Predictors of survival and technique success after reinsertion of peritoneal dialysis catheter following severe peritonitis.

BACKGROUND: Peritonitis remains the most important complication of peritoneal dialysis (PD). The success rate of restarting PD after severe peritonitis (peritonitis unresolved despite treatment with appropriate antibiotics for 3 days, or fungal or pseudomonas infections) is unclear. We wished to determine PD technique survival and overall mortality when PD is offered to these patients and to identify predictors of successful reinitiation. METHOD: We conducted a retrospective single-center study of 556 patients undergoing PD between January 2000 and December 2001. We collected demographic information from the 106 patients who had their PD catheter removed for peritonitis, details about their dialysis history and peritonitis, and whether they successfully restarted PD and if not, the reason. RESULTS: We divided patients into groups as follows: group 1 (n = 42) underwent catheter reinsertion, group 2 (n = 16) had no medical contraindication to restarting PD but the patients elected to remain on hemodialysis, group 3 (n = 35) were deemed medically unsuitable to return to PD, and group 4 (n = 13) were those that died within 4 weeks of presenting with peritonitis. If there were no medical contraindications, Indo-Asians were more likely to retry PD. In group 1, after a mean follow-up of 20 +/- 7.3 months, 23 of 42 patients restarted PD successfully. Technique survival for group 1 as a whole was 69% at 3 months and 55% at the end of follow-up. Patients of greater dialysis vintage were more likely to develop PD technique failure after restarting. Of those judged suitable for PD, there was no statistically significant difference in the mortality of patients who wished to either restart PD or remain on hemodialysis (group 1 vs group 2). Significant numbers of patients returned successfully to PD after pseudomonas and fungal peritonitis. CONCLUSION: Restarting PD after severe peritonitis was possible and safe. Ethnicity was an important predictor for wanting to retry PD, but not for technique failure: given the choice, Indo-Asians preferred PD and had a higher failure rate after restarting, but this did not reach statistical significance. Only dialysis vintage predicted technique failure. We conclude that, after severe peritonitis, patients should be given the choice to return to PD but risk stratification based on dialysis vintage is important. Patient retraining and creating a backup arteriovenous fistula might minimize morbidity in these high-risk patients.

Re-training and switching of PD system to reduce recurrent gram-positive PD peritonitis.

Intensive training and re-education of peritoneal dialysis (PD) exchange technique has been advocated to minimize peritonitis rate. However, re-education of patients that are established on PD for some years can be difficult and a minority of patients on PD remain susceptible to repeated episodes of peritonitis. The UV Flash Compact system (Baxter Healthcare) automates patient connection and disconnection during the PD exchange procedure and uses bactericidal UV irradiation to minimise the effects of touch contamination. We have explored the efficacy of retraining patients using this system for reducing peritonitis rates in a cohort of 10 patients in who repeated episodes of peritonitis due to gram +ve organisms suggest irrevocable breaches in sterile technique. These patients were converted from their existing PD system (6 Staysafe [Fresenius Medical Care], 4 Mini-solo [Baxter]). Mean follow up post-conversion was 10 months. There was a striking reduction in peritonitis caused by gram +ve pathogens from 1 in 8.5 to 1 in 50.5 months. Although it is not possible in this study to differentiate the impact of the UV Flash Compact as opposed to the effect of re-training, we advocate that patients with a high peritonitis burden from gram +ve organisms should be considered for conversion to the UV Compact system.