Dialysate White Blood Cell Change after Initial Antibiotic Treatment Represented the Patterns of Response in Peritoneal Dialysis-Related Peritonitis

Clinical outcomes in peritoneal dialysis with refractory peritonitis: significance of the day 5 cell count

BACKGROUND

Peritoneal dialysis-associated peritonitis is a common and severe complication of peritoneal dialysis, associated with high morbidity and mortality. However, there's a lack of research on refractory peritonitis, which is difficult to manage and has a poor prognosis. Our study aimed to investigate factors affecting clinical outcomes in peritoneal dialysis patients with refractory peritonitis over a 12-year period at a medical faculty hospital in Turkey.

METHODS

We conducted a retrospective study at a single center from January 2009 to December 2020, involving 135 patients with 236 episodes of refractory peritonitis. The average age of the patient cohort was 53.0 ± 15.9 years, and 72 (53.4%) of the patients were male. The leading identified causes of end-stage kidney disease were glomerulonephritis, hypertensive glomerulosclerosis, and diabetic nephropathy. Data on microbiological etiology, dialysate white blood cell counts, and patient demographics were analyzed to identify catheter removal risk factors. Statistical significance was set at p ≤ 0.05.

RESULTS

Comparative analysis between patients with and without catheter loss revealed no significant differences in gender, age, presence of diabetes, prior hemodialysis, or duration of peritoneal dialysis. However, multivariate logistic regression analysis showed that a dialysate white blood cell count exceeding 1000/mm3 on day 5 and hospitalization had a positive association with catheter loss, while the presence of gram-positive bacterial growth had an inverse correlation.

CONCLUSION

Our study shows that fifth-day dialysate white blood cell count predicts refractory peritonitis outcomes. Future research should focus on developing tools to manage catheter removal proactively and enhance patient prognosis.

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

Risk Factors of the Occurrence and Treatment Failure of Refractory Peritoneal Dialysis-Associated Peritonitis: A Single-Center Retrospective Study From China

BACKGROUND

This study aimed to investigate the clinical characteristics and prognosis of refractory peritoneal dialysis (PD)-associated peritonitis as well as the risk factors of its occurrence and treatment failure.

METHODS

A single-center retrospective cohort study was conducted among 519 patients undergoing PD from January 2007 to October 2021. According to the International Society for Peritoneal Dialysis guidelines, all episodes occurred in our center were divided into two groups: refractory and nonrefractory. Demographic, biochemical, and pathogenic bacteria and treatment outcome data were collected.

RESULTS

During the 15-year period, 282 episodes of peritonitis occurred in 166 patients undergoing PD. The refractory rate was 34.0% (96/282). Gram-positive organisms were the leading cause of peritonitis (47.9%); however, gram-negative organisms were predominant in refractory peritonitis (34.4%, p = 0.002). Multiple logistic regression revealed that gram-negative organism-based peritonitis, longer PD duration, and female sex were the significant independent predictors of refractory peritonitis. Among 96 refractory episodes, white blood cell (WBC) count, dialysate WBC on Day 3, and PD duration ≥5 years were the independent risk factors of treatment failure.

CONCLUSIONS

Gram-negative organism-based peritonitis, longer PD duration, and female sex were the independent risk factors of refractory peritonitis. Refractory peritonitis with higher WBC count, higher dialysate WBC on Day 3, and PD duration ≥5 years increased treatment failure risk and required immediate PD catheter removal. The timely identification of refractory peritonitis with high risk of treatment failure as well as timely PD catheter removal is important.

Peritonitis caused by Listeria monocytogenes and Burkholderia cepacia in a patient on peritoneal dialysis: a case report

Peritoneal dialysis (PD)-associated peritonitis is a major cause of peritoneal dysfunction and failure. The main issue regarding the treatment is whether to remove the catheter surgically or to treat with antibiotics alone. Notably, PD-associated peritonitis is commonly caused by gram-positive cocci, but rarely by Listeria monocytogenes and Burkholderia cepacia. Here, we report a patient diagnosed with PD-associated peritonitis caused by L. monocytogenes and B. cepacia who presented with a fever, abdominal pain, and turbid dialysate and had been receiving PD for over 20 years. After 2 weeks of antibiotic treatment, the catheter in the patient was surgically removed. Culture and pathology results revealed pathogen growth, foreign body granuloma with chronic inflammation, and inflammatory cells with fibroblast infiltration. The patient was switched to hemodialysis. She eventually recovered and was discharged. The patient presented fair health at the 3-month follow-up. In conclusion, sequential dialysate white blood cell count may help clinicians decide the course of treatment and guide the timing of surgical intervention.

Peritoneal Dialysis-Related Infections

Peritoneal dialysis (PD) represents an important treatment choice for patients with kidney failure. It allows them to dialyze outside the hospital setting, facilitating enhanced opportunities to participate in life-related activities, flexibility in schedules, time and cost savings from reduced travel to dialysis centers, and improved quality of life. Despite its numerous advantages, PD utilization has been static or diminishing in parts of the world. PD-related infection, such as peritonitis, exit-site infection, or tunnel infection, is a major concern for patients, caregivers, and health professionals-which may result in hesitation to consider this as treatment or to cease therapy when these complications take place. In this review, the definition, epidemiology, risk factors, prevention, and treatment of PD-related infection on the basis of the contemporary evidence will be described.

Rescue plan for CAPD peritonitis: Using ultrasonography as a guide on when to remove the catheter

INTRODUCTION

Ultrasound has been found to facilitate early identification of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

A retrospective analysis was carried out to evaluate the effectiveness of ultrasonography-guided removal of the Tenckhoff catheter in reducing complications like a shift to hemodialysis or death in CAPD patients.

RESULTS

The "peritonitis rescue plan" supported timely decision-making for the removal of the infected catheter and resulted in a lower peritonitis episode per patient per month ratio (from 1:36 to 1:122) in 2021, a lower death rate (from 19% to 6.6%) and lower incidences of shifts to hemodialysis (from 2%-9% to 0%) as compared to that before the implementation of the plan in 2019.

CONCLUSION

The implementation of the "peritonitis rescue plan" and the removal of the infected catheter within 3 days of peritonitis being detected was successful in improving the standard of care for patients undergoing CAPD.

Association between dialysis effluent leukocyte count after initial antibiotic treatment and outcomes of patients with peritoneal dialysis-associated peritonitis: a retrospective study

BACKGROUND

Among patients with peritoneal dialysis-associated peritonitis (PDAP), It has been regarded as an indicator of deterioration of clinical condition that peritoneal dialysis effluent leukocyte count (PDELC) cannot be restored to normal after initial antibiotic therapy. However, the precise relationship between PDELC on day 5 and the clinical outcomes of PDAP episodes remains uncertain.

AIMS

To explore the association between PDELC on day 5 and clinical outcomes of PDAP episodes.

METHODS

This retrospective study was based on the medical chart database of the Affiliated Hospital of Guangdong Medical University. Multivariable regressions were used to evaluate the association between PDELC on day 5 and 60-day mortality, half-year mortality, treatment failure, and the length of stay in hospital with adjustment for confounding factors.

RESULTS

A total of 549 PDAP episodes in 309 patients were enrolled. The total 60-day mortality, half-year mortality, and rate of treatment failure was 6.0%, 9.8%, and 14.2%, respectively. Compared with patients with normal PDELC, those with PDELC ≥2000 × 106/L on day 5 had significantly higher 60-day mortality (31.1% vs 2.7%), half-year mortality (35.6% vs 5.6%), and treatment failure (46.7% vs 5.7%). In multivariate adjusted regression, the ORs (95%CI) were 6.99 (2.33, 20.92; p = 0.001), 4.97(1.93, 12.77; p = 0.001), and 5.77 (2.07, 16.11; p = 0.001), respectively. Patients with PDELC were 100-2000 × 106/L on day 5 had a higher rate of treatment failure than those with normal PDELC (26.9% vs 5.7%) (OR = 3.03, 95%CI 1.42, 6.46; p = 0.004). After sensitivity analysis, the results remained robust.

CONCLUSIONS

Among patients with PDAP, increased PDELC on day 5 was associated with a greater risk of 60-day mortality, half-year mortality, and treatment failure.

Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients

Peritoneal dialysis (PD) patients are at high risk for peritonitis, an infection of the peritoneum that affects 13% of PD users annually. Relying on subjective peritonitis symptoms results in delayed treatment, leading to high hospitalisation costs, peritoneal scarring, and premature transition to haemodialysis. We have developed and tested a low-cost, easy-to-use technology that uses microscopy and image analysis to screen for peritonitis across the effluent drain tube. Compared to other technologies, our prototype is made from off-the-shelf, low-cost materials. It can be set up quickly and key stakeholders believe it can improve the overall PD experience. We demonstrate that our prototype classifies infection-indicating and healthy white blood cell levels in clinically collected patient effluent with 94% accuracy. Integration of our technology into PD setups as a screening tool for peritonitis would enable earlier physician notification, allowing for prompt diagnosis and treatment to prevent hospitalisations, reduce scarring, and increase PD longevity. Our findings demonstrate the versatility of microscopy and image analysis for infection screening and are a proof of principle for their future applications in health care.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

A Clinical Risk Prediction Tool for Peritonitis-Associated Treatment Failure in Peritoneal Dialysis Patients

A tool to predict peritonitis-associated treatment failure among peritoneal dialysis (PD) patients has not yet been established. We conducted a multicentre, retrospective cohort study among 1,025 PD patients between 2006 and 2016 in Thailand to develop and internally validate such a tool. Treatment failure was defined as either a requirement for catheter removal, a switch to haemodialysis, or peritonitis-associated mortality. Prediction model performances were analysed using discrimination (C-statistics) and calibration (Hosmer-Lemeshow test) tests. Predictors were weighted to calculate a risk score. In total, 435 patients with 855 episodes of peritonitis were identified; 215 (25.2%) episodes resulted in treatment failure. A total risk score of 11.5 was developed including, diabetes, systolic blood pressure <90 mmHg, and dialysate leukocyte count >1,000/mm³ and >100/mm³ on days 3-4 and day 5, respectively. The discrimination (C-statistic = 0.92; 95%CI, 0.89-0.94) and calibration (P > 0.05) indicated an excellent performance. No significant difference was observed in the internal validation cohort. The rate of treatment failure in the different groups was 3.0% (low-risk, <1.5 points), 54.4% (moderate-risk, 1.5-9 points), and 89.5% (high-risk, >9 points). A simplified risk-scoring scheme to predict treatment failure may be useful for clinical decision making regarding PD patients with peritonitis. External validation studies are needed.