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Peritoneal Dialysis International :... Mar 2022Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and...
Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.
Topics: Anti-Bacterial Agents; Antibiotic Prophylaxis; Humans; Peritoneal Dialysis; Peritonitis; Renal Dialysis
PubMed: 35264029
DOI: 10.1177/08968608221080586 -
Clinical Journal of the American... Jul 2019Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have... (Review)
Review
Peritonitis is a common and severe complication in peritoneal dialysis (PD). Detailed recommendations on the prevention and treatment of PD-associated peritonitis have been published by the International Society for Peritoneal Dialysis (ISPD), but there is a substantial variation in clinical practice among dialysis units. Prophylactic antibiotics administered before PD catheter insertion, colonoscopy, or invasive gynecologic procedures, daily topical application of antibiotic cream or ointment to the catheter exit site, and prompt treatment of exit site or catheter infection are key measures to prevent PD-associated peritonitis. When a patient on PD presents with clinical features compatible with PD-associated peritonitis, empirical antibiotic therapy, with coverage of both Gram-positive and Gram-negative organisms (including species), should be started once the appropriate microbiologic specimens have been obtained. Intraperitoneal is the preferred route of administration. Antifungal prophylaxis, preferably oral nystatin, should be added to prevent secondary fungal peritonitis. Once the PD effluent Gram stain or culture and sensitivity results are available, antibiotic therapy can be adjusted accordingly. A detailed description on the dosage of individual antibiotic can be found in the latest recommendations by the ISPD. The duration of antibiotics is usually 2-3 weeks, depending on the specific organisms identified. Catheter removal and temporary hemodialysis support is recommended for refractory, relapsing, or fungal peritonitis. In some patients, a new PD catheter could be inserted after complete resolution of the peritonitis. PD catheter removal should also be considered for refractory exit site or tunnel infections. After the improvement in clinical practice, there is a worldwide trend of reduction in PD-associated peritonitis rate, supporting the use of PD as a first-line dialysis modality.
Topics: Anti-Bacterial Agents; Catheter-Related Infections; Humans; Peritoneal Dialysis; Peritonitis
PubMed: 31068338
DOI: 10.2215/CJN.14631218 -
BMJ Case Reports Feb 2020Peritoneal tuberculosis (TB) is one of the most challenging forms of extrapulmonary tuberculosis to diagnose. This challenge can be compounded in low incidence regions,...
Peritoneal tuberculosis (TB) is one of the most challenging forms of extrapulmonary tuberculosis to diagnose. This challenge can be compounded in low incidence regions, and in patients with cirrhosis in whom the presence of ascites alone may not prompt further investigation. A delay in the diagnosis and treatment of peritoneal tuberculosis may lead to worse clinical outcomes. This case describes a 64-year-old Italian male with decompensated cirrhosis being evaluated for liver transplantation, who developed abdominal pain and a persistent inflammatory ascites with peritoneal thickening despite antibiotic therapy. Peritoneal tuberculosis was suspected, although non-invasive and invasive direct mycobacterial testing remained negative. A constellation of positive QuantiFERON-TB Gold In-Tube test, elevated ascitic adenosine deaminase and dramatic symptomatic and radiographic response to empiric anti-tuberculous therapy confirmed the diagnosis of peritoneal tuberculosis. This paper will review the approach to the diagnosis of peritoneal tuberculosis.
Topics: Abdominal Pain; Ascites; Diagnosis, Differential; Hematologic Tests; Humans; Male; Middle Aged; Peritoneum; Peritonitis, Tuberculous; Positron-Emission Tomography
PubMed: 32033999
DOI: 10.1136/bcr-2019-233131 -
Kidney360 Feb 2023Incremental peritoneal dialysis (IPD) is a strategy of RRT that is based on the prescription of a lower dose rather than the standard full dose of peritoneal dialysis... (Review)
Review
Incremental peritoneal dialysis (IPD) is a strategy of RRT that is based on the prescription of a lower dose rather than the standard full dose of peritoneal dialysis (PD). The clearance goals are achieved through the combination of residual kidney function (RKF) and peritoneal clearance. The dialysis prescription should be increased as the RKF declines. IPD has been associated with clinical, economic, and environmental advantages. We emphasize possible better quality of life, fewer mechanical symptoms, lower costs, slight adverse metabolic effects, and less plastic waste and water consumption. The potential benefits for RKF preservation and the lower risk of peritonitis have also been discussed. There are some concerns regarding this strategy, such as inadequate clearance of uremic toxins and/or severe electrolyte disturbances due to undetected loss of RKF, lower clearance of medium-sized molecules (such as β-2-microglobulin) which mostly depends on the total PD dwell time, and patients' reluctance to dose adjustments. Current clinical evidence is based on moderate-quality to low-quality studies and suggests that the outcomes of IPD will be at least identical to those of full dose. This review aims to define IDP, discuss strategies for prescription, and review its advantages and disadvantages according to the current evidence.
Topics: Humans; Peritoneal Dialysis; Peritoneum; Prescriptions; Quality of Life; Renal Dialysis
PubMed: 36821618
DOI: 10.34067/KID.0006902022 -
Cleveland Clinic Journal of Medicine Apr 2023Ascites is the most common decompensation-associated complication of cirrhosis leading to reduced survival. Following significant development of antimicrobial resistance... (Review)
Review
Ascites is the most common decompensation-associated complication of cirrhosis leading to reduced survival. Following significant development of antimicrobial resistance and studies comparing therapeutic options, the American Association for the Study of Liver Diseases released a new guidance providing an in-depth review of those studies and updated guidelines based on expert opinions and emerging data. We review salient 2021 guidance recommendations to provide brief pearls for diagnosis and management of ascites and relevant conditions associated with decompensated cirrhosis, such as hyponatremia, hepatic hydrothorax, spontaneous bacterial peritonitis, and hepatorenal syndrome, and use of transjugular intrahepatic shunt.
Topics: Humans; Ascites; Hepatorenal Syndrome; Liver Cirrhosis; Peritonitis
PubMed: 37011958
DOI: 10.3949/ccjm.90a.22028 -
Cell Nov 2021Increasing evidence indicates that the brain regulates peripheral immunity, yet whether and how the brain represents the state of the immune system remains unclear....
Increasing evidence indicates that the brain regulates peripheral immunity, yet whether and how the brain represents the state of the immune system remains unclear. Here, we show that the brain's insular cortex (InsCtx) stores immune-related information. Using activity-dependent cell labeling in mice (Fos), we captured neuronal ensembles in the InsCtx that were active under two different inflammatory conditions (dextran sulfate sodium [DSS]-induced colitis and zymosan-induced peritonitis). Chemogenetic reactivation of these neuronal ensembles was sufficient to broadly retrieve the inflammatory state under which these neurons were captured. Thus, we show that the brain can store and retrieve specific immune responses, extending the classical concept of immunological memory to neuronal representations of inflammatory information.
Topics: Animals; Colitis; Colon; Dextran Sulfate; Female; Immunity; Inflammation; Insular Cortex; Male; Mice; Mice, Inbred C57BL; Neurons; Peritoneum; Peritonitis; Synapses; Zymosan
PubMed: 34752731
DOI: 10.1016/j.cell.2021.10.013 -
Peritoneal Dialysis International :... Jul 2020Intraperitoneal vancomycin is the first-line therapy in the management of peritoneal dialysis (PD)-related peritonitis. However, due to the paucity of data, vancomycin... (Review)
Review
Intraperitoneal vancomycin is the first-line therapy in the management of peritoneal dialysis (PD)-related peritonitis. However, due to the paucity of data, vancomycin dosing for peritonitis in patients on automated peritoneal dialysis (APD) is empiric and based on clinical experience rather than evidence. Studies in continuous ambulatory peritoneal dialysis (CAPD) patients have been used to provide guidelines for dosing and are often extrapolated for APD use, but it is unclear whether this is appropriate. This review summarizes the available pharmacokinetic data used to inform optimal dosing in patients on CAPD or APD. The determinants of vancomycin disposition and pharmacodynamic effects are critically summarized, knowledge gaps explored, and a vancomycin dosing algorithm in PD patients is proposed.
Topics: Anti-Bacterial Agents; Humans; Kidney Failure, Chronic; Peritoneal Dialysis; Peritonitis; Vancomycin
PubMed: 32065053
DOI: 10.1177/0896860819889774 -
American Journal of Kidney Diseases :... Jul 2020Peritoneal dialysis (PD)-related peritonitis carries high morbidity for PD patients. Understanding the characteristics and risk factors for peritonitis can guide... (Observational Study)
Observational Study
RATIONALE & OBJECTIVE
Peritoneal dialysis (PD)-related peritonitis carries high morbidity for PD patients. Understanding the characteristics and risk factors for peritonitis can guide regional development of prevention strategies. We describe peritonitis rates and the associations of selected facility practices with peritonitis risk among countries participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS).
STUDY DESIGN
Observational prospective cohort study.
SETTING & PARTICIPANTS
7,051 adult PD patients in 209 facilities across 7 countries (Australia, New Zealand, Canada, Japan, Thailand, United Kingdom, United States).
EXPOSURES
Facility characteristics (census count, facility age, nurse to patient ratio) and selected facility practices (use of automated PD, use of icodextrin or biocompatible PD solutions, antibiotic prophylaxis strategies, duration of PD training).
OUTCOMES
Peritonitis rate (by country, overall and variation across facilities), microbiology patterns.
ANALYTICAL APPROACH
Poisson rate estimation, proportional rate models adjusted for selected patient case-mix variables.
RESULTS
2,272 peritonitis episodes were identified in 7,051 patients (crude rate, 0.28 episodes/patient-year). Facility peritonitis rates were variable within each country and exceeded 0.50/patient-year in 10% of facilities. Overall peritonitis rates, in episodes per patient-year, were 0.40 (95% CI, 0.36-0.46) in Thailand, 0.38 (95% CI, 0.32-0.46) in the United Kingdom, 0.35 (95% CI, 0.30-0.40) in Australia/New Zealand, 0.29 (95% CI, 0.26-0.32) in Canada, 0.27 (95% CI, 0.25-0.30) in Japan, and 0.26 (95% CI, 0.24-0.27) in the United States. The microbiology of peritonitis was similar across countries, except in Thailand, where Gram-negative infections and culture-negative peritonitis were more common. Facility size was positively associated with risk for peritonitis in Japan (rate ratio [RR] per 10 patients, 1.07; 95% CI, 1.04-1.09). Lower peritonitis risk was observed in facilities that had higher automated PD use (RR per 10 percentage points greater, 0.95; 95% CI, 0.91-1.00), facilities that used antibiotics at catheter insertion (RR, 0.83; 95% CI, 0.69-0.99), and facilities with PD training duration of 6 or more (vs <6) days (RR, 0.81; 95% CI, 0.68-0.96). Lower peritonitis risk was seen in facilities that used topical exit-site mupirocin or aminoglycoside ointment, but this association did not achieve conventional levels of statistical significance (RR, 0.79; 95% CI, 0.62-1.01).
LIMITATIONS
Sampling variation, selection bias (rate estimates), and residual confounding (associations).
CONCLUSIONS
Important international differences exist in the risk for peritonitis that may result from varied and potentially modifiable treatment practices. These findings may inform future guidelines in potentially setting lower maximally acceptable peritonitis rates.
Topics: Adult; Aged; Cohort Studies; Female; Humans; Internationality; Male; Middle Aged; Peritoneal Dialysis; Peritonitis; Practice Patterns, Physicians'; Prospective Studies; Treatment Outcome
PubMed: 31932094
DOI: 10.1053/j.ajkd.2019.09.016 -
Annals of Hepatology 2020Infections are a frequent complication and a major cause of death among patients with cirrhosis. The important impact of infections in general and especially spontaneous... (Review)
Review
Infections are a frequent complication and a major cause of death among patients with cirrhosis. The important impact of infections in general and especially spontaneous bacterial peritonitis on the course of disease and prognosis of patients with cirrhosis has been recognized for many years. Nevertheless, such importance has recently increased due to the comprehension of infection as one of the most prominent risk factors for patients to develop acute-on-chronic liver failure. Furthermore, the issue of infections in cirrhosis is a focus of increasing attention because of the spreading of multidrug resistant bacteria, which is an emerging concern among physicians assisting patients with cirrhosis. In the present paper, we will review the current epidemiology of infections in patients with cirrhosis and particularly that of infections caused by resistant bacteria, demonstrating the relevance of the subject. Besides, we will discuss the current recommendations on diagnosis and treatment of different kinds of infections, including spontaneous bacterial peritonitis, and we will highlight the importance of knowing local microbiological profiles and choosing empirical antibiotic therapy wisely. Finally, we will debate the existing evidences regarding the role of volume expansion with albumin in patients with cirrhosis and extraperitoneal infections, and that of antibiotic prophylaxis of spontaneous bacterial peritonitis.
Topics: Albumins; Anti-Bacterial Agents; Bacterial Infections; Drug Resistance, Multiple, Bacterial; Fluid Therapy; Humans; Liver Cirrhosis; Peritonitis; Plasma Substitutes; Risk Assessment; Risk Factors; Treatment Outcome
PubMed: 32533951
DOI: 10.1016/j.aohep.2020.04.010 -
Immunity Nov 2021Peritoneal immune cells reside unanchored within the peritoneal fluid in homeostasis. Here, we examined the mechanisms that control bacterial infection in the peritoneum...
Peritoneal immune cells reside unanchored within the peritoneal fluid in homeostasis. Here, we examined the mechanisms that control bacterial infection in the peritoneum using a mouse model of abdominal sepsis following intraperitoneal Escherichia coli infection. Whole-mount immunofluorescence and confocal microscopy of the peritoneal wall and omentum revealed that large peritoneal macrophages (LPMs) rapidly cleared bacteria and adhered to the mesothelium, forming multilayered cellular aggregates composed by sequentially recruited LPMs, B1 cells, neutrophils, and monocyte-derived cells (moCs). The formation of resident macrophage aggregates (resMφ-aggregates) required LPMs and thrombin-dependent fibrin polymerization. E. coli infection triggered LPM pyroptosis and release of inflammatory mediators. Resolution of these potentially inflammatory aggregates required LPM-mediated recruitment of moCs, which were essential for fibrinolysis-mediated resMφ-aggregate disaggregation and the prevention of peritoneal overt inflammation. Thus, resMφ-aggregates provide a physical scaffold that enables the efficient control of peritoneal infection, with implications for antimicrobial immunity in other body cavities, such as the pleural cavity or brain ventricles.
Topics: Animals; Bacterial Infections; Biomarkers; Cellular Microenvironment; Disease Models, Animal; Disease Susceptibility; Host-Pathogen Interactions; Inflammation Mediators; Macrophages, Peritoneal; Mice; Peritoneal Cavity; Peritonitis
PubMed: 34717795
DOI: 10.1016/j.immuni.2021.10.007