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

PERITONEAL MEMBRANE FROM PERITONITIS PROTECT PERITONEAL MEMBRANE FROM PERITONITIS

Extra safe and easy to understand PD system

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

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

Patients on CAPD who have peritonitis produce large amounts of pro-inflammatory cytokines sIL-6R IL-6 IL-8 MCP-1 MNC PMN Mediator concentration (pg/ml) Period post infection Hurst SM et al Immunity 2001;14:705-714

Effluent VEGF correlates with peritonitis severity WBC/mm3 VEGF effluent ρg/ml Szeto et al, Perit Dial Int 2002; 22:265-274

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

Peritonitis is associated with a protracted inflammatory process PD Effluent PD Effluent IL-6 TGF-β FGF-β IL-1 Modified from Lai KN AJKD 2000;35:644-52

Peritonitis and inflammatory severity “drives” to membrane change Thickness of submesothelial compact zone () No previous infection Previous infection Davies S et al Nephrol Dial Transplant 11:498-506,1996

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

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

Risk factors of peritonitis Medical Factors Patient factors System factors Non medical factors Modifiable Fixed Albumin Diabetes Mellitus Disconnet Exit site Depression Adherence Obesity Ethnicity

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

Peritoneal Dialysis International 2005, 25: 374–37

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

Strategie antimicrobiche per la prevenzione delle peritoniti in dialisi peritoneale: Linea Guida G. Amici, R. Russo, M. Feriani et al L’uso topico giornaliero, sull’emergenza cutanea del catetere peritoneale, della gentamicina riduce il rischio di peritonite (livello 2). L’utilizzo 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

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

PERITONEAL DIALYSIS-RELATED INFECTIONS RECOMMENDATIONS: 2005 UPDATE PREVENTION OF PD-RELATED INFECTIONS 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) Perit Dial Int 25: 107–131, 2005

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

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 127-32

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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