2. Coplication Of pertonal Dialysis
Dr Gh.Sarvari
Pediatric Nephrologist

3. Infectious Complications of PD

4. Peritonitis
➢ Despite a series of improvements in connection
technology, peritonitis remains the single most common
complications in PD children and the most important
cause of morbidity hospitalization and technique failure .
➢ Peritonitis annualized rate varies in different parts of the
world, from 0.64 in North America and 0.60 in Italy to the
exceptional rate of 0.17 episodes per PD treatment year in
Japanese children
➢ An inverse relationship between the age of the patient
and peritonitis rate
➢ The 2018 Annual Data Report from the United States
Renal Data System(USRDS) reported that infection is the
leading cause for hospitalization and the second-most
common cause of death in children receiving PD

5. Cont.
Although the microbiology, diagnosis, and management of peritonitis in
children undergoing CPD are similar to those of adult patients, there are some
issues that are unique or more common in pediatric CPD. These include:
●Fungal peritonitis is an infrequent complication in pediatric patients
undergoing CPD, accounting for up to 8 percent of peritonitis episodes .
Children with fungal peritonitis are more likely to be less than two years of
age. Successful therapy is the same as in adults with fungal peritonitis and
consists of combination therapy of antifungal medication and dialysis
catheter removal. The outcome of fungal peritonitis in children, however, is
more favorable than in adults, with a lower mortality rate .
●There is global variation in causative microbial agents in peritonitis in
children receiving CPD .As an example, the rate of Pseudomonas-based
peritonitis is eight times greater in the United States than in Europe. In
addition, there are significant differences in antibiotic susceptibility,
particularly with first generation cephalosporins and aminoglycosides.
These issues need to be considered when choosing empiric antibiotic
coverage while awaiting results from peritoneal fluid cultures

6. CLINICAL PRESENTATION
➢Abdominal pain – 79 to 88 percent
➢Fever– 29 to 53 percent
➢Nausea or vomiting – 31 to 51 percent
➢Cloudy effluent – 84 percent
➢Hypotension – 18 percent

7. Predisposing factors in children
➢Peritoneal catheter exit-site infection
➢ The higher incidence of gastrostomy
feeds
➢The use of diapers in infants
➢Young children who are not yet toilet
trained
➢Surgical procedures performed around
the time of PD catheter placement

8. Risk factors
➢ Recent invasive intervention (colonoscopy,
sigmoidoscopy, cystoscopy, hysteroscopy)
➢ Dental procedures
➢ Nasal S. aureus carriage
➢ Exit-site and/or tunnel infections
➢ Other factors that have been associated in various
studies include constipation, smoking and chronic
obstructive pulmonary disease (COPD), domestic pets,
obesity, depression, hypokalemia, hypoalbuminemia,
prior hemodialysis, use of bioincompatible solutions,
and living far away from the peritoneal dialysis clinic

9. MICROBIOLOGY
➢ The most common source of peritonitis is intraluminal
contamination; typically, this occurs if the patient uses
suboptimal sterile technique for connecting or
disconnecting the catheter to perform exchanges
("touch contamination").
➢ Other sources of peritonitis include periluminal
(contamination due to extension of bacteria from exit-
site or tunnel infection), visceral (contamination via
bacteria from bowel) and vaginal (rarely).
➢ In addition, peritonitis can develop via hematogenous
dissemination from a remote source.

10. MICROBIOLOGY(cont.)
➢Gram-positive organisms 45 to 65 percent
➢Gram-negative organism 15 to 35 percent
➢More than one organism has been reported
in 1 to 4 percent of cases
➢Culture negative 20 to 40 percent
➢Approximately 3 to 5 percent are caused by
fungi, mostly Candida species

11. Cont.
➢ Gram positive
1.Coagulase negativsatphylococcus
2.Streptococcus spp,
3.Staphylococcus aureus
4.Enterococcus spp
5.Corynebacterium
➢ Gram negative
1.Escherichia coli
2.Klebsiella spp
3.Pseudomonas aeruginosa

12. Diagnose
Peritonitis should be diagnosed if two or
more of following are present :
➢Consistent clinical features (abdominal
pain or cloudy effluent).
➢Peritoneal fluid white count is greater
than 100 cells/mm3 (or 0.1 x 109/L after
dwell time of at least two hours) and the
percentage of neutrophils is greater than
50 percent.
➢Positive effluent culture.

13. TREATMENT
Empiric antibiotics ((ISPD) guidelines)
➢ Gram-positive organisms may be covered by vancomycin or a
first-generation cephalosporin (such as cefazolin). In centers with
a high rate of methicillin-resistant organisms, vancomycin should
be used.
➢ Gram-negative organisms may be covered by a third- or fourth-
generation cephalosporin (such as cefepime or ceftazidime), an
aminoglycoside, or aztreonam
➢ If the Gram stain reveals yeast or other fungus, antifungal agents
should be started and the patient prepared for possible catheter
removal depending on the final culture results
➢ We administer antifungal prophylaxis among patients on
peritoneal dialysis who are treated with antibiotics for longer than
three days

14. After culture and sensitivity results are available
Single bacterial organism — The regimen should be adjusted after a
specific organism is identified and may be further adjusted based on
clinical response. Patients with cultures demonstrating methicillin-
resistant S. aureus warrant treatment with vancomycin; patients with
methicillin-sensitive S. aureus warrant treatment with a first-
generation cephalosporin such as cefazolin, if feasible.
Polymicrobial peritonitis --- Peritonitis due to multiple enteric
organisms or mixed gram-negative/gram-positive organisms should
raise concern for a concurrent intra-abdominal condition such as
ischemic bowel or diverticular disease. In such cases, imaging studies
and surgical consultation should be obtained
Empiric broad-spectrum antimicrobial therapy should include
coverage for anaerobes and gram-negative enteric bacilli. We
generally treat with metronidazole plus vancomycin plus an
aminoglycoside or ceftazidime.

15. Culture-negative peritonitis
➢ Patients with culture-negative peritonitis are treated
with empiric antibiotics covering both gram-positive
and negative organisms.
➢ We repeat the cell count and culture after three days of
empiric therapy.
➢ If there is improvement in cell count and clinical status
after three days and cultures continue to show no
growth, we continue either vancomycin or a first-
generation cephalosporin for a total of two weeks
➢ The Differential diagnosis for infectious causes of
culture-negative peritonitis includes mycobacterial and
fungal pathogens, Nocardia, and Legionella.

16. Indications for catheter removal
➢ Refractory peritonitis, defined as peritonitis that does not respond
to appropriate antibiotics within five days.
➢ Relapsing peritonitis, defined as a repeat episode of peritonitis
within four weeks of completion of an antibiotic course. The repeat
episode is caused by the same organism that caused the initial
episode or follows an episode of culture-negative peritonitis. We
may also remove the catheter if the patient develops a repeat
episode of peritonitis with the same species within two months of
completion of an antibiotic course
➢ Fungal or mycobacterial peritonitis.
➢ Peritonitis occurring in association with intra-abdominal
pathology, such as an abscess, perforation, or infarcted bowel.
➢ Culture-negative peritonitis with persistent symptoms and high
peritoneal white blood cell count.

17. Peritoneal Catheter Exit-Site and Tunnel Infection
Peritoneal catheter exit-site infection (ESI) represents an
important risk factor for peritonitis and frequently
requires catheter removal and replacement, especially
after its recurrence
Prophylactic measures:
➢ Cleansing the exit site with a sterile antiseptic solution
➢ Application of a topical antibiotic (mupirocin or
gentamicin) and Sterile gauze
➢ Immobilization of the catheter
➢ Phand hygiene, aseptic technique in any dialytic
maneuver, and appropriate provision of antibiotics
and/or transfer set change following touch
contamination

18. Exit-site score system. Infection should be
assumed with a cumulative exit-site score of 4 or greater

19. Risk factors associated with development of ESI
➢Poor competency of exit-site care
➢Catheter mobilization
➢Catheter pulling-out injury
➢Mechanical compression of the catheter
by a waist belt
➢Swimming
➢Presence of pets during exchanges
➢Compression of the exit site by a
peritoneal dialysis catheter bag

20. The causative agents
➢ Most infections are still caused by gram-
positive organisms, the percentage caused
by Staphylococcus aureus appears to have
decreased with increases in other gram-
positive organisms and gram-negative
organisms
➢ In addition, several studies have reported
infection caused by uncommon organisms
such as atypical mycobacteria, non-
diphtheria Corynebacteria,and Burkholderia
cepacia

21. TREATMENT
➢ We agree with the 2017 International
Society for Peritoneal Dialysis (ISPD)
guidelines that all exit-site infections
(ESIs) with or without tunnel involvement
should be treated with antibiotics .
➢The initial treatment of exit-site and
tunnel infections is the same.

22. Empiric therapy
➢ Gram-positive organism – A first-generation oral cephalosporin (such
as cephalexin) or a penicillinase-resistant penicillin (such as dicloxacillin).
We use clindamycin if the patient is allergic to penicillin.
➢ Gram-negative organism – Ciprofloxacin .If the patient cannot take
ciprofloxacin, we use intraperitoneal ceftazidime. Ceftazidime may be
given continuously (500 mg/L loading dose followed by 125 mg/L in all
subsequent exchanges) or intermittently (1000 to 1500 mg in one
exchange daily). For intermittent dosing of intraperitoneal antibiotics, the
dwell time should be at least six hours to allow adequate absorption
➢ Gram stain results unavailable or inconclusive – Both a first-generation
oral cephalosporin or a penicillinase-resistant penicillin
and ciprofloxacin . We use clindamycin if the patient is allergic to
penicillin .If the patient cannot take ciprofloxacin, we use
intraperitoneal ceftazidime as described above for gram-negative
organisms

23. Treatment duration and follow-up
➢ Antibiotic therapy is adjusted depending on
culture and sensitivity results.
➢ In addition, we re-evaluate clinically after one
week.
➢ If the patient is improving, we continue
antibiotics until the infection is completely
resolved and for a minimum of two weeks for
all organisms except Pseudomonas.
➢ If the patient has a Pseudomonas infection, we
treat for a minimum of three weeks.

24. Noninfectious complications of peritoneal dialysis
complications
Some of the noninfectious complications
are due to increased intra-abdominal
pressure:
➢ leaks (including hydrothorax or
pleuroperitoneal leaks)
➢Hernia formation
➢ local edema
➢Back pain
➢Gastrointestinal problems, such as
gastroesophageal reflux and delayed
gastric emptying

25. Cont.
➢Complications of CAPD/CCPD not
specifically related to intra-abdominal
pressure include:
➢ Hemoperitoneum
➢ Pain on infusion of dialysate
➢ Electrolyte imbalances
➢ Ultrafiltration failure

26. GASTROESOPHAGEAL REFLUX DISEASE AND DELAYED
GASTRIC EMPTYING
➢ Nausea, vomiting, a sensation of fullness, and epigastric discomfort are
commonly reported by patients on continuous ambulatory peritoneal
dialysis
➢ Gastrointestinal complaints, such as nausea and fullness, occur in as
many as 20 to 40 percent of CAPD patients, while approximately 14
percent report frequent vomiting .
➢ However, a paucity of data exists concerning the relationship between
these symptoms and the presence of gastroesophageal reflux disease
(GERD) or delayed gastric emptying (gastroparesis)
➢ There are many potential causes of such symptoms, including uremia,
medication-induced gastroenteritis, gastritis, and peptic ulcer disease.
➢ However, if the patient is well dialyzed (ie, has an adequate Kt/V) and
specific gastrointestinal causes of the symptoms have been excluded,
persistent upper gastrointestinal symptoms should prompt consideration
of GERD or gastroparesis
➢ Medical management of both GERD and gastroparesis is similar to that in
patients not on dialysis. Successful treatment of these problems is
important since, if left untreated, they have a significant adverse effect
upon the well-being and nutritional status of peritoneal dialysis patients.

27. Delayed gastric emptying
➢ Delayed gastric emptying is relatively common among
CAPD patients, including those without diabetes. In a
few small studies, delayed gastric emptying of solids
and liquids has been detected in approximately 50
percent of both symptomatic and asymptomatic
patients undergoing peritoneal dialysis .
➢ Normal gastric emptying results have been noted when
the peritoneal cavities are drained, thereby suggesting
that a mechanical or neurogenic mechanism triggered
by the presence of intra-abdominal fluid retards gastric
emptying

28. BACK PAIN
➢ Increased mechanical stress on the lumbar spine is common among
patients on continuous ambulatory peritoneal dialysis (CAPD); this is due,
in part, to the tendency of patients to assume a more lordotic position
because of increased intra-abdominal pressure .Some patients may also
have poor abdominal muscle tone, resulting from previous surgeries or
poor physical conditioning. These effects increase the mechanical stress
on the lumbar spine, thereby causing back pain or sciatica .
➢ Underlying degenerative disk disease, facet joint disease, and
osteoporosis may further exacerbate the back pain .
➢ Treatment — Other than general therapeutic measures, the treatment of
lower back pain in CAPD patients may include decreasing the dialysate fill
volume. However, since adequate dialysis must be maintained, changing
to continuous cycler peritoneal dialysis (CCPD) may be beneficial as
larger fill volumes may be tolerated when the patient is supine. In those
whose back pain is severe, transfer to hemodialysis may be necessary if
adequate clearance on CCPD cannot be achieved

29. PLEURAL EFFUSION DUE TO PLEUROPERITONEAL LEAK
➢ The development of a pleural effusion
(hydrothorax) in a patient on continuous
peritoneal dialysis may be due to systemic
volume overload, heart failure, or a local
pleural process.
➢ The presence of a pleural effusion without
other signs of heart failure or of peripheral
edema, particularly if the effusion is only right
sided, should prompt a search for a
pleuroperitoneal communication.
➢ The right side is more commonly affected than
the left,

30. Management
➢ The treatment of acute hydrothorax due to pleuroperitoneal leaks
depends upon the acuity and severity of the patient's symptoms
and the need and/or desire to continue with peritoneal dialysis as
a treatment modality.
➢ In most cases, simply draining the peritoneal cavity and avoiding
overnight (supine) dwells is sufficient. If the leak is small and the
patient has adequate residual function to permit intermittent
dialysis (eg, nocturnal peritoneal dialysis), peritoneal dialysis can
be continued.
➢ Chemical pleurodesis may be offered to the patient with recurrent
pleural effusion, unresponsive to conservative measures, who
needs and/or desires to continue with peritoneal dialysis.
➢ video-assisted thoracoscopic pleurodesis or repair may also be an
option for patients who failed conservative managemen

31. PAIN ON DIALYSATE INFUSION
This complaint is thought to be caused by:
➢ The acidic pH (pH 5.2 to 5.5) of
conventional lactate dialysate
➢Poor catheter position (such as abutting
against the bowel wall or peritoneal
cavity surfaces)
➢The dialysate temperature
➢High glucose concentration of hypertonic
dialysis solutions

32. Treatment
Treatment of infusion pain includes the following
measures, to be utilized in descending order:
➢ Neutralization of the solution by injecting sodium
bicarbonate into the bag prior to infusion (2 to 5 mEq/L)
➢ Slowing the rate of infusion
➢ Injection of local anesthetics into the dialysis solution
before infusing (1 percent lidocaine at 50 mg/exchange)
➢ Incompletely draining the fluid after a dwell period
➢ Catheter replacement
➢ Discontinuation of peritoneal dialysis

33. ELECTROLYT ABNORMALITIES
➢Hypokalemia
➢ 10 to 35 percent of patients on continuous
peritoneal dialysis require potassium supplements
Cellular uptake of potassium, prompted by the
intraperitoneal glucose load with subsequent
insulin release, and bowel losses may also play a
role in the hypokalemia observed in peritoneal
dialysis patients
➢ For stable chronic outpatients, liberalization of dietary potassium restriction and, when
needed, oral potassium replacement (usually 20 mEq/day, based upon individual patient
serum potassium determinations) are usually successful treatments for hypokalemia.
Potassium-sparing diuretics like spironolactone may also be effective in the peritoneal
dialysis patient with chronic hypokalemia with appropriate surveillance of serum
potassium levels . Intraperitoneal potassium may also be administered acutely if critical
hypokalemia exists

34. Cont.
➢Magnesium
➢ Hypermagnesemia, a common finding in peritoneal dialysis
patients, is due to positive magnesium balance resulting from
renal failure and the relatively high dialysate magnesium
concentration
➢ Hypermagnesemia suppresses PTH levels, thereby contributing to
adynamic bone disease in peritoneal dialysis patients
➢ Multiple factors can affect plasma magnesium concentration
including diet, nutritional status, albumin levels, medications like
proton pump inhibitors, and dialysis prescriptions
➢ A large cohort study of 10,692 incident peritoneal dialysis patients
beginning peritoneal dialysis found that 18 percent of patients had
a serum magnesium level <1.8 mg/dL, 21 percent had a
magnesium level of 1.8 to 2.0 mg/dL, and only 19 percent had a
level ≥2.4 mg/d

35. Hemoperitoneum
➢ Hemoperitoneum is mainly observed in
female PD patients in the reproductive age
➢ Rupture of ovarian corpus luteum cysts
➢ Acute catheter insertion
➢ Bleeding following omentectomy or other intra-
abdominal surgery
➢ Heavy physical activity
➢ Coagulopathy or anticoagulant therapy
➢ Trauma to the abdomen or the catheter
➢ Pancreatitis

36. ➢ PD effluent hematocrit >2 % suggests an
intraperitoneal pathology, thus deserving extensive
diagnostic studies, surgical consultation, and
consideration of laparoscopy or laparotomy .
➢ The type and urgency of treatment of hemoperitoneum
depend on its cause.
➢ Heparin may be added bloody dialysate (250–500 units
per liter) to prevent catheter obstruction by blood clots.

37. Abdominal Hernias
➢ The incidence of hernias is higher in the young
children than in adult
➢ PD patients Hernias can be incisional,
umbilical, or inguinal
➢ Almost all hernias must eventually be repaired
surgically.
➢ Prior to and 1–2 weeks following surgical
correction,dwell volume should be reduced by
up to 50 % and PD performed overnight in
recumbent position, avoiding daytime dwells