Peritoneal dialysis-related infections recommendations: 2016 update. What is new?

Peritoneal dialysis-related peritonitis due to Pasteurella multocida in Australia

Domestic animals are common in Australian households; however, there is little research into the potential risks these animals pose to patients undergoing in-home peritoneal dialysis (PD). Cats and dogs are known to carry many potential pathogens, including Pasteurella multocida. We reviewed the ANZDATA Peritoneal Dialysis Peritonitis Registry for cases of peritonitis due to Pasteurella multocida between 2011 and 2023. Cases identified were younger and more likely to be female compared with the Australian PD population who developed peritonitis due to other organisms. Of the total 32 episodes, 75% were using automated PD with glucose-based solutions. Two cases requiring removal of the PD catheter and transfer to haemodialysis and no deaths were reported. Whilst outcomes were largely favourable, it is likely that many of these cases could have been prevented. Education for people undergoing PD should include information about the potential infectious hazards of domestic animals.

Effectiveness of a Customized Peritoneal Dialysis Training Program in Reducing Infection and Dropout Rates: Insights From a Singapore Hospital

Introduction Peritoneal dialysis (PD) is an essential home-based treatment for end-stage kidney disease, known for enhancing patients' quality of life and being more cost-effective compared to hemodialysis. However, in Singapore, PD education lacks of standardization, with each unit adopting varied methods based on their own experiences and resources. To address this, our hospital developed a tailored four-day PD training program guided by the International Society for Peritoneal Dialysis guidelines, adapted to meet local needs and resource availability. Methodology This study employed a retrospective cohort design, including all incident adult patients aged 18 years and above who initiated PD at our hospital from September 2018 to July 2023. Data on PD dropout rates and PD-related infection rates, such as PD peritonitis and exit site infection rates, were obtained from electronic medical records. Results This study comprised 99 patients who began PD and completed their PD training program at our hospital between September 2018 and July 2023. Our tailored PD training program successfully reduced dropout rates and maintained infection rates within the International Society for Peritoneal Dialysis guidelines. Specifically, exit site infection rates fluctuated between 0.18 and 0.29 episodes per year, PD peritonitis rates ranged from 0.2 to 0.26 episodes per patient-year, and dropout rates significantly improved from 40% in 2019 to 7% in 2023 (OR = 0.45, 95% CI = 0.49 to 0.84, p = 0.010). Conclusions The tailored PD training program at our hospital effectively reduced PD-related infections and dropout rates among end-stage kidney disease patients. These findings suggest that structured, locally adapted training programs can substantially improve patient outcomes in PD.

Development of a Supramolecular Hydrogel for Intraperitoneal Injections

Local intraperitoneal drug administration is considered a challenging drug delivery route. The therapeutic efficiency is low, mainly due to rapid clearance of drugs. To increase the intraperitoneal retention time of specific drugs, a pH-sensitive supramolecular hydrogel that can act as a drug delivery vehicle is developed. To establish the optimal formulation of the hydrogel and to study its feasibility, safety, and tissue compatibility, in vitro, postmortem, and in vivo experiments are performed. In vitro tests reveal that a hydrogelator formulation with pH ≥ 9 results in a constant viscosity of 0.1 Pa·s. After administration postmortem, the hydrogel covers the parietal and visceral peritoneum with a thin, soft layer. In the subsequent in vivo experiments, 14 healthy rats are subjected to intraperitoneal injection with the hydrogel. Fourteen and 28 days after implantation, the animals are euthanized. Intraperitoneal exposure to the hydrogel is not resulted in significant weight loss or discomfort. Moreover, no macroscopic adverse effects or signs of organ damage are detected. In several intra-abdominal tissues, vacuolated macrophages are found indicating a physiological degradation of the synthetic hydrogel. This study demonstrates that the supramolecular hydrogel is safe for intraperitoneal application and that the hydrogel shows good tissue compatibility in rats.

Comparison of mortality according to baseline, first year, and mean albumin levels in peritoneal dialysis: a retrospective study

BACKGROUND

The relationship between hypoalbuminemia in peritoneal dialysis (PD) and mortality, risk of peritonitis, and decreased residual renal function (RRF) is known. However, we have not encountered a comprehensive study on which of the mean albumin values, at the beginning of peritoneal dialysis, in the first year, and during the peritoneal dialysis period, provide more predictive predictions regarding mortality, peritonitis risk, and RRF reduction.

METHODS

A total of 407 PD patients in whom PD was initiated and followed up and PD was terminated were included in the study. Albumin levels, peritonitis, and RRF at the beginning of PD and at 3-month periods during PD were recorded.

RESULTS

In the evaluation of the patients, there was a significant relationship between mean, first-year albumin values in RRF loss (p = 0.001, p = 0.006, respectively) and peritonitis (p < 0.001), but no significant correlation was found with baseline albumin values (p = 0.213, p = 0.137, respectively). In the comparison of mortality ROC analysis of PD patients, a significant correlation was found with mortality at baseline, first year, and mean albumin values (p < 0.001). However, in the multivariate Cox regression analysis, it was determined that there was a more significant relationship between first-year albumin and mean albumin values compared to baseline albumin values (HR 0.918 [95% CI 0.302-0.528] (p < 0.001)), (HR 1.161 [95% CI 0.229-0.429] (p < 0.001)), (HR 0.081 [95% CI 0.718-1.184] (p = 0.525)).

CONCLUSIONS

In conclusion, mean and first-year mean albumin levels provide more determinative predictions for mortality, risk of peritonitis, and maintenance of residual renal functions in peritoneal dialysis patients compared to baseline albumin.

The effect of rural and urban life on peritonitis rates in chronic peritoneal patients

BACKGROUND

It has been reported that living far from the peritoneal dialysis (PD) unit is a risk factor for peritonitis. Considering that PD units are urban located; the question of whether living in a rural area compared to an urban area is a risk factor for peritonitis has arisen.

METHODS

From March 2010 to August 2020, 335 episodes of peritonitis in 202 PD patients followed in a single center were evaluated retrospectively. People living in areas with a population <1000 were defined as living in rural areas regardless of their distance from the PD center. Cox regression analysis was used to identify independent factors associated with peritonitis.

RESULTS

A total of 202 PD patients were followed during 791 patient-years (mean follow-up of 3.9 years per patient). Total patients had 335 episodes of peritonitis and the rate of peritonitis was 0.42 episodes per year (episodes/patient-year). Cox regression analysis revealed that living environment (urban vs. rural) was not a risk factor for peritonitis (p = 0.57).

CONCLUSIONS

In Turkey, we report that living in a rural area in our region is not a risk factor for peritonitis. It is not the right approach for both the physician and the patient to be reluctant in the choice of PD due to the concern of peritonitis in rural areas.

Platelet-to-lymphocyte ratio and the first occurrence of peritonitis in peritoneal dialysis patients

BACKGROUND

Platelet-to-lymphocyte ratio (PLR) has been used as a potential biomarker of inflammation-related diseases, but its role in the peritoneal dialysis-related peritonitis (PDRP) is still uncertain. This study was aimed to investigate the association between PLR and the new-onset PDRP in peritoneal dialysis (PD) patients.

METHODS

In this multicenter retrospective study, 1378 PD Chinese PD patients were recruited from four centers, who were divided into the high PLR group (HPG) and the low PLR group (LPG) according to the cutoff value of PLR. The correlation between PLR and the new-onset PDRP was assessed using the Cox regression model analysis.

RESULTS

During follow-up, 121 new-onset PDRP events were recorded. Kaplan-Meier survival curve showed a higher risk of new-onset PDRP in the HPG (log-rank test, P < 0.001). After adjusting for confounding factors, the Cox regression model showed the risk of new-onset PDRP was higher in the HPG than that in the LPG (HR 1.689, 95%CI 1.096-2.602, P = 0.017). Competitive risk model analysis showed that significant differences still existed between the two PLR groups in the presence of other competitive events (P < 0.001).

CONCLUSION

PLR is independently associated with the new-onset PDRP in PD patients.

Bacterial Peritonitis Caused by Tsukamurella inchonensis in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

Background

Tsukamurella is an environmental saprophyte that potentially causes various infections in humans. It has been reported to cause rare opportunistic infections in immunocompromised patients or patients with indwelling foreign bodies.

Case Presentation

We report a case of continuous ambulatory peritoneal dialysis (CAPD)-related peritonitis caused by Tsukamurella inchonensis (T. inchonensis). The patient was admitted to our hospital while demonstrating a cloudy peritoneal dialysate. Peritoneal fluid sample culturing yielded yellow-greyish, dry and membrane-like colonies. Gram staining showed straight, gram-positive rods. The organism was identified to be Tsukamurella species by matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS). It was then characterized to be homologous to T. inchonensis in the GenBank database by 16S Ribosomal RNA Sequencing. The strain was susceptible to quinolones, carbapenems and linezolid, but intermediately resistant to vancomycin in drug susceptibility testing. Eventually, the peritonitis was controlled with meropenem and the patient discharged from the hospital.

Conclusion

Here, we describe the first case of CAPD-related peritonitis caused by T. inchonensis in China. Importantly, T. inchonensis show resistance to cephalosporins and heterogeneous resistance to vancomycin, guideline-based empiric therapy occasionally fails. Further analyses of similar cases are required to understand the characteristics and formulate appropriate therapy regimen for T. inchonensis infections.

Cloudy fluid, cloudy diagnosis

Here, we report a case of a patient with cloudy effluent that was initially diagnosed as bacterial peritonitis. The persistence of a cloudy effluent despite antibiotic therapy led to an extensive peritoneal dialysis (PD) effluent analysis, with the final diagnosis being high-grade B-cell lymphoma. This case will increase the awareness of this rare presentation of a lymphoproliferative disorder reminding clinicians to consider this diagnosis as a part of the differential diagnosis PD effluent.

Characterization of Oral Enterobacteriaceae Prevalence and Resistance Profile in Chronic Kidney Disease Patients Undergoing Peritoneal Dialysis

Chronic Kidney Disease (CKD) is a growing public-health concern worldwide. Patients exhibit compromised immunity and are more prone to infection than other populations. Therefore, oral colonization by clinically relevant members of the Enterobacteriaceae family, major agents of both nosocomial and dialysis-associated infections with frequent prevalence of antibiotic resistances, may constitute a serious risk. Thus, this study aimed to assess the occurrence of clinically relevant enterobacteria and their antibiotic resistance profiles in the oral cavity of CKD patients undergoing peritoneal dialysis (CKD-PD) and compare it to healthy controls. Saliva samples from all the participants were cultured on MacConkey Agar and evaluated regarding the levels of urea, ammonia, and pH. Bacterial isolates were identified and characterized for antibiotic resistance phenotype and genotype. The results showed that CKD-PD patients exhibited significantly higher salivary pH, urea, and ammonia levels than controls, that was accompanied by higher prevalence and diversity of oral enterobacteria. Out of all the species isolated, only the prevalence of Raoultella ornithinolytica varied significantly between groups, colonizing the oral cavity of approximately 30% of CKD-PD patients while absent from controls. Antibiotic resistance phenotyping revealed mostly putative intrinsic resistance phenotypes (to amoxicillin, ticarcillin, and cephalothin), and resistance to sulfamethoxazole (~43% of isolates) and streptomycin (~17%). However, all isolates were resistant to at least one of the antibiotics tested and multidrug resistance isolates were only found in CKD-PD group (31,6%). Mobile genetic elements and resistance genes were detected in isolates of the species Raoultella ornithinolytica, Klebsiella pneumoniae, Klebsiella oxytoca, Escherichia coli, and Enterobacter asburiae, mostly originated from CKD-PD patients. PD-related infection history revealed that Enterobacteriaceae were responsible for ~8% of peritonitis and ~ 16% of exit-site infections episodes in CKD-PD patients, although no association was found to oral enterobacteria colonization at the time of sampling. The results suggest that the CKD-induced alterations of the oral milieu might promote a dysbiosis of the commensal oral microbiome, namely the proliferation of clinically relevant Enterobacteriaceae potentially harboring acquired antibiotic resistance genes. This study highlights the importance of the oral cavity as a reservoir for pathobionts and antibiotic resistances in CKD patients undergoing peritoneal dialysis.

Neisseria cinerea-Mediated Peritonitis in an End-Stage Renal Disease Patient on Continuous Ambulatory Peritoneal Dialysis

Peritonitis can be a lethal outcome of peritoneal dialysis (PD), often leading to significant morbidity and mortality. It is caused mostly by gram-positive organisms. Neisseria cinerea is a gram-negative nasal and oropharyngeal commensal, rarely reported as an etiology of peritonitis in PD patients. Our patient was a 37-year-old female on continuous ambulatory peritoneal dialysis for the last seven years, who developed peritonitis found to be from Neisseria cinerea. She didn't respond to broad-spectrum antibiotics well and had to be switched to intermittent hemodialysis. We highlight this important microorganism that can lead to significant morbidity and an unfortunate change in dialysis modality.

Assisted peritoneal dialysis: a feasible KRT modality for frail older patients with end-stage kidney disease (ESKD)

Assisted PD is used as an alternative option for the growing group of frail, older ESKD patients unable to perform their own PD. This study was undertaken to investigate the outcomes of assisted PD in older patients by comparing assisted PD patients with self-care PD patients. This study included all patients aged 70 and above who started on PD in our hospital from 2009 to 2018. Patients were followed up until death, PD cessation or to the end of the study (December 31, 2019). Risk factors associated with mortality, peritonitis and technique failure were evaluated using both cause-specific hazards and subdistribution hazards models. 180 patients were enrolled, including 106 (58.9%) males with a median age of 77.5 (77.2-81.2) years. Among the 180 patients, 62 patients (34.4%) were assisted. Patients on assisted PD group were older, more likely to be female, more prevalent in DM and CVD, with a higher Charlson score than patients undergoing self-care PD (P all < 0.05). In the multivariable analysis, assisted patients had a comparable patient survival and peritonitis-free survival compared to self-care PD patients either in the Cox or in the FG models. According to a Cox model, the use of assisted PD was associated with a lower risk of technique failure (cs-HR 0.20, 95% CI 0.04-0.76), but the association lost its statistical significance in the Fine and Gray model. Our results suggest that assisted PD could be a safe and effective KRT modality for older ESKD patients who need assistance.

Experimental models in peritoneal dialysis (Review)

Peritoneal dialysis (PD) is one of the most commonly used dialysis methods and plays an important role in maintaining the quality of life of patients with end-stage renal disease. However, long-term PD treatment is associated with adverse effects on the structure and function of peritoneal tissue, which may lead to peritoneal ultrafiltration failure, resulting in dialysis failure and eventually PD withdrawal. In order to prevent the occurrence of these effects, the important issues that need to be tackled are improvement of ultrafiltration, protection of peritoneal function and extension of dialysis time. In basic PD research, a reasonable experimental model is key to the smooth progress of experiments. A good PD model should not only simulate the process of human PD as accurately as possible, but also help researchers to understand the evolution process and pathogenesis of various complications related to PD treatment. To better promote the clinical application of PD technology, the present review will summarize and evaluate the in vivo PD experimental models available, thus providing a reference for relevant PD research.

Overhydration and low serum prealbumin predict peritoneal dialysis-related peritonitis in continuous ambulatory peritoneal dialysis patients

Background

In this study, we focused on the role of overhydration (OH) and low serum prealbumin concentration in predicting peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 3-year period.

Methods

We measured serum prealbumin concentration and OH by body composition monitor in 278 CAPD patients (159 males and 119 females) with a mean age of 46 years and a median peritoneal dialysis (PD) duration of 21 months. Cases of PD-related peritonitis were collected over 3 years.

Results

After the 3-year follow-up, 44 patients were diagnosed with PD-related peritonitis (15.8%). Low education, serum glucose, prealbumin, and OH were independent risk factors for predicting peritonitis over 36 months in CAPD patients. Based on the ROC curve model and Kaplan-Meier analysis, we realized that low prealbumin and high OH were independent predictors of 3-year peritonitis in CAPD patients (Prealbumin: AUC = 0.838, cut-off value = 32.5 mg/dL, Se = 90.9%, Sp = 32.9%; OH: AUC = 0.851, cut-off value = 1.33 L, Se = 79.5%, Sp = 85.5%; and log-rank test p <  0.001, respectively).

Conclusion

Overhydration and low serum prealbumin were the independent predictors of PD-related peritonitis in CAPD patients.

The performance of the alarmin HMGB1 in pediatric diseases: From lab to clinic

INTRODUCTION

The ubiquitously expressed nonhistone nuclear protein high-mobility group box protein 1 (HMGB1) has different functions related to posttranslational modifications and cellular localization. In the nucleus, HMGB1 modulates gene transcription, replication and DNA repair as well as determines chromosomal architecture. When the post-transcriptional modified HMGB1 is released into the extracellular space, it triggers several physiological and pathological responses and initiates innate immunity through interacting with its reciprocal receptors (i.e., TLR4/2 and RAGE). The effect of HMGB1-mediated inflammatory activation on different systems has received increasing attention. HMGB1 is now considered to be an alarmin and participates in multiple inflammation-related diseases. In addition, HMGB1 also affects the occurrence and progression of tumors. However, most studies involving HMGB1 have been focused on adults or mature animals. Due to differences in disease characteristics between children and adults, it is necessary to clarify the role of HMGB1 in pediatric diseases.

METHODS AND RESULTS

Through systematic database retrieval, this review aimed to first elaborate the characteristics of HMGB1 under physiological and pathological conditions and then discuss the clinical significance of HMGB1 in the pediatric diseases according to different systems.

CONCLUSIONS

HMGB1 plays an important role in a variety of pediatric diseases and may be used as a diagnostic biomarker and therapeutic target for new strategies for the prevention and treatment of pediatric diseases.

APD or CAPD: one glove does not fit all

The use of Automated Peritoneal Dialysis (APD) in its various forms has increased over the past few years mainly in developed countries. This could be attributed to improved cycler design, apparent lifestyle benefits and the ability to achieve adequacy and ultrafiltration targets. However, the dilemma of choosing the superior modality between APD and Continuous Ambulatory Peritoneal Dialysis (CAPD) has not yet been resolved. When it comes to fast transporters and assisted PD, APD is certainly considered the most suitable Peritoneal Dialysis (PD) modality. Improved patients’ compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis have been also associated with APD. However, concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep are APD’s setbacks. Besides APD superiority over CAPD in fast transporters, the other medical advantages of APD still remain controversial. In any case, APD should be readily available for all patients starting PD and the most important indication for its implementation remains patient’s choice.

Pet-related Pasteurella multocida induced peritonitis in peritoneal dialysis: a case report and review of the literatures

Background

P. multocida (Pasteurella multocida) is animal-sourced gram-negative coccobacillus which can be transmitted to human through many animals including household pets. P. multocida induced peritoneal dialysis-related peritonitis has rarely been reported. In recent years, there has been an increase in the incidence of P. multocida induced peritoneal dialysis-related peritonitis, for the reason that patients with PD at home bred household pets. In this study, we present a case of a P. multocida induced peritoneal dialysis-related peritonitis, which is suspected to be caused through intimate contact with a household cat and we have reviewed 28 cases reported before and give suggestions for treatment and the way of prevention.

Case presentation

A 75-year-old man with end-stage renal disease (ESRD) for nearly 5 years on continuous ambulatory peritoneal dialysis (CAPD) was admitted to the nephrology department with a 1-week history of abdominal pain and a cloudy peritoneal dialysis effluent. Based on the history, physical examination and laboratory results with the findings in the peritoneal dialysis fluid, a diagnosis of peritoneal dialysis-related peritonitis was confirmed. The final culture of initial peritoneal effluent results indicated the organism was P. multocida. After a 12-day antibiotic treatment, the condition of patient was not improved. The patient was switched to ampicillin/sulbactam (3 g intravenously) twice every day and the condition was improved significantly. On further inquiring, the patient reported that he had had a cat at home and when the patient did CAPD, the cat was usually playing with the tubing or contacting the patient during CAPD.

Conclusion

In our case and reviewed cases, P. multocida induced peritoneal dialysis-related peritonitis could be cured by proper antibiotic treatment. If individuals keep the pet away from the PD process, the infection route may be severed. P. multocida induced peritoneal dialysis-related peritonitis does not need catheter removal and exchange with hemodialysis except long-time intractable peritonitis.

The relationship between oral diseases and infectious complications in patients under dialysis

OBJECTIVES

Association was investigated between oral health before dialysis and the incidence of systemic infections during dialysis. We hypothesized that low-grade systemic inflammation caused by poor oral health associates with infectious episodes in patients on dialysis, despite earlier eradication of oral infection foci.

SUBJECTS AND METHODS

A total of 117 patients (46 with peritoneal and 71 with hemodialysis) were examined and treated at predialysis stage and followed up during dialysis. Number of infection episodes and microorganisms cultured from blood and peritoneal fluid were analyzed. Number of teeth, periodontal inflammatory burden, and total dental index scores were assessed, and salivary matrix metalloproteinase 8, triggering receptor on myeloid cells 1, peptidoglycan recognition protein 1 (PGLYRP1), and interleukin-1β were measured.

RESULTS

In hemodialysis, 134 infection episodes were recorded, while peritoneal dialysis group had 77 peritonitis episodes. Culture-negative samples were 69% in hemodialysis and 23% in peritoneal dialysis group. Staphylococci were the most frequently associated microorganisms. Infections during dialysis did neither associate with oral health parameters nor associate with salivary inflammatory biomarkers, except for PGLYRP1, which associated with number of infection episodes during hemodialysis (p = .046).

CONCLUSIONS

A number of infection episodes during hemodialysis were associated with salivary PGLYRP1 but not the other salivary markers or oral infection markers.

Benefit of an operating vehicle preventing peritonitis in peritoneal dialysis patients: a retrospective, case-controlled study

BACKGROUND

Peritonitis, which is one of the leading complications of peritoneal dialysis (PD) worldwide, severely affected morbidity and mortality of the PD patients. Although many efforts have been made to prevent PD-related peritonitis, it seems impossible to prevent it completely. Many causes have been reported to lead to peritonitis, and contamination during bag exchange is one of the important risk factors for peritonitis.

METHODS

Here, we introduce an operating vehicle, which we invented to provide a sterile and safe space for bag exchange. A single-center, retrospective, case-control study was undertaken to determine whether this operating vehicle has a protective role in preventing peritonitis. In total, 462 continuous ambulatory peritoneal dialysis patients were included in this study from October 2014 to March 2017. According to their personal will, these patients chose to use operating vehicle or traditional method during their bag exchange. The demographic, clinical and laboratory data of these patients in the two groups were collected, analyzed and compared.

RESULTS

Of 462 patients with home dialysis, operating vehicle group consisted of 61 patients, and control group consisted of 401 patients. In the control group, over 677 patient-years, peritonitis occurred in 69 of 401 patients (17.2%), while in the operating vehicle group, over 60 patient-years, only 4 of 61 patients (6.6%) had episodes of peritonitis. The number of patients suffered from peritonitis was significantly decreased in the operating vehicle group (P = 0.034). Besides, there were a total of 99 episodes of peritonitis, and the rate was 1 episode every 7.2 patient-years in control group and 1 episode every 12 patient-years in the operating vehicle group. There was significant difference between the two groups (0.013). Positive dialysate cultures were obtained in majority of the peritonitis episodes (60.6%).

CONCLUSION

Operating vehicle might help to reduce PD-related peritonitis by preventing contamination during bag exchange. Further studies are still needed to demonstrate the protective role of the operating vehicle in preventing peritonitis.