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

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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. Links

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. Links
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. ogunc@akdeniz.edu.tr

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. John.H.Crabree@kp.org

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. twardowskiz@health.missouri.edu

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. Links


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. gfmstrippoli@katamail.com

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, exit-
site/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, exit-
site/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. Links

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. gfmstrippoli@katamail.com

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. cbonifati@katamail.com

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. Links


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. kate.wiggins@svhm.org.au

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 first-
generation 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. Links


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. kwiggins@medstv.unimelb.edu.au

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 peritoneal-
dialysis-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 Gram-
negative 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. Links

Peritoneal dialysis infections recommendations.

Piraino B.

University of Pittsburgh, PA 15213, USA. piraino@pitt.edu

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. benderf@dom.pitt.edu

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. piraino@msx.dept-med.pitt.edu

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. Links


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 end-
stage 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. Links

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. Links

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. gpeso@hulp.insalud.es

BACKGROUND: Patients treated with peritoneal dialysis (PD) have increased intra-
abdominal 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 15-
year 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. andreas.vychytil@meduniwien.ac.at

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 in-
center 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.
Piraino@pitt.edu

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. Links

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. michael-flanigan@uiowa.edu

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. negoid@health.missouri.edu

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. twardowskiz@health.missouri.edu

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. deveccpd@policlinico.mi.it

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