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Risk factors for the development of peritonitis in PD patients are widely studied&#46; Low serum albumin at the begining of dialysis&#44; immunosuppression and staphylococcal nasal carriage are some risk factors determined<span class="elsevierStyleSup">6&#44;7</span>&#46; Some other controversial risks are age&#44; diabetes and gender<span class="elsevierStyleSup">8&#44;9</span>&#46; According to some studies&#44; the introduction of automated peritoneal dialysis &#40;APD&#41;&#44; using a single connection each night&#44; showed a reduction in the incidence of peritonitis episodes compared with continuous ambulatory peritoneal dialysis &#40;CAPD&#41;&#44; as a result of the decrease in the number of daily disconnections<span class="elsevierStyleSup">10&#44;11</span>&#46; Obligatory referral which can be regarded as an indication of the reluctance of patients for PD is a potential factor studied recently<span class="elsevierStyleSup">12&#44;13</span>&#46; This study concentrates on potential risk factors&#44; more recently studied ones among the classical ones&#44; for peritonitis in PD patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIALS AND METHODS</span></p><p class="elsevierStylePara">We analysed 109 PD patients &#40;Female&#58;Male &#61; 42&#58;67&#41; followed up at least for 3 months in a centre&#44; a tertiary referral hospital for 360&#46;1 patient years&#46; The mean time on renal replacement therapy and on PD of the patient population were 59&#46;15 &#40;&#177; 43&#46;52&#41; months and 39&#46;75 &#40;&#177; 29&#46;32&#41; months&#44; respectively&#46; Mean age of the patients was 43&#46;4 &#177; 7&#46;5 years&#46; The most frequent aetiology underlying chronic kidney disease &#40;CKD&#41; was glomerulonephritis &#40;39&#46;4&#37;&#41;&#46; The underlying aetiology was diabetes mellitus in 17 &#40;15&#46;6&#37;&#41; of the patients&#46; Twenty two &#40;20&#46;2&#37;&#41; of the patients were on APD treatment&#46; In the study which is designed as a retrospective cohort study&#44; demographic characteristics&#44; conditions for choosing PD&#44; type of PD treatment&#44; some chemical tests and peritonitis episodes were recorded from the files of the patients &#40;table 1&#41;&#46; Peritonitis episodes recorded met the criteria of at least 2 of the following 3 conditions&#58; <span class="elsevierStyleItalic">1&#41;</span> symptoms and signs of peritoneal inflammation&#59; <span class="elsevierStyleItalic">2&#41;</span> peritoneal cell count exceeding 100 permicroL or polymorphonuclear cells &#62;50&#37; and&#47;or <span class="elsevierStyleItalic">3&#41;</span> positive culture<span class="elsevierStyleSup">14</span>&#46; Multiple episodes of the same patient recorded excluding relapsing and recurrent peritonitis&#46; Comorbidity index scores of the patients&#160;were&#160;calculated&#160;using the data from the files by using the&#160;Charlson Comorbidty Index&#160;&#40;CCI&#41; Score<span class="elsevierStyleSup">15</span>&#46;&#160;Nonparametric two-independent sample &#40;Mann- Whitney U&#41; test was used to determine the differences between<span class="elsevierStyleItalic"> </span>different groups of patients such as diabetic patients versus non-diabetics&#44; CAPD patients versus APD patients&#44; patients with single&#160;episode versus patients with multiple episodes&#59; and multiple regression analysis &#40;for the analysis of time to first peritonitis episode&#41; was used in order to determine the association between some factors and peritonitis episodes&#46; Statistical significance was defined as p &#60;0&#46;05&#46; All statistical analyses were performed using SPSS 13&#46;0&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">The rate of peritonitis in all PD patients was found to be 0&#46;22 episode&#47;patient year and 22 &#40;20&#46;18&#37;&#41; of the patients had more than one&#160;episode &#40;excluding recurrent and relapsing peritonitis&#41; through the whole follow up period&#46; The peritonitis rate in diabetic PD patients was found to be 0&#46;23 episode&#47;patient year while in non-diabetics the rate was 0&#46;22 episode&#47;patient year &#40;p &#62;0&#46;05&#41;&#46; On the other hand&#44; in CAPD patients solely&#44; the rate was 0&#46;22 episode&#47;patient year whereas the one in APD patients was 0&#46;21 episode&#47;patient year &#40;p &#62;0&#46;05&#41;&#46;</p><p class="elsevierStylePara">Twenty seven &#40;24&#46;8&#37;&#41; of the patients were allocated to PD due to obligatory reasons that mainly were&#160; loss of arteriovenous access possibility or social problems in reaching the HD unit&#46;</p><p class="elsevierStylePara">Table 1 shows some demographic properties&#44; comorbidity status&#160;and laboratory tests of the patients&#46; The patient population had a high frequency of anti- hepatitis C virus antibody &#40;anti-HCV ab&#41; positivity &#40;26&#46;6&#37;&#41;&#46;&#160;&#160;</p><p class="elsevierStylePara">According to multiple regression analysis for the analysis of time to first peritonitis episode&#44; the assosciated factors found were as follows&#59; PD allocation type &#40;p &#61; 0&#46;04&#59; RR &#61; 2&#46;6&#41;&#44; serum albumin level &#40;p &#61; 0&#46;05&#59; RR &#61; 1&#46;2&#41;&#44; and Anti-HCV Ab positivity &#40;p &#61; 0&#46;04&#59; RR &#61; 1&#46;5&#41;&#46; However&#44; sex&#44; diabetes&#44; the type of PD treatment&#44; duration of ESRD&#44; mean haemoglobin level&#44; mean C-reactive protein &#40;CRP&#41; level&#44; Hepatitis B surface antigen &#40;HBs Ag&#41; positivity&#160;and mean CCI&#160;score&#160;were not found to be significantly associated with peritonitis &#40;table 2&#41;&#46;</p><p class="elsevierStylePara">Table 3 shows the differences among patients according to PD allocation type&#46; The different characteristics of patients with or without anti-HCV Ab are shown on table 4&#46;</p><p class="elsevierStylePara">Twenty two patients &#40;20&#46;2&#37;&#41; had more than one&#160;episode during the follow-up period&#46; Fourteen of these patients &#40;64&#37;&#41; were females&#46; When patients with single episodes were compared to those with multiple episodes&#44; the percentage of female patients were significantly higher among those with multiple episodes &#40;p &#61; 0&#46;01&#41;&#46; Serum albumin level &#40;p &#61; 0&#46;001&#41;&#44; type of allocation to PD &#40;p &#61; 0&#46;01&#41; and type of PD treatment &#40;p &#61; 0&#46;03&#41; were also sigificantly different&#44; however the number of diabetic patients was not higher in patients with multiple episodes than in patients with single episodes&#46; The frequency of anti-HCV positivity was not significantly different in patients with multiple episodes when compared with patients with single episodes&#46; The results of comparisons between patients with single and multiple peritonitis episodes can be seen in table 5&#46;</p><p class="elsevierStylePara">At the end of the follow-up period&#44; 93 &#40;85&#46;3&#37;&#41; patients were still on peritoneal dialysis&#44; 4 &#40;4&#46;3&#37;&#41; patients were referred to hemodialysis&#44; 4 &#40;4&#46;3&#37;&#41; patients died while 8 &#40;8&#46;6&#37;&#41; patients were transplanted&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Peritonitis&#160;episode rate can vary from region to region and from centre to centre within the same country<span class="elsevierStyleSup">16&#44;17</span>&#46; The level of our centre was lower than those accepted by European Best Practice &#40;1&#58;24 months&#41; and International Society of Peritoneal Dialysis &#40;ISPD&#41; &#40;1&#58;18 months&#41; Guidelines<span class="elsevierStyleSup">18&#44;19</span>&#46;</p><p class="elsevierStylePara">Peritonitis rate in diabetics&#44; whether is higher or not compared to non-diabetics&#44; most of the time&#44; is a matter of debate in the literature<span class="elsevierStyleSup">6&#44;20&#44;21</span>&#46; But&#44; mostly the finding is towards a higher but non significant difference in the rate of peritonitis in diabetics&#44; same as our finding&#46; Additionally in multivarite regression analysis&#44; we could not show an association between diabetes and &#40;table 2&#41; peritonitis and morever there was no significant difference in terms of diabetes when patients with single and multiple peritonitis episodes were compared &#40;table 5&#41;&#46;</p><p class="elsevierStylePara">Mean level of serum albumin of the patients&#44; determined throughout the whole follow up period was found to be a significant factor associated with peritonitis according to regression analysis &#40;p &#61; 0&#46;05&#44; OR &#61; 1&#46;2&#41;&#46; Hypoalbuminaemia relates with a chronic state of inflammation due to renal failure and dialysis&#160;but it can also be related to malnutrition and overhydration<span class="elsevierStyleSup">22</span>&#46; In our study we could not find an association between chronic systemic inflammation&#44;&#160;determined by mean serum&#160;CRP levels&#44; and rate of peritonitis&#46; Accordingly&#44; the&#160;association between hypoalbuminemia and peritonitis we showed&#44; was probably&#160;indicating&#160;malnutrition to be the associated risk factor for peritonitis&#46; Whatever the reason&#44; it is certain that hypoalbuminaemia is a predisposing factor for peritonitis hence should be fought in PD patients in order to decrease peritonitis incidence<span class="elsevierStyleSup">23&#44;24</span>&#46;</p><p class="elsevierStylePara">In a very recent study&#44; obligatory referral to PD was found to be significantly related to higher mortality among PD patients<span class="elsevierStyleSup">12</span>&#46; In our study we found that obligatory referral is significantly related to higher peritonitis rates &#40;p &#61; 0&#46;04&#44; OR &#61; 2&#46;6&#41;&#46; In another recent study&#44; transferring from HD to PD was also found to be a risk factor for peritonitis<span class="elsevierStyleSup">13</span>&#46; Reasons of obligatory referral such as loss of AV access chance due to long years on HD&#160;may&#160;indicate more comorbid conditions in this group of patients which&#160;was shown in our study such that duration of ESRD&#44;&#160;mean CCI score and percentage of patients changed from haemodialysis were significantly higher in patients obligatorily allocated to PD treatment &#40;table 3&#41;&#46;&#160;However&#44; neither ESRD duration nor CCI score&#160;were found to be associated risk factors for peritonitis&#160;&#40;table 2&#41;&#46; Hence&#44; it should&#160;be kept in mind that&#44; lack of motivation of these patients in case of a mandatory referral can lead to problems like peritonitis and hence technical failure&#44; due to reluctance and carelessness in carrying out the PD procedure&#46; In order to understand&#160; better&#44; the contribution of each reason for increased mortality&#44; peritonitis and technical failure in these patients&#44; we need to carry out&#160;further prospective studies&#46;</p><p class="elsevierStylePara">We know APD is mainly driven by patient preference as it improves life style of patients&#46; It has also been considered to have an advantage over CAPD in reducing the incidence of peritonitis which have been shown in some studies<span class="elsevierStyleSup">25-27</span> whereas in others no difference were found between the two different modalities of PD treatment<span class="elsevierStyleSup">13&#44;28</span>&#46; In our study&#44; the rate of peritonitis was lower in APD patients when compared to CAPD patients &#40;0&#46;21 episode&#47;patient year vs 0&#46;22 episode&#47;patient year&#41; but the difference was not significant&#46; In multiple regression analysis&#44; type of PD treatment was not found to be a risk factor for peritonitis&#46; We believe&#44; in addition to lesser contact with catheter due to the technic of APD&#44; lower frequency of peritonitis among APD patients may partly be due to increased preference and hence motivation of the patients choosing APD&#46; Following comparison between patients with single episodes with the ones with multiple episodes we found a significantly higher number of CAPD patients in multiple episodes group which may be at least partly due to higher motivation of APD patients&#46; We believe a prospective trial considering motivation of the patients is needed for better understanding the difference in incidence of peritonitis between different types of PD treatments&#46;</p><p class="elsevierStylePara">The prevalance and seroconversion rates of anti-HCV ab positivity are lower in PD than HD patients which is considered to be an advantage of PD over HD<span class="elsevierStyleSup">29&#44;30</span>&#46; However&#44; there is no data comparing HCV status to peritonitis in PD patients&#46; In our study&#44; multiple regression analysis reveals anti-HCV ab positivity to be a factor associated with episodes of peritonitis in PD patients &#40;table 2&#41;&#46; Patients with anti HCV positivity were on dialysis for a longer period&#44; had a higher CCI score and were obliged to&#160;PD treatment more than anti-HCV negative patients &#40;table 4&#41;&#46;&#160;Probably this obligation was the real underlying associated&#160;factor for&#160;peritonitis in this group of patients&#46;</p><p class="elsevierStylePara">The results of statistical analysis of mutiple episodes compared to single episodes showed that serum albumin is significantly lower for patients who had more than one isolated peritonitis&#160;episode when compared with patients who had multiple episodes during follow up period &#40;p &#61; 0&#46;001&#41;&#46; Patients who had multiple episodes were also allocated to PD mandatorily more frequently than the ones who had single&#160;episode &#40;p &#61; 0&#46;01&#41; supporting the findigs in multiple regression analysis&#46; These two factors were consistent with associated risk factors for time to first peritonitis&#160;episode strenthening them to be risk factors for peritonitis episodes in PD patients&#46; Morever&#44; as mentioned above&#44; APD patients were less in number in multiple&#160;episode group than CAPD patients which might be related to difference in motivation between two dialysis treatment types&#46; Additionally&#44; there were significantly more females among patients with multiple episodes compared to ones with single episode&#46; In our study&#44; sex was not a risk factor for developing peritonitis episodes &#40;p &#61; 0&#46;5&#41;&#46; However&#44; female patients were found to have significantly more multiple episodesthan male patients&#46; In several studies female gender is shown to be a risk factor for peritonitis<span class="elsevierStyleSup">13&#44;31</span>&#46;</p><p class="elsevierStylePara">In conclusion&#44; mean serum albumin levels in a PD patient is significantly associated with peritonitis and should be closely monitored during follow up&#46; Obligatory referral which can be an indication of loss of motivation for peritoneal dialysis procedures is thought to be a strong risk factor for peritonitis in PD patients and should be further studied&#46; Patients with multiple&#160;episodes were more hypoalbuminemic&#44; had a higher frequency of mandatorry referral and they were mostly females when compared to patients with single&#160;episode during follow up&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;12528&#95;en&#95;10796&#95;t5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_12528_en_10796_t5.jpg" alt="Comparison of peritoneal dialysis patients who had single attack with patients who had multiple attacks "></img></a></p><p class="elsevierStylePara">Table 5&#46; Comparison of peritoneal dialysis patients who had single attack with patients who had multiple attacks </p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15493&#95;en&#95;10796&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15493_en_10796_t2.jpg" alt="Multiple regression analysis for factors associated with peritonitis episodes"></img></a></p><p class="elsevierStylePara">Table 2&#46; Multiple regression analysis for factors associated with peritonitis episodes</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15495&#95;en&#95;10796&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15495_en_10796_t1.jpg" alt="Demographic data&#44; comorbidity status and laboratory data &#40;mean levels&#41; of the patients"></img></a></p><p class="elsevierStylePara">Table 1&#46; Demographic data&#44; comorbidity status and laboratory data &#40;mean levels&#41; of the patients</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15496&#95;en&#95;10796&#95;t3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15496_en_10796_t3.jpg" alt="Comparison of characteristics of patients according to type of allocation to PD"></img></a></p><p class="elsevierStylePara">Table 3&#46; Comparison of characteristics of patients according to type of allocation to PD</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15498&#95;en&#95;10796&#95;t4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15498_en_10796_t4.jpg" alt="Comparison of characteristics of patients according to anti-hepatitis C virus antibody status"></img></a></p><p class="elsevierStylePara">Table 4&#46; Comparison of characteristics of patients according to anti-hepatitis C virus antibody status</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Aim&#58;</span> Peritonitis is one of the major comorbidities of peritoneal dialysis &#40;PD&#41; patients&#46; The aim of this study was to concentrate on potential risk factors&#44; including more recently studied ones among the classical ones for peritonitis&#44; in PD patients&#46; <span class="elsevierStyleBold">Materials and methods&#58;</span> We analysed 109 patients &#40;F&#47;M &#61; 42&#47;67&#41; followed up at least for 3 months in a single centre&#44; a tertiary referral hospital for 360&#46;1 patient years&#46; In the study which is designed as a retrospective cohort study&#44; demographic characteristics&#44; conditions for choosing PD&#44; type of PD treatment&#44; some chemical tests and peritonitis episodes were recorded from the files of the patients&#46; <span class="elsevierStyleBold">Results&#58; </span>The rate of peritonitis was found to be 0&#46;22 episode&#47;patient year and 22 &#40;20&#46;18&#37;&#41; of the patients had more than one episode&#46; Twenty seven &#40;24&#46;8&#37;&#41; of the patients were allocated to PD due to obligatory reasons&#46; According to multiple regression analysis&#44; the assosciated factors were found to be PD allocation type &#40;obligatory versus voluntary&#41; &#40;p &#61; 0&#46;04&#59; RR &#61; 2&#46;6&#41;&#44; serum albumin level &#40;p &#61; 0&#46;05&#59; RR &#61; 1&#46;2&#41;&#44; and anti-hepatitis C Virus Antibody positivity &#40;p &#61; 0&#46;03&#59; RR &#61; 1&#46;6&#41;&#46; Frequency of female patients were significantly higher in the group who had multiple episodes &#40;p &#61; 0&#46;01&#41;&#46; <span class="elsevierStyleBold">Conclusion&#58;</span> Obligatory referral which can be an indication of loss of motivation for peritoneal dialysis procedures&#44; is thought to be a strong risk factor for peritonitis in PD patients and should be further studied&#46; Patients with multiple episodes had a higher frequency of obligatory referral as expected and additionally&#44; they were higher in number of females when compared to the ones with single episode&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objetivo&#58;</span> La peritonitis es una de las principales comorbilidades que presentan los pacientes en di&#225;lisis peritoneal &#40;DP&#41;&#46; El objetivo de este estudio es centrarnos en los posibles factores de riesgo&#44; incluidos los de m&#225;s reciente estudio entre los ya cl&#225;sicos factores de la peritonitis en pacientes en DP&#46; <span class="elsevierStyleBold">Materiales y m&#233;todos&#58;</span> Analizamos 109 pacientes &#40;H&#47;M &#61; 67&#47;42&#41; sometidos a seguimiento durante al menos tres meses en un &#250;nico centro&#44; un hospital terciario con una tasa de 360&#44;1 a&#241;os-paciente&#46; En este trabajo&#44; concebido como un estudio de cohorte retrospectivo&#44; se registraron las caracter&#237;sticas demogr&#225;ficas&#44; las condiciones que llevaron a la DP&#44; tipo de DP&#44; pruebas qu&#237;micas y episodios de peritonitis&#46; Esta informaci&#243;n se extrajo de los historiales&#46; <span class="elsevierStyleBold">Resultados&#58; </span>Se descubri&#243; que la tasa de peritonitis era de 0&#44;22 episodios&#47;a&#241;os-paciente y 22 &#40;20&#44;18&#37;&#41; pacientes hab&#237;an padecido m&#225;s de un episodio&#46; Veintisiete &#40;24&#44;8&#37;&#41; de los pacientes recib&#237;an DP por obligaci&#243;n&#46; Gracias al an&#225;lisis de regresi&#243;n m&#250;ltiple&#44; se descubri&#243; que los factores relacionados eran el tipo de llegada al tratamiento &#40;obligatoria frente a voluntaria&#41; &#40;p &#61; 0&#44;04&#59; RR &#61; 2&#44;6&#41;&#44; los niveles de alb&#250;mina s&#233;rica &#40;p &#61; 0&#44;05&#59; RR &#61; 1&#44;2&#41;&#44; y la positividad para anticuerpos contra el virus de hepatitis C &#40;p &#61; 0&#44;03&#59; RR &#61; 1&#44;6&#41;&#46; La frecuencia de pacientes mujeres era significativamente mayor en el grupo que hab&#237;a padecido m&#250;ltiples episodios &#40;p &#61; 0&#44;01&#41;&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58; </span>La remisi&#243;n obligatoria&#44; que puede ser un indicio de la falta de motivaci&#243;n por los procedimientos de DP&#44; es un importante factor de riesgo de peritonitis en los pacientes en DP y merece ser objeto de estudio&#46; Como era de esperar&#44; los pacientes con m&#250;ltiples episodios presentaron una mayor frecuencia de remisi&#243;n obligatoria y adem&#225;s&#44; el n&#250;mero de mujeres era mayor en comparaci&#243;n con el grupo que hab&#237;a padecido un &#250;nico episodio&#46;</p>"
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Obligatory referral among other factors associated with peritonitis in peritoneal dialysis patients
Remisión obligatoria y otros factores relacionados con la peritonitis en pacientes en diálisis peritoneal
, D.D.. Oygarb, A.S.. Yalinb, M.R.. Altiparmakb, R.. Atamanb, K.. Serdengectib
b Department of Nephrology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Peritonitis is one of the major comorbidities of peritoneal dialysis &#40;PD&#41; patients&#46; Although the incidence of peritonitis has reduced in years with the introduction of new techniques&#44; it still constitutes one of the major drop-outs from PD<span class="elsevierStyleSup">1-3</span>&#46; It is the leading cause of technical failure and main reason for switching therapy to haemodialysis &#40;HD&#41;<span class="elsevierStyleSup">4&#44;5</span>&#46; The percentage of end-stage renal disease &#40;ESRD&#41; patients maintained on PD therapy is decreasing in some regions and centres &#40;USRDS data and ANZDATA registry&#41;&#59; complications from PD therapy mainly peritonitis&#44; may be the reason for the decline&#46;</p><p class="elsevierStylePara">There is variability in peritonitis rates by both region and program&#46; Peritonitis rate also varies by individual patients within a program&#46; Risk factors for the development of peritonitis in PD patients are widely studied&#46; Low serum albumin at the begining of dialysis&#44; immunosuppression and staphylococcal nasal carriage are some risk factors determined<span class="elsevierStyleSup">6&#44;7</span>&#46; Some other controversial risks are age&#44; diabetes and gender<span class="elsevierStyleSup">8&#44;9</span>&#46; According to some studies&#44; the introduction of automated peritoneal dialysis &#40;APD&#41;&#44; using a single connection each night&#44; showed a reduction in the incidence of peritonitis episodes compared with continuous ambulatory peritoneal dialysis &#40;CAPD&#41;&#44; as a result of the decrease in the number of daily disconnections<span class="elsevierStyleSup">10&#44;11</span>&#46; Obligatory referral which can be regarded as an indication of the reluctance of patients for PD is a potential factor studied recently<span class="elsevierStyleSup">12&#44;13</span>&#46; This study concentrates on potential risk factors&#44; more recently studied ones among the classical ones&#44; for peritonitis in PD patients&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIALS AND METHODS</span></p><p class="elsevierStylePara">We analysed 109 PD patients &#40;Female&#58;Male &#61; 42&#58;67&#41; followed up at least for 3 months in a centre&#44; a tertiary referral hospital for 360&#46;1 patient years&#46; The mean time on renal replacement therapy and on PD of the patient population were 59&#46;15 &#40;&#177; 43&#46;52&#41; months and 39&#46;75 &#40;&#177; 29&#46;32&#41; months&#44; respectively&#46; Mean age of the patients was 43&#46;4 &#177; 7&#46;5 years&#46; The most frequent aetiology underlying chronic kidney disease &#40;CKD&#41; was glomerulonephritis &#40;39&#46;4&#37;&#41;&#46; The underlying aetiology was diabetes mellitus in 17 &#40;15&#46;6&#37;&#41; of the patients&#46; Twenty two &#40;20&#46;2&#37;&#41; of the patients were on APD treatment&#46; In the study which is designed as a retrospective cohort study&#44; demographic characteristics&#44; conditions for choosing PD&#44; type of PD treatment&#44; some chemical tests and peritonitis episodes were recorded from the files of the patients &#40;table 1&#41;&#46; Peritonitis episodes recorded met the criteria of at least 2 of the following 3 conditions&#58; <span class="elsevierStyleItalic">1&#41;</span> symptoms and signs of peritoneal inflammation&#59; <span class="elsevierStyleItalic">2&#41;</span> peritoneal cell count exceeding 100 permicroL or polymorphonuclear cells &#62;50&#37; and&#47;or <span class="elsevierStyleItalic">3&#41;</span> positive culture<span class="elsevierStyleSup">14</span>&#46; Multiple episodes of the same patient recorded excluding relapsing and recurrent peritonitis&#46; Comorbidity index scores of the patients&#160;were&#160;calculated&#160;using the data from the files by using the&#160;Charlson Comorbidty Index&#160;&#40;CCI&#41; Score<span class="elsevierStyleSup">15</span>&#46;&#160;Nonparametric two-independent sample &#40;Mann- Whitney U&#41; test was used to determine the differences between<span class="elsevierStyleItalic"> </span>different groups of patients such as diabetic patients versus non-diabetics&#44; CAPD patients versus APD patients&#44; patients with single&#160;episode versus patients with multiple episodes&#59; and multiple regression analysis &#40;for the analysis of time to first peritonitis episode&#41; was used in order to determine the association between some factors and peritonitis episodes&#46; Statistical significance was defined as p &#60;0&#46;05&#46; All statistical analyses were performed using SPSS 13&#46;0&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">The rate of peritonitis in all PD patients was found to be 0&#46;22 episode&#47;patient year and 22 &#40;20&#46;18&#37;&#41; of the patients had more than one&#160;episode &#40;excluding recurrent and relapsing peritonitis&#41; through the whole follow up period&#46; The peritonitis rate in diabetic PD patients was found to be 0&#46;23 episode&#47;patient year while in non-diabetics the rate was 0&#46;22 episode&#47;patient year &#40;p &#62;0&#46;05&#41;&#46; On the other hand&#44; in CAPD patients solely&#44; the rate was 0&#46;22 episode&#47;patient year whereas the one in APD patients was 0&#46;21 episode&#47;patient year &#40;p &#62;0&#46;05&#41;&#46;</p><p class="elsevierStylePara">Twenty seven &#40;24&#46;8&#37;&#41; of the patients were allocated to PD due to obligatory reasons that mainly were&#160; loss of arteriovenous access possibility or social problems in reaching the HD unit&#46;</p><p class="elsevierStylePara">Table 1 shows some demographic properties&#44; comorbidity status&#160;and laboratory tests of the patients&#46; The patient population had a high frequency of anti- hepatitis C virus antibody &#40;anti-HCV ab&#41; positivity &#40;26&#46;6&#37;&#41;&#46;&#160;&#160;</p><p class="elsevierStylePara">According to multiple regression analysis for the analysis of time to first peritonitis episode&#44; the assosciated factors found were as follows&#59; PD allocation type &#40;p &#61; 0&#46;04&#59; RR &#61; 2&#46;6&#41;&#44; serum albumin level &#40;p &#61; 0&#46;05&#59; RR &#61; 1&#46;2&#41;&#44; and Anti-HCV Ab positivity &#40;p &#61; 0&#46;04&#59; RR &#61; 1&#46;5&#41;&#46; However&#44; sex&#44; diabetes&#44; the type of PD treatment&#44; duration of ESRD&#44; mean haemoglobin level&#44; mean C-reactive protein &#40;CRP&#41; level&#44; Hepatitis B surface antigen &#40;HBs Ag&#41; positivity&#160;and mean CCI&#160;score&#160;were not found to be significantly associated with peritonitis &#40;table 2&#41;&#46;</p><p class="elsevierStylePara">Table 3 shows the differences among patients according to PD allocation type&#46; The different characteristics of patients with or without anti-HCV Ab are shown on table 4&#46;</p><p class="elsevierStylePara">Twenty two patients &#40;20&#46;2&#37;&#41; had more than one&#160;episode during the follow-up period&#46; Fourteen of these patients &#40;64&#37;&#41; were females&#46; When patients with single episodes were compared to those with multiple episodes&#44; the percentage of female patients were significantly higher among those with multiple episodes &#40;p &#61; 0&#46;01&#41;&#46; Serum albumin level &#40;p &#61; 0&#46;001&#41;&#44; type of allocation to PD &#40;p &#61; 0&#46;01&#41; and type of PD treatment &#40;p &#61; 0&#46;03&#41; were also sigificantly different&#44; however the number of diabetic patients was not higher in patients with multiple episodes than in patients with single episodes&#46; The frequency of anti-HCV positivity was not significantly different in patients with multiple episodes when compared with patients with single episodes&#46; The results of comparisons between patients with single and multiple peritonitis episodes can be seen in table 5&#46;</p><p class="elsevierStylePara">At the end of the follow-up period&#44; 93 &#40;85&#46;3&#37;&#41; patients were still on peritoneal dialysis&#44; 4 &#40;4&#46;3&#37;&#41; patients were referred to hemodialysis&#44; 4 &#40;4&#46;3&#37;&#41; patients died while 8 &#40;8&#46;6&#37;&#41; patients were transplanted&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Peritonitis&#160;episode rate can vary from region to region and from centre to centre within the same country<span class="elsevierStyleSup">16&#44;17</span>&#46; The level of our centre was lower than those accepted by European Best Practice &#40;1&#58;24 months&#41; and International Society of Peritoneal Dialysis &#40;ISPD&#41; &#40;1&#58;18 months&#41; Guidelines<span class="elsevierStyleSup">18&#44;19</span>&#46;</p><p class="elsevierStylePara">Peritonitis rate in diabetics&#44; whether is higher or not compared to non-diabetics&#44; most of the time&#44; is a matter of debate in the literature<span class="elsevierStyleSup">6&#44;20&#44;21</span>&#46; But&#44; mostly the finding is towards a higher but non significant difference in the rate of peritonitis in diabetics&#44; same as our finding&#46; Additionally in multivarite regression analysis&#44; we could not show an association between diabetes and &#40;table 2&#41; peritonitis and morever there was no significant difference in terms of diabetes when patients with single and multiple peritonitis episodes were compared &#40;table 5&#41;&#46;</p><p class="elsevierStylePara">Mean level of serum albumin of the patients&#44; determined throughout the whole follow up period was found to be a significant factor associated with peritonitis according to regression analysis &#40;p &#61; 0&#46;05&#44; OR &#61; 1&#46;2&#41;&#46; Hypoalbuminaemia relates with a chronic state of inflammation due to renal failure and dialysis&#160;but it can also be related to malnutrition and overhydration<span class="elsevierStyleSup">22</span>&#46; In our study we could not find an association between chronic systemic inflammation&#44;&#160;determined by mean serum&#160;CRP levels&#44; and rate of peritonitis&#46; Accordingly&#44; the&#160;association between hypoalbuminemia and peritonitis we showed&#44; was probably&#160;indicating&#160;malnutrition to be the associated risk factor for peritonitis&#46; Whatever the reason&#44; it is certain that hypoalbuminaemia is a predisposing factor for peritonitis hence should be fought in PD patients in order to decrease peritonitis incidence<span class="elsevierStyleSup">23&#44;24</span>&#46;</p><p class="elsevierStylePara">In a very recent study&#44; obligatory referral to PD was found to be significantly related to higher mortality among PD patients<span class="elsevierStyleSup">12</span>&#46; In our study we found that obligatory referral is significantly related to higher peritonitis rates &#40;p &#61; 0&#46;04&#44; OR &#61; 2&#46;6&#41;&#46; In another recent study&#44; transferring from HD to PD was also found to be a risk factor for peritonitis<span class="elsevierStyleSup">13</span>&#46; Reasons of obligatory referral such as loss of AV access chance due to long years on HD&#160;may&#160;indicate more comorbid conditions in this group of patients which&#160;was shown in our study such that duration of ESRD&#44;&#160;mean CCI score and percentage of patients changed from haemodialysis were significantly higher in patients obligatorily allocated to PD treatment &#40;table 3&#41;&#46;&#160;However&#44; neither ESRD duration nor CCI score&#160;were found to be associated risk factors for peritonitis&#160;&#40;table 2&#41;&#46; Hence&#44; it should&#160;be kept in mind that&#44; lack of motivation of these patients in case of a mandatory referral can lead to problems like peritonitis and hence technical failure&#44; due to reluctance and carelessness in carrying out the PD procedure&#46; In order to understand&#160; better&#44; the contribution of each reason for increased mortality&#44; peritonitis and technical failure in these patients&#44; we need to carry out&#160;further prospective studies&#46;</p><p class="elsevierStylePara">We know APD is mainly driven by patient preference as it improves life style of patients&#46; It has also been considered to have an advantage over CAPD in reducing the incidence of peritonitis which have been shown in some studies<span class="elsevierStyleSup">25-27</span> whereas in others no difference were found between the two different modalities of PD treatment<span class="elsevierStyleSup">13&#44;28</span>&#46; In our study&#44; the rate of peritonitis was lower in APD patients when compared to CAPD patients &#40;0&#46;21 episode&#47;patient year vs 0&#46;22 episode&#47;patient year&#41; but the difference was not significant&#46; In multiple regression analysis&#44; type of PD treatment was not found to be a risk factor for peritonitis&#46; We believe&#44; in addition to lesser contact with catheter due to the technic of APD&#44; lower frequency of peritonitis among APD patients may partly be due to increased preference and hence motivation of the patients choosing APD&#46; Following comparison between patients with single episodes with the ones with multiple episodes we found a significantly higher number of CAPD patients in multiple episodes group which may be at least partly due to higher motivation of APD patients&#46; We believe a prospective trial considering motivation of the patients is needed for better understanding the difference in incidence of peritonitis between different types of PD treatments&#46;</p><p class="elsevierStylePara">The prevalance and seroconversion rates of anti-HCV ab positivity are lower in PD than HD patients which is considered to be an advantage of PD over HD<span class="elsevierStyleSup">29&#44;30</span>&#46; However&#44; there is no data comparing HCV status to peritonitis in PD patients&#46; In our study&#44; multiple regression analysis reveals anti-HCV ab positivity to be a factor associated with episodes of peritonitis in PD patients &#40;table 2&#41;&#46; Patients with anti HCV positivity were on dialysis for a longer period&#44; had a higher CCI score and were obliged to&#160;PD treatment more than anti-HCV negative patients &#40;table 4&#41;&#46;&#160;Probably this obligation was the real underlying associated&#160;factor for&#160;peritonitis in this group of patients&#46;</p><p class="elsevierStylePara">The results of statistical analysis of mutiple episodes compared to single episodes showed that serum albumin is significantly lower for patients who had more than one isolated peritonitis&#160;episode when compared with patients who had multiple episodes during follow up period &#40;p &#61; 0&#46;001&#41;&#46; Patients who had multiple episodes were also allocated to PD mandatorily more frequently than the ones who had single&#160;episode &#40;p &#61; 0&#46;01&#41; supporting the findigs in multiple regression analysis&#46; These two factors were consistent with associated risk factors for time to first peritonitis&#160;episode strenthening them to be risk factors for peritonitis episodes in PD patients&#46; Morever&#44; as mentioned above&#44; APD patients were less in number in multiple&#160;episode group than CAPD patients which might be related to difference in motivation between two dialysis treatment types&#46; Additionally&#44; there were significantly more females among patients with multiple episodes compared to ones with single episode&#46; In our study&#44; sex was not a risk factor for developing peritonitis episodes &#40;p &#61; 0&#46;5&#41;&#46; However&#44; female patients were found to have significantly more multiple episodesthan male patients&#46; In several studies female gender is shown to be a risk factor for peritonitis<span class="elsevierStyleSup">13&#44;31</span>&#46;</p><p class="elsevierStylePara">In conclusion&#44; mean serum albumin levels in a PD patient is significantly associated with peritonitis and should be closely monitored during follow up&#46; Obligatory referral which can be an indication of loss of motivation for peritoneal dialysis procedures is thought to be a strong risk factor for peritonitis in PD patients and should be further studied&#46; Patients with multiple&#160;episodes were more hypoalbuminemic&#44; had a higher frequency of mandatorry referral and they were mostly females when compared to patients with single&#160;episode during follow up&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;12528&#95;en&#95;10796&#95;t5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_12528_en_10796_t5.jpg" alt="Comparison of peritoneal dialysis patients who had single attack with patients who had multiple attacks "></img></a></p><p class="elsevierStylePara">Table 5&#46; Comparison of peritoneal dialysis patients who had single attack with patients who had multiple attacks </p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15493&#95;en&#95;10796&#95;t2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15493_en_10796_t2.jpg" alt="Multiple regression analysis for factors associated with peritonitis episodes"></img></a></p><p class="elsevierStylePara">Table 2&#46; Multiple regression analysis for factors associated with peritonitis episodes</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15495&#95;en&#95;10796&#95;t1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15495_en_10796_t1.jpg" alt="Demographic data&#44; comorbidity status and laboratory data &#40;mean levels&#41; of the patients"></img></a></p><p class="elsevierStylePara">Table 1&#46; Demographic data&#44; comorbidity status and laboratory data &#40;mean levels&#41; of the patients</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15496&#95;en&#95;10796&#95;t3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15496_en_10796_t3.jpg" alt="Comparison of characteristics of patients according to type of allocation to PD"></img></a></p><p class="elsevierStylePara">Table 3&#46; Comparison of characteristics of patients according to type of allocation to PD</p><p class="elsevierStylePara"><a href="grande&#47;10796&#95;108&#95;15498&#95;en&#95;10796&#95;t4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10796_108_15498_en_10796_t4.jpg" alt="Comparison of characteristics of patients according to anti-hepatitis C virus antibody status"></img></a></p><p class="elsevierStylePara">Table 4&#46; Comparison of characteristics of patients according to anti-hepatitis C virus antibody status</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Aim&#58;</span> Peritonitis is one of the major comorbidities of peritoneal dialysis &#40;PD&#41; patients&#46; The aim of this study was to concentrate on potential risk factors&#44; including more recently studied ones among the classical ones for peritonitis&#44; in PD patients&#46; <span class="elsevierStyleBold">Materials and methods&#58;</span> We analysed 109 patients &#40;F&#47;M &#61; 42&#47;67&#41; followed up at least for 3 months in a single centre&#44; a tertiary referral hospital for 360&#46;1 patient years&#46; In the study which is designed as a retrospective cohort study&#44; demographic characteristics&#44; conditions for choosing PD&#44; type of PD treatment&#44; some chemical tests and peritonitis episodes were recorded from the files of the patients&#46; <span class="elsevierStyleBold">Results&#58; </span>The rate of peritonitis was found to be 0&#46;22 episode&#47;patient year and 22 &#40;20&#46;18&#37;&#41; of the patients had more than one episode&#46; Twenty seven &#40;24&#46;8&#37;&#41; of the patients were allocated to PD due to obligatory reasons&#46; According to multiple regression analysis&#44; the assosciated factors were found to be PD allocation type &#40;obligatory versus voluntary&#41; &#40;p &#61; 0&#46;04&#59; RR &#61; 2&#46;6&#41;&#44; serum albumin level &#40;p &#61; 0&#46;05&#59; RR &#61; 1&#46;2&#41;&#44; and anti-hepatitis C Virus Antibody positivity &#40;p &#61; 0&#46;03&#59; RR &#61; 1&#46;6&#41;&#46; Frequency of female patients were significantly higher in the group who had multiple episodes &#40;p &#61; 0&#46;01&#41;&#46; <span class="elsevierStyleBold">Conclusion&#58;</span> Obligatory referral which can be an indication of loss of motivation for peritoneal dialysis procedures&#44; is thought to be a strong risk factor for peritonitis in PD patients and should be further studied&#46; Patients with multiple episodes had a higher frequency of obligatory referral as expected and additionally&#44; they were higher in number of females when compared to the ones with single episode&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Objetivo&#58;</span> La peritonitis es una de las principales comorbilidades que presentan los pacientes en di&#225;lisis peritoneal &#40;DP&#41;&#46; El objetivo de este estudio es centrarnos en los posibles factores de riesgo&#44; incluidos los de m&#225;s reciente estudio entre los ya cl&#225;sicos factores de la peritonitis en pacientes en DP&#46; <span class="elsevierStyleBold">Materiales y m&#233;todos&#58;</span> Analizamos 109 pacientes &#40;H&#47;M &#61; 67&#47;42&#41; sometidos a seguimiento durante al menos tres meses en un &#250;nico centro&#44; un hospital terciario con una tasa de 360&#44;1 a&#241;os-paciente&#46; En este trabajo&#44; concebido como un estudio de cohorte retrospectivo&#44; se registraron las caracter&#237;sticas demogr&#225;ficas&#44; las condiciones que llevaron a la DP&#44; tipo de DP&#44; pruebas qu&#237;micas y episodios de peritonitis&#46; Esta informaci&#243;n se extrajo de los historiales&#46; <span class="elsevierStyleBold">Resultados&#58; </span>Se descubri&#243; que la tasa de peritonitis era de 0&#44;22 episodios&#47;a&#241;os-paciente y 22 &#40;20&#44;18&#37;&#41; pacientes hab&#237;an padecido m&#225;s de un episodio&#46; Veintisiete &#40;24&#44;8&#37;&#41; de los pacientes recib&#237;an DP por obligaci&#243;n&#46; Gracias al an&#225;lisis de regresi&#243;n m&#250;ltiple&#44; se descubri&#243; que los factores relacionados eran el tipo de llegada al tratamiento &#40;obligatoria frente a voluntaria&#41; &#40;p &#61; 0&#44;04&#59; RR &#61; 2&#44;6&#41;&#44; los niveles de alb&#250;mina s&#233;rica &#40;p &#61; 0&#44;05&#59; RR &#61; 1&#44;2&#41;&#44; y la positividad para anticuerpos contra el virus de hepatitis C &#40;p &#61; 0&#44;03&#59; RR &#61; 1&#44;6&#41;&#46; La frecuencia de pacientes mujeres era significativamente mayor en el grupo que hab&#237;a padecido m&#250;ltiples episodios &#40;p &#61; 0&#44;01&#41;&#46; <span class="elsevierStyleBold">Conclusi&#243;n&#58; </span>La remisi&#243;n obligatoria&#44; que puede ser un indicio de la falta de motivaci&#243;n por los procedimientos de DP&#44; es un importante factor de riesgo de peritonitis en los pacientes en DP y merece ser objeto de estudio&#46; Como era de esperar&#44; los pacientes con m&#250;ltiples episodios presentaron una mayor frecuencia de remisi&#243;n obligatoria y adem&#225;s&#44; el n&#250;mero de mujeres era mayor en comparaci&#243;n con el grupo que hab&#237;a padecido un &#250;nico episodio&#46;</p>"
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