Characteristics of peritoneum after pentonitis in CAPD patients
Elzbieta Panasiuk, Bozena Pietrzak, Miroslaw Klos, Zofia Watikowicz
The disturbances in the diffusion transport and water ultrafiltration during CAPD were observed in patients with recurrences of peritonitis when compared to the group ofpatients without; however, these values were not significantly different between these groups at the beginning of the programme, in the group with recurrent peritonitis, some patients showed good diffusion transport despite the impairment of ultrafiltration, The assessment of the concentration of opsonizing substances in the peritoneal fluid at the beginning of CAPD, makes it possible to select patients with a high risk of recurrent peritonitis in further treatment.
Key wordsPeritoneal membrane, diffusion, ultrafiltration, peritonitis, risk of peritonitis
From the Department of Dialysis, Postgraduate Medical Center, Warsaw, Poland.
IntroductionThe properties of the peritoneum, especially its ability for diffusion and ultrafiltration of water , have a considerable effect on the efficiency of peritoneal dialysis, Preliminary assessment of these properties at the beginning of the CAPD programme enables the evaluation of the peritoneum as a dialyzing membrane. Checking these properties during the treatment helps to modify the course of further treatment (1-3). Since peritonitis, especially in its recurrent form, is one of the most serious complications of this method of dialysis, it may limit, in some patients, the efficiency of the treatment. The evaluation of the peritonitis risk at the beginning of CAPD based on the examination of the local peritoneal defense mechanisms may be useful for proper selection of patients for the CAPD programme (4-10). The influence of recurrent peritonitis on the indices of diffusion, ultrafiltration and local defense mechanisms of the peritoneum, have been retrospectively analyzed in order to find a test which, at the beginning of the programme, would provide a prognosis for the further course of CAPD.
Material and methodSeventeen patients aged 41.9 :t 11.9 years treated by CAPD for 18.9 :t 7.6 months (mean values), including 10 patients without a peritonitis during dialysis treatment (group I) and 7 patients with recurrences of peritonitis (frequency: I episode every 9.5 :t 2.1 patient months). The concentrations of IgG, C3 component of complement and fibronectin in the peritoneal fluid obtained from night exchanges were determined by a nephelometricmethod (11). Urea concentration wasdetermined by urease method, and creatinine by the picric acid method in a technicon SMA 60 autoanalyser. The determinations were made in the serum and in the peritoneal fluid obtained from a 4-hour exchange of dialysis fluid containing acetate as a buffer and glucose in a 1.5% concentration. In the case of urea and creatinine, peritoneal clearances (Cu, CcJ and the DIP index (DIP u, DIP cJ were calculated (2). In the same exchange of dialysis fluid the glucose absorption curve was determined. Glucose concentration in the peritoneal fluid was determined by the hexokinase method and expressed as percentage of the intraperitoneally infused amount. The determinations were made at the beginning of the CAPD programme, after peritonitis and 12 months of the treatment.
ResultsTable 1 shows the preliminary assessment of the diffusion ability of the peritoneum (C and DIP).
The results of clearances and DIP determinations at the beginning of CAPD did not differentiate patients without peritonitis (group I) from those with a history of recurrent peritonitis (group II). In our patients these parameters were within the range of low values, indicating the probability of modifying the dialysis technique in the following months.
In group II the recurrences of peritonitis had a significant effect on the indices of peritoneal diffusion ability, especially on the clearance values of the tested substances (Figure i) .
Table II shows an assessment of the peritoneal membrane's ability to ultrafiltration (glucose absorption curve) and creatinine DIP ratio at the occurrence of peritonitis. in the group of patients without peritonitis the glucose absorption curves, obtained at the beginning of CAPD and after 12 months, were normal.
In group II two subgroups were distinguished: lIa in which, despite abnormal ultrafiltration after an episode of peritonitis, an unchanged diffusion was observed and group lIb, in which serious disturbances of ultrafiltration were associated with an increase of the DIP cr ratio, indicating excessive permeability of the peritoneum.
Table III presents a retrospective evaluation of the concentrations of opsonizing substances in the peritoneal fluid depending on the frequency of peritonitis episodes. The preliminary determination of the concentration of opsonins in the peritoneal fluid in the patients without peritonitis have shown significantly higher values, as compared to those with peritonitis during the treatment.
DiscussionThe success of CAPD is due to the long term ability of the peritoneum to diffuse molecules and to ultrafiltrate, despite changes in the mesothelial cells resulting from the influence of the dialysate (12). It is believed (2) that routine determination of the DIP value for urea and creatinine and of the glucose equilibration curve, at the beginning and during the CAPD programme, could have a prognostic value for the further programme, especially in cases with a sudden fall of the residual renal function, andlor development of peritonitis. In our patients, the initial values of these parameters, determined according to other findings ( 1-3), did not differentiate patients with peritonitis during CAPD from those without it. The DIP values in our patients were lower than Twardowski ' s data (2) and could be due to the lower concentration of glucose in the dialysis solution used for our equilibration test, and to the probable differences in the individual properties of the peritoneum between various groups of patients . For these reasons, the results of diffusion and ultrafiltration studies were analyzed, in each case after an episode of peritonitis and in the 12th month of the treatment, and were compared with the initial values.
An episode of peritonitis in our patients was the main cause of a decrease of ultrafiltration, which is in agreement with other observations (3, 13-17) .Decreased ultrafiltration was associated with two types of changes of the DIP creatinine ratio. In certain patients previous peritonitis caused no change in the DIP creatinine value, while in the remaining cases peritoneal hyperpermeability for glucose and for creatinine was found. These patients required a relatively urgent transfer to haemodialysis after unsuccessful trials of change in the technique of peritoneal dialysis used routinely in case of reduced ultrafiltration.
It was recently demonstrated (4-10, 18) that the disturbances of local defensive mechanisms of the peritoneum, especially the low amount of opsonizing substances in the peritoneal fluid, pertained to frequent recurrences of peritonitis in certain patients. Our investigations proved that patients with recurrent peritonitis initially had low values of opsonins in the peritoneal fluid as compared to patients without inflammatory complications of the CAPO programme.
In the light of our observations it can be stated that monitoring in the peritoneal fluid the opsonins concentration, O/P of creatinine, and ultrafiltration capacity (glucose equilibration curve) at the beginning and during the CAPO may improve the programming of the treatment by CAPO, especially in the countries with limited availability of haemodialysis.
- Nikolakakis N, Rodger S, Goodship T. The assess ment of peritoneal function using a single hypertonic exchange. Perit Dial Bu111985; 5: 186.
- Twardowski Z, Nolph K, Khanna R, et at. Peritoneal equilibration test. Perit Dial Bu111987; 7: 138.
- Verger C, Celicout B. Peritoneal permeability and encapsulating peritonitis. Lancet 1985; 1: 986.
- Giacchino F, Rotunuo M, Pozzato M. Opsonisation capacity of plasma and peritoneal dialysate in CAPD patients. In: Maher J, etat. eds. Frontier in peritoneal dialysis. New York 1986: 569.
- Keane W, Peterson P. Peritonitis during continuous ambulatory peritoneal dialysis: the role of host defense mechanisms. Trans. ASAIO 1984; 30: 684.
- Keane W, Comty C, Verbrugh H. Opsonic deficiency of peritoneal dialysis effluent in continuous ambulatory peritoneal dialysis. Kidney Int. 1984; 25: 539.
- Keane W, Peterson P. Peritoneal host defense mechanism underlying peritonitis in CAPD patients. Perspectives in Perit Dia11986; 3: 2.
- KhannaR, KleinR, Vas, S. Fibronectin in the normal peritoneal fluids of patients on CAPD and during peritonitis. Perit Dial Bu111987; 7: 69.
- Lamperi S, Carozzi S. Prevention of peritonitis in continuous ambulatory peritoneal dialysis patients by intraperitoneal immunoglobulins. Nephrol Dial Transpl1987; 2: 454.
- Lamperi S, Carozzi S. Interferons, peritoneal macrophages and peritonitis in CAPD patients (Abstr). XXIV Congress EDTA-ERA, Berlin West 1987, 156.
- Tulczynski M. Laboratory methods of clinical diagnosis. PZWL, Warsaw 1972.
- Gotloib L, Shostack A, Barsella P. Continuous mesothelial injury and regeneration during long term peritoneal dialysis. Perit Dial Bu111987; 7: 148.
- Cole C, Prichard S, Waddell R. Increased use of hypertonic dialysate by CAPD patients following repeated episodes of peritonitis. Perit Dial Bu111984; 4: 6.
- Faller B, Marochial J-F. Loss of ultrafiltration in continuous ambulatory peritoneal dialysis: a role of acetate. Perit Dial Bull 1984; 4: 10.
- Intern. Coop. Study: A survey of ultrafiltration in continuous ambulatory peritoneal dialysis. PeritDiaIBuII1984;4: 137.
- Intern. Coop. Study: Factors affecting ultrafiltration in continuous ambulatory peritoneal dialysis. Perit Dial Bu111984; 4: 14.
- Manual MA. Failure of ultrafiltration in patients on CAPD. Perit Dial Bu111983; 3(Suppl): 38.
- Rubin J, Lin L. Host defense mechanisms in continuous ambulatory peritoneal dialysis. ClinNephro11983; 20: 140.