Persistent Sterile Peritoneal Inflammation after Catheter Removal for Refractory Bacterial Peritonitis Predicts Full-Blown Encapsulating Peritoneal Sclerosis

Abstract

♦ Background: Encapsulating peritoneal sclerosis (EPS) is the most serious complication of peritoneal dialysis, having high morbidity and mortality. To improve outcomes, early diagnosis is needed to direct treatment during the early inflammatory phase. However, in the early inflammatory phase, clinical features are nonspecific, and no reliable diagnostic criteria have been established. Because bacterial peritonitis and termination of dialysis are two important risk factors triggering the progression of EPS, patients with refractory bacterial peritonitis necessitating dialysis catheter removal are at particularly high risk of developing EPS. Many of these patients might indeed experience nonresolving sterile peritonitis (probably the inflammatory phase of EPS) before progression to full-blown disease (that is, the presence of intestinal obstruction). We undertook a retrospective study to compare, in this particular situation, the clinical characteristics of patients with or without sterile peritoneal inflammation, assessing their clinical outcomes in terms of short-term mortality and the chance of developing full-blown EPS. ♦ Methods: Our retrospective review included 62 patients whose dialysis catheter was removed because of refractory peritonitis between January 2005 and December 2010. ♦ Results: Of the 62 patients identified, 39 (63%) had persistent sterile peritoneal inflammation ("high-risk" group, n = 39), and 23 (37%) had resolution of inflammation without significant intra-abdominal collection after catheter withdrawal ("control" group, n = 23). Compared with the control group, the high-risk group had a significantly longer PD duration (71.6 ± 43.3 months vs 42.3 ± 29.9 months, p = 0.003), a higher dialysate-to-plasma ratio (D/P) of creatinine (0.768 ± 0.141 vs 0.616 ± 0.091, p = 0.004), and a higher computed tomography score for EPS (7.69 ± 2.98 vs 1.00 ± 1.00, p < 0.001). During the 6-month study period, the high-risk group had a higher chance of developing full-blown EPS (31% vs 0%, p = 0.002) and a higher 6-month all-cause mortality (36% vs 4.3%, p = 0.004). ♦ Conclusions: Persistent sterile peritoneal inflammation was common after dialysis catheter removal for refractory bacterial peritonitis, and the patients with such inflammation were at high risk of progression to full-blown EPS.Perit Dial Int 2013; 33(5):507-514 www.PDIConnect.com epub ahead of print:

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

“…More recent experimental data, however, suggest that a prolonged SIRS may be more a reflection of host immune activity than an indication of the presence of viable microorganisms. 13–15 As such, efforts have begun to shorten the duration of antimicrobial therapy in the presence of traditional markers of sepsis. These efforts have already been successful in other severe infections such as ventilator-associated pneumonia.…”

Recommendations for pathological diagnosis on biopsy samples from peritoneal dialysis patients

“…Representative pathological findings of severe peritonitis are fibrin exudation associated with strong inflammation in the acute phase [37], which causes mesothelial cell injury and interstitial fibrosis [56]. Such fibrin exudation and subsequent fibrosis are similarly found in EPS cases as described above.…”

Designing Epidemiology Studies to Determine the Incidence and Prevalence of Encapsulating Peritoneal Sclerosis (EPS)

“…It certainly is possible to review medical records and investigate recorded risk factors amongst cases and controls, e.g. PD treatment duration (2,6,7), PD modality, dialysis prescription, use of standard or less bio-incompatible dialysates (11), transporter status (5,10), peritonitis (6,12), concomitant medications (2), age (6), and other diseases and abdominal surgeries (2) that may potentially predispose PD patients to developing EPS. However, apart from duration of PD therapy, studies have often been contradictory, particularly with relation to the role of peritonitis episodes (3,6,7,10,12).…”