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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 1061-1064
Peritonitis in patients on peritoneal dialysis: A single-center experience from Dakar


Department of Nephrology, CHU Aristide Le DANTEC, Dakar, Senegal

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Date of Web Publication13-Sep-2012
 

How to cite this article:
Cisse MM, Hamat I, Gueye S, Seck SM, Ka EF, Tall AL, Niang A, Diouf B. Peritonitis in patients on peritoneal dialysis: A single-center experience from Dakar. Saudi J Kidney Dis Transpl 2012;23:1061-4

How to cite this URL:
Cisse MM, Hamat I, Gueye S, Seck SM, Ka EF, Tall AL, Niang A, Diouf B. Peritonitis in patients on peritoneal dialysis: A single-center experience from Dakar. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Jun 4];23:1061-4. Available from: http://www.sjkdt.org/text.asp?2012/23/5/1061/100953
To the Editor,

Peritoneal infections still remain one of the major complications of peritoneal dialysis (PD), and remain the leading cause of technique fai衍ure and morbidity in these patients. [1] We con苓ucted a study to determine the prevalence and risk factors of peritonitis among patients on PD in a single center in Dakar, Senegal. We retrospectively studied incident patients in the PD center of CHU Aristide Le DANTEC of Dakar from March 2004 to October 2007. Patients with end-stage renal disease (ESRD) on PD treatment for more than 15 days were included. Patients with a PD catheter who had not been started on PD were not included. A double-cuff Tenckoff catheter was used and was inserted by two trained surgeons under lo苞al anesthesia in all patients. All patients used a Y-set disconnect system. Patients on conti要uous ambulatory peritoneal dialysis (CAPD) were prescribed four exchanges a day while patients on automated peritoneal dialysis (APD) received six night exchanges and used a home cycler choice with bicarbonate-lactate bags. Frequency and time of occurrence of infec負ions, diabetic status, etiological factors, micro觔rganisms isolated as well as treatment and outcome were collected for each patient.

Statistical analysis was done using Epi Info 6.0; Kaplan-Meir analysis was used for survi赳al rate. A P-value of <0.05 was considered to be statistically significant.

Thirty-four incident patients were registered during our study period, of whom three were excluded (two were still in the training period and one died few days after catheter insertion). Thus, 31 patients were effectively studies and included ten who were on APD and 21 pa負ients who were on CAPD.

The mean age of the study patients was 49 ± 5 years (16-79 years). The sex ratio was 1.2, with 17 males and 14 females. Nephroangiosclerosis was the most common cause of ESRD (29%), followed by diabetic nephropathy (26%).

During the study period, 33 episodes of peri負onitis were diagnosed. The mean onset of peritonitis after starting dialysis was 16 ± 6 months (one to 56 months). Sixteen patients (80%) had one episode of peritonitis and two presented with four episodes of peritonitis each; both were diabetic with reduced visual acuity. The overall incidence rate of peritonitis was one peritonitis episode per 22 patient-months.

Forty-three percent of peritonitis was culture negative. The principal microorganisms iden負ified are listed in [Table 1].
Table 1: Microorganisms responsible for peritonitis in the study patients.

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Improper aseptic precautions were detected in 17 cases, and were correlated with the occur訃ence of peritonitis (P = 0.003). Other etiologic factors included exit-site and tunnel infections [Figure 1]. Peritonitis was more frequent in patients on CAPD (P = 0.02). Diabetes was not correlated with the occurrence of perito要itis (P = 0.05).
Figure 1: Causes of peritonitis in the study patients.

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First-line intraperitoneal antibiotics were cefotaxime (500 mg/bag) and gentamycin (20 mg/ bag) for five days. Systemic antibiotic therapy was used as secondary defense and was based on the culture-sensitivity reports. Fluconazole was used for Candida albicans peritonitis. Catheters were removed in four patients who did not respond after 21 days of antibiotic treatment and in the patient with fungal perito要itis. Seventy percent of peritonitis showed good response to treatment. During the study period, eight patients (26%) were transferred to hemodialysis mainly be苞ause of refractory peritonitis; of them, four had catheter ablation and three had catheter obstruction. Six deaths (19.5%) were noted: two died of sepsis secondary to peritonitis, one had sudden death, two died due to under dia衍ysis while in one patient the cause of death was undetermined. Sixteen patients continued to be on PD: 11 on CAPD and five on APD.

The global technique survival for patients at one, two and three years were, respectively, 62%, 45% and 38% [Figure 2] . The actuarial survival of patients without peritonitis at one and two years was 63% and 42%, respectively.
Figure 2: Overall survival of the technique in the study patients.

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The mean rate of peritonitis in our study was one peritonitis episode per 22 patient-months. This is due, in part, to the quality of patient's training and improvement in asepsis. Jamal et al found a similar rate. [2] In the Tunisian series, the reported rate of peritonitis among patients on CAPD was 14 episodes per patient-month. [3] This is probably due to the use of disconnect systems that have proven their efficacy in the prevention of peritonitis.

In our study, diabetes was not associated with increased incidence of peritonitis, although some some studies found it as a risk factor for peri負onitis in PD. [4],[5] Patients on CAPD presented with more episodes of peritonitis than those on APD (P = 0.002), probably due to the multiple manipulations that are done in CAPD. [3] In our series, 33% of peritonitis was caused by gram positive cocci, with Staphylococcus aureus and Streptococcus sp predominating. Our results are different from reports found in the literature, wherein infection with gram po貞itive cocci has been noted in 68-83% of peritonitis episodes, [6],[7] but are similar to the Tunisian series (36.6%). Jamal et al found that 18.2% of peritonitis was due to Staphylococcus epidermidis. In our series, most of the orga要isms isolated were gram negative, while in other reports these organisms were responsible for 13-24% of peritonitis episodes. [3],[8]-[10] We found pseudomonas in 9% of peritonitis (40% of gram negative peritonitis), while in the report from Tunisia, pseudomonas was found in 31% of gram negative peritonitis. [3] In Jamal's series, pseudomonas was isolated in 16.4% of all peritonitis. [2] One case of Candida peritonitis was diagnosed, treated unsuccessfully with fluconazole and was transferred to hemodialysis.

In the literature, the frequency of fungal peri負onitis is very low (0.01-0.11/ years). [2],[11] In 43% of our patients with peritonitis, the fluid was culture negative. This figure is high com計ared with the literature, but is similar to the report of Jamal who reported culture-negative peritonitis in 49% of their patients. [2]

The technique survival at one, two and three years were, respectively 62%, 45% and 38%. Our results are different from the Tunisian report, which found a survival rate at one, two and three years of 83.6%, 65.9% and 47.1%, respectively. [3] This difference may be because of our small sample size.

In conclusion, given the high incidence and prevalence of peritonitis, it is essential to im計rove preventive measures by imparting pro計er education to the patients and encourage active participation of the patients and the attendants.


   Acknowledgment Top


The authors wish to convey their thanks to Prof. Boucar Diouf, Chief of the Nephrology Department, Dakar.

 
   References Top

1.Ryckelynck JP, Lobbedez T, Hurault de Ligny B. Peritoneal dialysis. Encyc Med Chir. (Ed Scientifiques et Médicales Elseviers SAS, Paris Nephrologie-Urologie. 18-063-B-50, 2003, 8p).  Back to cited text no. 1
    
2.Jamal S. Complications of CAPD: a single center experience. Saudi J Kidney Dis Transpl 2005; 16:29-32.  Back to cited text no. 2
    
3.Karoui C. Treatment of uremic patients by automated peritoneal dialysis: Study of 78 cases. These Med Tunis, 2002. 133p.  Back to cited text no. 3
    
4.Bordes A, Campos-Herrero MI, Fernandez A. Predisposing and prognostic factors of fungal peritonis in peritoneal dialysis. Perit Dial Int1995;15:275-6.  Back to cited text no. 4
    
5.Mc Donald SP, Collins JF. Obesity is a risk factor for peritonitis in the Australian and New Zealand peritoneal dialysis patient populations. Perit Dial Int 2004;24:340-6.  Back to cited text no. 5
    
6.Abbad MA, Bernieh B, Sirwal IA, Mohamed AO. CAPD: Experience at Al Madinah Al Munawarah. Saudi J Kidney Dis Transpl 1997; 8:127-30.  Back to cited text no. 6
    
7.Benevent D, Benzakour M, Lagarde C, Leroux-Robert C. First-line treatment of peri負onitis in continuous ambulatory peritoneal dialysis. BDP 1992;2:5-10.  Back to cited text no. 7
    
8.Michel C, Al Khayat R, Viron B, Siohan P, Mignon F. How to diagnose and treat perito要eal infections in patients with terminal chro要ic renal insufficiency treated by peritoneal dialysis. Néphrologie 1995;16:55-69.  Back to cited text no. 8
    
9.Port FK, Held PJ, Nolph KD, Turenne MN, Wolfe RA. Risk of peritonitis and technique failure by CAPD connection technique: A national study. Kidney Int 1992;42:967-74.  Back to cited text no. 9
    
10.Rubin J, Rogers WA, Taylor HM, et al. Perito要itis during continuous ambulatory peritoneal dialysis. Ann Internal Med 1980;92:7-13.  Back to cited text no. 10
    
11.Lee SH, Chiang SS, Hseih SJ, Shen HM. Successful treatment of fungal peritonitis with intracatheter anti-fungal retention. Adv Perit Dial 1995; 11:172-5.  Back to cited text no. 11
    

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Correspondence Address:
Mouhamadou Moustapha Cisse
Department of Nephrology, CHU Aristide Le DANTEC, Dakar
Senegal
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DOI: 10.4103/1319-2442.100953

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