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1. The document discusses guidelines for the prevention and management of peritonitis from the ISPD 2022 updates. It focuses on key areas such as the standardized definitions of peritonitis, measurement of peritonitis rates, prevention strategies like exit site care and antibiotic prophylaxis, and treatment recommendations. 2. The new guidelines recommend monitoring peritonitis rates and aiming for a rate of less than 0.4 episodes per patient year. Prevention strategies discussed include proper exit site care, antibiotic prophylaxis before catheter placement and invasive procedures, and patient education. 3. Treatment guidelines cover initial antibiotic therapy based on peritonitis type and symptoms, and monitoring response and indications for catheter removal. Overall the document summar
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- 1. Journey through The roadless traveled Dr Ayman Seddik Associate Professor of Nephrology Ain Shams University 89% of RRT 11% RRT
- 2. 1-Where are wein PD map and rule of PD in RRT 2-ISPD guidelines on prevention and management of peritonitis 2022 UPDATES Our journey will have 2 stations
- 4. Ramesh Khanna &Karl D. Nolph Modalities of renal replacement therapy Interchangeable, depends on residual renal function
- 5. Initial assessment Renal clinic Inhospital consultation Transfer to HD Transplantation CKD Education Modality choice Life planning Timing of initiation of PD PD catheter r insertion Training for PD Maintenance care Management of complications JOURNEY THRU PD CLINIC
- 6. Physicians biasedagainst chronic PD poor outcome Patients have socio-cultural contra-indication Infrastructure for chronic PD available in less than half of dialysis units Physicians are not trained for PD
- 7. WHO ?? WHICH PATIENTTO OFFER PD ?? CONTRAINDICATIONS ??
- 8. European RenalBest Practice (ERBP) guidelines & ISPD guidelines recommend that all patients be educated about therapy options, so they can choose the modality that best suits them Initial dialysis modality selection There is insufficient evidence to support a general preference of HD over PD, or vice versa, for medical reasons. Therefore, the initial modality choice should be made primarily by the well informed patient.
- 9. MEDICAL Priorextensive abdominal surgery LARGE ABDOMINAL WALL HERNIAS ILEOSTOMY, COLOSTOMY
- 10. ❑ Inability totrain for PD ❑Limited eyesight ❑Insufficient social and family support ❑Unsafe or limited home living condition
- 11. Timing of the startof the dialysis Timing of placement of PD catheter Dose of dialysis to be targeted Maintenance of volume control Psychosocial status and quality of the life of the patient and their family
- 12. WHEN?? 1) TIME TOINITIATE 2) TIME FOR CATHTER INSERTION
- 13. Clearance orGFR 15ml/min as general guide Presence or absence early symptoms and signs of Uremia Other complication of advanced CKD Changes in nutritional status and decrease in calorie intake Deterioration in cognitive functioning/quality of life
- 14. Best insertedclose to time of initiation about 4 to 5 weeks prior to initiation of PD
- 18. PD DELIVERED MANUALLYOR WITH THE ASSISTANCE OF THE MACHINE – CYCLER DESCISION MADE AFTER DISCUSSION WITH PATIENT AND PATIENTS FAMILY
- 19. K/DOQI guidelinessuggest minimum Kt/V Urea of 1.7 combining dialysis and endogenous ( residual ) renal clearances Body surface area How many exchanges Volume of dialysis fluid instilled Tonicity of the fluid (GLUCODE CONCENTRATION IN PD FLUID ) is there long DWELL Duration of time patient on cycler
- 20.
- 21.
- 22. HIGH DOSECCPD OR OPTIMIZED
- 24. THE LONG DAYDWELL
- 25. • For asingle daily exchange for the long (8- to 16- hour) dwell during continuous ambulatory peritoneal dialysis (CAPD) or automated peritoneal dialysis (APD). • To improve (compared to 4.25% dextrose) long-dwell ultrafiltration and clearance of creatinine and urea nitrogen in patients with high average or greater transport characteristics, as defined using the peritoneal equilibration test (PET). EXTRANEAL INDICATIONS
- 26. CONTRAINDICATIONS 1-Known allergy tocornstarch or icodextrin 2-Maltose or isomaltose intolerance 3-Glycogen storage disease 4-Pre-existing severe lactic acidosis
- 28. Time line forperitoneal dialysis complications • A) NON INFECTIOUS COMPLICATIONS • I) Occurring early after surgery • Pain • Bleeding • II) Occurring later after surgery • Hemoperitoneum • Poor outflow or inflow • Leaks • Migration of the catheter • Increased IPP (Intra Peritoneal Pressure) • Hernia • Pain: infusion and drainage phases • Eosinophilic peritonitis at start of PD • sclerosing encapsulating peritonitis • B)INFECTIOUS COMPLICATIONS • EXIT SITE INFECTION • TUNNEL INFECTION • PERITONITIS PD COMPLICATIONS
- 29. Pain Bleeding • Managementof pain is important to maintain the patients comfort. • Avoid or manage severe cough • Always assess if dressing is clean and dry • If bleeding persists, advise the surgeon I) Occurring early after surgery
- 30. Poor Inflow orOutflow II) Occurring later after surgery Causes • Constipation • Catheter migration • Catheter obstruction with fibrin, blood •Omental wrapping
- 31. II) Occurring laterafter surgery Can look dramatic but will usually settle with time Can occur with menstrual cycle May need additional heparin if there are signs of clots (but usually the natural anticoagulants from peritoneal cells will prevent any such problems HEMOPERITONEIUM
- 32. II) Occurring laterafter surgery Catheter Migration Predisposing factors Prevention • Improper implantation or length • Direction of the subcutaneous tunnel and “memory” of catheter may lead to migration of the catheter. • Constipation • Perfect catheter insertion technique • Avoid and manage constipation
- 34. Conservative strategies suchas body position change Laxatives Flushing with heparinized saline (‘push-and-suck’ manipulation) Thrombolytic therapy (as per hospital’s protocol eg Urokinase), Fluoroscopic-guided manipulation using a guidewire Surgery: will be possible laparoscopically ISPD GUIDELINES : We recommend that each PD unit should have the ability to manipulate or reimplant PD catheters when necessary II) Occurring later after surgery Catheter Obstruction
- 35. II) Occurring laterafter surgery
- 36. II) Occurring laterafter surgery Hernia The most commonly seen hernias are incisional, umbilical and inguinal Incisional hernias may occur when the peritoneal catheter is placed through the midline instead of the paramedical approach through the rectus muscle. Risk factors Elderly patients Diabetic patients Worsened by elevation of intra-peritoneal pressure eg catheter malfunction problem so drainage is incomplete and pressure rises driving a leak
- 37. II) Occurring laterafter surgery • Assess and repair before starting PD • Surgical repair is necessary - hernias should be corrected either before or at catheter insertion. • Make sure reduction is possible – if not – then urgent surgical assessment ( OBSTRUCTED HERNIA ) • Stop PD temporarily around time of surgery ( TEMPORARY HD ) • Reintroduce PD with low volumes, supine posture, increase volume gradually over 2 weeks Hernia MANAGEMENT
- 38. Causes Management Infusion • Solutionjet effect on peritoneal membrane • Often found to be PD fluid pH related • Slower infusion speed • Use of biocompatible solutions. • Replacement of catheter if irritating peritoneal wall Drainage • Catheter pressing on peritoneal membrane or force of ‘suction’ is too strong • Drain time too prolonged • Lift up the drainage bag a little, decreasing gravity • Ensure PD cycler is not too high • Tidal modality could be used on APD
- 39. II) Occurring laterafter surgery Leaks of PD fluid Site of leaking can be: • Peri-catheter : leak may be observed directly through the exit site Illustrations courtesy of John Crabtree, MD
- 40. Persistant processus vaginalis(a remnant of embryonic development) : swelling is noted in the groin region – fluid is moving down the tissue planes until it stops at the inguinal ligament in the groin II) Occurring later after surgery Leaks of PD fluid CT peritoneography
- 41. Patient attend ERcomplain dyspnea increase while doing his PD , decreased UF , progresive weight gain CXR ? Diagnosis Leaks of PD fluid PERITONEO –PLEURAL LEAK
- 42. Rare, life-threatening complication,mostly after ≥ 6 years on PD, the peritoneum is massively thickened and calcified, leading to intestinal obstruction) II) Occurring later after surgery sclerosing encapsulating peritonitis
- 43. Dialysis Access remainsthe Achilles heel of peritoneal dialysis. Every year, 10% of PD patients switch to HD. After infectious-related PD complications, catheter-related issues are the second most common reason for technique failure.
- 44. Infectious complications inPD patients 1-Exit site infection 2- Tunnel infection 3- Peritonitis PREDICTABLE AND PREVENTABLE
- 45. Definitions and measurement of peritonitis; Preventionof peritonitis; Treatment of peritonitis: initial and subsequent; Monitoring response to peritonitis treatment including indications for catheter removal For a better understanding of this guideline, we will focus on the updates, and we will keep to a few key areas in the new recommendations:
- 46. 1-clinical features consistent withperitonitis: abdominal pain and/or cloudy dialysis effluent. 2-dialysis effluent white blood cell (WBC) count > 100/µL (after a dwell time of at least 2 h), with > 50% polymorphonuclear leukocytes (PMN). 3-positive dialysis effluent culture standardized definitions of PD-related peritonitis. ISPD 2022 guidelines Guideline recommendations: We recommend that peritonitis should be diagnosed when at least two of the following are present (1C): Definitions
- 47. PD peritonitis isfurther classified according to 1-causative organism 2-concomitant event (e.g. association with exit-site/tunnel infections or intra-abdominal pathology) 3-timing concerning previous episodes 4-outcomes.
- 48.
- 49. • Pre-PD peritonitisis a peritonitis episode occurring after PD catheter insertion and prior initiation of PD (first day of PD training or PD treatment). • PD catheter insertion-related peritonitis is defined as an episode of peritonitis that occurs within 30 days of PD catheter insertion and should be <5% of PD catheter insertion
- 50. • Recommended monitoringparameters also include • organism-specific peritonitis rates • antimicrobial susceptibilities • culture-negative peritonitis. ISPD peritonitis guideline recommends that every PD program should monitor the incidence and outcomes of PD peritonitis at least annually (1C). Measurement of peritonitis rate
- 51. • Peritonitis rateshould be calculated as the number of episodes per patient per year at risk (years counted from PD initiation). • The guideline recommends an achievable goal of <0.4 episodes/patient-year, a lower target than the 2016 guideline (<0.5 episodes/patient-year). • The proportion of culture-negative peritonitis should be less than 15% of all peritonitis episodes (1C). • percentage of peritonitis-free patients (targeting >80% peritonitis-free patients per year), and pre-PD peritonitis
- 52.
- 54. Classification of exitsites I - perfect ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE
- 55. Classification of exitsites II- GOOD ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE
- 56. Classification of exitsites III- Equivocal ISPD CATHETER-RELATED INFECTION RECOMMENDATIONS: 2017 UPDATE
- 57. Swelling 2 ISPD 2022 Wesuggest that exit-site infection is defined as the presence of purulent discharge, with or without erythema of the skin at the catheter- epidermal interface (not graded). Most serious S. aureus and P. aeruginosa. As these organisms frequently lead to peritonitis (Evidence), such infections must be treated aggressively
- 58. 2 weeks aftermissing to treat exit site infection , your patient came to ER with pain , redness , swelling at the tunnel site
- 59. Cloudy bag =peritonitis Flush with rapid exchange wash the peritoneum then Antibiotics as per unit protocol immediately in a 6 hour dwell 2.27% , Use first cloudy bag if possible – make sure patient brings it send for cell count , culture
- 60. Primary Prevention • CatheterPlacement - Prophylactic Antibiotic • In the guideline, there is only one 1A recommendation, which can be found both in the 2017 and 2022 ISPD guidelines: that systemic prophylactic antibiotics be administered before catheter placement. • Four randomized trials support this recommendation, including cefuroxime (Wikdahl et al, NDT 1997), Gentamicin, vancomycin, and Cefazolin versus no treatment (Lye et al, Scand J Urol Nephrol 1992; Gadallah et al, AJKD 2000). Prevention of peritonitis
- 61. Contamination of PDSystem • We suggest prophylactic antibiotics after wet contamination of the PD system to prevent peritonitis (2D). • We suggest advice be sought immediately from the treatment team if contamination during PD exchange is noted (Not Graded). Guideline recommendations: ISPD 2022 Peritonitis Guideline
- 63. Invasive gastrointestinal andgynecological procedures • We suggest antibiotic prophylaxis prior to colonoscopy (2C) and invasive gynecological procedure (2D). • We suggest drainage of PD fluid to keep the abdomen empty before endoscopic gastrointestinal and invasive or instrumental gynecological procedures (2D). Guideline recommendations: ISPD 2022 Peritonitis Guideline GI procedures, i.e. colonoscopy, without antibiotic prophylaxis, has a peritonitis incidence of 3.4 to 8.5%
- 64. Training Programs andMonitoring • We suggest that the characteristics of an optimal PD training programme (how, how long, where, when and by whom) remain uncertain (2C). • We recommend that PD exchange technique and knowledge be regularly reassessed and updated, with an emphasis on direct inspection of practice of PD technique (1C). Guideline recommendations: ISPD 2022 Peritonitis Guideline
- 65. Review postoperative instructionswith patient: • Maintain clean, dry, securely taped sterile dressing • Protect site from gross contamination and wetness • Immobilize catheter • Practice good hand hygiene . • Avoid heavy lifting, stair climbing, straining, and constipation until catheter is healed (2 to 6 weeks) • Notify PD unit in case of blood or other drainage, pain or tenderness, trauma to abdomen Restrict dressing changes following implantation to experienced PD staff Prevention of complications PATIENT EDUCATION FOR EARLY CATHTER CARE
- 66. Optimal long-term peritonealcatheter management focuses on maintaining a healthy exit site and catheter track. Catheter survival of greater than 80% at one year •ongoing assessment of the exit-site • institution of antibiotic prophylaxis •early identification and treatment of exit-site problems •prevention of contamination •immobilization of the catheter to protect from trauma. ISPD 2022 recommends one of the following: • Gentamicin 0.1% cream daily at exit-site effective in reducing both gram-positive and gram-negative infections • Mupirocin cream or ointment daily at exit-site effective in reduction of gram-positive infections • Apply to skin around catheter site only, not catheter
- 68. Domestic Pets andZoonotic Infections • We recommend PD patients take extra precautions to prevent peritonitis if domestic pets are kept (1C). • We suggest pets not be allowed in the room where PD exchange takes place, and where dialysis tubing, equipment and machine are stored (2A). Guideline recommendations: ISPD 2022 Peritonitis Guideline
- 69. Dietary and MedicationEffects •We suggest that avoidance and treatment of hypokalemia may reduce the risk of peritonitis (2C). Guideline recommendations: ISPD 2022 Peritonitis Guideline
- 70. Secondary Prevention • Toprevent fungal peritonitis, we recommend that anti-fungal prophylaxis be co-prescribed whenever PD patients receive an antibiotic course, regardless of the indication for that antibiotic course (1B). Guideline recommendations: ISPD 2022 Peritonitis Guideline
- 71. • If peritonitisis suspected, the guideline recommends that PD effluent be tested for cell count, differential gram stain, and culture (1B). • PD patients presenting with cloudy effluent should be presumed to have peritonitis and treated as such until the diagnosis can be confirmed or excluded (1C). initial management for PD patients presenting with a clinical diagnosis ISPD 2022 Peritonitis Guideline
- 72. We recommend thatIP antibiotics be the preferred route of administration as long as the compatibility and stability of the IP antibiotics allow, unless the patient has features of systemic sepsis (1B). • We suggest that IP aminoglycoside be administered as daily intermittent dosing (2B). • We recommend that prolonged courses of IP aminoglycoside be avoided (1C). We suggest that adjunctive oral N-acetylcysteine therapy may help to prevent aminoglycoside ototoxicity (2B). • There is insufficient evidence to make a recommendation as to whether patients on APD should be temporarily switched to CAPD during the treatment of peritonitis (Not Graded). ISPD 2022 Peritonitis Guideline
- 73. Treatment of peritonitis:initial and subsequent ISPD 2022 Peritonitis Guideline
- 74. Prescribing high-quality goal-directedPD In 2020, the ISPD published practice recommendations for prescribing high-quality goal-directed These recommendations represented a paradigm shift from the conventional, non- evidence-based and potentially harmful practice of prescribing PD to achieve so- called ‘dialysis adequacy’ based primarily on the unvalidated and imprecise surrogate measure of small solute clearance. • Instead, the new guidelines advocate a tailored, shared decision-making model. Such a PD plan should be developed by the person receiving PD in collaboration with their care team to ensure the delivery of high-quality PD that helps the patient to achieve their expressed, personal goals of care, and is informed by careful assessment of (in descending order of priority) patient-reported outcome measures (such as QOL and symptom burden), clinical measures (such as fluid status) and, to a much lesser extent, surrogate measures (such as RKF, bone mineral disorder parameters, nutritional indices, peritoneal membrane function and small solute clearance)
- 75. Worldwide, approximately 11%of patients on dialysis receive peritoneal dialysis (PD). Whilst PD may offer more autonomy and freedom compared with hemodialysis, infection, hospitalization, symptom burden, and patient/caregiver burnout and fatigue remain as major challenges to the success of PD. To some extent, this may be due to the inconsistency, heterogeneity, and lack of patient-prioritized outcomes reported in trials in patients on PD. The aim of the Standardised Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) study is to establish a core outcome set for trials in patients on PD based on the shared priorities of all stakeholders; which can help to improve the contribution of trials to shared-decision making.
- 76.
- 78. Evaluating candidacyfor PD is a MULTI-DISCIPLINARY task Timing of initiation of PD requires close assessment and follow up by the Nephrologist and Renal team PLACEMENT of catheter is best done about 4 to 5 weeks prior to anticipated initiation of PD as to allow 2 weeks of healing and 2 to 3 weeks of training
- 79. Catheter careis best done according to a SET PROTOCOL Adequate and complete training for PD is critical Primary and secondary prevention of complications is important for patient catheter and technique Early serious problems can usually be addressed without permanently discontinuing PD Comprehensive care of the PD patient starts early Providing high quality goal directed PD therapy is the target for ongoing trials
- 80.
- 81. APPENDIX : IP antibioticdosing recommendations for treatment of peritonitis.
- 83. Group Antibiotic Intermittent (1exchange daily for at least 6 h) Continuous (all exchanges) Aminoglycosides Amikacin 2 mg/kg daily173 Not advised Aminoglycosides Gentamicin 0.6 mg/kg daily174,175 Not advised Aminoglycosides Netilmicin 0.6 mg/kg daily165 Not advised Aminoglycosides Tobramycin 0.6 mg/kg daily Not advised Group Antibiotic Intermittent (1 exchange daily for at least 6 h) Continuous (all exchanges) Cephalosporins Cefazolin 15 mg/kg daily (for long dwell)176,177 LD 500 mg/L, MD 125 mg/Ld 168,179 Cephalosporins 20 mg/kg daily (for short dwell)178,176 Cephalosporins Cefepime 1000 mg daily LD 500 mg/L, MD 125 mg/Ld 168 Cephalosporins Cefoperazone No data LD 500 mg/L, MD 62.5–125 mg/L180 Cephalosporins Cefotaxime 500–1000 mg daily181 no data Cephalosporins Ceftazidime 1000–1500 mg daily (for long dwell) LD 500 mg/L, MD 125 mg/Ld 168,182 Cephalosporins 20 mg/kg daily (for short dwell)178 Cephalosporins Ceftriaxone 1000 mg daily183 No data
- 84. Group Antibiotic Intermittent (1exchange daily for at least 6 h) Continuous (all exchanges) Penicillins Penicillin G No data LD 50,000 unit/L, MD 25,000 unit/L13 Penicillins Amoxicillin No data MD 150 mg/L184 Penicillins Ampicillina 4 gm daily185 MD 125 mg/L186 Penicillins Ampicillin/sulbacta m LD 1000 mg/500 mg, MD 133.3 mg/66.7 mg187,188 Penicillins Piperacillin/tazobac tam No data LD 4 gm/0.5 gm, MD 1 gm/0.125 gm189 Penicillins Ticarcillin/clavulani c acid No data LD 3 gm/0.2 gm, MD 300 mg/20 mg/L190
- 86. Group Antibiotic Intermittent (1exchange daily for at least 6 h) Continuous (all exchanges) Antifungal Fluconazole IP 150–200 mg every 24 to 48 h215,216 (oral route is preferred: see Table 6) No data Antifungal Voriconazole IP 2.5 mg/kg daily217 (oral route is preferred: see Table 6) No data
- 87. APPENDIX : Systemic antibioticdosing recommendations for treatment of peritonitis.
- 88. group Drug Dosing AntibacterialAmoxicillin Oral 500 mg thrice daily219 Antibacterial Ciprofloxacin Oral 500–750 mg daily220 Antibacterial Oral 750 mg BD for CCPD221 Antibacterial Clarithromycin Oral 250 mg BD222,223 Antibacterial Colistin IV 300 mg loading (for critically ill patients), then 60–200 mg dailyb224-226 Antibacterial Dalbavancin IV 1500 mg over 30 min single dose227 Antibacterial Daptomycin IV 4–6 mg/kg every 48 h228 Antibacterial Ertapenema IV 500 mg daily229 Antibacterial Levofloxacin Oral 250 mg daily230 or 500 mg every 48 h Antibacterial Linezolid IV or oral 600 mg BD231,232 for 48 h, then 300 mg BD233 Antibacterial Moxifloxacin Oral 400 mg daily234,235 Antibacterial Rifampicin Oral or IV 450 mg daily for BW <50 kg; 600 mg daily for BW ≥50 kg Antibacterial Ticarcillin/clavulanic acid IV 3 gm/0.2 gm every 12 h Antibacterial Tigecycline IV 100 mg loading, then 50 mg every 12 h236,237 Antibacterial Trimethoprim/sulfametho xazole Oral 160 mg/800 mg BD238,239
- 89. group Drug Dosing Anti-fungal AmphotericinB desoxycholate IV 0.75–1.0 mg/kg/day over 4–6 h240 Anti-fungal Amphotericin B (liposomal) IV 3–5 mg/kg/day241,242 Anti-fungal Anidulafungin IV 200 mg loading, then 100 mg daily243,244 Anti-fungal Caspofungin IV 70 mg loading, then 50 mg daily243 Anti-fungal Fluconazole Oral 200 mg loading, then 100 mg daily240 Anti-fungal Flucytosine Oral 1 gm daily240 Anti-fungal Isavuconazole Oral or IV 200 mg every 8 h for 6 doses (48 h) loading, then 200 mg daily Anti-fungal Micafungin IV 100 mg daily243,245 Anti-fungal Posaconazole Oral tablet 300 mg every 12 h loading for two doses, then 300 mg daily246 Anti-fungal Voriconazole Oral 200 mg every 12 h