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complication of peritoneal dialysis
Coplication Of pertonal Dialysis
Dr Gh.Sarvari
Pediatric Nephrologist
Infectious Complications of PD
Peritonitis
➢ Despite a series of improvements in connection
technology, peritonitis remains the single most common
complications in PD children and the most important
cause of morbidity hospitalization and technique failure .
➢ Peritonitis annualized rate varies in different parts of the
world, from 0.64 in North America and 0.60 in Italy to the
exceptional rate of 0.17 episodes per PD treatment year in
Japanese children
➢ An inverse relationship between the age of the patient
and peritonitis rate
➢ The 2018 Annual Data Report from the United States
Renal Data System(USRDS) reported that infection is the
leading cause for hospitalization and the second-most
common cause of death in children receiving PD
Cont.
Although the microbiology, diagnosis, and management of peritonitis in
children undergoing CPD are similar to those of adult patients, there are some
issues that are unique or more common in pediatric CPD. These include:
●Fungal peritonitis is an infrequent complication in pediatric patients
undergoing CPD, accounting for up to 8 percent of peritonitis episodes .
Children with fungal peritonitis are more likely to be less than two years of
age. Successful therapy is the same as in adults with fungal peritonitis and
consists of combination therapy of antifungal medication and dialysis
catheter removal. The outcome of fungal peritonitis in children, however, is
more favorable than in adults, with a lower mortality rate .
●There is global variation in causative microbial agents in peritonitis in
children receiving CPD .As an example, the rate of Pseudomonas-based
peritonitis is eight times greater in the United States than in Europe. In
addition, there are significant differences in antibiotic susceptibility,
particularly with first generation cephalosporins and aminoglycosides.
These issues need to be considered when choosing empiric antibiotic
coverage while awaiting results from peritoneal fluid cultures
CLINICAL PRESENTATION
➢Abdominal pain – 79 to 88 percent
➢Fever– 29 to 53 percent
➢Nausea or vomiting – 31 to 51 percent
➢Cloudy effluent – 84 percent
➢Hypotension – 18 percent

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complication of peritoneal dialysis

  • 2. Coplication Of pertonal Dialysis Dr Gh.Sarvari Pediatric Nephrologist
  • 4. Peritonitis ➢ Despite a series of improvements in connection technology, peritonitis remains the single most common complications in PD children and the most important cause of morbidity hospitalization and technique failure . ➢ Peritonitis annualized rate varies in different parts of the world, from 0.64 in North America and 0.60 in Italy to the exceptional rate of 0.17 episodes per PD treatment year in Japanese children ➢ An inverse relationship between the age of the patient and peritonitis rate ➢ The 2018 Annual Data Report from the United States Renal Data System(USRDS) reported that infection is the leading cause for hospitalization and the second-most common cause of death in children receiving PD
  • 5. Cont. Although the microbiology, diagnosis, and management of peritonitis in children undergoing CPD are similar to those of adult patients, there are some issues that are unique or more common in pediatric CPD. These include: ●Fungal peritonitis is an infrequent complication in pediatric patients undergoing CPD, accounting for up to 8 percent of peritonitis episodes . Children with fungal peritonitis are more likely to be less than two years of age. Successful therapy is the same as in adults with fungal peritonitis and consists of combination therapy of antifungal medication and dialysis catheter removal. The outcome of fungal peritonitis in children, however, is more favorable than in adults, with a lower mortality rate . ●There is global variation in causative microbial agents in peritonitis in children receiving CPD .As an example, the rate of Pseudomonas-based peritonitis is eight times greater in the United States than in Europe. In addition, there are significant differences in antibiotic susceptibility, particularly with first generation cephalosporins and aminoglycosides. These issues need to be considered when choosing empiric antibiotic coverage while awaiting results from peritoneal fluid cultures
  • 6. CLINICAL PRESENTATION ➢Abdominal pain – 79 to 88 percent ➢Fever– 29 to 53 percent ➢Nausea or vomiting – 31 to 51 percent ➢Cloudy effluent – 84 percent ➢Hypotension – 18 percent
  • 7. Predisposing factors in children ➢Peritoneal catheter exit-site infection ➢ The higher incidence of gastrostomy feeds ➢The use of diapers in infants ➢Young children who are not yet toilet trained ➢Surgical procedures performed around the time of PD catheter placement
  • 8. Risk factors ➢ Recent invasive intervention (colonoscopy, sigmoidoscopy, cystoscopy, hysteroscopy) ➢ Dental procedures ➢ Nasal S. aureus carriage ➢ Exit-site and/or tunnel infections ➢ Other factors that have been associated in various studies include constipation, smoking and chronic obstructive pulmonary disease (COPD), domestic pets, obesity, depression, hypokalemia, hypoalbuminemia, prior hemodialysis, use of bioincompatible solutions, and living far away from the peritoneal dialysis clinic
  • 9. MICROBIOLOGY ➢ The most common source of peritonitis is intraluminal contamination; typically, this occurs if the patient uses suboptimal sterile technique for connecting or disconnecting the catheter to perform exchanges ("touch contamination"). ➢ Other sources of peritonitis include periluminal (contamination due to extension of bacteria from exit- site or tunnel infection), visceral (contamination via bacteria from bowel) and vaginal (rarely). ➢ In addition, peritonitis can develop via hematogenous dissemination from a remote source.
  • 10. MICROBIOLOGY(cont.) ➢Gram-positive organisms 45 to 65 percent ➢Gram-negative organism 15 to 35 percent ➢More than one organism has been reported in 1 to 4 percent of cases ➢Culture negative 20 to 40 percent ➢Approximately 3 to 5 percent are caused by fungi, mostly Candida species
  • 11. Cont. ➢ Gram positive 1.Coagulase negativsatphylococcus 2.Streptococcus spp, 3.Staphylococcus aureus 4.Enterococcus spp 5.Corynebacterium ➢ Gram negative 1.Escherichia coli 2.Klebsiella spp 3.Pseudomonas aeruginosa
  • 12. Diagnose Peritonitis should be diagnosed if two or more of following are present : ➢Consistent clinical features (abdominal pain or cloudy effluent). ➢Peritoneal fluid white count is greater than 100 cells/mm3 (or 0.1 x 109/L after dwell time of at least two hours) and the percentage of neutrophils is greater than 50 percent. ➢Positive effluent culture.
  • 13. TREATMENT Empiric antibiotics ((ISPD) guidelines) ➢ Gram-positive organisms may be covered by vancomycin or a first-generation cephalosporin (such as cefazolin). In centers with a high rate of methicillin-resistant organisms, vancomycin should be used. ➢ Gram-negative organisms may be covered by a third- or fourth- generation cephalosporin (such as cefepime or ceftazidime), an aminoglycoside, or aztreonam ➢ If the Gram stain reveals yeast or other fungus, antifungal agents should be started and the patient prepared for possible catheter removal depending on the final culture results ➢ We administer antifungal prophylaxis among patients on peritoneal dialysis who are treated with antibiotics for longer than three days
  • 14. After culture and sensitivity results are available Single bacterial organism — The regimen should be adjusted after a specific organism is identified and may be further adjusted based on clinical response. Patients with cultures demonstrating methicillin- resistant S. aureus warrant treatment with vancomycin; patients with methicillin-sensitive S. aureus warrant treatment with a first- generation cephalosporin such as cefazolin, if feasible. Polymicrobial peritonitis --- Peritonitis due to multiple enteric organisms or mixed gram-negative/gram-positive organisms should raise concern for a concurrent intra-abdominal condition such as ischemic bowel or diverticular disease. In such cases, imaging studies and surgical consultation should be obtained Empiric broad-spectrum antimicrobial therapy should include coverage for anaerobes and gram-negative enteric bacilli. We generally treat with metronidazole plus vancomycin plus an aminoglycoside or ceftazidime.
  • 15. Culture-negative peritonitis ➢ Patients with culture-negative peritonitis are treated with empiric antibiotics covering both gram-positive and negative organisms. ➢ We repeat the cell count and culture after three days of empiric therapy. ➢ If there is improvement in cell count and clinical status after three days and cultures continue to show no growth, we continue either vancomycin or a first- generation cephalosporin for a total of two weeks ➢ The Differential diagnosis for infectious causes of culture-negative peritonitis includes mycobacterial and fungal pathogens, Nocardia, and Legionella.
  • 16. Indications for catheter removal ➢ Refractory peritonitis, defined as peritonitis that does not respond to appropriate antibiotics within five days. ➢ Relapsing peritonitis, defined as a repeat episode of peritonitis within four weeks of completion of an antibiotic course. The repeat episode is caused by the same organism that caused the initial episode or follows an episode of culture-negative peritonitis. We may also remove the catheter if the patient develops a repeat episode of peritonitis with the same species within two months of completion of an antibiotic course ➢ Fungal or mycobacterial peritonitis. ➢ Peritonitis occurring in association with intra-abdominal pathology, such as an abscess, perforation, or infarcted bowel. ➢ Culture-negative peritonitis with persistent symptoms and high peritoneal white blood cell count.
  • 17. Peritoneal Catheter Exit-Site and Tunnel Infection Peritoneal catheter exit-site infection (ESI) represents an important risk factor for peritonitis and frequently requires catheter removal and replacement, especially after its recurrence Prophylactic measures: ➢ Cleansing the exit site with a sterile antiseptic solution ➢ Application of a topical antibiotic (mupirocin or gentamicin) and Sterile gauze ➢ Immobilization of the catheter ➢ Phand hygiene, aseptic technique in any dialytic maneuver, and appropriate provision of antibiotics and/or transfer set change following touch contamination
  • 18. Exit-site score system. Infection should be assumed with a cumulative exit-site score of 4 or greater
  • 19. Risk factors associated with development of ESI ➢Poor competency of exit-site care ➢Catheter mobilization ➢Catheter pulling-out injury ➢Mechanical compression of the catheter by a waist belt ➢Swimming ➢Presence of pets during exchanges ➢Compression of the exit site by a peritoneal dialysis catheter bag
  • 20. The causative agents ➢ Most infections are still caused by gram- positive organisms, the percentage caused by Staphylococcus aureus appears to have decreased with increases in other gram- positive organisms and gram-negative organisms ➢ In addition, several studies have reported infection caused by uncommon organisms such as atypical mycobacteria, non- diphtheria Corynebacteria,and Burkholderia cepacia
  • 21. TREATMENT ➢ We agree with the 2017 International Society for Peritoneal Dialysis (ISPD) guidelines that all exit-site infections (ESIs) with or without tunnel involvement should be treated with antibiotics . ➢The initial treatment of exit-site and tunnel infections is the same.
  • 22. Empiric therapy ➢ Gram-positive organism – A first-generation oral cephalosporin (such as cephalexin) or a penicillinase-resistant penicillin (such as dicloxacillin). We use clindamycin if the patient is allergic to penicillin. ➢ Gram-negative organism – Ciprofloxacin .If the patient cannot take ciprofloxacin, we use intraperitoneal ceftazidime. Ceftazidime may be given continuously (500 mg/L loading dose followed by 125 mg/L in all subsequent exchanges) or intermittently (1000 to 1500 mg in one exchange daily). For intermittent dosing of intraperitoneal antibiotics, the dwell time should be at least six hours to allow adequate absorption ➢ Gram stain results unavailable or inconclusive – Both a first-generation oral cephalosporin or a penicillinase-resistant penicillin and ciprofloxacin . We use clindamycin if the patient is allergic to penicillin .If the patient cannot take ciprofloxacin, we use intraperitoneal ceftazidime as described above for gram-negative organisms
  • 23. Treatment duration and follow-up ➢ Antibiotic therapy is adjusted depending on culture and sensitivity results. ➢ In addition, we re-evaluate clinically after one week. ➢ If the patient is improving, we continue antibiotics until the infection is completely resolved and for a minimum of two weeks for all organisms except Pseudomonas. ➢ If the patient has a Pseudomonas infection, we treat for a minimum of three weeks.
  • 24. Noninfectious complications of peritoneal dialysis complications Some of the noninfectious complications are due to increased intra-abdominal pressure: ➢ leaks (including hydrothorax or pleuroperitoneal leaks) ➢Hernia formation ➢ local edema ➢Back pain ➢Gastrointestinal problems, such as gastroesophageal reflux and delayed gastric emptying
  • 25. Cont. ➢Complications of CAPD/CCPD not specifically related to intra-abdominal pressure include: ➢ Hemoperitoneum ➢ Pain on infusion of dialysate ➢ Electrolyte imbalances ➢ Ultrafiltration failure
  • 26. GASTROESOPHAGEAL REFLUX DISEASE AND DELAYED GASTRIC EMPTYING ➢ Nausea, vomiting, a sensation of fullness, and epigastric discomfort are commonly reported by patients on continuous ambulatory peritoneal dialysis ➢ Gastrointestinal complaints, such as nausea and fullness, occur in as many as 20 to 40 percent of CAPD patients, while approximately 14 percent report frequent vomiting . ➢ However, a paucity of data exists concerning the relationship between these symptoms and the presence of gastroesophageal reflux disease (GERD) or delayed gastric emptying (gastroparesis) ➢ There are many potential causes of such symptoms, including uremia, medication-induced gastroenteritis, gastritis, and peptic ulcer disease. ➢ However, if the patient is well dialyzed (ie, has an adequate Kt/V) and specific gastrointestinal causes of the symptoms have been excluded, persistent upper gastrointestinal symptoms should prompt consideration of GERD or gastroparesis ➢ Medical management of both GERD and gastroparesis is similar to that in patients not on dialysis. Successful treatment of these problems is important since, if left untreated, they have a significant adverse effect upon the well-being and nutritional status of peritoneal dialysis patients.
  • 27. Delayed gastric emptying ➢ Delayed gastric emptying is relatively common among CAPD patients, including those without diabetes. In a few small studies, delayed gastric emptying of solids and liquids has been detected in approximately 50 percent of both symptomatic and asymptomatic patients undergoing peritoneal dialysis . ➢ Normal gastric emptying results have been noted when the peritoneal cavities are drained, thereby suggesting that a mechanical or neurogenic mechanism triggered by the presence of intra-abdominal fluid retards gastric emptying
  • 28. BACK PAIN ➢ Increased mechanical stress on the lumbar spine is common among patients on continuous ambulatory peritoneal dialysis (CAPD); this is due, in part, to the tendency of patients to assume a more lordotic position because of increased intra-abdominal pressure .Some patients may also have poor abdominal muscle tone, resulting from previous surgeries or poor physical conditioning. These effects increase the mechanical stress on the lumbar spine, thereby causing back pain or sciatica . ➢ Underlying degenerative disk disease, facet joint disease, and osteoporosis may further exacerbate the back pain . ➢ Treatment — Other than general therapeutic measures, the treatment of lower back pain in CAPD patients may include decreasing the dialysate fill volume. However, since adequate dialysis must be maintained, changing to continuous cycler peritoneal dialysis (CCPD) may be beneficial as larger fill volumes may be tolerated when the patient is supine. In those whose back pain is severe, transfer to hemodialysis may be necessary if adequate clearance on CCPD cannot be achieved
  • 29. PLEURAL EFFUSION DUE TO PLEUROPERITONEAL LEAK ➢ The development of a pleural effusion (hydrothorax) in a patient on continuous peritoneal dialysis may be due to systemic volume overload, heart failure, or a local pleural process. ➢ The presence of a pleural effusion without other signs of heart failure or of peripheral edema, particularly if the effusion is only right sided, should prompt a search for a pleuroperitoneal communication. ➢ The right side is more commonly affected than the left,
  • 30. Management ➢ The treatment of acute hydrothorax due to pleuroperitoneal leaks depends upon the acuity and severity of the patient's symptoms and the need and/or desire to continue with peritoneal dialysis as a treatment modality. ➢ In most cases, simply draining the peritoneal cavity and avoiding overnight (supine) dwells is sufficient. If the leak is small and the patient has adequate residual function to permit intermittent dialysis (eg, nocturnal peritoneal dialysis), peritoneal dialysis can be continued. ➢ Chemical pleurodesis may be offered to the patient with recurrent pleural effusion, unresponsive to conservative measures, who needs and/or desires to continue with peritoneal dialysis. ➢ video-assisted thoracoscopic pleurodesis or repair may also be an option for patients who failed conservative managemen
  • 31. PAIN ON DIALYSATE INFUSION This complaint is thought to be caused by: ➢ The acidic pH (pH 5.2 to 5.5) of conventional lactate dialysate ➢Poor catheter position (such as abutting against the bowel wall or peritoneal cavity surfaces) ➢The dialysate temperature ➢High glucose concentration of hypertonic dialysis solutions
  • 32. Treatment Treatment of infusion pain includes the following measures, to be utilized in descending order: ➢ Neutralization of the solution by injecting sodium bicarbonate into the bag prior to infusion (2 to 5 mEq/L) ➢ Slowing the rate of infusion ➢ Injection of local anesthetics into the dialysis solution before infusing (1 percent lidocaine at 50 mg/exchange) ➢ Incompletely draining the fluid after a dwell period ➢ Catheter replacement ➢ Discontinuation of peritoneal dialysis
  • 33. ELECTROLYT ABNORMALITIES ➢Hypokalemia ➢ 10 to 35 percent of patients on continuous peritoneal dialysis require potassium supplements Cellular uptake of potassium, prompted by the intraperitoneal glucose load with subsequent insulin release, and bowel losses may also play a role in the hypokalemia observed in peritoneal dialysis patients ➢ For stable chronic outpatients, liberalization of dietary potassium restriction and, when needed, oral potassium replacement (usually 20 mEq/day, based upon individual patient serum potassium determinations) are usually successful treatments for hypokalemia. Potassium-sparing diuretics like spironolactone may also be effective in the peritoneal dialysis patient with chronic hypokalemia with appropriate surveillance of serum potassium levels . Intraperitoneal potassium may also be administered acutely if critical hypokalemia exists
  • 34. Cont. ➢Magnesium ➢ Hypermagnesemia, a common finding in peritoneal dialysis patients, is due to positive magnesium balance resulting from renal failure and the relatively high dialysate magnesium concentration ➢ Hypermagnesemia suppresses PTH levels, thereby contributing to adynamic bone disease in peritoneal dialysis patients ➢ Multiple factors can affect plasma magnesium concentration including diet, nutritional status, albumin levels, medications like proton pump inhibitors, and dialysis prescriptions ➢ A large cohort study of 10,692 incident peritoneal dialysis patients beginning peritoneal dialysis found that 18 percent of patients had a serum magnesium level <1.8 mg/dL, 21 percent had a magnesium level of 1.8 to 2.0 mg/dL, and only 19 percent had a level ≥2.4 mg/d
  • 35. Hemoperitoneum ➢ Hemoperitoneum is mainly observed in female PD patients in the reproductive age ➢ Rupture of ovarian corpus luteum cysts ➢ Acute catheter insertion ➢ Bleeding following omentectomy or other intra- abdominal surgery ➢ Heavy physical activity ➢ Coagulopathy or anticoagulant therapy ➢ Trauma to the abdomen or the catheter ➢ Pancreatitis
  • 36. ➢ PD effluent hematocrit >2 % suggests an intraperitoneal pathology, thus deserving extensive diagnostic studies, surgical consultation, and consideration of laparoscopy or laparotomy . ➢ The type and urgency of treatment of hemoperitoneum depend on its cause. ➢ Heparin may be added bloody dialysate (250–500 units per liter) to prevent catheter obstruction by blood clots.
  • 37. Abdominal Hernias ➢ The incidence of hernias is higher in the young children than in adult ➢ PD patients Hernias can be incisional, umbilical, or inguinal ➢ Almost all hernias must eventually be repaired surgically. ➢ Prior to and 1–2 weeks following surgical correction,dwell volume should be reduced by up to 50 % and PD performed overnight in recumbent position, avoiding daytime dwells