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Peritoneal dialysis (PD)-associated peritonitis contributes significantly to morbidity and modalityfailure. The number of patients on PD is declining in Western countries, and peritonitis is a potential deterrent to the therapy. Here, we present a clinically significant decline in the rate of peritonitis at a single center over a 28-year period, with current rates significantly lower than the national average, and we review several factors that have contributed to those outcomes. Peritonitis and duration of follow-up have been recorded for all patients followed in our program since 1977. Introduction of important technological changes into the program were also recorded. All peritonitis rates are expressed as episodes/patient-year or episodes/n patient-months. Data are summarized for each calendar year since 1977. We followed 682 patients for a total follow-up duration of 15,435 patient-months. Glass bottles were changed to plastic bags in 1978. Straight connecting tubes were replaced by Y-sets in 1988. The presternal dialysis catheter was introduced in 1991 and has been the primary PD access since 1995. The peritonitis rate in 1977 was 5.8 episodes/patient-year, and that rate has progressively declined over the past 27 years to 0.35 episodes/patient-year in 2004. Technical improvements that contributed to the decline in overall peritonitis rates have been adopted nationwide. The largest improvement occurred with the switch from glass bottles to plastic bags, and to the closed-system Y-set that incorporated the flush-before-fill principle. Advances in catheter technology have also played a key role. Quality improvement in the program and long years of experience in overall care of PD patients are significant factors that cannot be measured quantitatively. Improvements have been made to exit-site care protocols, to exit-site evaluation and diagnosis, and to treatment strategies. Patient education and training in catheter care remain the important factor in a PD program. Many factors have contributed to the reduction of PD-associated peritonitis rates at our center Improved connectology, catheter care, and patient education play key roles in the reduction of peritonitis.

Effective management of peritonitis in chronic peritoneal dialysis patients requires a multidisciplinary approach. Nursing's role begins with the prevention of peritonitis by the development of sound program policies and procedures and effective patient education. Nursing activities at the time of infection focus on assessment and patient education. Nurses are also responsible for maintaining peritonitis data as well as directing or participating in related quality improvement activities.

Peritonitis is known to acutely affect the transport characteristics of the peritoneal membrane, however, the long-term effects are not known. We studied the effect of peritoneal inflammation on mean dialysate-to-plasma creatinine concentration ratio (D/P), dialysate protein losses (DPL, g/week), and dialysate albumin losses (DAL, g/week), done at six weeks or more postepisode, in 152 patients [102 (67%) males, mean age 57 years (range 21-91)]. These patients were on continuous ambulatory peritoneal dialysis for a mean of twelve months (range 1-97). A total of 94 distinct peritonitis episodes were managed in 47 patients (31%). The number of patients with 0, 1, 2, 3, 4, and 5 episodes of peritonitis were 105, 29, 3, 6, 4, and 5. These episodes were treated with a standard protocol. There were no statistically significant differences between the D/P, DPL, or DAL between the groups. The parameters did not show any correlation to time on dialysis. Thus, in conclusion, peritonitis, if promptly treated, does not cause any permanent change in D/P, DAL, or DPL.

Dialysate and blood leukocyte counts were measured during 130 episodes of peritonitis in 91 hospitalized patients on long-term peritoneal dialysis (CPD). The authors found that the blood/dialysate leukocyte count can be less than 1.0, and this is usually the case when dialysate leukocyte count exceeds 20,000/mm3. Dialysate leukocyte removal in a single 2 L drain bag can approach the leukocyte number in the entire circulating blood volume. Daily drainage can remove leukocytes in amounts exceeding the blood leukocyte pool 2 to 3 fold. The observed blood leukocyte counts throughout a range of 2,700 to 10,000 at dialysate leukocyte counts greater than 20,000 per mm3 may reflect: 1) leukocyte removal approaching maximum bone marrow output of leukocytes, and/or 2) increasing microcirculatory margination of leukocytes in those episodes of peritonitis associated with very high dialysate leukocyte counts.

We initiated a therapeutic program of continuous ambulatory peritoneal dialysis for patients with chronic renal failure. Our program resulted in many episodes of peritonitis arising from contamination due to the technical aspects of the procedure. Microbiologic evaluation showed that 73% of 97 episodes were culture positive, with gram-positive organisms causing most of the cases, especially early in dialysis. Gram-negative rods tended to occur later. Gram stains of dialysate effluent resulted in a disappointingly low yield of only 9% positivity. Cell counts were a dependable indicator of the presence of peritoneal inflammation and also of therapeutic success. Most patients responded well to intraperitoneal cephalothin, 125 mg/L for 10 to 14 d. The occurrence of peritonitis resulted in 0.93 years of hospitalization during the total of 15.45 patient-years on dialysis, which essentially negated the financial advantages of this method of treatment of chronic renal failure. For this to be a successful mode of therapy, advances in the prevention of peritonitis must be made.