Complications in Peritoneal Dialysis: Peritonitis and Exit -Site Infections
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Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis–associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data. Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis–associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data.
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Abstract The percentage of end‐stage renal disease (ESRD) patients in the United States maintained on continuous peritoneal dialysis (CPD) therapy is decreasing. Complications from CPD therapy, including peritonitis, may be the reason for the decline. Improvements in CPD technology and a better understanding of the risk factors that predispose patients to the development of peritonitis have been responsible for a decline in the rate of peritonitis. Yet peritonitis remains a significant cause of patient morbidity and mortality and the overall outcome of peritonitis is not acceptable. Factors that have limited our ability to lessen the impact of peritonitis include a lack of data on dosing antibiotics in patients on continuous cycling peritoneal dialysis (CCPD) therapy, a lack of knowledge concerning the biology of bacterial biofilm, and the development of resistance to the current prophylactic antibiotic protocols. Further studies are needed concerning the optimal management of the peritoneal catheter and whether it is feasible to resume CPD therapy after catheter removal.
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Peritoneal dialysis is an effective form of renal replacement therapy. Despite improvements in connection technology, peritoneal infection is still the most important preventable cause of patient morbidity and mortality. There has been a shift in focus from treatment to prevention of infection, but wide variation in peritonitis incidence across and within peritoneal dialysis populations remains. This minireview aims to highlight current best practice, whilst discussing controversies in the diagnosis, prediction, prevention and management of peritonitis. Exit-site infection will not be discussed per se but only as it relates to peritonitis.
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Summary Two cases of peritonitis following insertion of an aortofemoral bypass graft are reported. In both, treatment with peritoneal lavage and postoperative dialysis was successful.
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Objective: to analyze the complications related to peritonitis and catheter exit-site infections, in patients on peritoneal dialysis at home.Method: quantitative and cross-sectional study, carried out with 90 patients on peritoneal dialysis at home, in a municipality in the Northeast region of Brazil. For data collection, it was used two structured scripts and consultation on medical records. Descriptive analysis and comparison tests among independent groups were used, considering p<0.05 as level of statistical significance.Results: by comparing the frequency of peritonitis and the length of treatment, it was found that patients over two years of peritoneal dialysis were more likely to develop peritonitis (X²=6.39; p=0.01). The number of episodes of peritoneal catheter exit-site infection showed association with the length of treatment (U=224,000; p=0.015).Conclusion: peritonitis and catheter exit-site infection are associated with the length of treatment.
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To determine if disconnect systems reduce the incidence of exit-site infections when compared to nondisconnect systems.We prospectively monitored exit-site infections and peritonitis rates in 96 disconnect patients (Y-set, automated peritoneal dialysis (APD)) and 60 nondisconnect patients (spike, ultraviolet connection device (UVXD)).A freestanding chronic peritoneal dialysis unit staffed by physicians from both a medical school and a private setting.All patients who began peritoneal dialysis at our unit were monitored, regardless of cause of end-stage renal disease (ESRD) or age.Patients were dialyzed using the system (Y-set, spike, etc.) most appropriate for their life-style and their ability to administer self-care.We attempted to follow disconnect and nondisconnect patients for a similar median time on dialysis and compared differences in exit-site infections.Peritonitis rates (episodes/pt year) were reduced for disconnect (0.60) versus nondisconnect (0.99) systems (p = 0.0006). Despite the marked reduction in peritonitis rates, there was no difference in exit-site infection rates (0.35 vs 0.38), the time to the first exit-site infection, or the time to the first catheter removal for disconnect versus nondisconnect groups. When individual systems were compared, differences in exit-site infection rates (episodes/pt years) were noted (0.62,spike; 0.26,UVXD; 0.32,Y-set; 0.41,APD).We found no overall difference in exit-site infection rates for disconnect versus nondisconnect systems, despite a reduction in peritonitis rates for disconnect systems.
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We report here a one-stitch fixation method that prevents catheter tip migration during implantation of the double-cuffed straight Tenckhoff catheter.From July 2003 to September 2005, 38 patients with end-stage renal disease underwent implantation of the double-cuff straight Tenckhoff catheter for peritoneal dialysis by this method.No patient had catheter tip migration out of the true pelvis. No patient had pericatheter dialysate leakage or developed incisional hernia. Two patients (5.3%) experienced exit-site infection during the 2- and 5-month follow-up and they recovered well after wound care. Three patients (7.9%) developed peritonitis during the 3-day and 2- and 6-month follow-up; the conditions were controlled after antibiotic care. One patient (2.6%) experienced mechanical catheter obstruction during the 10-day follow-up due to omental wrapping; surgical revision was necessitated.We believe that the method is an easy, safe, and effective technique for preventing catheter tip migration.
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