The unwell patient on peritoneal dialysis: what you need to know on an acute medical take

Chronic kidney disease is common and its prevalence is increasing. Acceptance of patients onto renal replacement therapies is also increasing and currently it is estimated that around 640 people per million are on some form of renal replacement therapies (Renal Association, 2005), of whom 25% are over the age of 75 years. Annually, the acceptance rate for renal replacement therapy in adults is just over 100 people per million. Chronic kidney disease is associated with a heavy burden of co-morbidities, especially cardiovascular, where there is around a 10–20-fold increased incidence than in the general population (Foley et al, 1998).

Fungal peritonitis in children on peritoneal dialysis

Fungal peritonitis is a rare but serious complication in children on peritoneal dialysis (PD). In this study, risk factors were evaluated, and therapeutic measures were reviewed. A retrospective, multi-centre study was performed in 159 Dutch paediatric PD patients, between 1980 and 2005 (3,573 months). All peritonitis episodes were reviewed. Fungal peritonitis episodes were evaluated based on possible risk factors and treatment strategy. A total of 321 episodes of peritonitis occurred, with 9 cases of fungal peritonitis (2.9%). Candida peritonitis occurred most frequently (78%). Seven patients (78%) had used antibiotics in the prior month. Fungal peritonitis patients had a higher previous bacterial peritonitis rate compared to the total study population (0.13 versus 0.09 episodes/patient*month), with twice as many gram negative organisms. In all fungal peritonitis patients, the PD catheter was removed. In four patients restart on PD was possible. Fungal peritonitis is a rare complication of PD in children, but is associated with high technique failure. The most important risk factors are a high bacterial peritonitis rate, prior use of antibiotics, and previous bacterial peritonitis with gram negative organisms. The PD catheter should be removed early, but in children, peritoneal lavage with fluconazole before removal may be useful to prevent technique failure.

Continuous ambulatory peritoneal dialysis peritonitis: broth inoculation culture versus water lysis method

BACKGROUND/AIM

In the setting of empiric antibiotic treatment of peritoneal-dialysis-related peritonitis complications, the speed with which a bacteriological diagnosis can be achieved is of importance. We compare the clinical performance of two culture methods to diagnose the causative microorganisms as suggested by the International Society for Peritoneal Dialysis and the United Kingdom Health Protection Agency.

METHODS

We prospectively evaluated microbiological cultures of peritoneal fluid samples by the direct broth culture versus water lysis. Samples from 17 consecutive patients with dialysis-associated peritonitis were examined.

RESULTS

Of the 17 dialysates cultured, 14 (82.4%) were positive by one of the two methods. The final culture results agreed in 16 of 17 specimens (94.1%). The preliminary organism identification rate by Gram staining with the broth culture method was 70.6%, which was significantly greater than 17.6% by the water lysis method (p = 0.0019). In particular, the broth culture technique demonstrated superior Gram stain performance to identify Gram-positive organisms. Among the 13 dialysate samples positive by both methods, the broth culture method detected organisms faster than the water lysis method (1.3 +/- 0.7 vs. 2.6 +/- 1.6 days, p = 0.005).

CONCLUSIONS

Our results support the routine use of the broth culture technique using BacT/Alert blood culture bottles in order to facilitate early streamlining of empiric antibiotic therapy. Gram staining of sediments after centrifugation is associated with low diagnostic yield. Whether the lysis-centrifugation technique could provide additional value in case of peritonitis with a high likelihood of culture-negative results needs to be evaluated.

Fungal peritonitis in peritoneal dialysis patients: is previous antibiotic therapy an essential condition?

The aim of this study was to analyse the clinical and microbiological features of fungal peritonitis, in chronic peritoneal dialysis patients, focusing on non-traditional risk factors for this feared complication. From 2001 to 2004, five episodes of fungal peritonitis were diagnosed in five different patients, accounting for 4.5% of all peritonitis cases seen during this period. Candida spp. were the most frequent isolates. In all cases, peritoneal dialysis catheter removal and switching to haemodialysis were necessary. In these five cases of fungal peritonitis only one was preceded by antibiotic use, within the previous 3 months, the classical risk factor for fungal peritonitis. Identifying predisposing factors usually not taken into account, may lead to an early diagnosis and to a better understanding of fungal peritonitis pathogenesis.

Stability of moxifloxacin injection in peritoneal dialysis solution bags (Dianeal PD1 1·36%®and Dianeal PD1 3·86%®)

BACKGROUND AND OBJECTIVE

Moxifloxacin is a new fluorquinolone with broad-spectrum activity. It is suitable for treating peritonitis in peritoneal dialysis (PD) patients. The objective of this study was to test stability of moxifloxacin in PD solutions stored at different temperatures.

METHODS

Dialysis solution bags were used at two glucose concentrations; Dianeal PD1 1.36% and Dianeal PD1 3.86%. Moxifloxacin solution (2%) was injected into nine 2-L bags of Dianeal PD1 1.36% and nine bags of Dianeal PD1 3.86% under aseptic conditions to achieve a nominal concentration of 25 mg/L. Three bags of Dianeal PD1 1.36% and three bags of Dianeal PD1 3.86% were stored at each of three temperatures (4, 25 and 37 degrees C) and the same way for. Duplicate samples (2 mL) were taken at different times and precipitation, cloudiness, colour and pH was analysed. Moxifloxacin concentrations were measured using a modified HPLC method.

RESULTS

The mean moxifloxacin concentration in the Dianeal PD1 1.36% solution remained > or =90% of the initial concentration for 14 days at 4 degrees C, 7 days at 25 degrees C and 3 days at 37 degrees C. For Dianeal PD1 3.86% moxifloxacin concentrations remained > or =90% for 14 days at 4 degrees C, 3 days at 25 degrees C and 12 h at 37 degrees C.

CONCLUSIONS

Moxifloxacin shows sufficient stability in both PD bags for use in PD patients.

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.

Use of the embedded peritoneal dialysis catheter: Experience and results from a North American Center

Since 2000, the Ottawa Hospital Home Dialysis Program has used a variation on the embedded peritoneal dialysis catheter technique described by Moncrief et al. In this paper, we describe our approach to placement of peritoneal access and report our experience with 304 embedded catheters placed between January 2000 and December 2003. We review the advantages and disadvantages of this technique and describe factors that have been important to the success of our program.

Structural requirements for a successful chronic peritoneal dialysis program

Recently, there has been a decline in chronic peritoneal dialysis (CPD) utilization in several countries. And, in these countries, the percent of patients with end-sage renal disease maintained on CPD is less than nephrologists think is appropriate. The reasons for these problems are uncertain, but it is likely that difficulties with the structural organization of CPD facilities play a contributory role. This paper discusses the structural requirements for a successful CPD program, focusing attention on the following domains: (1) adequate chronic kidney disease education, (2) provision and support of physician training in the principles and practice of CPD, (3) adequate size and organization of CPD centers, (4) development of appropriate support systems within the CPD facility, and (5) development of appropriate continuous quality improvement programs to monitor a variety of domains, including adequacy of dialysis, peritonitis rates, catheter infections and problems, psychosocial status of patients, etc.

Three-year analysis of microbial aetiology and antimicrobial susceptibilities of PD peritonitis

The first-line antibiotic treatment of peritoneal dialysis (PD) peritonitis has to cover the most common causative microorganisms. Our aim was to analyse antimicrobial sensitivities of different empirical protocols for initial therapy of PD peritonitis. We analysed the aetiological microorganisms of PD peritonitis and their antimicrobial sensitivities during a 36-month period. Clinical characteristics of the cases were recorded. Altogether 86 PD peritonitides were diagnosed during the study period. In 58 cases, microbial cultures were positive with 72 different causative agents. 28 cases (33%) were culture-negative. Over-representation of icodextrin users was noted among the culture-negative cases. Staphylococcus aureus was the most frequent causative agent, often leading to severe course of illness. Of antimicrobial protocols for initial treatment of peritonitis tested in vitro, the combination of a first-generation cephalosporin and an aminoglycoside was superior to the combination of a first-generation cephalosporin and ceftazidime as well as to fluoroquinolone monotherapy but similar to the combination of vancomycin and ceftazidime. Based on antimicrobial sensitivities we continue using an aminoglycoside in the empirical treatment of PD peritonitis. In the present material, users of icodextrin PD fluid were over-represented among patients with culture-negative peritonitis.

Non-Pseudomonas Gram-negative peritonitis

Non-Pseudomonas Gram-negative organisms account for over 10% of cases of peritoneal dialysis-associated peritonitis. The key findings from a paper by Szeto et al. are discussed and compared with those from previous publications. This type of peritonitis has a high rate of catheter removal and technique failure. Results may be better with more aggressive antibiotic treatment. Other developments in the field are reviewed.

Peritonitis after liver transplantation: Incidence, risk factors, microbiology profiles, and outcome

Peritonitis occurring after liver transplantation (PLT) has been poorly characterized to date. The aims of this study were to define the incidence, risk factors, microbiology profiles, and outcome of nonlocalized PLT. This was a retrospective study of 950 cadaveric liver transplantation (LT) procedures in 837 patients, followed for a mean of 1,086 days (range, 104-2,483 days) after LT. PLT was defined as the presence of at least one positive ascitic fluid culture after LT. There were 108 PLT episodes in 91 patients occurring at a median of 14 days (range, 1-102 days) after LT. Significant risk factors associated with the development of PLT by multivariate analysis included pre-LT model for end-stage liver disease score, duration of LT surgery, Roux-en-Y biliary anastomosis, and renal replacement therapy after LT. Biliary complications, intra-abdominal bleeding, and bowel leak/perforation were associated with 34.3%, 26.9%, and 18.5% of episodes, respectively. Multiple organisms, gram-positive cocci, fungus, and multidrug-resistant bacteria were isolated in 61.1%, 92.6%, 25.9%, and 76.9% of ascitic fluid cultures, respectively. The 28 fungal PLT episodes were associated with bowel leak/perforation and polymicrobial peritonitis. Patients who developed PLT after their first LT had a significantly greater risk of graft loss or mortality compared to unaffected patients. Parameters significantly associated with these adverse outcomes by multivariate analysis were recipient age at LT and bowel leak or perforation after LT. In conclusion, PLT is a serious infectious complication of LT, associated with significant intra-abdominal pathology and reduced recipient and graft survival.

Diagnosis and management of enteric disease and abdominal catastrophe in peritoneal dialysis patients with peritonitis

Peritoneal dialysis (PD)-associated peritonitis rates have decreased significantly in recent years, especially Staphylococcus epidermidis and Staphylococcus aureus infections. Rates of gram-negative, polymicrobial, and fungal peritonitis have remained steady. The reported mortality of gram-negative and polymicrobial peritonitis varies widely (4%-50%). Most likely, the reason for this variability is that prognosis depends on the underlying etiology more than the specific microorganisms isolated. Gram-negative, polymicrobial, and fungal infection have variable association with documented visceral disease, and the highest mortality occurs in reports with the highest prevalence of intra-abdominal pathology. The odds ratio of death in PD patients with documented abdominal catastrophe and peritonitis is reported to be 20:1 compared with all other causes. Further reductions in PD-associated peritonitis mortality are likely to depend on earlier diagnosis and better management of intra-abdominal pathology. Presentation with hypotension, sepsis, lactic acidosis, and/or elevation of peritoneal fluid amylase should raise immediate concern for "surgical" peritonitis. Suspicion for visceral disease should also be high in patients with gram-negative, polymicrobial, and fungal infection or those who fail to improve rapidly as judged by clinical signs and symptoms, cell counts, and repeat cultures. Nonlocalizing physical examination and negative or nonspecific results of abdominal computed tomography do not rule out serious intra-abdominal disease. Immediate initiation of broad antibiotic coverage including for anaerobic infection is indicated when bowel pathology is suspected. Urgent surgical consultation, with active discussion and participation by the nephrologist, is advisable when visceral pathology is suspected and the patient is unstable or fails to improve rapidly.

Isolated Brucella peritonitis in a CAPD patient

Peritonitis is the most common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Brucellosis is a rare cause of bacterial peritonitis. Only 1 case was reported of a patient with brucella peritonitis during CAPD therapy. In that case, CAPD peritonitis was accompanied by acute brucellosis. We present the case of a patient with isolated brucella peritonitis receiving CAPD therapy without systemic manifestations of brucellosis who works as a farmer. Results of a serum agglutination test and blood cultures were negative; however, the patient's peritoneal fluid agglutination titer was 1:160 and samples inoculated into BACTEC (Becton Dickinson, NJ) bottles yielded Brucella melitensis. Because we were unable to isolate the organism in blood samples, transmission seems to be the result of direct inoculation, rather than hematogenous spreading. Therefore, our patient represents the first case of isolated brucella peritonitis during CAPD therapy. Successful treatment was obtained by using a treatment regimen of rifampin and doxycycline.

Pseudomyxoma Peritonei as a Cause of Culture-Negative Peritonitis for a Patient Undergoing Peritoneal Dialysis

Culture-negative peritonitis accounts for up to 20% of all peritoneal dialysis-related peritonitis, the causes of which include culture-associated technical errors, prior use of antibiotics, infection caused by certain unusual or fastidious microorganisms, the development of abdominal or retroperitoneal organ inflammation, and the presence of malignancies. Here, we report a patient with end-stage renal disease receiving peritoneal dialysis who presented with culture-negative peritonitis and ultrafiltration failure caused by the rare pseudomyxoma peritonei. For cases of culture-negative peritonitis such as this, early imaging studies may help recognize intraperitoneal/retroperitoneal visceral inflammation and malignant conditions.

Enterobacteriaceae peritonitis complicating peritoneal dialysis: A review of 210 consecutive cases

Enterobacteriaceae peritonitis is a serious complication in peritoneal dialysis (PD), but the clinical course of PD-related Enterobacteriaceae peritonitis remains unclear. We reviewed all Enterobacteriaceae peritonitis in our dialysis unit from 1995 to 2004. During this period, there were 1748 episodes of peritonitis recorded; 210 episodes (12.0%) in 123 patients were caused by Enterobacteriaceae. The most common species was Escherichia coli, accounting for 111 episodes. The primary response rate was 84.8% and complete cure rate was 58.1%. The presence of exit site infection was associated with a lower complete cure rate (43.2 versus 61.3%, P = 0.034). A total of 82 episodes (39.0%) did not respond to single antibiotic treatment despite sensitivity in vitro, and a second antibiotic was added. Patients treated with two antibiotics had a marginally lower risk of relapse and recurrence than those with one antibiotic (21.4 versus 36.1%, P = 0.051). The episodes that had recent antibiotic therapy had a marginally lower complete cure rate (49.3 versus 62.8%, P = 0.06). There was a gradual increase in the prevalence of resistance to several commonly used antibiotics over the years. Recent antibiotic therapy was associated with resistance to cefotaxime, ceftazidime, cefoperazone/sulbactam, and piperacillin/tazobactam. We conclude that Enterobacteriaceae peritonitis is a serious complication of PD. Recent antibiotic therapy is the major risk factor of antibiotic resistance. Exit site infection, and probably recent antibiotic therapy, is associated with poor therapeutic response. Contrary to the current recommendation, treatment with two antibiotics may reduce the risk of relapse and recurrence.

[Hospitalization of peritoneal dialysis patients: the impact of peritonitis episodes on the hospitalization rate]

Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.

Effect of two-chambered bicarbonate lactate-buffered peritoneal dialysis fluids on peripheral blood mononuclear cell and polymorphonuclear cell function in vitro

Low pH, high osmolality, increasing glucose concentration, and glucose degradation products (GDP) formed during heat sterilization of conventional peritoneal dialysis (PD) fluids have been shown to have a detrimental effect on cells involved in peritoneal host defense. The two-chambered PD fluid bag in which glucose at pH approximately 3 is separated from a bicarbonate (25 mmol/L)-lactate (15 mmol/L) buffer during heat sterilization permits PD fluids with lower GDP to be delivered to the patient at neutral pH. To establish the possible benefit of two-chambered bag PD fluids on peripheral blood mononuclear cell (PBMC) and polymorphonuclear (PMN) cell function, we compared conventional 1.5% Dianeal (1.5%D) with 1.5% two-chambered bag bicarbonate-lactate (1.5%D-B), and conventional 4.25% Dianeal (4.25%D) with 4.25% two-chambered bag bicarbonate-lactate (4.25%D-B). Furthermore, to study the effect of the sterilization process on PBMC and PMN function, we compared filter-sterilized 4.25%D (4.25%D-F) with 4.25%D and 4.25%D-B. PBMC were harvested by Ficoll-Hypaque separation, and 2.5 x 10(6) cells in RPMI were incubated with an equal volume of the test fluids for 4 hours, pelleted, and resuspended in RPMI containing 10 ng endotoxin for a further 20 hours. Tumor necrosis factor alpha (TNF-alpha) production by endotoxin-stimulated PBMC was not significantly different (P = 0.10) between 1.5%D-B and 1.5%D, but was significantly higher (P = 0.01) with 4.25%D-B compared with 4.25%D. PBMC exposed to filter-sterilized fluid (4.25%D-F) showed significantly higher endotoxin-stimulated TNF-alpha production compared with 4.25%D (P = 0.02), but was not significantly different from 4.25%D-B (P = 0.40). PMN were harvested by Ficoll-Hypaque separation and 10 x 10(6) cells incubated with test fluids for 30 minutes. After incubation, phagocytosis (phagocytosis index) was determined by the uptake of 14C-labeled Staphylococcus aureus, oxidative burst by reduction of ferricytochrome C to ferrocytochrome C on stimulation with PMA, and enzyme release by measurement of endotoxin-stimulated bactericidal/permeability increasing protein (BPI). Bicarbonate-lactate two-chambered fluids of similar osmolality and glucose concentration conferred a significant improvement in phagocytosis (P = 0.02 for 1.5%D-B and P < 0.001 for 4.25%D-B). Oxidative burst and BPI release were significantly higher in 4.25%D-B compared with 4.25%D (P < 0.001). Filter-sterilized 4.25%D-F conferred a significant improvement in phagocytosis and oxidative burst compared with 4.25%D (P < 0.001) or 4.25%D-B (P < 0.001). Furthermore, conventional 4.25%D was associated with significantly lower BPI release compared with 4.25%D-F (P = 0.01). GDP's acetaldehyde and 5-HMF were analyzed in 4.25%D-B, 4.25%D, and 4.25%D-F. Acetaldehyde was below the lower limit (0.79 ppm) of the standard curve in 4.25%D-B and 4.25%D-F fluids but was detected (3.76 to 5.12 ppm) in all of the 4.25%D fluids. Relative levels of 5-HMF in the 4.25%D-B (0.032 to 0.041 Abs @ 284 nm) and 4.25%D (0.031 to 0.036 Abs @ 284 nm) were similar. The lowest levels (0.001 Abs @ 284 nm) were observed in the filter-sterilized 4.25%D-F. The beneficial effects of two-chambered bicarbonate lactate-buffered PD fluids on PBMC and PMN function are probably related to reduction of GDP from heat sterilization of glucose in a separate chamber at a lower pH. This improvement in biocompatibility could have a beneficial affect on peritoneal defenses.