USAGE OF PARAMEDIAN APPROACH FOR CONTINUOUS AMBULATORY PERITONEAL DIALYSIS CATHETER INSERTION TECHNIQUE AND COMPLICATION

Objective: This study aims to review the usage and complication of paramedian approach for CAPD catheter insertion. Material & Methods: This is a retrospective study. All ESRD patients ongoing CAPD at the Dialysis Clinic of Zainoel Abidin General Hospital in Aceh, Indonesia between January 1, 2009 and December 31, 2018 were included in the present study. Complication outcomes included mechanical and infectious complications are documented and reviewed. Results: A total of 190 ESRD patients had been performed CAPD catheter insertion using paramedian approach in this period. Out of these patients, complication occurred in 31 cases (16.32%). All the complication that occurred in this study are 5 cases of leakage (2.63%), 9 cases of infection (4.74%), 8 cases of drainage problem (4.21%), 9 cases of malposition (4.74%), and no case of bowel perforation. From total of 9 cases of infections, 1 patient had peritonitis from the catheter insertion. The other infection was exit site infection. Conclusion: CAPD catheter insertion using paramedian approach is safe with low complication rates. It could decrease post-operative complications and can be recommended for CAPD catheter insertion technique due to its safety.

Negative-pressure wound therapy is effective for peritoneal dialysis catheter exit-site management in the early postoperative period

Peritoneal dialysis (PD) catheter exit-site care is critically important for the prevention of catheter-related infections (CRIs) and subsequent peritonitis. The postoperative management of the site is particularly essential because it has an open wound that is always adjacent to a PD catheter tube. This study aimed to examine the effectiveness of negative-pressure wound therapy (NPWT) for postoperative PD catheter exit sites. Thirty patients with end-stage renal disease who underwent simultaneous PD catheter insertion and exit-site formation were randomly assigned to receive NPWT (NPWT group) or conventional dressing (non-NPWT group) for the first seven postoperative days. The exit-site scores on the seventh postoperative day was lower in the NPWT group than in the non-NPWT group (p = 0.0049). Analysis of variance F statistic for the effect of NPWT over 180 days was highly significant (11.482595, p = 0.007). There were no statistically significant differences between the time to first CRI and PD-related peritonitis between the two groups. There was one case of CRI with relapsing peritonitis and catheter loss in the non-NPWT group. These findings demonstrate the association between NPWT and low exit-site score. NPWT can be recommended for the management of PD catheter exit sites in the early postoperative period.

Risk Factors of Catheter-Related Infection in Patients Undergoing Hemodialysis Using Double Lumen Catheter at Dr. M. Djamil Hospital Padang

Background. Chronic kidney disease (CKD) is a terminal disease requiring hemodialysis. Hemodialysis requires vascular access using a double lumen catheter (DLC). However, the use of DLC may increase complications mainly infection, either infection of exit site or bloodstream. This study is aimed to seek risk factors contributing to the incidence of central catheter-related infections in CKD patients with DLC undergoing HD at Dr. M. Djamil Hospital, Padang. Methods. This study is a prospective study on patients undergoing HD at Dr. M. Djamil Hospital, Padang. This study using consecutive sampling technique. Data were analyzed using SPSS version 25.0. Results. This study involved 40 CKD patients undergoing HD. Majority of the samples had bloodstream infections (67.5%). Clinical manifestations of purulent secretion, duration of catheter used, and hypoalbuminemia had significant differences in the incidence of DLC infection based on bloodstream infection and exit site infection (p<0.05). The most common bacterial found was Pseudomonas aeruginosa (22.5%) which was sensitive to ceftazidime, cefepime, meropenem, amikacin, gentamicin, ciprofloxacin. Conclusion. Factors contributing to the incidence of DLC-related infections at Dr. M. Djamil Hospital are duration of catheter use and hypoalbuminemia. Pseudomonas aeruginosa is the most common cause of DLC-related infections.

Peritoneal Vicenza “Short” Catheter Outcomes and Comparison with International Society for Peritoneal Dialysis Guidelines

<b><i>Introduction:</i></b> A well-functioning peritoneal catheter is key to success of peritoneal dialysis (PD). The Vicenza “short” catheter is a modified Tenckhoff catheter with a shorter intraperitoneal segment. The aim of this study was to evaluate the incidence of catheter-related complications and catheter survival rate using the Vicenza “short” catheter, according to the goals suggested by the International Society for Peritoneal Dialysis (ISPD) guidelines. Second, we compared insertion techniques used in our center. <b><i>Methods:</i></b> This is a retrospective cohort, single-center study analyzing incident PD patients undergoing Vicenza “short” peritoneal catheter placement between January 1, 2015, and December 31, 2019. As clinical outcomes, we evaluated catheter patency at 12 months, exit-site/tunnel infection and peritonitis within 30 days of catheter insertion, visceral injury, or significant hemorrhage during the procedure, in accordance with ISPD guidelines. <b><i>Results:</i></b> The percentage of patency at 12 months for all catheter insertion methods was 88.91%, and the percentage for laparoscopic placement was 93.75%. The exit-site/tunnel infection and peritonitis occurring within 30 days of catheter insertion were, respectively, 0.75% and 2.2%; the visceral injury leading to intervention was 0.75%. We did not have any case of significant hemorrhage. All results were in line with ISPD guidelines. <b><i>Conclusion:</i></b> We conclude that the Vicenza “short” catheter is a suitable device for peritoneal access. The implantation procedure is safe and easy to perform, and both nephrologists and surgeons can do it. A confident use and a proper implantation of the Vicenza “short” catheter help achieve the clinical ISPD goals for the PD access procedure in terms of catheter survival and complication rates.

COVID 19 Pneumonia and a Rare Form of Fungal Peritonitis in a Patient Survivor on Peritoneal Dialysis

Peritoneal dialysis (PD) related peritonitis is usually caused by bacteria, but viruses and fungi could also affect the peritoneal membrane and cause cloudy effluent with negative bacterial cultures. We present a case of a PD patient who survived fungal peritonitis caused by Geotrichum klebahnii (March 2015) and COVID-19 pneumonia (April 2021) with peritonitis probably caused by the SARS-CoV-2 virus. The fungal peritonitis followed one episode of exit-site infection and two episodes of bacterial peritonitis treated with a wide-spectrum antibiotic. The patient’s PD catheter was removed immediately upon the diagnosis of fungal peritonitis, and an antifungal treatment was continued for 3 weeks after catheter removal. The new peritoneal catheter was reinserted 8 weeks after complete resolution of peritonitis, and the patient continued treatment with PD. The patient developed severe Covid-19 pneumonia with a sudden appearance of cloudy peritoneal effluent. There was no bacterial or fungal growth on the effluent culture. A PCR test for SARS-CoV-2 in peritoneal effluent was not performed. The peritoneal effluent became transparent with the resolution of the severe symptoms of Covid-19 pneumonia.

948. Ventricular Assist Device Infection due to Non-tuberculous Mycobacteria Leading to Successful Heart Transplantation: A Case Report and Literature Review

Background A 59-year-old man with acute myelogenous leukemia and matched allogeneic hematopoietic stem-cell transplant and non-ischemic cardiomyopathy requiring a left ventricular assist device (LVAD; HeartMate II™) was admitted after the spontaneous rupture of an abdominal fistula in his lower abdomen, and cloudy discharge from the driveline (DL) exit site for months. Figure 1 Denied systemic symptoms but had leukocytosis. CT scan of the abdomen revealed soft tissue enhancement around the LVAD DL Figure 2. Cultures from DL discharge grew Mycobacterium chelonae. He underwent incision and drainage (I&D) of the abdominal fistula, with unroofing of the tissue over the DL. Antimicrobial course is summarized in Table. He was thought to be an appropriate heart transplant candidate one month later. Cultures from the LVAD sites were negative. He completed antimicrobials for 10 weeks after transplant. 32 months after heart transplant he has no signs of M. chelonae infection. Figure 1. Driveline exit site with scant cloudy discharge and a shallow 3 x 2-centimeter open lesion inferior to the umbilicus. Driveline track in dotted line. Figure 2. CT scan of the abdomen revealed soft tissue enhancement (red arrows) around the LVAD driveline in the lower abdomen. Methods We performed a literature review of all published cases involving Non-Tuberculous Mycobacteria (NTM) and LVADs. Collected: date, sex and age, onset, organism, type of LVAD, transplant, surgical debridement, antimicrobials, outcome. Results A total of 11 patients with LVAD infection due to NTM have been described in the literature. Four cases of NTM LVAD infection culminated in heart transplantation. Cases are summarized in Table 1. All transplanted cases had an indolent presentation and driveline discharge, without systemic symptoms. All underwent I&D and/or de-roofing of the driveline and were treated with at least two active antimicrobials for an extended course ranging from 4 months and up to 17 months after transplant. All cases did well from the infection standpoint. One died within 12 months from transplant rejection. Conclusion Treatment with a combination with at least two active agents is recommended and continued for many months. Effective surgical debridement of affected tissue and unroofing of the driveline beyond the affected velour, along with the removal of the infected device at the time of cardiac transplant, is key to success. Disclosures Susan J. Rehm, MD, Lilly (Individual(s) Involved: Self): Shareholder; Merck (Individual(s) Involved: Self): Shareholder; Pfizer (Individual(s) Involved: Self): Shareholder

Medicazione a base d’argento nella gestione dell’emergenza cutanea

Introduction: Exit-site (ES) and tunnel infections are the main infectious complication in peritoneal dialysis (PD); they also are risk factors for the development of peritonitis, for catheter removal and for dialysis drop-out. Up to now, besides the recommendations of the Guidelines there is no uniformity, nor on the classification, nor on the treatment strategies of the infected ES. Recent experiences are reported with alternative types of dressings that aim to reduce the incidence of ES infection and consequently of the subcutaneous tunnel. Methods: The Tuscan group conducted a retrospective observational study of 10 patients on PD who, showing signs of a suspected but not ascertained infection (negative microbiological culture), such as redness, edema, secretion, scab, had been medicated with silver-ions releasing Exit-Pad Ag. The aim was to evaluate and classify the evolution of ES lesions, in order to confirm the preventive efficacy of the silver-ions releasing dressing compared to the traditional ones. Results: After 4 weeks of treatment with Exit Pad Ag maintained in situ for 72 h, 6 patients no longer had any signs of inflammation. In 2 cases, several weeks of treatment were necessary to achieve a complete recovery, while in 2 other cases the signs of inflammation became negative in less time (2 weeks, 1 week). Conclusions: With the utilization of an alternative dressing such as Exit-Pad Ag on PD patients showing early signs of inflammation, the onset of a true infection can be prevented, with a progressive improvement of the ES.

Clinical course of peritoneal dialysis-related peritonitis due to non-tuberculosis mycobacterium – A single centre experience spanning 20 years

Background: Peritoneal dialysis (PD)-related peritonitis caused by non-tuberculous mycobacteria (NTM) are difficult to diagnose, is associated with significant morbidity and mortality, and clinical course remains unclear. We determined the prevalence and clinical course of peritonitis caused by these organisms through our kidney registry over 20-year period. Method: We reviewed all patients with NTM peritonitis identified in our tertiary centre between July 2000 and July 2020. The demographic characteristics, microbiological and clinical outcomes were examined. Result: Among 27 patients identified, 20 patients presented with abdominal pain and all had cloudy peritoneal fluid. Twenty-one cases had concomitant exit site infection and 14 cases had prior antibiotic use. The majority of the cases are caused by Mycobacterium chelonae (37%) and Mycobacterium fortuitum (29.7%), with most being resistant to fluoroquinolones (59.3%) and cefoxitin (73.1%). They are all sensitive to amikacin otherwise. None of the cases achieve primary response at day 10 and 20 cases resulted in Tenckhoff catheter removal. Only two of them were able to resume PD. Eight patients died in our cohort. The presence of exit site infection, the use of prior antibiotics and topical disinfectants did not associate with a poorer outcome. Conclusion: NTM peritonitis remains difficult to treat and often with a delay in diagnosis. Refractory peritonitis with negative culture and a poor response to standard antibiotics should raise a possibility of NTM infection and prompt catheter removal and an expert with experience treating NTM infections should be consulted.