Peritonitis in peritoneal
dialysis patients
Dr Cherelle Fitzclarence
Renal GP
July 2009
Overview
 Peritoneal Dialysis - principles
 Anatomy
 Physiology
 Pathology
 Presentations
 Management
 Key points
www.health.com/
Proteinuria
Care plan
STAGE 1 & 2
Proteinuria plus
eGFR 60+
(to determine eGFR
over 60, hand
calculate GFR using
Cockcroft-Gault
formula)
CKD
Care plan
ESKD
Care plan
STAGE 3
STAGE 4
STAGE 5
eGFR 30-59
eGFR 15-29
eGFR <15
ml/min
ml/min
MODERATE
SEVERE
KIDNEY
KIDNEY
DAMAGE
DAMAGE
PALLIATIVE CARE
ml/min
FAILURE
DIALYSIS
HAEMODIALYSIS
PERITONEAL DIALYSIS
TRANSPLANTATION
GFR = (140 - Age) x wt (kg)
se creat (mmol/Lt)
Males = GFR x 1.23
Chronic
Kidney
Disease
Diagnosis
End Stage
Kidney
Disease
Diagnosis
Kidney
Failure
SUPPORTIVE CARE APPROACH
Peritoneal Dialysis
 A form of renal replacement therapy for
patients with end stage kidney disease
 Endeavours to replace some of the functions
of the kidney such as





Removing waste products
Removing excess fluid
Correcting acid/base imbalances www.agingdiscodiva.com
Correcting electrolyte imbalances
High maintenance form of therapy requiring
meticulous compliance and effort on part of
patient
IDEAL BODY WEIGHT
IBW
 Normotensive (Good BP)
120/70
 No signs and symptoms of overload or
dehydration
 Set by:
 Home Training Staff Royal Perth Hospital
 Renal Doctor
 Dialysis Staff KSDC
FLUID ASSESSMENT
 Blood pressure
 JVP
 Weight
 Skin tugor
 Chest, SaO2, SOB
 Symptoms
 Oedema

Ankles
 Back
 Facial



Nausea,
vomiting
Diarrhoea
Dizziness
FLUID RESTRICTION
 800 – 1000 mls per day
 Weigh patient (will be required daily
– SAME SCALES and document
which ones)
 In hospital, remove jug
Peritoneal Dialysis
 Involves the passage of solutes and water
across a membrane that separates two fluid
containing compartments-blood and dialysate
 During dialysis 3 transport processes occur
simultaneously
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Diffusion
Ultrafiltration
Absorption
http://www.dialyse-45.net/int/info/techniques.htm
Peritoneal Dialysis
 2 types

CAPD – continuous ambulatory peritoneal
dialysis


Involves on average 4 dwells per day of 4-8
hours of 2 – 2.5L each
APD – automated peritoneal dialysis


Involves 3-10 exchanges overnight of varying
amounts
Usually but not always a daytime dwell
Peritoneal Dialysis
 Anatomy
 Serosal membrane lining the gut
 Thought to be the same as the body surface
area – usually 1-2 m2 in adult
 2 parts – visceral peritoneum lining the organs
(80% or the peritoneal surface area and the
parietal peritoneum lining the walls of the
abdominal cavity)
 Peritoneal blood flow can’t be measured but
indirectly estimated to be between 50100mls/min
Peritoneal Dialysis
Horizontal disposition of the peritoneum in the lower part of the abdomen.
www.theodora.com/anatomy/the_abdomen.html
Peritoneal Dialysis
 Visceral peritoneum blood supply is from the
superior mesenteric with venous drainage
from the portal system
 Parietal peritoneum blood supply is from the
lumbar, intercostal and epigastric arteries
while the venous drainage is via the IVC
 Main lymphatic drainage is via stomata in the
diaphragmatic peritoneum which drain into
the right lymphatic duct
Three pore model
 Peritoneal capillary is the critical barrier to
peritoneal transport
 Movement of solute and water movement
across the capillary is mediated by pores of
three different sizes

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Large pores 20-40 nm – protein transport
Small pores 4-6nm – small solutes eg urea,
creatinine, sodium, potassium, water
Ultrapores (aquaporins) <0.8nm – transport of
water
Three pore model of peritoneal
transport
Kidney International
ISSN: 0085-2538
EISSN: 1523-1755
© 2009 International Society of Nephrology
Peritoneal Transport - Diffusion
 Diffusion – uraemic solutes and potassium
diffuse from peritoneal capillary blood into the
dialysate. Glucose, lactate, bicarbonate and
calcium diffuse in the opposite direction.
 Diffusion depends on concentration gradient
(maximal at the start), effective peritoneal
surface area, intrinsic peritoneal membrane
resistance, molecular weight of the solute (eg
small molecules like urea, diffuse more
rapidly than larger molecules such as
creatinine)
Diffusion
www.indiana.edu/.../lecture/lecnotes/diff.html
Peritoneal Transport - Ultrafiltration
 Occurs as a consequence of the osmotic gradient between the
hypertonic dialysate and the relatively hypotonic peritoneal
capillary blood
 Driven by high concentration of glucose in dialysate
 Depends on;
 concentration gradient of the osmotic agent (glucose)
 peritoneal surface area
 hydraulic conductance of the peritoneal membrane
 reflection coefficient for the osmotic agent (how effectively
the osmotic agent diffuses out of the dialysate into the
peritoneal capillaries (0-1 is normal – the lower the value the
faster the osmotic gradient is lost. Gluc is 0.3 as opposed to
icodextrin which is close to 1)).
 Hydrostatic pressure gradient – cap press around 20mm
versus intraperitoneal pressure around 7mm Hg which
favours ultrafiltration
Ultrafiltration
http://www.dialysistips.com/principles.html
Peritoneal Transport – Ultrafiltration 2
 Depends on;
 Oncotic pressure gradient which acts to keep fluid in
blood, opposing ultrafiltration (low in
hypoalbuminaemic patients so ultrafiltration tends to
be high)
 Sieving – occurs when solute moves along with water
across a semipermeable membrane by convection but
some of the solute is held back – sieved. The solute
concentration in the ultrafiltrate that has passed
through the membrane is lower than the source
solution. Different solutes sieve differently ranging
from 0 (complete sieving) to 1 (no sieving)
 Other osmotic agents such as icodextrin with a large
reflection coefficient so ultrafiltration is sustained
Ultrafiltration
http://www.advancedrenaleducation.com/PeritonealDialysis/Ultrafiltration/HowtoAchieveAdequatePDUF/tabid/229/Default.aspx
Peritoneal Transport – Fluid
Absorption
 Occurs via the lymphatics at constant rate
 Typical values for peritoneal fluid absorption
are 1-2 mls/minute


Affected by intraperitoneal hydrostatic
pressure
Effectiveness of lymphatics
http://www.fmc-ag.com/gb_2006/en/05/glossar.html
Peritonitis
 Peritoneal Dialysis is a great form of renal
replacement therapy
 Peritonitis is a significant complication
 Incidence peritonitis episodes varies from 1/9
patient-months to 1/53 patient-months
(Grunberg 2005; Kawaguchi 1999)
 Our figures pending but are likely to be on
the lower end of the scale
Peritonitis in PD pts
 Risk Factors
 Diabetes
 Non caucasian
 Obesity
 Temperate climate
 Depression
 Possibly the peritoneal dialysis
modality but not proven
(Huang 2001; Oo 2005).
http://www.diabetesandrelatedhealthissues
.com/
Peritonitis in PD pts
 Significant morbidity
 Some mortality - It is estimated that PD-
associated peritonitis results in death in 6%
of affected patients (Troidle 2006).
gymsoap.com
Peritonitis in PD pts
 Catheter removal may become necessary if
pt is not responding to antibiotics or if
infection is fungal. May be temporary or
permanent
 Ultrafiltration failure can occur both acutely
due to increases in capillary permeability
(Ates 2000; Smit 2004) and in the longer
term resulting in technique failure (Coles
2000; Davies 1996).
Pathogenesis
 1. Potential routes of infection
 Intraluminal – improper technique; access to
bacteria via the catheter lumen
 Periluminal – bacteria present on skin surface
enter the peritoneal cavity via the catheter
tract
 Transmural – bacteria of intestinal origin
migrate through the bowel wall
 Haematogenous – peritoneum seeded via the
blood stream
 Transvaginal - ??
Pathogenesis
 2. Bacteria laden plaque – the intraperitoneal portion
of the catheter is covered with a bacteria laden
plaque - ? Role in pathogenesis of peritonitis
 3. Host defences – peritoneal leucocytes critical in
combating bacteria that have entered the
peritoneum. Affected by
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A. dialysis solution and ph – hypertonic solution
inhibits activity
B. Calcium levels – low calcium in dialysate inhibits
activity
Peritoneal IgG levels – low levels inhibit activity
HIV – little known effect
Aetiology
 Staph aureus
 Coag neg staph (S.Epidermidis)
 E coli
 Pseudomonas
 Sternotropomonas
 Candida
 Atypical TB
Diagnosis
 2 of the following 3 conditions

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Symptoms and signs of peritoneal
inflammation (pain, tenderness, guarding,
rebound)
Cloudy peritoneal fluid with increased white
cell count (specifically neutrophils)
Demonstration of bacteria on gram stain or
culture
Diagnosis – symptoms and signs
 Abdo pain most common but in a PD pt
suspect peritonitis if general malaise,
nausea, vomiting or diarrhoea
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Don’t be blinded by the PD
These pts get other pathology
EG. Strangulated hernia, withdrawal from
steroids (if they stop taking meds suddenly
and they happen to be on steroids), ruptured
viscus, ulcers, perforations etc
EXAMINE THE PATIENT
Diagnosis – symptoms and signs
Percentage
Symptoms
Abdo pain
95
Nausea and vomiting
30
Fever
30
Chills
20
Constipation or diarrhoea
15
Signs
Cloudy peritoneal fluid
99
Abdo tenderness
80
Rebound tenderness
10-50
Increased temperature
33
Blood leucocytosis
25
CRP
100 but can be delayed
Daugirdas JT et al 2007 p 419
Diagnosis – peritoneal fluid
 Cloudiness – when cell count greater than 100 x 106
Normal is around 10x106 but always less than 50x106
Mostly cloudiness means peritonitis but be aware of other
causes such as fibrin, blood, malignancy, chyle
Don’t write peritonitis off as a diagnosis if everything else fits but
the fluid is relatively clear – the changes can lag
Must get a WCC (peritoneal fluid) with specific neutrophil count.
Neutrophils required as the total number of white cells can vary
according to whether patient dry or wet etc. Normally
predominant cells are mononuclears and neutrophils are usually
less than 15% of total white cell count
Be aware of mimickers such as PID, ovulation, recent pelvic
examination which may affect the cell counts in the peritoneal
fluid
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Peritoneal fluid culture
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Send the whole bag
Label it (preferable with texta – label can sweat off)
Let the lab know it is coming
Ask for urgent gram stain and cell count and ask this
to be telephoned to you. Be aware that the gram
stain may be negative in 50% of cases of subsequent
culture proven peritonitis
 Also ask for M/C/S and fungal cultures
 Follow up the culture
 Do a full septic workup each time – including blood
cultures
Peritonitis
 Common things occur commonly and
peritonitis is unfortunately common in our
population of PD patients
 BUT
 Don’t lose sight of the bigger picture and
these patients can suffer from any other
pathology – always keep an open mind
Peritonitis Management
 Broad spectrum coverage
 Vancomycin (2.5g if more than 60kg / 2 g if 60kg or
less)
 Gentamicin (200mg if more than 60kg / 140mg if 60kg
or less)
 IP is better than IV (confirmed on large Cochrane
review April 2009)
 Await culture. If gram positive, then repeat the vanc
dose in 1 week. If gram negative then usually
ceftriaxone 1g intraperitoneally daily for 14 days

Things to note; if pseudomonas tube is very often lost.
May need to consider adding a second antibiotic such
as daily ciprofloxacin
PERITONITIS MANAGEMENT
Initial symptoms may include;
diarrhoea, vomiting, nausea,
abdominal pain, mental confusion or feeling unwell
COLLECT DRAINED BAG
*See additional resources (pink section) for drainage instructions
* Send entire bag for urgent MC&S (including WCC differential) and Fungal elements. ****
Must ‘cc’ KRSS ****
CLEAR BAG
must be able to read newspaper
bag
LOOK FOR OTHER CAUSES
Call PD Coordinator or
Renal GP
CLOUDY BAG
Intraperitoneal (IP) Antibiotics (see Procedures)
print through the
Give BOTH
Gentamycin –
160mgs if 60kgs or less
(gram –ve organisms)
200mg if > 60kgs
AND
Vancomycin 2gms if 60kgs or less
(gram +ve organisms)
2.5grams if > 60kgs
Give both in a 2L 2.3% bag
Dwell in the abdomen for minimum 6 hours
ATTENTION:
(Consult
microbiologist
if Vanc
or Gent while
allergy)
Vanc and
Gent
provide some
coverage
awaiting sensitivities.
****Further antibiotics WILL be required ****
If Staph/gram +ve, give IP Vancomicin again on Day 7
If gram negative, refer to sensitivities, but
usually 14 days of IP Ceftriaxone 1gm
YOU MUST follow up the MC & S 48 hours after initial IP treatment.
A WCC > 100 confirms peritonitis.
If the patient is not improving within 24 hrs, or any other concerns, contact PD coordinator
Peritonitis Mx
 CAPD/APD
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Drain abdomen and send bag off with path
request as above
Change the transfer set completely following
usual aseptic techniques
Load 2.3% 2 litre dialysate bag (use 1.5% bag
if patient hypotensive) with Vancomycin and
Gentamicin as per above guideline
Infuse bag into peritoneum
6 hour dwell
Peritonitis – fungal infection
 If fungal organisms are seen on gram stain,
or cultured, it is unlikely you will be able to
save the tube
 Once the tube is colonized, the only cure is
removal of tube, peritoneal rest (pt on
Haemodialysis for a few months) and then
start from scratch
Peritonitis
 If you think that the patient has peritonitis but you
think they have life threatening sepsis eg
hypotension, tachycardia, fever (or no fever as may
not be able to mount an immune response), altered
conscious state etc, your patient is likely to require IV
broad spectrum antibiotics. Ring the microbiologist
on call. Don’t wait to get IP regime in. That can go in
while you are making calls and obtaining results.
 Antibiotics must be given within 1 hour of
presentation – it is an emergency.
 I usually ring SCGH as they maintain a 24 hour
consultant micro roster 93463333 but remember all
our patients who require transfer must go to Royal
Perth Hospital as they are under the RPH consultant
Peritonitis
 Patients can have dual pathology
 Eg it is not uncommon for patients to have
peritonitis, delay treatment, splint their
abdomen and get pneumonia. This needs to
be treated as per the normal guidelines for
pneumonia
Peritonitis
 Additives to bags
 Vancomycin, aminoglycosides and
cephalosporins are safe to mix in the same
bag
 Aminoglycosides are incompatible with
penicillins
 Vancomycin is stable for 28 days in dialysate
(normal room temp)
 Cefazolin is stable for 8 days
 Gentamicin is stable for 14 days
 Heparin added decreases duration of stability
Peritonitis
 Often get formation of fibrin clots which
increases risk of catheter block
 May need to add 500units of heparin to 1 or 2
bags a day until fibrin clots decrease
 Constipation is common – you may need to
stop the calcium based phosphate binders
temporarily but better off using aperients
early and preventing the need to alter routine
meds
Peritonitis
 Fluid regimes
 Depends whether patient is overloaded or

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

underloaded
Can usually continue normal regime but tailor to
patient
If BP low, use 1.5% bags x 4 a day
If BP high use 2.3% bags, minimum of 4 a day
Aim for BP 120/
APD pts can continue on APD or if needed can
convert temporarily to CAPD – in Broome with
resources this should not be necessary
Peritonitis
 Can get changes in the permeability of the peritoneal
membrane
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Permeability to water, glucose and proteins is
increased
Rapid glucose absorption from the dialysis solution
reduces amount of ultrafiltration and can result in fluid
overload
May need high glucose concentration dialysate with
shorter dwells
Hyperglycaemia is common
Protein loss is increased in peritonitis so patients will
need high protein supplements
Peritonitis
 Don’t forget secondary causes of peritonitis

Perforated gastric or duodenal ulcer
Pancreatitis
Appendicitis
Diverticulitis
PID

Talk to the surgeon if you are not sure




Peritonitis
 You don’t necessarily have to admit the
patient
 Admission dictated by symptoms and distress
and often social circumstances up here
cms.ich.ucl.ac.uk/website/imagebank/images
blogs.southshorenow.ca/louise/
Peritonitis - bugs
 Staph – Vancomycin and repeat in 1 week
 Patients should have nasal carriage treated with
mupirocin bd for 5 days and then once a week of bd
for 5 days once a month
 Gram Negs – IP Ceftriaxone for 2 weeks and
consider repeating the dose of gentamicin after a
week or adding oral ciprofloxacin to the regime



Pseudomonas difficult to treat
Sternotrophomonas – usually requires 2 antibiotics
and usually for 4 weeks
Campylobacter not that common – responds to
gentamicin
Peritonitis
 Multiple organisms
 Have a high index of suspicion for secondary
peritonitis
 If not secondary peritonitis have 60% chance of curing
with appropriate antibiotics
 If one of the organisms is clostridium or bacteroides –
likely intra-abdominal abscess or perforated abdominal
viscus but exclude appendicitis, perforated ulcer,
pancreatitis and any other cause of secondary
peritonitis
 Occurrence of abdominal catastrophe in PD patient
has a high mortality
 Talk to the surgeon
 Add metronidazole
 Ship south
Peritonitis
 Culture negative disease
 If cell count less than 50 x 106…unlikely to
peritonitis
 If higher white cell count, then repeat empiric
therapy
 Make sure lab is doing cultures for AFB’s and
fungus
 If not improving consider legionella,
campylobacter, ureaplama, mycoplasma,
enteroviruses, fungus, histoplasma
capsulatum
Peritonitis
 Fungal peritonitis

Predisposing factors

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
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Prior antibiotic use especially if not full treatment
Immunosuppressive therapy
HIV
Malnutrition
Low albumin
Diabetes
Peritonitis
 Fungal peritonitis



We tend to try and save the tube by giving
antifungals but guidelines recommend prompt
removal of catheter, conversion to
haemodialysis for a few weeks and then start
from scratch
Penetration of antifungals to peritoneum other
than with IP administration, is poor
Peritonitis
 Refractory disease
 Defined as disease that is treated with
appropriate antibiotics for 5 days without
improvement
 Catheter removal necessary to reduce
morbidity and preserve peritoneum
 Increased with gram neg bugs
Peritonitis
 Relapsing disease
 Peritonitis with the same organism within 4 weeks of stopping




therapy
Usually Staph epidermidis or a gram negative organism
If pseudomonas or gram negatives, remove the catheter
If staph, may be able to rescue with repeat vancomycin weekly
for a month or may be able to remove the tube and
simultaneously insert a new tube (as opposed to any other
organism where a 2 month peritoneal rest is required)
Sometimes can use urokinase to strip the biofilm (bacteria
entrapped in fibrin in the peritoneal membrane) in relapsing
disease – last resort but worth a go
Peritonitis
 20% of episodes temporally associated with
exit site and tunnel infections (Piraino et al
2005)
 Treat exit site infections if red and purulent
 Swab it
 Start Flucloxacillin empirically and change or
add ciprofloxacin if gram neg
 Exit sites are another whole topic
Peritonitis
 Prevention

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Good technique
Hygiene
Mupirocin
Exit site care
Anchor tape
Cochrane Review 2009
 Implications for practice•
At the present time broad spectrum antibiotics should be initiated at the
time a diagnosis of peritonitis is made. When choosing antibiotics the
side-effect profile, local drug resistance patterns and previous antibiotic
use and infection history in the individual concerned should be
considered. In cases of recurrent peritonitis dialysis catheters should
be removed rather than using intraperitoneal urokinase.
•
 Currently available evidence from RCTs is inadequate in many areas of
clinical practice important in the management of PD-associated
peritonitis. This is a limiting factor in the provision of definitive
treatment guidelines.
Cochrane Review 2009

Implications for research•
Further studies are required to establish the most effective treatment for peritoneal dialysisassociated peritonitis. An essential feature of such studies is inclusion of enough patients to
ensure adequate power to assess meaningful long and short term outcomes. Short term
outcomes should extend beyond whether cure is achieved without catheter removal, for
example duration of systemic inflammation. Study of long-term outcomes should include
permanent transfer to haemodialysis, development of ultrafiltration failure patient death and
late recurrent episodes of peritonitis beyond four weeks from the original episode.
•
Specific interventions that would be of value include early versus late catheter removal.
Studies designed to study infections due to specific organisms would also be valuable. An
example is a study of glycopeptide versus cephalosporin therapy in peritonitis due to
coagulase negative Staphylococcal species. The majority of studies have included patients
on CAPD rather than APD hence studies designed to test the efficacy of antibiotics in APD
are required. This is particularly applicable to studies of intermittent versus continuous
dosing when cycler dwell times may well influence pharmacokinetics.
•
Future research should be conducted using standard definitions, with inclusion of
information about factors that may influence the response to therapy such as prophylaxis
regimens and dialysis solutions used. Current ISPD guidelines provide a comprehensive list
of requirements for future studies that should be referred to when designing studies.
Take home points
•Have a high index of suspicion
•Use the remote area manual
•Always let KRSS know of episode
•Copy all results to KRSS
•Don’t hesitate to ask if you are not sure – KRSS team, KRSS GP, Renal GP,
Nephrologist
www.learningradiology.com
Acknowledgements
 Thanks to Daugirdas et al 2007 – Handbook
of dialysis
 http://mrw.interscience.wiley.com/cochrane/cl
sysrev/articles/CD005284/frame.html
Thank you
 Questions
 renalgp@kamsc.org.au