Capd

1: Adv Perit Dial. 2008;24:65-8. Links

Risk factors and cause of removal of peritoneal dialysis catheter in patients on continuous ambulatory peritoneal dialysis. Nodaira Y, Ikeda N, Kobayashi K, Watanabe Y, Inoue T, Gen S, Kanno Y, Nakamoto H, Suzuki H. Department of Nephrology, Saitama Medical University, Saitama, Japan.

In the present study, we examined the risk factors and causes for removal of the peritoneal dialysis (PD) catheter in patients on continuous ambulatory PD (CAPD). Data were collected from the records of patients who received CAPD therapy from 1995 to 2007 in the Department of Nephrology, Saitama Medical University. During that time, 473 patients were introduced onto CAPD therapy and the PD catheter was removed from 63 patients. Catheters were removed in 30 patients (47%) because of peritoneal infection, in 11 (17%) because of dialysis failure, in 8 (13%) because of neoplasm of the gastrointestinal tract, in 6 (10%) because of perforation of the gastrointestinal tract, in 2 (3%) because of laceration of PD catheter, and in 3 each (5%) because of transplantation and home hemodialysis therapy. Duration of CAPD was 5.6 +/- 1.2 years. In patients who experienced peritoneal infection, causative organisms were Staphylococcus (mainly methicillin-resistant S. aureus), Candida, Pseudomonas, and non tuberculous Mycobacterium. Failure to continue PD therapy related to dialysis deficiency. All patients were examined for encapsulating peritoneal sclerosis (EPS) by computed tomography (CT) enhanced using contrast material. In 9 cases in which the CT findings indicated EPS, treatment with oral prednisolone (20 mg daily) was started; the dose was then gradually reduced over 1 year. After removal of the PD catheter, no patient developed EPS. All removed catheters were examined using electron microscopy. The catheters from patients who experienced PD peritonitis revealed biofilm formation; however, no biofilm formation was found in PD catheters removed from patients without infection. Despite appropriate antibiotic therapy, peritoneal infection remains the major cause of PD catheter removal. Biofilm formation might be an obstacle to PD continuation. PMID: 18986004 [PubMed - in process]

1: Perit Dial Int. 2008 Nov-Dec;28(6):626-31.

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Omental folding: a novel laparoscopic technique for salvaging peritoneal dialysis catheters. Goh YH. Department of Surgery, Selayang Hospital, Kuala Lumpur, Selangor, Malaysia.

BACKGROUND: Omental wrap is a common cause of catheter obstruction. Current laparoscopic techniques for correcting obstruction include omentopexy and omentectomy. This study evaluates the efficacy of a new laparoscopic technique for revision of obstructed peritoneal dialysis catheters. METHODS: Between November 2005 and November 2006, the technique was applied in 18 patients (6 female, 12 male; median age 50 years, range 16 - 73 years) on continuous ambulatory peritoneal dialysis with catheter malfunction secondary to omental wrap. Pneumoperitoneum was induced under general anesthesia. Three ports were inserted. The catheter was released from the omentum and repositioned in the pelvis. The omentum was then folded onto itself in a cephalad direction using silk sutures. This shortened the omentum. The risk of catheter migration was minimized with a polypropylene sling passed through the abdominal wall and around the catheter, then knotted subcutaneously. The sling allowed catheter removal without a new laparoscopy. The outcomes were prospectively evaluated. RESULTS: Median operating time was 90 minutes (range 35 - 160 minutes). Adhesiolysis was performed in 4 patients: 1 patient had port-site leakage of dialysate, which settled with abdominal rest; 1 patient had bleeding during adhesiolysis and laparoscopic hemostasis was successful; 1 patient had recurrent catheter obstruction 2 weeks post-operatively and was converted to hemodialysis; and 1 patient had recurrent malfunction secondary to small bowel wrap after 5.5 months; re-salvage was successful. The success rate of the first salvage procedure was 89%(16/18). The catheters were still functioning after a mean follow-up of 16.5 +/- 6.3 months (range 0.5 - 24 months). The 1-year catheter survival rate was 83.3%. CONCLUSIONS: Omental folding is a safe and effective technique for salvaging peritoneal dialysis catheters. PMID: 18981393 [PubMed - in process]

1: Perit Dial Int. 2005 Nov-Dec;25(6):551-5.

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Comment in: Perit Dial Int. 2005 Nov-Dec;25(6):541-3.

Minilaparoscopic extraperitoneal tunneling with omentopexy: a new technique for CAPD catheter placement. Ogunc G. Department of General Surgery, Akdeniz University Medical School, Dumlupinar Bulvari, Antalya, Turkey. [email protected]

BACKGROUND: Continuous ambulatory peritoneal dialysis (CAPD) is an effective form of treatment for patients with end-stage renal disease. Open insertion of peritoneal dialysis (PD) catheters is the standard surgical technique, but it is associated with a relatively high incidence of catheter-related problems. To overcome these problems, different laparoscopic techniques have been presented, being preferable to the open and percutaneous methods. OBJECTIVE: To introduce and evaluate the efficiency of laparoscopic omental fixation and extraperitoneal placement of the cuff-coil part (the straight portion) of the catheter to prevent catheter tip migration, pericatheter leakage, severe abdominal pain, and the obstruction caused by omental wrapping. SETTING: The study was carried out in the General Surgery Department, Akdeniz University Medical School, in Turkey. PATIENTS AND METHODS: Between November 2001 and March 2005, the technique was applied in 44 consecutive patients (mean age 51.6 years, range 18 - 67 years) with end-stage renal disease. During this laparoscopic technique, the omentum was first fixed onto the parietal peritoneum, and then the catheter was introduced through the subumbilical trocar site into the posterior rectus compartment and advanced toward the symphysis pubis. The catheter was then inserted into the abdominal cavity, passing the peritoneal opening, which was prepared before catheter insertion. The straight portion of the catheter was located into the extraperitoneal area of the anterior abdominal wall. The curled end, which contains the side-holes of the catheter, was placed into the true pelvis. Catheter position and patency were verified under direct vision using a 2 mm telescope. RESULTS: All procedures were completed laparoscopically. Operating time ranged between 40 and 100 minutes (median 52 minutes). There was no intraoperative complication or surgical mortality. Peritoneal dialysis was initiated within 15 - 24 hours after catheter implantation. After a median follow-up period of 17.4 months (range 1 - 38 months), early exit-site infection occurred in 1 of 44 patients. All catheters functioned well postoperatively. There was no pain during CAPD. CONCLUSION: This new laparoscopic technique using an extraperitoneal approach with omentopexy for PD catheter placement could prove extremely useful for preventing catheter malfunction caused by catheter tip migration, pericatheter leakage, omental wrapping, and periodic catheter movement that causes abdominal pain in CAPD. PMID: 16411520 [PubMed - indexed for MEDLINE]

1: Kidney Int Suppl. 2006 Nov;(103):S27-37. Links

Selected best demonstrated practices in peritoneal dialysis access. Crabtree JH. Department of Surgery, Southern California Permanente Medical Group, Kaiser Permanente Bellflower Medical Center, Bellflower, CA 90706, USA. [email protected]

Many burdensome interventions that adversely affect the utilization of peritoneal dialysis as renal replacement therapy and patient satisfaction with this treatment modality can be avoided by early peritoneal access placement with embedded catheters, implantation techniques that preempt common catheter complications, and the use of access devices that provide flexibility in exit site location. Catheter embedding consists of subcutaneously burying the external limb of the catheter tubing at the time of the insertion procedure. Interval exteriorization of the catheter is performed when dialysis is needed. Earlier commitment by patients to peritoneal dialysis can be achieved by elimination of catheter maintenance until dialysis is necessary. Catheter embedding is a practical strategy to avoid temporary hemodialysis with vascular catheters and reduces stress on operating room access by allowing more efficient scheduling as non-urgent procedures. Laparoscopic catheter placement enables proactive techniques not available to other conventional insertion methods. These techniques include rectus sheath tunneling to prevent catheter tip migration, selective prophylactic omentopexy to prevent omental entrapment, selective resection of epiploic appendages to prevent catheter obstruction, adhesiolysis to eliminate compartmentalization, and diagnosis and simultaneous repair of previously undiagnosed abdominal wall hernias. Both standard and extended 2-piece catheter systems are necessary to customize the peritoneal access to a variety of body configurations. Catheters should be able to produce lower abdominal, mid-abdominal, upper abdominal, and upper chest exit site locations that facilitate management by the patient without sacrificing deep pelvic position of the catheter tip or resulting in excessive tubing stress during passage through the abdominal wall. PMID: 17080108 [PubMed - indexed for MEDLINE]

1: Int J Artif Organs. 2006 Jan;29(1):2-40. Links

History of peritoneal access development. Twardowski ZJ. University of Missouri, Columbia, Missouri, USA. [email protected]

The first peritoneal accesses were devices that had been used in other fields (general surgery, urology, or gynecology): trocars, rubber catheters, and sump drains. In the period after World War II, numerous papers were published with various modifications of peritoneal dialysis. The majority of cases were treated with the continuous flow technique; rubber catheters for inflow and sump drains for outflow were commonly used. At the end of the 1940s, intermittent peritoneal dialysis started to be more frequently used. Severe complications of peritoneal accesses created incentive to design accesses specifically for peritoneal dialysis. The initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel for the first time designed a soft, polyvinyl intraperitoneal tube with metal weights to keep the catheter tip in the pelvic gutter where the conditions for drain are the best. In the 1950s, intermittent peritoneal dialysis was established as the preferred technique; polyethylene and nylon catheters became commercially available and peritoneal dialysis was established as a valuable method for treatment of acute renal failure. The major breakthrough came in the 1960s. First of all, it was discovered that the silicone rubber was less irritating to the peritoneal membrane than other plastics. Then, it was found that polyester velour allowed an excellent tissue ingrowth creating a firm bond with the tissue. When a polyester cuff was glued to the catheter, it restricted catheter movement and created a closed tunnel between the integument and the peritoneal cavity. In 1968, Tenckhoff and Schechter combined these two features and designed a silicone rubber catheter with a polyester cuff for treatment of acute renal failure and two cuffs for treatment of chronic renal failure. This was the most important development in peritoneal access. Technological evolution never ends. Multiple attempts have been made to eliminate remaining complications of the Tenckhoff catheter such as exit/tunnel infection, external cuff extrusion, migration leading to obstruction, dialysate leaks, recurrent peritonitis, and infusion or pressure pain. New designs combined the best features of the previous ones or incorporated new elements. Not all attempts have been successful, but many have. To prevent catheter migration, Di Paolo and his colleagues applied the old idea of providing weights at the catheter tips to Tenckhoff catheters. In another modification, Twardowski and his collaborators created a permanent bend to the intra-tunnel portion of the silicone catheter to eliminate cuff extrusions. The Tenckhoff catheter continues to be widely used for chronic peritoneal dialysis, although its use is decreasing in favor of swan-neck catheters. Soft, silicone rubber instead of rigid tubing virtually eliminated such early complications as bowel perforation or massive bleeding. Other complications, such as obstruction, pericatheter leaks, and superficial cuff extrusions have been markedly reduced in recent years, particularly with the use of swan-neck catheters and insertion through the rectus muscle instead of the midline. However, these complications still occur, so new designs are being tried. PMID: 16485237 [PubMed - indexed for MEDLINE]

1: Nippon Jinzo Gakkai Shi. 2003;45(4):378-80. Links

[Peritoneal dialysis catheter-related complications] [Article in Japanese]

Yata N, Ishikura K, Hataya H, Ikeda M, Honda M. Department of Nephrology, Tokyo Metropolitan Children's Hospital, Tokyo, Japan.

The introduction of a double-cuff swan neck type catheter has reduced the frequency of peritonitis. The frequency of complications associated with insertion of this catheter has remained unknown. We evaluated these complications in patients aged < 20 years at the start of the chronic peritoneal dialysis using double-cuff swan neck catheters. SUBJECTS AND METHODS: The data from 221 double-cuff swan neck catheters of 126 patients inserted in our hospital between 1990 and 2001 were compared with 102 single-cuff straight catheters of 54 patients between 1982 and 1990. The frequency of catheter-related complications, such as dislocation, leakage with in/outflow malfunction and infection(exit-site/tunnel infection and peritonitis within a month after catheter insertion) were estimated. RESULTS: We observed 37 dislocations(17%), 37 leakages(17%) and 36 infections(16%) of all double-cuff swan neck catheters. Twenty-nine catheters were removed due to catheter-related complications: 18 dislocations(8%), 2 leakages(1%) and 9 infections(4%). Catheter removal due to dislocation occurred significantly more frequently in 12% of children who were > or = 6 years old than in 1% of children < 6 years old(p = 0.002). Eighty-three percent of dislocations could be returned by the whiplash method(alpha-replacer, JMS, Tokyo). Of all single-cuff straight catheters, 10 catheters were removed due to catheter-related complications: 4 dislocations(4%), 6 leakages(6%) and 12 infections(12%). CONCLUSION: A single-cuff straight type catheter was more frequently replaced because of leakage and infection than a double-cuff swan neck type catheter. A double-cuff swan neck catheter was more frequently replaced because of dislocation than a single-cuff straight catheter. When a double-cuff swan neck catheter is inserted particularly in older children, care should be taken to avoid dislocation. PMID: 12806975 [PubMed - indexed for MEDLINE]

1: Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004680.

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Catheter type, placement and insertion techniques for preventing peritonitis in peritoneal dialysis patients. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Cochrane Renal Group, Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, 2145, NSW, Australia. [email protected]

BACKGROUND: As many as 15-50% of end-stage kidney disease patients are on peritoneal dialysis (PD), but peritonitis limits its more widespread use. Several PD catheter-related interventions have been purported to reduce the risk of peritonitis in PD. OBJECTIVES: To evaluate the use of catheter-related interventions for the prevention of peritonitis in PD. SEARCH STRATEGY: The Cochrane Renal Group's specialised register (June 2004), The Cochrane CENTRAL Register of Controlled Trials (The Cochrane Library Issue 2 2004), MEDLINE (1966-April 2004), EMBASE (1988-April 2004) and reference lists were searched without language restriction SELECTION CRITERIA: Trials comparing different catheter insertion techniques, catheter types, use of immobilisation techniques or different break in periods were included. Trials of different PD sets were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using a random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS: Seventeen eligible trials (1089 patients) were identified, eight of surgical strategies of catheter insertion, eight of straight versus coiled catheters, one of single cuff versus double cuff catheters and one of an immobiliser device. The methodological quality was suboptimal. There were no significant differences with laparoscopy compared with laparotomy for peritonitis, the peritonitis rate, exit-site/tunnel infection or catheter removal/replacement. Standard insertion with resting but no subcutaneous burying of the catheter versus implantation and subcutaneous burying was not associated with a significant reduction in peritonitis rate, exitsite/tunnel infection rate or all-cause mortality. Midline compared to lateral insertion showed no significant difference in the risk of peritonitis or exit-site/tunnel infection. There was no significant difference in the risk of peritonitis, peritonitis rate, exitsite/tunnel infection, exit-site/tunnel infection rate or catheter removal/replacement between straight versus coiled intraperitoneal portion catheters. One trial compared single versus double cuffed catheters and showed no significant difference in the risk of peritonitis, exit-site/tunnel infection or catheter removal/replacement. One trial compared immobilisation versus no immobilisation of the PD catheter and showed no significant difference in the risk of peritonitis and exit-site/tunnel infection. No trials of different break-in periods were identified. REVIEWERS' CONCLUSIONS: No major advantages from any of the catheter-related interventions which have been purported to reduce the risk of PD peritonitis could be demonstrated in this review. The frequency and quality of available trials are suboptimal. PMID: 15495125 [PubMed - indexed for MEDLINE]

1: Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004679.

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Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Cochrane Renal Group, Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, 2145, NSW, Australia. [email protected]

BACKGROUND: Peritoneal dialysis (PD) is used as substitutive treatment of renal function in a large proportion (15-50%) of the end-stage kidney disease (ESRD) population. The major limitation is peritonitis which leads to technique failure, hospitalisation and increased mortality. Oral, nasal, topical antibiotic prophylaxis, exit-site disinfectants and other antimicrobial interventions are used to prevent peritonitis. OBJECTIVES: The objective of this systematic review of randomised controlled trials (RCTs) was to evaluate what evidence supports the use of different antimicrobial approaches to prevent peritonitis in PD. SEARCH STRATEGY: The Cochrane CENTRAL Registry (issue 1, 2004), MEDLINE (1966-May 2003), EMBASE (1988-May 2003) and reference lists were searched for RCTs of antimicrobial agents in PD. SELECTION CRITERIA: Trials of the following agents were included: antibiotics by any route (oral, nasal, topical), exit-site disinfectants (chlorhexidine, povidone iodine, soap and water), vaccines, and ultraviolet germicidal devices. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data on the number of patients with one or more episodes and rates of peritonitis and exit-site/tunnel infection, catheter removal, catheter replacement, technique failure, toxicity of antibiotic treatments, all-cause mortality. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS: Nineteen trials, enrolling 1949 patients met our inclusion criteria. Nasal mupirocin compared with placebo significantly reduced the exit-site and tunnel infection rate (one trial, 2716 patient months, RR 0.58, 95% CI 0.40 to 0.85) but not peritonitis rate (one trial, 2716 patient months, RR 0.84, 95% CI 0.44 to 1.60). Perioperative intravenous antibiotics compared with no treatment significantly reduced the risk of early peritonitis (four trials, 335 patients, RR 0.35, 95% CI 0.15 to 0.80) but not exit site and tunnel infection (three trials, 114 patients, RR 0.32, 95% CI 0.02 to 4.81). No intervention reduced the risk of catheter removal or replacement. REVIEWERS' CONCLUSIONS: This review demonstrates that nasal mupirocin reduces exit-site/tunnel infection but not peritonitis. Preoperative intravenous prophylaxis reduces early peritonitis but not exit-site/tunnel infection. No other antimicrobial interventions have proven efficacy. Given the large number of patients on PD and the importance of peritonitis, the lack of adequately powered RCTs to inform decision making about strategies to prevent peritonitis is striking. PMID: 15495124 [PubMed - indexed for MEDLINE]

1: Int J Artif Organs. 2006 Jan;29(1):41-9. Links

Antimicrobial agents and catheter-related interventions to prevent peritonitis in peritoneal dialysis: Using evidence in the context of clinical practice. Bonifati C, Pansini F, Torres DD, Navaneethan SD, Craig JC, Strippoli GF. Department of Emergency and Organ Transplantation, Division of Nephrology, University of Bari, Bari - Italy. [email protected]

BACKGROUND: Peritonitis still represents a common and major complication of peritoneal dialysis. The broader adoption of several strategies, including antimicrobial and catheter related interventions, has been advocated to prevent or reduce the risk of peritonitis in peritoneal dialysis. METHODS: In this article we start with the presentation of a clinical case where concern exists about the strategies for preventing peritoneal dialysis peritonitis. We then look at the available evidence in the form of systematic reviews of randomized trials and individual randomized trials of interventions to prevent peritonitis in peritoneal dialysis. A summary of the evidence is provided and then put in context with the clinical case scenario. RESULTS: Nineteen eligible trials (1949 patients) of antimicrobial agents and 37 (2822 patients) of catheter related interventions to prevent peritonitis in peritoneal dialysis were identified. Nasal mupirocin compared with placebo significantly reduced the exit-site and tunnel infection rate (1 trial, 2716 patient months, RR 0.58, 95% CI 0.40 to 0.85) but not peritonitis rate (1 trial, 2716 patient months, RR 0.84, 95% CI 0.44 to 1.60). As for antimicrobial strategies, perioperative intravenous antibiotics compared with no treatment significantly reduced the risk of early peritonitis (4 trials, 335 patients, RR 0.35, 95% CI 0.15 to 0.80) but not exit site and tunnel infection (3 trials, 114 patients, RR 0.32, 95% CI 0.02 to 4.81). As for catheter related strategies, Y-set and twin-bag systems were superior to conventional spike systems (7 trials, 485 patients, RR 0.64, 95% CI 0.53 to 0.77) and no other catheter-related intervention was demonstrated to prevent peritonitis in PD. CONCLUSIONS: Evidence exists to support the use of perioperative intravenous antibiotic prophylaxis at the time of catheter placement, the twin-bag and Y-set system, as well as prophylaxis with mupirocin in Staphylococcus aureus nasal carriers. Despite lack of evidence, several other agents are used and recommended in major international guidelines, which is reasonable but requires further investigation. PMID: 16485238 [PubMed - indexed for MEDLINE

1: Am J Kidney Dis. 2007 Dec;50(6):967-88.

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Treatment of peritoneal dialysis-associated peritonitis: a systematic review of randomized controlled trials. Wiggins KJ, Johnson DW, Craig JC, Strippoli GF. Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia. [email protected]

BACKGROUND: Peritonitis frequently complicates peritoneal dialysis. Appropriate treatment is essential to reduce adverse outcomes. Available trial evidence about peritoneal dialysis peritonitis treatment was evaluated. SELECTION CRITERIA FOR STUDIES: The Cochrane CENTRAL Registry (2005 issue), MEDLINE (1966 to February 2006), EMBASE (1985 to February 2006), and reference lists were searched to identify randomized trials of treatments for patients with peritoneal dialysis peritonitis. INTERVENTIONS: Trials of antibiotics (comparisons of routes, agents, and dosing regimens), fibrinolytic agents, peritoneal lavage, and intraperitoneal immunoglobulin. OUTCOMES: Treatment failure, relapse, catheter removal, microbiological eradication, hospitalization, all-cause mortality, and adverse reactions. RESULTS: 36 eligible trials were identified: 30 trials (1,800 patients) of antibiotics; 4 trials (229 patients) of urokinase; 1 trial of peritoneal lavage (36 patients); and 1 trial of intraperitoneal immunoglobulin (24 patients). No superior antimicrobial class was identified. In particular, glycopeptides and firstgeneration cephalosporins were equivalent (3 trials, 387 patients; relative risk [RR], 1.84; 95% confidence interval [CI], 0.95 to 3.58). Simultaneous catheter removal/replacement was superior to urokinase at decreasing treatment failures (1 trial, 37 patients; RR, 2.35; 95% CI, 1.13 to 4.91). Continuous and intermittent intraperitoneal antibiotic dosing were equivalent regarding treatment failure (4 trials, 338 patients; RR, 0.69; 95% CI, 0.37 to 1.30) and relapse (4 trials, 324 patients; RR, 0.93; 95% CI, 0.63 to 1.39). One trial showed superiority of intraperitoneal antibiotics over intravenous therapy. LIMITATIONS: The method quality of trials generally was suboptimal and outcome definitions were inconsistent. Small patient numbers led to inadequate power to show an effect. Interventions, such as optimal duration of antibiotic therapy, were not evaluated. CONCLUSIONS: Trials did not identify superior antibiotic regimens. Intermittent and continuous antibiotic dosing are equivalent treatment strategies. PMID: 18037098 [PubMed - indexed for MEDLINE]

1: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005284.

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Comment in: Nat Clin Pract Nephrol. 2008 Jul;4(7):356-7.

Treatment for peritoneal dialysis-associated peritonitis. Wiggins KJ, Craig JC, Johnson DW, Strippoli GF. St Vincent's Hospital, Nephrology, Level 4, Clinical Sciences Building, Fitzroy, VIC, Australia, 3065. [email protected]

BACKGROUND: Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence. OBJECTIVES: To evaluate the benefits and harms of treatments for PD-associated peritonitis. SEARCH STRATEGY: We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction.Date of search: February 2005 SELECTION CRITERIA: All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included. DATA COLLECTION AND ANALYSIS: Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI. MAIN RESULTS: We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal. AUTHORS' CONCLUSIONS: Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm. PMID: 18254075 [PubMed - indexed for MEDLINE

1: Int J Artif Organs. 2003 Aug;26(8):698-714. Links

Peritoneal catheter exit-site infections: predisposing factors, prevention and treatment. Thodis E, Passadakis P, Ossareh S, Panagoutsos S, Vargemezis V, Oreopoulos DG. Department of Nephrology, Medical School Democritus University of Thrace, Alexandroupolis, Greece.

Catheter-related infections, exit-site-tunnel infections and peritonitis remain the Achilles heel of peritoneal dialysis. Although the overall incidence of peritonealdialysis-related infectious complications has been reduced since the introduction of the Y-set and double bag system, approximately one-fifth of peritonitis episodes are associated with catheter exit-site and tunnel infections. Since its development in 1968, the Tenckhoff catheter has become one of the most widely used peritoneal catheters, and many have proposed that a number of modifications have made it a better choice. Controversies concerning the effect on exit-site infections of catheter(s) with one or two cuffs, with straight, coiled, Swan-Neck, or other modifications led to the randomized controlled studies that are reviewed in this paper. Several studies have confirmed that mupirocin, applied at the exit-site as part of regular exit-site care, reduces the risk of S. aureus exit-site and tunnel infections. Recently, the emergence on a world-wide basis of mupirocin-resistant S. aureus (MuRSA) in peritoneal dialysis patients has brought this prophylactic strategy into question. However the low frequency of resistant organisms after four years of mupirocin prophylaxis suggests that we can continue its use with annual surveillance. Once established, exit-site infections may respond to appropriate treatment, but if not the only option may be catheter removal and replacement. Although peritonitis risk has decreased over the past decade, mainly due to improvements in connection technology, exit-site and tunnel infections have not. An exit-site infection that does not respond to treatment may lead to tunnel infection and to persistent peritonitis, which may require catheter removal and occasionally discontinuation of the peritoneal dialysis. Therefore it is important to be familiar with these factors that predispose to exit-site infection and to know how to prevent and to treat such infections. This review will discuss factors that predispose to catheter-related exit-site infections, techniques of exit-site care, and ways to prevent exit-site infection, with emphasis on S. aureus infections and their treatment. PMID: 14521167 [PubMed - indexed for MEDLINE

1: J Am Soc Nephrol. 2005 Feb;16(2):539-45. Epub 2004 Dec 29.

Links Randomized, double-blind trial of antibiotic exit site cream for prevention of exit site infection in peritoneal dialysis patients. Bernardini J, Bender F, Florio T, Sloand J, Palmmontalbano L, Fried L, Piraino B. Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.

Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P = 0.005). Time to first catheter infection was longer using gentamicin (P = 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P = 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P = 0.03), with a striking decrease in Gramnegative peritonitis (0.02/yr versus 0.15/yr; P = 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients. PMID: 15625071 [PubMed - indexed for MEDLINE

1: Contrib Nephrol. 2006;150:181-6.

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Peritoneal dialysis infections recommendations. Piraino B. University of Pittsburgh, PA 15213, USA. [email protected]

Peritonitis remains a serious problem in peritoneal dialysis patients accounting for technique failure and contributing to mortality. Many peritonitis episodes are due to contamination at the time of the exchange and exit site infections. Protocols can be implemented by programs to diminish the risk of infection. Careful training, especially in handwashing technique and in doing the connection, are critical for preventing contamination related peritonitis. Peritonitis due to exit site infections can be reduced by use of exit site antibiotic cream. Gentamicin as opposed to mupirocin exit site prophylaxis reduces not only S. aureus but also P. aeruginosa infections. Refractory exit site infections can be managed with simultaneous catheter replacement. Once peritonitis occurs, prompt institution of empiric antibiotics, dictated by the history of the program's infections, should be done. Initial therapy is then modified once the culture results are known. Catheters require removal if the peritonitis fails to resolve within 5 days of appropriate antibiotic therapy or if peritonitis is relapsing. Fungal peritonitis is best treated with prompt catheter removal. Implementation of protocols to prevent peritonitis and careful attention to both the organisms causing peritonitis and the rate of infection by a peritoneal dialysis center are essential for reducing infectious complications. Once infections occur, rapid steps to treat and manage are important to diminish the risk of mortality and subsequent peritoneal damage, areas requiring more research. PMID: 16721009 [PubMed - indexed for MEDLINE

1: Kidney Int Suppl. 2006 Nov;(103):S44-54. Links

Prevention of infectious complications in peritoneal dialysis: best demonstrated practices. Bender FH, Bernardini J, Piraino B. Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA. [email protected]

Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk. PMID: 17080111 [PubMed - indexed for MEDLINE]

1: Adv Ren Replace Ther. 2000 Oct;7(4):280-8. Links

Peritoneal infections. Piraino B. Renal Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. [email protected]

Peritoneal dialysis related infections include infection of the catheter exit site, subcutaneous pathway, or effluent. Exit-site infections, predominately owing to Staphylococcus aureus, are defined as purulent drainage at the exit site, although erythema may be a less serious type of exit-site infection. Tunnel infections are underdiagnosed clinically, and sonography of the tunnel is useful to delineate the extent of the infection and to evaluate response to antibiotic therapy. S aureus infections occur more frequently in S aureus carriers and immunosuppressed patients and can be reduced by mupirocin prophylaxis either intranasally or at the exit site. Patients with peritonitis present with cloudy effluent and usually pain, although 6% of patients may initially have pain without cloudy effluent. A white blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear cells, has long been the hallmark of peritonitis. Empiric therapy is controversial, with some recommending cefazolin and others vancomycin (with cefatazidime for Gram-negative coverage). The choice should depend on the center's antibiotic sensitivity profile; those centers with a high rate of Enterococcus- or methicillin resistant organisms should use vancomcycin. Peritonitis episodes occurring in association with a tunnel infection with the same organism seldom resolve with antibiotics and require catheter removal. Other indications for catheter removal are refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff involvement that does not respond to antibiotic therapy (based on ultrasound criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal pathology. Centers can reduce dialysis related infections to very low levels by proper catheter selection and insertion, careful selection and training of patients, avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus. Further research is required to identify methods to reduce the risk of enteric peritonitis. Copyright 2000 by the National Kidney Foundation, Inc. PMID: 11073560 [PubMed - indexed for MEDLINE

1: Semin Dial. 2001 Jan-Feb;14(1):50-4.

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Dialysate leaks in peritoneal dialysis. Leblanc M, Ouimet D, Pichette V. Nephrology Division, Maisonneuve-Rosemont Hospital, University of Montreal, Quebec, Canada.

Dialysate leakage represents a major noninfectious complication of peritoneal dialysis (PD). An exit-site leak refers to the appearance of any moisture around the PD catheter identified as dialysate; however, the spectrum of dialysate leaks also includes any dialysate loss from the peritoneal cavity other than via the lumen of the catheter. The incidence of dialysate leakage is somewhat more than 5% in continuous ambulatory peritoneal dialysis (CAPD) patients, but this percentage probably underestimates the number of early leaks. The incidence of hydrothorax or pleural leak as a complication of PD remains unclear. Factors identified as potentially related to dialysate leakage are those related to the technique of PD catheter insertion, the way PD is initiated, and weakness of the abdominal wall. The pediatric literature tends to favor Tenckhoff catheters over other catheters as being superior with respect to dialysate leakage, but no consensus on catheter choice exists for adults in this regard. An association has been found between early leaks (< or =30 days) and immediate CAPD initiation and perhaps median catheter insertion. Risk factors contributing to abdominal weakness appear to predispose mostly to late leaks; one or more of them can generally be identified in the majority of patients. Early leakage most often manifests as a pericatheter leak. Late leaks may present more subtly with subcutaneous swelling and edema, weight gain, peripheral or genital edema, and apparent ultrafiltration failure. Dyspnea is the first clinical clue to the diagnosis of a pleural leak. Late leaks tend to develop during the first year of CAPD. The most widely used approach to determine the exact site of the leakage is with computed tomography after infusion of 2 L of dialysis fluid containing radiocontrast material. Treatments for dialysate leaks include surgical repair, temporary transfer to hemodialysis, lower dialysate volumes, and PD with a cycler. Recent recommendation propose a standard approach to the treatment of early and late dialysate leaks: 1-2 weeks of rest from CAPD, and surgery if recurrence. Surgical repair has been strongly suggested for leakage causing genital swelling. Delaying CAPD for 14 days after catheter insertion may prevent early leakage. Initiating CAPD with low dialysate volume has also been recommended as a good practice measure. Although peritonitis and exit-site infections are the most frequent causes of technical failure in peritoneal dialysis (PD), dialysate leaks represent one of the major noninfectious complications of PD. In some instances, dialysate leakage may lead to discontinuation of the technique (1). Despite its importance, the incidence, risk factors, management, and outcome of dialysate leakage are poorly characterized in the literature. We will review the limited available information on this topic in the next few sections. PMID: 11208040 [PubMed - indexed for MEDLINE]

Adv Ren Replace Ther. 1998 Jul;5(3):157-67. Links

Erratum in: Adv Ren Replace Ther 1998 Oct;5(4):353.

Sclerosing peritonitis in continuous ambulatory peritoneal dialysis patients: one center's experience and review of the literature. Afthentopoulos IE, Passadakis P, Oreopoulos DG, Bargman J. Toronto Western Hospital, Ontario, Canada.

Sclerosing peritonitis (SP) is a severe life-threatening condition for patients undergoing continuous ambulatory peritoneal dialysis (CAPD). This report reviews our experience and that reported in the literature concerning the prevalence of SP in CAPD patients, predisposing factors, and in particular, the role of peritonitis, its clinical presentation, diagnosis, treatment, and prevention. A total of 1,288 endstage renal disease (ESRD) patients entered our peritoneal dialysis (PD) program between September 1977 and September 1997, seven of whom (0.54%) developed SP. The annual incidence of SP was 0.37 per 1,000 patient years, male-to-female ratio was 2.5 (M/F:5/2), mean age was 39+/-16 (median, 37; range, 23 to 61) years, and the median duration on CAPD was 62 (range, 12 to 144) months. Five patients were on CAPD for > or =4 years and two for less than 4 years before they were diagnosed with SP. All SP patients presented with clinical symptoms suggestive of intestinal obstruction, and five patients had decreased solute or fluid removal and had to increase the daily dialysate volume (3/7) or the tonicity of the fluid (4.25%) (3/7) or to combine a regular hemodialysis (HD) session with CAPD (2/7). There was a mean weight loss of 5+/-6 (median, 2; range, 0 to 18) kg. All patients had an episode of peritonitis at a mean time of 2+/-1 (median, 1; range, 1 to 3) months before the diagnosis of SP. The peritonitis was due to Staphylococcus aureus in four and Staphylococcus epidermidis, fungi, and Escherichia coli in one each. The definitive diagnosis of SP was established by laparotomy in four patients or postmortem examination in one patient, while in the remaining two there was no surgical confirmation; however, we believe the diagnosis was extremely likely because of the presence of clinical and radiologic criteria for SP. After the diagnosis of SP, all patients had their catheters removed, CAPD was discontinued permanently, and they were transferred to HD. Although there are isolated case reports of successful outcomes after surgical intervention, especially in patients in whom a peritoneal "cocoon" is related to severe peritonitis, usually the prognosis following surgery is poor. Treatment with immunosuppressive agents has been reported to be beneficial in the treatment of SP, although this has not been confirmed by all investigators. Among our SP patients, five (72%) died of sepsis (3/5) in a mean period of 10+/-5 (median, 9; range, 6 to 17) months after the diagnosis of SP and two are still alive on HD. SP is a rare but serious complication of CAPD. Severe peritonitis, especially in patients on dialysis for more than 4 years, may lead to SP As the prevalence of SP increases in patients on long-term CAPD, early detection is important because of the high morbidity and mortality associated with this condition. PMID: 9686626 [PubMed - indexed for MEDLINE

1: Dig Surg. 1998;15(6):697-702.

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Sclerosing encapsulating peritonitis: early and late results of surgical management in 32 cases. French Associations for Surgical Research. Célicout B, Levard H, Hay J, Msika S, Fingerhut A, Pelissier E. Clinique des Presles, Epinay-sur-Seine, France.

OBJECTIVE: To propose guidelines for treatment based on the study of early and late outcome after various surgical procedures for sclerosing encapsulating peritonitis (SEP). PRIMARY BACKGROUND DATA: SEP is rare. The main complication is intestinal obstruction. Ideal treatment is resection of the membrane, whenever possible. Mortality and morbidity, however, have not been well analyzed. METHODS: The case records and histopathological reports of 32 operated cases of SEP (18 centers during 16 years) were retrospectively studied. Patients underwent four types of procedures: group 1 (n = 5), membrane resection; group 2 (n = 12), enterolysis with partial excision of the membrane; group 3 (n = 7), intestinal resection, and group 4 (n = 8), exploratory laparotomy only. Five cases were considered as idiopathic. Medical and surgical antecedent history for the 27 other cases (6 patients had associations) included laparotomy for carcinoma (n = 14) or benign disorders (n = 5), beta-blocker treatment (n = 4), cirrhotic ascites (n = 4), generalized peritonitis (n = 3) and continuous ambulatory peritoneal dialysis (n = 3). Indications for operation included subacute (n = 22) or acute intestinal obstruction (n = 6), abdominal mass (n = 8), other clinical presentations (n = 4) and asymptomatic SEP discovered during surgery for portacaval shunt (n = 1). Seven patients had two associated clinical presentations. All cirrhotic patients with ascites and the asymptomatic patient were in group 4. None of the imaging techniques (plain radiograms, barium follow-through, sonograms and CT scans) were formally contributive to the preoperative diagnosis of SEP. RESULTS: In group 1, both complicated patients, one with an inadvertent intraoperative intestinal wound, the other with a postoperative intestinal leak, healed uneventfully. In group 2, 4 inadvertent intraoperative intestinal wounds led to 4 postoperative leaks with 3 consequent deaths. One further patient died of persistent intestinal obstruction. In group 3, 1 inadvertent intestinal intraoperative wound healed uneventfully and 2 deaths, one due to persistent intestinal obstruction associated with anastomotic leakage and the other due to ventricular fibrillation, were noted. In group 4, there were no intraoperative wounds, no postoperative morbidity or deaths. The median follow-up was 49.5 months (range 4-142 months). Seven patients (1 or 2 in each group) experienced transient episodes of subacute intestinal obstruction between 1 month and 6 years after discharge, none of which required a repeat operation. Eight patients (in all groups) died of their initial cancer between 4 and 75 months after discharge. CONCLUSIONS: Our results suggest that: (1) resection of the membrane

should be attempted when feasible; (2) in case of inadvertent intestinal wound(s), the most proximal one should be brought out as a stoma, and partial resections should not be anastomosed primarily, but (3) no surgical treatment is required in ascites, asymptomatic SEP or subacute intestinal obstruction. PMID: 9845640 [PubMed - indexed for MEDLINE]

1: Adv Perit Dial. 1990;6:64-71. Links

Early and late peritoneal dialysate leaks in patients on CAPD. Tzamaloukas AH, Gibel LJ, Eisenberg B, Goldman RS, Kanig SP, Zager PG, Elledge L, Wood B, Simon D. Department of Medicine, Albuquerque V.A. Medical Center.

Dialysate leaks, which occurred in 386 CAPD patients over 11 years, were analyzed retrospectively. 18 patients developed 21 early leaks (within 30 days of catheter insertion) and 18 patients developed 28 late leaks (beyond 30 days of catheter insertion). 8 patients had multiple (2-6) leaks. Both early and late leaks, particularly if they were multiple, were associated with conditions that affect adversely tissue healing and tensile strength. Median surgical insertion was apparently associated with a higher incidence of early leaks. Early leaks were manifested externally, usually through the exit site, and did not require imaging. Late leaks were manifested usually by poor dialysate outflow, localized edema and subcutaneous fluid collections. One third of the late leaks required radiological imaging. Hernias caused 42% of the late leaks. Early leaks were managed by temporary discontinuation of CAPD alone (57%) or surgery. Most late leaks (67%) required surgery. Conservative means (change to IPD, observation) were applied for the management of a few late leaks. Both early and late leaks resulted frequently in replacement of peritoneal catheters, but only late leaks resulted in permanent discontinuation of peritoneal dialysis. Paramedian surgical insertion, waiting period of 10-14 days between catheter insertion and initiation of CAPD, and low starting dialysate volumes have resulted in apparent reduction of the incidence of the early, but not of the late leaks. Dialysate leaks have serious consequences on the performance of CAPD. Early leaks differ from late leaks in some clinical manifestations. Preventive measures have decreased the incidence of early, but not of the late leaks. PMID: 1982843 [PubMed - indexed for MEDLINE]

1: Perit Dial Int. 2003 May-Jun;23(3):249-54.

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Risk factors for abdominal wall complications in peritoneal dialysis patients. Del Peso G, Bajo MA, Costero O, Hevia C, Gil F, Díaz C, Aguilera A, Selgas R. Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain. [email protected]

BACKGROUND: Patients treated with peritoneal dialysis (PD) have increased intraabdominal pressure and a high prevalence of abdominal wall complications. OBJECTIVE:The purpose of this study was to determine the incidence of hernias and peritoneal leaks in our PD patients and to investigate their potential risk factors. PATIENTS: We studied 142 unselected patients treated with PD during the past 5 years, including those that were already on PD and those that started PD during this period. Mean age was 54 years and mean follow-up on PD was 39 months. 72 patients had been treated with only continuous ambulatory PD (CAPD), 8 with automated PD (APD), and 62 with both modalities. RESULTS: 53 patients (37%) developed hernia and/or leak. A total of 39 hernias and 63 leaks were registered. The overall rates were 0.08 hernias/patient/year and 0.13 leaks/patient/year. 17 patients had both abdominal complications. Hernia was most frequently located in the umbilical region, and the most frequent site of leakage was the pericatheter area. Both complications appeared more frequently during the CAPD period (87% of hernias, 81% of leaks). The rate of hernias was higher in patients treated only with CAPD than in those that used only cyclers [0.08 vs 0.01 hernias/patient/year, not significant (NS)]. No patient treated only with APD had peritoneal leak; 25% (18/72) of patients treated with CAPD developed this complication (p = 0.18, NS). Dialysate exchange volumes ranged from 2000 to 2800 mL. 25 (66%) patients required surgical repair of the hernia, with recurrence in 7 patients (28%). 27 (84%) patients with leaks were initially treated with transitory temporary transfer to hemodialysis, low volume APD, or intermittent PD for 4 weeks. The leak recurred in half of the cases and surgical repair was necessary in 12 cases. The development of hernia and/or leak did not correlate with gender, diabetes, duration of follow-up, type of PD, history of abdominal surgery, or with the largest peritoneal exchange volume used. Polycystic kidney disease was the only factor associated with higher rate of hernias (p = 0.005), whereas increased age (p = 0.04) and higher body mass index (p = 0.03) were significantly associated with the appearance of leaks. CONCLUSION: Abdominal hernias and peritoneal leaks are very frequent in the PD population. Advanced age, polycystic kidney disease, and high body mass index are independent risk factors for their development. Automated PD with low daytime fill volume should be considered in all patients at risk for hernias and/or leaks. PMID: 12938825 [PubMed - indexed for MEDLINE

1: Nephrol Dial Transplant. 2007 May;22(5):1437-44. Epub 2007 Feb 17.

Links Intraperitoneal pressure in PD patients: relationship to intraperitoneal volume, body size and PD-related complications. Dejardin A, Robert A, Goffin E. Department of Nephrology, Université catholique de Louvain, Brussels, Belgium.

BACKGROUND: The clinical determinants of intraperitoneal pressure (IPP) are ill defined, and the potential impact of elevated IPP on peritoneal dialysis (PD)-related complications is still a matter of debate. We measured IPP in newly started PD patients, assessed its clinical determinants and analysed the incidence of PD-related complications. METHOD: IPP was measured in 61 consecutive patients [46 males and 15 females, 47 automated peritoneal dialysis (APD) and 14 continuous ambulatory peritoneal dialysis (CAPD), aged: 52+/-17 years], an average of 2 months after PD onset, using increasing (from 0 to 3000 ml) dialysate volumes. The prescription of day and night dialysate infusion volumes was made to avoid IPP>16 cm H2O. We assessed the relationship between baseline clinical characteristics and IPP and the putative influence of IPP on subsequent PD-related complications, such as hernias, late leakage, gastro-oesophageal reflux (GOR) and enteric peritonitis (EP). IPP at the time of the complication was computed by linear interpolation across available couples of data (volume and IPP). Correlations were assessed using Pearson's r; Kaplan-Meier survival curves with log-rank test were used for complication occurrence analysis. RESULTS: At baseline, mean IPP was 13.5+/-3.3 (5-22.5) cm H2O for 2000 ml inflow; IPP rose linearly as intraperitoneal volume (IPV) increased [R2=0.96, 95% CI (0.88; 1.00)]. IPP was significantly higher in patients with a higher body mass index (BMI) (P=0.03) but age, gender, weight, height, body surface area (BSA), diabetes mellitus or a past history of abdominal surgery did not correlate with IPP. Incidence of abdominal wall complications or GOR was not correlated with IPP. Patients with a night IPP>14 cm H2O had a higher incidence of EP (P=0.039) and a worse survival free of EP (P=0.03). CONCLUSION: This study shows a strong linear correlation between IPP and IPV, a significant impact of BMI on IPP and a higher incidence of EP in patients with higher IPP. We recommend to measure IPP in PD patients to guide the prescription of intraperitoneal volumes. PMID: 17308323 [PubMed - indexed for MEDLINE

1: Adv Perit Dial. 1998;14:105-7. Links

The risk of hernia with large exchange volumes. Hussain SI, Bernardini J, Piraino B. University of Pittsburgh School of Medicine, Renal Electrolyte Division, Pennsylvania, USA.

Large exchange volumes of 2.5 and 3 L are frequently necessary to improve clearances to the level suggested by the DOQI guidelines. However, abdominal wall hernias are a well known complication of peritoneal dialysis (PD) related to increased abdominal pressure, and might increase with higher exchange volumes. We studied the effect of using higher exchange volumes in PD patients on the incidence of hernia formation. Seventy-nine (12%) of 656 PD patients over a 15year span developed abdominal wall hernias. Eleven percent of patients using 2 L or smaller volumes, 15% of patients using more than 2 L but less than 3 L, and 13% of patients using 3 L developed hernias (not significantly different). Five percent of patients on cyclers for their entire PD experience (3 of 63 patients) developed one or more hernias, compared to 13% of patients on continuous ambulatory peritoneal dialysis for at least part of their experience (P = 0.06). The use of larger volumes increased dramatically over time; only 11% of patients used more than 2-L exchange volumes during the years 1982 through 1986, compared to 73% in the period from 1992 to 1997. We conclude that increased volumes in PD patients do not lead to an increased risk of hernia formation. Exchange volumes can be increased as needed to improve clearances. PMID: 10649704 [PubMed - indexed for MEDLINE]

1: Kidney Int Suppl. 2006 Nov;(103):S96-S103. Links

The role of tidal peritoneal dialysis in modern practice: A European perspective. Vychytil A, Hörl WH. Department of Medicine III, Division of Nephrology and Dialysis, Medical University Vienna, Vienna, Austria. [email protected]

Tidal peritoneal dialysis (TPD) has been introduced to optimize adequacy of peritoneal dialysis (PD). Early studies reported similar or even better small solute clearances with TPD than those achieved with continuous ambulatory peritoneal dialysis or continuous cyclic peritoneal dialysis. However, in many studies treatment volumes were much higher during TPD compared with other PD modalities. Based on current evidence, TPD provides no advantage of increased small solute clearances, middle molecule clearances, or peritoneal ultrafiltration as compared to non-tidal automated peritoneal dialysis (APD) when dialysate flow is kept constant. However, TPD reduces drainage pain and nightly alarms during cycler treatment. Tidal volume should be kept as high as possible in these patients, especially in those with low average peritoneal transport rates. Based on theoretical considerations and little evidence, TPD could provide better clearances than conventional APD when a very high dialysate flow (>or=5 l/h) is used. Such dialysate flow rates are not routinely prescribed in home APD patients. However, they may be interesting for incenter PD patients. One randomized crossover trial reported higher small solute clearances with TPD compared to non-tidal APD in patients with acute renal failure. TPD is also the preferred treatment modality in patients with ascites as it allows a controlled outflow of fluid from the peritoneal cavity. Newer treatment modalities, for example, continuous flow PD, may be interesting alternatives in an effort to increase efficacy of PD in the future. However, because such treatment regimens are expensive and elaborate they have not been established for routine use until now. PMID: 17080119 [PubMed - indexed for MEDLINE]

1: Kidney Int Suppl. 2006 Nov;(103):S91-5. Links

Tidal PD: its role in the current practice of peritoneal dialysis. Fernando SK, Finkelstein FO. New Haven CPD, Renal Research Institute, St Raphael's Hospital, Yale University School of Medicine, New Haven, CT 06511, USA.

The role of tidal peritoneal dialysis (TPD) has been the subject of several studies over the past 30 years. The use of the newest generation of cyclers combined with the increasing number of chronic peritoneal dialysis (CPD) patients being maintained on cycler therapy has stimulated a reexamination of the role of TPD in the care of CPD patients. Several studies over the past decade have examined solute clearances with TPD in patients. These studies suggest that TPD does not result in an increase in clearances when compared to conventional intermittent peritoneal dialysis (IPD). TPD is now primarily used for comfort in patients who experience pain at the start of inflow and/or at the end of outflow. In TPD, the presence of at least some fluid in the abdomen during the exchanges generally eliminates these episodes of pain. It has recently been suggested that accurate assessment of drain and fill phases during automated PD may be helpful in redefining a role for TPD in CPD patients. If the 'slow' drainage time can be kept to a minimum, then it is possible that the efficiency of PD could be enhanced. Defining the critical volume and then optimizing the TPD regimen could perhaps increase the clearances noted with TPD. PMID: 17080118 [PubMed - indexed for MEDLINE]

1: Minerva Urol Nefrol. 2006 Jun;58(2):161-9. Links

Preventing peritoneal dialysis related infections. Piraino B. Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. [email protected]

Peritonitis is still a serious problem in peritoneal dialysis (PD) patients and is associated with mortality. To improve outcomes in PD patients, attention must be focused on preventing peritonitis. This involves attention to training, connection methodologies, PD catheter insertion protocols. To prevent catheter-related peritonitis, the use of gentamicin cream at the exit site for daily routine care is recommended. Other causes of peritonitis include bowel sources, fungal overgrowth often related to prolonged antibiotic care, and peritonitis secondary to procedures. Relapsing peritonitis and refractory exit site infections should be managed by replacing the catheter. Every PD program needs to closely examine every episode to determine the cause, and then undertake an approach to prevent further episodes. PMID: 16767069 [PubMed - indexed for MEDLINE]

1: Perit Dial Int. 2005 Mar-Apr;25(2):132-9.

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Peritoneal catheters and exit-site practices toward optimum peritoneal access: a review of current developments. Flanigan M, Gokal R. University of Iowa, University of Iowa Hospitals, Department of Medicine, Iowa City, IA 52240-4060, USA. [email protected]

OBJECTIVE: This review updates the 1998 International Society for Peritoneal Dialysis (ISPD) recommendations for peritoneal dialysis catheters and exit-site practices (Gokal R, et al. Peritoneal catheters and exit-site practices toward optimum peritonealaccess: 1998 update. Perit Dial Int 1998; 18:11-33.) DESIGN: DATA SOURCES: The Ovid and PubMed search engines were used to review the Medline databases of January 1980 through June 2003. Searches were restricted to human data; primary key word searches included dialysis, peritoneal dialysis, and continuous ambulatory peritoneal dialysis cross referenced with access, catheter, dialysis catheter, peritoneal dialysis catheter, and Tenckhoff catheter. Related searches were provided via the PubMed related articles link. Study Selection: Reports were selected if they provided identifiable information on catheter design, catheter placement technique, and survival or placement complications. Reports without such data were excluded from review. Each study was then categorized by its characteristics: single-center or multicenter; retrospective or prospective; controlled trial, with or without random patient assignment; or review article. MAIN RESULTS: There are few randomized controlled evaluations testing how catheter design and/or placement influence long-term survival and function, and these are typically conducted at a single center. The majority of reports represent retrospective single-center experiences, and these are supplemented by occasional multicenter data registries. CONCLUSIONS: There is substantial variability in catheter outcomes between centers, and this variability is more closely correlated with operator and center characteristics than with catheter design. Some catheter designs appear to impact long-term catheter success, and, in some cases, specific patient characteristics and dialysis formats combine with specific catheter designs to influence catheter survival. Most reporters prefer two-cuff designs and placement of the deep cuff at an intramuscular location. Intramuscular cuff placement results in fewer pericatheter leaks and hernias, but makes catheter removal more difficult. High-risk patients (those with previous pelvic surgery) benefit from visual inspection of the peritoneum during catheter placement, and in randomized controlled trials, catheters with pre-shaped arcuate subcutaneous segments ("swan neck" designs) reduce the risk of early drainage failure via "migration." PMID: 15796138 [PubMed - indexed for MEDLINE]

1: Adv Perit Dial. 2006;22:147-52. Links

Current trends in the use of peritoneal dialysis catheters. Negoi D, Prowant BF, Twardowski ZJ. University of Missouri-Columbia, School of Medicine, Department of Medicine, Division of Nephrology, 65212, USA. [email protected]

The Tenckhoff catheter was developed in 1968 and has been widely used since for chronic peritoneal dialysis (PD) patients. Variations of the Tenckhoff catheter have been designed over the years in a search for the ideal PD catheter--an access that can provide reliable dialysate flow rates with few complications. Currently, data derived from randomized, controlled, multicenter trials dedicated to testing how catheter design and placement technique influence long-term catheter survival and function are scarce. As a result, no firm guidelines exist at the national or international levels on optimal PD catheter type or implantation technique. Also, no current statistics on the use of PD catheters are available. The last survey was carried out using an audience response system at the Annual Peritoneal Dialysis Conference in Orlando, Florida, in January 1994. The present analysis is based on a new survey done at the 2005 Annual Dialysis Conference in Tampa, Florida. It is a snapshot of preferences in catheter design and implantation technique in 2004 from an international sample of 65 respondent chronic PD centers. The Tenckhoff catheter remains the most widely used catheter, followed closely by the swan-neck catheter in both adult and pediatric respondent centers. Double-cuff catheters continue to be preferred over single-cuff catheters, and coiled intraperitoneal segments are generally preferred over straight intra-peritoneal segments. Surgical implantation technique remains the prevailing placement method in both pediatric and adult respondent centers. PMID: 16983959 [PubMed - indexed for MEDLINE]

1: Int J Artif Organs. 2006 Jan;29(1):2-40. Links

History of peritoneal access development. Twardowski ZJ. University of Missouri, Columbia, Missouri, USA. [email protected]

The first peritoneal accesses were devices that had been used in other fields (general surgery, urology, or gynecology): trocars, rubber catheters, and sump drains. In the period after World War II, numerous papers were published with various modifications of peritoneal dialysis. The majority of cases were treated with the continuous flow technique; rubber catheters for inflow and sump drains for outflow were commonly used. At the end of the 1940s, intermittent peritoneal dialysis started to be more frequently used. Severe complications of peritoneal accesses created incentive to design accesses specifically for peritoneal dialysis. The initial three, in the late 1940s, were modified sump drains; however, Ferris and Odel for the first time designed a soft, polyvinyl intraperitoneal tube with metal weights to keep the catheter tip in the pelvic gutter where the conditions for drain are the best. In the 1950s, intermittent peritoneal dialysis was established as the preferred technique; polyethylene and nylon catheters became commercially available and peritoneal dialysis was established as a valuable method for treatment of acute renal failure. The major breakthrough came in the 1960s. First of all, it was discovered that the silicone rubber was less irritating to the peritoneal membrane than other plastics. Then, it was found that polyester velour allowed an excellent tissue ingrowth creating a firm bond with the tissue. When a polyester cuff was glued to the catheter, it restricted catheter movement and created a closed tunnel between the integument and the peritoneal cavity. In 1968, Tenckhoff and Schechter combined these two features and designed a silicone rubber catheter with a polyester cuff for treatment of acute renal failure and two cuffs for treatment of chronic renal failure. This was the most important development in peritoneal access. Technological evolution never ends. Multiple attempts have been made to eliminate remaining complications of the Tenckhoff catheter such as exit/tunnel infection, external cuff extrusion, migration leading to obstruction, dialysate leaks, recurrent peritonitis, and infusion or pressure pain. New designs combined the best features of the previous ones or incorporated new elements. Not all attempts have been successful, but many have. To prevent catheter migration, Di Paolo and his colleagues applied the old idea of providing weights at the catheter tips to Tenckhoff catheters. In another modification, Twardowski and his collaborators created a permanent bend to the intra-tunnel portion of the silicone catheter to eliminate cuff extrusions. The Tenckhoff catheter continues to be widely used for chronic peritoneal dialysis, although its use is decreasing in favor of swan-neck catheters. Soft, silicone rubber instead of rigid tubing virtually eliminated such early complications as bowel perforation or massive bleeding. Other complications, such as obstruction, pericatheter leaks, and superficial cuff extrusions have been markedly reduced in recent years, particularly with the use of swan-neck catheters and insertion through the rectus muscle instead of the midline. However, these complications still occur, so new designs are being tried.

PMID: 16485237 [PubMed - indexed for MEDLINE]

1: Adv Perit Dial. 2003;19:255-9. Links

Is it safe to simultaneously remove and replace infected peritoneal dialysis catheters? Review of the literature and suggested guidelines. Mitra A, Teitelbaum I. University of Colorado Health Sciences Center, Denver, Colorado, USA.

Since the introduction of Y-connector technology and the subsequent reduction in the frequency of peritonitis, catheter-related infections have become the primary infectious complication in patients on peritoneal dialysis (PD). Such infections may lead to prolonged morbidity, recurrent peritonitis, and catheter failure. Despite appropriate treatment of catheter-related infections, removal of the catheter is sometimes necessary. The timing of catheter removal and replacement has been the focus of significant discussion. The International Society for Peritoneal Dialysis recommends a 3-week interval, but also allows for individualized timing. Long staging periods present problems that simultaneous removal and replacement (SRR) of the catheter may obviate. Here, we review a body of literature on SRR and present guidelines as to when SRR of an infected PD catheter may be considered a safe alternative to a staged procedure. PMID: 14763074 [PubMed - indexed for MEDLINE]

1: G Ital Nefrol. 2007 Nov-Dec;24 Suppl 40:s42-9. Links

[Evaluation of peritoneal catheters and connection systems in peritoneal dialysis] [Article in Italian]

De Vecchi AF. UOC di Nefrologia e Dialisi, Fondazione Ospedale Maggiore, Policlinico Mangiagalli e Regina Elena, Milano. [email protected]

Evaluation of peritoneal catheters is based on the material, the number and type of cuffs, the length and intraperitoneal shape of the catheter, and its site of insertion. Final cost is another important issue which should take into account differences in the incidence of complications, in the number of hospitalizations, and in the simplicity of catheter insertion. Double-cuff catheters are used more than single-cuff catheters. The most commonly used catheter shapes are the classical Tenckhoff, the swan neck, the coil, and self-locating catheters. The latter are more expensive than Tenckhoff catheters but seem to offer some advantages, even if not sustained by adequate controlled trials so far. In addition, placement of these catheters may require different techniques or skills compared to the classical Tenckhoff. The most recent Italian guidelines based only on grade 1 and 2 evidence exclude that the type of catheter may influence the infection rate. There are no data from prospective controlled studies to evaluate the incidence of mechanical complications, hospitalization and technique survival. With regard to dialysis systems, it is still unclear if new plastic materials may offer any advantage over PVC. There is grade 1 evidence that Y-set and double-bag systems reduce the peritonitis rate compared to standard 1-way systems. The available data do not indicate significant differences in the incidence of peritonitis using Y-set compared with double-bag systems. The higher cost of double-bag systems is counteracted by shorter and easier training and by better acceptance by the patients. PMID: 18034411 [PubMed - indexed for MEDLINE