Predicting outcomes of peritoneal-dialysis-associated peritonitis based on dialysate white blood cell count.
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Journal Article↗
Biomedical subjects
Mark D Faber
Publications and source records attributed to Mark D Faber.
Diagnosis and management of enteric disease and abdominal catastrophe in peritoneal dialysis patients with peritonitis.
Peritoneal dialysis (PD)-associated peritonitis rates have decreased significantly in recent years, especially Staphylococcus epidermidis and Staphylococcus aureus infections. Rates of gram-negative, polymicrobial, and fungal peritonitis have remained steady. The reported mortality of gram-negative and polymicrobial peritonitis varies widely (4%-50%). Most likely, the reason for this variability is that prognosis depends on the underlying etiology more than the specific microorganisms isolated. Gram-negative, polymicrobial, and fungal infection have variable association with documented visceral disease, and the highest mortality occurs in reports with the highest prevalence of intra-abdominal pathology. The odds ratio of death in PD patients with documented abdominal catastrophe and peritonitis is reported to be 20:1 compared with all other causes. Further reductions in PD-associated peritonitis mortality are likely to depend on earlier diagnosis and better management of intra-abdominal pathology. Presentation with hypotension, sepsis, lactic acidosis, and/or elevation of peritoneal fluid amylase should raise immediate concern for "surgical" peritonitis. Suspicion for visceral disease should also be high in patients with gram-negative, polymicrobial, and fungal infection or those who fail to improve rapidly as judged by clinical signs and symptoms, cell counts, and repeat cultures. Nonlocalizing physical examination and negative or nonspecific results of abdominal computed tomography do not rule out serious intra-abdominal disease. Immediate initiation of broad antibiotic coverage including for anaerobic infection is indicated when bowel pathology is suspected. Urgent surgical consultation, with active discussion and participation by the nephrologist, is advisable when visceral pathology is suspected and the patient is unstable or fails to improve rapidly.
Anti-Bacterial Agents↗
Fivefold reduction in peritonitis using a multifaceted continuous quality initiative program.
Despite recent advances in peritoneal dialysis (PD) systems, peritonitis is a significant clinical problem in patients on PD. Risk factors for peritonitis are identifiable and modifiable and require focused intervention. During a baseline period in 1998, we observed consistent differences in peritonitis rates among patients using various PD connection systems. In January 1999, motivated by a need to reduce peritonitis, we initiated a multifaceted continuous quality initiative (CQI) program that included retraining all current patients and all new patients 6 months after initiation and then annually; changing from plastic to titanium adapters between the catheter and the transfer set; and using equipment from a single PD manufacturer for all new patients and for current patients with high peritonitis rates. Furthermore, all patients using HomeChoice cyclers (Baxter Healthcare Corporation, McGaw Park, IL, U.S.A.) were taught to use the Compact Exchange Device II to avoid contamination when spiking solution bags. Peritonitis rates improved from 1 episode per 7.5 patient-months (over 512 patient-months) in 1998 to 1 episode per 36.5 patient-months (over 292 patient-months) as of September 2002. Further analysis also showed a significant difference in peritonitis rates between equipment produced by various manufacturers. There was a statistically significant difference in peritonitis for automated peritoneal dialysis systems. Patients using the Freedom Cycler PD+ (Fresenius Medical Care, Frankfurt, Germany) had an average peritonitis rate of 1 episode per 6.9 patient-months as compared with patients using the HomeChoice cycler (Baxter Healthcare), who experienced 1 episode of peritonitis per 23.9 patient-months on average (p < 0.0001). For continuous ambulatory peritoneal dialysis patients using UltraBag (Baxter Healthcare), the peritonitis rate was 1 episode per 26 patient-months as compared with the Premier Double Bag (Fresenius Medical Care), for which a peritonitis rate of 1 episode per 6.3 patient-months was seen (p < 0.0001). Comparison of the UltraBag (1 episode per 26.0 patient-months) with the Disposable Freedom Set, a single-bag "Y" system (Fresenius Medical Care; 1 episode per 7.5 patient-months) yielded similar results (p < 0.0001). We conclude that ongoing CQI efforts can significantly reduce peritonitis rates. Our efforts included aggressive patient retraining, protocol changes, use of a titanium adapter between the catheter and the transfer set, and careful choice of connectology systems (possible supplier-dependent effect).
Aged↗
Feasibility of adequate solute clearance in obese patients on peritoneal dialysis: a cross-sectional study.
BACKGROUND: It is widely assumed that obese patients are poorly suited for peritoneal dialysis (PD). Mathematical models predicting weight limits to achieve adequate solute clearance in anuric patients on continuous ambulatory PD therapy do not apply to the majority of obese patients on PD therapy. METHODS: To define the extent to which obesity or large body size interferes with successful PD, the feasibility of achieving adequate solute clearance, defined by the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines, was studied. We reviewed prospectively recorded data for 25 obese patients (body mass index > or = 29) from a group of 58 prevalent PD patients treated in an inner-city ambulatory dialysis center. Adequacy of solute clearances was assessed by comparing weekly Kt/V and weekly creatinine clearance (WCC) with those recommended by the K/DOQI. Adequacy also was examined separately for large patients, defined as those with total-body water (TBW) by the Watson and Watson equation of 48 L or greater. Similar analyses were performed separately for 10 anuric obese patients. RESULTS: Eighty four percent and 88% of the 25 obese patients achieved K/DOQI targets for weekly Kt/V and WCC, respectively. Among the 10 anuric obese patients, 90% and 70% achieved these targets. Only 60% of those with TBW of 48 L or greater met the Kt/V target. CONCLUSION: PD remains a viable option for obese patients with end-stage renal disease. It is possible for the majority of obese patients on PD therapy to achieve solute clearances recommended by the K/DOQI.
Body Mass Index↗