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PubMed1996

CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis.

OBJECTIVE: The purpose of this study was to determine the potential of CT for distinguishing tuberculous peritonitis from peritoneal carcinomatosis in 135 clinically or pathologically proven cases. MATERIALS AND METHODS: Abdominal CT scans in 135 patients of tuberculous peritonitis (n = 42) and peritoneal carcinomatosis (n = 93) with documented omental, mesenteric, or peritoneal pathology were retrospectively reviewed. CT findings were evaluated in each group of patients for the morphologic appearance of mesenteric or omental abnormalities as well as for visualization of the spleen and liver, the lymph nodes, and ascites. Statistical comparisons using multivariate logistic regression analysis were performed to adjust for the differences in CT findings between the two groups. RESULTS: Mesenteric changes were more commonly seen in patients with tuberculous peritonitis (98%) than in patients with peritoneal carcinomatosis (70%) (p < .01). Micronodules (less than 5 mm in diameter) were noted in approximately one half of patients with tuberculous peritonitis or peritoneal carcinomatosis, but macronodules (> or = 5 mm in diameter) were much more frequently seen in patients with tuberculous peritonitis (52%) than in patients with peritoneal carcinomatosis (12%) (p < .01). The omentum appeared to be more irregularly infiltrated in peritoneal carcinomatosis patients (p < .01). The thin omental line covering the infiltrated omentum was seen in 13 patients with tuberculous peritonitis but in only four patients with peritoneal carcinomatosis (p < .01). In peritoneal or extraperitoneal masses in patients with tuberculous peritonitis, a low-density center was seen in 18 cases (43%) and calcification was noted in six cases (14%). The prevalences of splenomegaly and splenic calcification were higher in patients with tuberculous peritonitis. Using multivariate analysis, we calculated the sensitivity of CT for predicting tuberculous peritonitis and peritoneal carcinomatosis as 69% and 91%, respectively. CONCLUSION: Although most CT findings that we analyzed overlap these diseases, using a combination of CT findings increased our ability to distinguish tuberculous peritonitis from peritoneal carcinomatosis.

Adult↗
PubMed2004

Changes in the organisms of resistant peritonitis in patients on continuous ambulatory peritoneal dialysis.

Peritonitis is one of the most serious complications of continuous ambulatory peritoneal dialysis (CAPD). Approximately 20% of peritonitis infections have been reported to be resistant to initial therapy, either failing to resolve with appropriate antibiotics or relapsing within 2 weeks of antibiotic discontinuation. To investigate the current situation with regard to resistant peritonitis, we retrospectively examined the incidence and the organisms of resistant peritonitis in our unit over a period of 9 years. From January 1, 1994, to January 1, 2003, we introduced 325 patients onto CAPD. At January 1, 2003, we followed up 172 patients who were receiving CAPD in our unit. During 1994-1996, 12 cases of peritonitis and 3 cases of resistant peritonitis (25%) occurred among our patients. Microbiologic examination revealed that the organisms involved in peritonitis were alpha-streptococcus (17%), coagulase-negative staphylococcus [CNS (17%)], and methicillin-sensitive Staphylococcus aureus [MSSA (17%)]. The organisms of resistant peritonitis were methicillin-resistant S. aureus [MRSA (67%)] and methicillin-resistant CNS (33%). During 1997-1999, 39 cases of peritonitis and 13 cases of resistant peritonitis (33%) occurred among our patients. The most frequently cultured organisms in peritonitis were CNS (26%), Candida species (13%), and alpha-streptococcus (10%). The organisms of resistant peritonitis were methicillin-resistant CNS (46%) and Candida species (38%). In the most recent 3-year period (2000-2002), our patients experienced 57 cases of peritonitis and 24 cases of resistant peritonitis (42%). The organisms of peritonitis were alpha-streptococcus (46%), CNS, MSSA, Escherichia coli, and Candida species (38%). However, the organisms of resistant peritonitis were methicillin-resistant CNS (13%), Candida species (21%), Pseudomonas aeruginosa (13%), Serratia (13%), Citrobacter (13%), and Corynebacterium (13%). In the last several years, methicillin-resistant CNS has come to be main organism of resistant peritonitis. In addition, opportunistic infection has become a serious peritonitis problem. Given these data, we conclude that the incidence of resistant peritonitis is increasing and that the organisms of resistant peritonitis are changing.

Bacterial Infections↗
PubMedDate not supplied

Peritoneal accumulation of AGE and peritoneal membrane permeability.

BACKGROUND: In continuous ambulatory peritoneal dialysis (CAPD), the peritoneal membrane is continuously exposed to high-glucose-containing dialysis solutions. Abnormally high glucose concentration in the peritoneal cavity may enhance advanced glycosylation end-product (AGE) formation and accumulation in the peritoneum. Increased AGE accumulation in the peritoneum, decreased ultrafiltration volume, and increased peritoneal permeability in long-term dialysis patients have been reported. AIM: The purpose of the study was to evaluate the relation between peritoneal membrane permeability and peritoneal accumulation of AGE. METHODS: Peritoneal membrane permeability was evaluated by peritoneal equilibration test (PET) using dialysis solutions containing 4.25% glucose. Serum, dialysate, and peritoneal tissue levels of AGE were measured by ELISA method using polyclonal anti-AGE antibody. Peritoneal biopsy was performed during peritoneal catheter insertion [new group (group N), n = 18] and removal [long-term group (group LT), n = 10]. Peritoneal catheters were removed due to exit-site infection not extended into the internal cuff (n = 6) and ultrafiltration failure (n = 4) after 51.6+/-31.5 months (13 - 101 months) of dialysis. PET data obtained within 3 months after the initiation of CAPD or before catheter removal were included in this study. Ten patients in group N and 4 patients in group LT were diabetic. Patients in group LT were significantly younger (46.5+/-11.1 years vs 57.5+/-1.3 years) and experienced more episodes of peritonitis (3.5+/-2.1 vs 0.2+/-0.7) than group N. RESULTS: Peritoneal tissue AGE level in group LT was significantly higher than in group N, in both nondiabetic (0.187+/-0.108 U/mg vs 0.093+/-0.08 U/mg of hydroxyproline, p < 0.03) and diabetic patients (0.384+/-0.035 U/mg vs 0.152+/-0.082 U/mg of hydroxyproline, p < 0.03), while serum and dialysate levels did not differ between the groups in both nondiabetic and diabetic patients. Drain volume (2600+/-237 mL vs 2766+/-222 mL, p = 0.07) and D4/D0 glucose (0.229+/-0.066 vs 0.298+/-0.081, p < 0.009) were lower, and D4/P4 creatinine (0.807+/-0.100 vs 0.653+/-0.144, p< 0.0001) and D1/P1 sodium (0.886+/-0.040 vs 0.822+/-0.032, p < 0.0003) were significantly higher in group LT than in group N. On linear regression analysis, AGE level in the peritoneum was directly correlated with duration of CAPD (r = 0.476, p = 0.012), number of peritonitis episodes (r = 0.433, p = 0.0215), D4/P4 creatinine (r = 0.546, p < 0.027), and D1/P1 sodium (r = 0.422, p = 0.0254), and inversely correlated with drain volume (r = 0.432, p = 0.022) and D4/D0 glucose (r = 0.552, p < 0.0023). AGE level in the peritoneal tissue and dialysate were significantly higher in diabetics than in nondiabetics in group LT, while these differences were not found in group N. Serum AGE level did not differ between nondiabetics and diabetics in either group N or group LT. Drain volume and D4/D0 glucose were lower and D4/P4 creatinine and D1/P1 sodium higher in diabetics than in nondiabetics in both groups. CONCLUSION: Peritoneal accumulation of AGE increased with time on CAPD and number of peritonitis episodes, and was directly related with peritoneal permeability. Peritoneal AGE accumulation and peritoneal permeability in diabetic patients were higher than in nondiabetic patients from the beginning of CAPD.

Female↗
PubMed1998

Are phospholipase A2 and nitric oxide involved in the alterations in peritoneal transport during CAPD peritonitis?

The alterations in peritoneal permeability characteristics during peritonitis can only partly be explained by the increased concentrations of prostaglandins and cytokines in the dialysate. Fifteen patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with 16 peritonitis episodes were examined in the acute phase of the infection by using standard peritoneal permeability analyses (SPAs). In 9 of these patients, a control SPA could be performed. The contribution of nitric oxide (NO), prostaglandins, and the acute phase reactants C-reactive protein (CRP) and secretory phospholipase A2 (sPLA2) were analyzed. The mass transfer area coefficients (MTACs) of low-molecular-weight solutes increased during peritonitis: urea 26%, creatinine 45%, and urate 45%. The MTAC of CO2, calculated to estimate peritoneal blood flow, was 71 mL/min (34 to 254 mL/min) during peritonitis and 55 mL/min (42 to 63 mL/min) after recovery, P < or = .05. The peritoneal protein clearances were also greater during peritonitis, but this increase was not related to the molecular weight of the protein. Therefore the restriction coefficients to macromolecules were not different. The net ultrafiltration in all peritonitis episodes was lower as compared with the control dwells: -97 mL (-196 to 19 mL) versus 25 mL (-132 to 216 mL), P = .03. The prostaglandin concentrations in dialysate were greater during peritonitis than after recovery. The median increase was 199% for prostaglandin E2 (PGE2), 68% for 6-keto-prostaglandin F1alpha (6-keto-PGF1alpha), and 44% for thromboxane B2 (TxB2). Plasma sPLA2 values were 22.7 microg/L (7.3 to 407.6) during peritonitis and 8.9 microg/L (5.5 to 11.5) after recovery, P < .01. The increased plasma sPLA2 during peritonitis correlated with plasma CRP (r = .6; P = .02). The peritoneal clearances of sPLA2 were greater during peritonitis, but this could be attributed completely to the increased peritoneal transport. Both during peritonitis and after recovery, the sPLA2 clearances did not exceed the predicted values based on transport from the circulation to the dialysate. No evidence was found for local production of nitrite or nitrate. However, the MTAC of cyclic guanosine monophosphate (cGMP) was greater during the experiments performed 48 to 72 hours after the onset of peritonitis, which suggests the synthesis of NO. It can be concluded that peritonitis does not induce detectable local release of sPLA2 and that the inflammation-induced increase in the vascular surface area could not be attributed to NO in the acute phase. The activation of inducible NO synthase may occur after 48 hours.

Adult↗
PubMedDate not supplied

Comparison of peritoneal fluid and peripheral blood pH, bicarbonate, glucose, and lactate concentration as a diagnostic tool for septic peritonitis in dogs and cats.

OBJECTIVE: To establish a reliable diagnostic tool for septic peritonitis in dogs and cats using pH, bicarbonate, lactate, and glucose concentrations in peritoneal fluid and venous blood. STUDY DESIGN: Prospective clinical study. ANIMALS: Eighteen dogs and 12 cats with peritoneal effusion. METHODS: pH, bicarbonate, electrolyte, lactate, and glucose concentrations were measured on 1- to 2-mL samples of venous blood and peritoneal fluid collected at admission. The concentration difference between blood and peritoneal fluid for pH, bicarbonate, glucose, and lactate concentrations were calculated by subtracting the peritoneal fluid concentration from the blood concentration. Peritoneal fluid was submitted for cytologic examination and bacterial culture. Peritonitis was classified as septic or nonseptic based on cytology and bacterial culture results. RESULTS: In dogs, with septic effusion, peritoneal fluid glucose concentration was always lower than the blood glucose concentration. A blood-to-fluid glucose (BFG) difference > 20 mg/dL was 100% sensitive and 100% specific for the diagnosis of septic peritoneal effusion in dogs. In 7 dogs in which it was evaluated, a blood-to-fluid lactate (BFL) difference < -2.0 mmol/L was also 100% sensitive and specific for a diagnosis of septic peritoneal effusion. In cats, the BFG difference was 86% sensitive and 100% specific for a diagnosis of septic peritonitis. In dogs and cats, the BFG difference was more accurate for a diagnosis of septic peritonitis than peritoneal fluid glucose concentration alone. CONCLUSIONS: A concentration difference > 20 mg/dL between blood and peritoneal fluid glucose concentration provides a rapid and reliable means to differentiate a septic peritoneal effusion from a nonseptic peritoneal effusion in dogs and cats. CLINICAL RELEVANCE: The difference between blood and peritoneal fluid glucose concentrations should be used as a more reliable diagnostic indicator of septic peritoneal effusion than peritoneal fluid glucose concentration alone.

Animals↗
PubMed1992

Polymicrobial peritonitis in patients on continuous peritoneal dialysis.

Little data are available about the characteristics, outcome, and risk factors for polymicrobial peritonitis in patients on continuous peritoneal dialysis. We therefore reviewed the 43 episodes of polymicrobial peritonitis that occurred in 39 of our patients over the 11.5 years of our program. Polymicrobial peritonitis represented 9% (43/492) of all peritonitis episodes. Only three episodes of polymicrobial peritonitis were associated with an enteric source. Sixteen percent (7/43) of the polymicrobial peritonitis episodes were associated with catheter infections. Staphylococcus aureus was one of the cultured organisms in 33% of the polymicrobial peritonitis episodes. Patients with polymicrobial peritonitis had higher rates of tunnel infection (0.28/yr v 0.18/yr) and overall peritonitis (1.23/yr v 0.81/yr) than patients with single-organism peritonitis. Black patients were more likely to have polymicrobial peritonitis (12/56 v 27/338 whites, chi 2 = 9.8, P less than 0.005). Patient age, gender, time on peritoneal dialysis, insulin dependence, and cause of end-stage renal disease had no influence on polymicrobial peritonitis. Significantly more catheters were removed for polymicrobial peritonitis than for single-organism peritonitis (17/42 v 89/420, chi 2 = 7.05, P less than 0.01), but in 60% of the episodes, the polymicrobial peritonitis was successfully treated without catheter removal. Polymicrobial peritonitis often occurs without gram-negative organisms and extension of catheter infection may be involved in some cases. For unclear reasons, black patients are at higher risk of polymicrobial peritonitis.

Bacteria↗
PubMed2000

Polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.

We retrospectively evaluated 232 continuous ambulatory peritoneal dialysis (CAPD) patients entering our program from January 1, 1987, to December 31, 1997, for polymicrobial peritonitis. Polymicrobial peritonitis occurred in 16% of the patients (polymicrobial-peritonitis group), whereas 52% of the patients had peritonitis episodes with only a single organism (single-organism group), and 32% of the patients had no episode of peritonitis. Polymicrobial peritonitis accounted for 8% of the 554 peritonitis episodes, occurred after 23 +/- 20 months on peritoneal dialysis (PD), and was preceded by greater than three episodes of peritonitis in 73% of the patients. Peritonitis rates were greater in the polymicrobial-peritonitis group compared with patients in the single-organism group (1.8 versus 1.2 episodes/patient-year; P: < 0.001). The majority of polymicrobial infections involved gram-negative and/or fungal pathogens, but in 21% of the episodes, only gram-positive organisms were identified. An intra-abdominal process was identified in only 7% of the patients. Catheter loss overall was greatest in the polymicrobial-peritonitis group (65% versus single-organism group, 30% versus patients without peritonitis, 5%; P < 0.001), but only 33% of the polymicrobial infections resulted in catheter loss. At last follow-up, 70% of the patients in the polymicrobial-peritonitis group had permanently transferred to hemodialysis compared with 25% from the single-organism group and 15% from the no-peritonitis group (P < 0.001). In conclusion, polymicrobial peritonitis is an infrequent but serious complication of CAPD that occurs late in the course of PD and is often preceded by recurrent episodes of peritonitis. Polymicrobial peritonitis is rarely the result of a catastrophic intra-abdominal process, and although the majority of patients can be successfully treated without catheter removal, the long-term prognosis is poor, with a high rate of transfer to hemodialysis.

Adult↗
PubMed2000

Role of intraperitoneal urokinase in acute peritonitis and prevention of catheter loss in peritoneal dialysis patients.

Some studies have demonstrated the efficacy and safety of intraperitoneal (i.p.) urokinase in the resolution of recurrent or relapsing peritonitis, while others have not. Most studies were small, and they varied in methodology. Furthermore, the role of i.p. urokinase in shortening the duration of peritonitis or in preventing recurrence after initial peritonitis has not been examined. In addition, no previous studies have examined the role of i.p. urokinase in preventing, after first infection, catheter loss due to unresolving (resistant) peritonitis. Over a period of 3 years, we prospectively randomized into two groups all peritoneal dialysis (PD) patients who developed a first episode of peritonitis. Group I (n = 40) received i.p. urokinase on the first day of diagnosis (5000 IU intraluminally in the peritoneal catheter and left for 4 hours before next exchange). Group II (n = 40) received no urokinase. The duration of peritonitis was assessed by daily PD fluid white blood cell (WBC) count. Indications for catheter removal were: persistent peritonitis after four days from initiation of antibiotic therapy, or peritonitis with multiple organisms, suggesting bowel perforation. No statistically significant difference was seen between the two groups in regard to primary cause of end-stage renal disease (ESRD), age, sex, race, weight, type of dialysis [continuous ambulatory peritoneal dialysis (CAPD), automated peritoneal dialysis (APD), continuous cycling peritoneal dialysis (CCPD)], or duration of dialysis prior to first peritonitis. No statistically significant difference was seen between the two groups in the duration of peritonitis or in the severity of symptoms and signs of peritonitis. Neither was any difference seen in the peritonitis recurrence or relapse rate (10% in the urokinase group vs 7.5% in the control group). Nine patients lost their catheters (3 in the urokinase group: 1 Pseudomonas aeruginosa and 2 Candida tropicalis; 6 in the control group: 1 Klebsiella pneumonia, 1 enterococcus, 2 Pseudomonas aeruginosa, and 2 Candida tropicalis). The difference in the rate of catheter loss between the two groups was not statistically significant; it appeared to relate to the type of organism rather than to the response to urokinase. In conclusion, i.p. urokinase plays no significant role in shortening the course of peritonitis or in preventing recurrence or loss of the PD catheter. Loss of PD catheters in patients having their first peritonitis appears to be related primarily to the type of organism causing the infection.

Acute Disease↗
PubMed2000

Increased protein loss during peritonitis associated with peritoneal dialysis is neutrophil dependent.

BACKGROUND: Peritonitis in peritoneal dialysis patients is accompanied by an enhanced migration of neutrophils (PMNs) and increased protein loss into the peritoneal cavity; however, the role of PMNs in governing increased protein loss during peritonitis associated with peritoneal dialysis is unknown. METHODS: We determined the importance of PMNs in governing changes in peritoneal permeability to protein in New Zealand White rabbits in which acute peritonitis was induced by adding 4 x 106 colony-forming units of Escherichia coli to 35 mL/kg of 0.9% saline dialysate. The total leukocyte and PMN migration into the peritoneal cavity was assessed by differential cell counts in the dialysate, and peritoneal permeability to protein was evaluated by calculating the dialysate to plasma concentration ratio for total protein as a function of time during a six- or eight-hour dwell. In series 1 experiments, leukocytes were depleted from the rabbit circulation by an intravenous injection of mustine (1.2 mg/kg) three days before the experiment; in series 2 experiments, integrin-dependent PMN migration into the peritoneal cavity was inhibited by an intravenous injection of monoclonal antibody (mAb) 60.3 (2 mg/kg) directed against the integrin CD18 on leukocytes five minutes before the experiment. RESULTS: In series 1 experiments, mustine decreased circulating leukocytes by 82 +/- 5% (mean +/- SEM) and circulating PMNs by 93 +/- 3%. Total leukocyte and PMN migration into the peritoneal cavity and peritoneal permeability to protein were decreased in mustine-treated rabbits after exposure to E. coli in the dialysate to levels similar to those found in rabbits without bacterial peritonitis. In series 2 experiments, an intravenous injection of anti-CD18 antibody also abrogated both the enhanced PMN migration into the peritoneal cavity and the increased peritoneal permeability to protein after exposure to E. coli in the dialysate. CONCLUSIONS: PMN migration into the peritoneal cavity is integrin dependent. Increased protein loss during acute, gram-negative bacterial peritonitis in a rabbit model of peritoneal dialysis is PMN dependent.

Acute Disease↗
PubMed2001

Hyaluronan modifies inflammatory response and peritoneal permeability during peritonitis in rats.

The effect of high-molecular-weight hyaluronan (HA) on peritoneal and systemic inflammation and peritoneal permeability to water and solutes was studied during endotoxin-induced peritonitis in rats. Acute peritonitis was induced by adding lipopolysaccharide (LPS) to the dialysis fluid (Dianeal 3.86; Baxter Healthcare, Ireland, Castlebar). HA was added to the dialysis solution in a concentration of 10 mg/dL. During 4- and 8-hour dwells of the dialysis fluid, we studied the intensity of peritoneal (dialysate) and systemic (blood) inflammation (dialysate cell count and differential, cytokine and HA levels), as well as the transperitoneal transport of solutes and water. In rats, the addition of LPS to the dialysis fluid induced changes in inflammatory reaction and transperitoneal transport similar to those seen in continuous ambulatory peritoneal dialysis patients with peritonitis. During peritonitis, the addition of HA to the dialysis fluid reduced the loss of ultrafiltration, which resulted in a greater peritoneal creatinine clearance during the 8 hours of dwell (29.9 +/- 6.7 mL/8 h in the HA-LPS group versus 19.7 +/- 7.8 mL/8 h in the LPS group; P < 0.05). Dialysate interferon-gamma (INF-gamma) levels during peritonitis were greater in HA-treated animals (536.8 +/- 296.6 pg/mL in the HA-LPS group versus 169.8 +/- 137.8 pg/mL in the LPS group; P < 0.05). Dialysate elastase activity increased during peritonitis (44.4 +/- 9.3 versus 14.2 +/- 4.1 U/mL in peritonitis-free rats); during peritonitis, the increase in dialysate elastase activity was less pronounced in the rats that had HA in the dialysate (27.3 +/- 4.1 U/mL versus the LPS group; P: < 0.01). We conclude that HA added to the dialysis fluid reduces loss of ultrafiltration during peritonitis in rats. In the presence of HA dialysate, INF-gamma levels during peritonitis increased, whereas elastase activity decreased; these changes might improve the peritoneal immune reaction during peritonitis and at the same time prevent peritoneal membrane injury.

Acute Disease↗
PubMedDate not supplied

The longitudinal effect of a single peritonitis episode on peritoneal membrane transport in CAPD patients.

OBJECTIVE: To evaluate the longitudinal effect of a single peritonitis episode on peritoneal membrane transport. DESIGN: A prospective longitudinal study. SETTING: Department of nephrology in a university hospital. PATIENTS: Eighteen continuous ambulatory peritoneal dialysis patients with peritonitis. METHODS: Peritoneal transport for low, middle, and high molecular weight (MW) solutes was evaluated by peritoneal equilibration test (PET). The first PET was performed on the day following the diagnosis of peritonitis. The test was repeated at weeks 1, 2, 4, 12, and 24 and the results were compared to baseline PET data obtained before peritonitis. In addition, dialysate CA125 concentration and leukocyte count were measured. RESULTS: During peritonitis there were significant increases in dialysate-to-plasma (D/P) ratios for all low, middle, and high MW solutes except potassium, and decreases in D4/D0 glucose ratio and ultrafiltration (UF) volume. Over the subsequent 2 weeks, solute transport gradually decreased to the baseline values then remained unchanged during follow-up. Although net UF volume demonstrated a similar course during the study, it did not completely return to the baseline value. No decrease in D/P sodium ratio was found at 60 minutes during the PET performed 24 weeks after peritonitis. The percent change in solute transport during peritonitis compared to baseline value was significantly correlated with a solute's MW (r = 0.776, p = 0.014). The slope of the regression line for D/P ratios versus MW, in double logarithmic scale, before peritonitis (-0.73 +/- 0.09) was steeper than the slope during peritonitis (-0.59 +/- 0.08). CONCLUSIONS: These findings indicate that a single peritonitis episode does not permanently affect peritoneal solute transport. However, the loss of net UF that accompanies peritonitis is not completely recovered, probably due to impairment of transcellular water transport. The transport changes associated with peritonitis may be due to the combined effect of increased effective peritoneal surface area and intrinsic permeability. Our findings suggest that the latter mechanism seems to be more important.

Adult↗
PubMedDate not supplied

Changes in water transport across the peritoneum during treatment with continuous ambulatory peritoneal dialysis in selected patients with and without peritonitis.

BACKGROUND: The natural course of longitudinal changes in peritoneal permeability and membrane area has been studied mostly by performing single-dwell studies in selected patients during treatment with peritoneal dialysis. PURPOSE: To evaluate the permeability characteristics of the peritoneal membrane by measuring drained ultrafiltration volume relative to initial glucose concentration in dialysis fluid from the start to the end of continuous ambulatory peritoneal dialysis (CAPD) treatment in a selected cohort of patients with and without peritonitis. DESIGN: A retrospective analysis of a group of patients whose peritoneal function was prospectively followed by recording drained ultrafiltration volume and glucose concentration in dialysis fluid for each dwell time, every day, during the time in CAPD treatment. Mean values from a 1-month period starting after the first 3 weeks of CAPD treatment were compared with the mean values from the last month of treatment. Approximately 11 500 exchanges were analyzed. Evaluations were done separately for short (day) and long (night) dwell times. PATIENTS AND STATISTICS: Of 132 patients commencing CAPD treatment in the time period selected for inclusion, 51 had enough data to be included in this study. Of these, 29 patients experienced one or more episodes of successfully treated peritonitis. The selection of patients was not based upon patient characteristics, but upon criteria to satisfy predefined demands, such as number of measurements in each period, time since an episode of peritonitis, and time on CAPD treatment. Data were analyzed in three different groups: patients with episodes of peritonitis, patients without peritonitis, and both groups together. To assess changes between monthly mean at the start and at the end of CAPD, paired t-test was performed. Patients were also stratified into two groups according to low and high glucose in dialysis fluid at the start of CAPD (cutoff = 2 g/dL). Additionally, we used linear regression analyses to predict the level of drained ultrafiltration volume for a given level and change in glucose concentration. Mean treatment time for the entire group was 20 months (median 14.3 months), ranging from 6 to 69 months. RESULTS: No statistical differences in glucose concentrations were found between the periods compared. In the entire group there was an increase in ultrafiltration volume from the start to the end of CAPD treatment, for both day (p = 0.009) and night (p = 0.013) exchanges. Also, for patients without peritonitis, an increase appeared for day (p = 0.046) and night exchanges (p = 0.053). However, for the cohort with peritonitis, only an insignificant increase was indicated. Patient characteristics, diabetic patients, the need for glucose in dialysis fluid when commencing CAPD treatment, the number of episodes of peritonitis, and time on CAPD did not influence the change in ultrafiltration. Regression analyses showed higher ultrafiltration response to a given level and change in glucose concentration at the end of CAPD treatment compared to the start values, also for the cohort with peritonitis. The regression coefficient between these variables was also significantly changed for both day (p < 0.0001) and night (p = 0.027) exchanges. CONCLUSION: A significant change in the regression coefficient between glucose in dialysis fluid and ultrafiltration volume reflects an increase in ultrafiltration response to a given level and change in glucose concentration during time on CAPD treatment. A parallel change after 5- and 9-hour dwells can be explained by a decrease in peritoneal surface area combined with a lesser decrease in peritoneal conductivity. However, changes in Starling forces across the peritoneal membrane are possible even in the absence of changes in peritoneal membrane characteristics.

Biological Transport↗
PubMedDate not supplied

Reduced lymphatic drainage of dialysate from the peritoneal cavity during acute peritonitis in sheep.

OBJECTIVES: The purpose of this study was to investigate the effects of acute peritonitis on lymphatic drainage of the peritoneal cavity in conscious sheep. DESIGN: Peritonitis was induced with the addition of 1% casein or 1% albumin to the dialysis solution. Thirty sheep (5 groups of 6) were used in this study. One group received 50 mL/kg intraperitoneal infusions of Dianeal 4.25% (486 mOsm/L); a second group received 1% casein-Dianeal 4.25% (493 mOsm/L); a third group received 1% albumin-Dianeal 4.25% (487 mOsm/L). In the fourth and fifth groups (controls and casein-injected) lymph was collected from the caudal mediastinal lymph node and the thoracic duct, both of which are involved in the lymphatic drainage of the peritoneal cavity (peritonitis induced with casein). (125)I-human serum albumin (25 mu CI) was added to the dialysate as the lymph flow marker. Lymph drainage was estimated from (1) the appearance of the intraperitoneally administered tracer in the blood; (2) the disappearance of the tracer from the peritoneal cavity; and (3) the recovery of tracer in lymph. RESULTS: In noncannulated animals the cumulative volume removed by lymphatics over 6 hours (based on tracer recovery in blood) was 10.5 +/- 1.0 mL/kg in control animals versus 5.0 +/- 0.6 mL/kg and 8.6 +/- 1.2 mL/kg in casein and albumin-infused sheep, respectively. The suggestion of decreased lymph drainage in peritonitis was supported by the cannulation experiments. While the cumulative fluid removed from the peritoneal cavity over 6 hours in caudal lymph was unaffected by peritonitis (3.8 +/- 0.4 mL/kg in controls vs 3.6 +/- 0.5 mL/kg in casein-injected animals), peritonitis reduced flow into the thoracic duct from 3.0 +/- 0.3 to 1.1 +/- 0.3 mL/kg. The sum of the volume removed in lymph in the cannulated preparations was 6.8 +/- 0.4 mL/kg in controls versus 4.7 +/- 0.5 mL/kg in the peritonitis group. The total volume removed from the cavity (including an estimate of flow based on the residual recovery of tracer in blood) was reduced from 12.6 +/- 1.4 in controls to 7.8 +/- 0.6 mL/kg in the peritonitis sheep. In contrast, estimates of lymph drainage based on the disappearance of tracer from the peritoneal cavity suggested that lymph drainage increased (from 16.6 +/- 1.6 mL/kg in controls to 17.8 +/- 1.5 mL/kg and 25.5 +/- 1.7 mL/kg in the casein and albumin groups, respectively, in noncannulated animals and from 15.3 +/- 1.4 mL/kg in controls to 25.0 +/-1.7 mL/kg in the cannulated group). In both noncannulated and cannulated sheep the total recovery of tracer was less in the peritonitis groups. CONCLUSIONS: These studies demonstrated that lymph drainage of the peritoneal space was decreased in a casein peritonitis model. The decrease in lymph drainage is most obvious in the visceral pathway leading to the thoracic duct; however, diaphragmatic drainage into the right lymph duct may also be inhibited. The disappearance of tracer from the peritoneal cavity was elevated during peritonitis. Tracer disappearance has been used to estimate lymph drainage, but this approach suggested, incorrectly, that lymph flow had increased.

Acute Disease↗
PubMed2004

Peritoneal T cell responses can be polarized toward Th1 or Th2 in children on chronic peritoneal dialysis.

Peritoneal T cell responses can be polarized toward Th1 or Th2 in children on chronic peritoneal dialysis. Previous studies on the peritoneal immune system described the presence of activated T lymphocytes in peritoneal effluents from subjects on chronic peritoneal dialysis (CPD). Since Th1/Th2 polarized response can influence the outcome of specific infectious diseases, we investigated if activated Th1/Th2 cells can be detected in peritoneal effluents during peritoneal dialysis, in order to better understand the role of T cells in the mechanisms of peritoneal defense. We have studied 8 children (4 males, 4 females, mean age 5.8 +/- 5.7 years, range 0.3-13.4) on CPD. Peritoneal cells have been isolated from peritoneal effluents by centrifugation. Immunofluorescent staining of intracellular cytokines for flow cytometric analysis was used to detect the percentage of T cells producing either IFN-gamma (Th1) or IL-4 (Th2). In the initial study 3 months after CPD initiation, high percentages of IFN-gamma positive peritoneal T cells (38% and 63%) were detected in two subjects; this finding is consistent with a Th1 polarization of peritoneal T cells. In another subject, high percentages of IL-4 positive T cells (31%) were detected, suggesting a Th2 polarization of peritoneal T cell response. Small amounts of either Th1 or Th2 T cells (2-4%) were also detected in the other subjects. At the 1 year follow-up, Th1 polarization persisted in one subject (18% IFN-gamma positive peritoneal T cells), in another a shift from Th1 to Th2 was observed, and in the other subject a down regulation of both T cell subsets occurred. The finding that a predominance of T cells producing either IFN-gamma or IL-4 was found in 3 out of 8 children strongly suggests that peritoneal T cell responses can be polarized toward Th1 or Th2. The decrease of Th1 and/or Th2 polarized T cells in the peritoneum of 4 out of 6 subjects (after 1 year) suggests that CPD can play an immunosuppressive role on T cell peritoneal responses. Further studies are needed in order to define whether different T helper activation patterns are associated with a higher risk of peritoneal infection or of peritoneal damage.

Adolescent↗
PubMed1999

Evaluation of peritoneal fluid pH, glucose concentration, and lactate dehydrogenase activity for detection of septic peritonitis in horses.

OBJECTIVE: To determine whether peritoneal fluid pH, glucose concentration, and lactate dehydrogenase activity can be used to differentiate horses with septic peritonitis from those with nonseptic peritonitis. DESIGN: Prospective study. ANIMALS: 46 horses, including 10 healthy horses, 15 horses with septic peritonitis, and 21 horses with nonseptic peritonitis. PROCEDURE: Peritoneal fluid and blood samples were analyzed for pH, glucose concentration, and lactate dehydrogenase activity. Complete blood cell counts were performed, and peritoneal fluid samples were submitted for bacterial culture. RESULTS: Horses with septic peritonitis had significantly lower peritoneal fluid pH and glucose concentrations than horses with nonseptic peritonitis and healthy horses. Compared with other tests, serum-to-peritoneal fluid glucose concentration differences > 50 mg/dl had the highest diagnostic use for detection of septic peritonitis. Peritoneal fluid pH < 7.3, glucose concentration < 30 mg/dl, and fibrinogen concentration > 200 mg/dl were also highly indicative of septic peritonitis. CLINICAL IMPLICATIONS: Peritoneal fluid pH and glucose concentration can be used to assist in the identification of horses with septic peritonitis. These measurements can provide an early indication of sepsis, especially if cytologic evaluation of peritoneal fluid is unavailable or results are equivocal and peritoneal fluid bacterial culture results are pending.

Animals↗
PubMed2005

Pyridoxamine improves functional, structural, and biochemical alterations of peritoneal membranes in uremic peritoneal dialysis rats.

BACKGROUND: We previously suggested that biochemical alterations of peritoneal membrane associated with long-term peritoneal dialysis might be, at least in part, accounted for by reactive carbonyl compounds overload originating both from uremic circulation and heat sterilization of glucose peritoneal dialysis fluid. In the present study, we utilized a uremic rat model on peritoneal dialysis and evaluated the protective effects of pyridoxamine, a recently developed inhibitor of advanced glycation end product (AGE), on structural, functional, and biochemical alterations of peritoneal membrane. METHODS: Uremic rats were generated by subtotal nephrectomy, some of which were undergone peritoneal dialysis with dialysate and/or given intraperitoneal pyridoxamine. Functional [dialysate/plasma ratio (D/P)(urea, creatinine), D/D(0 glucose)], structural (density of blood vessels in peritoneal membrane tissues), and molecular biochemical [formation of pentosidine, an AGE, by high-performance liquid chromatography (HPLC) assay and expressions of vascular endothelial growth factor (VEGF), and fibroblast growth factor 2 (FGF-2), by semiquantitative polymerase chain reaction (PCR) and/or immunohistochemistry] alterations of peritoneal membrane were assessed. RESULTS: Uremic peritoneal membrane was characterized by an increased functional area of exchange for small solutes between blood and dialysate, vascular proliferation, increased AGE genesis, and up-regulated expressions of angiogenic cytokines. The peritoneal membrane alterations associated with peritoneal dialysis are similar but more severe than those in uremia without peritoneal dialysis. Pyridoxamine given in uremic rats with peritoneal dialysis significantly improved functional and structural alterations. This improvement was accompanied by reduction of AGE accumulation and of angiogenic cytokines expressions. CONCLUSION: Peritoneal carbonyl stress derived from uremia as well as peritoneal dialysis procedure might contribute to the vascular proliferation through induction of bioactive molecules and to an increased functional area, eventually leading to ultrafiltration failure. Pyridoxamine may be beneficial in protection of uremic peritoneal membrane on peritoneal dialysis.

Animals↗
PubMed1998

Nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis.

The aim of this study was to determine whether nitric oxide (NO) production is altered during peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD), and if so, whether there is an association between this alteration and the severity and prognosis of CAPD-induced peritonitis. The study population comprised 30 patients with 30 episodes of peritonitis. Thirteen patients without peritonitis were used as CAPD-control, and eighteen patients with normal renal function were used as normal-control. Total NO metabolites (NOx; nitrite + nitrate) were measured by the Griess method to reflect nitric oxide production. Peritoneal dialysate effluent and plasma were collected from 30 patients during episodes of peritonitis every day for the first 3 days, and then every 3 days for 2 weeks or until the patients were discharged. Plasma NOx levels in the control, CAPD-control, and CAPD-peritonitis groups were 87.0 +/- 11.5, 163.0 +/- 30.7 and 146.3 +/- 18.1 microM, respectively. Dialysate NOx levels in the CAPD-control and CAPD-peritonitis groups were 91.8 +/- 13.1 and 103.8 +/- 14.1 microM, respectively, and dialysate NOx levels did not differ between the two groups. The peak dialysate/plasma (D/P) ratios during the acute phase exceeded 1.0 in 46.7% of the patients of the CAPD-peritonitis group. The D/P ratios of NOx levels before and after treatment were 1.03 +/- 0.07 and 0.56 +/- 0.05, respectively. On the contrary, NOx levels in dialysate after treatment were not decreased, but those in plasma were increased after effective treatment. The peak D/P ratio increased 2.1-fold in the bacterial peritonitis group and 2.3-fold in the fungal peritonitis group, compared with the CAPD-control group. The lowest D/P ratios after treatment were similar to those in the CAPD-control group in patients with effective treatment, but remained 1.5-fold higher in patients for whom treatment was ineffective. In the evolutional study, the D/P ratios of NOx levels gradually declined to CAPD-control group levels (6.6 +/- 2.5 days) after effective antibiotic treatment, but it took longer for leukocyte counts in the peritoneal dialysate effluents (3.8 +/- 1.2 days) to normalize. In 5 patients with refractory peritonitis (Candida infection in three, Staphylococcus aureus infection in two), the D/P ratios of NOx levels remained elevated by 1.5-fold despite treatment, and the catheters were removed. These results suggest that dialysate NOx may be influenced not only by local NO production, but also by plasma NO or NOx diffusion. Therefore, we can suppose that the D/P ratio of NOx levels provides more clinical significance than dialysate NOx levels only. In conclusion, the D/P ratios of NOx levels may serve as a marker to assess the severity of peritoneal inflammation, treatment efficacy, and progression of refractory peritonitis in CAPD patients with peritonitis.

Adult↗
PubMedDate not supplied

Methodological issues in assessing the incidence of peritoneal dialysis-associated peritonitis in children.

OBJECTIVES: To evaluate the distribution of peritonitis incidence and assess the usefulness of patient-specific peritonitis rates in children. DESIGN: 49 children on automated peritoneal dialysis (PD) followed during a 2-year observation period. SETTING: Single-center, academic children's hospital. PATIENTS: 49 children aged 2 months to 18 years; 24 prevalent, 25 incident during the observation period. Cumulative observation time was 639 patient-months. MAIN OUTCOME MEASURES: Cohort-specific peritonitis incidence, median patient-specific peritonitis incidence, mean peritonitis incidence by gamma-Poisson (negative binomial) modeling, peritonitis-free survival by Kaplan-Meier life-table analysis. RESULTS: 68 new peritonitis episodes and 21 relapses occurred in 27 patients. The distribution of patient-specific peritonitis incidence was bimodal, with a large group experiencing no or very few episodes, and another cluster around 1 episode per 6-9 months. Overall cohort-specific peritonitis incidence was 1.28, median subject-specific incidence 0.99, and mean incidence according to negative binomial modeling 1.04 (95% confidence interval 1.02-1.06) episodes per patient-year. Median peritonitis-free survival time was 6.9 months. In those patients who developed peritonitis, subject-specific peritonitis incidence was inversely correlated with patient age (r = -0.42, p < 0.05) and duration of chronic PD at last observation (r = -0.42, p < 0.05). CONCLUSIONS: Since the distribution of peritonitis in children is non-Gaussian, the average risk of peritonitis is more accurately expressed by the median of the individual subject-specific peritonitis rates or by the mean incidence estimate obtained by the negative binomial distribution model. The assignment of a personal peritonitis risk to each patient permits risk factor analysis by routine statistical methods, even in smaller populations.

Adolescent↗