IN THE NAME OF GOD F.SAMADIAN NEPHROLOGIST. Peritonitis and Exit Site Infection.
Transcript of IN THE NAME OF GOD F.SAMADIAN NEPHROLOGIST. Peritonitis and Exit Site Infection.
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IN THE NAME OF GOD
F.SAMADIAN NEPHROLOGIST
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Peritonitis and Exit Site Infection
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the introduction of Y-set and double-bag disconnect systems has reduced this to approximately one episode per patient every 24 months
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Potential routes of infection: Intraluminal Periluminal Transmural HematogenousTransvaginal
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Intraluminal:
This allows bacteria to gain access to the peritoneal cavity via the catheter lumen
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Periluminal:
Bacteria present on the skin surface can enter the peritoneal cavity via the peritoneal catheter tract
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Transmural: Bacteria of intestinal origin can enter the
peritoneal cavity by migrating through the bowel wall
This is the usual mechanism of peritonitis associated with diarrheal statesdiarrheal states and/or instrumentation of the coloninstrumentation of the colon and may be seen also with strangulated herniastrangulated hernia
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Hematogenous:
Less commonly, peritonitis is due to bacteria that have seeded the peritoneum from a distant site by way of the bloodstream
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Transvaginal:
it may explain some instances of Candida peritonitis
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The responsible pathogen is almost always a bacterium, usually of the Gram-positive variety
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The occurrence of fungal peritonitis (e.g., Candida) is uncommon
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Infections with Mycobacterium tuberculosis or other type of mycobacteria have been reported but are unusual
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Diagnostic criteria for peritonitis: At least two of the following three conditions
should be present: symptoms and signs of peritoneal inflammation cloudy peritoneal fluid with an elevated
peritoneal fluid cell count (more than 100/mcL) due predominantly (more than 50%) to neutrophils
demonstration of bacteria in the peritoneal effluent by Gram stain or culture
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Symptoms and signs:
The most common symptom of peritonitis is abdominal pain
However, peritonitis should be suspected whenever a patient suffers from generalized malaise, particularly if nausea, vomiting, or diarrhea is also present
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Not all abdominal pain in a patient receiving PD is peritonitis
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Strangulated hernia is a common mimic for peritonitis
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Cloudiness of the fluid:
The peritoneal fluid generally becomes cloudy when the cell count exceeds 50-100/mcL
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In most patients, sudden onset of cloudy fluid with appropriate abdominal symptoms is sufficient evidence of peritonitis to warrant initiation of antimicrobial therapy
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However, peritoneal fluid cloudiness may be due to other factors (e.g., fibrin, blood, or, rarely, malignancy or chyle)
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On the other hand, a relatively translucent peritoneal fluid does not completely exclude the possibility that peritonitis is present (early in the course of peritonitis)
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The absolute peritoneal fluid cell count in CAPD patients is usually <50 cells/mcL and is often <10 cells/mcL
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Normally, the peritoneal fluid contains predominantly mononuclear cells (macrophages, monocytes, and, to a lesser extent, lymphocytes)
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The percentage of neutrophils does not normally exceed 15% of the total nonerythrocyte cell count and a value >50% strongly suggests peritonitis, whereas one >35% should raise suspicion
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Vancomycin or a first-generation cephalosporin such as cefazolin or cephalothin is used in combination with an antibiotic to cover Gram-negative organisms such as ceftazidime
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It is now recommended that aminoglycosides be avoided if possible in patients with residual renal function because of their nephrotoxicity
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CAPD Loading dose: Infuse 2 L of 1.5% dextrose
dialysis solution containing:1 g ceftazidime1 g cefazolin1,000 units/L heparin Allow to dwell for 3-4 hours.
Continue regular CAPD schedule. Add 125 mg per L ceftazidime, 125 mg/L cefazolin, and 1,000 units/L heparin to each dialysis solution bag
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If a patient appears toxic recommend a single loading dose IV
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Duration of therapy: If patient improvement is prompt,
antimicrobial therapy should be continued for a total of 14 days
If a cephalosporin is being used, then some physicians will switch to PO therapy after the first 5 days
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Severe S. aureus infections require antimicrobials for 3 weeks, and treatment with one IP antistaphylococcal drug plus PO rifampin is recommended
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Patients in whom S. aureus peritonitis develops not uncommonly are found to carry this organism in the nose nose
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This can be accomplished with intranasal mupirocin (b.i.d. for 5 days every 4 weeks) or oral rifampin (300 mg b.i.d. for 5 days every 3 months
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Exit site infection
Approximately one fifth of peritonitis episodes are temporally associated with exit site and tunnel infections
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Etiology and pathogenesis: Exit site infections are predominantly due to S.
aureus or Gram-negative organisms, particularly Pseudomona
In contrast to peritonitis, S. epidermidis is the causative organism in <20% of patients
eradication of the carrier state is very helpful to effective management
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Treatment is dependent on whether there is erythema alone or erythema in conjunction with purulent drainage
In the former case, topical treatment with hypertonic saline compresses, hydrogen peroxide, or mupirocin 2% ointment is usually sufficient
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Treatment is more problematic and more prone to failure when there is purulent drainage
some exit site infections extend into the subcutaneous tunnel
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The major risk factor for exit site infection is staphylococcal nasal carriage nasal carriage
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Persistently positive nasalpositive nasal cultures are associated with a 3-4 fold3-4 fold increase in risk of staphylococcal exit site infection
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Protocols used include
-rifampin (600 mg PO for 5 days),
-mupirocin (2% ointment twice daily for 5 days every 4 weeks)
-trimethoprim-sulfamethoxazole (single-strength tablet three times weekly)
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Mechanical Complications of Peritoneal Dialysis
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The instillation of dialysis fluid into the peritoneal cavity is accompanied by an increase in intra-abdominal pressure (IAP)
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The two principal determinants of the magnitude of the increased IAP are dialysate volumevolume and the positionposition of the patient during the dwell
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The supine supine position is associated with the lowest IAP for a given dialysate volume; sittingsitting entails the highest
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Hernia formation
as many as 10%-20% of patients may develop a hernia at some time on peritoneal dialysis
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Potential risk factors for hernia formation -Large dialysis solution volume -Sitting position -Isometric exercise -Valsalva maneuver (e.g., coughing) -Recent abdominal surgery -Pericatheter leak or hematoma -Obesity -Multiparity -Congenital anatomical defects
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Many different types of hernias have been described in the peritoneal dialysis patient
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Types of hernias reported in peritoneal dialysis patientsVentralEpigastricPericatheterUmbilicalInguinal (direct and indirect)FemoralSpigelianRichterForamen of MorgagniCystoceleEnterocele
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Pericatheter hernias need to be differentiated from masses caused by a hematoma, seroma, or abscess
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Ultrasonography Ultrasonography CTscan CTscan MRIMRI
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Small hernias pose the greatest risk of incarceration or strangulation of bowel
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Abdominal wall and pericatheter leak
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Abdominal wall leak may be difficult to diagnose clinically
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It may be mistaken for ultrafiltration failure when dialysate returns are less than the instilled volume
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The diagnosis should be considered with:
-decreased effluent volumes
-weight gain
-protuberant abdomen
-absence of generalized edema
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The patient should stand during the examination as this may reveal asymmetry of the abdomen
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Diagnosis can be proven using contrast CT scanning
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Pericatheter leak usually occurs as a postoperative complication of catheter implantation
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In most cases, the leak seals spontaneously
If it persists, the catheter should be removed and reinserted at another site
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In contrast to pericatheter leaks, abdominal wall leaks can occur early or late
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Sometimes surgical repair is feasible
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Vaginal leaks can also occur
Some may result from tracking of dialysate through the fallopian tubes and may resolve with tubal ligationtubal ligation
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Genital edema:
Dialysate can reach the genitalia by two routes
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One is by traveling through a patent processus vaginalis to the tunica vaginalis, resulting in hydrocele
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The second route is through a defect in the abdominal wall, often associated with the catheter
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This complication is often painful and distressing to the patient who is quick to bring it to medical attention
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CT peritoneography should be performed to distinguish which route has led to the genital swelling (i.e., anterior abdominal wall or processus vaginalis)
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Peritoneal dialysis should be temporarily stopped
Bed rest and scrotal elevation are helpful
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A leak via a patent processus vaginalis can be repaired surgically
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If the leak is through the anterior abdominal wall, replacement of the catheter can be helpful
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Respiratory complications:
Hydrothorax
Under the influence of raised IAP, dialysate can travel from the peritoneal to the pleural cavity, leading to a pleural effusion composed of dialysis effluent
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These defects may be congenital,congenital, in which case hydrothorax can occur with the first dialysis exchange, or acquiredacquired, whereby hydrothorax can be a late complication
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They occur almost exclusively on the right right sideside, probably because the left hemidiaphragm is mostly covered by heart and pericardium
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Symptoms of hydrothorax range from asymptomaticasymptomatic pleural effusion to severe severe shortness of breath shortness of breath
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Such symptoms may worsen with administration of hypertonic dialysatehypertonic dialysate, which raises IAP
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Thoracentesis can be done for diagnosis or to relieve symptoms
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The most diagnostic feature of the pleural fluid is the very high glucose levelvery high glucose level, although this is not always a consistent finding
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It is typically transudatetransudate, with variable numbers of leukocytes
transudative
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Radionuclide scanning with technetium is also helpful
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Back pain:
The presence of dialysate in the peritoneal cavity both raises IAP and swings the center of gravity forward, producing lordotic stress on the lumbar vertebrae and paraspinal muscles
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Some patients benefit from the performance of more frequent frequent exchanges with smaller dialysate exchanges with smaller dialysate volumesvolumes
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Metabolic Complications of Peritoneal Dialysis
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Glucose absorption
Glucose has the advantage of being cheap, stable, and relatively nontoxic to the peritoneum
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up to 100g per day of glucose may be absorbed, which represents 500-800 kcal per day
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This constitutes a significant portion of the recommended total energy intake of about 2,500 kcal per day (35 kcal/kg per day) in a 70-kg patient
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In some patients, this provides a welcome source of calories since achieving the nutritional recommendation for PD is often difficult
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In patients who start PD obese obese, the glucose loading from PD may contribute to further weight gain
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glucose absorption results in increased insulin secretioninsulin secretion, which together with insulin resistance (a common feature of chronic renal failure) results in plasma insulin levels that are persistently high
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Hyperinsulinemia may be an independent risk factor for the development of atherosclerosis
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Patients who were previously well controlled on oral hypoglycemics often require increased doses of these medications, and they may even require a change to insulin therapyinsulin therapy after the initiation of PD
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To minimize glucose absorption, patients should be advised on appropriate salt appropriate salt and water managementand water management, which will diminish the need for hypertonic solutions to maintain fluid balance
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Lipid abnormalities
patients on PD have a variety of lipid abnormalities
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Typically, they have high total and LDL cholesterol, high triglycerides, low HDL cholesterol, high apoB, low apoA-I, and high lipoprotein(a) levels
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Compared with hemodialysis patients, the most striking differences are the high apoB protein and LDL cholesterol levels, which are usually normal in hemodialysis patients
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Protein loss:
PD is associated with significant loss of protein across the peritoneum
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This loss is about 0.5 g/L of dialysate drainage, but may be higher and account for as much as 10-20 g per day
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The major component of the protein losses is albumin
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Acute peritoneal inflammation is associated with substantially greater protein losses, and a rapid reduction in serum albumin is common during episodes of peritonitis
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The protein loss itself may become an indication to terminate peritoneal dialysis temporarily or, on occasion, permanently
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Hypokalemia/hyperkalemiakm: PD solution contains no potassium Usually only patients who are
noncompliant in performing their dialysis exchanges or who have excessive potassium intake have ongoing problems with hyperkalemia
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However, hypokalemia has been reported in 10%-30% of CAPD patients
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These cases are usually associated with poor nutritional intake, and most can be managed by liberalizing the diet
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Dialysis solution calcium level
PD solutions are available with 2.5 mEq/L or 3.5 mEq/L calcium concentrations
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The 3.5 mEq/L dialysis solution keeps the patient in positive calcium balance
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The standard solution is now considered to be the 1.25 mM (2.5 mEq/L) calcium solution
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Hypocalcemia is not common in patients on PD because of the widespread use of calcium-based phosphate binders and vitamin D
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