Long-term incidence of peritonitis in CAPD patients treated by the Y set technique: experience in a single center

Our experience of peritonitis in 156 patients over an 8-year period represents 186 episodes of peritonitis and 4,964 patient-months of CAPD. The incidence of peritonitis was significantly greater (1 episode every 8.6 patient-months) when the Oreopoulos technique was used and dropped to 1 episode every 43.3 patient-months when the Y set system was used. Of the 109 patients using the Y set system, 88 (80.7%) never had episodes of peritonitis, whereas only 7 (16.7%) of the 42 patients using the Oreopoulos technique were free of peritonitis. For 23 patients shifted from the Oreopoulos to the Y set technique, the incidence of peritonitis dropped from 1/9.8 to 1/35.2 episodes/patient-months.     

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.     

Risk of peritonitis and technique failure by CAPD connection technique: a national study.

Peritonitis has been a leading complication of long-term therapy with continuous ambulatory peritoneal dialysis (CAPD). This study was designed to evaluate the risk of peritonitis and technique failure according to the initial CAPD connection technique. Patients from all U.S. facilities starting CAPD therapy at home between January 1 and June 30, 1989 were followed for up to 21 months on the initial CAPD connection technique to change in technique or dialytic modality, to transplantation, death or loss to follow-up. Patients were grouped into standard connection techniques (SCT) (N = 1,133), Y-set (N = 1,067), standard UV set (N = 916) and O-set (N = 167). The time to first peritonitis episode was analyzed actuarially and by using the Cox proportional hazards model which adjusted for age, sex, race, cause of ESRD, CAPD program size and ESRD therapy prior to CAPD. Peritonitis occurred on average at 9.0 month intervals with SCT, 15.0 months with Y-set, 13.4 with standard UV and 9.4 with O-set. The relative risk (RR by Cox analysis) of first peritonitis compared to SCT was 0.60 (40% lower) for the Y-set (P less than 0.01), 0.75 for standard UV (P less than 0.01), and similar to SCT (RR = 0.96) for the O-set (NS), all else being equal. Analysis time to second (N = 1,271) peritonitis episode gave similar results as did analysis of time to CAPD technique failure. Significantly higher RR of peritonitis and technique failure was observed for younger and black patients. These findings suggest the utilization of connection techniques with superior results.     

Continuous cycling peritoneal dialysis is associated with lower rates of catheter infections than continuous ambulatory peritoneal dialysis

Continuous cycling peritoneal dialysis (CCPD), unlike continuous ambulatory peritoneal dialysis (CAPD), provides freedom from daytime exchanges and is associated with lower rates of peritonitis. However, catheter infection (CI) rates have not been reported for CCPD. Previous data suggested that a CAPD disconnect system (Y-set) was associated with lower rates of CI. These results suggested that patients on CCPD, which is also a disconnect system, might also have low CI rates. We evaluated our CCPD patients for infection rates and compared them with two groups of matched control CAPD patients, one using a spike system and one a Y-set disconnect system to evaluate this hypothesis. The CCPD patients had the lowest rates of CIs (0.5 episodes per year or one episode every 25 months), followed by the CAPD patients using the Y-set (0.8 episodes per year or one episode every 14 months). CAPD patients using the spike system had the highest rates of CIs (1.2 episodes per year or one episode every 10 months). Peritonitis rates followed the same pattern among the patient groups: CCPD, 0.3 episodes per year; CAPD, Y-set 0.5 episodes per year; CAPD, spike system 1.3 episodes per year. Our data suggest that disconnect systems, such as the CAPD Y-set and CCPD, reduce CIs, as well as peritonitis.     

Exit-site and tunnel infections in continuous ambulatory peritoneal dialysis patients

One hundred two exit-site infections (ESI) were diagnosed in 63 of 163 (38.6%) patients, with an incidence of one episode every 23.7 patient-months in patients with a history of ESI, whereas in the overall continuous ambulatory peritoneal dialysis (CAPD) population the incidence was one episode every 48.7 patient-months. In diminishing order of frequency, the bacteria isolated were Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Escherichia coli. The probability of remaining free of ESI was 72% at 1 year and 45% at 5 years. The ESI that led to catheter removal were due to S aureus and gram-negative rods. In 13 (48%) of 27 S aureus ESI unresponsive to antibiotics and local care, deroofing and outer cuff shaving completely resolved the ESI. Despite this treatment, the catheters of the remaining 14 patients had to be removed because of peritonitis associated with the tunnel infection. In conclusion, ESI is a major cause of CAPD failure. In our series, shaving the cuff as a rescue treatment was effective for almost 50% of the patients with antibiotic-resistant S aureus ESI.     

Do the Y-set and double-bag systems reduce the incidence of CAPD peritonitis? A systematic review of randomized controlled trials.

BACKGROUND: Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis. This systematic review sought to determine if modifications of the transfer set (Y-set or double-bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes. METHODS: Based on a comprehensive search strategy, we undertook a systematic review of randomized or quasi-randomized controlled trials comparing double-bag and/or Y-set CAPD exchange systems with standard systems, or comparing double-bag with Y-set systems, in patients with end-stage renal disease (ESRD) treated with CAPD. Only published data were used. Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Its statistical package, Metaview 3.1, calculated an odds ratio (OR) for dichotomous data and a (weighted) mean difference for continuous data with 95% confidence intervals. RESULTS: Twelve eligible trials with a total of 991 randomized patients were identified. In trials comparing either the Y-set or double-bag systems with the standard systems, significantly fewer patients (133/363 vs 158/263; OR 0.33, 95% CI 0.24-0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis was consistently greater. When the double-bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (44/154 vs 66/138; OR 0.44, 95% CI 0.27-0.71) and the number of patient-months on CAPD per episode of peritonitis was also greater. CONCLUSIONS: Double-bag systems should be the preferred exchange systems in CAPD.     

Long-Term Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Peritonitis: Surgery can be Avoided

INTRODUCTION

Continuous ambulatory peritoneal dialysis (CAPD) has become the preferred method of home dialysis for patients with end-stage renal failure. Peritonitis is a common and serious complication and requires prompt diagnosis and treatment. The aim of this study was to assess what proportion of patients with CAPD peritonitis that required surgical intervention for on-going sepsis or for peritonitis-related bowel obstruction.

PATIENTS AND METHODS

All patients presenting with a first episode of CAPD peritonitis during the 5-year period from 1994–1998 were identified from a prospectively maintained database. Data collected included patient demographics, details of peritonitis episodes and their treatment, and details of any surgical intervention undertaken.

RESULTS

A total of 500 episodes were identified in 168 patients of whom 162 had complete follow-up representing 488 peritonitis episodes. Sixty-three patients experienced one episode of peritonitis, 33 two episodes, 20 had three episodes, and 46 had more than three episodes. None of the patients underwent surgery either primarily or for complications of the infective episode. A total of 465 episodes were due to a single organism (95%) and the remainder were due to multiple organisms (5%). The most common causative organisms were Gram-positive cocci (308 episodes; 71%) followed by Gram-negative bacilli (106 episodes; 24%). In 55 patients (34%), the same organism was implicated in consecutive admissions. Patients with autosomal dominant polycystic kidney disease (ADPKD), whilst accounting for 12 of 169 (7%) patients in the cohort, experienced 23 of 125 (18.4%) episodes of peritonitis by Gram-negative cocci. Such infections were seen in 8 of 12 (66.7%) ADPKD patients and accounted for 23 of 40 (57.5%) infections experienced by the ADPKD patients.

CONCLUSIONS

Whilst CAPD peritonitis is a common problem in the renal failure population, with almost 100 episodes per year, it would appear that most episodes can be managed using intraperitoneal antibiotics without the need for surgical intervention.     

Clinical outcomes of systemic lupus erythematosus patients undergoing continuous ambulatory peritoneal dialysis.

OBJECTIVES: The purpose of this study was to evaluate the outcome of systemic lupus erythematosus (SLE) patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Eighteen SLE patients who had been undergoing CAPD for at least 3 months in our unit were compared with 36 other age- and gender-matched non-diabetic CAPD patients with an underlying primary chronic glomerulonephritis (CGn). The clinical outcome, infective complications, lupus activities, biochemical parameters, haemoglobin level and the use of erythropoietin were reviewed. RESULTS: The duration of dialysis of the two studied groups was not different, with a mean of 35.4 months for the SLE group and 36.7 months for the CGn group. Before dialysis, SLE patients had a significantly lower albumin level (30.4+/-6.6 vs 35.4+/-5.59 g/dl, P<0.01), while the mean haemoglobin levels of the two groups were similar (8.5+/-1.8 g/dl for SLE vs 9.0+/-1.9 g/dl for the control group). However, the weekly dose of erythropoietin (EPO) used was significantly higher in the SLE group (6000 vs 3818 U/week, P<0.01) to maintain a similar haemoglobin level during dialysis. Regarding the infective complications, the SLE group had a higher peritonitis rate (5.7 episodes/100 patient-months vs 2.4 episodes/100 patient-months, P<0.05), and an increase in the non catheter related infection rate (6.67 episodes/100 patient-months vs 1.1 episodes/100 patient-months, P<0.001). However, no significant difference could be demonstrated in the Tenckhoff catheter exit site infection rate (2 episodes/100 vs 1.7 episode/100 patient-months). The number of patients who received a kidney transplant or required a change of mode to haemodialysis was similar among the two groups. Seven patients died during the follow-up period, and the overall mortality rate was much higher in the SLE group than in the control group (0.83/100 vs 0.15/100 patient-months, P<0.05). CONCLUSIONS: SLE patients on CAPD have a significantly lower pre-dialysis serum albumin level and use a higher dose of Epo to achieve a comparable haemoglobin level than other non-diabetic CGn CAPD patients. They also have a poorer prognosis in terms of infective complications and mortality rate.     

Successful prophylaxis for fungal peritonitis in patients on continuous ambulatory peritoneal dialysis: six years' experience

Fungal peritonitis as a serious complication of continuous ambulatory peritoneal dialysis (CAPD) is often associated with severe morbidity, CAPD "drop-out" and, occasionally, death. Most episodes of fungal peritonitis occur during or after a period of antibiotic treatment of various bacterial infections, usually bacterial peritonitis. From April 1979 to December 1982 (period I), 10 episodes of fungal peritonitis occurred during 415 patient-months, ie, 10.5% of all peritonitis episodes recorded in our CAPD program. After the introduction of oral prophylaxis with 3 x 500,000 IU [corrected] nystatin during every course of antibiotic treatment, only four episodes of fungal peritonitis occurred during 2,102 patient-months, ie, 3.1% of all peritonitis episodes from January 1983 to March 1989 (period II). This difference between the first and second periods is significant (P less than 0.05). Moreover, none of the four patients who contracted fungal peritonitis in the second period received nystatin prophylaxis. Thus, the simple measure of oral prophylaxis using this nonabsorbable antifungal agent in every case of an antibiotic treatment largely eliminates the risk of fungal peritonitis in patients on CAPD.     

Clinical significance of exit-site infections due to Xanthomonas in CAPD patients: a comparison with Pseudomonas infection

We have assessed the clinical significance of exit-site infectionssecondary to Xanthomonas maltophilia in continuous ambulatoryperitoneal dialysis (CAPD) patients, and compared them withepisodes due to Pseudomonas. The study was a retrospective surveyof all episodes of Xanthomonas and Pseudomonas-related exit-siteinfections (ESI) in all patients treated in our unit between1984 and 1992. Thirteen episodes of Xanthomonas-related ESIwere observed in eight patients and 17 episodes of Pseudomonas-relatedESI were seen in 15 patients. Xanthomonas-related ESI was frequently associated with othermicroorganisms, while Pseudomonas related ESI was not (66% versus5%, P<0.02). Only one episode of Xanthomonas-related ESIresulted in peritonitis and subsequent catheter removal, after15 months of resistant colonization. Another case was consideredto be chronic and indolent, as the Xanthomonas-related ESI continuedafter 23 months of local treatment. The other 11 episodes wereresolved either without treatment or with an antibiotic creamafter 7–120 days. However, all but two episodes of Pseudomonas-relatedESI required intravenous antibiotics (usually ceftazidime);seven patients developed peritonitis, and 11 required surgicalcatheter manipulation (five external cuff extrusion, and sixcatheter removal) (1/13 Xanthomonas-related versus 11/17 Pseudomonas-relatedESI, P<0.03) Most Xanthomonas-related ESI do not lead to peritonitis, andconstitute a mild condition, easily treatable without parenteralantibiotics or catheter replacement. The appearance of otherassociated organisms and the favourable evolution with localtreatment suggest a saprophytic behaviour for Xanthomonas inour CAPD patients. On the contrary, Pseudomonas-related ESIis usually severe, requires parenteral antibiotics, frequentlyleads to peritonitis, and requires catheter replacement.     

Incidence of CAPD peritonitis in patients using UVXD or O-set systems

Eighty-one patients were placed either on the O-set (39) or the UVXD germicidal system (42). Total experience was 13.7 +/- 8.0 and 17.8 +/- 14.8 months, respectively. There were 48 and 85 new episodes of peritonitis in 24 and 28 patients, respectively, and an additional 11 and 28 episodes of relapse or probable relapse. The peritonitis rate was 1 episode each 11.14 and 8.83 patient months, which was not significantly different. There was no significant difference between the 2 groups in terms of the mean numbers of peritonitis-free days (393.7 versus 503.8) or in the mean time to the first episode of peritonitis (6.60 versus 6.54 months). The odds ratio of relative risk of peritonitis with the two systems was 1:1.17 (O-set:UVXD). There appears to be no difference in ability of the two systems to prevent peritonitis.     

The effect of the Y-set on catheter infection rates in continuous ambulatory peritoneal dialysis patients

We hypothesized that catheter infections in continuous ambulatory peritoneal dialysis (CAPD) patients may be reduced with a disconnect system. We examined this theory in 116 CAPD patients over a 2-year period. In CAPD patients who switched to the Y-set (n = 22), the catheter infection rate decreased from one per 13 patient-months to one per 26 patient-months (P = 0.05), whereas the catheter infection rate in matched controls (n = 22) remained unchanged. Patients who began CAPD using the Y-set (n = 36) had catheter infection rates of one per 14 patient-months versus one per 8 patient-months in matched controls (n = 36, P = 0.05). Staphylococcus aureus was the most common cause of catheter infections in both groups of patients. However, Pseudomonas aeruginosa replaced Staphylococcus epidermidis as the second most common cause of catheter infections in the patients using the Y-set. The number of catheters that had to be removed due to catheter infections, mainly those due to S aureus or P aeruginosa, was the same in the Y-set and control groups. We conclude that the Y-set system is associated with reduced numbers of catheter infections, but that catheter loss from catheter infections remains a serious problem.     

Peritonitis in continuous ambulatory peritoneal dialysis: analysis of an 8-year experience

Experiences with peritonitis in a continuous ambulatory peritoneal dialysis (CAPD) program at a single center over 8 years were reviewed. Home-acquired peritonitis rates have been less than 1 episode per patient year since 1982. Gram-positive organisms continue to account for most episodes in a similar proportion. Actual known contamination could be pinpointed in only 7.4% of cases, but was strongly suspected in 35.8% of episodes. Exit site and/or tunnel infections were thought to have caused 20% of the cases. Intrinsic peritonitis probably accounted for 10.5%. Recurrence of peritonitis with the same organisms following cessation of antibiotics represented only 2.1% of cases.     

Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis.

BACKGROUND: Automated peritoneal dialysis (APD) and twin-bag (TB) systems are two major peritoneal dialysis (PD) modalities. Published data comparing the infectious complications of these modalities is limited. Subjects and methods. Ninety-five patients using APD (the APD group) and 117 patients using TB system (the TB group) were recruited. Among them, 35 patients used both modalities. The two groups' clinical characteristics, incidences of infectious complications, and the time intervals to first PD-related infection were compared. RESULTS: Clinical characteristics, incidence of exit-site infection (ESI), and time intervals to first ESI were similar in the TB and APD groups. The incidence of peritonitis in the APD group (1.22 episodes/100 patient-months) was significantly (P < 0.001) lower than that of the TB group (2.28 episodes/100 patient-months). Using the Cox proportional hazard model, APD was found to have a lower risk of peritonitis relative to TB systems, with marginal significance (RR 0.58, P = 0.051). CONCLUSION: APD was found to have a lower peritonitis rate than the TB system. Since reducing the peritonitis rate helps to maintain technical survival during PD, from this viewpoint, APD may be preferred for patients undergoing PD, unless contraindicated.     

Impact of new dialysis solutions on peritonitis rates

Peritonitis remains a major cause of morbidity among patients on peritoneal dialysis (PD), yet there is little information about the effect of new biocompatible dialysis solutions on peritonitis rates and treatment. In our unit, information on each peritonitis episode is prospectively collected. Since 2003, bicarbonate/lactate dialysate has been gradually introduced for new patients and for patients experiencing abdominal pain with conventional lactate solutions. From 2002 to 2005, data from 121 episodes of peritonitis (71 automated PD and 50 continuous ambulatory PD) were analyzed; 107 episodes occurred in patients using standard lactate dialysate and 14 episodes in patients using bicarbonate/lactate solution. Patients using bicarbonate/lactate had a significantly lower peritonitis rate of 1 per 52.5 patient-months compared to those using standard lactate dialysate (1 per 26.9 patient-months) (P=0.0179). Response to treatment, however, was not affected by the type of dialysate; cure rates (71.4 and 69.1%, respectively) and recurrence rates (21.4 and 15.8%, respectively) were not significantly different. Catheter removal was required in three (21.4%) patients using bicarbonate/lactate and 23 (22.4%) patients using lactate solution. Use of biocompatible dialysate appears to reduce the peritonitis rate by 50%, although this has to be confirmed in a randomized study. The type of dialysate, on the other hand, does not affect response to treatment.     

Peritoneal dialysis-associated peritonitis in Scotland (1999-2002).

BACKGROUND: Peritonitis is a major complication of peritoneal dialysis (PD). We have performed a national study of all patients on PD in Scotland over a 3.5 year period examining the causes of technique failure, rates of peritonitis, causative organisms, clinical outcomes and differences between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). METHODS: All 10 adult renal units in Scotland participated in the study and the data include all 1205 patients who were on PD in Scotland from January 1999 to June 2002. The data were collected prospectively by the PD nurses and reported to the Scottish Renal Registry every 6 months. RESULTS: Refractory or recurrent peritonitis was the cause of technique failure in 167 patients (42.6% of all cases of technique failure). There were 928 cases of peritonitis in 1487 patient-years, which equates to an overall peritonitis rate of one episode every 19.2 months. The peritonitis rates for APD and CAPD were similar at one episode every 20.3 months and one episode every 18.6 months, respectively. These results include 88 cases of peritonitis due to relapse or re-infection. There was a statistically significant difference (P = 0.012) in peritonitis rates between units using nasal mupiricin (one episode every 21.9 months) and those that did not (one episode every 18.3 months). Coagulase-negative Staphylococcus was the most common cause of peritonitis (29%), although this rate is lower than in historic studies. The overall initial cure rate was 75%. The initial cure rate for APD was 77.2% and for CAPD was 73.7%. No causative organism was isolated in 17% of cases. CONCLUSION: PD-associated peritonitis is the leading cause of technique failure in Scotland. We validate previous studies showing a decrease in the proportion of peritonitis episodes that are caused by coagulase-negative staphylococci. APD peritonitis rates are not significantly better than CAPD peritonitis rates in Scotland, and the initial cure rates for APD and CAPD are similar.     

Use of pulsed-field gel electrophoresis in the analysis of recurrent Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis

BACKGROUND/AIM: The purpose of this study was to evaluate pulsed-field gel electrophoresis (PFGE) for distinguishing between relapse and reinfection of Staphylococcus aureus infections in patients on continuous ambulatory peritoneal dialysis (CAPD). METHODS: Between July 1993 and May 1997, 4 patients with recurrent CAPD-associated infections caused by S. aureus we enrolled in this study. There were nine episodes of peritonitis, one episode of temporary double lumen catheter infection, and one episode of Hickman catheter infection. A total of eleven S. aureus isolates were collected from peritoneal fluid (n = 9) and blood (n = 2). PFGE typing was applied. RESULTS: In our study, from PFGE typing, the 11 S. aureus isolates were classified into seven patterns. Antibiogram profiling classified only four patterns. Patient A had a reinfection by another strain of S. aureus, and patient B had three episodes of peritonitis caused by the same strain of S. aureus due to exit site infections. Patient C had two episodes of CAPD peritonitis caused by two different strains, respectively. Patient D had four episodes of S. aureus infection (three CAPD peritonitis and one bacteremia); the first two episodes of peritonitis were caused by an identical strain of S. aureus, whereas the subsequent two infections were caused by other organisms. CONCLUSION: PFGE has a high discriminatory power and can be an assistant method to antibiogram profiling for distinguishing relapse from reinfection in CAPD-associated peritonitis.     

Technical survival of CAPD catheters: comparison between percutaneous and conventional surgical placement techniques.

BACKGROUND: Percutaneous peritoneal dialysis catheter (PDC) placement is a well-tolerated, rapidly performed bedside procedure that allows a rapid initiation of CAPD. We compared the technical survival of PDCs while comparing the mode of insertion. METHODS: We retrospectively reviewed 215 PDCs inserted over a 60-month period in 191 patients on CAPD therapy. Of these, 133 were placed percutaneously by nephrology staff (group P) and 82 were placed using conventional surgical techniques by surgical staff (group S). The total experience accumulated was 4000 patient-months: 2260 patient-months in group P and 1740 patient-months in group S. RESULTS: The incidence of complications in PDCs did not differ between the groups (1 episode/33 patient-months in group P and 1 episode/29 patient-months in group S). Two episodes of early leakage and 9 episodes of late leakage were observed in group P compared with one early leakage and 4 episodes of late leakage in group S. Of the mechanical complications in group P, 8.86% were due to catheter malfunction, including catheter tip migration and obstruction, compared with 12.63% in group S. The incidence of catheter infections was 1 episode/73 patient-months in group P and 1 episode/62 patient-months in group S. Significantly more catheters were removed in group S compared with group P (40% vs 16%, P<0.001). One-year and 2-year technical survivals were 90% and 82% in group P, and 73% and 60% in group S (P=0.0032), respectively. CONCLUSIONS: Percutaneous bedside placement of PDCs by nephrologists provides a safe and reliable access for peritoneal dialysis.     

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.     

The role of continuous ambulatory peritoneal dialysis in end-stage renal failure due to multiple myeloma

A study in 10 patients (eight male, two female; mean age 61.9 +/- 10.7 years) suffering from multiple myeloma (MM) and end-stage renal failure (ESRF) is detailed. Continuous ambulatory peritoneal dialysis (CAPD) was the preferred mode of chronic dialysis in all the patients. Survival after diagnosis was 32.2 +/- 23.9 months. Survival after starting dialysis was 24.6 +/- 20.6 months. All patients on CAPD were adequately dialyzed and in good fluid control. Peritonitis was the main problem on CAPD (one episode per 5.6 patient-months). The majority of peritonitis episodes responded to intraperitoneal antibiotic therapy. One patient with Staphylococcus aureus peritonitis, septicemia, and neutropenia secondary to chemotherapy, died. Recommendations for prophylaxis and treatment of peritonitis are given. Three patients were transferred to hemodialysis. The use of subclavian vein catheters during hemodialysis was associated with a high incidence of gram-positive septicemia. Alkylating agent-based chemotherapy resulted in hematological responses in five patients. Survival after diagnosis in those responders was 47.4 +/- 25.6 months, compared with 17.0 +/- 7.2 months in the nonresponders (P less than 0.05). All responders subsequently relapsed. Four patients died with progressive myeloma. Bone marrow suppression resulted in a high blood transfusion requirement, neutropenia, and thrombocytopenia associated with bleeding into the gastrointestinal tract and central nervous system. Uremic myeloma patients can be adequately dialyzed using CAPD. Those patients who do not have an initial hematological response have a poor prognosis.