Higher Risk Of Peritonitis Research Articles

#1060 Prevalence and adverse outcomes of hypokalemia and the role of potassium supplementation in patients receiving peritoneal dialysis

Abstract Background and Aims Hypokalemia is common and potentially life-threatening in patients undergoing peritoneal dialysis (PD). The reported prevalence of hypokalemia in PD patients varies significantly across studies, with ongoing debate about its association to adverse outcomes and the effects of potassium supplementation. Method We searched MEDLINE, Embase, Web of Science and references from eligible studies from database inception through September 2023 without language restriction for randomized controlled trials (RCTs), cohort studies, case-control studies, and cross-sectional studies on the prevalence and adverse outcomes (all-cause mortality, cardiovascular mortality, infection-related mortality, and PD-associated peritonitis) of hypokalemia or the role of potassium supplementation in patients receiving PD. Random effects meta-analysis is conducted to pool Hazard ratio (HR) and 95% confidence interval (CI) for the outcomes of interest. The certainty of findings was rated according to GRADE criteria. Results Out of 3 298 reports identified, 23 studies involving 59 433 participants met inclusion criteria. The prevalence of hypokalemia across all definitions was 37.9% (95% CI: 27.2-52.7%), 19.0% (95% CI: 13.0-27.6%) (Fig. 1), and 4.4% (95% CI: 1.9-10.2%) for patients with potassium level below 4.0, 3.5 and 3.0 mmol/L. Hypokalemia was associated with increased risk of all-cause mortality (HR: 1.49; 95% CI: 1.18-1.89) (Fig. 2), cardiovascular mortality (HR: 1.50; 95% CI: 1.19-1.88), and PD-associated peritonitis (HR: 1.53; 95% CI: 1.23-1.88). These associations were consistent, but evidence was predominantly of low to very low certainty. Results for subgroup and sensitivity analyses were consistent with the primary finding. Only two studies examined the impact of correcting hypokalemia with potassium supplementation in PD patients, and the results are inconclusive. Conclusion Hypokalemia is common and portends poorer survival and higher risk of peritonitis among PD patients. Further research into the optimal prevention and treatment strategies for hypokalemia is warranted to improve outcomes.

#6921 INFECTIOUS PERITONITIS DURING PEDIATRIC PERITONEAL DIALYSIS

Abstract Background and Aims Peritoneal dialysis (PD) is the dialysis treatment modality of choice used to treat pediatric patients with end-stage kidney disease (ESKD), thanks to its various benefits. However, infectious complications, mainly infectious peritonitis (IP), can occur, leading to morbidity, mortality and technique's failure. In this study, we aimed to describe the deferent infectious complications observed in children on PD and to investigate the risk factors for the occurrence of IP. Method In this study, we retrospectively collected the records of 99 patients who were treated with PD within the last eleven years (2010-2020) in the department of pediatrics of the University Hospital Charles Nicolle in Tunis. We adopted the terminology of the International Society of Peritoneal Dialysis (ISPD) to define peritonitis and its outcome. Analysis examining possible predictive factors of IP were performed using parametric and non-parametric tests and multivariate logistic regression in multivariate analysis. Results Ninety-nine patients were on PD during our study period, of which 65 patients had a total of 120 episodes of IP. The incidence of IP was 0.41 episodes per patient/year. The average time to onset of the first episode of IP was 1.2 years [3 days – 5.54 years]. Clinical signs of IP were dominated by abdominal pain (78.3%) and fever (50.4%). The PD effluent was cloudy in 78.3% of cases. Peritoneal dialysis fluid culture was positive in 33.3% of episodes with a predominance of gram-positive germs (62.8%). The evolution of this IP was favourable in 91.5% of cases with a response to antibiotics. 7% of episodes were relapsing of which five were during the first episode of IP. IP recurrence occurred in one patient. A catheter change was required over 16 episodes of IP, and hemodialysis sessions were necessary in 27 patients, temporary in 10 patients. The multivariate study identified the following predictive factors of IP: poor adherence to treatment (OR=3.851; 95%CI: 1.369-10.837; P = .011) and weight less than 15 Kg (OR=6.314; 95%CI: 1.333- 29.897; P = .02). Conclusion Considering the high risk of peritonitis in children on PD, it is imperative to establish a primary prevention based on training of the child's caregivers and families. Continous quality improvement program and PD technique must systematically reviewed in every peritonitis episode. Nutritional management of children prior to the start of PD is necessary to limit the risk of IP.

Oral Health-Related Quality of Life, A Proxy of Poor Outcomes in Patients on Peritoneal Dialysis

IntroductionWe sought to evaluate the associations of poor oral health hygiene with clinical outcomes in patients receiving peritoneal dialysis (PD).MethodsAs part of the multinational Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 participating PD centers throughout Thailand were enrolled from May 2016 to December 2019. The data were obtained from questionnaires that formed part of the PDOPPS. Oral health-related quality of life (HRQoL) used in this study was the short form of the oral health impact profile (oral health impact profile [OHIP]-14, including 7 facets and 14 items). Patient outcomes were assessed by Kaplan-Meier analysis. Cox proportional hazards model regression was used to estimate associations between oral HRQoL and clinical outcomes.ResultsOf 5090 PD participants, 675 were randomly selected, provided informed consent, and completely responded to the OHIP-14 questionnaire. The median follow-up time of the study was 3.5 (interquartile range = 2.7–5.1 months) years. Poor oral health was associated with lower educational levels, diabetes, older age, marriage, and worse nutritional indicators (including lower time-averaged serum albumin and phosphate concentrations). After adjusting for age, sex, comorbidities, serum albumin, shared frailty by study sites, and PD vintage, poor oral health was associated with increased risks of peritonitis (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI]: 1.06–2.00) and all-cause mortality (adjusted HR = 1.55, 95% CI: 1.04–2.32) but not hemodialysis (HD) transfer (adjusted HR = 1.89, 95% CI: 0.87–4.10) compared to participants with good oral health.ConclusionPoor oral health status was present in one-fourth of PD patients and was independently associated with a higher risk of peritonitis and death.

Clinical profile and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis-associated peritonitis at a tertiary care center

BackgroundWe present risk factors, clinical profile, and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis who were managed at our center. MethodsAll consecutive patients with CAPD-associated peritonitis who presented to our center between July 2018 and December 2019 were included in the study. Risk factors, microbiological spectrum, clinical profile, and outcome of patients were studied. ResultsEighty-five patients with CAPD-associated peritonitis and 50 patients who never had peritonitis during the study period were included. Diabetes Mellitus (OR 0.058, 95% CI0.007–0.493, p < 0.05), residence in rural area (OR 3.376, 95% CI 1.084–10.516, p < 0.05), duration of peritoneal dialysis (OR 0.935, 95% CI 0.886–0.987, p < 0.05), mean serum hemoglobin (OR 1.674, 95% CI 1.119–2.502, p < 0.05) and serum albumin (OR 0.148, 95% CI 0.066–0.333, p < 0.05) were associated with higher risk of peritonitis in CAPD patients. Eight-three patients (98.8%) had turbid CAPD fluid and 52 (61.2%) had fever at the time of presentation to the hospital. The mean CAPD fluid TLC on day 1, 3, and 5 were 2034.3 ± 3330.1 cells/cumm, 1049.0 ± 1210.9 cells/cumm, and 605.2 ± 950.5 cells/cumm, respectively. The organisms isolated were two Escherichia coli (2.4%), one Staphylococcus aureus (1.2%), one Klebsiella (1.2%), two Acinetobacter (2.4%), 10 Fungal organisms (11.7%), and in two (2.4%) cases, Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction (PCR) of CAPD fluid. Thirty-seven (43.5%) patients had a complete cure and 48 (56.5%) patients were refractory to treatment; hence catheter was removed in them (catheter loss). Six (7.0%) patients died during the study period. ConclusionCAPD-associated peritonitis is an important risk factor for technique failure. The majority of episodes are culture-negative, and PCR can help in detecting fungal and tubercular peritonitis early in the course.

Peritonitis Affects the Relationship Between Low-Density Lipoprotein Cholesterol and Cardiovascular Events in Peritoneal Dialysis Patients

BackgroundIn peritoneal dialysis (PD), the relationship among low-density lipoprotein cholesterol (LDL-C), peritonitis, and cardiovascular (CV) disease has not been clarified. This study was performed to explore their associations in a large PD cohort. MethodsThis retrospective cohort study included incident patients who received PD catheter insertion in our centre. The primary outcome was the first CV event (nonfatal myocardial infarction, CV death, non-haemorrhagic stroke, or any arterial revascularization procedure). Secondary outcomes were the occurrence of peritonitis, CV mortality, and all-cause mortality. ResultsThis study included 1294 patients, whose mean age was 48.1 years. After adjustment for confounders in negative binomial regression models, lower LDL-C quartiles were independently associated with a higher risk of peritonitis, compared with the highest quartile. The multivariate competing risk model showed no significant association between baseline LDL-C and the first CV event in the overall population. However, stratified analysis showed that each 1 mmol/L increase in LDL-C was independently associated with a 21% (subdistribution hazard ratio: 1.21, 95% confidence interval: 1.06-1.39) increased risk of the first CV event among peritonitis-free patients, and with a 20% (subdistribution hazard ratio: 0.80, 95% confidence interval: 0.65-0.99) decreased risk among patients with peritonitis. Moderating-effect analysis showed that the presence of peritonitis significantly influenced the relationships between LDL-C and CV events (P < 0.001). Similar results were also observed in the relationship between LDL-C and mortality. ConclusionsPD patients with lower baseline LDL-C had a higher risk of peritonitis. The effect of LDL-C on CV events and mortality was different by the presence of peritonitis events.

Self-Care Peritoneal Dialysis Patients with Cognitive Impairment Have a Higher Risk of Peritonitis in the Second Year.

Cognitive impairment is common among patients on peritoneal dialysis (PD). We hypothesize that cognitive impairment has a negative impact on the outcome of patients on PD, especially with regard to peritonitis. This was a single-center 2-year prospective cohort study involving 206 patients at 1 PD unit. Cognitive impairment was defined by the latest Hong Kong Montreal Cognitive Assessment Score (HK-MoCA) multiple cut-offs as determined by age and years of education. Eighty percent of patients had come back for interval HK-MoCA. The HK-MoCA was performed at baseline and after 1 year on PD. Potential risk factors for cognitive impairment and peritonitis were studied separately for the first and second year. For cognitive impairment at baseline, multivariate analyses showed that age (odds ratio [OR] 1.003, 95% confidence interval [CI] 1.003 - 1.065, p = 0.03), female sex (OR 3.57, 95% CI 1.60 - 7.97, p = 0.002), peripheral vascular disease (PVD) (OR 3.46, 95% CI 1.33 - 9.01, p = 0.01), and hemoglobin level (OR 0.60, 95% CI 0.43 - 0.84, p = 0.003) were statistically significant factors. For cognitive impairment at 1 year, multivariate analyses showed that age (OR 1.07, 95% CI 1.02 - 1.012, p = 0.007), female sex (OR 5.87, 95% CI 1.86 - 18.5, p = 0.003), and PVD (OR 3.68, 95% CI 1.07 - 12.84, p = 0.04) were statistically significant independent factors for cognitive impairment at 1 year.For self-care PD patients in the second year, patients with cognitive impairment had a higher rate of peritonitis and proportionately more patients suffered from both peritonitis and exit-site infection than non-cognitively impaired patients in the second year (0.50 vs 0.27 episodes per year, p = 0.048; 25% vs 7.2%, p = 0.049). Logistic regression showed that only HK-MoCA-defined cognitive impairment and HK-MoCA scores at 1 year were factors predicting peritonitis (risk ratio [RR] 3.2 [95% CI 1.03 - 9.95], p = 0.04 and RR 0.92 [95% CI 0.86 - 0.995], p = 0.04 respectively). In summary, increasing age, female sex, anemia, and presence of PVD are risk factors for cognitive impairment in PD patients. Self-care PD with cognitive impairment at 1 year has a higher risk for PD-related peritonitis in the second year. Interval HK-MoCA assessment is recommended to detect cognitive impairment in our local PD patients.

Peritoneal Infections in Children Undergoing Acute Peritoneal Dialysis at a Tertiary/Quaternary Central Hospital in Kwazulu-Natal, South Africa.

In a resource-limited setting, acute peritoneal dialysis (APD) is the modality of choice as a form of renal replacement therapy in children with acute kidney injury (AKI). However, there is a high risk of peritonitis that causes significant morbidity and mortality. Data on PD and peritonitis in developing countries are scarce. The purpose of this retrospective study was to determine the prevalence of APD-related peritonitis at a central referral hospital in KwaZulu-Natal, South Africa. A retrospective study from January 2010 until December 2014 was done at Inkosi Albert Luthuli Central Hospital (IALCH). All children under the age of 13 years with AKI requiring APD were included in the study. Forty children were included in the study. Age ranged from 0.2 years to 12.25 years; 25 (62.5%) were male and 15 (37.5%) female. Twenty-seven (67.5%) were admitted to the intensive care unit (ICU) and 13 (32.5%) to the pediatric high care ward. Septicemia with multi-organ dysfunction was the was the main cause of AKI requiring APD in 18 (45%) children followed by poststreptococcal glomerulonephritis in 8 (20%). Acute PD was complicated by culture-proven peritonitis in 19 (47.5%) children of whom 16 (84.2%) had a single organism cultured while in 3, (15.7%) there was a mixed culture. The total number of organisms cultured was 24: 8 (33.3%) were gram-positive organisms, 12 (50%) gram-negative organisms, and 4 (16.67%) fungal. The Paediatric Index of Mortality (PIM) 2 Score risk of mortality was 99.4% for patients admitted to ICU. Mortality rate was 65%, and 14 (53%) of the children who demised had peritonitis. This study showed an inordinately high complication rate of peritonitis, mostly secondary to gram-negative organisms, of children undergoing APD in a central referral hospital. The use of surgically placed, tunneled catheters, meticulous attention to aseptic techniques and judicious use of antimicrobials is highly recommended in reducing the incidence of peritonitis in children undergoing APD.

Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative.

The Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative is a quality improvement initiative that aims to reduce peritoneal dialysis-associated infections in pediatric patients on chronic peritoneal dialysis. Our objectives were to determine whether provider compliance with peritoneal dialysis catheter care bundles was associated with lower risk for infection at the individual patient level and describe the epidemiology, risk factors, and outcomes for peritonitis in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative. We collected peritoneal dialysis characteristics, causative organisms, compliance with care bundles, and outcomes in children with peritonitis between October of 2011 and September of 2014. Chi-squared tests, t tests, and generalized linear mixed models were used to assess risk factors for peritonitis. Of 734 children enrolled (54% boys; median age =9 years old; interquartile range, 1-15) from 29 centers, 391 peritonitis episodes occurred among 245 individuals over 10,130 catheter-months. The aggregate annualized peritonitis rate was 0.46 episodes per patient-year. Rates were highest among children ≤2 years old (0.62 episodes per patient-year). Gram-positive peritonitis predominated (37.8%) followed by culture-negative (24.7%), gram-negative (19.5%), and polymicrobial (10.3%) infections; fungal only peritonitis accounted for 7.7% of episodes. Compliance with the follow-up bundle was associated with a lower rate of peritonitis (rate ratio, 0.49; 95% confidence interval, 0.30 to 0.80) in the multivariable model. Upward orientation of the catheter exit site (rate ratio, 4.2; 95% confidence interval, 1.49 to 11.89) and touch contamination (rate ratio, 2.22; 95% confidence interval, 1.44 to 3.34) were also associated with a higher risk of peritonitis. Infection outcomes included resolution with antimicrobial treatment alone in 76.6%, permanent catheter removal in 12.2%, and catheter removal with return to peritoneal dialysis in 6% of episodes. Lower compliance with standardized practices for follow-up peritoneal dialysis catheter care in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative was associated with higher risk of peritonitis. Quality improvement and prevention strategies have the potential to reduce peritoneal dialysis-associated peritonitis.

Serum 25-Hydroxyvitamin D Level Could Predict the Risk for Peritoneal Dialysis-Associated Peritonitis.

♦ As an immune system regulator, vitamin D is commonly deficient among patients on peritoneal dialysis (PD), which may contribute to their impaired immune function and increased risk for PD-related peritonitis. In this study, we aimed to investigate whether vitamin D deficiency could predict the risk of peritonitis in a prospective cohort of patients on PD. ♦ We collected 346 prevalent and incident PD patients from 2 hospitals. Baseline demographic data and clinical characteristics were recorded. Serum 25-hydroxyvitamin D (25[OH]D) was measured at baseline and prior to peritonitis. The mean doses of oral active vitamin D used during the study period were also recorded. The outcome was the occurrence of peritonitis. ♦ The mean age of patients and duration of PD were 58.95 ± 13.67 years and 28.45 (15.04 - 53.37) months, respectively. Baseline 25(OH)D level was 16.15 (12.13 - 21.16) nmol/L, which was closely associated with diabetic status, longer PD duration, malnutrition, and inflammation. Baseline serum 25(OH)D predicted the occurrence of peritonitis independently of active vitamin D supplementation with a hazard ratio (HR) of 0.94 (95% confidence interval [CI] 0.90 - 0.98) after adjusting for recognized confounders (age, gender, dialysis duration, diabetes, albumin, residual renal function, and history of peritonitis). Compared to the low tertile, middle and high 25(OH)D level tertiles were associated with a decreased risk for peritonitis with HRs of 0.54 (95% CI 0.31 - 0.94) and 0.39 (95% CI 0.20 - 0.75), respectively. ♦ Vitamin D deficiency evaluated by serum 25(OH)D rather than active vitamin D supplementation is closely associated with a higher risk of peritonitis.

Prevention of Peritonitis in Peritoneal Dialysis

Reducing the frequency of peritonitis for patients undergoing peritoneal dialysis (PD) continues to be a challenge. This review focuses on recent updates in catheter care and other patient factors that influence infection rates. An experienced nursing staff plays an important role in teaching proper PD technique to new patients, but nursing staff must be cognizant of each patient's unique educational needs. Over time, many patients become less adherent to proper dialysis technique, such as washing hands or wearing a mask. This behavior is associated with higher risk of peritonitis and is modifiable with re-training. Prophylactic antibiotics before PD catheter placement can decrease the infection risk immediately after catheter placement. In addition, some studies suggest that prophylaxis against fungal superinfection after antibiotic exposure is effective in reducing fungal peritonitis, although larger randomized studies are needed before this practice can be recommended for all patients. Over time, exit site and nasal colonization with pathogenic organisms can lead to exit-site infections and peritonitis. For patients with Staphylococcus aureus colonization, exit-site prophylaxis with either mupirocin or gentamicin cream reduces clinical infection with this organism. Although there are limited data for support, antibiotic prophylaxis before gastrointestinal, gynecologic, or dental procedures may also help reduce the risk of peritonitis.

High serum DcR3 levels are associated with the occurrence of peritonitis in patients receiving chronic peritoneal dialysis

BackgroundPeritoneal dialysis (PD)-related peritonitis is a serious complication that typically leads to hospitalization, catheter loss, and even mortality. Previous studies of the risk factors for peritonitis are discordant. To date, no biomarker associated with PD-related peritonitis has been investigated. However, it has been shown that serum decoy receptor 3 (DcR3) is a valuable marker in predicting the outcome of several inflammatory diseases. The aim of this study was to investigate whether serum DcR3 is a predictor of peritonitis in chronic PD patients. MethodsWe conducted a prospective cohort study of PD patients in the PD unit of a tertiary referral center from March 1 to November 30, 2007, and followed up until December 31, 2009. Clinical and laboratory parameters were recorded and serum DcR3 was measured to assess risk factors for developing PD-related peritonitis. ResultsA total of 77 patients (38 men and 39 women; mean age 58 ± 13 years) were enrolled in this study. The average time on PD was 24.5 months and 46 patients (60%) were diabetic. The mean follow-up duration was 499 ± 17 days. The rate of peritonitis incidence was 0.17 episodes per patient-year. Baseline serum DcR3 in 77 patients was 1.94 ± 1.23 ng/mL. Kaplan–Meier survival analysis showed that patients with serum DcR3 > 1.8 ng/mL had a higher risk of peritonitis than those with serum DcR3 < 1.8 ng/mL (p = 0.016). The Cox proportional hazard model further showed that high serum DcR3 (>1.8 ng/mL) was an independent risk factor for subsequent peritonitis (hazard ratio 3.61, 95% CI 1.17–11.08; p = 0.03). ConclusionSerum DcR3 was associated with increased risk of PD-related peritonitis.

Risk Factors and Outcome of Contamination in Patients on Peritoneal Dialysis—A Single-Center Experience of 15 Years

Contamination is an important risk factor for peritoneal dialysis (PD)-related peritonitis. The present study outlines the clinical characteristics and outcomes of PD patients experiencing touch contamination. We reviewed the case records of PD patients from 1995 to 2010. Patients who experienced contamination of their PD system were identified and stratified into "dry" and "wet" contamination groups. Risk factors, microbiology, and clinical outcomes were compared. Of 548 episodes of touch contamination, 246 involved dry contamination, and 302, wet contamination. After contamination, 17 episodes of peritonitis (3.1%) developed; all episodes occurred in the wet contamination group (p < 0.001). The incidence of peritonitis after wet contamination was 5.63%. Prophylactic antibiotics significantly reduced the risk of peritonitis (1 of 182 episodes, p < 0.001). Half the patients experiencing peritonitis had either culture-negative or staphylococcal episodes, and most of those episodes responded to intraperitoneal antibiotics. In 2 patients, peritonitis was attributable to Pseudomonas, and in 3, to Acinetobacter. In these latter patients, outcomes were less favorable, with catheter removal being required in 4 of the 5 episodes. The overall rate of peritonitis was low after contamination. Wet contamination was associated with a much higher risk of peritonitis. Prophylactic antibiotics after wet contamination were effective in preventing peritonitis.

Remote indigenous peritoneal dialysis patients have higher risk of peritonitis, technique failure, all-cause and peritonitis-related mortality

The number of indigenous patients with end-stage kidney disease (ESKD) is increasing in Australia, reflecting a similar trend in other countries. Because many indigenous patients live in remote areas, peritoneal dialysis (PD) is often preferred. Compared to non-indigenous PD patients, indigenous patients have increased complication rates but the effect of residential locations on outcomes remains unclear. The aim of this study is to examine the association between race and PD outcomes stratified by location. Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, all adult ESKD patients commencing PD in Australia between 1995 and 2008 were included. Patients were stratified as non-indigenous or indigenous race and were grouped according to their residential location, the latter stratified into metropolitan, regional and remote areas. Outcomes evaluated included peritonitis, technique failure, peritonitis-related and all-cause mortality. Regional and/or remote PD patients generally have a greater risk peritonitis-related complications and/or mortality compared to metropolitan patients. However, remote indigenous PD patients had the greatest risk of all PD-related complications, including all-cause and peritonitis-related mortality. This registry analysis demonstrates that non-metropolitan PD patients, especially remote indigenous patients, have higher complication rates, suggesting that environmental factors are important in determining PD outcomes.

The Relationship of P1 and Lewis Antigens with Peritoneal Dialysis–Related Escherichia Coli Peritonitis

It has been known that the P1 and Lewis antigens on red blood cells (RBCs) affect the risk of Escherichia coli-related urinary tract infection. In the present study, we investigated the associations between those antigens and peritoneal dialysis (PD)-related peritonitis and E. coli peritonitis. We recruited 155 patients (66 men, 89 women) who were under PD treatment in July 2005, checked the P1 and Lewis antigen status of their RBCs, reviewed their medical charts, and recorded the dates and the causative pathogens of peritonitis episodes. The relationships between peritonitis and the antigens were analyzed. The mean age of these PD patients was 52.5 +/- 14.9 years, and the mean PD duration was 39.8 +/- 38.2 months. A total of 66 peritonitis episodes occurred (over 93.4 patient-months) in 41 patients, with 8 patients having more than 1 episode. In particular, E. coli peritonitis accounted for 16 of the 66 peritonitis episodes. We fitted two multiple Cox proportional hazards models (with the robust variance method) for predicting the hazard rates of peritonitis-free and E. coli peritonitis-free survival times to our right-censored data with recurrent events. We found that patients on PD treatment for less than 4 years with (A) lower serum albumin, (B) one or more previous peritonitis episodes, or (C) negative Lewis a and positive Lewis b antigens (secretor) would be at higher risk of peritonitis. And, conditioning on blood type, the PD patients with one or more previous peritonitis episodes and (A) positive P1 antigen, (B) negative Lewis a and positive Lewis b antigens (secretor), or (C) positive Lewis a and negative Lewis b antigens (non-secretor) would be at higher risk of E. coli peritonitis.

Feasibility and Safety of Endoscopic Submucosal Dissection (ESD) for Treatment of Colorectal Tumors and Effectiveness of Measures to Prevent Complications. -Compared to Therapeutic Results from Gastric ESD-

Background: Endoscopic submucosal dissection (ESD) is now widely accepted for treatment of early gastric cancer and ESD is currently being applied to treat colorectal cancer . There are concerns, however, about the possible high risk of peritonitis caused by perforations during ESD in the colon due to its thin wall and the presence of stool. Objective: Evaluate feasability and safety of colonic ESD and effectiveness of preventive measures against complications in comparison with therapeutic results from gastric ESD. Patients: In the gastric group (male/female: 67/9; mean age: 68.7 ± 8.6 years), 76 patients with 81 lesions were treated at Tokyo Medical University Hospital from April 2005 to November 2007. In the colonic group (male/female: 6/5; mean age: 64.0 ± 7.8 years), 11 patients with 11 lesions were treated at the same facility from June 2006 to November 2007. Methods: We compared lesion sizes, en-bloc resection rates, procedure times, length of hospital stays following ESD procedures and incidence of complications between the two groups. As for preventive measures taken to prevent complications during colonic ESDs, carbon dioxide insufflation was utilized to reduce patient discomfort and a bipolar needle-knife (B-knife) and an insulation-tip knife (IT knife) were initially used to reduce the risk of perforation. More recently, we have been using a newly designed ball-tip B-knife to further enhance operational safety. In order to prevent peritonitis, patients were given 2000-3000ml of polyethylene glycol (PEG) together with antibiotics the mornings of their procedures. Results: Mean lesion size was 20.7 ± 11.8 mm (range, 5-60 mm) in the gastric group and 50 ± 33mm (range, 20-110 mm) in the colonic group. The en-bloc resection rate was 90.6% compared to 72.2% and mean procedure time was 104.0 ± 70.5 minutes compared to 200.2 ± 188.3 minutes in the gastric and colonic groups, respectively. Mean length of hospital stay following ESD was shorter in the colonic group; 7.3 ± 3.9 days (range, 3-10 days) compared to in the gastric group; 10.2 ± 8.3 days (range, 5-31 days). The incidence of complications was 6 cases (7.4%) of delayed bleeding and 2 cases (2.5%) of perforation in the gastric group while there were no complications whatsoever in the colonic group. Conclusions: It is possible that colonic ESD is as safe as gastric ESD provided instruments developed specifically for use in the colon are used and adequate measures are taken to prevent complications. Under such circumstances, we consider ESD to be a feasible therapy for colorectal tumors.

Assisted Peritoneal Dialysis. Experience in a French Renal Department

The French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system. This study was conducted to evaluate the impact of a private home-nurse network on one dialysis program. This was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003. Of these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 +/- 10 vs 52 +/- 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 +/- 2.5 vs 4.3 +/- 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year. Assisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis: Impact of a Compulsory Switch From a Standard to a Y-Connector System in a Single North American Center

One hundred one continuous ambulatory peritoneal dialysis (CAPD) patients from a single North American center were analyzed in a retrospective and cross-over study for peritonitis rates using a standard system (Travenol System II) or a Y-shaped disconnect-disinfectant system (Travenol O-set). Twenty-one of 34 patients using the standard set (group I) had 53 episodes of peritonitis in 508 patient-months or one episode per 9.6 patient-months. Nine of 17 patients switching from the standard to the disconnect-disinfectant system (group II) experienced 22 episodes of peritonitis in 275 patient-months or one episode per 12.5 patient-months on the standard set, while six patients had 10 episodes of peritonitis in 275 patient-months or one episode per 27.5 patient-months on the disconnect-disinfectant system (P less than 0.04). Twenty-eight of 67 new CAPD patients starting on the disconnect-disinfectant system (group III) had 37 episodes of peritonitis in 1,086 patient-months or one episode per 29.4 patient-months (P less than 0.01 v group I). Exit-site infections (ESI) occurred in 35.3% of patients using the standard set versus 34.3% of those using the O-set. The presence of an ESI was not associated with a higher risk of peritonitis, but modified the bacteriological profile of subsequent peritonitis episodes in patients using the O-set, favoring the organisms isolated from the exit site. Decreases in peritonitis rates with the O-set were due to a reduction of peritonitis episodes secondary to most bacterial agents and not only to skin organisms. Diabetics using intraperitoneal insulin had similar peritonitis and ESI rates as nondiabetics.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased Risk of Staphylococcus epidermidis Peritonitis in Patients on Dialysate Containing 1.25 mmol/L Calcium

Peritoneal macrophage function is decreased in vitro in the presence of dialysate with 1.25 mmol/L calcium compared with that containing 1.75 mmol/L calcium. Theoretically, patients using this dialysate may have a higher risk of peritonitis. Nineteen patients on continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) were converted from dialysate with 1.75 mmol/L calcium (mean time, 33 +/- 26 months) to that with 1.25 mmol/L calcium, for some or all exchanges (mean time, 10 +/- 4.7 months). Peritonitis rates were compared with 19 control patients who remained on dialysate with 1.75 mmol/L calcium. The two groups were matched for the proportion of diabetics, sex, age, use of the Y-set, and dialysis modality (CAPD, CCPD). Peritonitis rates were similar in the study patients before conversion to 1.25 mmol/L calcium dialysate and in the control patients (0.49 v 0.58 episodes/patient-year, respectively). After conversion to dialysate with 1.25 mmol/L calcium, the peritonitis rate was 0.82 episodes/patient-year contrasted to 0.58 episodes/patient-year in the control patients (P = 0.09). The peritonitis rate due to Staphylococcus epidermidis was 0.51 episodes/patient-year when 1.25 mmol/L calcium dialysate was used, and 0.19 episodes/patient-year for the comparable period in the control patients on 1.75 mmol/L calcium dialysate (P = 0.005). The proportion of peritonitis episodes due to S epidermidis increased from 20% to 61% after conversion to 1.25 mmol/L calcium (P = 0.01). The increased risk of peritonitis due to S epidermidis in patients using dialysate with 1.25 mmol/L calcium is consistent with a previous study demonstrating that clearance of S epidermidis by peritoneal macrophages is less effective with a decrease in the dialysate calcium content.(ABSTRACT TRUNCATED AT 250 WORDS)