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.

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.

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.

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.

Effectiveness of a continuous interactive communication system for home care nursing assistance of peritoneal dialysis

Background The Japanese population is aging quickly. New methods of supporting peritoneal dialysis (PD) for elderly patients are essential if we are to increase the number of such patients. Methods We established a two-way communication system between a central hospital and stations for visiting nurses. Home care nurses provided physicians at the central hospital with clinical findings for patients undergoing assisted PD. We compared 11 patients undergoing PD assisted by home care nurses in continuous interactive communication with the central hospital (cases) with 11 patients undergoing unassisted PD who were matched by sex, primary disease, estimated glomerular filtration rate at the start of PD, and age at the start of PD (controls). The variables compared were hospitalization due to heart failure, exit-site infection, peritonitis, and the composite of these causes during a 1-year period. In addition, we compared patient clinical factors between groups. Results Although differences in the number of hospitalizations attributable to exit-site infection, peritonitis, and heart failure were not significant, the difference in the number of hospitalizations attributable to a composite of these causes was significant. Exit-site scores were significantly better in the case group than in the control group. Conclusions PD assisted by home care nurses using an established continuous interactive communication system was associated with significantly better exit-site scores. Fewer cases than controls were hospitalized.

Repeat exit site infection in peritoneal dialysis patient with polycythemia vera – a case report

Background Infectious complications of peritoneal dialysis (PD) remain a common cause of catheter loss and discontinuation of PD. Exit site infection (ESI) constitutes a significant risk factor for PD-related peritonitis and determination of predisposing states is relevant. We here present a case of repeat ESI due to Pseudomonas aeruginosa in a PD patient with skin changes in the course of polycythemia vera (PV). Case presentation A 73-year-old PD patient with chronic kidney disease secondary to renal amyloidosis and ankylosing spondylitis, presented to the nephrology unit with signs of ESI. In 2006 he was diagnosed with PV and since then has was successfully treated with hydroxyurea; however, he reported recurrent episodes of developing skin nodules in the course of the disease. Exit site swab yielded Pseudomonas aeruginosa and the infection developed in the ulcerated PV nodule that appeared in exit site 2 weeks earlier. Patient was treated with intraperitoneal amikacin and oral ciprofloxacin, however, due to neurological complications, the treatment had to be interrupted and finally catheter was removed. Similar episode of ESI with Pseudomonas aeruginosa developed in the patient two years earlier and also required catheter removal. Conclusion This is the first case report demonstrating the development of ESI on the polycythemia vera skin lesion in this area. Skin manifestations of PV might be a predisposing factor to ESI in PD patients.

Clinical and microbiological factors predicting outcomes of nonfermenting gram-negative bacilli peritonitis in peritoneal dialysis

Peritonitis due to gram-negative bacilli (GNB), particularly nonfermenting GNB (NF-GNB), is a serious complication of peritoneal dialysis with a low resolution rate. Beyond the patient’s condition, microbiological properties such as antimicrobial resistance, biofilm production and other virulence factors can explain the poor outcomes. This study aimed to evaluate the influence of patient condition, microbiological characteristics, including biofilm production, and treatment on peritonitis outcome. We reviewed the records of 62 index episodes caused by NF-GNB that occurred between 1997 and 2015 in our center. The etiologies were species of Pseudomonas (51.6%), Acinetobacter (32.2%), and other NF-GNB (16.1%). There was a high (72.9%) proportion of biofilm producer lineages. The in vitro susceptibility rate of Pseudomonas spp. to amikacin, ciprofloxacin, and ceftazidime was significantly greater than that of Acinetobacter spp. and other species; however, there was a similar low resolution rate (< 45%) among the episodes attributable to them. Preexisting exit-site infection was independently associated with nonresolution. No other factor, including biofilm production, was associated with the outcome. The higher in vitro susceptibility of Pseudomonas compared to other NF-GNB that presented a similar resolution rate suggests that bacterial virulence factors such as biofilms can act in concert, thereby worsening the outcome.

Management of peritoneal dialysis Mycobacterium abscessus exit-site infection: A case report and literature review

Peritoneal dialysis associated infections are common and associated with high morbidity and mortality, if not treated in a timely manner. Mycobacterium abscessus is an uncommon pathogen in peritoneal dialysis associated infections, but is resistant to standard antimicrobial therapies used. Here we present a case of a 56 year-old male with end stage kidney disease on peritoneal dialysis for 7 years who developed a Mycobacterium abscessus exit-site infection. Peritonitis and peritoneal dialysis catheter tunneled line infections were ruled out and he was treated with linezolid, amikacin, and azithromycin. He required peritoneal dialysis catheter removal and hemodialysis conversion. Antibiotics were de-escalated based on erm inducibility and antibiotic sensitivities. Linezolid and amikacin were continued for approximately 7 total weeks, with complete resolution of the infection. Further research is needed to refine challenges in the management of Mycobacterium abscessus exit-site infections, including risk factors for development of Mycobacterium abscessus, optimal selection of empiric antibiotic therapies, duration of antibiotics, and peritoneal dialysis catheter re-insertion timing.

Does minimally invasive approach reduce risk of infection after ventricular assist device implantation?

Background: We analyzed patients with left ventricular assist device (LVAD) related and specific infection, and aimed to determine whether surgical technique implantation affect the frequency of infection. Methods: We retrospectively analyzed the data of 99 patients who received LVAD at our department between June 2013 and June 2019. Patients were divided into two groups according to the surgical technique. Group A ( n = 58) was conventional sternotomy (CS) and group B ( n = 41) was on-pump minimally invasive left thoracotomy (MILT). Demographics, preoperative risk factors, LVAD infections, surgical incision site, driveline site, and outcomes were compared between these two groups. Results: Mean follow up time was 589 ± 480 (31–2171) days. Infection was detected in 34% (41/99) of LVAD patients. Admission to emergency department and intensive care unit (ICU) in last 6 months were significantly higher in MILT group. There was no difference between the two groups in terms of driveline exit site infection (CS: 28%, MILT: 27%) ( p > 0.05). Seven (17%) patients had infection in the thoracotomy incision site area in the MILT group. The rate of ICU hospitalization in the last 6 months was seen as the only independent risk factor increasing the frequency of infection (R = 0.30; p = 0.016). Survival analysis at 60 days, 1 year and 2 years showed no difference between the two groups ( p = 0.09). Conclusions: Despite advances in pump technology and surgical technique, infection is still an important cause of mortality and morbidity.

MO786HEPARIN VERSUS SODIUM BICARBONATE CATHETER LOCK SOLUTION: AN ALTERNATIVE LOCK HEMODIALYSIS CATHETER?

Background and Aims Infections and thrombosis of central venous catheter (CVC) in hemodialysis patients are the major causes of catheter loss resulting in hospitalization and increased costs. Interdyalitic catheter lock solutions, usually heparin, avoid these complications. Among the many, sodium bicarbonate has been proved as effective and safe catheter lock solution due to its antimicrobial and antithrombotic properties. The aim of this study was to compare the efficacy of two different CVC lock solution: sodium heparin versus sodium bicarbonate, to prevent catheter–related thrombosis and infection in hemodialysis patients Method They were enrolled, in a 12 months case-control study, 17 hemodialysis patients with tunneled hig-flux CVC (femoral or internal jugular). Each patient was evaluated in its common treatment for CVC dysfunction (Qb, CVC that works in reverse branches during the hemodialysis session, use of urokinase or extra lock with sodium heparin or 4% citrate) and infection (WBC count, C reactive protein -CRP, bloodstream culture, exit-site infection -ESI) during standard sodium heparin CVC lock solution (hep-lock), for the first 6 months, and then, during sodium bicarbonate lock solution (10 mEq/10 ml, bic-lock) for following 6 months. aPTT, PLT, Hct and albumin are also montly evaluated. Type and anticoagulant dose during hemodialysis sessions were unchanged over the study as well as any antiplatelet/anticogulant home therapy. Results Fifteen patients on 17 completed the study and the main results are reported in table 1. There were no significant differences between patients on demographics and number of catheter days treatments for both study periods. The blood flow was similar in either study phases and stable during the hemodialysis sessions (Qb 225±13 ml/m’ at 2-hours vs 225±15 ml/min at start of dialysis), even the use of reverse branches was similar. Hep-lock showed a lower usage of extra lock drug in comparison with Bic-lock (0,4% vs 3,1%, p&lt;0,05), data confirmed also for Urokinase (1,9% vs 3,4%, p=0,274). None bloodstream are registred while ESI and WBC count show no significant differences between two study periods. No HD catheter was loss during the study due to thrombosis or infection. Finally, Hct, CRP and Albumin was found slightly lower on Bic-lock phase. Conclusion There is no CVC ideal lock solution and although sodium bicarbonate is inexpensive and readily avalaible our data shows better CVC performances with sodium heparin.