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P3: verso un concetto più ampio di dialisi peritoneale Proteggere per preservare Roberto Russo.

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Presentazione sul tema: "P3: verso un concetto più ampio di dialisi peritoneale Proteggere per preservare Roberto Russo."— Transcript della presentazione:

1 P3: verso un concetto più ampio di dialisi peritoneale Proteggere per preservare Roberto Russo

2 PROTECT PERITONEAL MEMBRANE FROM PERITONITIS

3 Extra safe and easy to understand PD system

4 Peritonitis is a cause of … Peritoneal membrane damage Hospitalization and pain Catheter loss Technique failure Death

5 IL-1β TNF-α IL-8 INITIATION IL-8 IFN-γ IL-1β TNF-α AMPLIFICATION TRANSITION MCP-1 IFN-γIL-1β TNF-α IL-6/sIL6R sgp 130 RANTES RESOLUTION The sequence of events in peritoneal inflammation

6 Patients on CAPD who have peritonitis produce large amounts of pro-inflammatory cytokines Hurst SM et al Immunity 2001;14: sIL-6RIL-6 IL-8 MCP-1 Period post infection Mediator concentration (pg/ml) MNC PMN

7 Effluent VEGF correlates with peritonitis severity WBC/mm 3 VEGF effluent ρg/ml Szeto et al, Perit Dial Int 2002; 22:

8 Peritonitis is associated with a protracted inflammatory process Period post infection % Leukocytes CXCR1 expression (PMN) CD14 expression (MNC) CD3 expression (T-cells) Days % surface expression Topley and Parker, 2005

9 Peritonitis is associated with a protracted inflammatory process Modified from Lai KN AJKD 2000;35: PD Effluent IL-6 TGF-β FGF-β IL-1

10 Peritonitis and inflammatory severity drives to membrane change Davies S et al Nephrol Dial Transplant 11: ,1996 Thickness of submesothelial compact zone ( ) No previous infection Previous infection

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12 Repeated peritoneal inflammation drives the fibrotic process Fibroblast proliferation Activation cycle with infected PDE Proliferation Index Topley and Parker, 2005 Collagen III synthesis Activation cycle Collagen III/Actin OD ratio

13 Pattern of inflammation may become deregulated during PD PMN Monocytes Lymphocytes PMN Monocytes Lymphocytes Time (days) Resident leukocyte populations in PD are suggestive of chronic inflammatory phenotype AcuteDysregulatedChronic

14 Risk factors of peritonitis Medical Factors Patient factors System factors Non medical factors ModifiableFixedAlbumin Diabetes Mellitus Disconnet Exit site DepressionAdherenceObesityEthnicity

15 American Journal of Kidney Diseases, Vol 45, No 2, 2005: pp 372–380

16 Peritoneal Dialysis International 2005, 25: 374–37

17 Prevention of peritonitis Catheter placement Exit site care Connection method Training Antibiotic prophylaxis for procedures Prevention of bowel source peritonitis Prevention of fungal peritonitis

18 Strategie antimicrobiche per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida G. Amici, R. Russo, M. Feriani et al Luso topico giornaliero, sullemergenza cutanea del catetere peritoneale, della gentamicina riduce il rischio di peritonite (livello 2). Lutilizzo di antibiotici, nella profilassi perioperatoria del posizionamento dei cateteri per dialisi peritoneale, è in grado di ridurre efficacemente solo gli episodi di peritonite precoce (livello 1). La nistatina per via orale, in associazione alla terapia antibiotica, è efficace nel prevenire le peritoniti da Candida (livello 2). Giornale Italiano di Nefrologia 2007; 24(S-37):S125-S135

19 Strategie correlate al catetere per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida A. De Vecchi, R. Corciulo, M. Salomone, R. Russo et al I set a Y e i sistemi a doppia sacca riducono il rischio di peritonite nei pazienti in dialisi peritoneale rispetto al sistema convenzionale (livello 1). Giornale Italiano di Nefrologia 2007; 24 (S-37); S136-S148

20 Training methods influence the risk of PD infections (Evidence). There is an association between both severe constipation and enteritis and peritonitis due to enteric organisms (Evidence). Prevention of catheter infections (and thus peritonitis) is the primary goal of exit-site care. Antibiotic protocols against S. aureus are effective in reducing the risk of S. aureus catheter infections (Evidence) PERITONEAL DIALYSIS-RELATED INFECTIONS RECOMMENDATIONS: 2005 UPDATE PREVENTION OF PD-RELATED INFECTIONS Perit Dial Int 25: 107–131, 2005

21 Effect of Peritoneal Dialysis Nurses and Training Peritonitis rates per 1,000 Patients Months Hall G et al, Nephrol Nurs J 2004

22 Patient re-training in PD: why and when it is needed Multi centered italian study: 353 patients answered a questionnaire 191 patients had a home visits with score card 23% were non-compliant with exchange procedure. Russo et al KI suppl 2006: 103; S

23 Summary Peritonitis remains a serious complication of peritoneal dialysis. Most peritonitis is due to either contamination with the PD exchange or exit site infection (ESI) and can be prevented by protocols. Training and retraining of the patients, use of the best connection technology and use of exit site antibiotic cream to prevent ESI are keys to preventing peritonitis from contamination.

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