Fibrin glue is useful in preventing early dialysate leakage in children on chronic peritoneal dialysis.

OBJECTIVE: To assess if application of fibrin glue sealant to the peritoneal cuff suture is useful in the prevention of early dialysate leakage in children with end-stage renal disease on chronic peritoneal dialysis (CPD). DESIGN: Single-center, open-label, prospective randomized study. SETTING: University Pediatric Hospital. METHODS: 52 catheters were implanted in 45 children (mean age 6.2 +/- 4.5 years). Catheters were randomly assigned to either the control group or the sealant group. In the latter group, 1 mL of fibrin glue sealant was applied to the peritoneal cuff suture. 18 catheters were used for the first time within 5 days after implantation (early-used catheters). Leakage, exit-site or tunnel infection, peritonitis, and adverse secondary effects were evaluated during the initial 60 days after implantation. RESULTS: No adverse secondary effects were seen after the application of the fibrin glue sealant. The incidence of exit/tunnel infection and peritonitis was similar in the two groups. The incidence of leakage was significantly lower in the sealant group (p < 0.02). In the early-used catheters, leakage was detected in 9% of the catheters in the sealant group and in 57% of the control group (p < 0.05). CONCLUSIONS: The application of 1 mL of fibrin glue to the peritoneal cuff suture prevented early dialysate leakage without secondary adverse effects in children on CPD.     

Surgical management of refractory exit-site/tunnel infection of Tenckhoff catheter: technical innovations of partial replantation.

OBJECTIVE: Catheter-related infection has been the major cause of catheter removal for peritoneal dialysis (PD) patients. A salvage technique--partial replantation of the infected catheter--was developed in our hospital to rescue catheters with refractory exit-site or tunnel infection. PATIENTS: We performed 26 partial replantations of Tenckhoff catheters for 23 patients with refractory exit-site or tunnel infection and 2 patients with near-cuff perforation of the catheter. Their problems were all resolved successfully without interruption of PD. INTERVENTIONS: We removed the infected portion of the catheter and preserved the still-functioning internal conduit, connecting it to a divided new catheter. All of the patients resumed PD immediately after the advancement of the new catheter through a new subcutaneous tunnel and exit site on the opposite side. RESULTS: No technical complications such as disconnection of the catheter or leakage of dialysate were noted. Repeated partial replantation of the catheter was done for 1 patient with a new refractory exit-site infection. Tunnel infection was not an absolute contraindication for this procedure. About one third (34.6%) of our patients had preoperative tunnel infection. CONCLUSION: Partial replantation of a Tenckhoff catheter is a simple and effective procedure for patients with refractory exit-site/tunnel infection and patients with near-cuff perforation of the catheter. Repeated partial replantation is also feasible for repeat exit-site infections.     

不同类型腹膜透析导管临床应用体会

目的观察不同类型腹膜透析导管的近期并发症的发生率情况及防治体会。方法68例终末期肾衰竭行维持性腹膜透析治疗患者分为两组。组1：28例患者采用Tenckhoff曲管;组2：40例患者采用鹅颈直管。两组患者随访时间均大于6个月。观察两组患者的腹膜透析液引流速度、隧道感染、出口感染、导管移位、腹膜透析液渗漏等发生情况。结果两组患者腹膜透析液引流速度的隧道感染率和出口感染率无差别（P〉0.05）.Tenckhoff管组5例患者出现导管移位（17.8%）,而swan-neck导管组仅2例（5%）,两组相比有显著性差异（P〈0.05）。进一步分析发现前组患者漂管发生于第一周3例（60%）,第二周2例（40%）,而鹅颈直管发生漂管多于1周内。另外鹅颈直管组有3例患者于术后第一周出现引流不畅,拔管时发现导管内均有大量蛋白凝块阻塞。结论不同类型导管各有优缺点,鹅颈直管的导管移位率明显低于Tenckhoff导管,但易发生透析液引流不畅,而Tenckhoff导管不容易发生堵管。在置管过程中调整swan-neck腹膜透析管外段与腹正中线的角度后能明显改观引流速度。改观     

A randomized controlled trial comparing mupirocin versus Polysporin Triple for the prevention of catheter-related infections in peritoneal dialysis patients (the MP3 study).

BACKGROUND: Peritonitis remains the most serious complication of peritoneal dialysis (PD). Gram-positive organisms are among the most common causes of PD peritonitis; however, recent trends show increasing rates of gram-negative and fungal infections. Strategies to prevent peritonitis include the use of prophylactic topical mupirocin at the site where the PD catheter exits from the abdominal wall; however, mupirocin does not afford protection against gram-negative or fungal infections. The aim of this study is to determine if the incidence of catheter-related infections (exit-site infection, tunnel infection, or peritonitis) is significantly reduced by the routine application of Polysporin Triple antibiotic ointment (Pfizer Canada, Markham, Ontario, Canada) in comparison to mupirocin ointment. METHODS AND DESIGN: The Mupirocin Versus Polysporin Triple Study (MP3) is a multicenter, randomized, double-blinded controlled study comparing Polysporin Triple (P3) against the current standard of care. The aim of the study is to recruit 200 patients being treated with or starting on PD and randomize them to receive either mupirocin or P3 at the catheter exit site. Patients will be followed for 18 months or until death or transfer from PD to an alternate treatment modality. The primary outcome will be the time to first catheter-related infection. Catheter-related infections will be strictly defined using current guidelines and categorized into exit-site infections, infective peritonitis, or tunnel infections. The primary analysis will be an intention-to-treat analysis. DISCUSSION: The results of this study will help determine if the use of P3 is superior to mupirocin ointment in the prevention of catheter-related infections and will help guide evidence-based best practices.     

Clinical outcomes of immediate full-volume exchange one year after peritoneal catheter implantation for CAPD.

OBJECTIVE: To evaluate actual risk of complications and 1-year catheter survival of immediate full-volume 2000-mL dialysate exchange after peritoneal catheter implantation. DESIGN AND SETTING: A prospective randomized comparative study in a university hospital kidney center. PATIENTS: The study included 59 end-stage renal disease patients entering into a continuous ambulatory peritoneal dialysis program between January 1996 and December 1997. INTERVENTIONS: In group 1 (n = 21), exchange volume was gradually increased from 500 mL per 3 hours to full-volume exchange over 13 days. In group 2 (n = 38), full-volume exchange per 6 hours was performed from the day of catheter implantation. Bed rest with minimal activity was recommended for the first 3 days in both groups. MAIN OUTCOME MEASURES: Occurrence of catheter-related complications such as dialysate leakage, drainage failure, malposition, infectious complications, and, ultimately, catheter loss were observed for 1 year. RESULTS: After straight Tenckhoff catheter implantation, pericatheter dialysate leaks occurred in 9.5% of group 1 and in 10.5% of group 2 patients (no significance, NS). Within 1 month of implantation, the incidences of tunnel or exit-site infection, catheter malposition, and outflow failure were not significantly different between the two groups. Abdominal discomfort was noted in 2 patients from group 2. Peritonitis occurred in 9.5% and 5.3% (NS) within 2 weeks of catheter implantation, and in 14.3% and 10.5% (NS) after more than 2 weeks in group 1 and group 2, respectively. Early catheter loss within 1 month occurred in 4.8% of patients in group 1 and 5.3% in group 2 (NS). The causes of loss were persistent leakage in group 1, and persistent leakage combined with tunnel infection and outflow failure in group 2.The duration of hospitalization from the day of catheter insertion to discharge was definitely shorter in group 2 compared to group 1 (9.9 +/-0.6 days vs 15.0 +/- 0.8 days, p < 0.001). For 1-year follow-up, the frequencies of peritonitis were 0.062 +/- 0.015/patient-month in group 1 and 0.076 +/- 0.018/patient-month in group 2 (NS). The actual 1-year catheter survival was 85.7% in group 1 and 84.2% in group 2 (NS). CONCLUSIONS: One-year catheter survival after immediate full-volume peritoneal dialysis exchange was 84.2%. This study did not show any evidence that immediate full-volume exchange causes more short- or long-term complications compared to the stepwise volume increment method.     

Determinants of catheter loss following continuous ambulatory peritoneal dialysis peritonitis.

BACKGROUND: Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis. Patients and METHODS: We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal (n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved. RESULTS: The incidence of PD catheter loss increased as the number of organisms cultured increased (p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level (p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/microL (p < 0.001), those with concomitant tunnel infection (p < 0.001), those with concomitant exit-site infection (p = 0.005), and those with presence of catastrophic intra-abdominal visceral events (p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance (p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi (p < 0.001), anaerobes (p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095). CONCLUSION: PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/muL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.     

腹膜透析管浅涤纶套外露的形成原因分析与护理

目的 分析腹膜透析患者腹膜透析管浅涤纶套外露的原因及护理体会.方法 收集解放军第四五五医院肾脏科2005年1月至2010年1月间腹膜透析患者380例,回顾性分析其中发生腹膜透析管浅涤纶套外露的10例患者的形成原因.380例腹膜透析患者均采用常规的腹膜透析手术方法,术后常规护理.采用百特鹅颈腹膜透析管,百特双联腹膜透析液.将其中发生了浅涤纶套外露的10例患者按手术因素,护理因素,自身因素与其他因素进行分析阐述.结果 因手术因素造成涤纶套外露的1例,护理因素造成涤纶套外露的1例,自身因素造成涤纶套外露的 8例.结论 腹膜透析患者浅涤纶套外露临床发生较少,但对患者的生活质量、生存率及腹膜透析治疗持续时间等影响较大,应引起临床重视.我们通过加强换药,个别指导,加强营养,皮下隧道延长等措施后,未发生腹膜炎、腹膜透析拔管等严重并发症及后果.     

A comparative analysis on the incidence of peritonitis and exit-site infection in CAPD and automated peritoneal dialysis.

OBJECTIVE: To compare the incidence of peritonitis and exit-site infection in an ample group of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis in a single center during a 10-year period. DESIGN: Nonrandomized, prospective study. SETTING: Public, tertiary care hospital providing peritoneal dialysis care to a population of (approximately) 750 000 people. PATIENTS: We studied 213 patients on CAPD and 115 on automated peritoneal dialysis (APD) starting therapy between January 1989 and August 1998, with a minimum follow-up of 3 months. MAIN OUTCOME MEASURES: Using a multivariate approach, we compared the incidence, clinical course, and outcome of peritonitis and exit-site infections in both groups, controlling for other risk factors for the complications studied. RESULTS: The incidence of peritonitis was higher in CAPD than in APD (adjusted difference 0.20 episodes/ patient/year, 95% confidence interval 0.08 - 0.32). There was a trend for CAPD patients to present earlier with peritonitis than APD patients, yet the incidence of and survival to the first exit-site infection were similar in both groups. The etiologic spectrum of infections displayed minor differences between groups. Automated PD patients were more frequently hospitalized for peritonitis, but otherwise, the complications and outcome of peritonitis and exit-site infections did not differ significantly between patients on CAPD and those on APD. CONCLUSIONS: Automated PD is associated with a lower incidence of peritonitis than is CAPD, while exit-site infection is similarly incident under both modes of therapy. The etiologic spectrum, complications, and outcome of peritonitis and exit-site infection do not differ markedly between CAPD and APD. Prevention of peritonitis should be included among the generic advantages of APD over CAPD.     

A prospective randomized study of the effect of a subcutaneously "buried" peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection.

OBJECTIVE: A new method for implantation of peritoneal dialysis (PD) catheters was described in 1991. The distal part of the catheter is buried subcutaneously and exteriorized at the start of PD. This study was designed to evaluate the effect of such a subcutaneous rest period on the incidence of peritonitis and exit-site infections (ESI). DESIGN: Sixty patients were randomized to either the new method (B group; n = 30) or to not having the distal part buried subcutaneously (NB group; n = 30). Sixty-five patients (NS group) were not randomized as they had to start PD within 1-2 weeks after implantation. The Moncrief-Popovich catheter was used in the B and NB groups and a standard Tenckhoff catheter was used in the NS group. PATIENTS: Patients scheduled for PD treatment, judged not in need of PD for at least 6 weeks after implantation. RESULTS: There was no statistically significant difference in the cumulative probability of not developing peritonitis during the first 6, 12, and 24 months. The incidence of the first episode of peritonitis was 1/40, 1/26, and 1/33 treatment-months in the B, NB, and NS groups, respectively. The incidence of ESI was 1/103 and 1/95 treatment-months in the B and NS groups, respectively. The cumulative probability of not developing ESI was similar in both groups. There were no episodes of ESI in the NB group. The difference in the number of ESI between the NB and NS groups was significant (p < 0.05). CONCLUSIONS: Subcutaneous burying of the distal catheter segment prior to starting PD does not reduce the risk of contracting peritonitis or exit-site infection.     

Prevention of peritonitis in children on peritoneal dialysis.

We reviewed methods of preventing peritonitis in children. A considerable body of evidence indicates that peritonitis rates are lowest with the use of a double-cuffed catheter, with a downward directed tunnel, placed by an experienced surgeon. Evidence in adults, but lacking in children, suggests that exit-site mupirocin will lower Staphylococcus aureus exit-site infections and thus peritonitis rates. The risk of peritonitis due to contamination can be diminished by the avoidance of spiking and by the provision of a long training period. Catheter removal and replacement for catheter-related peritonitis may be done simultaneously in certain circumstances and is useful in decreasing the risk of recurrent peritonitis. Antibiotic prophylaxis at the time of catheter insertion, for contamination, during dialysate leaks, and for invasive procedures appears to be useful in diminishing peritonitis risk.     

A simple method to prevent peritoneal dialysis catheter tip migration.

BACKGROUND: We report here a one-stitch fixation method that prevents catheter tip migration during implantation of the double-cuffed straight Tenckhoff catheter. METHODS: From July 2003 to September 2005, 38 patients with end-stage renal disease underwent implantation of the double-cuff straight Tenckhoff catheter for peritoneal dialysis by this method. RESULTS: No patient had catheter tip migration out of the true pelvis. No patient had pericatheter dialysate leakage or developed incisional hernia. Two patients (5.3%) experienced exit-site infection during the 2- and 5-month follow-up and they recovered well after wound care. Three patients (7.9%) developed peritonitis during the 3-day and 2- and 6-month follow-up; the conditions were controlled after antibiotic care. One patient (2.6%) experienced mechanical catheter obstruction during the 10-day follow-up due to omental wrapping; surgical revision was necessitated. CONCLUSIONS: We believe that the method is an easy, safe, and effective technique for preventing catheter tip migration.     

Immediate initiation of CAPD following percutaneous catheter placement without break-in procedure.

OBJECTIVE: To evaluate the effect of a modified method of percutaneous catheter placement without a break-in procedure on the development of catheter-related complications in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: A prospective, observational clinical study. SETTING: Peritoneal dialysis (PD) units of two university-based hospitals. PATIENTS AND METHODS: This study included 51 consecutive patients on CAPD. A straight double-cuffed Tenckhoff catheter with a straight intraperitoneal segment was used, and all catheters were inserted using a modified percutaneous placement method under local anesthesia. The catheter was introduced directly into the deep pelvis through an intramuscular tract, which had been created by tapered dilators. Peritoneal dialysis was initiated immediately after catheter insertion without a break-in procedure. Catheter-related complications were surveyed during the 12 months after initiation of CAPD. RESULTS: Within the first month, only 1 pericatheter leakage (1.9%) was detected. There were no cases of visceral perforation or severe hemorrhage during catheter insertions. Catheter malfunction due to catheter tip migration, exit-site infection, and peritonitis developed in only 1.9%, 3.9%, and 3.9% of patients, respectively. After 1 month following catheter insertion, no further incidences of pericatheter leakage occurred during the follow-up period. All catheters, except one that was reinserted due to tip migration, survived throughout the study period. CONCLUSION: The rates of pericatheter leakage and other catheter-related complications are relatively low in CAPD patients using our percutaneous catheter placement method without a break-in procedure. This procedure is comparatively simple and less invasive than other catheter placement methods, and allows for immediate start of PD after catheter insertion, without a break-in procedure.     

Staphylococcus aureus prophylaxis and trends in gram-negative infections in peritoneal dialysis patients.

OBJECTIVE: To examine gram-negative exit-site infection and peritonitis rates before and after the implementation of Staphylococcus aureus prophylaxis in peritoneal dialysis (PD) patients. DESIGN: Prospective data collection with periodic implementation of protocols to decrease infection rates in two PD programs. PATIENTS: 663 incident patients on PD. INTERVENTIONS: Implementation of S. aureus prophylaxis, beginning in 1990. MAIN OUTCOME MEASURES: Rates of S. aureus, gram-negative, and Pseudomonas aeruginosa exit-site infections and peritonitis. RESULTS: Staphylococcus aureus exit-site infection and peritonitis rates fluctuated without significant trends during the first decade (without prophylaxis), then began to decline during the 1990s subsequent to implementation of prophylaxis, reaching levels of 0.02/year at risk and zero in the year 2000. Gram-negative infections fell toward the end of the 1980s, due probably to the implementation of better connectology. However, there have been no significant changes for the past 6 years. There was little change in P. aeruginosa infections over the entire time period. Pseudomonas aeruginosa is now the most common cause of catheter infection and catheter-related peritonitis. CONCLUSIONS: Prophylaxis against S. aureus is highly effective in reducing the rate of S. aureus infections but has no effect on gram-negative infections. Pseudomonas aeruginosa is now the most serious cause of catheter-related peritonitis.     

Prospective comparison of downward and lateral peritoneal dialysis catheter tunnel-tract and exit-site directions.

OBJECTIVE: Guidelines for optimal peritoneal dialysis access support both downward and lateral exit-site directions. Numerous clinical reports support the superiority of downward exit sites but none substantiate lateral configurations. METHODS: This prospective study compared infectious and mechanical complications between 85 catheters with a preformed arcuate bend to produce a downward exit site and 93 catheters with a straight intercuff segment configured to create a lateral exit site. RESULTS: Kaplan-Meier survivals were not different for time to first exit-site infection (p = 0.62), tunnel infection (p = 0.89), or peritonitis (p = 0.38) for downward and lateral exit-site directions. Poisson regression showed no differences in rates (episodes/patient-year) of exit-site infection (0.26 vs 0.27, p = 0.86), tunnel infection (0.02 vs 0.03, p = 0.79), peritonitis (0.42 vs 0.43, p = 0.87), or catheter loss (0.06 vs 0.09, p = 0.29) for downward and lateral exit sites. Kaplan-Meier analyses of antibiotic-free intervals for exit-site (p = 0.94) and peritonitis infections (p = 0.72) were not different for the two groups. There was one case of catheter tip displacement with flow dysfunction in each group. There were no pericatheter hernias or spontaneous cuff extrusions. Catheter survival between groups was not different (p = 0.20). CONCLUSIONS: Catheter types employing downward and lateral tunnel-tract and exit-site configurations produce equivalent outcomes for infectious and mechanical complications.     

Effect of preventing Staphylococcus aureus carriage on rates of peritoneal catheter-related staphylococcal infections. Literature synthesis.

OBJECTIVE: To determine whether specific preventive measures reduce the rate of peritoneal catheter-related infections and peritoneal catheter loss due to Staphylococcus aureus. DESIGN: Structured literature synthesis. METHODS: Relevant studies were identified by MEDLINE search, from personal files, and from the reference lists of retrieved articles. We analyzed English-language studies on treatment targeted at S. aureus, with at least 10 subjects and at least 3 months of follow-up, and data on staphylococcal peritoneal dialysis catheter infections. We excluded noncontrolled studies. Two investigators abstracted data using a structured form. RESULTS: We evaluated six studies with concurrent controls and eight studies with historical controls. In one randomized, placebo-controlled, blinded study, periodic nasal mupirocin ointment reduced the rate of staphylococcal exit-site infection from 0.42 to 0.12 episodes/patient-year (p = 0.006), but had no effect on the rates of staphylococcal tunnel infection, peritonitis, or catheter loss. In one randomized study without placebo control, periodic oral rifampin reduced the rate of staphylococcal exit-site infection from 0.65 to 0.22 epi/pt-yr (p = 0.011), but had no effect on the rate of staphylococcal peritonitis. In another nonblinded, randomized, controlled study, the use of either rifampin or mupirocin was associated with low rates of staphylococcal catheter infections and catheter loss. In one study with historical controls, the rate of staphylococcal exit-site infection and peritonitis was lower after oral rifampin prophylaxis. In seven other studies comparing nasal or exit-site mupirocin to historical controls, the rate of staphylococcal exit-site infection decreased from 0.17 to 0.05 epi/pt-yr, the rate of staphylococcal peritonitis decreased from 0.18 to 0.06 epi/pt-yr, and the rate of catheter loss decreased from 0.09 to 0.05 epi/pt-yr during the mupirocin period. CONCLUSION: The literature provides strong evidence that staphylococcal carriage prophylaxis using either oral rifampin or mupirocin ointment in the nares or exit site reduces significantly the rate of exit-site infection due to Staphylococcus aureus. Weaker evidence based on studies with historical controls suggests that rifampin or mupirocin prophylaxis also reduces the rate of staphylococcal peritonitis and peritoneal catheter loss. Studies with a stronger level of evidence are needed to verify this last point.     

Diverticular disease and treatment with gastric acid inhibitors do not predispose to peritonitis of enteric origin in peritoneal dialysis patients.

OBJECTIVE: Enteric peritonitis (EP) is an infrequent complication of peritoneal dialysis (PD), with severe consequences for peritoneal membrane viability and patient outcome. Factors such as diverticular disease and gastric acid inhibitors have been implicated in its appearance. We investigated several risk factors, including those mentioned below, that can influence the development of EP. DESIGN: Retrospective cross-sectional study. SETTING: Tertiary-care public university hospital. PATIENTS: Fifty-seven PD patients treated in our PD unit during August 1998. MAIN OUTCOME MEASURES: A barium enema was performed on 50 of the 57 patients (the remaining 7 patients refused it) in order to exclude the presence of diverticulosis. All episodes of peritonitis occurring in those patients, including EP, were registered. Enteric peritonitis was defined as that caused by gram-positive, gram-negative, or fungus micro-organisms that colonized the intestinal tract, excluding episodes secondary to genitourinary tract or peritoneal catheter exit-site infections. RESULTS: Twenty-four patients showed diverticular disease in the barium enema, but only 5 of them (21%) had any EP episode. Five of the 26 patients with no diverticula (19%) had EP. Fifty-five episodes of peritonitis were reported in 21 patients; 15 episodes of EP (27.3% of all) developed in 11 patients. Seven of the 11 patients (64%) required peritoneal catheter removal and 3 of them (27%) finally were transferred to hemodialysis due to consequences of the EP episode. Logistic regression analysis did not find any of the independent variables analyzed (age, sex, time on PD, type of PD, peritoneal transport parameters, presence of polycystic kidney disease, constipation or diverticulosis, or treatment with gastric acid inhibitors, or phosphate-binding agents) to be risk factors for developing EP. CONCLUSIONS: Neither diverticulosis nor treatment with gastric acid inhibitors seem to be risk factors for developing peritonitis of enteric origin in PD patients. This type of peritonitis has to be promptly identified and treated in order to diminish the high frequency of peritoneal catheter removal and PD dropout due to such episodes.     

Comparison of exit-site infections in disconnect versus nondisconnect systems for peritoneal dialysis.

OBJECTIVE: To determine if disconnect systems reduce the incidence of exit-site infections when compared to nondisconnect systems. DESIGN: We prospectively monitored exit-site infections and peritonitis rates in 96 disconnect patients (Y-set, automated peritoneal dialysis (APD)) and 60 nondisconnect patients (spike, ultraviolet connection device (UVXD)). SETTING: A freestanding chronic peritoneal dialysis unit staffed by physicians from both a medical school and a private setting. PATIENTS: All patients who began peritoneal dialysis at our unit were monitored, regardless of cause of end-stage renal disease (ESRD) or age. INTERVENTION: Patients were dialyzed using the system (Y-set, spike, etc.) most appropriate for their life-style and their ability to administer self-care. MAIN OUTCOME: We attempted to follow disconnect and nondisconnect patients for a similar median time on dialysis and compared differences in exit-site infections. RESULTS: Peritonitis rates (episodes/pt year) were reduced for disconnect (0.60) versus nondisconnect (0.99) systems (p = 0.0006). Despite the marked reduction in peritonitis rates, there was no difference in exit-site infection rates (0.35 vs 0.38), the time to the first exit-site infection, or the time to the first catheter removal for disconnect versus nondisconnect groups. When individual systems were compared, differences in exit-site infection rates (episodes/pt years) were noted (0.62,spike; 0.26,UVXD; 0.32,Y-set; 0.41,APD). CONCLUSION: We found no overall difference in exit-site infection rates for disconnect versus nondisconnect systems, despite a reduction in peritonitis rates for disconnect systems.     

Experience using presternal catheter for peritoneal dialysis in Poland: a multicenter pediatric survey.

OBJECTIVES: Permanent and adequate access to the peritoneal cavity is the key to successful chronic peritoneal dialysis (PD). A variety of catheter designs and implantation techniques have been developed to achieve optimal peritoneal access. One such new and modified PD catheter is the presternal catheter [swan neck presternal catheter (SNPC)], with the exit site located on the chest wall. DESIGN: A multicenter survey was undertaken to summarize 10 years of experience with the presternal catheter in children in Poland. SETTING: Four pediatric institutions using the SNPC in children: (1) Medical University of Warsaw, Warsaw; (2) Children's Memorial Health Institute, Warsaw; (3) District Children's Hospital, Szczecin; (4) University of Medical Sciences, Poznan. PATIENTS: During the past 10 years, 20 presternal catheters were implanted in 19 children, aged 0.2-17.7 years (mean 8 +/- 5.8 years), with end-stage renal failure.The main indications for the SNPC include urinary diversion (ureterocutaneostomy or vesicostomy), use of diapers, young age, obesity, abdominal wall weakness, and recurrent exit-site infections (ESI) with previous abdominal PD catheters. INTERVENTION: In all children the presternal catheter was implanted surgically under general anesthesia by one surgeon. Uniform operative technique and uniform perioperative management were used. RESULTS:The mean observation time for the 20 presternal catheters was 24.8 +/- 25 months (range 1-83 months). The ESI rate was 1/70.9 patient-months (0.17 episodes per year), tunnel infection rate was 1/248 patient-months (0.05 episodes per year), and the overall peritonitis rate was 1/26.6 patient-months (0.51 episodes per year). Non-infectious complications associated with the SNPC included disconnection of both sections (2 children) and trauma to the exit site located on the chest wall (4 children). Mean survival time of the presternal catheter, as calculated by the Kaplan-Meier method, was 57.5 +/- 8.5 months; 50% catheter survival reached 72 months. CONCLUSIONS: The good outcome in patients with a SNPC validates the rationale for the presternal catheter design and should encourage its more widespread use. The SNPC seems to be suitable for any patient on PD; however, this catheter is particularly useful in patients with specific indications (ie., higher tendency to ESI). The SNPC allows safe and long-term chronic PD in very young children using diapers and in patients with urinary diversion.     

Toxic shock syndrome in two CAPD patients with Staphylococcus aureus exit-site infection.

Toxic shock syndrome (TSS) is an illness defined by the occurrence of fever, rash, hypotension, multiple organ system dysfunction, and desquamation. Nonmenstrual TSS is often associated with surgical or nonsurgical cutaneous infections, which are rarely purulent or inflamed (Reingold AL, et al. Nonmenstrual toxic shock syndrome: a review of 130 cases. Ann Intern Med 1982; 96:871-4). Toxic shock syndrome associated with peritoneal exit-site infection but without peritonitis is extremely unusual (Sherbotie JR, et al. Toxic shock syndrome with Staphylococcus aureus exit-site infection in a patient on peritoneal dialysis. Am J Kidney Dis 1990; 15:80-3). We describe 2 patients that met the Centers for Disease Control case definition of TSS secondary to a peritoneal dialysis catheter exit-site infection with signs of mild inflammation and growth of Staphylococcus aureus, but with no evidence of peritonitis.     

强化健康教育在腹膜透析相关性腹膜炎预防中的作用

目的探讨强化教育预防腹膜透析相关性腹膜炎的效果。方法纳入2006年1月至2009年12月在我院腹膜透析中心参加随访、CAPD〉3个月的991例患者。定期分析腹膜透析相关性腹膜炎危险因素的变化。运用成人教育理论,采用培训与复训、门诊随访、电话随访以及派发健康教育宣传资料等形式对患者进行预防腹膜透析相关性腹膜炎的强化教育。结果患者平均年龄（49．2±16．1）岁,男560例（56．5％）,女431例（43．5％）,腹膜透析持续时间3．0～170．9个月（中位数20．1个月）,第一位原发病为肾小球。肾炎占59．2％。经过持续强化教育后,本中心腹膜透析相关性腹膜炎发病率由57．2个病人月,逐渐延长至61．3个病人月腹膜炎发病率下降。相比2006年,2009年因换液操作环节引起的腹膜炎所占比例下降（χ2=8．229,P=0．004）,因出口处感染诱发的腹膜炎持续维持较低水平（〈5％）,而因胃肠道问题引起的腹膜炎所占比例增加（χ2=9．720,P=0．002）。结论强化教育可以减少腹膜透析相关性腹膜炎的发生,尤其是因换液操作环节引起的腹膜炎发病率。因胃肠道问题引起腹膜炎的预防教育仍值得进一步关注。