Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: a prospective study

A prospective study on peritoneal eosinophilia was conducted in 23 continuous ambulatory peritoneal dialysis (CAPD) patients for a mean period of 7.9 months. Peritoneal eosinophilia as defined by peritoneal eosinophil count exceeding 100/mm3 was found in 60.8% of patients. Most developed peritoneal eosinophilia within 3 months of the initiation of dialysis, although the phenomenon could occur as early as one day or as late as 6 months after dialysis. Fifty-seven percent of those with peritoneal eosinophilia also had peripheral blood eosinophilia. Although most peritoneal eosinophilic episodes subsided in a month, in one patient the process grumbled on for 150 days. The number of peritonitis episodes was not significantly different between patients with peritoneal eosinophilia and those without. The only distinction between the two groups of patients was that those who developed peritoneal eosinophilia had a significantly (P = .002) higher serum IgE concentration initially as well as throughout the period of observation.     

The comparison in terms of early complications of a new technique and percutaneous method for the placement of CAPD catheters

BACKGROUND: Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. SUBJECTS AND METHOD: Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. RESULTS: In all of the subjects, dialysis was started soon after catheter placement. No peroperative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. CONCLUSION: The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.     

Pseudomonas peritonitis associated with continuous ambulatory peritoneal dialysis: a six-year study

In a population of 214 patients on continuous ambulatory peritoneal dialysis (CAPD), 415 peritoneal infections occurred between 1980 and 1986. Fourteen of these infectious events were caused by Pseudomonas aeruginosa (3.4%). None of those patients with P aeruginosa peritonitis were cured by medical therapy alone. Peritoneal catheter removal was necessary to achieve resolution of the infection. Significant patient morbidity from Pseudomonas infection included loss of peritoneal space for further dialysis and abscess formation. Our data suggests that prompt catheter removal should be seriously considered for chronic ambulatory peritoneal dialysis patients who develop P aeruginosa peritonitis.     

Laparoscopic placement of peritoneal dialysis catheter (same day dialysis).

BACKGROUND AND OBJECTIVE: Peritoneal dialysis (PD) remains the generally accepted method for management of renal failure in chronic and acute renal failure. Despite the rapidly increasing use of continuous ambulatory peritoneal dialysis (CAPD) since its introduction, controversy persists as to the efficacy and exact role of the modality in the treatment of end stage renal failure. The aim of this paper is to present the experience with laparoscopic placement of a peritoneal dialysis catheter and starting the peritoneal dialysis on the same day. METHODS: The laparoscopic placement of a peritoneal dialysis catheter was performed on 11 patients (10 males and 1 female) with an average age of 35 years, over a 12-month period. The procedure was done using two 5 mm abdominal trocars. The precise position of the catheter on the pelvis was ensured laparoscopically. One to two liters exchange dialysis was used for every patient, and no leakage was recorded. RESULTS: The patients tolerated the procedure well. The peritoneal dialysis was started immediately. Patients were discharged after an overnight stay, and PD was carried out routinely. CONCLUSION: The results of laparoscopic placement of a peritoneal dialysis catheter show the following advantages: minimal incision; less surgical trauma; the procedure hastens the early start of peritoneal dialysis and has no complications.     

营养不良和慢性炎症对肠炎相关性腹膜炎腹透患者的影响

目的：探讨慢性炎症状态和营养状况对肠道感染相关性腹膜炎的腹膜透析患者的影响。方法：对我院腹膜透析中心2000年～2010年间收治的持续性不卧床腹膜透析并发腹膜炎的患者进行回顾性研究。将肠道感染相关性腹膜炎的患者（1组）,其他原因导致的腹膜炎的患者（2组）作为对照,比较两组临床和实验室数据,分析肠道感染相关性腹膜炎与免疫功能、营养状况等的关系。结果：1组12例,发生感染性腹膜炎23例次,2组31例,发生感染性腹膜炎53例次。与2组相比,1组患者血压和水肿情况明显升高,CRP明显增加,血红蛋白和血浆白蛋白明显降低,SGA评分营养不良的发生率较高（以上所有数据P〈0.05）。结论：与其他原因导致腹膜炎的患者相比,肠道感染相关性腹膜炎的患者的营养不良、慢性炎症和容量负荷较重。加强营养,积极治疗肠炎可能有助于该病的预防和控制。     

The Comparison in Terms of Early Complications of a New Technique and Percutaneous Method for the Placement of CAPD Catheters

Background. Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. Subjects and method. Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. Results. In all of the subjects, dialysis was started soon after catheter placement. No per-operative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. Conclusion. The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.     

Treatment of resistant CAPD peritonitis by temporary discontinuation of peritoneal dialysis

Resistant continuous ambulatory peritoneal dialysis (CAPD) peritonitis (recurrent or persistent infection) is traditionally treated by removal of the CAPD catheter and a period off peritoneal dialysis. In a pilot study we have treated 8 patients with recurrent staphylococcal peritonitis and 3 patients with persistent staphylococcal peritonitis by stopping CAPD for a 2-week period, the CAPD catheter being left in-situ. All 8 patients with recurrent peritonitis and 2 of the 3 patients with persistent peritonitis had resolution of their infection; the third patient required catheter removal to clear the infection. There were no acute problems associated with stopping CAPD, and there was no evidence of loss of peritoneal filtration capacity on restarting CAPD. This novel approach to the treatment of resistant CAPD peritonitis should reduce the number of CAPD catheters replaced and therefore diminish the risks and inconvenience to patients that such replacements entail.     

Simultaneous peritoneal dialysis catheter insertion and removal in catheter-related infections without interruption of peritoneal dialysis

Catheter-related infections result in high patient morbidity, the need for temporary haemodialysis, and high costs. These infections are the main cause of limited technique survival in peritoneal dialysis. We introduced a protocol for the simultaneous peritoneoscopic insertion and removal of peritoneal catheters in patients with catheter-related infections. Peritoneal dialysis was continued the day after surgery using low-volume dwells and a dry abdomen during the daytime. The dialysate leukocyte count had to be below 100/mm³ before exchanging catheters, which was performed under antibiotic therapy based on culture sensitivity. The old catheter was removed after the new catheter had been inserted in the opposite abdominal region. CAPD patients were switched to APD for 1 week, which made prolonged hospitalization necessary. Simultaneous catheter insertion and removal was performed 25 times in 22 patients on CCPD and 15 times in 14 patients on CAPD. In CCPD patients, peritoneal dialysis was restarted after 1.0+0.1 days in 24 cases. One patient had sufficient residual renal function and discontinued CCPD until day 10. In 10 CAPD patients (11 procedures) APD was started 1.3±0.2 days after the procedure with CPD beginning 7.1±0.6 days thereafter. Three CAPD patients preferred haemodialysis and restarted CAPD 10.0±2.1 days after surgery. One patient continued CAPD the day after surgery. In addition to minor complications (e.g. position-dependent outflow problems), dialysate leakage occurred in two patients. Two patients developed peritonitis within the first 30 days after surgery, one of which was procedure related. One patient had severe lower gastrointestinal bleeding 2 weeks after the procedure, which was not related to the catheter replacement. Ultimately, in 38 of 40 procedures the patients could successfully continue peritoneal dialysis. We conclude that simultaneous insertion and removal of a peritoneal dialysis catheter without interruption of peritoneal dialysis is a safe procedure in patients with catheter-related infections.     

Peritoneal drainage: an important element in host defence against staphylococcal peritonitis in patients on CAPD.

The growth of Staphylococcus aureus and coagulase-negative staphylococci were studied in fresh and effluent peritoneal dialysate from patients on continuous ambulatory peritoneal dialysis (CAPD). Peritoneal drainage during CAPD removes bacterial contaminants from the peritoneal cavity with an efficiency that depends upon the volume of peritoneal fluid remaining after drainage (residual volume). Combination of our data on the growth of coagulase-negative staphylococci in dialysate with a mathematical model of peritoneal drainage during CAPD shows that a residual volume of less than 800 ml (normal = approximately 400 ml) will prevent survival in the peritoneal fluid. A residual volume of less than 200 ml is required to eliminate S. aureus because of its faster rate of growth in dialysate. Previous work has shown that numbers of macrophages are too few to influence bacterial growth in the peritoneal dialysate. Coagulase-negative staphylococci adhere poorly to mesothelial cells in culture. Survival within the peritoneal cavity during CAPD probably depends on colonization of the PD catheter. Coagulase-negative staphylococcal peritonitis is likely to be localized to areas of the peritoneal membrane in close contact with the PD catheter. S. aureus is able to multiply in the peritoneal dialysate during CAPD and thereby causes generalized peritonitis.     

A novel minimally invasive technique for insertion of peritoneal dialysis catheter

The placement of a continuous ambulatory peritoneal dialysis (CAPD) catheter by conventional open surgical or trocar technique may cause a number of complications such as infection, hemorrhage, leakage, incisional hernia, and visceral organ perforation. Most complications are related to open surgery or insertion of the catheter with the guidewire without direct visualization. Insertion of the catheter laparoscopically under direct visualization has been previously described. The authors who described this technique used two or three ports for the camera and instruments. In this study we describe a laparoscopic technique for insertion of the peritoneal dialysis catheter under direct visualization with use of one-camera port and an accessory 2-mm umbilical incision. This prospective study was performed with the approval of the ethics committee of the Gazi University Hospital, in Ankara, Turkey. There were a total of eight patients: five males and three females, with an average age of 34.3 years (range, 11-54), who underwent laparoscopic CAPD insertion between 1997 and 2000. The catheter was inserted into the abdominal cavity 2 cm below the umbilicus. The subcutaneous tunnel was made with the assistance of a specially designed L-shaped trocar. All patients did well after the operation and had excellent cosmetic results. There was one leak in the early postoperative period, which was treated conservatively. The average operating time was 34.7 minutes (range, 25-45 minutes). The laparoscopic approach for peritoneal dialysis catheter insertion, for management of transmigrated CAPD catheters, and to resolve omental occlusions should be considered as an alternative to open surgery, especially for patients who have peritoneal adhesions secondary to a history of abdominal surgeries or recurrent peritonitis.     

Image-guided peritoneal access and management of complications in peritoneal dialysis

The principal complications of continuous ambulatory peritoneal dialysis (CAPD), namely malposition of the dialysis catheter, peritonitis, exit site infection, leakage of dialysis fluid, sclerosing peritonitis, and renal cysts and tumors, are considered in this article. The techniques that are used to reposition displaced dialysis catheters and extend the duration of dialysis are described. The role of imaging in establishing the diagnosis of peritonitis is relatively small. However, both computed tomography (CT) and ultrasound may be used to identify loculation of fluid and localized sites of sepsis, and permit percutaneous drainage. Ultrasonography of the catheter track through the percutaneous tissues allows identification of pericatheter collections in patients with exit-site infection. The technique of CT peritoneography is helpful in establishing sites of dialysis fluid leakage. These commonly occur at the site of entry of the dialysis catheter, through abdominal incisions, or along the patent tunica vaginalis into the scrotum. The appearances on CT of sclerosing peritonitis reflect pathologic changes and are characterized by the presence of peritoneal thickening and calcification. Bowel obstruction, which may develop in sclerosing peritonitis, can be identified on abdominal radiographs or barium studies of the gastrointestinal tract. Acquired renal cystic disease and renal carcinomas occur in a significant proportion of patients undergoing CAPD. Ultrasound is the investigation of first choice in the identification and clarification of the pathology (cystic or solid) of suspected renal masses.     

Peritoneal eosinophilia associated with Paecilomyces variotii infection in continuous ambulatory peritoneal dialysis

A 65-year-old woman maintained on continuous ambulatory peritoneal dialysis (CAPD) presented with a 5-month history of intermittent cloudy bags and sterile peritoneal and peripheral blood eosinophilia, which failed to clear despite conventional antibiotics. Impaired catheter inflow and delayed effluent drainage gradually occurred and intracatheter streptokinase, administered to rectify catheter dysfunction, dislodged a catheter cast composed of fungal hyphae of Paecilomyces variotii. Fungal peritonitis and Paecilomyces fungemia ensued, which were treated with amphotericin B and catheter removal. Peripheral eosinophilia rapidly resolved. Paecilomyces is a saprophytic fungus found in soil and water that is capable of infecting prosthetic devices. Eosinophils may have accumulated in this case in response to particulate fungal cell antigens being washed into the peritoneal cavity during dialysis. Chronic fungal catheter infection should be excluded in cases of late onset, persistant peritoneal eosinophilia on CAPD.     

Predictors of the outcome following peritoneal dialysis-related bacterial-complicating peritonitis

Objective To investigate the risk factors predicting the outcome of peritoneal dialysis (PD)-related bacterial-complicating peritonitis. Methods In this retrospective study, all the episodes of PD-related bacterial peritonitis presenting during Jan 2009 to Dec 2013 in our center were reviewed. Clinical and laboratory parameters at the onset of peritonitis, including patient demographic information, age, gender, duration of PD, residual renal function, local and systemic inflammation state, daily exchange number, peritoneal glucose exposure and so on, were recorded. Patients episodes were divided into three groups according to the outcome: complete cure (complete resolution of peritonitis without relapse or recurrence or repeat), peritonitis-related catheter removal/death group, and relapse (relapse or recurrence or repeat) group. Results 187 CAPD patients with 27.15(11.15, 53.13) PD duration were enrolled in the study. Total of 347 episodes of bacterial peritonitis in these patients were analyzed, with 130 episodes of gram-positive bacterial infection, 71 episodes of gram-negative bacterial infection, 15 episodes of polymicrobial and 131 episodes of cultured negative. Compared to the complete cure group and the relapse group, gram negative bacterial infection was more prevalent in the peritonitis-related catheter removal/death group. Furthermore, patients in the peritonitis-related catheter removal/death group showed longer PD age (P﹤0.01) and higher serum hs-CRP (P﹤0.01). Compared to the complete cure group, the serum albumin concentration was lower in the peritonitis-related catheter removal/death group (P﹤0.01). Kt/V was significantly lower in the relapse group than that in the complete cure group (P﹤0.05). Logistic analysis indicated age, non gram positive bacterial infection and increased hs-CRP were independent predictors for peritonitis-related catheter removal or death. Conclusions Age, non gram positive bacterial infection and hs-CRP are risk factors predicting peritonitis-related catheter removal or death in CAPD patients.     

Surgical management of peritoneal dialysis catheters in children: five-year experience with 1,800 patient-month follow-up

Currently at our institution more than 90% of the children with end-stage renal disease are managed with continuous ambulatory peritoneal dialysis (CAPD) in preference to hemodialysis until a successful transplant is accomplished. Recent refinements in CAPD catheters and dialysis techniques have greatly added to the many medical, psychological, and economic advantages of CAPD compared with chronic hemodialysis. Ninety-three patients less than 21 years of age underwent insertion of 167 peritoneal dialysis (PD) catheters over a 5-year period. A variety of PD catheters were used, including 121 (73%) double-cuff Tenckhoff catheters, 22 (13%) single-cuff, and 24 (14%) column disc catheters (Lifecaths, Physio-Control Corp, Redmond, WA). There were three (3%) noncatheter-related mortalities and minimal significant morbidity during the 1,819 patient-months of catheter use. Exit site infections (61%) and peritonitis (59%) were frequent but minor complications, occasionally requiring catheter replacement. Other noninfectious complications included abdominal hernias (42%), dialysis leaks (14%), distal cuff extrusion (11%), catheter obstruction (7%), and hydrothorax (2%). Forty-five of the 60 hernias (75%) were surgically repaired in patients while receiving CAPD. Persistent or recurrent peritonitis was common with Pseudomonas, Serratia, and fungal infections and often resulted in catheter removal and loss of the peritoneal dialysis membrane. Catheter survival for the double-cuff Tenckhoff was significantly better (P .005) than the single-cuff or Lifecath. Based on this experience we have found that using specific operative techniques for CAPD catheter placement and early surgical management for severe peritonitis reduces the incidence of complications and modality failure.     

Modification of the percutaneous approach to peritoneal dialysis catheter placement under peritoneoscopic visualization: clinical results in 78 patients.

The placement of percutaneous peritoneal dialysis catheters under direct peritoneoscopic visualization is a relatively new technique for establishing peritoneal dialysis access. In this study, in which a modification of the Seldinger technique was used to facilitate the placement of the peritoneoscope, the experience with 82 consecutive catheterization procedures in 78 patients is reported. In 2 (2.4%) of 82 catheterization procedures, we were unable to enter the peritoneal cavity but experienced no other complications unique to the percutaneous approach. Of the 80 successful catheterization procedures, 76 represented first-time catheter placement and constituted a population subjected to life-table analysis examining catheter survival rates, the time to first cutaneous exit site or s.c. tunnel infection, and the time to first episode of peritonitis. After a follow-up period of 50.1 patient yr, 11 catheters were lost because of catheter dysfunction. Other clinical complications included peritoneal fluid leaks at the cutaneous exit site in 11 instances (0.22/patient yr), cutaneous exit site infection in 7 instances (0.14/patient yr), s.c. tunnel infection in 2 instances (0.04/patient yr), and 34 episodes of peritonitis (0.68/patient yr). The results of this study demonstrate that the suggested modification of the percutaneous placement of peritoneal dialysis catheters, under peritoneoscopic visualization, is a viable method for establishing peritoneal access.     

Fungal peritonitis in continuous ambulatory peritoneal dialysis--the Auckland experience.

Fungal infection is an uncommon cause of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD). We report our center's experience with 38 episodes of fungal peritonitis occurring in 33 patients, out of a total of 503 patients managed on CAPD over 11 1/2 years, and review the relevant literature. Our usual management philosophy has been one of early peritoneal catheter removal without antifungal therapy. In those with worsening clinical features, and in those with persistence of signs and symptoms beyond 48 hours after catheter removal, antifungal drugs were administered. Only five patients received antifungal therapy initially, followed by later catheter removal. Seventy-six percent of patients treated by catheter removal alone (N = 21) and 64% of patients treated by catheter removal followed by antifungal therapy (N = 11) were successfully reestablished on CAPD. A policy of early catheter removal, usually alone, but followed by antifungal therapy in select cases, can be associated with a mortality rate of less than 15% and a high rate of return to effective peritoneal dialysis.     

Catheter infections as a factor in the transfer of continuous ambulatory peritoneal dialysis patients to hemodialysis

The effect of peritoneal catheter infections on the transfer of continuous ambulatory peritoneal dialysis (CAPD) patients to hemodialysis over a 9-year period were examined. Twenty-seven percent (68/247) of all patients were transferred permanently to hemodialysis after a mean of 15 +/- 14 months of CAPD. An additional 29% transferred temporarily one or more times during the study period (mean time of peritoneal dialysis, 35 +/- 23 months). The reasons for permanent transfer to hemodialysis were catheter infections (15/68, 22%), peritonitis (13/68, 19%), catheter infections associated with peritonitis (10/68, 15%), patient preference (9/68, 13%), mechanical problems (4/68, 6%), noncompliance (7/68, 10%), inadequate clearance or ultrafiltration (6/68, 9%), with other reasons for the remainder (4/68, 6%). Temporary transfers to hemodialysis were also mainly due to catheter infections (32%), peritonitis (23%), and simultaneous catheter infections and peritonitis (24%). Catheter infection rates were much higher in the groups that permanently and temporarily were transferred to hemodialysis in comparison with those patients who remained on peritoneal dialysis. We conclude that catheter infections are a leading cause of both temporary and permanent transfer of CAPD patients to hemodialysis.     

Rothia dentocariosa repeat and relapsing peritoneal dialysis-related peritonitis: a case report and literature review

Peritonitis is well recognized as the Achilles tendon of peritoneal dialysis (PD). Reoccurrence of peritonitis due to the same organism, defined as either repeat or relapsing peritonitis under the 2005 guidelines by the International Society for Peritoneal Dialysis, often results in PD technique failure. Rothia dentocariosa, a low-virulent human oropharynx commensal, is a rarely reported pathogen in human infection, particularly infective endocarditis. R. dentocariosa PD-related peritonitis is exceedingly uncommon yet potentially results in repeat or relapsing peritonitis which requires catheter removal. We report a case of R. dentocariosa repeat and relapsing peritonitis in a PD patient who was treated successfully with antimicrobial therapy.     

The value of low-dose intraperitoneal immunoglobulin administration in the treatment of peritoneal dialysis-related peritonitis

BACKGROUND: Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD). The value of immunomodulatory therapeutic approaches and, especially, methods aimed at augmenting opsonization in the treatment of peritoneal dialysis (PD)-related peritonitis is unclear. In this study, the effect of intraperitoneal (IP) immunoglobulin (Ig) usage, as an approach for strengthening opsonization, was evaluated in CAPD peritonitis. METHODS: The study included 24 patients with CAPD peritonitis. The patients were divided into two groups, A and B, each consisting of 12 patients. There were no significant differences between the groups in terms of age, gender, CAPD duration, and peritonitis rate. Empiric antibiotic treatment was a 2-week IP ampicillin+sulbactam/netilmycin combination. Group B was additionally given low-dose IP IgG (2 mL = 320 mg) with every exchange. The dialysate leucocyte counts were obtained in both groups until the number was <100 cells/microL to monitor the response to peritonitis treatment. RESULTS: In group A, the number of exchanges done until the dialysate leucocyte counts decreased to <100/mL was 13.9 +/- 1.4 and for group B 6.6 +/- 0.4 (p<0.001). The reduction in neutrophils was significantly faster in group B compared to group A (p<0.001). The number of exchanges until abdominal pain completely disappeared was 12.5 +/- 1.7 in group A and 5.6 +/- 0.7 in group B (p<0.001). CONCLUSIONS: The results of this study show that low-dose, continuous IP IgG administration in the treatment of PD-related peritonitis is safe and effective in shortening the treatment time.