Pathophysiology and prevention of peritonitis in peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
Peritonitis is one of the major complications of peritoneal dialysis and remains the primary reason why patients switch from peritoneal dialysis to hemodialysis . A review of the factors responsible for peritonitis in this setting and the modalities that can be used to reduce the frequency of this complication are presented in this topic review.
PATHOPHYSIOLOGY AND CAUSES
Peritonitis associated with peritoneal dialysis is most often due to contamination with pathogenic skin bacteria, with Staphylococcus epidermidis and Staphylococcus aureus accounting for the majority of cases. (See "Microbiology and therapy of peritonitis in continuous peritoneal dialysis".)
The intact peritoneum and the defense mechanisms of the mesothelium are probably the most important barriers to the development of peritonitis in peritoneal dialysis patients and play an important role in limiting the infection to the peritoneum, where peritonitis does develop. The incidence of systemic bacteremia in association with peritoneal dialysis peritonitis is extremely low (<1 percent), in contrast to the reported 30 percent with surgical peritonitis  and 39 to 76 percent of spontaneous peritonitis in cirrhotic patients with ascites [3,4].
A number of factors contribute to the development of peritonitis in patients on peritoneal dialysis, even when the patient is maximally skilled with the dialysis technique:
●The patient on continuous ambulatory peritoneal dialysis (CAPD) usually connects and disconnects from the transfer set many times a day and, therefore, must perform a large number of sterile exchanges per year; it would be naive to assume that bacterial contamination does not occur at times. In comparison, a patient on continuous cycling peritoneal dialysis (CCPD) or ambulatory peritoneal dialysis (APD) needs to connect or disconnect from the transfer set far fewer times, and, therefore, the peritonitis rate is generally lower than that in patients on CAPD. (See 'Different peritoneal dialysis systems' below.)
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- PATHOPHYSIOLOGY AND CAUSES
- Sources of contamination
- Exit-site infection
- Proper training
- Prophylactic antibiotic administration for procedures
- Y and double-bag systems
- Different peritoneal dialysis systems
- Different peritoneal dialysis solutions
- Staphylococcus aureus nasal carriage
- Treatment of catheter infections
- Secondary bacterial peritonitis
- Fungal peritonitis
- Catheter removal after renal transplantation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS