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.     

Plasma interleukin-6 levels in continuous ambulatory peritoneal dialysis and hemodialysis patients.

Plasma levels of interleukin-6 (IL-6), a cytokine known to be involved in lymphocyte activation and in inflammation, were studied in 10 normal volunteers, 21 continuous ambulatory peritoneal dialysis (CAPD) patients and 41 hemodialysis patients. Plasma IL-6 levels in hemodialysis patients were significantly higher than those in normal volunteers and CAPD patients (p less than 0.05). The means of plasma IL-6 concentrations before and after hemodialysis did not change significantly. While IL-6 in peritoneal dialysate was detectable in only 3 of the 21 CAPD patients without peritonitis, it was extremely high in 2 patients with bacterial peritonitis. IL-6 levels decreased as peritonitis subsided.     

Pancreatitis: an important cause of abdominal symptoms in patients on peritoneal dialysis

In an eight-month period, four patients in our peritoneal dialysis program developed acute pancreatitis, an incidence significantly higher than that in our hemodialysis program. Diagnosis was difficult since the symptoms of pancreatitis were similar to those of peritoneal dialysis-associated peritonitis. Further difficulties in diagnosis were due to unreliability of serum amylase levels and "routine" ultrasound examinations in suggesting the presence of pancreatitis. Computerized tomography performed in three patients showed enlarged, edematous pancreata with large extrapancreatic fluid collections in all cases. Two patients died, one directly due to complications of pancreatitis. One patient was changed to hemodialysis and showed clinical and radiologic resolution of his pancreatitis. One patient remains on peritoneal dialysis but has now had four attacks of acute pancreatitis. No patient had classic risk factors for development of pancreatitis. Review of patient histories showed no common historical factors except for renal failure itself, peritoneal dialysis, peritonitis, catheter surgery, and hypoproteinemia. It is possible that metabolic abnormalities related to absorption of glucose and buffer from dialysate or absorption of a toxic substance present in dialysate, bags, or tubing can cause pancreatitis in patients on peritoneal dialysis. We feel that a diagnosis of pancreatitis should be considered when peritoneal dialysis patients present with abdominal pain, particularly if peritoneal fluid cultures are negative or if patients with positive cultures do not have prompt resolution of symptoms with appropriate antibiotic therapy.     

Superior mesenteric artery syndrome complicating dialysis patients with peritoneal failure--report of 3 cases

We report 3 cases of superior mesenteric artery syndrome in patients previously on maintenance peritoneal dialysis converted to hemodialysis after peritoneal failure. All 3 patients presented with repeated vomiting and severe malnutrition. It is postulated that complications arising from peritoneal dialysis such as peritoneal sclerosis, adhesions and collections after CAPD peritonitis may be important contributing factors for the SMA syndrome in these 3 patients. All of them succumbed within six months of diagnosis. The first 2 patients received gastrointestinal bypass surgery and died post-operatively due to impaired wound healing and nosocomial sepsis. The 3rd patient was treated conservatively with nasoduodenal feeding but succumbed to aspiration pneumonia. It is postulated that complications arising from peritoneal dialysis including peritoneal sclerosis, adhesions and collections after CAPD peritonitis may contribute to the SMA syndrome in these patients. Our experience suggests that SMA syndrome in end-stage renal disease patients is associated with high surgical morbidity and mortality possibly related to their poor pre-morbid condition and pre-existing malnutrition. Aggressive parenteral nutrition should be considered to build up the general status before proceeding to surgical intervention.     

Peritoneal dialysis in infants and children

Pediatric renal failure patients can be restored to health with peritoneal dialysis more easily, more comfortably, and more safely than with hemodialysis. During the past 3.5 years, we have treated 22 children with either acute (less than 30 days) or chronic (greater than 30 days) peritoneal dialysis (PD) at Henrietta Egleston Hospital for Children. They ranged in age from 2 weeks to 15 1/6 years, mean 5.2 years. The indications for acute dialysis were renal failure following cardiac surgery (4); hemolytic-uremic syndrome (4); and renal failure associated with bromide intoxication (1), congenital urethral stricture (1), or bronchopulmonary dysplasia (1). Chronic dialysis was utilized for end-stage renal disease caused by glomerulonephritis (5), chronic infection (2), hemolytic-uremic syndrome (1), cystinosis (1), congenital renal artery stenosis (1), and unknown etiology (1). Thirty-four adult or pediatric Tenckhoff catheters were utilized to deliver PD for from 6 to 551 days (18 months). Pediatric Tenckhoff catheters must be pre-measured in order to have the Dacron cuffs glued to the appropriate position on the catheter (7-12 cm from the end) to fit the child. There were seven catheter-related infections in four patients; three required catheter revision and four were treated medically. There were eight catheter-related mechanical problems, all of which required re-operation. All of those on chronic PD and seven of those on acute PD survived for an overall survival of 82 per cent. All surviving patients have been restored to health either by recovery of renal function (6 patients), renal transplantation (8 patients), or maintenance of chronic ambulatory peritoneal dialysis (4 patients).     

Feasibility of resuming peritoneal dialysis after severe peritonitis and Tenckhoff catheter removal

Published guidelines suggest that after an episode of severe peritonitis that requires Tenckhoff catheter removal, peritoneal dialysis can be resumed after a minimum of 3 wk. However, the feasibility of resuming peritoneal dialysis after Tenckhoff catheter removal remains unknown. One hundred patients were identified with peritonitis that did not respond to standard antibiotic therapy in a specific center. Their clinical course was reviewed; in all of them, Tenckhoff catheters were removed and reinsertion was attempted at least 4 wk later. In 51 patients, the Tenckhoff catheter was successfully reinserted and peritoneal dialysis was resumed (success group). In the other 49 patients, reinsertion failed and the patient was put on long-term hemodialysis (fail group). The patients were followed for 18.5 +/- 16.8 mo. The overall technique survival was 30.8% at 24 mo. In the success group, 11 patients were changed to long-term hemodialysis within 8 mo after their return to continuous ambulatory peritoneal dialysis. In the fail group, 18 of the 20 deaths occurred within 12 mo after conversion to long-term hemodialysis. After resuming peritoneal dialysis, there was a significant decline in net ultrafiltration volume (0.38 +/- 0.16 to 0.21 +/- 0.19 L; P = 0.03) and a trend of rise in dialysate-to-plasma ratios of creatinine at 4 h (0.664 +/- 0.095 to 0.725 +/- 0.095; P = 0.15). Forty-five patients (88.2%) required additional dialysis exchanges or hypertonic dialysate to compensate for the loss of solute clearance or ultrafiltration, although there was no significant change in dialysis adequacy or nutritional status. It was concluded that after an episode of severe peritonitis that required Tenckhoff catheter removal, only a small group of patients could return to peritoneal dialysis. An early assessment of peritoneal function after Tenckhoff catheter reinsertion may be valuable.     

Chronic peritoneal dialysis.

Since the introduction of the permanent peritoneal catheter, interest in chronic peritoneal dialysis is increasing. The automatic peritoneal dialysis cycler and the reverse osmosis peritoneal dialysis machine have been other development that made chronic peritoneal possible. Chronic peritoneal dialysis is indicated for the children, the elderly, those without hemodialysis access sites, those living along (for home dialysis) and the diabetics, whose retinopathy seems to progress less on peritoneal dialysis than on hemodialysis. Patients awaiting a kidney transplant can be maintained equally satisfactorily on peritoneal dialysis as on hemodialysis. Because of its simplicity almost any patient can be trained for home peritoneal dialysis, and a high incidence of rehabilitation can be achieved. A flow rate of 4 1/hr with 21 exchanges, 40 hours a week, seem to the ideal dialysis requirements. Complications of chronic peritoneal dialysis include those related to the permanent catheter such as one or two way obstruction and those related the dialysis itself. The latter can be either acute (i.e. peritonitis etc.) or chornic such as neuropathy, renal osteodystrophy, anemia etc. Integrated with hemodialysis and transplantation, peritoneal provides the nephrologists with the ability to treat his patients with the most appropriate treatment.     

Renal transplantation of patients on chronic peritoneal dialysis

A retrospective review of patients transplanted from peritoneal dialysis was performed to assess the risk of this form of dialysis for patients awaiting renal transplantation. Eighteen transplants have been performed in 16 patients, ages 6 to 57 years, undergoing chronic peritoneal dialysis over the past 4 years. Sixteen were from cadaver donors, and two were from living related donors (LRD). The patients had been undergoing intermittent peritoneal dialysis or continuous ambulatory peritoneal dialysis (CAPD) using permanent silastic catheters, from five days to 4 years. No patient had clinical evidence for peritonitis at the time of transplantation. The peritoneal catheter was removed at the time of transplant in all cadaver donor recipients without complication. One recipient of a LRD kidney had the catheter removed two days prior to transplant. Cultures of the catheter were sterile in 16 cases. Two patients had positive peritoneal catheter cultures at the time of transplant but were treated with appropriate antibiotics and never developed clinical peritonitis. Fourteen transplants had postoperative fevers. No definite source was found in 13; one had fever in relation to acute graft rejection. The fevers resolved in all patients either spontaneously or subsequent to therapy. Other complications were similar to those seen in patients transplanted from hemodialysis. Hemodialysis was performed as needed pretransplant and posttransplant using a temporary femoral vein catheter or arteriovenous fistula without complication. Nine patients are alive with a functioning kidney 1 to 36 months posttransplant (mean 17 months). Six transplants rejected (five patients), and one failed secondary to renal vein thrombosis. Two patients died posttransplant, one after a cerebrovascular accident, and one due to an unknown cause 1 month postnephrectomy for rejection. In conclusion, patients undergoing chronic peritoneal dialysis can be successfully transplanted without a significant incidence of complications related to their peritoneal dialysis.     

Hyperlipidemia in uremic children: response to peritoneal dialysis and hemodialysis.

Hemodialysis and hyperlipidemia have been associated in both adults and children. The present study indicates hyperlipidemia in uremic children treated with peritoneal dialysis and implies that the cardiovascular risk felt to exist with hemodialysis also exists in peritoneal dialysis. Thirty-eight children with chronic renal insufficiency or end-stage renal disease were followed serially under varying conditions of medical management, hemodialysis, peritoneal dialysis, and transplantation. Serum triglyceride concentrations in patients on peritoneal dialysis were not significantly different from those in patients on hemodialysis, but both were significantly higher (P less than 0.01) than concentrations in patients on medical management and transplantation.     

Sclerosing peritonitis with gross peritoneal calcification: a case report.

We report the case of a patient on dialysis for 13 years, including continuous ambulatory peritoneal dialysis (CAPD) for 11 years, who developed sclerosing peritonitis with gross peritoneal calcification. The patient first presented with abdominal pain in January 1990, when peritoneal calcification was detected for the first time. Her symptoms settled spontaneously and 1 year later she presented with acute peritonitis and adynamic ileus. The peritonitis settled with antibiotics and Tenchkoff catheter removal, but the ileus persisted. She was commenced on long-term parenteral nutrition, but never recovered useful bowel function. After 8 weeks of hemodialysis and total parenteral nutrition, a further laparotomy for an acute abdomen showed what appeared to be extensive bowel infarction and peritoneal calcification. She died several days later. Of significance, peritoneal calcification was first noted on x-ray and computed tomography (CT) scan while the patient was still largely asymptomatic and before peritoneal ultrafiltration capacity was significantly impaired. Unlike other reported cases of calcifying peritonitis, sclerosing peritonitis was present and calcification was far more extensive. It was not associated with factors such as frequent infective peritonitis or acetate dialysate. Calciphylaxis was not present nor was there any abnormality of calcium-phosphate metabolism. The outcome of this case suggests that patients with recurrent or persistent bowel symptoms on long-term CAPD should have early abdominal x-ray or CT scanning to exclude sclerosing peritonitis or bowel calcification. If present, consideration should be given to transferring the patient to another therapeutic dialysis modality if possible.     

Experience with using extracorporeal methods of detoxification in acute diseases of the organs of the abdominal cavity]

Results of treatment of 295 patients are presented. Among them there were 128 patients with diffuse purulent peritonitis, 109 with acute pancreatitis and 58 with destructive cholecystitis. In the complex treatment extracorporeal methods of detoxication therapy were included: plasmapheresis, hemo- or lymphosorption, perfusion ofautologous blood through the xenogenous spleen. Indications to each of the methods are considered. It was found that when using the therapy in question clinical symptoms of endotoxicosis were eliminated 1.5 times quicker and the leukocytic intoxication index was corrected more successfully as well as was the level of toxins of middle molecular mass, functional activity of blood neutrophils, immune link of homeostasis and ++cardio-hemodynamic parameters.     

Tuberculous peritonitis complicating long-term peritoneal dialysis. Report of 5 cases and review of the literature

The characteristics of 5 patients who developed tuberculous peritonitis while receiving long-term peritoneal dialysis (PD) are presented. There were 2 males and 3 females. 3 patients were on intermittent and 2 were on continuous ambulatory peritoneal dialysis when tuberculous peritonitis was first diagnosed. None of the patients had recently received immunosuppression therapy or were diabetics. The clinical presentations were similar to other forms of peritonitis complicating PD except for a more insidious onset. As extraperitoneal involvement and peritoneal lymphocytosis were rarely present, the diagnosis was mainly dependent on the direct demonstration of Mycobacterium tuberculosis with smear (1 patient) and culture (4 patients). In 1 patient with a pleuroperitoneal communication, the diagnosis was made by pleural biopsy and a positive response to antituberculous therapy. All patients responded to treatment with a combination of three antituberculous drugs which included streptomycin, isoniazid, rifampicin and pyrazinamide. Two patients were transferred to hemodialysis. In 3 patients, peritoneal dialysis was continued. Peritoneal clearance and ultrafiltration capacity were unchanged for up to 16 months after treatment in 2 patients who continued peritoneal dialysis but was reduced by 30 and 50%, respectively, in the remaining patient. Only 1 patient died, but her death was not directly related to tuberculous peritonitis. It was concluded that with a high index of suspicion and early institution of treatment, tuberculous peritonitis complicating PD can be successfully treated with low mortality and without compromising the dialysis capacity of the peritoneal membrane.     

Recent peritonitis associates with mortality among patients treated with peritoneal dialysis

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.     

Peritoneal catheter colonization by Penicillium sp : Case report and review of penicillium-related complications in peritoneal dialysis

Fungal peritonitis is an uncommon, serious complication of peritoneal dialysis, usually caused by Candida sp . Asymptomatic fungal colonization of the peritoneal catheter is less frequent. Penicillium sp have only rarely been reported as a cause of peritoneal complications in peritoneal dialysis. We report a case of fever and peritoneal catheter malfunction associated with catheter colonization by Penicillium sp , in the absence of signs or symptoms of acute peritonitis. Cultures of the dialysate grew Penicillium sp, and histological examination showed penetration of the catheter by hyphae. The peritoneal catheter was removed, and the patient was maintained on hemodialysis and oral itraconazole for 6 weeks before successfully returning to continuous cycling peritoneal dialysis (CCPD). One case of Penicillium catheter colonization and seven of Penicillium peritonitis in peritoneal dialysis patients have been previously published in the English literature. Detailed data were provided in five reports. Delayed diagnosis was frequent (mean ± SD 31 ± 24 days after the onset of symptoms). Peritonitis cases were treated with catheter removal and antifungal medications, and the outcome was always satisfactory. We conclude that Penicillium should be considered a pathogenic fungus, not a contaminant, when isolated from peritoneal dialysis specimens, and should be treated accordingly. However, Penicillium may colonize the peritoneal catheter in the absence of peritonitis, and the prognosis of Penicillium peritonitis is good despite a frequent delay in diagnosis.     

Renal transplantation in patients with indwelling continuous ambulatory peritoneal dialysis catheters

Controversy exists regarding management of the continuous ambulatory peritoneal dialysis catheter in patients undergoing renal transplantation. We performed 30 transplants (23 cadaveric and 7 living related) in 27 patients with indwelling continuous ambulatory peritoneal dialysis catheters. Dialysis was necessary in the immediate post-transplantation period in 9 of 30 patients (30 per cent). Of these 9 patients 3 had temporary hemodialysis and 6 resumed continuous ambulatory peritoneal dialysis with the indwelling catheter. Two postoperative complications clearly were related to the continuous ambulatory peritoneal dialysis catheter: 1 patient required abdominal exploration for control of bleeding related to disruption of peritoneal adhesions at the time the continuous ambulatory peritoneal dialysis catheter was removed and 1 suffered an abscess at the catheter site 1 month after the catheter was removed. No patient experienced peritonitis during immunosuppression after transplantation. We support leaving the continuous ambulatory peritoneal dialysis catheter during and after transplantation to simplify pre-transplantation patient care and to avoid the possible need for temporary post-transplantation hemodialysis in many patients.     

Pathogenesis of enteral insufficiency in patients with postoperative peritonitis

Enteral insufficiency is considered to trigger the syndrome of endogenous intoxication and, further, multiple organ failure. Enteral insufficiency often accompanies postoperative septic complications, such as peritonitis. Morphologic changes of the intestinal wall by septic peritonitis consisted of edema, fibrinous degradation of muscular layer and dystrophy of local nervous pathways. Microbiologic analysis of intestinal and gastric contents, peritoneal fluid and blood samples demonstrated a broad spectrum of pathogenic flora. Besides, enterotoxin allocated from blood and intestinal contents coincided in all cases. Adequate algorithm of detoxication, including extracorporal methods, had been worked out.     

心脏术后低排综合征致急性肾功能衰竭的腹膜透析治疗

目的　探讨腹膜透析对心脏术后低排综合征 (LOS)致急性肾功能衰竭 (ARF)的疗效。方法　 2 4例心脏术后引起LOS合并多脏器功能衰竭 (MSOF)致ARF者 ,因不适合血液透析 (HD) ,于确诊后 2 4小时内进行腹膜透析 (PD)治疗。结果　 12例患者多脏器严重衰竭死亡 ,9例患者PD 3～30天内肾功能恢复 ,3例治疗后病情好转 ,自动出院。结论　心脏术后LOS致MOSF合并有ARF者 ,PD具有较好的治疗效果。     

Direct peripheral venopuncture: another new choice of temporary vascular access

BACKGROUND: Femoral, subclavian, and internal jugular veins access have been widely used for temporary vascular access for hemodialysis, but their use has been associated with a significant complication rate. We report in three selected hemodialysis patients with the procedure of direct peripheral venopuncture as temporary vascular access to reduce complications. METHODS: We have demonstrated hemodialysis via direct puncture of peripheral veins of the antecubital fossa (cephalic vein in the process of arterial inflow to dialyzer and venous outflow from dialyzer to basilic vein) as temporary vascular access for these patients. RESULTS: Renal function of case 1 and case 2 progress to normal status after several sessions of dialytic therapy as well as quit hemodialysis, and case 3 successfully shifts to peritoneal dialysis following four sessions of dialytic therapy. CONCLUSIONS: We recommend this short-term access contribute a important additional new choice in selected patients with acute, reversible renal failure, obstructive uropathy, initiation of peritoneal dialysis, patients on peritoneal dialysis with peritonitis, or under plasmapheresis therapy.     

Mitral insufficiency associated with primary antiphospholipid syndrome and chronic renal failure

We report a case of 52-year-old woman with primary antiphospholipid syndrome who developed mitral insufficiency and chronic renal failure. Continuous ambulatory peritoneal dialysis was started preoperatively due to thrombocytopenia that was aggravated by hemodialysis. Mitral annuloplasty was performed since the mitral valve was not severely damaged. Her postoperative hemodynamics were stable, and anticoagulant therapy was controlled easily. She recovered from severe thrombocytopenia while on continuous ambulatory peritoneal dialysis. Valvular heart disease is a well known feature of primary antiphospholipid syndrome, and there have been several reports about valve replacement in patients who had antiphospholipid syndrome with or without systemic lupus erythematosus. However, valve repair has been reported in only a few such patients. We believe that valve repair is better than valve replacement in patients with antiphospholipid syndrome because of its hypercoagulable tendency. In addition, it seems that continuous ambulatory peritoneal dialysis is a suitable method for the perioperative management of patients with antiphospholipid syndrome who suffer from chronic renal failure as well as thrombocytopenia, and require cardiac surgery under cardiopulmonary bypass.     

持续性非卧床腹膜透析与肾移植（附46例报告）

单独应用持续性非卧床腹膜透析（ＣＡＰＤ）后行肾移植４６例，死亡１０例，死因为术后粘连性肠梗阻２例，急性排斥反应４例，败血症、自发性肾破裂、肝脓疡各１例，慢性排斥２年后再次移植死亡１例．本组术后无腹膜炎发生．