P3: verso un concetto più
ampio di dialisi peritoneale
Proteggere per preservare
Roberto Russo
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
AMPLIFICATION
IL-8
IL-6/sIL6R
IL-1β
TNF-α
TRANSITION
IFN-γ
IL-1β
TNF-α
IL-8
MCP-1
RANTES
IFN-γ
Mediator concentration (pg/ml)
Patients on CAPD who have peritonitis produce
large amounts of pro-inflammatory cytokines
sIL-6R
IL-6
MNC
PMN
IL-8
MCP-1
Period post infection
Hurst SM et al Immunity 2001;14:705-714
Effluent VEGF correlates with
peritonitis severity
1000
VEGF effluent ρg/ml
800
600
400
200
0
0
2000
4000
6000
WBC/mm3
8000
10000
12000
Szeto et al, Perit Dial Int 2002; 22:265-274
Peritonitis is associated with a protracted
inflammatory process
100
CXCR1 expression (PMN)
80
60
MNC
Neutrophils
40
100
20
0
0
5
10
15
20
100
75
CD14 expression (MNC)
% Leukocytes
80
60
40
20
0
0
5
10
15
20
25
50
25
CD3 expression (T-cells)
20
0
15
10
D1
D2
D3
D4
D5
5
Period post infection
0
0
5
10
Days
15
20
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 ()
2500
2000
1500
1000
500
0
0
No previous
infection
1
Previous
infection
2
3
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
0,3
0,15
0
Hit 1
Hit 2
Hit3
Activation cycle with infected PDE
3
2
1
0
1
2
3
Activation cycle
Topley and Parker, 2005
Pattern of inflammation may become
deregulated during PD
PMN
PMN
Monocytes
Monocytes
Lymphocytes
Lymphocytes
Time (days)
Acute
Time (days)
Dysregulated
Chronic
Resident leukocyte populations in PD are suggestive of chronic inflammatory phenotype
Risk factors
of peritonitis
Medical
Factors
Patient
factors
Albumin
Diabetes Mellitus
Non medical
factors
System
factors
Modifiable
Fixed
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.
Protect
Preserve