The efficacy of silver-ion implanted catheters in reducing peritoneal dialysis-related infections.

BACKGROUND: Dialysis-related infections are the commonest cause of catheter loss and transfer to hemodialysis. Surface modifications of the catheter that reduce infections are of major importance. OBJECTIVE: The efficacy of silver-ion treated catheters in reducing dialysis-related infections was tested. METHODS: The study design was a prospective, randomized controlled trial. Patients were implanted with either a silver-treated study catheter or a control catheter. Prospective collection of data included infectious complications and catheter survival. RESULTS: The subject groups were comprised of 67 silver-treated catheters and 72 control catheters. Demographic characteristics of the study and control groups were equal. Exit-site infection rates for the study group and control group (0.52 and 0.45 episodes/patient-year of dialysis respectively) were not different by Poisson regression analysis (p > 0.4). Peritonitis rates were identical for the two groups (0.37 episodes/patient-year) and were not different by Poisson analysis (p > 0.9). Antibiotic-free intervals between infections for the study and control groups were not significantly different for exit-site infections (p = 0.58), peritonitis (p = 0.44), or both infections combined (p = 0.47). Actuarial analyses showed no differences between the groups in the probability of remaining free of exit-site infection (p > 0.2) or peritonitis (p > 0.7). Similarly, catheter survival was not significantly different between the groups (p > 0.6). CONCLUSION: Surface modification of catheters with ion beam implantation of silver produced no clinical effect with respect to reducing dialysis-related infections.     

Prospective comparison of downward and lateral peritoneal dialysis catheter tunnel-tract and exit-site directions.

OBJECTIVE: Guidelines for optimal peritoneal dialysis access support both downward and lateral exit-site directions. Numerous clinical reports support the superiority of downward exit sites but none substantiate lateral configurations. METHODS: This prospective study compared infectious and mechanical complications between 85 catheters with a preformed arcuate bend to produce a downward exit site and 93 catheters with a straight intercuff segment configured to create a lateral exit site. RESULTS: Kaplan-Meier survivals were not different for time to first exit-site infection (p = 0.62), tunnel infection (p = 0.89), or peritonitis (p = 0.38) for downward and lateral exit-site directions. Poisson regression showed no differences in rates (episodes/patient-year) of exit-site infection (0.26 vs 0.27, p = 0.86), tunnel infection (0.02 vs 0.03, p = 0.79), peritonitis (0.42 vs 0.43, p = 0.87), or catheter loss (0.06 vs 0.09, p = 0.29) for downward and lateral exit sites. Kaplan-Meier analyses of antibiotic-free intervals for exit-site (p = 0.94) and peritonitis infections (p = 0.72) were not different for the two groups. There was one case of catheter tip displacement with flow dysfunction in each group. There were no pericatheter hernias or spontaneous cuff extrusions. Catheter survival between groups was not different (p = 0.20). CONCLUSIONS: Catheter types employing downward and lateral tunnel-tract and exit-site configurations produce equivalent outcomes for infectious and mechanical complications.     

Comparison of exit-site infections in disconnect versus nondisconnect systems for peritoneal dialysis.

OBJECTIVE: To determine if disconnect systems reduce the incidence of exit-site infections when compared to nondisconnect systems. DESIGN: We prospectively monitored exit-site infections and peritonitis rates in 96 disconnect patients (Y-set, automated peritoneal dialysis (APD)) and 60 nondisconnect patients (spike, ultraviolet connection device (UVXD)). SETTING: A freestanding chronic peritoneal dialysis unit staffed by physicians from both a medical school and a private setting. PATIENTS: All patients who began peritoneal dialysis at our unit were monitored, regardless of cause of end-stage renal disease (ESRD) or age. INTERVENTION: Patients were dialyzed using the system (Y-set, spike, etc.) most appropriate for their life-style and their ability to administer self-care. MAIN OUTCOME: We attempted to follow disconnect and nondisconnect patients for a similar median time on dialysis and compared differences in exit-site infections. RESULTS: Peritonitis rates (episodes/pt year) were reduced for disconnect (0.60) versus nondisconnect (0.99) systems (p = 0.0006). Despite the marked reduction in peritonitis rates, there was no difference in exit-site infection rates (0.35 vs 0.38), the time to the first exit-site infection, or the time to the first catheter removal for disconnect versus nondisconnect groups. When individual systems were compared, differences in exit-site infection rates (episodes/pt years) were noted (0.62,spike; 0.26,UVXD; 0.32,Y-set; 0.41,APD). CONCLUSION: We found no overall difference in exit-site infection rates for disconnect versus nondisconnect systems, despite a reduction in peritonitis rates for disconnect systems.     

Effect of preventing Staphylococcus aureus carriage on rates of peritoneal catheter-related staphylococcal infections. Literature synthesis.

OBJECTIVE: To determine whether specific preventive measures reduce the rate of peritoneal catheter-related infections and peritoneal catheter loss due to Staphylococcus aureus. DESIGN: Structured literature synthesis. METHODS: Relevant studies were identified by MEDLINE search, from personal files, and from the reference lists of retrieved articles. We analyzed English-language studies on treatment targeted at S. aureus, with at least 10 subjects and at least 3 months of follow-up, and data on staphylococcal peritoneal dialysis catheter infections. We excluded noncontrolled studies. Two investigators abstracted data using a structured form. RESULTS: We evaluated six studies with concurrent controls and eight studies with historical controls. In one randomized, placebo-controlled, blinded study, periodic nasal mupirocin ointment reduced the rate of staphylococcal exit-site infection from 0.42 to 0.12 episodes/patient-year (p = 0.006), but had no effect on the rates of staphylococcal tunnel infection, peritonitis, or catheter loss. In one randomized study without placebo control, periodic oral rifampin reduced the rate of staphylococcal exit-site infection from 0.65 to 0.22 epi/pt-yr (p = 0.011), but had no effect on the rate of staphylococcal peritonitis. In another nonblinded, randomized, controlled study, the use of either rifampin or mupirocin was associated with low rates of staphylococcal catheter infections and catheter loss. In one study with historical controls, the rate of staphylococcal exit-site infection and peritonitis was lower after oral rifampin prophylaxis. In seven other studies comparing nasal or exit-site mupirocin to historical controls, the rate of staphylococcal exit-site infection decreased from 0.17 to 0.05 epi/pt-yr, the rate of staphylococcal peritonitis decreased from 0.18 to 0.06 epi/pt-yr, and the rate of catheter loss decreased from 0.09 to 0.05 epi/pt-yr during the mupirocin period. CONCLUSION: The literature provides strong evidence that staphylococcal carriage prophylaxis using either oral rifampin or mupirocin ointment in the nares or exit site reduces significantly the rate of exit-site infection due to Staphylococcus aureus. Weaker evidence based on studies with historical controls suggests that rifampin or mupirocin prophylaxis also reduces the rate of staphylococcal peritonitis and peritoneal catheter loss. Studies with a stronger level of evidence are needed to verify this last point.     

Surgical management of refractory exit-site/tunnel infection of Tenckhoff catheter: technical innovations of partial replantation.

OBJECTIVE: Catheter-related infection has been the major cause of catheter removal for peritoneal dialysis (PD) patients. A salvage technique--partial replantation of the infected catheter--was developed in our hospital to rescue catheters with refractory exit-site or tunnel infection. PATIENTS: We performed 26 partial replantations of Tenckhoff catheters for 23 patients with refractory exit-site or tunnel infection and 2 patients with near-cuff perforation of the catheter. Their problems were all resolved successfully without interruption of PD. INTERVENTIONS: We removed the infected portion of the catheter and preserved the still-functioning internal conduit, connecting it to a divided new catheter. All of the patients resumed PD immediately after the advancement of the new catheter through a new subcutaneous tunnel and exit site on the opposite side. RESULTS: No technical complications such as disconnection of the catheter or leakage of dialysate were noted. Repeated partial replantation of the catheter was done for 1 patient with a new refractory exit-site infection. Tunnel infection was not an absolute contraindication for this procedure. About one third (34.6%) of our patients had preoperative tunnel infection. CONCLUSION: Partial replantation of a Tenckhoff catheter is a simple and effective procedure for patients with refractory exit-site/tunnel infection and patients with near-cuff perforation of the catheter. Repeated partial replantation is also feasible for repeat exit-site infections.     

Exit-site infection in children on peritoneal dialysis: comparison of two types of peritoneal catheters.

OBJECTIVE: To review our experience with two types of peritoneal catheters, the standard Tenckhoff catheter and the swan-neck presternal catheter (SNPC). DESIGN: A retrospective study was undertaken to compare exit-site infection (ESI) rates using two types of peritoneal catheters in children. SETTING: Medical University of Warsaw, Warsaw, Poland. PATIENTS: During the past 10 years, 60 peritoneal catheters were implanted in 50 children with end-stage renal failure: 46 straight, double-cuffed Tenckhoff in 37 children (mean age 11.8 +/- 4.2 years, range 3.1 - 18.5 years), and 14 presternal in 13 children (mean age 10.6 +/- 5 years, range 0.3-17.7 years). The SNPCs were used in special clinical situations such as recurrent ESI with previous abdominal peritoneal catheters, obesity, presence of ureterocutaneostomies, use of diapers, and young age. For the statistical analysis, only the first catheter placed in each child was chosen: 34 standard Tenckhoff catheters and 9 SNPCs. INTERVENTION: In all children, peritoneal catheters were implanted surgically under general anesthesia by one surgeon; uniform operative technique and perioperative management was used. RESULTS: The mean observation time for 46 standard Tenckhoff catheters was 23.8 +/- 21.1 months, and for 14 SNPCs 25.1 +/- 27.0 months. The ESI rate was 1/17.4 patient-months (0.69 episodes/year) for Tenckhoff catheters and 1/70.2 patient-months (0.17 episodes/year) for SNPCs. The observed differences in ESI rates between the groups reported did not achieve statistical significance. CONCLUSIONS: The risk of ESI may be lower with presternal catheters. Confirmation of these findings requires further prospective clinical investigation in large numbers of patients.     

Determinants of catheter loss following continuous ambulatory peritoneal dialysis peritonitis.

BACKGROUND: Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis. Patients and METHODS: We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal (n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved. RESULTS: The incidence of PD catheter loss increased as the number of organisms cultured increased (p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level (p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/microL (p < 0.001), those with concomitant tunnel infection (p < 0.001), those with concomitant exit-site infection (p = 0.005), and those with presence of catastrophic intra-abdominal visceral events (p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance (p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi (p < 0.001), anaerobes (p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095). CONCLUSION: PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/muL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.     

Correlation Between Glycemic Control and the Incidence of Peritoneal and Catheter Tunnel and Exit-Site Infections in Diabetic Patients Undergoing Peritoneal Dialysis

♦ Background: Diabetes mellitus, especially if complicated by poor glycemic control, portends an increased risk of infection. The significance of this association in the case of diabetic patients undergoing peritoneal dialysis (PD) has not been assessed.♦ Methods: Using a retrospective observational design, we analyzed the association between glycemic control at the start of PD (estimated from glycosylated hemoglobin levels) and the risk of peritoneal and catheter tunnel and exit-site infections during follow-up in 183 incident patients on PD. We used the median value of glycosylated hemoglobin to classify patients into good (group A) or poor (group B) glycemic control groups. We applied multivariate strategies of analysis to control for other potential predictors of PD-related infection.♦ Results: Groups A and B differed significantly in age, dialysis vintage, use of insulin, and rate of Staphylococcus aureus carriage. Neither the incidence (0.60 episodes in group A vs 0.56 episodes in group B per patient-year) nor the time to a first peritoneal infection (median: 42 months vs 38 months) differed significantly between the study groups. In contrast, group B had a significantly higher incidence of catheter tunnel and exit-site infections (0.23 episodes vs 0.12 episodes per patient-year) and shorter time to a first infection episode (64 months vs 76 months, p = 0.004). The difference persisted in multivariate analysis (adjusted hazard ratio: 2.65; 95% confidence interval: 1.13 to 6.05; p = 0.013). We observed no differences between the study groups in the spectrum of causative organisms or in the outcomes of PD-related infections.♦ Conclusions: Poor glycemic control is a consistent predictor of subsequent risk of catheter tunnel and exit-site infection, but not of peritoneal infection, among diabetic patients starting PD therapy.     

The effect of body weight on CAPD related infections and catheter loss

CAPD related infections and catheter loss continue to be the major problems facing the peritoneal dialysis patient. Few risk factors for infections and catheter loss have been identified. We hypothesized that overweight and underweight patients may be at increased risk for infections and catheter related problems. We examined the effect of the patient's weight at the start of peritoneal dialysis on the subsequent peritonitis and catheter infection rates, as well as catheter loss. Weight was expressed as a percentage of ideal body weight (IBW). Those patients who were more than 110% of IBW were considered to be overweight, 90 to 110% of IBW normal and less than 90%, underweight. An equivalent percentage of patients were overweight and underweight at the initiation of peritoneal dialysis (55/228, 24% for both groups). Overweight, normal, and underweight patients had peritonitis rates of 1.0, 0.9, and 0.8 episodes/y and catheter infection rates of 1.1, 1.2, and 0.8 episodes/y, respectively. Despite these similar rates, catheter loss due to infectious complications was greatest in the overweight group and least in the underweight group (p less than 0.05). No obvious explanation for the difference in catheter loss rate was found. Neither S. aureus nor P. aeruginosa infections occurred more frequently in the overweight patients. However, S. aureus infections more often led to catheter loss in the overweight patients. Catheter loss due to catheter leaks and failure to drain was similar in the three groups of patients. We conclude that deviation from ideal body weight at the initiation of dialysis is not a risk factor for CAPD related infections.(ABSTRACT TRUNCATED AT 250 WORDS)     

Experience using presternal catheter for peritoneal dialysis in Poland: a multicenter pediatric survey.

OBJECTIVES: Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall. DESIGN: A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland. SETTING: Four pediatric institutions using the SNPC in children: (1) Medical University of Warsaw, Warsaw; (2) Children's Memorial Health Institute, Warsaw; (3) District Children's Hospital, Szczecin; (4) University of Medical Sciences, Poznan. PATIENTS: During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2-17.7 years (mean 8 +/- 5.8 years), with end-stage renal failure.The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exit-site infections (ESI) with previous abdominal PD catheters. INTERVENTION: In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used. RESULTS:The mean observation time for the 20 presternal catheters was 24.8 +/- 25 months (range 1-83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Non-infectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan-Meier method, was 57.5 +/- 8.5 months; 50% catheter survival reached 72 months. CONCLUSIONS: The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications (ie., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion.     

Staphylococcus aureus prophylaxis and trends in gram-negative infections in peritoneal dialysis patients.

OBJECTIVE: To examine gram-negative exit-site infection and peritonitis rates before and after the implementation of Staphylococcus aureus prophylaxis in peritoneal dialysis (PD) patients. DESIGN: Prospective data collection with periodic implementation of protocols to decrease infection rates in two PD programs. PATIENTS: 663 incident patients on PD. INTERVENTIONS: Implementation of S. aureus prophylaxis, beginning in 1990. MAIN OUTCOME MEASURES: Rates of S. aureus, gram-negative, and Pseudomonas aeruginosa exit-site infections and peritonitis. RESULTS: Staphylococcus aureus exit-site infection and peritonitis rates fluctuated without significant trends during the first decade (without prophylaxis), then began to decline during the 1990s subsequent to implementation of prophylaxis, reaching levels of 0.02/year at risk and zero in the year 2000. Gram-negative infections fell toward the end of the 1980s, due probably to the implementation of better connectology. However, there have been no significant changes for the past 6 years. There was little change in P. aeruginosa infections over the entire time period. Pseudomonas aeruginosa is now the most common cause of catheter infection and catheter-related peritonitis. CONCLUSIONS: Prophylaxis against S. aureus is highly effective in reducing the rate of S. aureus infections but has no effect on gram-negative infections. Pseudomonas aeruginosa is now the most serious cause of catheter-related peritonitis.     

腹膜透析患者导管外出口护理的现状调查

目的 调查北京市和深圳市多所腹膜透析中心患者导管外出口护理的现状,并分析影响患者导管外出口护理行为的原因,为做好临床腹膜透析患者的培训提供依据。 方法 采用自制问卷对北京市及深圳市12所腹膜透析中心门诊随访的1 204例腹膜透析患者的导管外出口护理情况进行调查。结果 北京市和深圳市腹膜透析患者导管外出口护理得分为（44.76±5.85）分,导管外出口评估和无菌技术得分偏低。单因素分析显示,有无导管外出口感染史、不同换药操作者、不同导管外出口位置、不同文化程度、不同透析龄的患者导管外出口护理得分的比较,差异有统计学意义（P<0.05）。多元线性回归分析显示,影响导管外出口护理得分的因素为透析龄、导管外出口感染史、换药操作者、文化程度及导管外出口位置。结论 腹膜透析患者导管外出口护理得分尚可,但导管外出口评估和无菌技术得分较低,仍需进一步加强培训,尤其是对透析龄长、有感染史的患者。     

A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.

OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD.     

A prospective randomized study of the effect of a subcutaneously "buried" peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection.

OBJECTIVE: A new method for implantation of peritoneal dialysis (PD) catheters was described in 1991. The distal part of the catheter is buried subcutaneously and exteriorized at the start of PD. This study was designed to evaluate the effect of such a subcutaneous rest period on the incidence of peritonitis and exit-site infections (ESI). DESIGN: Sixty patients were randomized to either the new method (B group; n = 30) or to not having the distal part buried subcutaneously (NB group; n = 30). Sixty-five patients (NS group) were not randomized as they had to start PD within 1-2 weeks after implantation. The Moncrief-Popovich catheter was used in the B and NB groups and a standard Tenckhoff catheter was used in the NS group. PATIENTS: Patients scheduled for PD treatment, judged not in need of PD for at least 6 weeks after implantation. RESULTS: There was no statistically significant difference in the cumulative probability of not developing peritonitis during the first 6, 12, and 24 months. The incidence of the first episode of peritonitis was 1/40, 1/26, and 1/33 treatment-months in the B, NB, and NS groups, respectively. The incidence of ESI was 1/103 and 1/95 treatment-months in the B and NS groups, respectively. The cumulative probability of not developing ESI was similar in both groups. There were no episodes of ESI in the NB group. The difference in the number of ESI between the NB and NS groups was significant (p < 0.05). CONCLUSIONS: Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection.     

Chronic peritoneal dialysis catheters in children: a fifteen-year experience of the Italian Registry of Pediatric Chronic Peritoneal Dialysis.

OBJECTIVE: To analyze data on 503 chronic peritoneal dialysis (CPD) catheters implanted between 1986 and 2000 in pediatric patients enrolled in the Italian Registry of Pediatric Chronic Peritoneal Dialysis (the Registry), comparing three different time periods: 1986-1990, 1991-1995, and 1996-2000. DESIGN: Retrospective study. SETTING: 23 dialysis centers participating in the Registry. METHODS: Data were collected from questionnaires filled in every year. The information for each peritoneal catheter included type, site and technique of insertion, exit-site orientation, exit-site care, complications, survival, and reason for removal. PATIENTS: 503 catheters were implanted in 363 pediatric patients aged younger than 15 years at the start of CPD: 97 catheters in patients under 2 years of age, 67 in patients aged 2-5 years, and 339 in patients over 5 years of age. Mean patient age at onset of CPD was 8.0 +/- 5.1 years. All catheters were surgically implanted and omentectomy was performed in 82.4% of cases. The catheters used were Tenckhoff [468 (93.0%): 443 double cuff, 25 single cuff] and double-cuffed Valli [35 (7.0%)]. The entry site was in the midline in 153 cases (30.4%) and paramedian in 350 (69.6%). RESULTS: During 9048 dialysis-months we observed 451 catheter-related complications, yielding an incidence of 1 episode/20.1 CPD-months: 330 catheter infections (exit-site and/or tunnel infections), 26 leakages, 26 dislocations, 24 obstructions, 22 cuff extrusions, 6 hemoperitoneums, 17 others. 171 catheters were removed due to catheter-related causes; exit-site and/or tunnel infections were the main cause for removal (75.4%), followed by obstruction, dislocation, outer-cuff extrusion, and leakage. Younger children (< 2 years) had a higher risk of infectious causes of catheter removal compared to children aged 2-5 years (p = 0.004) and over 5 years of age (p = 0.002). During the 15-year observation period, a significant reduction in the incidence of leakage was observed and risk of leakage was lower in catheters with paramedian entry site compared to catheters with midline entry site. Removal and replacement of peritoneal catheters during the same surgical operation was performed in 76.3% of catheter removals. Catheter survival rate was 78.1% at 12 months, 58.5% at 24 months, 43.8% at 36 months, and 34.6% at 48 months. No difference in catheter survival was observed in younger children (< 2 years) compared with the two other age groups: < 2 years versus 2-5 years hazard ratio 0.7, 95% confidence interval (95%CI) 0.4-1.2; < 2 years versus > 5 years hazard ratio 0.8, 95%CI 0.5-1.1. CONCLUSIONS: In this survey, we observed better catheter survival in comparison with data reported by the Registry in 1998. Catheter survival improved especially in younger children (< 2 years), a group that previously had a decreased catheter survival rate compared to older age groups. In addition to the progressive increase in experience acquired by dialysis centers, this upward trend may also be related to greater use of double-cuffed catheters, with paramedian exit site, and a higher frequency of omentectomy.     

Comparison of peritonitis rates during long-term use of standard spike versus Ultraset in continuous ambulatory peritoneal dialysis (CAPD)

Continuous ambulatory peritoneal dialysis (CAPD) is an increasingly popular means of end-stage renal disease replacement therapy. Unfortunately, peritonitis continues to be a major source of both morbidity and mortality. The Ultraset incorporates a "flush-before-fill" concept which should theoretically decrease peritonitis rates when compared to the standard spike procedure, while allowing patients the convenience of disconnect. To investigate the impact of long-term use of the Ultraset on peritonitis rates, we conducted the following study. We prospectively compared 21 new CAPD patients using the standard spike to 20 new CAPD patients using the Ultraset. Peritonitis episodes, episodes of exit-site infection, and the association of peritonitis with exit-site infection were monitored. Peritonitis rates were 7.57 months/episode for the group using the standard spike vs. 27.79 months/episode in the group using the Ultraset. Exit-site infection rates were 22.21 months/infection with the standard spike vs. 37.05 months/infection with the Ultraset. Using Kaplan-Meier plots, there was a statistically significant difference in the estimated time to the first episode of peritonitis, but there was no statistically significant difference regarding the risk of exit-site infections.     

Staphylococcus aureus nasal carriage, exit-site infection and catheter loss in patients treated with continuous ambulatory peritoneal dialysis (CAPD)

Over a three-year period, 217 episodes of bacterial peritonitis occurred in 183 patient years. Thirty-seven episodes were due to Staphylococcus aureus and 19 (51%) of these required removal of the catheter to eradicate infection. This compared with catheter loss in 4/63 (6.3%) coagulase negative staphylococci infections (p less than 0.001); 7/67 (9.5%) culture negative peritonitis (p less than 0.001); and 10/30 (33.3%) episodes due to gram-negative organisms (p less than 0.05). Over half (51.3%) the episodes due to S. aureus were associated with exit-site infections, and this rose to 100% (10/10) with recurrent peritonitis (p less than 0.01). A prospective analysis of nasal carriage and exit-site infections due to S. aureus was carried out in 87 patients. Exit-site infections were present in 21 (24%), almost entirely due to different strains as judged by sensitivity patterns and phage typing. Nasal carriage, defined as two positive swabs within the study period, was present in 20 (23%) patients. Fourteen (70%) of these had exit-site infections due to the same strain as that isolated from the nose, whereas no patient grew different strains from either site. Nasal carriage increased the risk of infection sixfold (p less than 0.001).     

Exit-site infection during continuous and cycling peritoneal dialysis in children

A 10-year retrospective review of pediatric patients on peritoneal dialysis showed that 50 of 83 had 132 episodes of exit-site infection (ESI). Thirty-nine episodes were purulent. The most prevalent organism was Staphylococcus aureus. Staphylococcus epidermidis was also common, usually occurring in purulent infections. Gram-negative organisms were responsible for 23 ESIs, with Pseudomonas species being the most common. Age, sex, concomitant primary disease type, length of training, dressing techniques, quality of daily dialysis technique, use of diapers, and pyelostomies did not affect the incidence of ESI. However, 40% of children with a skin infection from other sites had associated peritoneal catheter ESI. Thirty-eight episodes of ESI in 28 patients resulted in peritonitis; the main organisms involved were Staphylococcus and Pseudomonas species. Catheters were replaced in 13 patients with peritonitis, but there was no difference in the incidence of ESI before and after catheter replacement.     

Percutaneous Peritoneal Dialysis Catheter Insertion by a Nephrologist: A New,Simple, and Safe Technique

♦ Background: Insertion of the peritoneal dialysis (PD) catheter by a nephrologist has been encouraged by several studies. The ultimate goal is to provide safe, timely, and effective catheter insertion without an unduly long wait time or delay. The success of PD depends partly on the ease of catheter insertion. We developed a new technique for percutaneous PD catheter insertion by nephrologists. Our new technique, in addition to being easy, proved to be safe and to eliminate the need for the peel-away sheath.♦ Methods: Data were collected prospectively on all patients having a PD catheter inserted by a nephrologist using our new technique (40 catheters in 38 patients). All catheters were evaluated for infectious and mechanical complications.♦ Results: The mean duration of the procedure from skin sterilization to the end of insertion was 24 ± 3 minutes. No bowel perforation or serious hemorrhage was recorded. Poor initial drainage was recorded in 12.5% of the catheters (n = 5) during the 4 weeks after insertion. The incidence of early exit-site leakage was 2.5% (1 catheter). Episodes of exit-site infection occurred in 5.0% and 12.5% of catheters (within 1 month and by the end of study period respectively). Two episodes of peritonitis were reported by the end of the 12-month period. Catheter survival was 95.0% and 87.5% at 6 months and 12 months respectively.♦ Conclusions: Percutaneous bedside placement of PD catheters using our new technique is safe and carries less morbidity in terms of bowel perforation, catheter-related infection, and exit-site leak. In addition, our new technique appears to have a high success rate and to offer considerable savings in terms of operating time.     

不同类型腹膜透析导管临床应用体会

目的观察不同类型腹膜透析导管的近期并发症的发生率情况及防治体会。方法68例终末期肾衰竭行维持性腹膜透析治疗患者分为两组。组1：28例患者采用Tenckhoff曲管;组2：40例患者采用鹅颈直管。两组患者随访时间均大于6个月。观察两组患者的腹膜透析液引流速度、隧道感染、出口感染、导管移位、腹膜透析液渗漏等发生情况。结果两组患者腹膜透析液引流速度的隧道感染率和出口感染率无差别（P〉0.05）.Tenckhoff管组5例患者出现导管移位（17.8%）,而swan-neck导管组仅2例（5%）,两组相比有显著性差异（P〈0.05）。进一步分析发现前组患者漂管发生于第一周3例（60%）,第二周2例（40%）,而鹅颈直管发生漂管多于1周内。另外鹅颈直管组有3例患者于术后第一周出现引流不畅,拔管时发现导管内均有大量蛋白凝块阻塞。结论不同类型导管各有优缺点,鹅颈直管的导管移位率明显低于Tenckhoff导管,但易发生透析液引流不畅,而Tenckhoff导管不容易发生堵管。在置管过程中调整swan-neck腹膜透析管外段与腹正中线的角度后能明显改观引流速度。改观