Longitudinal study of peritoneal defence mechanisms in patients on continuous ambulatory peritoneal dialysis (CAPD)

Peritoneal cellular and humoral defence mechanisms have been examined in a group of 16 patients over a nine-month period from the day of commencement of continuous ambulatory peritoneal dialysis (CAPD). Significant decreases in the levels of IgG, C3, and opsonic activity occurred with the passage of time in the over-night peritoneal dialysis effluent (PDE). The ability of PDE to inhibit in vitro growth of Staphylococcus epidermidis also decreased. The number of cells in the PDE and their ability to kill S. epidermidis decreased, although there was no significant change in their ability to ingest this organism. These results suggest that the immunological protection of the peritoneal cavity decreases with time, and this may account for the increase in the incidence of peritonitis with length of time on CAPD that some workers have reported.     

Trimethoprim-sulfamethoxazole pharmacokinetics during continuous ambulatory peritoneal dialysis (CAPD)

Ten adult patients on continuous ambulatory peritoneal dialysis (CAPD) received one dose of trimethoprim-320 mg (TMP) and sulfamethoxazole 1600 mg (SMX) orally (p.o.), intravenously (i.v.), and intraperitoneally (i.p.) on three separate occasions to characterize the pharmacokinetics of both drugs. Concentrations of both TMP and SMX were measured in serum and dialysate by HPLC to 48 h. Half-life, total body clearance (TBC), and peritoneal clearance (PCl) were determined. The mean half-life of TMP was 28 h, while for SMX it was 12.5 h. Relative to the i.v. dose, the bioavailability following oral administration for TMP was 98% and 87% for SMX. Intraperitoneal bioavailability was 73% for TMP and 65% for SMX after a 4-h dwell. After 24 h, regardless of the route of administration, less than 3% of TMP and less than 6% of SMX appeared in dialysate. We conclude that peritoneal losses contribute insignificantly to TMP/SMX elimination during CAPD.     

Beta-2 microglobulin removal during continuous ambulatory peritoneal dialysis (CAPD)

Beta-2 microglobulin (B2M) handling in continuous ambulatory peritoneal dialysis (CAPD) was characterized in acute and chronic clinical studies. Average clearance rate was 0.7 mL/min and mean mass transfer coefficient, KoA, was calculated to be 0.95 cm2/min; these values are in the range expected from extrapolation of published data for other large solutes. In chronic studies with both anuric and oliguric populations, CAPD was shown to be much more effective than conventional hemodialysis in removing B2M and, in fact, CAPD removal rates were equivalent to those reported for high flux dialysis therapies. However, this greater extraction was not associated with any clinically significant reduction in circulating plasma concentrations. These trends remained valid in both the anuric and oliguric subsets of the study population.     

Loss of ultrafiltration in continuous ambulatory peritoneal dialysis (CAPD)

Fifteen patients on long-term continuous ambulatory peritoneal dialysis (CAPD) were assessed with respect to net ultrafiltration capacity. Eight patients were defined as having good and seven as having poor ultrafiltration on the basis of net ultrafiltrate obtained/mmol glucose infused. Subsequently, dialysate was sampled at times 0, 1, 15, 30, 60, 90, 120, 180, and 240 min. No difference in residual volume was observed between the groups. A significantly greater decrease in dialysate sodium during the initial dialysis period in those patients with good as compared to those with poor ultrafiltration occurred, reflecting a greater transcapillary movement of electrolyte poor ultrafiltrate. In those with good ultrafiltration, glucose transfer was normal in five and rapid in three, suggesting the latter had low rates of lymphatic reabsorption. Five of seven patients with poor ultrafiltration had no fall in dialysate sodium in association with a high rate of glucose transfer, suggesting a low rate of transcapillary water movement and normal to high lymphatic absorption. Two patients with low ultrafiltration had an initial fall in dialysate sodium with a normal glucose transfer and thus net ultrafiltration is low due to elevated lymphatic reabsorption. We thus propose that the relative contribution of transcapillary water movement and lymphatic reabsorption can be determined by assessing net ultrafiltration and dialysate sodium concentration in conjunction with solute transfer.     

Peritonitis-related deaths in continuous ambulatory peritoneal dialysis (CAPD) patients

A total of 636 episodes of peritonitis occurred in 440 patients who entered our continuous ambulatory peritoneal dialysis (CAPD) program from September 1977 to February 1988. Sixteen patients (8 male and 8 female, aged 37-77 years) died during an episode of peritonitis (fatality rate 2.5%). They had been on CAPD for 3 to 105 (average 39) months. Six of them were diabetics. The peritonitis rate among these 16 patients were 1 episode per 12 patient months, while the corresponding figure for the whole (440) CAPD population was 14 patient months. Risk factors present in the 16 patients were: cardiovascular disease (12), cerebrovascular accident (2) peripheral artery disease (1) and pulmonary fibrosis (1). Fever and leukocytosis were present on admission in 11 patients, while total serum proteins and albumin were significantly lower (p less than 0.001) than the corresponding values before peritonitis (56 +/- 8 vs. 65 +/- 5). Staph. aureus was isolated in 8 patients (50%), multiple organisms in 6, Pseudomonas and Candida albicans in 1 each. An abdominal abscess was found in 4 (25%) patients. The peritoneal catheter was removed between the 5th and 10th day in 6 and after the 10th day in 7 patients. Peritonitis with sepsis was the cause of death in 13 patients. Contributing factors were cardiovascular accident in 9, uremic coma in 2, extensive GI bleeding in 2, GI perforation in 2, intestinal infarction in 1, and pneumonia in 2 patients. We conclude that the risk of peritonitis-related death in CAPD patients is increased with Staph. aureus or multibacterial peritonitis. Contributing factors are concomitant cardiovascular disease and delayed (greater than 5 days) catheter removal.     

The management of hydrothorax in continuous ambulatory peritoneal dialysis (CAPD)

Four patients on continuous ambulatory peritoneal dialysis (CAPD) developed large, symptomatic pleural effusions after commencing peritoneal dialysis. Pleuroperitoneal fistula in each case was diagnosed by the presence of a high glucose content in pleural fluid, with a normal corresponding blood sugar, and was confirmed by isotope or contrast peritoneography. Two patients had their effusions drained percutaneously, and then underwent pleural sclerosis with intracavitary tetracycline. Two patients had a thoracotomy performed, of which no fistula was identified in one case, and the other patient underwent pleurectomy. All four patients successfully recommenced CAPD several weeks after therapy, without recurrence of effusions. We conclude that pleuroperitoneal connections associated with CAPD do not mandate cessation of peritoneal dialysis and conversion to maintenance haemodialysis. Definitive diagnosis requires aspiration of pleural effusions for glucose estimation. Contrast or isotopic peritoneography is helpful in localising the fistula, but in our experience did not alter management. Simple sclerotherapy is effective and avoids the need for a formal thoracotomy.     

Peritoneal surface-active material in continuous ambulatory peritoneal dialysis (CAPD) patients

Phospholipids have been demonstrated to be present in the peritoneal dialysis effluent of 34 patients on continuous ambulatory peritoneal dialysis (CAPD). The phospholipids present have been characterized by chromatography and their relative concentrations are fairly consistent from patient to patient. The predominant phospholipid is phosphatidylcholine (81%). Surface activity of this phospholipid has been demonstrated. The concentration of total phospholipid correlates with the time the patient had been on CAPD. It is lower in those patients who have been on dialysis longer.     

Prospected randomized study of two Y devices in continuous ambulatory peritoneal dialysis (CAPD)

To evaluate acceptability, safety, and efficacy of a Y set with two short branches (TAS) filled with electrolytic chloroxidizer solution during the dwell time, 60 patients were randomly allocated to be treated with the traditional Y set (TCS) or with the TAS. Twenty-three were new patients whereas the remaining 37 were patients already on continuous ambulatory peritoneal dialysis (CAPD) with the TCS. The follow-up was 416.5 months in the control group and 387.4 months in the test group. During the study period there were 6 peritonitis episodes in each group with an incidence of 1 episode every 69.4 patient-months in the control group and 1 episode every 64.6 patient-months in the test group. Twenty-four patients (80%) in the control group and 27 (90%) in the test group were free from peritonitis. The probability to remain free from peritonitis was respectively 87% and 83% in the test group and in control group after 12 months, 70% and 78% after 21 months. Seventy-nine percent of the patients who used both systems preferred the TAS for better handling, lower encumbrance, and major safety. One patient preferred the TCS, three patients did not find any differences between the two devices.     

An outpatient maneuver to treat bloody effluent during continuous ambulatory peritoneal dialysis (CAPD)

Asymptomatic episodes of grossly bloody effluent during continuous ambulatory peritoneal dialysis (CAPD) can be treated by following a simple therapeutic maneuver. The patient performs one to three rapid exchanges using unwarmed (room temperature), 1.5% dextrose-containing dialysate. No dwell time is employed. This treatment proves successful in a variety of clinical settings, and no adverse effects have been noted. Infusion of unwarmed dialysate likely induces peritoneal vasoconstriction and thus favors hemostasis. Bleeding of nonperitoneal etiology, such as renal cyst hemorrhage or retrograde menstruation, proves resistant.     

Ampicillin and sulbactam pharmacokinetics and pharmacodynamics in continuous ambulatory peritoneal dialysis (CAPD)

The fixed combination antibiotic ampicillin/sulbactam may provide a new, safe, and effective method of treating dialysis-related bacterial peritonitis. The pharmacokinetics of this antibiotic combination were determined in patients receiving continuous ambulatory peritoneal dialysis (CAPD). The pharmacodynamic activity of this drug was also determined by use of mean bactericidal titers against selected bacterial strains. Six noninfected CAPD patients in a randomized two-way crossover study were given a fixed dose of ampicillin (2 gm) and sulbactam (1 gm) either intravenously or intraperitoneally. The mean peak ampicillin and sulbactam serum concentrations following intravenous dosing were 170.3 and 87.5 micrograms/mL, respectively. The mean peak serum concentrations of ampicillin and sulbactam following intraperitoneal dosing were 48.0 and 27.8 micrograms/mL, respectively. Absolute bioavailabilities of the intraperitoneal ampicillin and sulbactam doses were 60% and 68%. Both drugs exhibited similar distribution and elimination characteristics. Renal failure markedly reduced drug elimination. Intraperitoneal administration of ampicillin/sulbactam provided satisfactory inhibitory and bactericidal antibiotic titers for most organisms in dialysate at 6 h but not 24 h. Ampicillin/sulbactam (2 gm/1 gm) should be administered every 12 h to patients with peritoneal dialysis-related peritonitis.     

Lymphoma-mimicking peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD)

Cloudy dialysate in a patient on continuous ambulatory peritoneal dialysis (CAPD) most commonly reflects an increased number of leukocytes secondary to bacterial peritonitis. In the absence of infection, increased quantities of eosinophils, red blood cells, fibrin, or chyle may produce cloudy dialysate in these patients. We report the case of a CAPD patient presenting with cloudy dialysate and symptoms suggestive of bacterial peritonitis. Analysis of the dialysate revealed no microorganisms. The turbidity of the dialysate was related to an increased number of atypical lymphocytes consistent with a B cell lymphoma. Peritoneal dialysis continued uneventfully despite neoplastic disease within the peritoneum. It is recommended that malignant involvement of the peritoneum be added to the differential diagnosis of cloudy dialysate occurring in CAPD patients.     

Campylobacter jejuni peritonitis during chronic ambulatory peritoneal dialysis (CAPD)

A patient treated with chronic ambulatory peritoneal dialysis developed recurrent peritonitis. During a fourth episode, Campylobacter jejuni was cultured from the dialysate. She responded well to streptokinase and imipenem.     

Ciprofloxacin in plasma and peritoneal dialysate after oral therapy in patients on continuous ambulatory peritoneal dialysis

The quinolone antibiotic ciprofloxacin offers the possibility of effective oral treatment of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) if a sufficiently high concentration is attained in peritoneal dialysate. The pharmacokinetics of oral ciprofloxacin have been studied in ten CAPD patients given 250 mg qds for two days. Five patients were being treated for peritonitis with gentamicin and cefuroxime; the remaining five were receiving inpatient training for CAPD or were being treated for other problems. Ciprofloxacin concentration in plasma and in dialysate were determined by HPLC. There were not differences in plasma and dialysate kinetics in patients with and without peritonitis. Plasma levels were higher and the elimination half-life was longer than those reported for healthy subjects. Dialysate and plasma levels were significantly correlated (r2 = 0.87, P = 0.001), with dialysate levels consistently lower than plasma levels. Dialysate levels exceeded 1 mg/l in seven patients. The mean peak dialysate level (2.17 +/- 1.63 mg/l) exceeded the MIC of ciprofloxacin for 32 of 34 bacterial strains responsible for peritonitis. Ciprofloxacin shows promise as a useful oral treatment of CAPD-associated peritonitis.     

Splenic abscess and peritonitis in a continuous ambulatory peritoneal dialysis (CAPD) patient

A 26-year-old female was on continuous ambulatory peritoneal dialysis (CAPD) because of diabetic end-stage renal failure. She developed an acute peritonitis that relapsed repeatedly despite appropriate antibiotic treatment. Investigations showed the presence of a splenic abscess, and splenectomy and peritoneal cannula removal were required. The patient died of myocardial infarction two weeks postoperatively. This is the first recorded case of peritonitis secondary to splenic abscess in a CAPD patient. Autopsy findings suggest that the abscess developed from infection of a splenic infarct.     

Disconnect during continuous ambulatory peritoneal dialysis (CAPD): retrospective experience with three different systems

Disadvantages of continuous ambulatory peritoneal dialysis (CAPD), such as inconvenience and bulkiness of the apparatus, inflexibility of infusion volume, and predictable peritonitis incidence may be altered by using systems which allow disconnection from the tubing and bag after each exchange. At University of Michigan we have followed 35 patients using the O set with sodium hypochlorite (Baxter Healthcare Corp.) for 15.5 +/- 10 months, 16 patients using the Y configuration Ultraset (Baxter Healthcare Corp.) for 8.1 +/- 5 months, and 6 patients using a universal adapter (Delmed Corp.) for 14.3 +/- 7 months. Failure occurred in 7 cases (18%) at 12 +/- 8 months using the O set (3 elective, 3 related to peritonitis, 1 ultrafiltration difficulty), and 1 (7%) at 3 months using the Ultraset (related to peritonitis). Accidental sodium hypochlorite infusion occurred 8 times in 6 patients, 4 patients still on CAPD without residual effect and 2 in whom infusion contributed to failure but not to ultrafiltration difficulty. Cumulative per-patient-year (episode/months) peritonitis rates of 0.75 (1/16.4), 0.65 (1/18.4) and 0.88 (1/14.3), respectively, compare favorably with the overall center experience of 0.96 (1/12.2) (NIH-CAPD Registry). Peritonitis rates did not differ during use of any of the disconnect systems between patients with prior CAPD experience compared to patients without prior CAPD experience.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of nutritional status in patients on continuous ambulatory peritoneal dialysis (CAPD)

We designed this study to evaluate the nutritional conditions of 16 continuous ambulatory peritoneal dialysis (CAPD) patients. In all these patients we did a monthly 1-day clinical, anthropometrical, biochemical, and nitrogen balance evaluation: a minimum of 3 and a maximum of 9 monthly evaluations in all patients. The results were analyzed in two groups: Group I (N = 8) with neutral or positive nitrogen balances, and Group II (N = 8) with one or more negative nitrogen balances. The sex distribution, mean age in years, time on CAPD, and period of study in this protocol were similar in both groups. Group I maintained a positive nitrogen balance and steady values in the anthropometric measurements (triceps fat fold, upper-arm circumference, body weight). Group II showed a significant decrease in both the anthropometric values and the nitrogen balance during the episodes of peritonitis. In this same group, when peritonitis subsided, the protein intake increased, nitrogen balance became positive, and the anthropometric values improved. When all the nutritional evaluations were analyzed we found a significant and direct linear correlation between nitrogen intake and nitrogen balance in g/kg/day (N = 60; nitrogen balance = nitrogen intake x 0.75 - 0.101; r = 0.71; p less than 0.001). We also contrasted the presence of peritonitis with the nitrogen balance and the anthropometric values using Spearman rank correlation coefficient and obtained a very high correlation (0.997 to 0.999). Blood values (blood urea, serum creatinine, serum phosphate, serum potassium, and hemoglobin) were not very sensitive to detect differences within or between groups along the study.(ABSTRACT TRUNCATED AT 250 WORDS)