A prospective evaluation of blood culture versus standard plate techniques for diagnosing peritonitis in continuous ambulatory peritoneal dialysis

Peritonitis remains a major cause of morbidity in patients treated with continuous ambulatory peritoneal dialysis (CAPD). Culture-negative episodes of peritonitis occur at rates of up to 20%, and in part may reflect inadequate culturing techniques of peritoneal effluent. Through a large, prospective study, the improved sensitivity of a blood culture system, when compared with a standard plate technique (P = 0.001), for the detection of bacterial growth in 67 episodes of CAPD peritonitis is demonstrated. Improved recognition of infections caused by gram-positive organisms, primarily Staphylococcus epidermidis, was especially significant using the blood culture system (P = 0.0001). Because of improved sensitivity and a decreased time to organism identification, particularly with infections caused by S epidermidis, the most common cause of bacterial peritonitis in CAPD patients, we suggest that a blood culture system be the standard means of culturing peritoneal fluid in CAPD patients with peritonitis. The lysis-centrifugation system of culturing peritoneal fluid is also discussed in comparison with the blood culture system.     

Usefulness of 23S rRNA amplification by PCR in the detection of bacteria in CAPD peritonitis

BACKGROUND: Peritonitis is the most common complication of continuous ambulatory peritoneal dialysis (CAPD), and the spectrum of organisms causing CAPD peritonitis is broad. Polymerase chain reaction (PCR) has recently broadened its diagnostic capabilities in infectious diseases. PCR can provide a sensitive method for identifying causative infectious organisms. METHODS: To evaluate the usefulness of 23S bacterial ribosomal RNA amplification and direct sequencing for the detection of infectious organisms, we compared PCR with bacteriological culture for the analysis of dialysates from CAPD peritonitis patients. Thirty-two samples from CAPD peritonitis patients with current antibiotic use and control samples from 30 CAPD patients without peritonitis were examined by PCR with sequencing analysis and by conventional bacteriological culture. In addition, 95 culture-positive samples and 39 culture-negative samples from CAPD peritonitis patients before antibiotic treatment were analyzed by PCR assay. RESULTS: In the control samples from patients without CAPD peritonitis, false-positive rates were relatively rare: 3 of 30 in the PCR study and 2 of 30 in the culture study. Of the 134 CAPD peritonitis samples collected before antibiotic therapy, positive cultures were obtained in 70.9% (95/134) of them. In 75 of the culture-positive samples, the same microorganisms were confirmed by PCR assay, and the others showed discrepant results as compared with culture study. In 30 of the 39 culture-negative samples, microbial organisms were detected by PCR assay. Of the 32 samples from patients who developed CAPD peritonitis during antibiotic treatment, 17 (53.1%) were positive by PCR assay, and 5 (15.6%) were positive by culture. CONCLUSION: Our study suggests that broad-spectrum PCR with RNA sequencing can complement culture methods in the diagnosis of CAPD peritonitis, especially in patients with previous or current antibiotic use.     

Correlation between peritoneal mesothelial cell cytology and peritoneal histopathology with respect to prognosis in patients on continuous ambulatory peritoneal dialysis

BACKGROUND: Sclerosing encapsulating peritonitis (SEP) is a serious complication seen in patients on long-term continuous ambulatory peritoneal dialysis (CAPD). We have previously reported that mesothelial cells in effluent dialysate significantly increased in size as the duration of CAPD progressed. In this study, we investigated the relationship between mesothelial cytology, histopathology of the peritoneum, and clinical outcomes of 34 CAPD patients. METHODS: When peritoneal dialysis catheters were inserted (n = 7) or removed (n = 27), a peritoneal biopsy was performed and results compared with mesothelial cytology in effluent dialysate. RESULTS: A significant positive correlation was noted between the duration of CAPD and the surface area of peritoneal mesothelial cells (r = 0.721, p < 0.0001). The surface area of mesothelial cells in peritoneal sclerosis (n = 9; 584 +/- 97 microm(2)) was significantly greater than in peritoneal fibrosis (n = 14; 389 +/- 26 microm(2), p < 0.05), pathologic acute peritonitis (n = 3; 223 +/- 10 microm(2), p < 0.005), and normal peritoneum (n = 7; 247 +/- 12 microm(2), p < 0.001). The surface area in sclerosing peritonitis (n = 1; 1,200 microm(2)) was greater than that of all the others. Giant cells were found in the 1 case with sclerosing peritonitis and in 3 of 9 cases with peritoneal sclerosis, although they were found in only 1 of 14 patients with peritoneal fibrosis and in none of those with pathologic acute peritonitis or normal peritoneum. As the surface area of mesothelial cells increased to more than 400 microm(2) and giant cells appeared in the effluent, the frequency of peritoneal sclerosis and/or clinical SEP increased. CONCLUSION: An increase in the mesothelial cell surface area and the emergence of giant cells in the effluent indicate advanced peritoneal histopathology, and may be useful indicators to determine appropriate timing of discontinuation of CAPD to prevent the development of SEP.     

胰岛素不同给药途径对CAPD患者腹膜炎发生率的影响

目的 探讨终末期糖尿病肾病患者腹膜透析时胰岛素不同给药途径对腹膜炎发生率的影响,为合理使用胰岛素、减少腹膜炎发生率提供临床依据.方法 将47例终末期糖尿病肾病行持续非卧床腹膜透析(CAPD)患者随机分为腹腔组(23例)和皮下组(24例),腹腔组行腹腔给药(胰岛素加入腹膜透析液中行CAPD治疗),皮下组予皮下注射胰岛素.比较两组患者腹膜炎发生率并分析其发生原因,胰岛素用量、费用,低血糖事件发生率及血糖控制水平.结果 两组患者腹膜炎发生率、血糖控制水平、低血糖事件发生率比较.差异无统计学意义(均P>0.05);腹腔应用胰岛素剂量是皮下注射胰岛素剂量的2倍,但腹腔给药比皮下注射费用低4.73倍.发生腹膜炎的原因主要为已培训人员操作不规范及更换未经正规培训的人员操作.结论 在规范培训、严格考核、定期追踪随访CAPD患者的情况下,胰岛素腹腔内给药不会增加腹膜炎的发生率,且可减少费用,减轻患者痛苦,为CAPD治疗依从性较好的患者提供了控制血糖的新途径.     

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。     

Treatment of gram-positive peritonitis with two intraperitoneal doses of vancomycin in continuous ambulatory peritoneal dialysis patients

Eight patients with end-stage renal failure on continuous ambulatory peritoneal dialysis (CAPD), who developed peritonitis, received an intraperitoneal dose of vancomycin (30 mg/kg body weight) with 6 h of peritoneal dwell and then resumed their routine CAPD schedule. Vancomycin concentration in serum, peritoneal dialysate (PD) from an overnight dwell and 1, 2 and 3 h after a new exchange was measured at 48 h (in 5 patients) and 7 days (in 6 patients). Except for an occasional 1-hour peritoneal fluid sample on the 7th day, all samples had satisfactory vancomycin levels. Five of the 8 patients who had gram-positive peritonitis and 1 with 'sterile' peritonitis received another similar intraperitoneal dose of vancomycin at the 7th day. All of these patients had good therapeutic response with a negative PD culture 3 weeks after the cessation of therapy and no relapse of infection in at least 1 month of follow-up. We conclude that 2 intraperitoneal doses of vancomycin (30 mg/kg body weight) given 1 week apart with 6 h of intraperitoneal dwell is an effective and adequate treatment for gram-positive and 'sterile' peritonitis in CAPD patients.     

Coccidioidal peritonitis associated with continuous ambulatory peritoneal dialysis

We report the first three cases of peritonitis due to the fungus Coccidioides immitis occurring during continuous ambulatory peritoneal dialysis (CAPD). At the time of diagnosis, none of the patients had evidence of active infection outside of the peritoneal cavity. Clues suggesting the diagnosis including a previous history of pulmonary coccidioidomycosis, an excess number of eosinophils in the peritoneal fluid, and failure to respond to therapy directed against bacteria. C immitis in peritoneal fluid was more readily isolated on specific fungal culture media than on routine bacterial culture media. In no instances did potassium hydroxide (KOH) preparations of the fluid reveal fungi. Coccidioidal peritonitis during CAPD appears to be a localized form of extrapulmonary coccidioidomycosis that has a relatively benign course once the peritoneal catheter is removed.     

终末期糖尿病肾脏病腹膜透析时胰岛素用药途径的探讨

目的比较终末期糖尿病肾脏病患者腹膜透析时不同途径给予胰岛素时腹膜炎的发生率。方法将50例行持续性非卧床腹膜透析（CAPD）的终末期糖尿病肾脏病患者随机分组，腹腔注射组25例，于腹腔内注射胰岛素；皮下注射组25例，于皮下注射胰岛素。比较2组透析前后收缩压、舒张压、尿量、超滤量及腹膜透析后腹膜炎发生率。结果2组透析前后收缩压、舒张压、尿量、超滤量均无统计学差异（P〉0．05）。腹腔注射组发生腹膜炎共11例次，发生率为1次／26．0个患者月；皮下注射组发生腹膜炎共13例次，发生率为1次／22．9个患者月。结论终末期糖尿病肾脏病患者行CAPD时，腹腔内注射胰岛素不会增加腹膜炎的发生率，对依从性好的患者是首选方法。     

Use of intraperitoneal urokinase for resistant bacterial peritonitis in continuous ambulatory peritoneal dialysis

Intraperitoneal (IP) urokinase is a fibrinolytic agent that has been used in the adjunctive treatment of continuous ambulatory peritoneal dialysis (CAPD) and resistant and relapsing peritonitis. However, its efficacy and role in treating resistant CAPD bacterial peritonitis remain unclear and results from previous prospective studies have been conflicting. We prospectively randomized 88 CAPD patients with bacterial peritonitis resistant to initial empirical IP antibiotics into two groups: IP urokinase 60,000 IU and a placebo group. Patients were treated concomitantly with susceptible antibiotics according to culture results. Peritoneal dialysate grew pseudomonas aeruginosa in 13 patients (14.8%), non-pseudomonas bacteria in 63 patients (71.6%) and negative cultures in 12 patients (13.6%). For the clinical outcomes, there were no significant differences in the primary response rates (61.4 vs. 50%), relapse rates (9.1 vs. 13.6%), Tenckhoff catheter removal rates (22.7 vs. 29.5%) and mortality rates (6.8 and 6.8%) between the urokinase group and the controls (p=ns). Subgroup analysis of culture negative patients (n=12) also demonstrated no sgnificant benefit for urokinase treatment. No significant adverse effects were encountered with the IP urokinase instillation. Total median peritonitis-related length of hospitalization for the urokinase group and controls were 7 and 11 days, respectively (p=0.32). We concluded that IP urokinse plays no significant role as an adjuvant therapy in the treatment of bacterial CAPD peritonitis resistant to initial IP antibiotic therapy.     

Proteomic Analysis of Peritoneal Dialysate Fluid in Patients with Dialysis-Related Peritonitis

The prognosis of uremia patients on continuous ambulatory peritoneal dialysis (CAPD) is related to frequent peritonitis rate. Frequent peritonitis will lead to peritoneum failure, making CAPD unfeasible. We have performed proteomic profiling of peritoneal dialysis effluent samples from a cross-section of CAPD patients with and without peritonitis in order to identify biomarkers of peritonitis. We performed 2D gel electrophoresis and surface-enhanced laser esorption/ionization time of flight mass spectrometry (SELDI-TOF MS) on peritoneal dialysis effluent from 16 subjects with peritonitis. A genetic algorithm search of principal component space revealed a group of a peak distinguishing peritonitis-positive subjects, with mass/charge (m/z) values of 11,117.4. Our analyses identified the peak at m/z 11,117.4 with an accuracy of 95% for classifying peritonitis. Mass spectrometric analysis of peritonitis PDE samples identified the 11,117.4 protein as β2-microglobulin (B2M). Using an unbiased protein profiling approach, we have validated previously reported findings of B2M as a biomarker associated with CAPD peritonitis. Prospective studies are warranted to establish additional biomarkers that would be predictive of peritoneal dialysis peritonitis. Besides, extending the study to a larger number of patients with subgroup analyses may yield additional information of the peritoneal dialysate proteins in association with dialysis adequacy, residual renal function, nutritional status, and risk of peritoneal infection.     

Proteomic analysis of peritoneal dialysate fluid in patients with dialysis-related peritonitis

The prognosis of uremia patients on continuous ambulatory peritoneal dialysis (CAPD) is related to frequent peritonitis rate. Frequent peritonitis will lead to peritoneum failure, making CAPD unfeasible. We have performed proteomic profiling of peritoneal dialysis effluent samples from a cross-section of CAPD patients with and without peritonitis in order to identify biomarkers of peritonitis. We performed 2D gel electrophoresis and surface-enhanced laser esorption/ionization time of flight mass spectrometry (SELDI-TOF MS) on peritoneal dialysis effluent from 16 subjects with peritonitis. A genetic algorithm search of principal component space revealed a group of a peak distinguishing peritonitis-positive subjects, with mass/charge (m/z) values of 11,117.4. Our analyses identified the peak at m/z 11,117.4 with an accuracy of 95% for classifying peritonitis. Mass spectrometric analysis of peritonitis PDE samples identified the 11,117.4 protein as beta2-microglobulin (B2M). Using an unbiased protein profiling approach, we have validated previously reported findings of B2M as a biomarker associated with CAPD peritonitis. Prospective studies are warranted to establish additional biomarkers that would be predictive of peritoneal dialysis peritonitis. Besides, extending the study to a larger number of patients with subgroup analyses may yield additional information of the peritoneal dialysate proteins in association with dialysis adequacy, residual renal function, nutritional status, and risk of peritoneal infection.     

Use of pure bicarbonate-buffered peritoneal dialysis fluid reduces the incidence of CAPD peritonitis.

BACKGROUND: Advances in bag connection technology have reduced the incidence of peritonitis in CAPD patients but there is little information on the effect of the new peritoneal dialysis fluids. METHODS: We studied the incidence of CAPD peritonitis for about 3 years in 100 incident patients--50 patients dialysed with lactate-buffered solution, pH 5.5 and containing glucose degradation products (GDP) (lactate group), and 50 patients with pure bicarbonate-buffered solution, pH 7.4 and low GDP (bicarbonate group). Patients in both groups were similar in age, sex, length of time on CAPD, connection technology and handling of dialysis. RESULTS: In the lactate group, 74 episodes of peritonitis were recorded compared with 43 in the bicarbonate group, i.e. one episode per 21 patient-months with the lactate dialysis fluid and one episode per 36 patient-months with the bicarbonate dialysis fluid (OR 0.58, 95% CI 0.37-0.91, P = 0.017). A total of 3369 exchanges per episode of peritonitis were recorded for bicarbonate compared with 2004 exchanges per episode of peritonitis in the lactate group. The majority of organisms isolated in both groups were Gram-positive bacteria, with a predominance of the oropharyngeal and cutaneous endogenous flora. Three episodes of fungal peritonitis occurred in the lactate group and none in the bicarbonate group. CONCLUSIONS: Our results suggest that the pure bicarbonate-buffered peritoneal dialysis fluid appears to reduce the frequency of peritonitis in CAPD patients possibly in relation to greater biocompatibility and maintenance of peritoneal membrane structural integrity. Similar results can probably relate to all low-GDP solutions.     

Bactericidal Activity of Peritoneal Macrophages from Continuous Ambulatory Dialysis Patients

A radiometric assay is described for measuring phagocytosisand intracellular killing of Staphylococcus epidermidis by peritonealcells from continuous ambulatory peritoneal dialysis (CAPD)patients. Using this method it is possible to determine simultaneouslyand independently, in a single assay, whether peritoneal cellsfrom CAPD patients possess defects in either ingestion or intracellularkilling. Assays were performed on peritoneal cells obtainedfrom 28 samples of spent dialysis fluid from CAPD patients.In the majority of cases these cells were able to efficientlyphagocytose and kill opsonised Staph. epidermidis, althoughthe degree of intracellular killing was slightly reduced comparedwith peritoneal cells obtained from eight normal controls undergoinglaparoscopy. Overall there was no correlation between the degreeof phagocytosis or intracellular killing and susceptibilityof patients to peritonitis, although cells from two patientswith a high incidence of peritonitis did show abnormally pooringestion and/or killing. In a number of samples only low numbersof cells (<10⁶) were recovered in total from the overnightbags, and there was a significant inverse correlation betweenthe number of cells in the fluid and the length of time on CAPD     

Intraperitoneal (IP) vancomycin therapy for CAPD peritonitis--a prospective, randomized comparison of intermittent v continuous therapy

The use of intraperitoneal (IP) vancomycin as initial, single agent therapy for gram positive and "no organism" continuous ambulatory peritoneal dialysis (CAPD) peritonitis is described, comparing continuous and intermittent administration schedules. "Continuous" therapy consisted of an IP 1-g loading dose of vancomycin followed by 30 mg/L dialysate effluent. "Intermittent" therapy consisted of 2 IP doses of 30 mg vancomycin/kg body weight--the initial dose delivered at diagnosis and the second dose 1 week later. All patients presenting with peritonitis (n = 90) were randomized to receive either continuous or intermittent vancomycin therapy. Patients in whom gram negative organisms and fungi were identified by microscopy and culture were transferred to therapy with a more appropriate antibiotic (n = 39). In the remainder (n = 51), CAPD peritonitis was treated solely with vancomycin (continuous, n = 21; intermittent, n = 30). Clinical resolution was seen in all patients, requiring a mean of 3.2 days for macroscopic clearing of dialysate effluent. Recurrence of peritonitis within 1 month of cessation of therapy was unusual and did not vary between treatment protocols (4/21 v 3/30; P = NS). There were no differences in observed side effects. Thus, IP vancomycin proved to be a useful single agent therapy for gram positive and no organism CAPD peritonitis. Therapy with two IP doses was effective and as safe as continuous IP vancomycin therapy, and therefore should replace other vancomycin administration schedules in the treatment of CAPD peritonitis.     

Leukotriene release from peripheral and peritoneal leukocytes following exposure to peritoneal dialysis solutions

During continuous ambulatory peritoneal dialysis (CAPD), peritoneal host defence mechanisms are repeatedly exposed to dialysis solutions (with unphysiological composition) which may compromise peritoneal immune cell functions. In this context, the current study focused on the capacity of peripheral and peritoneal PMN to release leukotrienes following exposure to conventional CAPD dialysates. PMN were obtained from peripheral blood of healthy volunteers and from the peritoneal effluent of CAPD patients with acute peritonitis. Following isolation, cells were incubated in fresh CAPD dialysates or control buffer, and calcium ionophore A23187-stimulated leukotriene synthesis was measured. Additional experiments included RP-HPLC analysis and radioactivity monitoring of lipoxygenase products in PMN labelled with 14C-arachidonic acid. Leukotriene B4 and leukotrienes C4/D4/E4 were determined by radioimmunoassay. Ionophore-triggered leukotriene release from cells exposed to control buffer was pronounced in inflammatory peritoneal PMN (70.4 +/- 31.3 ng/5 x 10(6) cells LTB4 and 13.4 +/- 19.8 ng/5 x 10(6) cells LTC4/D4/E4, mean +/- SD, n = 14) when compared to healthy peripheral PMN (26.6 +/- 16.9 ng/ml LTB4 and 6.3 +/- 6.6 ng/ml LTC4/D4/E4, n = 12). Incubation in fresh solutions for peritoneal dialysis severely depressed leukotriene release from both cell populations. These results indicate a severe inhibition of cellular responsiveness as a consequence of dialysate exposure which could contribute to the impairment of host defence early in the CAPD cycle.     

Fungal peritonitis during continuous ambulatory peritoneal dialysis: a report of 17 cases

Seventeen cases of fungal peritonitis and one case of Nocardia asteroides peritonitis were observed in 141 patients during the first 5 years of our continuous ambulatory peritoneal dialysis program (CAPD). Fungal peritonitis accounted for 7% of the episodes of peritonitis observed in this interval. There were eight deaths associated with fungal peritonitis. In only three instances could factors predisposing to fungal peritonitis be identified. We were unable to predict who would develop fungal peritonitis by analysis of nutritional, demographic, or technical factors associated with the dialysis procedure. The diagnosis of fungal peritonitis was easily established using routine blood agar culture techniques. Successful management of these patients included prompt removal of the Tenckhoff catheter and intravenous (IV) administration of amphotericin.     

Recurrent peritonitis: evidence for possible viral etiology.

A 45-year-old woman who was treated with continuous ambulatory peritoneal dialysis (CAPD) developed recurrent peritonitis characterized by cloudy effluents, elevated white blood cell (WBC) counts (predominantly lymphocytes), and negative culture results. This case report suggests that she may have had viral peritonitis as indicated by a positive viral culture, the presence of viral antibodies in serum and peritoneal dialysis effluent (PDE), hematological findings, and cell surface receptor studies. The possibility of a viral cause should be considered in patients with culture-negative peritonitis, especially if they do not respond to antibiotics.     

维持性腹膜透析患者腹膜透析相关性葡萄球菌腹膜炎的发生率及危险因素分析

目的 探讨维持性腹膜透析患者腹膜透析相关性葡萄球菌腹膜炎的发生率及相关危险因素.方法 以中山大学附属东华医院腹膜透析中心192例患者为研究对象.根据腹膜透析液培养结果分成腹膜炎组与正常组.采用多因素logistic回归分析腹膜透析相关性葡萄球菌腹膜炎的危险因素.结果 共16例（8.3％）患者发生腹膜透析相关性葡萄球菌腹膜炎.致病菌以表皮葡萄球菌为主,占50.0％（8/16）.治愈12例（75.0％）,死亡1例.高龄（OR=1.35,95％ CI 1.16～7.68,P=0.026）、糖尿病（OR =3.34,95％ CI 1.90～6.54,P＜0.001）、低血红蛋白（OR=1.68,95％ CI 1.21～6.48,P=0.022）及低白蛋白血症（OR=1.04,95％ CI1.02～1.07,P=0.036）是腹膜透析相关性葡萄球菌腹膜炎的相关危险因素.结论 腹膜透析相关性葡萄球菌腹膜炎发生率较高;高龄、低血红蛋白、糖尿病及低白蛋白血症是其相关危险因素.     

Peritoneal fluid and solute transport: influence of treatment time, peritoneal dialysis modality, and peritonitis incidence

The integrity of the peritoneal membrane in peritoneal dialysis (PD) is of major importance for adequate dialysis and fluid balance. However, alterations in peritoneal fluid transport, such as ultrafiltration failure, often develop during long-term PD. To investigate peritoneal solute and fluid transport and to analyze the influence of treatment time, peritonitis incidence, and PD modality (continuous ambulatory PD [CAPD] or automated PD [APD]), a cross-sectional study with an extended peritoneal transport test that used dextran 70 in 2 L of glucose was performed in 23 nonselected chronic PD patients. Compared were long-term (>40 mo) with short-term PD patients (<40 mo), CAPD with APD patients, and those with a peritonitis incidence of >0.25/yr to those with an incidence of <0.25/yr. Dialysate/plasma (D/P) ratio and mass transfer area coefficient of creatinine, lymphatic absorption rate (LAR), transcapillary ultrafiltration, and effective ultrafiltration were measured. Long-term PD patients had higher D/P ratio of creatinine (73.5 +/- 2.3% versus 65.9 +/- 2.2%; P < 0.01) and higher LAR (243 +/- 69 ml/4 h versus 96 +/- 31 ml/4 h; P < 0.03), both resulting in lower effective ultrafiltration (242 +/- 35 ml/4 h versus 324 +/- 30 ml/4 h; P < 0.05). D/P ratio (r = 0.66) and LAR (r = 0.67) were positively correlated to PD duration. Patients on APD compared with those on CAPD and patients with a history of peritonitis compared with those without did not differ in terms of D/P ratio, mass transfer area coefficient, LAR, transcapillary ultrafiltration, and effective ultrafiltration. Lower ultrafiltration after long-term PD is both the result of increased small solute transport and increased lymphatic absorption. APD or CAPD modality and peritonitis incidence do not have a significant influence on small solute transport or fluid kinetics.     

Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis.

BACKGROUND: Acute, massive, unilateral hydrothorax is an uncommon but well-recognized complication of peritoneal dialysis. Its clinical course and treatment outcome after a recently advocated technique of video-assisted thoracoscopic (VATS) talc pleurodesis remains unclear. METHODS AND RESULTS: Between July 1998 and March 2002, among 475 CAPD patients in two regional hospitals in Hong Kong, nine patients (three men, six women, mean age 53+/-12 years) developed acute hydrothorax due to pleuroperitoneal communication (R=8, L=1) within 5.8+/-4.2 months (median, 5.2 m; range, 2 days to 11.6 months) of commencing peritoneal dialysis. Analysis of simultaneously obtained peritoneal and pleural fluid in all subjects only showed concordance in protein content (consistently<4 g/l), while fluid glucose and lactate dehydrogenase levels were not comparable. The methylene blue test was negative (n=4). Radionuclide scan (n=6) and contrast CT peritoneography (CTP, n=3) detected pleuroperitoneal communication in half and one-third of the patients, respectively. All patients underwent pleurodesis achieved by talc insufflation into the pleural cavity under VATS guidance. All patients were successfully returned to peritoneal dialysis. After a mean follow-up of 18.8+/-12.5 months, hydrothorax recurred in one patient (at 7 months after pleurodesis), who was successfully treated by repeating the procedure. CONCLUSIONS: Hydrothorax complicating CAPD is more commonly right-sided, and tends to occur within the first year of starting peritoneal dialysis. Isotope scan and CTP are insensitive in diagnosing pleuroperitoneal communication. A low pleural fluid protein content is the most consistent biochemical finding. VATS talc pleurodesis is a safe and reliable treatment of choice that allows sustained continuation of CAPD with low recurrence rate.