Continuous Ambulatory Peritoneal Dialysis Associated with Peritonitis in Older Patients John Valente, Mo, William Rappaport, MD, Tucson, Arizona Our recent experience with peritonitis in patients over the age of 55 years undergoing continuous ambulatory peritoneal dialysis between 1979 and 1989 is reviewed. Thirty-seven patients in this age group underwent Tenckhoff catheter insertion. Severe catheter-related peritonitis occurred at a rate of 1.41 episodes per patient per year. Overall, there were 61 episodes of peritonitis in 31 patients, with an overall mortality rate of 7%. When systemic signs of sepsis were present, this rate rose to 25%. All deaths were associated with fungal, pseudomonal, or polymicrobial infections. Management of these infections may require aggressive measures including repeated laparotomy for control of sepsis.
ontinuous ambulatory peritoneal dialysis (CAPD) is considered by many the treatment of choice for C chronic renal failure in the elderly. Literature addressing the complications of peritoneal dialysis indicates an increased risk in elderly and diabetic patients but attributes the increased mortality in elderly patients to the expected death rate in this age group [1-3]. Indeed, the excellent results achieved in the elderly in the United Kingdom supported the role of CAPD in patients over 55 years of age[4,5]. The challenges associated with caring for elderly patients with renal failure and CAPD-related peritonitis prompted us to review this problem in our patients.
ditions, i.e., diverticulitis. Catheter insertion was performed in the operating room either under local or general anesthesia. Catheter position was verified radiologically prior to closing. After surgery, all patients were instructed and observed over a 1- to 3-month period by experienced dialysis nurses. The criteria for diagnosing catheter-related peritonitis included all of the following: (1) abdominal pain and tenderness, (2) no other source of peritonitis, (3) elevated white blood cell count (WBC) in the peritoneal effluent (> 100 WBC/mm3), and (4) isolation of bacteria from the peritoneal fluid sent for culture. Up until 1988, all patients with catheter-related peritonitis were hospitalized and received both intravenous as well as intraperitoneal lavage with appropriate antibiotics. Since 1988, selected patients have been treated on an outpatient basis, again receiving both systemic (oral or intravenous) as well as intraperitoneal antibiotics. In addition, patients with polymicrobial infections underwent an aggressive work-up to exclude a hollow viscous source of peritonitis. If patients did not respond with clinical improvement of their peritonitis within 48 hours, the catheter was removed without formal abdominal exploration. Laparotomy was recommended only after removal of the catheter failed to control the sepsis. All documented episodes of CAPD-related peritonitis were examined with respect to presenting symptoms, vital signs on admission, WBC counts, culture results, WBC counts in the peritoneal fluid, catheter removal, and eventual patient outcome. Risk factors for morbidity and mortality from CAPD-related peritonitis in the elderly were identified. Statistical evaluation was performed using chisquare analysis and Student's t test.
RESULTS Thirty-seven patients with a mean age of 65.1 years underwent Tenckhoff catheter insertion. Twenty-five men and 12 women were followed for an average of 3.5 42.1 years. The causes of the renal failure are outlined in MATERIAL AND METHODS A retrospective chart review of all CAPD patients Table I. Overall, there were 61 episodes of peritonitis in 31 aged more than 55 years at the time of Tenckh0ff catheter insertion was performed during the period from Janu- patients, for a rate of 1.41 episodes per patient per year. ary 1979 to January 1989 at the University Medical The average time from catheter insertion to the first Center and the Veterans Administration Medical Center. episode was 1.8 years. The microbiology of these infecPatients were chosen for peritoneal dialysis if they were tions is shown in Table II. The most frequent isolate was reliable and could manage the catheter, had no history of Staphylococcus epidermidis. During the study period, abdominal surgery that would limit the flow of the dialy- there were only two episodes of non-catheter-related perisate, and had no history of any inflammatory bowel con- tonitis caused by a ruptured appendix and a perforated sigmoid colon, respectively. Both patients presented with From the Departmentof Surgery,UniversityMedicalCenter,Tucson, diffuse abdominal rigidity and were operated on shortly Arizona. after admission. Requests for reprints shouldbe addressedto WilliamRappaport, Sixteen episodes of peritonitis were associated with MD, 1501North CampbellAvenue,Tucson,Arizona85724. Manuscript submitted June 28, 1989, revised October 10, 1989, signs of systemic sepsis on admission. Eighty-one percent (13 of 16) in this group failed to respond to medical and acceptedOctober 17, 1989.
THE AMERICAN JOURNAL OFSURGERY VOLUME159 JUNE 1990 579
VALENTEAND RAPPAPORT
TABLE I
Causes of Renal Failure
Diagnosis
No. of Patients (%)
Diabetic nephropathy Hypertension Polycystlc kidney disease Glomerulonephritis Pyelonephritis Carcinoma*
19 (51) 6 (16) 5 (14) 5 (14) 1 (3) 1 (3)
Total
37 - -
" Bilateral nephrectomies for renal carcinoma.
TABLE lI
Microbiology of CAPD Peritonitis Organism
n
Staphylococcus epidermidis Escher/chia colt Enterobacter species Pseudomonas species Staphylococcus aureus Streptococcus species Polymicrobial Coccidioidomycosis Other gram-negative Other gram-positive
12 5 9 9 5 2 13 1 4 1
Total
61
TABLE 1II Morbidity Related to Microbiology of Infection
Infection
n
Sepsis
Catheter removed
Death
Polymicroblal Gram-negative Gram-positive Coccidioidomycosis*
13 27 20 1
7 (54%)* 5 (19%) 3 (15%) 1 (100%)
9 (69%)* 8 (30%) 4 (20%) 1 (100%)
2 (15%) 1 (4%) ,.. 1 (100%)
Total
61
16 (26%)
22 (36%)
4 (7%)
* p < 0.05.
TABLE IV
Frequency of Peritonitis In the General Population Undergoing CAPD
Author & Reference Swartz [ 1] Smith and Flanigan [6] Piraino eta/ [7'] Nissenson [3] Bullmaster at al [8] Robinson et al [9] FJnan and Guillou [ 10] Gloor eta/ [ 11] Brown eta/ [ 12] Total
580
Patients
Frequency of Peritonitis (patients/yr)
68 126 172 775 115 140 68 50 36
1.60 1.0S 1.03 1.50 t.30 1.14 1.06 2.40 2.00
1,550
1.39
THE AMERICAN JOURNAL OF SURGERY
management of their infection and required catheter removal versus only 19% (9 of 46) of episodes without sepsis (p
ontinuous ambulatory peritoneal dialysis (CAPD) is considered by many the treatment of choice for C chronic renal failure in the elderly. Literature addressing the complications of peritoneal dialysis indicates an increased risk in elderly and diabetic patients but attributes the increased mortality in elderly patients to the expected death rate in this age group [1-3]. Indeed, the excellent results achieved in the elderly in the United Kingdom supported the role of CAPD in patients over 55 years of age[4,5]. The challenges associated with caring for elderly patients with renal failure and CAPD-related peritonitis prompted us to review this problem in our patients.
ditions, i.e., diverticulitis. Catheter insertion was performed in the operating room either under local or general anesthesia. Catheter position was verified radiologically prior to closing. After surgery, all patients were instructed and observed over a 1- to 3-month period by experienced dialysis nurses. The criteria for diagnosing catheter-related peritonitis included all of the following: (1) abdominal pain and tenderness, (2) no other source of peritonitis, (3) elevated white blood cell count (WBC) in the peritoneal effluent (> 100 WBC/mm3), and (4) isolation of bacteria from the peritoneal fluid sent for culture. Up until 1988, all patients with catheter-related peritonitis were hospitalized and received both intravenous as well as intraperitoneal lavage with appropriate antibiotics. Since 1988, selected patients have been treated on an outpatient basis, again receiving both systemic (oral or intravenous) as well as intraperitoneal antibiotics. In addition, patients with polymicrobial infections underwent an aggressive work-up to exclude a hollow viscous source of peritonitis. If patients did not respond with clinical improvement of their peritonitis within 48 hours, the catheter was removed without formal abdominal exploration. Laparotomy was recommended only after removal of the catheter failed to control the sepsis. All documented episodes of CAPD-related peritonitis were examined with respect to presenting symptoms, vital signs on admission, WBC counts, culture results, WBC counts in the peritoneal fluid, catheter removal, and eventual patient outcome. Risk factors for morbidity and mortality from CAPD-related peritonitis in the elderly were identified. Statistical evaluation was performed using chisquare analysis and Student's t test.
RESULTS Thirty-seven patients with a mean age of 65.1 years underwent Tenckhoff catheter insertion. Twenty-five men and 12 women were followed for an average of 3.5 42.1 years. The causes of the renal failure are outlined in MATERIAL AND METHODS A retrospective chart review of all CAPD patients Table I. Overall, there were 61 episodes of peritonitis in 31 aged more than 55 years at the time of Tenckh0ff catheter insertion was performed during the period from Janu- patients, for a rate of 1.41 episodes per patient per year. ary 1979 to January 1989 at the University Medical The average time from catheter insertion to the first Center and the Veterans Administration Medical Center. episode was 1.8 years. The microbiology of these infecPatients were chosen for peritoneal dialysis if they were tions is shown in Table II. The most frequent isolate was reliable and could manage the catheter, had no history of Staphylococcus epidermidis. During the study period, abdominal surgery that would limit the flow of the dialy- there were only two episodes of non-catheter-related perisate, and had no history of any inflammatory bowel con- tonitis caused by a ruptured appendix and a perforated sigmoid colon, respectively. Both patients presented with From the Departmentof Surgery,UniversityMedicalCenter,Tucson, diffuse abdominal rigidity and were operated on shortly Arizona. after admission. Requests for reprints shouldbe addressedto WilliamRappaport, Sixteen episodes of peritonitis were associated with MD, 1501North CampbellAvenue,Tucson,Arizona85724. Manuscript submitted June 28, 1989, revised October 10, 1989, signs of systemic sepsis on admission. Eighty-one percent (13 of 16) in this group failed to respond to medical and acceptedOctober 17, 1989.
THE AMERICAN JOURNAL OFSURGERY VOLUME159 JUNE 1990 579
VALENTEAND RAPPAPORT
TABLE I
Causes of Renal Failure
Diagnosis
No. of Patients (%)
Diabetic nephropathy Hypertension Polycystlc kidney disease Glomerulonephritis Pyelonephritis Carcinoma*
19 (51) 6 (16) 5 (14) 5 (14) 1 (3) 1 (3)
Total
37 - -
" Bilateral nephrectomies for renal carcinoma.
TABLE lI
Microbiology of CAPD Peritonitis Organism
n
Staphylococcus epidermidis Escher/chia colt Enterobacter species Pseudomonas species Staphylococcus aureus Streptococcus species Polymicrobial Coccidioidomycosis Other gram-negative Other gram-positive
12 5 9 9 5 2 13 1 4 1
Total
61
TABLE 1II Morbidity Related to Microbiology of Infection
Infection
n
Sepsis
Catheter removed
Death
Polymicroblal Gram-negative Gram-positive Coccidioidomycosis*
13 27 20 1
7 (54%)* 5 (19%) 3 (15%) 1 (100%)
9 (69%)* 8 (30%) 4 (20%) 1 (100%)
2 (15%) 1 (4%) ,.. 1 (100%)
Total
61
16 (26%)
22 (36%)
4 (7%)
* p < 0.05.
TABLE IV
Frequency of Peritonitis In the General Population Undergoing CAPD
Author & Reference Swartz [ 1] Smith and Flanigan [6] Piraino eta/ [7'] Nissenson [3] Bullmaster at al [8] Robinson et al [9] FJnan and Guillou [ 10] Gloor eta/ [ 11] Brown eta/ [ 12] Total
580
Patients
Frequency of Peritonitis (patients/yr)
68 126 172 775 115 140 68 50 36
1.60 1.0S 1.03 1.50 t.30 1.14 1.06 2.40 2.00
1,550
1.39
THE AMERICAN JOURNAL OF SURGERY
management of their infection and required catheter removal versus only 19% (9 of 46) of episodes without sepsis (p
