p3: verso un concetto più ampio di dialisi peritoneale proteggere per preservare roberto russo
TRANSCRIPT
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P3: verso un concetto più ampio di dialisi peritoneale
Proteggere per preservareProteggere per preservare
Roberto Russo
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PROTECT
PERITONEAL MEMBRANE FROM
PERITONITIS
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Extra safe and easy to understand Extra safe and easy to understand PD system PD system
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Peritonitis is a cause of …
Peritoneal membrane damage
Hospitalization and pain
Catheter loss
Technique failure
Death
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IL-1βTNF-α
IL-8INITIATION
IL-8
IFN-γ
IL-1βTNF-α
AMPLIFICATION
TRANSITION
MCP-1
IFN-γIL-1βTNF-α
IL-6/sIL6R
sgp 130
RANTES
RESOLUTION
The sequence of events in peritoneal inflammation
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Patients on CAPD who have peritonitis producelarge amounts of pro-inflammatory cytokines
Hurst SM et al Immunity 2001;14:705-714
sIL-6R IL-6
IL-8 MCP-1
Period post infectionPeriod post infection
Med
iato
r co
nce
ntr
atio
n (
pg
/ml)
MNC
PMN
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Effluent VEGF correlates with peritonitis severity
0
200
400
600
800
1000
0 2000 4000 6000 8000 10000 12000
WBC/mm3
VEG
F effl
uent
ρg/
ml
Szeto et al, Perit Dial Int 2002; 22:265-274
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Peritonitis is associated with a protractedinflammatory process
0
25
50
75
100
D1 D2 D3 D4 D5
MNC Neutrophils
Period post infection
% L
euko
cyte
s
0
5
10
15
20
25
0 5 10 15 20
0
20
40
60
80
100
0 5 10 15 20
0
20
40
60
80
100
0 5 10 15 20
CXCR1 expression (PMN)
CD14 expression (MNC)
CD3 expression (T-cells)
Days
% s
urfa
ce e
xpre
ssio
n
Topley and Parker, 2005
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Peritonitis is associated with a protracted inflammatory process
Modified from Lai KN AJKD 2000;35:644-52
PD Effluent PD Effluent
IL-6
TGF-βFGF-β
IL-1
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Peritonitis and inflammatory severity “drives” to membrane change
Davies S et al Nephrol Dial Transplant 11:498-506,1996
0
500
1000
1500
2000
2500
0 1 2 3
Thic
knes
s of
sub
mes
othe
lial c
ompa
ct z
one
()
No previousinfection
Previousinfection
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Repeated peritoneal inflammation drives the fibrotic process
0
0,15
0,3
Hit 1 Hit 2 Hit3
Fibroblast proliferation
Activation cycle with infected PDE
Prol
ifera
tion
Inde
x
Topley and Parker, 2005
0
1
2
3
1 2 3
Collagen III synthesis
Activation cycle
Colla
gen
III/A
ctin
OD
ratio
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Pattern of inflammation may become deregulated during PD
PMN Monocytes
Lymphocytes
PMN
Monocytes
Lymphocytes
Time (days) Time (days)
Resident leukocyte populations in PD are suggestive of chronic inflammatory phenotype
Acute Dysregulated Chronic
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AlbuminAlbuminDiabetes MellitusDiabetes Mellitus
DisconnetDisconnetExit siteExit site
DepressionDepressionAdherenceAdherence
ObesityObesityEthnicityEthnicity
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American Journal of Kidney Diseases, Vol 45, No 2 , 2005: pp 372–380
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Peritoneal Dialysis International 2005, 25: 374–37
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Prevention of peritonitis
• Catheter placement• Exit site care• Connection method• Training• Antibiotic prophylaxis for procedures• Prevention of bowel source
peritonitis• Prevention of fungal peritonitis
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Strategie antimicrobiche per la prevenzionedelle 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
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Strategie correlate al catetere per la prevenzionedelle 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
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• 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)
PERITONEAL DIALYSIS-RELATED INFECTIONSRECOMMENDATIONS: 2005 UPDATE PREVENTION OF PD-RELATED INFECTIONS
Perit Dial Int 25: 107–131, 2005
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Effect of Peritoneal Dialysis Nurses and Training
Peritonitis rates per 1,000 Patients Months
Hall G et al, Nephrol Nurs J 2004
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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
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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.
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PreserveProtect