Comparison of peritonitis rates and patient survival in automated and continuous ambulatory peritoneal dialysis: a 10-year single center experience

Peritonitis is a common complication in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). In this retrospective study, peritonitis rates and patient survival of 180 patients on CAPD and 128 patients on APD were compared in the period from January 2005 to December 2014 at Al-Nafisi Center in Kuwait. All patients had prophylactic topical mupirocin at catheter exit site. Patients on CAPD had twin bag system with Y transfer set. The peritonitis rates were 1 in 29 months in CAPD and 1 in 38 months in APD (p?<?0.05). Percentage of peritonitis free patients over 10-year period in CAPD and APD were 49 and 60%, respectively (p?<?0.05). Time to develop peritonitis was 10.25?±?3.1 months in CAPD compared to 16.1?±?4 months in APD (p?<?0.001). Relapse and recurrence rates were similar in both groups. Median patient survival in CAPD and APD groups with peritonitis was 13.1?±?1 and 14?±?1.4 months respectively (p?=?0.3) whereas in peritonitis free patients it was 15?±?1.4 months in CAPD and 23?±?3.1 months in APD (p?=?0.025). APD had lower incidence rate of peritonitis than CAPD. Patient survival was better in APD than CAPD in peritonitis free patients but was similar in patients who had peritonitis.     

Peritoneal morphology in children treated by continuous ambulatory peritoneal dialysis

Fifty peritoneal biopsies (PB) from 35 patients with end-stage renal disease, treated by continuous ambulatory peritoneal dialysis (CAPD) and aged 2 months to 18 years, were examined by light microscopy (n=50) and/or scanning electron microscopy. PB were performed during surgical procedures immediately before the start of, during, or after the cessation of CAPD treatment. PB from 15 children without renal disease undergoing laparatomy were examined similarly. Before the start of CAPD, a scarcity and shortening of the mesothelial microvilli was observed by scanning electron microscopy. During and after CAPD, variable alterations of mesothelium, interstitium and capillaries were found. The mesothelial layer was absent in all 5 PB obtained during episodes of active peritonitis. In patients treated by CAPD for longer than 6 months, mesothelial denudation was observed more frequently (6/11) than in children treated for shorter periods (1/7) (P<0.08). Fibrosis of the peritoneal membrane was present in about 50% of patients during or after the cessation of CAPD without impairment of peritoneal function. No correlation was found between the presence of fibrosis and the frequency of peritonitis or the duration of CAPD treatment.     

The Prevalence and Clinical Features of Tuberculous Peritonitis in CAPD Patients in Turkey,Report of Ten Cases from Multi-centers

Objective.?To determine the rate, risk factors and outcome of Tuberculous Peritonitis (TBP) in patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our units. Design.?Retrospectively, we reviewed the medical data of all CAPD patients from 12 centers for TBP, covering the period between 1986 and 12 2002. Setting.?All patients were from 12 renal clinics at tertiary-care university hospitals. Results.?Ten cases of TBP were identified among the CAPD patients in our centers. There were five male and five female patients with a mean age of 37.2 years. None of the patients had tuberculosis history, 6 patients had predominance of PNL. One patient had coincidental bacterial peritonitis. Two patients were successfully treated without the removal of the Tenckhoff catheter. Conclusion.?TBP in CAPD patients is a very rare complication. In contrast to predominance of lymphocytes in nonuremic patients with tuberculous peritonitis, CAPD patients with tuberculous peritonitis may have predominance of PNL on examination of the peritoneal fluid. Since TBP has high morbidity and mortality, early diagnosis and treatment of disease are extremely important for improving outcome.     

Acinetobacter co-infection and coagulase-negative Staphylococcus: case report and literature review

Continuous ambulatory peritoneal dialysis (CAPD) is a safe, convenient, and cost-effective therapy in end-stage renal disease. The major complication of peritoneal dialysis (PD) is peritonitis. Gram-positive cocci are isolated in majority of the episodes. Among gram-negative bacteria, Acinetobacter species have been reported in peritonitis, sometimes as a concomitant that may be asymptomatic and require no treatment. Little has been written about the clinical features and outcome of PD-related peritonitis caused by co-infection of Acinetobacter species with other pathogens. We herein present a case of peritonitis caused by co-infection with Acinetobacter species and coagulase-negative staphylococci, which resulted in patient dropout and mortality. We review the literature about Acinetobacter peritonitis and current treatment protocols.     

Impaired cellular host defence in peritoneal dialysis by two granulocyte inhibitory proteins

Bacterial and fungal peritonitis is associated with a high riskof morbidity and mortality in patients undergoing continuousambulatory peritoneal dialysis (CAPD). Impaired cellular hostdefence in the peritoneal cavity underlies this risk. Two granulocyteinhibitory proteins with a molecular weight of 28000 dalton(GIP I) and about 9500 dalton (GIP II) with homology to light-chainproteins and beta respectively, were isolated from peritonealdialysis effluents. In vitro, both granulocyte inhibitory proteinsinhibit PMNL glucose uptake, phagocytosis and intracellularkilling of bacteria. The IC₅₀ of GIP I or GIP II required forinhibition of half-maximal FMLP-induced or PMA-stimulated PMNLfunction was found to be in the nanomolar range, suggestingvery specific inhibition. These data may explain, at least inpart, defective local cellular host defence in CAPD patients.     

Repeated cat-associated peritonitis in a patient on automated nocturnal intermittent peritoneal dialysis

A 49-year-old man had three episodes of bacterial peritonitis in the 8 months after he started nocturnal intermittent peritoneal dialysis (NIPD) at home, using an automated cycler device. When peritonitis was first diagnosed, Enterobacter agglomerance was cultured in his peritoneal fluid. In the second and third episodes, Pasteurella multocida and alpha-Streptococcus were isolated, respectively. These bacteria are unusual pathogens in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Detailed questioning revealed that a domestic cat had bitten the dialysis tube before the patient experienced the second episode of peritonitis. Pasteurella multocida is part of the normal oral flora in cats and dogs. We isolated Pasteurella multocida from the teeth of the patient's cat. Enterobacter agglomerance is part of the common bacterial flora in animal's alimentary tract, and alpha-Streptococcus is commonly found in animal's respiratory tracts. Since the patient removed the cat from his bedroom, he has had no peritonitis. NIPD is a very convenient sysytem for patients in the final stage of renal failure; however, patients must be aware of the risks associated with keeping pets in their homes. This case is the first report of cat-associated peritonitis in Japan. Received: July 9, 1998 / Accepted: September 24, 1998     

Case Report: Peritonitis by <Emphasis Type="Italic">Penicillium</Emphasis> spp. in a Patient Undergoing Continuous Ambulatory Peritoneal Dialysis

Even though prominent technical improvements in continuous ambulatory peritoneal dialysis (CAPD) treatments during the last decade, peritonitis keeps its place as an important cause of morbidity and mortality in these patients. Among them fungal peritonitis is happened to be the most difficult one to deal with and comes out serious clinical presentation. It is presented here a case of CAPD related fungal peritonitis caused by Penicillium spp. This case experienced recently relapsing bacterial episodes of peritonitis and received long term antibiotics intraperitoneally and systemically. Eventually, Penicillium spp. was detected in several cultures of peritoneal effluent and also tip of Tenckhoff catheter, therefore it was considered as a causative agent. Then, the catheter was removed and amphotericin B therapy was performed. But the general condition of the patient did not improve till surgically drainage of peritoneal collection which was determined by MR (Magnetic Resonance) examination of abdomen after antifungal treatment was completed and Penicillium spp. in the drainage samples was not determined anymore.     

Adult and pediatric peritonitis rates in a home dialysis program: comparison of continuous ambulatory and continuous cycling peritoneal dialysis

We reviewed our 115-month experience with continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) in adult and pediatric patients to determine whether there is a difference in the incidence of peritonitis between patients performing CAPD or CCPD. Peritonitis rates were similar in patients performing CAPD or CCPD in both the adult and pediatric age groups. The overall CAPD peritonitis rate was significantly lower in adult patients when compared with pediatric patients. There was no difference in peritonitis rates for CCPD between adult and pediatric patients. When the data are divided into 3-year subgroups, the incidence of peritonitis is significantly lower in adult patients undergoing either CAPD or CCPD when compared with pediatric patients during the years 1986 to 1988. There is significant improvement over time in the incidence of peritonitis in both adult and pediatric patients performing CCPD; similarly, there is a trend toward improvement in patients performing CAPD. Staphylococcus species organisms remain the most common bacterial cause of peritonitis, except in pediatric patients under the age of 2 years or with nephrostomies, where gram-negative rod infections were more common. Peritonitis resulted in discontinuation of peritoneal dialysis in a greater number of adult patients. These results suggest that the number of catheter manipulations is not important in determining the incidence of peritonitis. Pediatric patients are more likely than adult patients to develop peritonitis with either CAPD or CCPD. Adult patients are more likely than pediatric patients to discontinue peritoneal dialysis secondary to peritonitis.     

Unusual causes of peritonitis in patients undergoing continuous peritoneal dialysis with emphasis on Listeria monocytogenes.

Peritonitis remains a significant cause of morbidity in ESRD patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Staphylococcus species, Streptococcus species, and less commonly, gram-negative rods comprise the majority of isolated organisms. Other organisms, including unusual bacteria, fungi, and mycobacteria, comprise 5% or less of cases. Many of the uncommon causes of CAPD peritonitis have been reviewed, with special emphasis on antimicrobial therapy and whether catheter removal was required. The presumed third case of CAPD-associated peritonitis caused by Listeria monocytogenes is also described. In contrast to two other reported cases, our patient was not overtly immunosuppressed. L. monocytogenes infection should therefore be considered in CAPD patients with gram-positive rod peritonitis, even if immunocompetence is presumed.     

Fas Expression on Peritoneal Macrophages during Continuous Ambulatory Peritoneal Dialysis Peritonitis

Background. Peritonitis is a common complication of end stage renal failure (ESRF) patients receiving continuous ambulatory peritoneal dialysis (CAPD). Peritoneal macrophage may participate in the activation of specific T cells and in the generation of local cell-mediated immunity to various pathogens. The purpose of this study is to investigate the possible role of macrophage in CAPD patients with peritonitis. Methods. We evaluated the expression of Fas receptor (CD95), ICAM-1 (CD54), CD25, and CD69 by two-color flow cytometry on extravasted macrophages from 16 ESRF patients on CAPD with peritonitis (peritonitis-positive) and compared them to 11 ESRF patients on CAPD without peritonitis (peritonitis-negative) and normal controls. Results. We found an increased expression of CD95, CD54, and CD25 on macrophage in peritonitis-positive group compared to controls (all p < 0.001). In the peritonitis-positive group, the CD95 expression was significantly higher than that of the peritonitis-negative group (p < 0.001). The expression of CD54, CD25, and CD69, however, was not significantly different between the peritonitis-positive and peritonitis-negative CAPD subgroups. Conclusion. We found an abnormally increased percentage of macrophage-expressing Fas receptor and ICAM-1, and the percentage of CD95+ macrophage, but not those of other markers, were increased among the subset of CAPD patients with peritonitis. The later finding suggests that this macrophage phenotype is associated with peritonitis occurring in CAPD.     

Streptococcus agalactiae: A rare peritoneal infection in a continuous ambulatory peritoneal dialysis patient

Streptococcus agalactiae causes a rare and often fatal peritonitis in continuous ambulatory peritoneal dialysis (CAPD). A 52-year-old white female with Alport and chronic kidney disease was initiated on CAPD treatment. Nineteen months later she had a S. agalactiae peritonitis identified and received initially gentamicin–cephalothin, which was changed to ceftazidime, tobramycin, and vancomycin. Recovery started after peritoneal catheter removal. After 3 weeks, severe leucopenia occurred. Granulokine and steroids were given. Six weeks later, she felt well and an abdominal video laparoscopic procedure disclosed a diffuse peritoneal fibrosis, precluding CAPD resumption. She is now doing well on hemodialysis (HD).     

Streptococcus gordonii Peritonitis in a Patient on CAPD

We report the first case of Streptococcus gordonii-related continuous ambulatory peritoneal dialysis (CAPD) peritonitis. He is a 69-year-old man with end-stage renal failure due to chron ic glomerulonephritis who had been put on CAPD for 1 year. He was successfully treated with a 2-week course of cefazolin. This case highlights the emerging threat that S. gordonii can be the source of infection in patients on CAPD.     

Non-compliance to the continuous ambulatory peritoneal dialysis procedure increases the risk of peritonitis

Background

Peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) is the leading cause of technique failure. Information on the impact of non-compliance in performing CAPD exchange on peritonitis is limited. We aimed to find the prevalence of non-compliance to the CAPD procedure and its influence on the incidence of peritonitis.

Methods

This observational study included 30 adult patients undergoing CAPD. The CAPD exchange procedure was observed at home and assessed as per the structured checklist and categorized into poor, average and good compliance. The compliance was correlated with the episodes of peritonitis in previous 1?year.

Results

The patients?? mean age was 52?±?13?years and the mean duration of CAPD was 2.1?±?0.9?years. Only 16.5% of patients were good performers, while 67% were average performers, and 16.5% were poor performers. The technique skill was similar across all the steps of the procedure. The most common improperly performed steps were: not putting on a face mask in 68%, not flushing the tubing system in 60%, and not washing hands in 24%. Poor adherence to procedure was independent of age, gender, education and duration of dialysis. Ten episodes of peritonitis occurred in 5 patients over 1-year period. Peritonitis occurred in 60% of poor performers, whereas fully compliant patients had no peritonitis. Also 40% of the poorly compliant patients had multiple episodes of peritonitis.

Conclusions

Poor compliance in performing the CAPD procedure is a modifiable risk factor for peritonitis. Adherence to recommended aseptic technique is the cornerstone of peritonitis prevention.     

Relapsing Bacillus licheniformis peritonitis in a continuous ambulatory peritoneal dialysis patient

Bacillus licheniformis is a rare pathogen in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Only one case of B. licheniformis peritonitis has been previously reported but relapsing peritonitis by same species has not been reported. A 31-year-old man undergoing CAPD was admitted to our hospital with diarrhoea and turbid peritoneal effluent. Although B. licheniformis was cultured at his previous admission, we did not consider the species as a pathogen. After the same species was cultured twice consecutively at the subsequent admission, we confirmed that B. licheniformis was a pathogen of CAPD peritonitis. After appropriate intraperitoneal antibiotics therapy, the patient improved. He is currently undergoing CAPD without catheter removal.     

Successful treatment of Aspergillus peritonitis in a peritoneal dialysis patient

Aspergillus peritonitis is a rare, potentially fatal complication of continuous ambulatory peritoneal dialysis (CAPD). We report the successful treatment of refractory fungal peritonitis in an 8-year-old girl treated by peritoneal dialysis for 3.3 years. This is the second report of Aspergillus thermomutatus (telemorph: Neosartorya pseudofischeri) in humans. Comprehensive treatment included early removal of the CAPD catheter, the use of liposomal amphotericin B, and the use of itraconazole. Received: 21 August 2001 / Revised: 17 December 2001 / Accepted: 18 December 2001     

Comparison of Blood and Peritoneal Lymphocytes from Continuous Ambulatory Peritoneal Dialysis Patients,Asymptomatic and with Peritonitis

Objective. The purpose of this study was to compare the characteristics of the blood immunophenotype of CAPD patients with and without peritonitis and to compare the phenotypes of peripheral blood lymphocytes (PBL) and peritoneal lymphocytes (PL) in CAPD patients with peritonitis. Methods. Fifty-seven CAPD patients (20 with peritonitis and 37 without peritonitis) were recruited in the study (mean age 66,88 ± 13,48, male/female 16/21). Lymphocyte subsets (CD2+, CD3+, CD3+/4+, CD3+/8+, CD3-/16 + 56+, CD4/CD8 ratio) were quantitated by using monoclonal antibodies and dual-color flow cytometric analysis. With the above method we measured PBL in patients with and without peritonitis. In patients with peritonitis we also measured PL. Results. CD2 were slightly decreased in patients with peritonitis. Those patients also had more intense CD3 + /CD4+ lymphopenia (p < 0.05) and larger expansion of NK cells (p < 0.05). Patients with peritonitis appeared to have a lower ratio of CD4/CD8 (p < 0.05). All the above results are shown to . Following the onset of peritonitis, a consistent finding in all patients was a significant increase in CD2 population of PL compared with PBL (85.71 ± 9.20 versus 82.60 ± 7.34, p < 0.05) as well as in CD3 population (77.01 ± 13.09 versus 68.74 ± 13.43, p < 0.05). An increased number of CD3/8 in PL compared with PBL (33.70 ± 9.34 versus 27.98 ± 10.77, p < 0.05) was also noted. Conclusions. In the present study, we found important immune activation in asymptomatic CAPD patients. The activation increases during peritonitis. The causes and the clinical consequences of chronic activation remain unknown.     

Infectious and catheter-related complications in pediatric patients treated with peritoneal dialysis at a single institution

Continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) are the predominant dialytic modalities for the majority of children while awaiting transplantation. Wide acceptability of peritoneal dialysis is hindered by infectious complications. A retrospective review of 367 pediatric patients treated with CAPD/CCPD for at least 3 months from September 1980 through December 1994 revealed that the peritonitis incidence ranged from 1.7 to 0.78 episodes per patient-year. No differences in peritonitis rates were observed between patients treated with CAPD or CCPD. Gram-positive organisms were responsible for the majority of peritonitis episodes. Age, sex, race, primary renal disease, presence of nephrotic syndrome, and serum albumin level were not associated risk factors. Longer time on treatment and diminished serum IgG level were associated with increased peritonitis incidence. Treatment was successfully completed at home in most cases. Almost half of the catheter losses were caused byStaphylococcus, Pseudomonas, and fungal peritonitis and tunnel/exit-site infections. Infectious complications are still the major causes of morbidity and treatment failure in patients treated with CAPD/CCPD. Thus, controlled studies are needed to assess methods for prevention or improvement of peritonitis rates in this patient population.     

CD4/CD8 T‐Cell Ratio in Peritoneal Dialysis Effluents Predicts the Outcome of Peritonitis in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

This study aimed to clarify the role of peritoneal T‐lymphocytes in peritoneal immune defense mechanisms. This study was designed to examine the changes in T‐cell subpopulations during peritonitis in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Our observations were correlated to responses to treatment and with outcomes. The present study was carried out in 20 patients (8 males, 12 females) under CAPD. Peritonitis was diagnosed according to the criteria defined by the Ad Hoc Advisory Committee on Peritonitis Management. Peritoneal dialysate effluent (PDE) samples were collected from our patients, and lymphocyte subsets (CD2+, CD3+, CD3+/4+, CD3+/8+, CD3?/16+56+, CD4/CD8 ratio) were quantitated by using monoclonal antibodies. CD4/CD8 ratio was measured every day during peritonitis until the patients had completely recovered. The serial measurements of the CD4/CD8 ratio made in the PDE during peritonitis followed two patterns: the first pattern was characterized by a progressive increase in the CD4/CD8 ratio. The CD4/CD8 ratios on days 5, 6, and 7 were significantly higher than those on day 1 (P < 0.05). Overall, the patients who exhibited pattern 1 had favorable clinical courses. The second pattern was characterized by high initial CD4/CD8 ratios, which progressively decreased significantly (P < 0.05). This second pattern was associated with a delayed clinical response to treatment. Symptoms and signs of peritonitis persisted beyond 72 h. The pattern of the CD4/CD8 ratio in PDE may determine the outcome of peritonitis in CAPD patients.     

Analysis of microbial spectrum and antibiotic resistance in the patients of peritoneal dialysis related peritonitis

Objective To investigate the microbial spectrum and antibiotic resistance of continuous ambulatory peritoneal dialysis (CAPD) related peritonitis and guide the clinical rational use of antimicrobial agents. Methods A retrospective analysis was made of CAPD related peritonitis in 236 cases with peritoneal dialysate culture results in the Second Hospital Affiliated to Soochow University from Jan 1, 2009 to Jun 30, 2013. Distribution of pathogenic bacteria and its resistance to common antibiotics were analyzed. Results Among 236 cases of peritoneal dialysate cultured cases, 185 cases were positive (78.39%). A total of 193 strains were cultured, including 138 Gram-positive strains (71.50%), 44 Gram-negative strains (22.80%) and 11 fungi (5.70%). Eight cases of polyinfection were found and 2 strains were cultured. The isolated organisms included Simple Gram-positive organisms in 5 cases, mixed Gram-positive and Gram-negative organisms in 3 cases. Drug sensitivity test of the Gram-positive strains showed that antibiotics with the lowest resistance were vancomycin (0), Teicoplanin(0), linezolid(0). Drug sensitivity test of the Gram-negative bacteria showed that antibiotics with the lowest resistance were amikacin(0), imipenem(0), meropenem(0), Cefoperazone/sulbactam(0). The isolated bacteria were resistant to multiple antibiotics. A total of 236 cases of9 patients died in 236 cases, including 3 cases of fungal infection, 3 cases of Gram-negative bacteria infection, 2 cases of Gram-positive bacteria infection, one cases of culture-negative. Peritonitis related mortality rate was 3.81%; 13 cases transferred to hemodialysis, including 6 cases of fungal infection. The total catheter removal rate was 5.51%. 10 cases gave up treatment, the others were cured. The cure rate was 86.44%. ConclusionsThe main pathogen of CAPD related peritonitis is Gram-positive bacteria. Traditional treatment of peritonitis with first generation combined third generation cephalosporins is not suitable for CAPD related peritonitis. The empiric initial treatment of peritonitis recommended the use of vancomycin combined Cefoperazone/sulbactam or amikacin .     

Pulmonary and peritoneal tuberculosis in a CAPD patient

Patients with chronic renal failure have an increased incidence of tuberculosis due to decreased cellular immunity. More than half of the tuberculosis infection in these patients presented with extrapulmonary involvement. Tuberculous peritonitis is an important problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Simultaneous pulmonary and peritoneal tuberculosis is a very rare condition. We describe a 39-year-old man with culture negative CAPD peritonitis. In spite of conventional antimicrobial therapy the patient had persistent fever, weight loss, and night sweats. Approximately after one month from starting treatment, both sputum specimen and peritoneal fluid were positive for mycobacterium. Quadruple therapy for tuberculosis has been started. The response to treatment was promptly. He is still on treatment for six months and receiving CAPD. Tuberculous peritonitis should always be considered when patients on CAPD develop culture negative peritonitis treated with conventional antibiotics without improvement. In addition, the existence of extraperitoneal tuberculosis, especially pulmonary disease must be investigated.