Frequent problems in peritoneal dialysis PD

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					 Frequent problems in
peritoneal dialysis (PD)

      Martina Pechula Thut
       December 3, 2008




                             Spital Zollikerberg
                  Agenda
•   Introduction
    – Historical excurse
    – Some facts and figures

•   Frequent problems
    – Peritonitis
      • Exit site and tunnel infection
    – Peritoneal membrane: structure changes
 Historical view
                                      Stephen Hales: rinsing of the
                                      peritoneum with wine and
                                      Bristol water (1744)




Ganter: „Ueber die Beseitigung
giftiger Stoffe aus dem Blute durch
Dialyse“ Münch Med
Wochenschrift 1923




                 1976 landmark
                 paper: CAPD
                            Historical View



PD solutions in big glass bottles until 1978




                                        Tenckhoff H. 1968
        Worldwide Situation

• Around 950‘000 on hemodialysis

• Only around 130‘000 on PD

• In Switzerland around 8.6% on PD
  November 2008
In the long run PD has same death
             rate as HD




                J Am Soc Nephrol 2003: 14; 2851-60
    PD improves prognosis after
          transplantation

 Graft
 survival



Recipient
 survival

                           Golfarb-Rumyanzev et al.
                           Am J Kidney Dis 2005
             Scheme of PD
                            Solutions

Peritoneum




                             Catheter
 A close-up of a normal peritoneal
            membrane




After Nolphe. Textbook of
peritoneal dialysis Kluwer 1994
  How the three-pore model
        explains PD




                       Comp Clin Nephrology
Diffusion/Convection   2007
Drained peritoneal volume as a
    function of dwell time
              Synopsis of PD problems

Infectious                         Non-infectious
Peritonitis    Peritoneal       Peritoneum      Intra-          Metabolic
               catheter         and solutions   abdominal       changes
               related                          pressure
Exit site                       Pain
               Dislocation                      Hernia
                                UF-failure
               Leak                             Leak
Tunnel                          Encapsulated
infection      Cuff Extrusion   peritoneal      Lumbalgia
                                sklerosis
               Intestinal
               perforation                      Reflux
                                                Gastroparesis


                Hemoperitoneum
Peritonitis – have a look!
      Evolutions in PD and impact on
              peritonitis rate
                          35
Peritonitis rate (pmts)

                                                                  disconnect
                          30
                          25
                                                                   Y-Set
                          20
                                                       Titanium
                          15                 Plastic
                                             bags
                          10
                                   Glass
                          5        bottles


                          0
                               1970 1975 1980 1985 1990 1995 2000
                                                                           ISPD 2005
                               In Zurich: 1/52pmts
Infections make up for almost 50
percent of all PD hospitalizations

         11%    Peritonitis
                   25%        Peritonitis
                              other infections
   27%                        operation
                              cardial problems
                 19%
                              other
          18%


                                Fried et all. AJKD 1999
Reasons for switching from PD to
  HD have changed over time
50
45
40
35
30
25                                                                        1978-1998
20                                                                        1999-2004
15
10
 5
 0
     Peritonitis   Burn out    UF Failure      Quality      Operation



                              Lameire N, Van Biesen W. Blod Purif. 2006
       Definition of Peritonitis
1. Cloudy bag

2. > 100 white blood cells/mm3
   (neutrophils > 50%)

3. Abdominal pain

4. Identify the type of causative organisme

                            Piraino B et al. Perit Dial Int 2005
 Minimum standard for peritonitis
             rate
• One peritonitis per 18 patient-months
  (or 0.67 per one patient-year)




ISPD Guidlines 2005
Most PD-patients never have a
         peritonitis
# of peritonitis; percent of all patients
                                3   4
                        2
                                3 5
                            3


               1
                   25


                                             65
                                                  no




                                            Finkelstein ES, et al. AJKD 2002
                       Etiology of Peritonitis
touch contamination


   catheter realated


   enteral problems


    perioperatively


       diarrhoe/UTI


             sepsis


          unknown


                                                                          %
                       0   10    20   30        40             50
                                           Harwell. Perit Dial Int 1997
Staphylococcus aureus at work




 HPML=Mesothel; PMO= Macrophagen;
                                      Topley N et al.
 PMN=Neutrophile; HPFB=Fibroblasten
                                      Immunology 1996,
                                      Kidney Int. 1994
        Prevention of Peritonitis

• Enhanced training

• Improved exit site care

• Antibiotic cover at catheter insertion

• S.aureus nasal carriage to prevent peritonitis with
  this organism

• Local use of mupirocin or gentamicin
                            Piraino B et al: Perit Dial Int 2005
                            Bernardini J et al: J Am Soc Nephrol 2005
                            Hall G et al: Nephrol Nurs J 2004
Mupirocin or Gentamicin cream
       for prevention?




      Lim et al. NDT 2005   Bernardini J. et al. JASN 2005
‚Mit Kanonen auf Spatzen
       Schiessen?‘
   Exit site Infection (ESI) – a clinical
                 diagnosis




                                          Cortesy: R. Cleeren, USZ


ESI Score (positiv >4 points): swelling, crusting, pain and
discharge (1-2 points)
 ESI prevention




No local antibiotics
Local NaCl 0.9%

                       Cortesy: R. Cleeren, USZ
Tunnel infection
         Therapy is empirical

According to center and local microbiological
situation

Initial therapy to cover gram negativ and positiv
organisme

Vancomycin, Cephalosporins and
Aminoglycosides

                              Piraino et al. Perit Dial Int 2005
       Longterm changes of peritoneal
           membrane through the
                microskope




Fusshöller A. Pediatr Nephrol 2008   Yanez-Mo et al. N Engl J Med 2003
Peritoneal membrane thickening
kicks-in after about 4 to 6 years




                       Williams JD. Et al. JASN 2002
What do we find in peritoneal
  membrane thickening




           Aroiera LS et al. JASN 2007
What happens
Why it happens
Some solutions cause lower
  concentration of GDPs




Schalkwijk et al. Perit Dial Int 2000;20:796
   Positive long-term effect of
ACEI/ARB on peritoneal membrane




                Kolesnyk I. et al. NDT 2008
                  Closing remarks
Mortality in PD is equal to       Both, infections and
                              6
HD                                solutions may cause
                                  changes of peritoneal
                                  membrane structure and
                                  function
Peritonitis and ESI
continue to be the most
frequent problems in PD
                                  The knowleage of
                                  pathophysiological
                                  mechanism of peritoneal
Enhanced training and             membrane in PD is in
improved ES care are              progress. It will be a key
important preventive              factor to improve PD and
measures                          finally its acceptance.
Thank you for your attention!

				
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