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.     

Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids.

BACKGROUND: Icodextrin dialysate used for peritoneal dialysis contains an iso-molar glucose polymer solution, which provides sustained ultrafiltration over long dwell times and is considered a valuable approach to reduce intraperitoneal glucose exposure. However, several side effects have been described, including abdominal pain and allergic and hypersensitivity reactions. Also, reactions compatible with chemical peritonitis have been reported. Over the period of a few months (January 2002-May 2002), a remarkable increase in the number of continuous ambulatory peritoneal dialysis (CAPD) patients using icodextrin dialysate diagnosed with sterile peritonitis was observed in our unit. METHODS: Five of the CAPD patients using icodextrin dialysate in our unit and diagnosed with sterile peritonitis were screened for leucocyte count and leucocyte differentiation during a follow-up period of 77 +/- 23 days. In addition, expression of CD14, a receptor for lipopolysaccharide (LPS), on the peripheral and peritoneal monocyte population was analysed. These results were compared to CAPD patients suffering from bacterial peritonitis. RESULTS: The peritoneal leucocyte count of CAPD patients using icodextrin dialysate and diagnosed with sterile peritonitis did not decrease significantly before treatment with icodextrin dialysate was interrupted, whereas it currently disappeared within 2-4 days in proven bacterial peritonitis. The sterile, cloudy icodextrin effluent contained an excess of macrophages on the day of diagnosis, whereas in bacterial peritonitis essentially an increase in the granulocyte population was observed. No elevation in the eosinophil population was observed. In contrast to bacterial peritonitis, we observed no increase in CD14 expression on the peripheral and peritoneal macrophages on the day of presentation and during the follow-up period. CONCLUSIONS: Specific batches of the icodextrin CAPD fluids contain a macrophage chemotactic agent, which causes a sustained inflammatory state in the peritoneal cavity. Because no increase in the expression of the LPS receptor CD14 could be observed, the increased peritoneal leucocyte count is probably not caused by LPS or LPS-like (possibly peptidoglycan-like) contamination.     

Dialysate leaks in peritoneal dialysis

Dialysate leakage represents a major noninfectious complication of peritoneal dialysis (PD). An exit-site leak refers to the appearance of any moisture around the PD catheter identified as dialysate; however, the spectrum of dialysate leaks also includes any dialysate loss from the peritoneal cavity other than via the lumen of the catheter. The incidence of dialysate leakage is somewhat more than 5% in continuous ambulatory peritoneal dialysis (CAPD) patients, but this percentage probably underestimates the number of early leaks. The incidence of hydrothorax or pleural leak as a complication of PD remains unclear. Factors identified as potentially related to dialysate leakage are those related to the technique of PD catheter insertion, the way PD is initiated, and weakness of the abdominal wall. The pediatric literature tends to favor Tenckhoff catheters over other catheters as being superior with respect to dialysate leakage, but no consensus on catheter choice exists for adults in this regard. An association has been found between early leaks (< or =30 days) and immediate CAPD initiation and perhaps median catheter insertion. Risk factors contributing to abdominal weakness appear to predispose mostly to late leaks; one or more of them can generally be identified in the majority of patients. Early leakage most often manifests as a pericatheter leak. Late leaks may present more subtly with subcutaneous swelling and edema, weight gain, peripheral or genital edema, and apparent ultrafiltration failure. Dyspnea is the first clinical clue to the diagnosis of a pleural leak. Late leaks tend to develop during the first year of CAPD. The most widely used approach to determine the exact site of the leakage is with computed tomography after infusion of 2 L of dialysis fluid containing radiocontrast material. Treatments for dialysate leaks include surgical repair, temporary transfer to hemodialysis, lower dialysate volumes, and PD with a cycler. Recent recommendation propose a standard approach to the treatment of early and late dialysate leaks: 1-2 weeks of rest from CAPD, and surgery if recurrence. Surgical repair has been strongly suggested for leakage causing genital swelling. Delaying CAPD for 14 days after catheter insertion may prevent early leakage. Initiating CAPD with low dialysate volume has also been recommended as a good practice measure. Although peritonitis and exit-site infections are the most frequent causes of technical failure in peritoneal dialysis (PD), dialysate leaks represent one of the major noninfectious complications of PD. In some instances, dialysate leakage may lead to discontinuation of the technique (1). Despite its importance, the incidence, risk factors, management, and outcome of dialysate leakage are poorly characterized in the literature. We will review the limited available information on this topic in the next few sections.     

Peritoneal-mediastinal leakage complication of peritoneal dialysis

The authors report a case of mediastinal fluid collection resulting from peritoneal-mediastinal communication after continuous ambulatory peritoneal dialysis (CAPD). To the best of the authors’ knowledge, this is the first reported case in the medical literature. A dry cough developed in the patient who had been receiving CAPD for 4 years. A mediastinal mass owing to peritoneal leakage of dialysate to the mediastinum was confirmed by a computed tomography scan taken 4 hours after the intraperitoneal infusion of contrast-mixed dialysate. The leakage persisted for 12 weeks after the discontinuation of CAPD fluid instillation.     

Evaluation of continuous ambulatory peritoneal dialysis

This study was undertaken to ascertain whether 19 patients maintained on continuous ambulatory peritoneal dialysis (CAPD) for at least 1 year experienced any deterioration in peritoneal membrane function. Selected serum chemistries and skinfold measurements were also evaluated to determine whether patients dialyzed by CAPD could maintain a normal nutritional status. This study demonstrates that patients maintained on CAPD had stable dialysate protein losses, glucose absorption from the dialysate, and constant urea, creatinine, and sodium removal. When these patients were subdivided by incidence of peritonitis, the group with a lower incidence of peritonitis (one episode every 349 +/- 155 SEM days) showed stable serum protein concentration and improvement in upper arm area whereas the group with a high incidence of peritonitis (one episode every 95 +/- 7 SEM days) showed a reduction in upper arm muscle area. Thus, our data suggest that over a 1-year period, there is no deterioration in peritoneal membrane characteristics and CAPD is effective in maintaining the nutritional status of the patient. However, both membrane function and nutritional status may be impaired by frequent episodes of infection.     

Mycobacterium avium complex-associated peritonitis in a patient on continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis remains a major cause of morbidity in the dialysis population. Typically, infection is caused by gram positive bacteria and treated with empiric antibiotics. A subset of patients, however, develop culture negative peritonitis and may be infected with fungal or mycobacterial organisms. We present a case of Mycobacterium avium complex-associated peritonitis in a HIV negative patient on CAPD. Our patient suffered from technique failure and died from unrelated causes before treatment could be completed.     

Persistence of Candida despite seemingly adequate systemic and intraperitoneal amphotericin B treatment in a patient on CAPD

A case of Candida peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD) is presented. Despite 2 weeks of intravenous and 4 weeks of intraperitoneal amphotericin B, good clinical response, and repeatedly negative fungal cultures from the peritoneal dialysate, her Tenckhoff catheter upon removal grew the same Candida species. This case emphasizes the point that Candida may persist on the catheter despite seemingly adequate antifungal treatment and good clinical and microbiologic response.     

Reversible peritoneal calcification in a patient treated by CAPD

The patient, a female, aged 65 years, developed diffuse peritoneal calcification nine years after commencing CAPD therapy. No abdominal symptoms or evidence of peritonitis were discovered during this period. Before peritoneal calcification was detected, a dialysate with a high glucose concentration (3.86%) had been used once daily for 16 months. In the case of this patient, it was not possible to discover any of the previous indicated etiologies of peritoneal calcification such as significantly elevated values for the product Ca x P, overt secondary hyperparathyroidism, or relapsing peritonitis. It was realized that the use of a high-glucose dialysate in a patient on long-term CAPD treatment had been one causative factor. After peritoneal calcification had been confirmed, the calcium concentration of the dialysate changed from 3.5 mEq/l to 2.5 mEq/l and the patient was put on a regime of 2.0 g alumigel (aluminum-containing phosphate binders) a day. Eight months later, a CT scan was taken. The peritoneal calcification has clearly been mitigated. At present, CAPD therapy is being continued in the absence of any abdominal symptoms.     

Down-regulation of CD43 molecule expression on intraperitoneal neutrophils in CAPD patients with peritonitis

To assess the release of proteases from neutrophils infiltrated into the peritoneal cavity in continuous ambulatory peritoneal dialysis (CAPD), we investigated the regulation of CD43, LAM-1 and Mac-1 expression on the neutrophil plasma membrane using FACS analysis in CAPD patients with peritonitis. Five CAPD patients with peritonitis and five CAPD patients without peritonitis were studied. CD43 expression was immunohistochemically determined in both groups of patients using flow cytometry, and comparisons were made between the two groups. Down-regulation of CD43 and LAM-1, and up-regulation of Mac-1 were demonstrated on neutrophils obtained from CAPD dialysate of peritonitis patients after 1-h dwell time. Further up-regulation of Mac-1 developed until a dwell time of 4 h. Immunoblot analysis for neutrophil lysate from dialysate showed the presence of the asialo form of CD43 molecules and their fragments, which may be produced by cleavage of the CD43 molecule at extracellular sites. The intraperitoneal neutrophils in dialysate from CAPD patients with peritonitis are continuously activated during dwell time, and proteases may be released from neutrophils into dialysate after only a short dwell time.     

Growth factors in continuous ambulatory peritoneal dialysis effluent. Their relation with peritoneal transport of small solutes.

Recent studies reveal conflicting results on the change of solute transfer with time on continuous ambulatory peritoneal dialysis (CAPD) and recurrent peritonitis. Herein, we performed a cross-sectional study of 76 patients on CAPD to examine their peritoneal permeability by measuring the dialysate to serum ratio of creatinine (D/P) and the mass transfer area coefficients of creatinine (MTACCr) or glucose (MTACGlu). Transforming growth factor-beta1 (TGF-beta1), platelet-derived growth factor (PDGF), and epidermal growth factor (EGF) were measured in the dialysate by ELISA. TGF-beta1 mRNA in peritoneal macrophages were determined by a quantitative polymerase chain reaction. We failed to observe any correlation between the duration on dialysis and the peritoneal permeability in those patients with no previous peritonitis. Frequency of peritonitis episode did not affect the MTACCr, MTACGlu, or D/P. The MTACCr correlated well with MTACGlu (r = 0.78, p = 0. 001) and with D/P (r = 0.98, p < 0.0001). No inverse correlation was demonstrated between dialysate PDGF or EGF and the peritoneal permeability. A positive correlation was demonstrated between the dialysate TGF-beta1 and MTACCr, MTACGlu or D/P (r = 0.64, 0.54, and 0.64 respectively, p < 0.001). The dialysate TGF-beta1 levels in patients with low D/P (相似文献   

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.     

Decreased size of peritoneal macrophage during peritonitis in continuous ambulatory peritoneal dialysis patients.

From January 1987 to July 1988, 30 patients suffering from end-stage renal disease were treated with continuous ambulatory peritonitis dialysis (CAPD) therapy. Serial cell number, size and cycle of the peritoneal macrophage (PM) in these patients were measured before and during episodes of peritonitis from the time they started CAPD therapy. Patients with peritonitis were divided into high peritonitis occurrence (HPOG) and low peritonitis occurrence (LPOG) groups. Both before and during occurrence of peritonitis, there were no significant differences in the number of PM cells in the dialysate taken from patients in the HPOG and LPOG. When peritonitis occurred, the size and cell cycle S/Go-G1 ratio decreased about 3 days after the onset of peritonitis. It progressed to the lowest level 7-10 days later, then progressively recovered. However, the dialysate PM cells from the HPOG took a much longer time to recover to the preperitonitis size. When dialysate PM cells from patients without peritonitis were put into the dialysate of HPOG patients on day 10 of peritonitis and incubated for 24 h, an obvious decrease in cell size could be identified. On the other hand, when the PM cells from HPOG patients with peritonitis on day 10 were incubated 24 h with the dialysate from patients without peritonitis, there were obvious increases in cell size. These results suggest there may be a substance (or substances) in the peritonitis dialysate, which contribute(s) to the shrinkage of PM cell size.     

Continuous ambulatory peritoneal dialysis and sclerosing encapsulating peritonitis: tamoxifen as a new therapeutic agent?

Sclerosing encapsulating peritonitis (SEP) is a serious complication of long-term continuous ambulatory peritoneal dialysis (CAPD), very likely related to a persisting expression of the transforming growth factor beta1 (TGFbeta1) gene on peritoneal mesothelial cells. We report the case of a 67-year-old uremic woman who developed SEP eight years after being placed on CAPD, complicated by eight episodes of bacterial peritonitis. CAPD was therefore stopped and the patient transferred to hemodialysis. The diagnosis of SEP was confirmed by physical findings (vomiting, abdominal pain with palpable mass, ileus, cachexia) and CT data. The patient was treated with tamoxifen (10 mg/day) for three months, and gradually recovered, a subsequent CT showing a significant reduction of the thickness of peritoneal and intestinal loops. Tamoxifen probably interferes with TGFbeta1 and may be useful in the treatment of this CAPD complication.     

Definitions of Differences and Changes in Peritoneal Membrane Water Transport Properties

A survey is given comparing measurements of transperitoneal water transport in different clinical situations with analyses based on the so-called "pore theory." This model links the measured changes to physical alterations of the peritoneal membrane. The calculations include "equivalent pore radius," effective "membrane area" and diffusive length, the transport resistance of the unstirred dialysate layer, and the residual intraperitoneal volume after dialysate drainage. The clinical appearances include individual differences in transperitoneal transport characteristics, changes in transperitoneal transport over time on continuous ambulatory peritoneal dialysis (CAPD) and during peritonitis, the pharmacological effect on the transport properties, and the effect of peritoneal catheter dislocation on ultrafiltration capacity. The main conclusions are as follow: During CAPD treatment the measurement of intraperitoneal solute equilibration and "mass-transfer-area coefficients" for urea and creatinine is less sensitive than the measurement of ultrafiltration volume in revealing peritoneal membrane changes. Differences and changes found have mostly a combined physical explanation, but one is more or less dominant. Changes in peritoneal membrane area seem to be the most dominant cause of changes in transperitoneal transport during time on CAPD and when sodium nitroprusside was added to the peritoneal dialysate. Changes during peritonitis can be explained by changes in pore radius and depth. Individual differences can be explained by differences in "membrane" area and in resistance of the unstirred dialysate fluid. High residual dialysate volume can give rise to clinical problems and should be considered when placing the catheter in the peritoneal cavity.     

Continuous Cyclic Peritoneal Dialysis: A Preliminary Report

Continuous cyclic peritoneal dialysis (CCPD) was designed to reduce the high incidence of peritonitis and eliminate the multiple interruptions created by dialysate exchanges during the day needed for CAPD, while maintaining the quality of dialysis. Three nocturnal cycles with 2 liters of dialysate lasting 3 hours each are provided by an automated cycler while the patient sleeps. Two liters are left in the abdomen in the morning. Only one daily connection and one disconnection are required between the peritoneal catheter and the cycler line. Our 84 patient months experience with 14 patients reveals a low incidence of peritonitis (1 per 42 patient months), satisfactory ultrafiltration rates and clearances that compare favorably with those of CAPD (C_urea 67, C_creatinine 58, and C_B12 45 L/wk). Blood pressure control has been excellent while most patients enjoy liberal diets.
This preliminary study suggests that CCPD may indeed reduce the rate of peritonitis, provide excellent clearance and ultrafiltration, allow more free time to the patient and maintain a steady physiological state.     

Diabetes,Intraperitoneal Insulin,and CAPD

In patients on continuous ambulatory peritoneal dialysis (CAPD), hemoglobin A₁ was measured in order to assess the effect of the high content of glucose in the dialysate solution. In five diabetics on CAPD, insulin was added to the dialysate in an attempt to maintain continuous control of blood glucose throughout the day. Glycosylated hemoglobin was elevated in seven diabetics prior to the initiation of CAPD (12.0 ± 2.3%) as it was in six non-diabetics after several months on CAPD. (9.6 ± 0.90%). With the use of intraperitoneal insulin, satisfactory control of blood glucose could be achieved and the rate of peritonitis was not increased. However, regardless of whether blood glucose was well-controlled or not, hemoglobin A₁ as well as triglyceride values rose in diabetics on CAPD.     

Candida parapsilosis peritonitis complicated with infected pancreatic pseudocysts in a peritoneal dialysis patient: a challenge for nephrologists

In continuous ambulatory peritoneal dialysis (CAPD)-related cases of fungal peritonitis, Candida parapsilosis (C. parapsilosis) has become as common as Candida albicans (C. albicans) in fungal isolates. This report describes a 74-year-old male CAPD patient who received bypass surgery for coronary artery disease, followed by an episode of bacterial peritonitis. The peritonitis was successfully treated with intraperitoneal antibiotics. However, C. parapsilosis peritonitis with concomitant pancreatitis and infected pseudocysts occurred one month later. Despite surgical drainage and intravenous administration of fluconazole, fungal peritonitis persisted. Finally, he died of nosocomial pneumonia. This case demonstrates the poor outcome of C. parapsilosis peritonitis, suggesting a more aggressive treatment in peritoneal dialysis patients.     

Idiopathic eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: experience with percutaneous catheter placement

BACKGROUND: Peritoneal fluid eosinophilia (PFE), which is classically associated with idiopathic eosinophilic peritonitis (EP), has been known as a common event in patients on continuous ambulatory peritoneal dialysis (CAPD). However, our recent retrospective study of CAPD patients following percutaneous catheter placement showed that PFE occurred rarely. The aim of this prospective study was to clarify the incidence and characteristics of idiopathic EP and PFE in patients on CAPD following percutaneous catheter placement. METHODS: Forty-eight patients on CAPD following percutanous catheter placement were recruited for the present study. Peritoneal dialysis was initiated immediately after catheter insertion without break-in period. A cytological study of dialysate was performed on days 1, 2, 3, 4, 5, 6, 7, 14 and 30 after initiation of CAPD, and then monthly for 6 months. In addition, a cytological study was performed also when a patient revealed abdominal pain or cloudy peritoneal effluent. RESULTS: PFE developed in three (6.3%) patients during the study period. The incidence of idiopathic EP and PFE without any clinical findings suggestive of PD-related peritonitis was 2.1% and 4.2% respectively. All cases of PFE, including idiopathic EP, developed on a mean of 13 day following initiation of CAPD and resolved spontaneously after a mean of 7 days. There was no significant difference in IgE levels or the occurrence of peripheral blood eosinophilia between patients with PFE and those without. CONCLUSION: Idiopathic EP is infrequent among patients on CAPD following percutaneous catheter placement, but should be differentiated from infectious PD-related peritonitis.     

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.