Increased Serum Lactate in Peritoneal Dialysis Patients Presenting with Intercurrent Illness

Trinh, Emilie; Saiprasertkit, Nalinee; Bargman, Joanne M.

doi:10.3747/pdi.2017.00169

Cited by 11 publications

(8 citation statements)

References 18 publications

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Section: Not All Peritonitis Is Pd Peritonitismentioning

confidence: 99%

“…Of note, mild elevation in serum lactate level in patients with peritonitis may not necessarily indicate tissue hypoperfusion or bowel ischemia because it can be the result of delayed metabolism of the lactate buffer used in the PD solutions. 80 If imaging of the abdomen in these cases is performed, air under the diaphragm may be a finding. However, the clinical significance of this sign can be variable.…”

Section: Not All Peritonitis Is Pd Peritonitismentioning

confidence: 99%

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Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

2020

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Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis–associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data.

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Section: Not All Peritonitis Is Pd Peritonitismentioning

confidence: 99%

Section: Not All Peritonitis Is Pd Peritonitismentioning

confidence: 99%

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

2020

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“…In addition, albumin‐adjusted calcium was an extremely poor predictor of ionized calcium in peritoneal dialysis and this was only marginally improved with use of total calcium. Lactate use as a buffer in peritoneal dialysate solutions and reports of hyperlactatemia without hypoperfusion 22 may contribute. Misclassification of calcium status also occurred in stage 5 CKD despite a higher mean albumin level, however, it was less marked that that in dialysis patients.…”

Section: Discussionmentioning

confidence: 99%

Misclassification of calcium status in end‐stage kidney disease using albumin‐adjusted calcium levels

et al. 2021

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Background Albumin‐adjusted calcium remains widely used in clinical practice with guidelines for chronic kidney disease (CKD) mineral bone disorder recommending the use of serum calcium for monitoring. This is despite ionized calcium being the biologically active fraction. This study aimed to investigate the ability of total calcium and albumin‐adjusted calcium to correctly assign calcium status in stage 5/5D CKD across non‐dialysis, haemodialysis and peritoneal dialysis patients. Methods Over a 6‐months, 352 paired serum and ionized calcium samples were collected from stage 5 (n = 58) and 5D (n = 294, 196 haemodialysis, 98 peritoneal dialysis) CKD patients in a tertiary‐hospital setting. Albumin‐adjusted calcium was calculated using the modified‐Payne formula. Ionized calcium was the reference standard. The agreement between the two methods in assigning calcium status was assessed using Cohen's weighted kappa (κ) statistic. Results Albumin‐adjusted calcium was a poor predictor of calcium status compared to ionized calcium in stage 5/5D CKD (observed agreement 0.42, weighted κ 0.20, 95% CI 0.15–0.26). Dialysis dependence was associated with worse agreement (observed agreement 0.38, weighted κ 0.14, 95% CI 0.09–0.19). Total calcium was more reliable, however, remained inaccurate. Calcium status was not more accurately classified in those with higher albumin levels ≥30 g/L (observed agreement 0.47, weighted κ 0.23, 95% CI 0.10–0.36). Conclusion Total calcium provides better approximation of calcium status than albumin‐adjusted calcium in stage 5/5D CKD. Albumin‐adjusted calcium tends to ‘overcorrect’ serum calcium upward. Clinicians should use ionized calcium where accurate measure of calcium is indicated, with total calcium used as the next best option where resources are limited.

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“…5,7,9,10 Signs and symptoms of peritonitis may be severe and physicians who do not routinely care for PD patients may suspect other causes and thus order potentially unnecessary abdominal imaging. 11 Moreover, the presence of free air under the diaphragm on upright radiography, which suggests a perforated viscus in non-PD patients, may be seen in asymptomatic PD patients. Therefore, this may also lead unexperienced physicians to order potentially unnecessary abdominal imaging.…”

Section: Discussionmentioning

confidence: 99%

Utility of Abdominal Imaging in Peritoneal Dialysis Patients Presenting With Peritonitis

Trinh

Bargman

2020

Can J Kidney Health Dis

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Background: Peritonitis remains a major complication in peritoneal dialysis (PD). Abdominal imaging is often performed in the setting of peritonitis to evaluate for concomitant intra-abdominal processes. However, the usefulness of this procedure is unknown. Objective: The aim of this study was to assess the prevalence of abdominal imaging performed in the setting of PD peritonitis and to evaluate clinical parameters associated with abnormal imaging results to identify clinical situations in which radiographic examinations are informative. Design: This is a retrospective cohort study. Setting: The study was conducted at the Toronto General Hospital, Ontario, Canada. Patients: We studied 166 episodes of PD peritonitis in 114 patients between January 1, 2011, and June 30, 2016. Measurements: Baseline demographics, characteristics of PD peritonitis, and characteristics of abdominal imaging performed. Methods: The association between relevant clinical parameters and abnormal abdominal imaging was examined using a univariate and multivariate logistic regression model. Results: Abdominal imaging (computed tomography [CT] scan or ultrasound) was performed in 68 cases (41%). Patients were more likely to undergo imaging if they required hospitalization, were admitted to the intensive care unit (ICU), had polymicrobial or fungal organisms causing peritonitis, had relapsing/recurrent/refractory peritonitis, had an indication for hemodialysis or PD catheter removal, or presented with hypotension, tachycardia, or an elevated serum lactate. Of the imaging performed, abnormalities were found in 32 cases (47%). The most common findings were bowel obstruction, intra-abdominal collection, and biliary abnormalities. In the univariate analysis, ICU admission (43.3% vs 14.3%, P < .01) and need for temporary or permanent hemodialysis (62.5% vs 30.6%, P < .01) were associated with imaging abnormalities. Importantly, the peritonitis organism was not associated with abnormal imaging results. In a multivariate analysis, ICU admission was the only significant clinical parameter associated with imaging abnormalities with an odds ratio (OR) of 4.4 (95% confidence interval [CI]: 1.1-17.4, P = .04). Limitations: Single-center study, small sample size, and lack of detailed information on the exact indications leading to abdominal imaging. Conclusions: Abdominal imaging is commonly performed in the setting of PD peritonitis. Abnormalities are not infrequent and are present in almost half of the cases, with need for ICU admission being the most significant clinical parameter associated with abnormal findings. Therefore, abdominal imaging should be performed in carefully selected patients with PD peritonitis, especially if there is evidence of hemodynamic instability. While the finding of fungal or polymicrobial peritonitis was a driver for abdominal imaging, the presence of these organisms did not predict radiologic abnormalities.

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Increased Serum Lactate in Peritoneal Dialysis Patients Presenting with Intercurrent Illness

Cited by 11 publications

References 18 publications

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

Peritoneal Dialysis–Associated Peritonitis: Suggestions for Management and Mistakes to Avoid

Misclassification of calcium status in end‐stage kidney disease using albumin‐adjusted calcium levels

Utility of Abdominal Imaging in Peritoneal Dialysis Patients Presenting With Peritonitis

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