Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis

BackgroundPeritoneal dialysis has become commonly used for renal replacement therapy; however, some patients withdraw from peritoneal dialysis due to complications, including peritoneal dialysis-related peritonitis, resulting in the low number of patients on peritoneal dialysis. Risk factors for peritoneal dialysis withdrawal due to peritoneal dialysis-related peritonitis are less certain. This retrospective study aimed to investigate these risk factors.MethodsWe retrospectively analyzed clinical characteristics, laboratory data, and causative microorganisms of 204 episodes of peritoneal dialysis-related peritonitis between 2007 and 2018 at our institution.ResultsOf the 204 episodes, 38 resulted in withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis. The number of peritonitis episodes per patient-year and the incidence of cardiovascular disease were significantly higher in the withdrawal group. Similarly, this group had low levels of serum creatinine, urea nitrogen, serum albumin, alanine aminotransferase, cholinesterase and high C-reactive protein, and second dialysate cell counts after antibiotic administration. Multivariate logistic regression analysis revealed that serum albumin (odds ratio: 0.465; 95% confidence interval: 0.249–0.868; P = 0.016) and cardiovascular disease (odds ratio: 2.508; 95% confidence interval: 1.184–5.315; P = 0.016) exhibited significant differences.ConclusionsThe results of this study suggest that hypoalbuminemia and the presence of cardiovascular disease were independent risk factors for withdrawal from peritoneal dialysis due to peritoneal dialysis-related peritonitis.     

Candida parapsilosis peritonitis has more complications than other Candida peritonitis in peritoneal dialysis patients

Candida parapsilosis is the most prevalent pathogen of fungal peritonitis in peritoneal dialysis (PD). The difference between C. parapsilosis peritonitis and other C. species for clinical outcomes and treatment responses to fungal peritonitis remains unclear. This retrospective study of fungal peritonitis attempts to answer that question. A total 22 patients with fungal peritonitis in 762 PD patients were enrolled in this study. The mean age of the 22 patients, 9 males and 13 females, was 54.7 +/- 12.5 years with a mean PD duration of 39.7 +/- 33.4 months. Candida species accounted for 86% (19 cases) of fungal peritonitis and 41% (9 cases) were C. parapsilosis. Thirteen (59%) patients received fluconazole as monotherapy; others received either amphotericin B alone or in combination with fluconazole. Catheters were removed for all patients. The mean duration from peritonitis onset to catheter removal was 5.8 +/- 4.1 days. Eleven (50%) patients developed severe complications, with abscess formation or persistent peritonitis after catheter removal. C. parapsilosis peritonitis had a higher complication rate than other Candida species (78% versus 20%, p = 0.012). In patients who received fluconazole as monotherapy, the rate of severe complications of C. parapsilosis peritonitis was statistically higher than those of other Candida species (100% versus 29%, p = 0.013). Because of different severity and prognosis, C. parapsilosis peritonitis in PD patients should be treated more aggressively than other Candida species.     

Ketoconazole prevents Candida sepsis in critically ill surgical patients

We conducted a prospective, randomized, double-blind, placebo-controlled study to determine whether or not ketoconazole could prevent yeast colonization or invasion in critically ill adult surgical patients. Fifty-seven patients in a surgical intensive care unit (SICU) with three or more clinical risk factors for Candida infection were randomized to receive ketoconazole, 200 mg via the gastrointestinal tract daily (27 patients), or placebo (30 patients). Patients with hepatic dysfunction were excluded. The study was continued for 21 days or until one week after discharge from the SICU, whichever was longer. Stool cultures were obtained every three days and other cultures as indicated clinically. Patients were observed for yeast colonization (sputum, urine, stool, or wound) and invasion (fungemia or deep tissue focus). The incidence of Candida colonization was significantly lower in the ketoconazole group than the placebo group. Invasive yeast sepsis developed in five (17%) of the placebo-treated patients and in no patient in the ketoconazole group, a significant difference. Length of stay in the SICU was significantly lower in the ketoconazole group, as were the basic SICU patient charges. Sixty percent of the patients with invasive fungal sepsis died.     

Proteomic analysis of peritoneal dialysate fluid in patients with dialysis-related peritonitis

The prognosis of uremia patients on continuous ambulatory peritoneal dialysis (CAPD) is related to frequent peritonitis rate. Frequent peritonitis will lead to peritoneum failure, making CAPD unfeasible. We have performed proteomic profiling of peritoneal dialysis effluent samples from a cross-section of CAPD patients with and without peritonitis in order to identify biomarkers of peritonitis. We performed 2D gel electrophoresis and surface-enhanced laser esorption/ionization time of flight mass spectrometry (SELDI-TOF MS) on peritoneal dialysis effluent from 16 subjects with peritonitis. A genetic algorithm search of principal component space revealed a group of a peak distinguishing peritonitis-positive subjects, with mass/charge (m/z) values of 11,117.4. Our analyses identified the peak at m/z 11,117.4 with an accuracy of 95% for classifying peritonitis. Mass spectrometric analysis of peritonitis PDE samples identified the 11,117.4 protein as beta2-microglobulin (B2M). Using an unbiased protein profiling approach, we have validated previously reported findings of B2M as a biomarker associated with CAPD peritonitis. Prospective studies are warranted to establish additional biomarkers that would be predictive of peritoneal dialysis peritonitis. Besides, extending the study to a larger number of patients with subgroup analyses may yield additional information of the peritoneal dialysate proteins in association with dialysis adequacy, residual renal function, nutritional status, and risk of peritoneal infection.     

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.     

Pulmonary artery catheterization and mortality in critically ill patients

Pulmonary artery catheters are widely used in intensive care,but evidence to support their widespread use is sparse. Somepublished data suggest that greater mortality is associatedwith use of these catheters. The largest study to date lookedat >5500 patients in several centres in America and founda greater 30 day mortality in those patients receiving a pulmonaryartery catheter. We tested the hypothesis that, on our intensivecare unit, mortality was greater for those patients receivinga pulmonary artery catheter. Using a propensity score to accountfor severity of illness, the odds ratio for mortality in thosepatients receiving a pulmonary artery catheter was 1.08 (95%confidence interval 0.87–1.33). We believe that continueduse of the pulmonary artery catheter is safe; a large randomizedcontrolled trial examining outcome is unlikely to provide anadequate answer. Br J Anaesth 2000; 85: 611–5 ^* Corresponding author     

Predictive factors of outcome following staphylococcal peritonitis in continuous ambulatory peritoneal dialysis

BACKGROUND AND AIMS: Staphylococcus epidermidis and other coagulase-negative staphylococci (CoNS) are the most common agents of continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Episodes caused by Staphylococcus aureus evolve with a high method failure rate while CoNS peritonitis is generally benign. The purpose of this study was to compare episodes of peritonitis caused by CoNS species and S. aureus to evaluate the microbiological and host factors that affect outcome. MATERIAL AND METHODS: Microbiological and clinical data were retrospectively studied from 86 new episodes of peritonitis caused by staphylococci species between January 1996 and December 2000 in a university dialysis center. The influence of microbiological and host factors (age, sex, diabetes, use of vancomycin, exchange system and treatment time on CAPD) was analyzed by logistic regression model. The clinical outcome was classified into two results (resolution and non-resolution). RESULTS: The odds of peritonitis resolution were not influenced by host factors. Oxacillin susceptibility was present in 30 of 35 S. aureus lineages and 22 of 51 CoNS (p = 0.001). There were 32 of 52 (61.5%) episodes caused by oxacillin-susceptible and 20 of 34 (58.8%) by oxacillin-resistant lineages resolved (p = 0.9713). Of the 35 cases caused by S. aureus, 17 (48.6%) resolved and among 51 CoNS episodes 40 (78.4%) resolved. Resolution odds were 7.1 times higher for S. epidermidis than S. aureus (p = 0.0278), while other CoNS had 7.6 times higher odds resolution than S. epidermidis cases (p = 0.052). Episodes caused by S. haemolyticus had similar resolution odds to S. epidermidis (p = 0.859). CONCLUSIONS: S. aureus etiology is an independent factor associated with peritonitis non-resolution in CAPD, while S. epidermidis and S. haemolyticus have a lower resolution rate than other CoNS. Possibly the aggressive nature of these agents, particularly S. aureus, can be explained by their recognized pathogenic factors, more than antibiotic resistance.     

Management of peritonitis in the critically ill patient

Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.     

Hypoxic hepatitis in critically ill patients: incidence, etiology and risk factors for mortality

Purpose  

Hypoxic hepatitis may be induced by hemodynamic instability or arterial hypoxemia in critically ill patients. We investigated the incidence, etiology, association with systemic ischemic injury and risk factors for mortality in this population.     

Candida colonization and subsequent infections in critically ill surgical patients.

OBJECTIVE. The authors determined the role of Candida colonization in the development of subsequent infection in critically ill patients. DESIGN. A 6-month prospective cohort study was given to patients admitted to the surgical and neonatal intensive care units in a 1600-bed university medical center. METHODS. Patients having predetermined criteria for significant Candida colonization revealed by routine microbiologic surveillance cultures at different body sites were eligible for the study. Risk factors for Candida infection were recorded. A Candida colonization index was determined daily as the ratio of the number of distinct body sites (dbs) colonized with identical strains over the total number of dbs tested; a mean of 5.3 dbs per patient was obtained. All isolates (n = 322) sequentially recovered were characterized by genotyping using contour-clamped homogeneous electrical field gel electrophoresis that allowed strain delineation among Candida species. RESULTS. Twenty-nine patients met the criteria for inclusion; all were at high risk for Candida infection; 11 patients (38%) developed severe infections (8 candidemia); the remaining 18 patients were heavily colonized, but never required intravenous antifungal therapy. Among the potential risk factors for candida infection, three discriminated the colonized from the infected patients--i.e., length of previous antibiotic therapy (p < 0.02), severity of illness assessed by APACHE II score (p < 0.01), and the intensity of Candida spp colonization (p < 0.01). By logistic regression analysis, the latter two who were the independent factors that predicted subsequent candidal infection. Candida colonization always preceded infection with genotypically identical Candida spp strain. The proposed colonization indexes reached threshold values a mean of 6 days before Candida infection and demonstrated high positive predictive values (66 to 100%). CONCLUSIONS. The intensity of Candida colonization assessed by systematic screening helps predicting subsequent infections with identical strains in critically ill patients. Accurately identifying high-risk patients with Candida colonization offers opportunity for intervention strategies.     

The relationship of abdominal perfusion pressure with mortality in critically ill pediatric patients

PurposeTo the best of our knowledge, in the literature, there is no data regarding clinical utility of the abdominal perfusion pressure (APP) in critically ill children. Thus, in the present study, we aimed to investigate the clinical utility of APP in predicting of survival in critically ill children with IAH.DesignA prospective cohort study of patients between 1 month to 18 years who had risk for intra-abdominal hypertension from June 2013 to January 2014.SettingPediatric intensive care unit (PICU) at a tertiary university hospital.PatientsThirty-five (16 female) PICU patients who had risk for the development of IAH were included. Serial intraabdominal pressure (IAP) and mean arterial pressure (MAP) measurements were performed. Abdominal perfusion pressure was calculated using the formula (MAP-IAP).Measurements and Main ResultsOverall mortality rate was 49% (n = 17). The mortality rate in patients with IAP mean ≥ 10 mmHg (n = 27, 77%) was 55% (n = 15), while 53% (n = 16) in patients with IAP max ≥ 10 mmHg (n = 30, 86%) and 47% (n = 7) in patients with IAP min ≥ 10 mmHg (n = 15, 43%). Overall mean APP was 58 ± 20 mmHg. Logistic regression analysis revealed that decrease in minAPP was associated with increased risk for mortality (Odds ratio for each 1 mmHg decrease in APP was 1.052 [CI 95%, 1.006–1.100], p < 0.05). ROC curve analysis revealed that, in predicting mortality, area under curve for minAPP was 0.765. The optimal cut-off point for APP was obtained as 53 mmHg with the 77.8% sensitivity and 70.6% specificity using the IU method.ConclusionsOur findings showed that APP seems to be a useful tool in predicting mortality. Interventions to improve APP may be associated with better outcomes in critically ill PICU patients.Level of evidenceLevel II.Type of studyDiagnostic.     

危重患者谵妄发生的危险因素分析

目的探讨危重患者ICU谵妄发生的危险因素。方法选择2015年1~6月我院ICU收治的年满18周岁,ICU停留时间大于24h的174例患者,采用CAM-ICU每天两次对患者进行评估,并将患者分为谵妄组与非谵妄组。采用单因素和多因素logistic回归对酗酒史等12个因素与谵妄发生之间的关系进行分析。结果 174例患者中谵妄发生率为22例(12.64%)(谵妄组),非谵妄组为152例(87.36%)。Logistic回归分析结果显示:冠心病史(OR 3.932,95%CI 1.225~12.617)、手术(OR 9.691,95%CI 2.103~44.657)、低氧血症(OR 6.595,95%CI 1.377~31.585)、苯二氮?类药(OR 7.620,95%CI 1.713~33.899)是危重患者发生ICU谵妄的危险因素(P0.05或P0.01)。结论冠心病史、手术、低氧血症、苯二氮?类药是危重患者发生ICU谵妄的独立危险因素,应及早行谵妄筛查,积极预防ICU谵妄的发生。     

Acquired hypernatraemia is an independent predictor of mortality in critically ill patients

This study reports the incidence and associated mortality of acquired hypernatraemia (Na > 150 mmol.l⁻¹) in a general medical/surgical intensive care unit. Patients admitted over a 5-year period with normal sodium values were eligible for inclusion; exclusions were made for burn/neurosurgical diagnoses and for hypertonic saline therapy. From 3475 admissions (3317 patients), 266 (7.7%) episodes of hypernatraemia were observed. Hospital mortality was 33.5% in the hypernatraemic group and 7.7% in the normonatraemic group (p < 0.001). Acquired hypernatraemia was an independent risk factor for in-hospital mortality (OR 1.97, 95% CI 1.37–2.82, p < 0.001). Intermediate sodium levels (145–150 mmol.l⁻¹) were associated with increased mortality (OR 1.42, 95% CI 1.02–1.98). Uncorrected sodium at discharge (p = 0.001) and peak sodium (p = 0.001) were better predictors of mortality than time to onset (p = 0.71) and duration of hypernatraemia (p = 1.0). Hypernatraemia avoidance is justified, but determinants of hypernatraemia and benefits of targeted treatment strategies require further elucidation.     

A brief episode of hypotension increases mortality in critically ill trauma patients

OBJECTIVE: Hypotension is associated with increased mortality, however previous studies have failed to account for the depth and duration of hypotension. We evaluated the effect of the duration of hypotension on outcome in injured patients. METHODS: Trauma patients admitted to the intensive care unit (ICU) from 1999 to 2000 were prospectively evaluated. Patients transferred to a ward 相似文献   

Oliguria is an early predictor of higher mortality in critically ill patients

Oliguria is a valuable marker of kidney function and a criterion for diagnosing and staging acute kidney injury (AKI). However, the utility of urine output as a specific metric for renal dysfunction is somewhat controversial. To study this issue further we tested whether urine output is a sensitive, specific, and early measure for diagnosing and staging AKI in 317 critically ill patients in a prospective observational study. Urine output was assessed every hour and serum creatinine every 12 to 24 h. The sensitivity and specificity of different definitions of oliguria for the diagnosis of AKI were compared with the Acute Kidney Injury Network serum creatinine criterion. The incidence of AKI increased from 24%, based solely on serum creatinine, to 52% by adding the urine output as a diagnostic criterion. Oliguric patients without a change in serum creatinine had an intensive care unit mortality rate (8.8%) significantly higher than patients without AKI (1.3%), and similar to oliguric patients with an increase in serum creatinine (10.4%). The diagnosis of AKI occurred earlier in oliguric than in non-oliguric patients. Oliguria of more than 12 h and oliguria of 3 or more episodes were associated with an increased mortality rate. Thus, urine output is a sensitive and early marker for AKI and is associated with adverse outcomes in intensive care unit patients.