History Of Peritonitis Research Articles

DPP-4 as a Possible Biomarker of Inflammation Before Abdominal Surgery for Chronic Pathology: Our Experience with Elective Cholecystectomy.

Background and objectives: Dipeptidyl-Peptidase 4 (DPP-4) is a protein expressed in numerous cells and tissues. Recently it has shown its involvement as a catalyst in the inflammatory response in various pulmonary, autoimmune, intestinal and other pathologies. The objective of this study was to compare the preoperative serum levels of DPP-4 in patients with and without surgical finding of perivesicular inflammation. Materials and methods: a cross-sectional analytical study nested in a prospective cohort, including patients scheduled for elective cholecystectomy, without surgical complications, that were 18–70 years of age, with low cardiovascular risk, without a history of peritonitis, pancreatitis, or jaundice and underwent ERCP protocol, type 2 diabetes mellitus, acute inflammatory (Protein C Reactive < 3 mg/L, leucocytes < 10 1000/mm3), neoplastic, nephrologic or liver disease, the use of anti-inflammatory drugs, steroids and/or antibiotics, the use of pacemakers or metallic implants and without major amputations and whom agreed to participate by providing their informed consent. Ethical and Research register: 45–16. Prior to surgery we compiled anthropometric data and a blood sample to determine the serum levels of DPP-4. The presence of perivesicular inflammation was determined in the surgery. The data was analyzed using the statistical program Rstudio. Results: High BMI values were observed (27.8 ± 6.4); waist circumference (94.7 ± 15.1) and percentage of fat mass (34.7 ± 11.7), showing a cumulative frequency of 65.9% for overweight/obesity. In 27.3% of the interventions, intraoperative perivesicular inflammation findings were reported. The serum levels of DPP-4 were lower in the group of patients with perivesicular inflammation (3947.6 ± 1659.5 vs. 3053.2 ± 1469.6, LC95% of the difference: 160.4–1628.3), being statistically significant (p = 0.018). Conclusions: In the subacute or chronic phases of cholecystitis, there appears to be a constant consumption of DPP-4, which would modulate a better immune response that could be related to the reduction of postoperative complications, so the use of Serum levels of DPP-4 as an early biomarker could improve the diagnostic accuracy of this pathology and the surgical approach.

Peritoneal Dialysis Vintage and Glucose Exposure but Not Peritonitis Episodes Drive Peritoneal Membrane Transformation During the First Years of PD.

The impact of peritoneal dialysis (PD) associated peritonitis on peritoneal membrane integrity is incompletely understood. Children are particularly suited to address this question, since they are largely devoid of preexisting tissue damage and life-style related alterations. Within the International Peritoneal Biobank, 85 standardized parietal peritoneal tissue samples were obtained from 82 children on neutral pH PD fluids with low glucose degradation product (GDP) content. 37 patients had a history of peritonitis and 16 of the 37 had two or more episodes. Time interval between tissue sampling and the last peritonitis episode was 9 (4, 36) weeks. Tissue specimen underwent digital imaging and molecular analyses. Patients with and without peritonitis were on PD for 21.0 (12.0, 36.0) and 12.8 (7.3, 27.0) months (p = 0.053), respectively. They did not differ in anthropometric or histomorphometric parameters [mesothelial coverage, submesothelial fibrosis, blood, and lymphatic vascularization, leukocyte, macrophage and activated fibroblast counts, epithelial-mesenchymal transition (EMT), podoplanin positivity and vasculopathy]. VEGF and TGF-ß induced pSMAD abundance were similar. Similar findings were also obtained after matching for age and PD vintage and a subgroup analysis according to time since last peritonitis (<3, <6, >6 months). In patients with more than 24 months of PD vintage, submesothelial thickness, vessel number per mmm section length and ASMA fibroblast positivity were higher in patients with peritonitis history; only the difference in ASMA positivity persisted in multivariable analyses. While PD duration and EMT were independently associated with submesothelial thickness, and glucose exposure and EMT with peritoneal vessel density in the combined groups, submesothelial thickness was independently associated with EMT in the peritonitis free patients, and with duration of PD in patients with previous peritonitis. This detailed analysis of the peritoneal membrane in pediatric patients on PD with neutral pH, low GDP fluids, does not support the notion of a consistent long-term impact of peritonitis episodes on peritoneal membrane ultrastructure, on inflammatory and fibrotic cell activity and EMT. Peritoneal alterations are mainly driven by PD duration, dialytic glucose exposure, and associated EMT.

Adhesiolysis-Related Challenges for Laparoscopic Procedures after Ventral Hernia Repair with Intraperitoneal Mesh.

Background: Laparoscopic procedures in patients with history of abdominal surgery can be challenging due to the unknown risk of postoperative adhesions (POA). The intraperitoneal onlay mesh procedures (IPOM) are frequently used for open or laparoscopic repair for incisional and ventral hernia. The risk of PoA can be increased in these patients, thus, any further laparoscopic exploration might be considered difficult. The aim of our study is to analyze the adhesiolysis-related challenges and complications in patients requiring laparoscopic surgery after IPOM ventral hernia repair. Methods: All the patients who underwent any laparoscopic procedure after open or video-assisted IPOM ventral hernia repair in Ponderas Academic Hospital from May 2011 to December 2018, were retrospectively analyzed. Two trained experts reviewed all video recordings and collected data on surgical history, adhesion location and density, dissection difficulty, interval time to release adhesions from the mesh and complications. Results: Twenty-nine patients were included into the study. There were 17 females, mean age of 58.0 +- 14.5 years, mean BMI of 28.7 +- 7.0 Kg/m2 and a median number of abdominal surgeries of 3/ patient. Risk factors for adhesion formation, other than the mesh itself were found in16 patients. The median time from the last IPOM procedure to the laparoscopic exploration was 26 months and it was related to the hernia repair technique in 21 patients and indicated for other pathologies in 8 patients.Adherences to the mesh were found in the majority of the cases (96%).The mean score of surface adhesion and adhesion tenacity was 4.0 +- 1.7 and 3.0 +- 0.8, respectively. The median time to complete the adhesiolysis to the mesh was 22 minutes. Small bowel was open during the dissection in six patients. Mesh migration was encountered in two. There were three conversions to open surgery and one to robotic surgery. History of peritonitis and septic complications at the last surgery were significantly associated with a higher rate of conversion. One surgical site infection and no mesh infection were encountered. The median postoperative hospital stay was 4 days. The 30-day postoperative mortality was nil. The median postoperative follow-up was 13 months. There are 3 recurrent incisional hernias. Conclusions: The study demonstrates that laparoscopic approach after previous IPOM is feasible but challenging. Adherences to the mesh are expected in the majority of the cases. History of peritonitis, a large number of open abdominal procedures, and septic complication at last surgery correlate with a high difficulty of adhesiolysis.

Viridans streptococcus peritonitis in peritoneal dialysis: clinical characteristics and comparison with concurrent polymicrobial infection

BackgroundThe clinical course of Viridans streptococci (VS) peritonitis in patients undergoing peritoneal dialysis (PD) is rarely reported. This study examined the association of clinical factors with VS peritonitis.MethodsWe retrospectively reviewed clinical data from patients with VS peritonitis from March 1990 to February 2016 in a PD center in Taiwan and evaluated clinical profiles and treatment outcomes.ResultsA total of 109 episodes of VS peritonitis in 71 patients identified. Among these patients, 57 had mono-VS peritonitis and 14 had concurrent polymicrobial infections. The median time interval from PD initiation to the first VS peritonitis episode was 18 months (range, 0.6–144 months). Among clinical outcomes, most VS peritonitis episodes were completely cured regardless of a history of peritonitis. All episodes with catheter removal occurred in those without a history of recent antibiotic use.ConclusionVS peritonitis in patients undergoing PD typically has favorable treatment outcomes. Antibiotic therapy should be started promptly.

3:00 PM Abstract No. 282 Transjugular intrahepatic portosystemic shunting reduces paracentesis rates in patients with cirrhosis and ascites: a population-based analysis

Ascites is a leading cause of morbidity and mortality in patients with cirrhosis. Transjugular intrahepatic portosystemic shunting (TIPS) has been shown to improve refractory ascites in cirrhotic patients based on a series of clinical trials. The purpose of this study was to conduct a population-level analysis of the utilization and impact of TIPS in cirrhotic patients with ascites. Using administrative data from all inpatient and outpatient hospital encounters in California (2009-2011), patients with cirrhosis complicated by ascites were identified. The utilization of TIPS and its influence on ascites management was evaluated in this patient population. A total of 180,286 patients with cirrhosis were identified, of whom 36,751 patients (20.3%) were noted to have non-malignant/non-cardiogenic ascites. Within this population of cirrhotic patients with ascites, 1,166 TIPS were performed in 1,150 patients (3.1%). There was a greater baseline rate of paracenteses for the TIPS vs non-TIPS patients (mean 1.44 vs 1.05 procedures/month, P < 0.001). There was a significance decrease in the frequency of paracenteses for patients following TIPS (0.4 procedures per month, P < 0.001). There was also a significant decrease in hospital visits for peritonitis following TIPS (P = 0.02). There was a non-significant trend towards increased hepatic encephalopathy following TIPS (P = 0.08). TIPS is associated with reduced frequency and complications of paracenteses for the management of refractory ascites in patients with cirrhosis. TIPS has a low utilization rate in this population, but the benefits of the procedure should be weighed with the risks of hepatic encephalopathy.Tabled 1TIPSNo TIPSP ValuePatients (n)115035601Gender (% female)5657< 0.001Comorbidities (%) Coagulopathy86.363.3< 0.001 Obesity30.518.5< 0.001 Renal failure46.735.3< 0.001 CHF15.721.3< 0.001 Viral hepatitis53.950.0< 0.001History of malignancy (%)0.35.7< 0.001Baseline history of hepatic encephalopathy (%)62.232.1< 0.001Baseline history of peritonitis (%)70.215.9< 0.001Baseline paracentesis rate (procedure/month)1.441.05< 0.001 Open table in a new tab

Risk factors for encapsulating peritoneal sclerosis: Analysis of a 36‐year experience in a University Hospital

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication that occurs in peritoneal dialysis (PD) therapy. The present study aimed to identify the risk factors, especially peritonitis and biocompatible PD fluid. The study included 703 patients who received PD between January 1980 and March 2015 at two centres. The patients were divided into two groups: those who had developed EPS (EPS group: n = 44) and those who had no documentary evidence of EPS (non-EPS group: n = 659). The independent risks of EPS were determined by univariate and multivariate logistic models. Encapsulating peritoneal sclerosis occurred in 44/703 (6.3%) patients between January 1980 and March 2015. In multivariate logistic models of risk factors correlated with EPS, dialysate to plasma creatinine ratio (D/P Cr) by peritoneal equilibration test (PET) and history of peritonitis were risk factors for EPS development (P < 0.01, respectively) in addition to PD duration. Especially, total duration of peritonitis, defined by period between onset and resolution of peritonitis, was an important risk factor for EPS development in patients with a history of peritonitis. Receiver operating characteristic (ROC) curve analysis revealed that cut-off point for EPS development was 36 days. Moreover, biocompatible PD fluid contributed to decreased EPS development. Both the longer duration of peritonitis and higher D/P Cr, as well as the longer PD duration, were risk factors for EPS development. Furthermore, use of biocompatible PD fluid contributed to the decrease in EPS development.

Alteration of membrane complement regulators is associated with transporter status in patients on peritoneal dialysis.

IntroductionA growing body of evidence from animal models and cell culture studies indicate an important role of a local regulatory complement system (CS) in peritoneal injury during peritoneal dialysis (PD). We investigated the expression of the local regulatory CS (reflected by CD46,CD55,CD59) in the peritoneal tissue of patients with different membrane function characteristics.Patients and methodsBiopsies from the parietal peritoneum were taken from 24 patients on PD, 22 uremic patients prior to PD. PD patients were grouped according to the dialysate-to-plasma ratio of creatinine (D/P Cre) and ratio of dialysate glucose at 4 hours versus dialysate glucose at time zero (D/D0 glucose) into low or low-average peritoneal transport status (L/LA) and high-average or high-transport status (HA/H) groups. CD46, CD55, and CD59 RNA expression were analyzed by real-time polymerase chain reaction (RT-PCR). Further localization of membrane complement regulators (CRegs) and semiquantitatively analysis was done by immunohistochemistry (IHC).ResultsCD46 and CD59 expression were similar in all groups. CD55 expression was significantly decreased in the HA/H group compared to the L/LA group and to uremic controls (p < 0.05 and p = 0.05, respectively). No statistically significant differences in CD46, CD55, and CD55 expression were detected when considering the history of peritonitis. There was no statistically significant correlation between PD duration and the expressions of CD46, CD55, and CD59. IHC revealed strong CD46, CD55, and CD59 expression in mesothelial cells. CD55 and CD59 were additionally detected in the vasculature. Using IHC, CD46 was lower in PD patients compared to uremic controls (p>0.05), but there was no difference between the L/LA compared to the H/HA group. Moreover IHC confirmed decreased expression of CD55 in the HA/H group compared to the L/LA group and uremic controls (p<0.0001 and p = 0.0001, respectively).ConclusionCD55 expression is decreased in patients with fast transporter membrane function, whereas peritonitis and PD duration do not appear to alter CReg expression.

Prognostic impact of peritonitis in hemodialysis patients: A national-wide longitudinal study in Taiwan.

BackgroundPeritonitis has been independently associated with increased morbidity and mortality in peritoneal dialysis patients. However, there are few reports on peritonitis in hemodialysis patients. We aim at investigating both the risk profiles and prognostic impact of peritonitis in hemodialysis patients.MethodsThis nation-wide longitudinal study uses claims data obtained from the Taiwan National Health Insurance Research Database. A total of 80,733 incident hemodialysis patients of age ≥ 20 years without a history of peritonitis were identified between January 1, 1998 and December 31, 2009. Predictors of peritonitis events were estimated using Cox proportional hazard models. Time-dependent Cox proportional hazard models were used to estimate hazard ratio for mortality attributed to peritonitis exposure.ResultsOf 80,733 incident hemodialysis patients over a 13-year study period, peritonitis was diagnosed in 935 (1.16%), yielding an incidence rate of 2.91 per 1000 person-years. Female gender, liver cirrhosis and polycystic kidney disease were three of the most significant factors for peritonitis in both non-diabetic and diabetic hemodialysis patients. The cumulative survival rate of patients with peritonitis was 38.8% at 1 year and 10.1% at 5 years. A time-dependent Cox multivariate analysis showed that peritonitis had significantly increased hazard ratio for all cause mortality. Additionally, the risk of mortality remained significantly higher for non-diabetic hemodialysis patients that experienced peritonitis.ConclusionsThe risk of peritonitis in hemodialysis patients is higher in female gender, liver cirrhosis and polycystic kidney disease. Although peritonitis is a rare condition, it is associated with significantly poorer outcome in hemodialysis patients.

Encapsulating peritoneal sclerosis

Encapsulating peritoneal sclerosis (EPS) is a complication of peritoneal dialysis (PD) with a low prevalence but high mortality. It is characterized by peritoneal inflammation and fibrosis with subsequent development of intestinal encapsulation. It is associated with a long lapse on PD, frequent episodes of peritonitis, high glucose solution use, and high peritoneal transport status. To report the clinical features of patients on PD, who developed EPS. Review of medical records of 12 patients aged 43 ± 10 years (eight women) who developed EPS. The mean time spent on PD was 98 months. The main clinical manifestations were abdominal pain in 82% and ultrafiltration failure in 63%. In 92%, there was a history of peritonitis and 75% had high peritoneal transport at the time of diagnosis. The main findings in computed tomography were peritoneal calcification and thickening. There was a biopsy compatible with the diagnosis in 10 cases. Treatment consisted in withdrawal from PD, removal of PD catheter and the use of corticoids and tamoxifen. After withdrawal from PD 50% of patients became asymptomatic. The rest had intermittent abdominal pain and altered bowel movements. Two patients died (17%). EPS is a serious complication of PD, which should be suspected in any patient with compatible clinical symptoms, long time on PD, multiple episodes of peritonitis and high peritoneal transport profile.

Stump appendicitis in a 2 year-old patient. Case report and literature review

La apendicitis del muñón es una causa poco común de abdomen agudo quirúrgico en niños, razón por la cual su diagnóstico no se sospecha con frecuencia. Este artículo reporta el caso de un paciente de dos años admitido en el servicio de urgencias por vómito, dolor abdominal y fiebre.Al ingreso, el paciente presentaba taquicardia, taquipnea, distensión abdominal y dolor difuso a la palpación del abdomen; los laboratorios evidenciaban leucocitosis, trombocitosis y elevación de la PCR. Inicialmente, se consideró obstrucción intestinal con base en antecedentes de peritonitis secundaria a una apendicitis perforada; sin embargo, debido al deterioro hemodinámico y al aumento del dolor abdominal, fue llevado a laparotomía exploratoria de urgencia.Durante el procedimiento se encontró peritonitis generalizada con apendicitis de la base, perforación intestinal, múltiples adherencias y, de forma incidental, un divertículo de Meckel. Se realizaron las intervenciones quirúrgicas correspondientes, y por su grave estado, fue hospitalizado en la unidad de cuidados intensivos (UCI), en donde recibió tratamiento con antibiótico de amplio espectro por 14 días y varios lavados peritoneales; por último, el paciente fue dado de alta satisfactoriamente.Aunque la apendicitis del muñón no es una causa frecuente de abdomen agudo, es necesario considerarla en aquellos pacientes con antecedentes de apendicitis y que ingresan por dolor abdominal, ya que la demora en el tratamiento se asocia con mayor morbilidad y aumento en los costos de atención.

Addition of Alanyl-Glutamine to Dialysis Fluid Restores Peritoneal Cellular Stress Responses - A First-In-Man Trial.

BackgroundPeritonitis and ultrafiltration failure remain serious complications of chronic peritoneal dialysis (PD). Dysfunctional cellular stress responses aggravate peritoneal injury associated with PD fluid exposure, potentially due to peritoneal glutamine depletion. In this randomized cross-over phase I/II trial we investigated cytoprotective effects of alanyl-glutamine (AlaGln) addition to glucose-based PDF.MethodsIn a prospective randomized cross-over design, 20 stable PD outpatients underwent paired peritoneal equilibration tests 4 weeks apart, using conventional acidic, single chamber 3.86% glucose PD fluid, with and without 8 mM supplemental AlaGln. Heat-shock protein 72 expression was assessed in peritoneal effluent cells as surrogate parameter of cellular stress responses, complemented by metabolomics and functional immunocompetence assays.ResultsAlaGln restored peritoneal glutamine levels and increased the primary outcome heat-shock protein expression (effect 1.51-fold, CI 1.07–2.14; p = 0.022), without changes in peritoneal ultrafiltration, small solute transport, or biomarkers reflecting cell mass and inflammation. Further effects were glutamine-like metabolomic changes and increased ex-vivo LPS-stimulated cytokine release from healthy donor peripheral blood monocytes. In patients with a history of peritonitis (5 of 20), AlaGln supplementation decreased dialysate interleukin-8 levels. Supplemented PD fluid also attenuated inflammation and enhanced stimulated cytokine release in a mouse model of PD-associated peritonitis.ConclusionWe conclude that AlaGln-supplemented, glucose-based PD fluid can restore peritoneal cellular stress responses with attenuation of sterile inflammation, and may improve peritoneal host-defense in the setting of PD.

Effect of propranolol on survival in patients with decompensated cirrhosis: a nationwide study based Danish patient registers.

We assessed the impact of propranolol on death, risk of hepatorenal syndrome and peritonitis in patients with cirrhosis. This study was a retrospective observational study and data were retrieved from Danish databases. We used our own criteria to stratify the patients into groups of patients with mildly decompensated cirrhosis or severely decompensated cirrhosis. A subgroup of patients with a history of peritonitis was also analyzed. Follow-up time was limited to 2 years from cohort entry. The reported hazard ratios (HR) with 95% confidence interval (CI) were based on a propensity score matched cohort. Among 3719 patients, we found 3075 patients with mildly and 644 with severely decompensated cirrhosis. Propranolol was used by 20% of the patients. Among the patients with mildly decompensated cirrhosis, propranolol use vs. non-propranolol was related with a HR of 0.7 (95% CI 0.6-0.9) and among the patients with severely decompensated cirrhosis, the HR was 0.6 (95% CI 0.4-0.9). Reduced mortality was found for doses of propranolol lower than 160 mg/day only. Among 361 patients with peritonitis, we found reduced mortality in the propranolol group with a HR of 0.5 (95% CI 0.3-0.8). The use of propranolol was associated with a HR of 0.4 (95% CI 0.2-0.9) for developing peritonitis during follow-up among patients with severely decompensated cirrhosis. In patients with decompensated cirrhosis, we found an association between propranolol use and reduced mortality risk for doses lower than 160 mg/day.

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.

Adhesiolysis in Patients Undergoing a Repeat Median Laparotomy.

Adhesiolysis during repeat surgery is associated with a high incidence of iatrogenic enterotomies and an increase in postoperative complications. Identification of risk factors would improve preoperative counseling and operating room strategy. The aim of this study was to identify preoperative risk factors for prolonged and difficult adhesiolysis in a repeat median laparotomy. This is a prospective cohort study. Univariate and multivariate analyses were used to assess the risk factors for prolonged and difficult adhesiolysis. This study was conducted at Radboud University Medical Center. Patients participating in the LAPAD study (ClinicalTrials.gov Identifier: NCT01236625) undergoing an elective repeat median laparotomy were selected. Detailed data regarding adhesiolysis to gain entry to the abdomen and adhesions underneath the previous incision were gathered by direct observation. A total of 259 patients underwent a repeat median laparotomy. Adhesiolysis was required for 230 patients (89%); the remaining 29 patients (11%) did not have adhesions underneath the incision. Median adhesiolysis time underneath the midline incision was 10 minutes (interquartile range, 5-25). Seventy-six patients (29%) had grade 1 or grade 2 adhesions; 108 (42%) had grade 3; and 46 (18%) had grade 4. The number of previous laparotomies was the only independent risk factor for prolonged (p ≤ 0.01; 95% CI, 2.5-14.10) and difficult adhesiolysis (p ≤ 0.01; OR, 4.21; 95% CI, 1.74-10.17). History of peritonitis, anatomical location of previous surgery, and the time interval between consecutive median laparotomies did not prolong adhesiolysis. This study involved retrospective data collection of patients' medical histories. No data were collected on the severity of previous peritonitis. This study demonstrates that 4 or more previous laparotomies and the presence or history of an intraperitoneal synthetic mesh are independently associated with a longer duration of adhesiolysis needed to gain access to the abdomen. A short time interval between median laparotomies or a history of peritonitis did not prolong the duration of adhesiolysis.

Escherichia Coli Peritonitis in Peritoneal Dialysis: The Prevalence, Antibiotic Resistance and Clinical Outcomes in a South China Dialysis Center

Escherichia coli (E. coli) peritonitis is a frequent, serious complication of peritoneal dialysis (PD). The extended-spectrum β-lactamase (ESBL)-producing E. coli peritonitis is associated with poorer prognosis and its incidence has been on continuous increase during the last decades. However, the clinical course and outcomes of E. coli peritonitis remain largely unclear. All of the E. coli peritonitis episodes that occurred in our dialysis unit from 2006 to 2011 were reviewed. The polymicrobial episodes were excluded. In total, ninety episodes of monomicrobial E. coli peritonitis occurred in 68 individuals, corresponding to a rate of 0.027 episodes per patient-year. E. coli was the leading cause (59.2%) of monomicrobial gram-negative peritonitis. ESBL-producing strains accounted for 35.5% of E. coli peritonitis. The complete cure rate and treatment failure rate of E. coli peritonitis were 77.8% and 10.0% respectively. Patients with preceding peritonitis had a higher risk of ESBL production as compared to those without peritonitis history [odds ratio (OR): 5.286; 95% confidence interval (CI): 2.018 - 13.843; p = 0.001]. The risk of treatment failure was significantly increased when the patient had a baseline score of Charlson Comorbidity Index (CCI) above 3 (OR: 6.155; 95% CI: 1.198 - 31.612; p = 0.03), or had diabetes mellitus (OR: 8.457; 95% CI: 1.838 - 38.91; p = 0.006), or hypoalbuminemia (≤ 30g/l) on admission (OR: 13.714; 95% CI: 1.602 - 117.428; p = 0.01). Prolonging the treatment course from 2 to 3 weeks or more reduced the risk of relapse and repeat significantly (p < 0.05). E. coli peritonitis remains a common complication of PD. The clinical outcomes of E. coli peritonitis are relatively favorable despite the high ESBL rate. A history of peritonitis is associated with increased risk for ESBL development. The severity of baseline comorbidities, the presence of diabetes mellitus and hypoalbuminemia at admission are associated with poor outcomes.

Investigating Hyponatremia, Exit-Site Management and Discharge Planning

Investigating Hyponatremia, Exit-Site Management and Discharge Planning

Ultrasonographic evaluation of peritoneal membrane thickness and comparison with the effectiveness and duration of CAPD

The few studies on the morphology and functions of CAPD and peritoneum have tended to use histological and histomorphometrical methods. However, such methods are known to require biopsy, which is an invasive method. The present study aims to determine the morphological changes established by ultrasonography in CAPD patients, as well as achieving a comparison between these changes and the functional properties of peritoneum in CAPD. We aim to determine the effects of the duration of CAPD upon peritoneal thickness. The study included 42 CAPD patients. Twenty-four of them had peritoneal dialysis (PD) duration of less than 24 months (Group 1) and 18 of them had PD duration of longer than 48 months (Group 2). Patients with a history of surgery involving the peritoneum and abdomen and with a history of peritonitis in the last 3 months were excluded. We examined the parietal peritoneum by trans-abdominal ultrasonography. There was a statistically significant positive correlation between PD duration and peritoneal thickness of each quadrant. There was a statistically significant negative correlation between membrane thickness and creatinine clearance (CrCl), peritoneal Kt/V (pKt/V) and normalized protein catabolic rate. There was a positive significant correlation between membrane thickness and dialysate/plasma creatinine ratio. There was a statistically significant difference between the two groups according to their peritoneal membrane thickness. CrCl and pKt/V values were better in Group 1 than in Group 2. Our study revealed that increased PD duration may have a relation with increased peritoneal membrane thickness, and this can be associated with less effective PD. Ultrasound imaging has an important role for evaluating peritoneal membrane thickness without using an invasive method such as biopsy and can be performed easily in dialysis clinics.

First Case Report of Post Liver Transplant Adrenal Metastasis of Hepatocellular Carcinoma Thatʼs Well Within Milan Criteria

Purpose: Background: Liver transplantation (LT) offers promising therapy for a subset of patients with hepatocellular cancer (HCC). HCC within Milan criteria can recur in 8-10% of post LT cases, but there are no reports of adrenal metastases post LT if HCC was within Milan criteria. We report first such case of exclusive extrahepatic adrenal metastasis post LT despite HCC being well within Milan criteria. Case: A 60-year-old Hispanic male ex-drug user with Hepatitis C, genotype 1b, cirrhosis without a history of peritonitis or variceal bleeding underwent LT after radiologic evidence of HCC. He had no other medical history except bilateral hearing loss and noncontributory family history. He denied current drug or alcohol use and smokes an occasional cigar. On exam, he had hepatosplenomegaly without ascites. CT scan showed an isolated 3 cm HCC and the explant confirmed the same in segment 6 of the liver without lymphovascular invasion. His pre LT laboratory studies revealed AFP of 317 and MELD score of 9 which was upgraded to 22 based on UNOS criteria. Post LT Course: He was put on cyclosporine, mycophenolate for immunosuppression. His post LT course was uneventful until three years after which he presented with fevers and chills. Work-up for possible infectious causes was negative and he was started on empiric ganciclovir as he was CMV recipient positive, donor negative. However, CT scan and PET scan revealed an isolated 8-cm left adrenal mass. The patient underwent adrenalectomy and pathology confirmed keratin- and HCA-positive metastatic HCC with necrosis. His immunosuppression was transitioned to sirolimus and he is currently doing well. Discussion: HCC has been cured by LT in a carefully selected group of patients who meet strict criteria. Previous cases of adrenal metastases first describe a patient well outside Milan criteria who was transplanted and then presented post-LT with reccurence intrahepatically, intravascularly and with metastasis to the adrenal gland. The second case presented with three segments of liver involvement with vascular invasion at the time of LT. And finally, the third case described synchronous intra- and extra-hepatic metastasis postoperatively.Figure: [1028] Left: Adrenaal mass. Right: Adrenal mass separate from kidney.

Pentraxin 3 as a new biomarker of peritoneal injury in peritoneal dialysis patients

It is well known that bioincompatible peritoneal dialysate plays a central role in the development of peritoneal fibrosis. Peritoneal inflammation continues even after the cessation of peritoneal dialysate stimulation. It is important to establish the definition of persistent inflammation in the peritoneal cavity at the cessation of peritoneal dialysis (PD). The objective of the present study was to determine whether pentraxin 3 (PTX3) in peritoneal effluent (PE) may be a new biomarker in PD patients. Serum, PE, and peritoneal specimens were obtained from 50 patients with end-stage kidney disease at Juntendo University Hospital. Samples of 19 patients were obtained at the initiation of PD and those of 31 patients at the cessation of PD. PTX3, high-sensitivity CRP, and MMP-2 and IL-6 were analyzed. An immunohistological examination using an anti-PTX3 antibody was performed. Expressions of PTX3 were observed in endothelial cells, fibroblasts, and mesothelial cells in the peritoneum. The PTX3 level in PE at the cessation of PD was significantly higher than that at the initiation of PD. Effluent PTX3 levels in patients with a history of peritonitis or a PD duration of more than 8 years were significantly higher than those in patients without peritonitis or patients with a PD duration of <8 years. The PTX3 level was significantly correlated with MMP-2 and IL-6 levels in PE, as well as the thickness of the submesothelial compact zone and the vasculopathy. It appears that PTX3 may be a new biomarker of peritoneal inflammation and progressive fibrosis.

Long-term effects of peritonitis on peritoneal dialysis outcomes

Prevalence of peritoneal dialysis is low in part because of the perceived high risk for complications such as peritonitis. However, in the most recent era, peritonitis incidence and its effects on patient outcomes may have diminished. The aim of this study was to analyze peritonitis incidence and its impact on patient and technique survival, as well as on the kidney transplantation rate and outcome. All peritoneal dialysis patients from a county hospital between year 2001 and 2011 were retrospectively included. Patients were divided into two groups with respect to peritonitis. The primary composite end-point consisted of a 3-year patient mortality or technique loss. Secondary end-points were patient survival and probability of kidney transplantation with respect to peritonitis history. Among 85 study patients, there were 61 peritonitis episodes. The incidence of peritonitis was 0.339 ± 0.71 episode per patient per 12 months or one episode per 29.3 ± 22.2 patient-months. The time to peritonitis was shorter, and peritonitis was more likely in patients on continuous ambulatory peritoneal dialysis than in automated peritoneal dialysis patients. Patient and technique survival and transplantation rate were similar in the group with and without peritonitis history. The primary end-point was recorded in 35 % of patients with peritonitis history and in 54 % of those without peritonitis (p = 0.04). In a multivariate analysis, the only variable significantly associated with the primary end-point and with patient survival was patient age at start of peritoneal dialysis. In contemporary peritoneal dialysis patients, timely treated peritonitis may not be associated with adverse patient and technique outcomes. The transplantation rate is unaffected by the peritonitis history. Peritoneal dialysis may be promoted as the first dialysis method in appropriate patients.