic arteriovenous grafts has recently been recognized as a frequent cause of bacteremia and morbidity among HD patients. High proportions of infections related to the vascular access are caused by staphylococcal organisms, which carry high rates of mortality, recurrence, and metastatic complications. Management of vascular access-related infection has two aspects: The first relates to the choice, duration, and mode of administration of antibiotic therapy. Empiric antibiotic therapy, guided by demographic data and severity of illness, should be employed when the causative organisms are unknown. Prolonged administration of specific parenteral antibiotics is crucial in decreasing complications of infection, especially in cases of staphylococcal bacteremia. The second aspect relates to management of the vascular access. Efforts directed toward bacteriological cure should be concurrent with efforts to preserve native venous access sites whenever possible. Efforts to prevent vascular access-related infection should focus on increasing placement of arteriovenous fistulas and minimizing insertion of central venous dialysis catheters. Careful inspection and monitoring of the vascular access is of paramount importance in early detection of vascular access site-related infections. Several new approaches aimed at preventing catheter and prosthetic graft-related infection are being explored.

Clinical course of peritonitis due to Pseudomonas species complicating peritoneal dialysis: a review of 104 cases

BACKGROUND

Peritonitis due to Pseudomonas species is a serious complication in continuous ambulatory peritoneal dialysis (CAPD) patients. The clinical course of peritonitis due to Pseudomonas complicating CAPD remains unclear.

METHODS

All of the Pseudomonas species episodes of peritonitis in our dialysis unit were studied from 1995 to 1999. During this period, there were 859 episodes of peritonitis recorded, 113 of which were caused by the Pseudomonas species. Nine episodes were excluded because they were mixed growth. The remaining 104 episodes in 68 patients were reviewed.

RESULTS

The underlying renal diagnosis and prevalence of comorbid conditions of the 68 patients were similar to those found in our entire dialysis population. There was a history of antibiotic therapy within 30 days of the onset of peritonitis due to the Pseudomonas species in 69 episodes (66.3%). In 47 episodes (45.2%) there was a concomitant exit site infection. The overall primary response rate was 60.6% and the complete cure rate was 22.1%. The presence of exit site infection was associated with a lower primary response rate (22 in 47 vs. 41 in 57 episodes, P < 0.01) and a lower complete cure rate (5 in 47 vs. 18 in 57 episodes, P < 0.02). The episodes that had received recent antibiotic therapy had a significantly lower complete cure rate than the de novo cases (8 in 69 vs. 15 in 35 episodes, P < 0.001). Episodes receiving third-generation cephalosporin as part of the initial antibiotic regimen had a significantly higher primary response rate than the ones that initially received aminoglycoside (54 in 81 episodes vs. 8 in 22 episodes, P < 0.05), but their complete cure rates were similar. Twenty-four cases failed to respond to antibiotics and the Tenckhoff catheter was removed. The chance of returning to CAPD was higher when the Tenckhoff catheter was removed on day 10 than on day 15 (9 in 14 cases vs. 5 in 10 cases), although the result was not statistically significant. The Tenckhoff catheter was removed and replaced at another site simultaneously in another 14 cases after the effluent cleared up. None of these patients had a relapse of peritonitis within three months.

CONCLUSIONS

Recent antibiotic therapy is the major risk factor for peritonitis due to the Pseudomonas species. Exit site infection and recent antibiotic therapy are associated with poor therapeutic response to antibiotics. When the therapeutic response is suboptimal, early Tenckhoff catheter removal may help preserve the peritoneum for further peritoneal dialysis. Elective Tenckhoff catheter exchange after clearing up the peritoneal dialysis effluent may also reduce the likelihood of relapse. It is desirable to use third-generation cephalosporin in the initial antibiotic regimen for peritonitis treatment in localities with a high incidence of peritonitis due to the Pseudomonas species.

Cefazolin dialytic clearance by high-efficiency and high-flux hemodialyzers

Cefazolin dialytic clearance has not been determined in patients undergoing hemodialysis with high-efficiency or high-flux dialyzers. The objective of this study is to determine the pharmacokinetics and dialytic clearance of cefazolin and develop dosing strategies in these patients. Twenty-five uninfected subjects undergoing chronic thrice-weekly hemodialysis were administered a single dose of intravenous cefazolin (15 mg/kg) after their standard hemodialysis session. Fifteen subjects underwent hemodialysis with high-efficiency hemodialyzers, and 10 subjects underwent hemodialysis with high-flux hemodialyzers. Blood and urine samples were collected serially over the interdialytic period, during the next intradialytic period, and immediately after the next hemodialysis session. Serum and urine concentrations of cefazolin were determined by high-performance liquid chromatography. Differential equations describing a two-compartment model were fit to the cefazolin serum concentration-time data over the study period, and pharmacokinetic parameters were determined. Mean dialytic clearance values for cefazolin were significantly greater in the high-flux group compared with the high-efficiency group (30.9 +/- 6.52 versus 18.0 +/- 6.26 mL/min, respectively; P: < 0.05). Cefazolin reduction ratios were significantly greater (0.62 +/- 0.08 versus 0.50 +/- 0.07; P: < 0.005) in the high-flux group compared with the high-efficiency group and correlated well with equilibrated urea reduction. The pharmacokinetic model developed from patient data was used to simulate cefazolin serum concentration data for high-efficiency and high-flux dialyzers. Cefazolin doses of 15 or 20 mg/kg after each hemodialysis session maintained adequate serum concentrations throughout a 2- or 3-day interdialytic period regardless of hemodialyzer type.

Initial treatment of peritoneal dialysis peritonitis without vancomycin with a once-daily cefazolin-based regimen

To reduce the use of vancomycin, the current recommendations of the International Society of Peritoneal Dialysis (PD) for the initial treatment of peritonitis complicating PD are to administer intraperitoneal (IP) cefazolin or cephalothin in every PD fluid bag, together with once-daily gentamicin. In view of the inherent impracticalities of this regimen, we studied the efficacy of once-daily cefazolin (1.5 g) IP with gentamicin IP as initial treatment for primary (nonrecurrent) PD peritonitis. This regimen has been used in all episodes of peritonitis not associated with tunnel or exit-site infections or fluid leaks. Sixty-nine episodes in 61 patients were analyzed (44 patients, continuous ambulatory PD; 22 patients, automated PD; and 3 patients, hospital-based intermittent PD), of which 38 episodes (55%) were gram-positive infections, 6 episodes (9%) were gram-negative infections, and 18 episodes (26%) had negative culture results. Four patients died within 4 weeks of infection (none considered attributable to inadequate treatment of their peritonitis). Ten catheters (14.5%) required removal to clear the infection; 7 catheters were in patients with gram-negative infections. The relapse rate within 4 weeks of ceasing antibiotic therapy was 8.9%. Compared with the results of 40 episodes of peritonitis treated initially with our previous IP vancomycin and gentamicin regimen, successful treatment (no death, catheter removal, or recurrence) was achieved in 52 of 69 episodes in the cefazolin group (75.4%) versus 23 of 40 episodes in the vancomycin group (57.5%; P: = 0.058). In conclusion, once-daily IP cefazolin and gentamicin for the initial treatment of PD peritonitis is at least as effective as a vancomycin-based regimen and is well tolerated.

Successful use of recombinant tissue plasminogen activator in a patient with relapsing peritonitis

Intraperitoneal (IP) administration of either streptokinase (SK) or urokinase (UK) has assumed an adjunctive role to antibiotic therapy in selected patients with relapsing peritonitis. In these circumstances, bacteria may be protected from antibiotics through sequestration in either fibrinous structures or biofilms within the lumen of the peritoneal dialysis (PD) catheter or the peritoneal cavity. In some cases, it appears that disruption of these sheltered microenvironments by thrombolytic agents facilitated eradication of the offending organism and obviated the need for catheter removal, replacement, or interim hemodialysis. Although IP SK has been generally well tolerated as additive therapy in relapsing peritonitis, sporadic reports of significant complications, such as abdominal pain, fever, and severe hypotension, have precluded its more widespread acceptance. The only other thrombolytic agent used in this setting, UK, is presently unavailable because of a manufacturing shortfall. Therefore, adjunctive thrombolytic therapy for relapsing peritonitis is currently restricted. To circumvent these limitations, we devised an IP tissue plasminogen activator (tPA) protocol to eliminate recurring infection in a patient undergoing chronic ambulatory PD. After a third episode of peritonitis caused by Enterobacter cloacae, treated twice previously with an adequate antibiotic regimen, we instilled 6 mL of tPA (1 mg/mL) into the PD catheter for a 2-hour dwell time. The treatment was well tolerated and, in conjunction with a third course of antibiotic therapy, has produced an infection-free interval of 8 months.

Factors predicting outcome of fungal peritonitis in peritoneal dialysis: analysis of a 9-year experience of fungal peritonitis in a single center

Fungal peritonitis causes significant morbidity and mortality for patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We retrospectively reviewed 70 episodes of fungal peritonitis in a single center over the last 9 years in 896 CAPD patients. Seventy percent of the episodes of fungal peritonitis were caused by Candida species, among which 50% were Candida parapsilosis. As a result of fungal peritonitis, 44% of the patients died, whereas further peritoneal dialysis failed in 14%, requiring a change to long-term hemodialysis. Only 37% managed to continue CAPD. The remaining 5% either underwent transplantation or were lost to follow-up. We identified the factors associated with poor outcome, namely mortality and technique failure. The presence of abdominal pain, bowel obstruction, and a catheter remaining in situ were significantly associated with greater mortality. Abdominal pain, antibiotic use within 3 months before fungal peritonitis, and complication by bowel obstruction were associated with greater technique failure. In choosing antifungal agents with catheter removal, oral fluconazole alone appears equally as effective as combined oral fluconazole with 5-flucytosine for peritonitis caused by Candida species. For peritonitis caused by species other than Candida, the choice of antifungal therapy needs to be individualized, based on fungal species and sensitivities.

Dialysis access related infections

Infection is a common cause of morbidity and mortality in end-stage renal disease patients. Unintentional pathogens are introduced into an immunocompromised host during hemodialysis and peritoneal dialysis by means of the access (arteriovenous fistula, arteriovenous graft, central venous catheter, or peritoneal dialysis catheter). Gram positive organisms are most common with Staphylococcus aureus and coagulase negative Staphylococcus predominating. Preventive measures are mandatory and the key to decreasing infection rates.

Analysis of microbiological trends in peritoneal dialysis-related peritonitis from 1991 to 1998

The microbial cause of peritoneal dialysis-related peritonitis is an important determinant of clinical outcome and the basis of widely used treatment guidelines. Five hundred forty-six cases of peritonitis in 374 patients from 1991 to 1998 were analyzed. The rate of peritonitis declined significantly from 1.37 episodes/patient-year in 1991 to 0.55 episode/patient-year in 1998 (P = 0.02). The rate of Gram-positive peritonitis decreased significantly from 0.75 to 0.28 episode/patient-year during the same period (P = 0.02). Conversely, the occurrence of Gram-negative peritonitis remained constant at approximately 0.16 episode/patient-year (P = 0.28). Staphylococcus epidermidis and Staphylococcus aureus were the most common causes of peritonitis, isolated in 27.8% and 19.3% of the culture-positive cases, respectively. A distinct decrease in peritonitis caused by S epidermidis was observed, with 0.40 episode/patient-year in 1991 compared with 0.11 to 0.20 episode/patient-year during subsequent years. The rate of infections caused by S aureus decreased significantly over time from a high of 0.21 episode/patient-year in 1992 to a low of 0.04 episode/patient-year in 1998 (P = 0.01). Pseudomonas aeruginosa, Escherichia coli, and KLEBSIELLA: species were the most common causes of Gram-negative peritonitis, identified in 7.1%, 6.8%, and 5.2% of culture-positive cases, respectively. The most dramatic increase in antibiotic resistance was seen among S epidermidis. From 1991 and 1992 to 1997 and 1998, resistance to ciprofloxacin increased from 5.4% to 47.8% (P = 0.003), and resistance to methicillin increased from 18.9% to 73.9% (P = 0.03). Our study showed significant trends in the causative pathogens of peritoneal dialysis-related peritonitis and dramatic increases in antibiotic resistance. These data support further study and warrant reevaluation of current treatment practices.

National guidelines for the judicious use of glycopeptides in Belgium

OBJECTIVE

The 'HICPAC guidelines', published in the USA in 1995 stressed the crucial role of restrictive usage of glycopeptides in the strategy to limit the emergence and spread of resistant enterococci. Because controversy still remains in Belgium on the necessity and feasability of restricting glycopeptide usage, the infectious diseases advisory board (IDAB) developed a consensus statement on the judicious use of glycopeptides in Belgium.

METHODS

The literature on the indications for glycopeptide treatment was reviewed, categorized and discussed by a working party of the IDAB.Consequently, the IDAB reached consensus on the warranted indications for glycopeptide use in Belgium.

RESULTS

The opinion of the IDAB-members is reported in a consensus statement specifying the indications for treatment and for prophylaxis with glycopeptide antimicrobials, as well as the situations where glycopeptides should not be used, taking into account the specific epidemiology of bacterial resistance, the availability of antibiotics and the common prescribing practices in Belgium.

CONCLUSIONS

The IDAB concludes that restrictive usage of glycopeptides must also be a priority in Belgium. Guidelines on the judicious use of these antibiotics adapted to the national situations must contribute to this objective.

Peritoneal dialysis. Prevention and control of infection

In spite of the reduction in peritonitis and catheter-related infection rates in patients undergoing peritoneal dialysis, these infections remain major sources of morbidity and transfer to haemodialysis. Touch contamination at the time of doing the exchanges is still a major cause of peritonitis and leads to Gram-positive organisms (coagulation-negative staphylococcus) being the most common pathogens. Newer exchange techniques have reduced this incidence but the more serious pathogens (Staphylococcal aureus, pseudomonas and fungi) remain a major problem. Treatment has to be immediate, and hence empirical, giving adequate cover for both Gram-positive and Gram-negative organisms. The use of vancomycin as an initial antibacterial has been discontinued because of the problem of vancomycin-resistant enterococcus. Recent guidelines advocate the use of a first generation cephalosporin combined with ceftazidime (if the urine output is >100 ml/day) or an aminoglycoside in anuric patients. Subsequent therapy changes are made upon bacterial isolation and sensitivities. Vancomycin is reserved for methicillin-resistant staphylococcus. Peritoneal catheter-related infections (exit site and tunnel) are predominantly caused by S. aureus and pseudomonal organisms and can be difficult to eradicate. Tunnel infections invariably involve the catheter dacron cuffs and therefore are more likely to lead to peritonitis; in this situation catheter removal is the treatment of choice. Treatment of exit-site infections is with oral antibacterials (penicillinase-resistant penicillins, cefalexin). Vancomycin is avoided if possible. The identification that nasal carriage of S. aureus predisposes to exit-site and tunnel infections has led to prophylactic regimens to combat this problem. Mupirocin applied at the exit site leads to a reduction in catheter-related infections and peritonitis.

Trends in patient and technique survival in peritoneal dialysis and strategies: how are we doing and how can we do better?

The best data on long term trends in patient and technique survival on dialysis come from North America. Mortality rates on both peritoneal (PD) and hemodialysis (HD) have fallen over the past one to two decades in both the US and Canada with the decline in the US being relatively greater in older and diabetic patients. There is some suggestion that this improvement may be proportionately greater in PD, relative to HD, patients in both the US and Canada. Overall, mortality rates on PD are similar to, or better than, those on HD in the early years of treatment, except in older US diabetic patients. In later years, patients on HD do relatively better than those on PD in the US but not in Canada. The biggest cause of mortality on dialysis is cardiovascular disease and the risk factors for this in the dialysis population generally, and particularly on PD, are reviewed, including newly appreciated ones such as hyperhomocysteinemia, high lipoprotein (a) levels and inflammation/malnutrition. Possible preventative and therapeutic strategies are also considered. Technique failure (TF) rates are high in PD but Canadian data suggest they have fallen over the past 20 years, primarily due to a reduction in cases due to peritonitis. TF rates due to inadequate dialysis have increased and an interpretation of this as well as an approach to reducing it are suggested.

Immunoglobulins in chronic renal failure of childhood: effects of dialysis modalities

BACKGROUND

It is not clear whether low serum levels of IgG (subclasses), previously demonstrated in children on peritoneal dialysis (PD), are related to the PD procedure or to factors associated with chronic renal failure (CRF). The aim of our study was to analyze the effect of PD on serum and PD effluent (PDE) IgG and subclass levels in children with end-stage renal failure.

METHODS

We measured albumin, IgG, IgA, IgM, and IgG subclasses in serum and PDE from children on PD (N = 40) and compared the serum values with those of children treated with hemodialysis (HD, N = 23) or presenting with CRF but not yet dialyzed (CRF; N = 63), and with a group of healthy controls (HCs; N = 67). Sixteen PD children could be followed sequentially from before starting PD and eight during a peritonitis episode.

RESULTS

Forty percent of the PD children showed reduced serum IgG2 levels (P = 0.0003) compared with 35% in HD (P = 0.006), 33% in CRF (P = 0.001), and 9% in HC children. IgG1 deficiencies were observed in 25% of PD patients (P < 0.0001), 4% of HD (P = NS), 16% of CRF (P = 0.0005), and 0% of HC children. IgG3 and IgG4 deficiencies were observed less frequently. Peritoneal clearances were similar for total IgG, IgG1, IgG2, and IgG4, but were lower for IgG3 (P < 0.05). No relationships were found between clearances and age or duration of PD treatment. Total IgG (P = 0. 003) and IgG1 (P = 0.002) levels declined just after starting PD. Peritonitis was associated with temporarily increased peritoneal loss of Ig, while the serum concentrations were unaffected. No significant relationship was found between the peritonitis incidence and reduced IgG or subclasses. However, all children with two or more peritonitis episodes per year had a reduced Ig level.

CONCLUSIONS

Although the mean serum concentrations of immunoglobulins were normal in all studied groups, a deficiency of one or more IgG subclasses was present in all groups with renal failure, suggesting inhibition of their synthesis by the uremic state. Ig deficiencies were more frequently found in PD, likely caused by protein loss in PDE. A high peritonitis incidence was associated with reduced serum Ig levels.

Fungal peritonitis in children receiving peritoneal dialysis: a report of the NAPRTCS

BACKGROUND

The rarity of fungal peritonitis (FP) in children receiving chronic peritoneal dialysis (PD) has limited the amount of information available regarding the risk factors and management associated with this infection.

METHODS

We reviewed all cases of FP occurring in patients entered into the dialysis registry of the NAPRTCS between January 1992 and May 1996 in an attempt to identify risk factors for infection, treatment strategies, and patient outcome data. A total of 1592 patients who were less than 21 years of age were enrolled in the dialysis registry and received maintenance PD during the period of observation.

RESULTS

Of the total 1729 episodes of peritonitis in these patients occurring over 1732 patient-years of follow-up, FP accounted for 51 (2.9%) of the episodes. The patients on PD who developed FP were similar to those who did not develop FP with regard to race, gender, dialysis modality, and dialysis access characteristics. The overall peritonitis rate in patients who developed FP was 2.2 episodes per patient-year compared with 0.96 episodes per patient-year in the patients who did not develop this infection (P < 0.0001). In 25 (49%) cases, the FP was the patient's initial episode of peritonitis. Whereas recent antibiotic usage was present in 23 (56%) of 41 patients with FP, there was no statistically significant relationship (P = 0.26) noted between the presence of a gastrostomy and the development of FP. Candida species caused 33 of 42 (78.6%) FP episodes. Therapy consisted of PD catheter removal and Amphotericin B in the majority of patients. Six months after diagnosis, 27 patients remained on PD, twelve patients were receiving hemodialysis, and only three patients had died, in each case for reasons unrelated to their FP episode.

CONCLUSION

FP is an infrequent cause of peritonitis in children receiving chronic PD. The presence of a gastrostomy does not appear to predispose patients to the development of this infection, and successful therapy most often consists of a combination of antifungal medication and dialysis catheter removal. The outcome of FP in children appears to be more favorable than in the adult dialysis population.

Peritoneal dialysis adequacy and risk of death

BACKGROUND

The purpose of this study was to evaluate the relationship between dialysis dose, patient characteristics, and medical comorbidities on mortality in chronic peritoneal dialysis patients.

METHODS

This work comprised a study cohort of 1446 patients obtained from a random sample of chronic peritoneal dialysis patients from each dialysis center in three southeastern states. Data collected on a standardized form were used to calculate weekly Kt/V urea and creatinine clearance. Data were linked to Network files containing data on patient demographic and medical comorbidities.

RESULTS

Both weekly Kt/V urea and creatinine clearance were measured at least once in only 60.5% of continuous ambulatory peritoneal dialysis (CAPD) patients and 63.7% of cycler patients. Among the 873 patients who had at least one calculable adequacy measure, the mean (+/-SD) weekly Kt/V urea was 2.13 +/- 0.55, and the normalized mean weekly creatinine clearance was 62.9 +/- 20.4 L/week/m2. During the seven month period of follow-up, there were 140 deaths. In separate logistic regression models that included all of the studied risk factors, using separate variables for the urinary and peritoneal components of dialysis adequacy, each 10 L/week/1.73 m2 increase in the urinary component of weekly creatinine clearance was associated with a 40% decreased risk of death, and each 0.1 unit increase in the urinary component of weekly Kt/V urea was associated with a 12% decreased risk of death. In contrast, the dialysate components of neither weekly creatinine clearance nor weekly Kt/V urea were predictive of death. Other factors that were associated with an increased risk of death included increasing age, diabetes mellitus as the cause of end-stage renal disease (ESRD), and a history of myocardial infarction.

CONCLUSIONS

Residual renal function, as expressed by weekly creatinine clearance or Kt/V urea, is an important predictor of death in chronic peritoneal dialysis patients. The nonsignificant findings regarding peritoneal clearances and mortality may possibly be secondary to the narrow range of peritoneal clearances in this study cohort.

Peritoneal coccidioidomycosis: case report and review

Peritonitis is an unusual extrapulmonary manifestation of coccidioidomycosis. Peritoneal involvement often has an indolent course and may resolve spontaneously. Optimal management has not been defined; however, fluconazole's spectrum of activity, pharmacokinetic profile, and efficacy in dialysis-related yeast peritonitis suggest that it may be an effective treatment. To our knowledge, we report the first case of coccidioidal peritonitis treated with fluconazole and review the literature.

Gel clot LAL assay in the initial management of peritoneal dialysis patients with peritonitis: a retrospective study

BACKGROUND

Indiscriminate use of broad-spectrum antibiotic treatment of peritonitis in peritoneal dialysis patients may have either unwanted side-effects or contribute to the development of antibiotic resistance. This may be avoided by improved diagnosis at presentation. The Limulus amoebocyte lysate assay is a convenient test detecting bacterial endotoxins or fungal beta glucans. This study evaluates a qualitative Limulus amoebocyte lysate test as a diagnostic tool used at presentation of a peritoneal dialysis patient with peritonitis.

METHODS

One-hundred and eleven episodes of peritonitis in peritoneal dialysis patients have been analysed retrospectively. Limulus amoebocyte lysate results at presentation were compared with culture results. A Limulus amoebocyte lysate assay was performed using a commercial kit by incubating a mixture of dialysate effluent and Limulus amoebocyte lysate reagent at 37 degrees C. The development of a stable solid clot was considered positive. The specificity and sensitivity of the test were calculated.

RESULTS

The specificity of the Limulus amoebocyte lysate assay was found to be 98% and the sensitivity 74%. Limulus amoebocyte lysate assay was false-negative in 13 cases of Gram-negative peritonitis (22%). Limulus amoebocyte lysate was positive in three of seven cases of fungal peritonitis. The study included one case each with false-positive Limulus amoebocyte lysate and with culture-negative peritonitis.

CONCLUSIONS

The Limulus amoebocyte lysate assay is a convenient and valuable diagnostic tool for excluding Gram-positive peritonitis in peritoneal dialysis patients. This allows more specific antibiotic treatment at presentation and may avoid the development of bacterial resistance. A negative Limulus amoebocyte lysate test is not reliable for the exclusion of Gram-negative peritonitis. In the absence of a positive culture result 48 h after presentation, accompanied by a delayed response to treatment, a positive Limulus amoebocyte lysate assay may indicate the presence of fungus. This justifies early empiric antifungal treatment before definitive culture results are made available. Routine Limulus amoebocyte lysate assay of dialysate effluent from continuous ambulatory peritoneal dialysis patients presenting with peritonitis is recommended.

Effect of peritonitis on peritoneal transport characteristics: glucose solution versus polyglucose solution

BACKGROUND

Peritonitis is a common clinical problem and contributes to the high rate of technique failure in continuous ambulatory peritoneal dialysis treatment. The present study investigated the effect of peritonitis on peritoneal fluid and solute transport characteristics using glucose and polyglucose (icodextrin) solutions.

METHODS

A four-hour dwell was performed in 32 Sprague-Dawley rats (8 rats in each group), with 131I albumin as an intraperitoneal volume marker. Peritonitis was induced by an intraperitoneal injection of 2 mL lipopolysaccharide (100 microg/mL phosphate-buffered saline) four hours before the dwell. Each rat was intraperitoneally infused with 25 mL of 3.86% glucose [glucose solution control group (Gcon) and glucose solution peritonitis group (Gpts)] or 7.5% icodextrin solution [icodextrin solution control group (Pgcon) and icodextrin peritonitis group (PGpts)].

RESULTS

Net ultrafiltration was significantly lower (by 44%) in the Gpts as compared with the Gcon group, but was significantly higher (by 138%) in the PGpts as compared with the PGcon group. The peritoneal fluid absorption rate, including the direct lymphatic absorption rate, was significantly increased (by 78%) in the Gpts group as compared with the Gcon group. However, the total fluid absorption did not differ between the PGpts and the PGcon groups. The dialysate osmolality decreased much faster in the Gpts group as compared with the Gcon group, resulting in significantly lower (by 9%) transcapillary ultrafiltration in the Gpts group. In contrast, the dialysate osmolality increased faster in the PGpts group as compared with the PGcon group, resulting in higher (by 40%) transcapillary ultrafiltration in the PGpts group. The in vitro increase in dialysate osmolality was also higher in the PGpts group as compared with the PGcon group. The solute diffusive transport rates were, in general, increased in the two peritonitis groups as compared with their respective control groups.

CONCLUSIONS

Our results suggest the following: (1) Peritonitis results in decreased net ultrafiltration using glucose solution caused by (a) decreased transcapillary ultrafiltration and (b) increased peritoneal fluid absorption. (2) Ultrafiltration induced by the icodextrin solution appears to be related to the increase in dialysate osmolality (mainly because of the degradation of icodextrin). (3) Peritonitis results in increased degradation of icodextrin and a faster increase in dialysate osmolality and therefore better ultrafiltration, whereas the fluid absorption rate does not change. (4) Peritonitis results in increased peritoneal diffusive permeability.

Pharmacokinetics of Intraperitoneal Piperacillin/Tazobactam in Patients on Peritoneal Dialysis with and without Pseudomonas Peritonitis

Objective

The objective of this study was to assess the pharmacokinetics of intraperitoneal (IP) administration of the antibiotic combination piperacillin/tazobactam (PIP/TAZ) to patients on chronic ambulatory peritoneal dialysis (CAPD) with and without pseudomonas peritonitis.

Design

Open-labeled study.

Setting

The study was carried out in the CAPD unit of Assaf Harofeh Medical Center, Zerifin, Israel.

Patients and Methods

Six patients participated in the study, 4 had pseudomonas peritonitis, all were given an IP loading dose of 4 g/0.5 g PIP/TAZ. Twenty-four hours after the initial dose, a maintenance dose of 0.5 g/0.0625 g PIP/TAZ was administered with each dialysate exchange for a period of 1 week. The patients without peritonitis received only the loading dose. High performance liquid chromatography was used to determine the concentrations of PIP/TAZ in plasma obtained at 0, 30, 60, 90, 120, 360, 480, 600, 720, and 1440 minutes after administration. Samples of the dialysate fluid for determination of PIP/TAZ concentration were collected at 6, 10, 14, 24, and 72, 120, and 168 hours.

Results

After the loading dose, the highest plasma PIP concentration (Cmax) was 51.6 ± 21.25 μg/mL and appeared at 1.5 ± 0.45 hours (tmax). During the maintenance period plasma PIP concentration was 5.2 ± 4.75 μg/mL. Tazobactam was detected in the plasma of 1 patient only. The concentration of TAZ in the dialysate fluid during the maintenance period was 2.3 ± 0.5 μg/mL.

Conclusions

Piperacillin administered IP at 4 g reached plasma concentrations comparable to intravenous administration and considered therapeutic (above the MIC90for Pseudomonas aeruginosa) in CAPD patients with or without peritonitis. The maintenance dose, however, should be augmented. Tazobactam could not be detected in the plasma of most patients and the therapeutic implications of IP administration of TAZ cannot be directly correlated to intravenous administration.

Stability of cefepime in peritoneal dialysis solution

OBJECTIVE

To determine the stability of cefepime in peritoneal dialysis solution.

DESIGN

Cefepime HCl was added to premade bags of Delflex peritoneal dialysis solution with 1.5% dextrose to produce a cefepime concentration of approximately 100 microg/mL. Peritoneal dialysis solution bags were stored at 4, 25, and 37 degrees C to simulate refrigeration, room temperature, and body temperature, respectively. Samples were drawn at scheduled times up to 336, 168, and 48 hours, respectively, after the addition of cefepime HCl. Cefepime concentrations were measured by HPLC.

SETTING

This study was performed at a university-affiliated tertiary care hospital.

OUTCOME MEASURE

If the mean concentration of the samples at a given time and condition was >90% of the initial concentration, cefepime was considered stable at that time and condition.

RESULTS

The mean HPLC results for samples drawn at each time and condition were all >90%.

CONCLUSIONS

Cefepime is stable in peritoneal dialysis solution with dextrose 1.5% for 14 days refrigerated, seven days at room temperature, and 48 hours at 37 degrees C.

Prophylactic antibiotic therapy prior to dental treatment for patients with end-stage renal disease

In the United States, there is a large and growing population of patients undergoing dialysis because of end-stage renal disease (ESRD). These patients present special management considerations for dentists, including antibiotic prophylaxis for the prevention of bacterial endocarditis (BE). ESRD patients, particularly those with an arteriovenous shunt for hemodialysis access, are predisposed to valvular endocarditis. Thus, BE prevention is the primary goal of antibiotic prophylaxis prior to dental or other invasive procedures in these patients. Bacteremia may predispose to infection of synthetic vascular access grafts, although this form of endovascular infection in ESRD patients has not been as well-characterized as BE. Antibiotic prophylaxis may be of some benefit for prevention of synthetic graft infections as well as BE. Poor dentist and physician compliance with BE prophylaxis regimens, as well as errors in dosing, timing, or duration of prophylaxis, have been reported. These problems are of particular concern in the treatment of chronically ill patients. In this article, we review the rationale for prophylactic antibiotic therapy prior to dental procedures in ESRD patients with vascular access. We also elaborate on the current American Heart Association guidelines for BE prophylaxis, and address special considerations for ESRD patients.

Peritoneal dialysis

Peritoneal dialysis has now become an established form of renal replacement therapy; nearly half the patients on dialysis in the UK are treated in this way. Survival of patients is now equal to that with haemodialysis. However, long-term peritoneal dialysis (>8 years) is limited to a small percentage of patients because of dropout to haemodialysis for inherent complications of peritoneal dialysis--peritonitis, peritoneal access, inadequate dialysis, and patient-related factors. However, improvements in the understanding of the pathophysiological processes involving the peritoneal membrane have paved the way for advances in the delivery of adequate dialysis, more biocompatible dialysis fluids, and automated peritoneal dialysis. Other technical advances have led to a reduction in peritonitis. Peritoneal dialysis is an important dialysis modality and should be used as an integral part of RRT programmes.

Current and future modalities for functional renal replacement

Approximately 310,000 Americans suffer from end-stage renal disease, with more than 70,000 new cases reported each year. Advances in immunosuppressive therapy for transplanted patients, in addition to the refined care of patients who are dependent on dialysis, have led to an improved survival for patients with renal failure. Structural, molecular, and pharmacologic developments continue to enhance the efficacy and safety of dialysis in the future. In addition, progressive improvements in the past 2 decades in organ transplantation, a greater insight into the immunobiology of graft rejection, and better surgical and medical management have resulted in improved outcomes. Although renal xenotransplantation is still in its early stages of development, additional research is leading this technology forward. Recent successes in harvesting and expanding renal cells in vitro and the development of biologically active synthetic materials allow for the creation of three-dimensional functioning renal units, which, in the future, may be applied ex vivo or in vivo for partial or full replacement of kidney function.

Peritoneal dialysis-associated peritonitis caused by Propionibacteria species

There are an increasing number of reports about unusual causes of peritonitis in peritoneal dialysis (PD) patients. The Propionibacteria species is a microorganism that is a normal skin flora. Under the presence of certain risk factors, it may produce serious infections. Patients at risk of having Propionibacteria sp infections have malignancy, diabetes mellitus, foreign bodies, or immunodeficiency. We describe a PD-associated peritonitis in a 51-year-old woman that was caused by Propionibacteria sp. This patient's risk factors for developing Propionibacteria sp peritonitis include a history of CREST syndrome, malignancy of the breast, and recent catheter surgery. To our knowledge, this is the first case of a PD-associated peritonitis caused by Propionibacteria sp reported in the literature.

Pharmacokinetics of intraperitoneal fluconazole during continuous cycling peritoneal dialysis

OBJECTIVE

To investigate the pharmacokinetic characteristics of intraperitoneal fluconazole in patients undergoing continuous cycling peritoneal dialysis (CCPD).

DESIGN

Prospective, nonrandomized, single-dose, open-label study.

PARTICIPANTS

Five noninfected volunteer CCPD patients.

INTERVENTIONS

Patients received a single dose of intraperitoneal fluconazole 200 mg during their long daytime dwell. Blood samples were collected before and 1, 3, 6, 12 (end of first dwell), 24 (after overnight cycling), 48, 72, 96, and 120 hours after dosing. Used dialysate was collected throughout the study. Unless the patient was anuric, urine was collected for the first 48 hours.

MAIN OUTCOME MEASURE

Fluconazole concentrations were assayed by gas-liquid chromatography. Pharmacokinetic parameters were calculated using standard noncompartmental techniques.

RESULTS

The bioavailability of intraperitoneal fluconazole was 96% +/- 2% over a 12-hour dwell, absorption half-life was 2.5 +/- 1.2 hours, serum elimination half-life was 71.65 +/- 12.76 hours, and volume of distribution was 0.66 +/- 0.13 L/kg. Peritoneal clearance was 5.96 +/- 0.93 mL/min and proportional to total dialysate volume. Renal clearance was proportional to renal creatinine clearance.

CONCLUSIONS

Current treatment guidelines for fungal peritonitis suggest fluconazole 200 mg intraperitoneally every 24 hours. Our data suggest that this dose, administered every 48 hours, is more than sufficient to maintain serum and peritoneal concentrations above the minimum inhibitory concentration for most Candida spp. Other factors, such as residual renal function and dialysis prescription, may also need to be considered.

Intraperitoneal thrombolytic therapy for peritoneal dialysis-associated peritonitis

OBJECTIVE

To review the literature pertaining to the use of adjunctive thrombolytic therapy for the treatment of peritoneal dialysis-associated peritonitis (PDAP).

DATA SOURCES

A MEDLINE search was conducted (January 1966-December 1997) to find articles using the terms peritonitis, peritoneal dialysis, and each thrombolytic drug. References from these articles were then reviewed to identify further sources.

DATA EXTRACTION

Representative case reports and clinical trials are summarized in this report. Information regarding thrombolytic dosing, administration techniques, and reported efficacy rates are included from both case reports and clinical trials.

DISCUSSION

Thrombolytic agents administered intraperitoneally appear to facilitate antibiotic penetration into the biofilm formed by certain bacteria. Numerous case reports of intraperitoneal thrombolytic adjunctive therapy for recurrent or persistent PDAP have indicated that these agents may have a role in the treatment of selected patients. Urokinase and streptokinase are the only thrombolytics that have been studied. They appear to have similar efficacy, but the adverse drug event rate with streptokinase is unacceptably high. The efficacy of therapy with urokinase is probably inferior to removal of the peritoneal dialysis catheter, but, if successful, allows for the continuation of peritoneal dialysis therapy.

CONCLUSIONS

In conjunction with appropriate antibiotic therapy, intraperitoneal instillation of urokinase should be reserved for patients who develop two or more episodes of recurrent or persistent PDAP in the absence of poor compliance and in whom dialysis catheter removal should be avoided (i.e., they cannot tolerate hemodialysis).