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PubMed2003

[Effect of peritonitis frequency on the effectiveness of peritoneal dialysis and effect of peritoneal dialysis effectiveness on the frequency of peritonitis].

UNLABELLED: Peritonitis is the most serious complication of peritoneal dialysis treatment for ESRD. There is no unanimous attitude yet concerning the influence of PD adequacy on the frequency of peritonitis. PATIENTS: The paper reports on a study of interrelation of peritonitis frequency and PD adequacy in 61 patients (27 women, 34 men) during a 5-year period. The group included 88% of all PD patients (61 of totally 69). RESULTS AND DISCUSSION: The patients experienced a total of 71 peritonitis episodes over a total of 1615 months of PD treatment. There was one peritonitis episode per 23 months of treatment on an average. When a patient who experienced 11 peritonitis episodes was excluded, the average frequency of peritonitis turned to one in 26 months. Peritonitis frequency and PD adequacy showed a significant negative correlation (r = 0.25, p < 0.05). PD adequacy expressed as total weekly Kt/V did not differ between the patients with and those without a history of peritonitis (Kt/V+ = 1.87 +/- 0.21, Kt/V- = 1.88 +/- 0.24; t = 0.17, p > 0.05). The frequency of peritonitis in men was twofold that in women, i.e. one peritonitis in every 17.24 +/- 11.67 months of treatment in men, and one peritonitis in every 37.81 +/- 13.11 months in women. The difference was statistically significant (t = 6.39, p < 0.01). However, PD adequacy did not differ between men and women (Kt/V = 1.84 +/- 0.21: 1.92 +/- 0.23, t = 1.40, p > 0.05). Patients with more adequate dialysis (n = 51) (Kt/V = 1.70) had one peritonitis in every 23.16 +/- 20.07 months on an average, and those with less adequate dialysis one peritonitis in 21.82 +/- 18.12 months of treatment. The difference was not statistically significant (t = 0.21, p > 0.05). The patients in whom PD was the first method of ESRD treatment (n = 55) experienced one peritonitis in every 24.04 +/- 12.51 months of treatment on an average, and those in whom PD was the second method of ESRD treatment (n = 6) had one peritonitis in 15.68 +/- 13.54 months of treatment. The difference was not significant (t = 1.45, p > 0.05). The difference in dialysis adequacy between these two groups was not significant either, even though the patients with PD as the first method had more adequate dialysis (1.88 +/- 0.22: 1.83 +/- 0.27; t = 0.44, p > 0.05). CONCLUSION: Peritonitis frequency and PD adequacy are significantly negatively correlated. The patients with higher peritonitis frequency had less adequate dialysis, while the patients with less adequate dialysis had peritonitis more frequently. However, the patients with a history of peritonitis had not significantly less adequate dialysis, nor the patients with less adequate dialysis had a significantly higher frequency of peritonitis.

Adult↗
PubMed1999

Effects of peritoneal rest on peritoneal transport and peritoneal membrane thickening in continuous ambulatory peritoneal dialysis rats.

OBJECTIVE: To evaluate the effects of peritoneal rest on peritoneal transport and morphology in a rat model of peritoneal dialysis. DESIGN: Twenty-four rats (Sprague-Dawley, male, 250-300 g) were divided into three groups: group 1 (control, n = 6) without dialysis, group 2 (n = 9) sacrificed immediately after 3 weeks of dialysis, and group 3 (n = 9) sacrificed after 4 weeks of peritoneal rest after 3 weeks of dialysis. Both dialysis groups were dialyzed twice daily with an intraperitoneal instillation volume of 25 mL of 3.86% dextrose solution for 3 weeks. Peritonitis was induced by supplementing the dialysis fluid with lipopolysaccharide (5 microg/mL) on days 8, 10, and 12 in both dialysis groups. Peritoneal equilibration tests were performed on each animal at baseline. The equilibration tests were repeated at the 4th and the 8th week of dialysis. Morphometric analyses of the peritoneal membrane were carried out in tissue specimens obtained at the time of sacrifice. RESULTS: The D/D0 ratio for glucose at two hours in groups 2 and 3 at the beginning of week 4 was significantly lower than at baseline, indicating an increase in peritoneal permeability to glucose after 3 weeks of dialysis. D/D0 in group 3 at the beginning of week 8, after 4 weeks of peritoneal rest, was significantly higher than at week 4. The drain volume in groups 2 and 3 at week 4 was significantly lower than at baseline; however, the drain volume in group 3 at week 8 was significantly higher than at week 4. The thickness of the parietal peritoneal membrane in group 3 was significantly greater than in group 1 and less than in group 2 (group 1, 11.4+/-7.6 microm; group 2, 37.5+/-18.4 microm; group 3, 21.4+/-12.1 microm). CONCLUSIONS: Peritoneal rest improves ultrafiltration in rats by decreasing the hyperpermeability of glucose and also reduces the degree of peritoneal thickening. These data suggest that dialysis-induced changes in peritoneal transport and morphology are reversible under the conditions of peritoneal rest in this experimental model.

Animals↗
PubMed1995

Serum CA-125 level in end-stage renal disease patients maintained on chronic peritoneal dialysis or hemodialysis: the effect of continuous presence of peritoneal fluid, peritonitis, and peritoneal catheter implantation.

Serum Ca-125, an ovarian tumor marker, is used to screen and follow up patients with overian cancer. Normal values (< 35 U/ml) have been reported in patients with end-stage renal disease and patients maintained on chronic hemodialysis (HD). Non-malignant ascites has been associated with high serum levels of CA-125, suggesting that the presence of fluid in the peritoneal cavity may stimulate its release. We studied 38 HD and 43 chronic ambulatory peritoneal dialysis (CAPD) patients with regard to serum CA-125 levels. In the HD patients, the mean +/- SE serum CA-125 level was 10.1 +/- 1.7 U/ml (range < 5-39) with 8% of the patients having serum levels of > 35 U/ml. In the CAPD patients, the mean serum CA-125 level in all samples collected (n = 68) was 17.7 +/- 2.7 U/ml (range < 5-101, p < 0.01 vs. HD) with 16% of the sera showing levels of > 35 U/ml. The high serum CA-125 levels in the CAPD patients were from sera obtained within 2 months of diagnosis of peritonitis, peritoneal dialysis (PD) catheter implantation, or intra-abdominal surgery. When serum samples from this 2-month period were excluded, the mean serum CA-125 level was 8.9 +/- 1.5 U/ml (p = NS vs. HD) and only 1 patient had an abnormal level. Peritoneal dialysate CA-125 levels during an episode of peritonitis were significantly higher than at the baseline (69.1 +/- 14.2 vs. 21 +/- 2.5, p = 0.004) and both were significantly higher than the serum levels (p < 0.0001). Serum CA-125 levels were also the same in both sexes and races. In conclusion, it was found that while the serum CA-125 level is within normal limits in the majority of HD and stable CAPD patients, it is not uncommon that it is elevated in CAPD patients within 2 months of peritonitis, PD catheter placement, or intra-abdominal surgery, particularly when peritoneal exchanges are temporarily on hold in the latter two. The serum CA-125 level should be interpreted with caution in the CAPD patients as it may be a non-specific marker of peritoneal irritation. It was also found that there was a significant removal of CA-125 by the peritoneal fluid which markedly increased during episodes of peritonitis.

Abdomen↗
PubMedDate not supplied

Peritoneal protein loss in patients with high peritoneal permeability: comparison between continuous ambulatory peritoneal dialysis and daytime intermittent peritoneal dialysis.

BACKGROUND: Dialysate protein loss is involved in the etiology of hypoalbuminemia and malnutrition on continuous ambulatory peritoneal dialysis (CAPD). Patients with high peritoneal membrane permeability had the lowest serum albumin (Alb) and highest dialysate protein concentrations and achieved higher small solute dialysis/plasma equilibration in a shorter time than patients with low peritoneal transport. The aim of this prospective crossover study was to evaluate whether protein loss might be decreased in patients with high peritoneal permeability on short dwell-time (DT) peritoneal dialysis. METHODS: Five high and nine high-average peritoneal transport patients were subjected to the following sequential dialysis schemes (four exchanges/day, glucose 1.5%): scheme A, three daytime exchanges (4-6 h DT) and one nightly (8-12 h DT) for 2-3 days, scheme B, 3-h DT each and dry peritoneum at night during 5 days, a wash-out period similar to scheme A, and scheme C, 2-h DT each and dry peritoneum the remainder of day and night during 5 days. Dialysate Alb, IgG, IgA, and IgM losses and adequacy of dialysis were evaluated at the end of each scheme. RESULTS: Dialysate IgM was not detected. All protein losses were reduced with the short DT dialysis schemes; however, dialysis CCl and KT/V(urea) were also decreased. In patients with high peritoneal transport type, the 3-h DT dialysis scheme achieved a reduction in Alb loss without significant reduction of adequacy of dialysis. CONCLUSIONS: Peritoneal Alb, IgG, and IgA losses are significantly reduced in patients with high peritoneal permeability on short dwell-time dialysis and extended dry periods. However, a reduction of dialysis contribution to small solute clearances was also observed, Three-hour dwell-time dialysis may be particularly useful in patients with high peritoneal transport type, as it tends to reduce peritoneal protein loss without notably reducing adequacy of dialysis.

Adult↗
PubMed1996

Risk factors for peritonitis in long-term peritoneal dialysis: the Network 9 peritonitis and catheter survival studies. Academic Subcommittee of the Steering Committee of the Network 9 Peritonitis and Catheter Survival Studies.

To determine factors involved in peritoneal dialysis-associated peritonitis and catheter loss, all point prevalent peritoneal dialysis patients in Health Care Finance Administration (HCFA) end-stage renal disease (ESRD) Network 9 were followed throughout 1991 for peritonitis events and throughout 1991 to 1992 for catheter survival. Data were collected by questionnaires compiled by the dialysis facility and validated by network staff. Peritonitis was reported 1,168 times in 729 of the 1,930 patients. By gamma-Poisson regression, a significantly increased risk for peritonitis was observed for patients with previous peritonitis, black race, and those dialyzing with standard connectors or cyclers compared with disconnect systems. Decreased risks were observed for patients with longer ESRD experience and when prophylactic antibiotics were administered before catheter insertion. Postinsertion leakage, diabetes, visual problems, previous or current immunosuppression, and physical activity were not risk factors. Infection of any kind caused the removal of 68% of the 414 catheters lost. Patients with downward-directed tunnels were less likely to experience concomitant exit site/tunnel infections associated with peritonitis. Peritonitis episodes with Staphylococcus epidermidis-like organisms were more likely to resolve with a single course of antibiotics. Perhaps because of their higher infection rate, blacks were more likely than whites to use a disconnect system. In general, the outcome of peritonitis in blacks was similar to that in whites, except that blacks were less likely to be hospitalized and were less likely to die.

Catheters, Indwelling↗
PubMed1994

Cell populations present in the nocturnal peritoneal effluent of patients on continuous ambulatory peritoneal dialysis and their relationship with peritoneal function and incidence of peritonitis.

OBJECTIVE: To study the relationship between peritoneal effluent cells and infection rate and to relate this population with functional characteristics. DESIGN: Prospective, longitudinal, and comparative study. SETTING: Outpatient continuous ambulatory peritoneal dialysis (CAPD) unit of a university medical center. PARTICIPANTS: Seventy-one uninfected patients, treated for 0-156 months on CAPD, in stable condition were studied (33 female, 38 male). INTERVENTIONS: Nocturnal peritoneal effluent (NPE) was drained with EDTA (2.5 mmol/L) at 37 degrees C and centrifuged at 2500 rpm for 9 minutes. MEASUREMENTS: Accumulated peritoneal inflammation days/year and ultrafiltration/diffusion (mass transfer coefficients (MTCs) for small molecules) capacities were recorded. Cellular count (cells/night) was performed using a Neubauer chamber. Macrophage function was assessed by cytochemical (lysosomal enzyme content: ANAE, beta-glucuronidase, acid phosphatase) and immunohistochemical procedures (expression of membrane antigens, CD4, 11b, 11c, 14, 16, 25, 35, and 71). RESULTS: The macrophage is the most frequently appearing cell in the NPE. Cell count decreases over time on CAPD (from 20 x 10(6) to 5 x 10(6) after the first year). Intrapatient variability was low, but interpatient differences were marked. Mesothelial cell count remained stable over time (0.25-0.5 x 10(6)). Four of our patients showed a "transforming" change in these cells. Previous incidence of peritonitis and values of functional measurements did not correlate with cell count or expressions of macrophage function (lysosome enzyme content and percentage of cells expressing different membrane antigens). CONCLUSION: There is difficulty interpreting the results on peritoneal effluent cells and their relationship with the incidence of peritonitis and functional characteristics of the peritoneum. No definite conclusions can be drawn other than the great interpatient and intrapatient variability. The presence of abnormal peritoneal cells with undetermined origin and function suggests the need for periodic studies of peritoneal effluent cells on long-term CAPD patients.

Cell Count↗
PubMed2002

Effect of repeated peritonitis on peritoneal membrane function in children on chronic peritoneal dialysis.

BACKGROUND: Chronic peritoneal dialysis (CPD) is the most commonly used method of pediatric dialysis. The preservation of peritoneal membrane function is essential for successful peritoneal dialysis. Two main factors are responsible for long-term loss of membrane function. Peritonitis, the major complication of CAPD, can be life-threatening and lead to more rapid failure of the technique. The other factor is continuous exposure of peritoneal membrane to bioincompatible dialysis solutions. To investigate the role of repeated peritonitis on peritoneal membrane function, we performed a retrospective study to elucidate the association between peritonitis episodes and peritoneal membrane solute transport characteristics. METHODS: From 1996-2000, 32 pediatric peritoneal dialysis patients were included in this study. According to the peritonitis occurrence frequency, 8 patients were divided into HPO group (peritonitis occurrence rate > or = 5 times/year), and 24 patients were divided into LPO group (peritonitis occurrence rate < or = 1 time/year). The mean age of study patients was 13.95 +/- 5.27 years. The peritoneal equilibration test was performed to evaluate the peritoneal membrane dialyzing function. RESULTS: The mean duration of peritoneal dialysis was 3.31 +/- 1.08 years. The change of peritoneal solute transport (AD/P), computed by subtraction of 4-hour D/P at baseline PET study from that at the last follow-up PET study, showed significant difference (p < 0.05) between HPO (-0.234 + 0.074) and LPO (-0.040 +/- 0.079) groups of children. There was also a significant correlation between repeated peritonitis occurrence and PET deterioration(p < 0.05). The relative risk was 2.63. CONCLUSIONS: Children with frequent peritonitis occurrence have significant decreasing peritoneal solute transport and decreasing PET scaling in follow-up period.

Adolescent↗
PubMed1991

Usefulness of peritoneal fluid amylase levels in the differential diagnosis of peritonitis in peritoneal dialysis patients.

Peritonitis continues to be a major cause of morbidity in peritoneal dialysis patients despite recent technological advances (Y systems) that have reduced peritonitis rates to much more acceptable levels. Most of the time when a peritoneal dialysis patient presents with peritonitis, it is infectious in origin. However, these patients occasionally develop other intra-abdominal pathology that requires more intensive medical care or, at times, surgical intervention. To help in the early differential diagnosis of the cause of peritonitis in these patients, peritoneal fluid amylase levels were prospectively obtained from 50 patients presenting to the hospital with peritonitis. Thirty-nine of them had typical infectious peritonitis, and their mean peritoneal fluid amylase level was 11.1 (range, 0 to 90). Six patients had pancreatitis and a mean peritoneal fluid amylase level of 550 U/L (range, 100 to 1,140 U/L). Five patients were found to have other intra-abdominal pathology, and their mean peritoneal fluid amylase level was 816 U/L (range, 142 to 1,746 U/L). In patients who did not respond to initial therapy, sequential peritoneal fluid amylase levels did not increase in patients with typical infectious peritonitis whereas it did increase in patients with other intra-abdominal pathology. In conclusion, it was found that peritoneal fluid amylase levels were helpful in the differential diagnosis of peritonitis in these patients. An elevated level (greater than 100 U/L) differentiated those patients with other intra-abdominal causes of peritonitis from those with typical infectious peritonitis.

Amylases↗
PubMedDate not supplied

Longitudinal study of peritoneal membrane function in continuous ambulatory peritoneal dialysis: relationship with peritonitis and fibrosing factors.

BACKGROUND: The peritoneal equilibration test (PET) is a useful assessment of peritoneal function in continuous ambulatory peritoneal dialysis (CAPD) patients. However, the natural course of longitudinal change in peritoneal transport is not well defined. PATIENTS: We studied 105 unselected CAPD patients. Average age at enrollment was 50.7 +/- 11.3 years. METHODS: A PET was performed at enrollment. Peritoneal transport was expressed as dialysate-to-plasma creatinine ratio at 4 hours (DIP). Fibrosing factors and mesothelial cell markers, including TGFbeta, epidermal growth factor (EGF), platelet-derived growth factor (PDGF), hyaluronan, and cancer antigen 125 (CA125), were measured in overnight peritoneal dialysate effluent (PDE). Patients were followed for two years. Peritonitis episodes were recorded. Severe peritonitis was defined as an episode that required catheter removal or antibiotic therapy for more than 3 weeks. After two years, 75 patients were still alive and on CAPD. RESULTS: The PET was repeated in 64 patients, of whom 35 were male and 9 had diabetes. The change in D/P over two years was represented as AD/P. No significant change in peritoneal transport was seen after two years (D/P: 0.56 +/- 0.12 vs 0.55 +/- 0.13). A centripetal pattern of change in D/P was observed. The deltaD/P had normal distribution and was inversely correlated with D/P at baseline (r = -0.427, p < 0.005). Both results suggest a regression-to-mean phenomenon. The deltaD/P had no significant correlation with the total number of peritonitis episodes (Spearman r = 0.052, p = 0.74), but after severe peritonitis, affected patients had higher deltaD/P than patients who experienced no severe infection (0.040 +/- 0.136 vs -0.032 +/- 0.120, p < 0.05). For patients with no episodes of severe peritonitis (n = 47), deltaD/P was weakly correlated with baseline TGFbeta level (r = -0.506, p < 0.01). No correlation was seen between the levels of other fibrosing factors and change in peritoneal transport. CONCLUSIONS: Our findings suggest that the centripetal change of peritoneal transport probably reflects a regression-to-mean phenomenon. Peritoneal transport increases after severe peritonitis. The role of TGFbeta levels in PDE with regard to longitudinal change in peritoneal transport requires further study.

Adolescent↗
PubMed1994

The impact of peritonitis on peritoneal and systemic acid-base status of patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To assess the possible effects of peritonitis on peritoneal and systemic acid-base status. DESIGN: pH, pCO2, lactate, and total leukocyte and differential count were simultaneously determined in the overnight dwell peritoneal dialysis effluent (PDE) and arterial blood in noninfected patients (controls) and on days 1, 3, and 5 from the onset of peritonitis. SETTING: University multidisciplinary dialysis program. PATIENTS: Prospective analysis of 63 peritonitis episodes occurring in 30 adult CAPD patients in a single center. RESULTS: In controls, mean (+/- SD) acid-base parameters were pH 7.41 +/- 0.05, pCO2 43.5 +/- 2.6 mm Hg, lactate 2.5 +/- 1.5 mmol/L in the PDE, and pH 7.43 +/- 0.04, PaCO2 36.8 +/- 3.8 mm Hg, lactate 1.4 +/- 0.7 mmol/L in the blood. In sterile (n = 6), gram-positive (n = 34), and Staphylococcus aureus (n = 9) peritonitis PDE pH's on day 1 were, respectively, 7.29 +/- 0.07, 7.32 +/- 0.07, and 7.30 +/- 0.08 (p < 0.05 vs control). In gram-negative peritonitis (n = 14) PDE pH was 7.21 +/- 0.08 (p < 0.05 vs all other groups). A two-to-threefold increase in PDE lactate was observed in all peritonitis groups, but a rise in pCO2 was only seen in gram-negative peritonitis. Acid-base profile of PDE had returned to control values by day 3 in sterile, gram-positive and Staphylococcus aureus peritonitis and by day 5 in gram-negative peritonitis. Despite a slight increase in plasma lactate on the first day of peritonitis, arterial blood pH was not affected by peritonitis. CONCLUSION: PDE pH is decreased in continuous ambulatory peritoneal dialysis (CAPD) peritonitis, even in the absence of bacterial growth. In gram-negative peritonitis, PDE acidosis is more pronounced and prolonged, and pCO2 is markedly increased. Arterial blood pH is not affected by peritonitis.

Acid-Base Equilibrium↗
PubMed1996

Longitudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis.

BACKGROUND: Peritoneal infection and poor ultrafiltration continue to be the major causes of treatment failure in CAPD. The combined effects of peritonitis and the continuous exposure to dialysis fluid remain the most likely candidates affecting the peritoneum in the long term. The purpose of this study was to observe the effects of peritonitis and dialysis on longitudinal peritoneal function. METHODS: The peritoneal equilibration test (PET) was utilized to quantify longitudinal changes in low-molecular-weight solute transfer (D/P(creat)) and ultrafiltration (UF) in 233 patients treated with CAPD. Of these, 166 represented an unselected cohort (Group 1) studied prospectively from commencing treatment for up to 54 months, and 67 were selected patients (Group 2) with PET data available at commencement of the study, having been on dialysis for a minimum of 18 months. PETs were performed either 6-monthly or following peritonitis episodes. RESULTS: Data on the short-term effect of peritonitis kinetics were pooled for groups 1 and 2. Single, isolated episodes (n = 86) had no significant effect on D/P(creat) or UF, whereas recurrences or clusters of infection (n = 70) caused increases in D/P(creat) and reductions in UF, the significance of which increased with the number of episodes. There were significant correlations between both changes in D/P(creat) and UF with the cumulative dialysate leukocyte count, regardless of infecting organism, suggesting that intensity of peritoneal inflammation is also important. Those organisms associated with greater change in peritoneal kinetics, e.g. S. aureus, Pseudomonas, also had the highest neutrophil counts. The longitudinal changes in peritoneal kinetics were analysed for patients in group 1 only. There was a highly significant increase in D/P(creat) after 6 months treatment; this increased further with time on treatment, reaching further significance at 42 and 48 months. There was an associated reduction in UF. In view of the short-term effects of peritonitis on kinetics group 1 was further subdivided into patients who were either peritonitis free or only experienced isolated infections, group 1a, and those that had multiple infection episodes, group 1b. Treatment drop-out, due to death or technical failure occurred at double the rate in group 1b, who also had significantly higher D/P(creat) and lower UF at 1, 6, 12, 18 and 24 months of treatment. Group 1a subsequently caught up, however, indicating that peritonitis is not the only factor influencing long-term changes in peritoneal kinetics. CONCLUSIONS: These data suggest that solute transfer increases and UF declines with time on peritoneal dialysis. This process is exacerbated and accelerated by peritonitis, and appears to be proportional to the degree of associated inflammation and number of infections in close proximity.

Adolescent↗
PubMed1997

Outcomes of single organism peritonitis in peritoneal dialysis: gram negatives versus gram positives in the Network 9 Peritonitis Study.

The use of the "peritonitis rate" in the management of patients undergoing peritoneal dialysis is assuming importance in comparing the prowess of facilities, care givers and new innovations. For this to be a meaningful outcome measure, the type of infection (causative pathogen) must have less clinical significance than the number of infections during a time interval. The natural history of Staphylococcus aureus, pseudomonas, and fungal peritonitis would not support that the outcome of an episode of peritonitis is independent of the causative pathogen. Could this concern be extended to other more frequently occurring pathogens? To address this, the Network 9 Peritonitis Study identified 530 episodes of single organism peritonitis caused by a gram positive organism and 136 episodes caused by a single non-pseudomonal gram negative (NPGN) pathogen. Coincidental soft tissue infections (exit site or tunnel) occurred equally in both groups. Outcomes of peritonitis were analyzed by organism classification and by presence or absence of a soft tissue infection. NPGN peritonitis was associated with significantly more frequent catheter loss, hospitalization, and technique failure and was less likely to resolve regardless of the presence or absence of a soft tissue infection. Hospitalization and death tended to occur more frequently with enterococcal peritonitis than with other gram positive peritonitis. The outcomes in the NPGN peritonitis group were significantly worse (resolution, catheter loss, hospitalization, technique failure) compared to coagulase negative staphylococcal or S. aureus peritonitis, regardless of the presence or absence of a coincidental soft tissue infection. Furthermore, for the first time, the poor outcomes of gram negative peritonitis are shown to be independent of pseudomonas or polymicrobial involvement or soft tissue infections. The gram negative organism appears to be the important factor. In addition, the outcome of peritonitis caused by S. aureus is worse than that of other staphylococci. Thus, it is clear that all peritonitis episodes cannot be considered equivalent in terms of outcome. The concept of peritonitis rate is only meaningful when specific organisms are considered.

Aged↗
PubMed1996

Peritoneal nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis.

Nitric oxide plays an important role in mediating the inflammatory process. The aim of this study was to evaluate if nitric oxide production was increased during peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD), and the association with the prognosis. The study population comprised 21 patients with 22 episodes of peritonitis. Fifteen patients without peritonitis were controls. Nitrate was measured by HPLC and nitrite by the Griess method, to reflect nitric oxide production. Peritoneal dialysate effluent and plasma were collected from six patients during peritonitis and 1 week after treatment to study changes in dialysate:plasma ratio. In 15 patients, nitrite was measured during peritonitis and every 3 days for 2 weeks or until normalized for evolutional changes. The dialysate:plasma ratios of nitrate and nitrite during peritonitis were reduced 26% and 41.5%, respectively, after 1 week of treatment, indicating the peritoneal production of nitric oxide during peritonitis. In the evolutional study, a 5.1-fold increase of peak nitrite levels in bacterial peritonitis (n = 13) and a 2.5-fold increase in fungal peritonitis (n = 3) were observed compared to controls. Nitrite gradually declined to control levels (9.3 +/- 7.2 days) after effective antibiotic treatment, but took longer than to normalize leukocyte count in the peritoneal dialysate effluent (3.9 +/- 1.9 days). In four patients with refractory peritonitis (Candida infection in three, Acinetobacter infection in one), the nitrite levels remained elevated 2-fold despite treatment, and the catheters were removed. It is concluded that nitrite levels in peritoneal dialysate effluent may serve as a marker to assess treatment efficacy in CAPD patients with peritonitis.

Acinetobacter Infections↗
PubMed2001

Correlation between peritoneal mesothelial cell cytology and peritoneal histopathology with respect to prognosis in patients on continuous ambulatory peritoneal dialysis.

BACKGROUND: Sclerosing encapsulating peritonitis (SEP) is a serious complication seen in patients on long-term continuous ambulatory peritoneal dialysis (CAPD). We have previously reported that mesothelial cells in effluent dialysate significantly increased in size as the duration of CAPD progressed. In this study, we investigated the relationship between mesothelial cytology, histopathology of the peritoneum, and clinical outcomes of 34 CAPD patients. METHODS: When peritoneal dialysis catheters were inserted (n = 7) or removed (n = 27), a peritoneal biopsy was performed and results compared with mesothelial cytology in effluent dialysate. RESULTS: A significant positive correlation was noted between the duration of CAPD and the surface area of peritoneal mesothelial cells (r = 0.721, p < 0.0001). The surface area of mesothelial cells in peritoneal sclerosis (n = 9; 584 +/- 97 microm(2)) was significantly greater than in peritoneal fibrosis (n = 14; 389 +/- 26 microm(2), p < 0.05), pathologic acute peritonitis (n = 3; 223 +/- 10 microm(2), p < 0.005), and normal peritoneum (n = 7; 247 +/- 12 microm(2), p < 0.001). The surface area in sclerosing peritonitis (n = 1; 1,200 microm(2)) was greater than that of all the others. Giant cells were found in the 1 case with sclerosing peritonitis and in 3 of 9 cases with peritoneal sclerosis, although they were found in only 1 of 14 patients with peritoneal fibrosis and in none of those with pathologic acute peritonitis or normal peritoneum. As the surface area of mesothelial cells increased to more than 400 microm(2) and giant cells appeared in the effluent, the frequency of peritoneal sclerosis and/or clinical SEP increased. CONCLUSION: An increase in the mesothelial cell surface area and the emergence of giant cells in the effluent indicate advanced peritoneal histopathology, and may be useful indicators to determine appropriate timing of discontinuation of CAPD to prevent the development of SEP.

Adult↗
PubMedDate not supplied

Peritoneal sodium mass removal in continuous ambulatory peritoneal dialysis and automated peritoneal dialysis: influence on blood pressure control.

BACKGROUND/AIM: Sodium and water retention is common in peritoneal dialysis patients and contributes to cardiovascular disease. As peritoneal sodium removal depends partly on dwell time, and automated peritoneal dialysis (APD) often uses short dwell time exchanges, the aim of this study was to compare the 24-hour peritoneal sodium removal in APD and standard continuous ambulatory peritoneal dialysis (CAPD) patients and to analyze its possible influence on blood pressure control. METHODS: A total of 53 sodium balance studies (30 in APD and 23 in CAPD) were performed in 36 stable peritoneal dialysis patients. The 24-hour net removal of sodium was calculated as follows: M = ViCi - VdCd, where Vd is the 24-hour drained volume, Cd is the solute sodium concentration in Vd, Vi is the amount of solution used during a 24-hour period, and Ci is the sodium concentration in Vi. Peritoneal sodium removal was compared between APD and CAPD patients. Residual renal function, serum sodium concentration, daily urinary sodium losses, weekly peritoneal Kt/V and creatinine clearance, 4-hour dialysate/plasma creatinine ratio, proportion of hypertonic solutions, net ultrafiltration, systolic and diastolic blood pressures, and need for antihypertensive therapy were also compared between the groups. RESULTS: Peritoneal sodium removal was higher (p < 0.001) in CAPD than in APD patients. There were no significant differences in residual renal function, serum sodium concentration, urinary sodium losses, peritoneal urea or creatinine clearances, 4-hour dialysate/plasma creatinine ratio, or proportion of hypertonic solutions between groups. The net ultrafiltration was higher in CAPD patients and correlated strongly (r = 0.82; p < 0.001) with peritoneal sodium removal. In APD patients, peritoneal sodium removal increased significantly only in those patients with a second daytime exchange. The systolic blood pressure was higher (p < 0.05) in APD patients, and the proportion of patients with antihypertensive therapy was also higher in APD patients, although no significant relationship between blood pressure values and amount of peritoneal sodium removal was found. CONCLUSIONS: The 24-hour sodium removal is higher in CAPD than in APD patients, and there is a trend towards better hypertension control in CAPD patients. As hypertension control and volume status are important indices of peritoneal dialysis adequacy, our results have to be considered in the choice of the peritoneal dialysis modality.

Adult↗
PubMed1995

Effects of intraperitoneal cyclooxygenase inhibition on inflammatory mediators in dialysate and peritoneal membrane characteristics during peritonitis in continuous ambulatory peritoneal dialysis.

Peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) can be used as an in vivo model to study the contribution of mediators in dialysate to the regulation of peritoneal permeability. Previously we reported that changes in the peritoneal appearance rates of the cytokines interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF alpha) were related to alterations in the effective peritoneal surface area. Changes in the intrinsic peritoneal permeability were mainly related to those in the peritoneal appearance rate of the prostanoid prostaglandin E2 (PGE2) and partly also to that of IL-6. In this intervention study the role of these mediators was further analyzed. Eleven peritonitis episodes were followed on 8 consecutive days from the start of the infection and once after recovery. Indomethacin was given intraperitoneally during the first 3 days. beta 2-Microglobulin clearance was used as indicator of the effective peritoneal surface area. The intrinsic peritoneal permeability was characterized functionally by the restriction coefficient. The 15 peritonitis episodes studied previously served as the control group. This study supports the formerly obtained relationships in two ways. First, significant reductions were observed for peritoneal PGE2, 6-keto-PGF1 alpha, and TxB2 during cyclooxygenase inhibition to 6%, 0.6%, and 9% of the values on day 1, whereas simultaneously the intrinsic permeability was less increased. This indomethacin effect on intrinsic permeability was not entirely significant, probably because of the additional role of IL-6, which was not influenced by indomethacin. Also, the appearance rate of TNF alpha in the effluent was not affected by cyclooxygenase inhibition. Accordingly, the changes in the effective surface area were similar to those in the control group. Second, in 8 of the 11 cases, new rises both in peritoneal PGE2 and in intrinsic permeability occurred after discontinuation of indomethacin. Rebounds were not seen for TNF alpha or IL-6, and, consistently, not for the effective surface area. In conclusion, local cyclooxygenase inhibition results in a less-increased intrinsic permeability during peritonitis but has no effect on the effective surface area. These data support our previous finding that IL-6 and TNF alpha contribute to alterations in surface area, whereas PGE2 is more involved in intrinsic peritoneal permeability changes.

Adult↗
PubMed1999

Comparing peritonitis in continuous ambulatory peritoneal dialysis patients versus automated peritoneal dialysis patients.

The purpose of our study was to compare the incidence of peritonitis between continuous ambulatory peritoneal dialysis (CAPD) treatment (Group I) and automated peritoneal dialysis (APD) treatment (Group II) taking into account the same population. We compared 20 patients with a follow-up of 215 patient-months on CAPD and 252 patient-months on APD. Demographic data, diagnosis, peritoneal equilibration test (PET) results, adequacy, and peritonitis rate were analyzed. Diagnoses included glomerulopathy 35%, autosomal dominant polycystic kidney disease (ADPKD) 20%, Type II diabetes 10%, systemic lupus erythematosus 5%, interstitial nephritis 5%, nephrolitiasis 5%, and unknown 20%. PET results showed that the group consisted of 30% high transporters, 45% high-average transporters, and 25% low-average transporters. Kt/V for Group I was 1.3 +/- 0.3, and for Group II, 1.83 +/- 0.48. Creatinine clearance for Group I was 43.64 +/- 7.31 L/week/1.73 m2, and for Group II, 52.42 +/- 13.47 L/week/1.73 m2. Group I presented a peritonitis rate of 8.3 episodes/patient-month, and Group II presented a rate of 18.9 episodes/patient-month. Gram-positive organisms were responsible for 49.8% of episodes of peritonitis in Group I (S. aureus 26.6%, S. epidermidis 16.6%, others 10%) and 83% of peritonitis episodes in Group II (S. epidermidis 46.6%, S. aureus 20%). Gram-negative organisms were responsible for 16.5% of episodes of peritonitis in Group I. No gram-negative peritonitis was seen in Group II. APD patients developed two cases of candida peritonitis. Our preliminary results show that Group II exhibited a decrease in peritonitis rate while achieving better adequacy. In CAPD and APD peritonitis, gram-positive organisms predominated. In APD, we observed an increase in S. epidermidis incidence. No gram-negative organisms were observed in APD. It seems that APD is a safer treatment owing to the lower peritonitis incidence.

Adult↗
PubMed1991

Decreased size of peritoneal macrophage during peritonitis in continuous ambulatory peritoneal dialysis patients.

From January 1987 to July 1988, 30 patients suffering from end-stage renal disease were treated with continuous ambulatory peritonitis dialysis (CAPD) therapy. Serial cell number, size and cycle of the peritoneal macrophage (PM) in these patients were measured before and during episodes of peritonitis from the time they started CAPD therapy. Patients with peritonitis were divided into high peritonitis occurrence (HPOG) and low peritonitis occurrence (LPOG) groups. Both before and during occurrence of peritonitis, there were no significant differences in the number of PM cells in the dialysate taken from patients in the HPOG and LPOG. When peritonitis occurred, the size and cell cycle S/Go-G1 ratio decreased about 3 days after the onset of peritonitis. It progressed to the lowest level 7-10 days later, then progressively recovered. However, the dialysate PM cells from the HPOG took a much longer time to recover to the preperitonitis size. When dialysate PM cells from patients without peritonitis were put into the dialysate of HPOG patients on day 10 of peritonitis and incubated for 24 h, an obvious decrease in cell size could be identified. On the other hand, when the PM cells from HPOG patients with peritonitis on day 10 were incubated 24 h with the dialysate from patients without peritonitis, there were obvious increases in cell size. These results suggest there may be a substance (or substances) in the peritonitis dialysate, which contribute(s) to the shrinkage of PM cell size.

Adolescent↗