Exit site infection in peritoneal dialysis : predictive factors for adverse outcome
DOI:
https://doi.org/10.25796/bdd.v2i3.21333Keywords:
Peritoneal dialysis, exit site infections, outcomes, catheter, Dialyse péritonéale, infection site de sortie, survie, cathéterAbstract
Infection-related complications in patients on peritoneal dialysis (PD) is a leading complication.
Our aim was to evaluate the type and natural course of ESI events in a cohort of PD treated in last decade of our PD program.
Registry data of ESI events (n=126, in 74 patients) were retrieved. ESI protocols followed standard international guidelines. A systematic quality control is performed.
The median follow-up was 29.1 (14.0-47.4) months. In this population the adverse outcomes of TI rate and peritonitis rate was 0.12 and 0.13 patient/year, respectively. Male sex (0.048), older age (0.007) and Staphylococcus aureus (SA) agent (0.006) were predictive of TI while non-optional PD and lower levels of albumin were predictive of peritonitis. After grouping the ESI events according to the date of the occurrence of infection (group 1: 2008 to 2012, group 2: 2013 to 2017 and group 3: 2018) a substantial increase of TI in 2018 was evident (P <0.001 when comparing group 3 vs 1 and 0.005 when comparing group 2 and 3). When ESI occurs simultaneous with TI, the probability of not reaching cure is 65%. Drop-out occurred in 50% of ESI without peritonitis vs 86% with peritonitis (P <0.001). SA is the microorganism most implicated in the failure to heal (P 0.002) and drop-out (P 0.010).
In spite of a number of efforts to reduce ESI, a regular audit still point to the need for protocols review in order to avoid adverse outcomes. Focused training of patients is mandatory but also prophylaxis and antibiotic protocols deserve improvement.
References
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[4] Holley JL, Bernardini J, Piraino B. Risk factors for tunnel infections in continuous peritoneal dialysis. Am J Kidney Dis 1991; 18:344–8.
[5] Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Catheter-related interventions to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. J Am Soc Nephrol 2004; 15:2735–46.
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[7] Rubin J, Didlake R, Raju S, Hsu H. A prospective randomized evaluation of chronic peritoneal catheters. Insertion site and intraperitoneal segment. ASAIO Trans 1990; 36: M497–500.
[8] Restrepo CA, Buitrago CA, Holguin C. Implantation of peritoneal catheters by laparotomy: nephrologists obtained similar results to general surgeons. Int J Nephrol Renovasc Dis 2014; 7:383–90.
[9] de Moraes TP, Campos RP, de Alcântara MT, Chula D, Vieira MA, Riella MC, et al. Similar outcomes of catheters implanted by nephrologists and surgeons: analysis of the Brazilian peritoneal dialysis multicentric study. Semin Dial 2012; 25:565–8.
[10] Cox TC, Blair LJ, Huntington CR, Prasad T, Kercher KW, Heniford BT, et al. Laparoscopic versus open peritoneal dialysis catheter placement. Surg Endosc 2016; 30:899–905.
[11] Xie H, Zhang W, Cheng J, He Q. Laparoscopic versus open catheter placement in peritoneal dialysis patients: a systematic review and meta- analysis. BMC Nephrol 2012; 13:69.
[12] Chula DC, Campos RP, de Alcântara MT, Riella MC, do Nascimento MM. Percutaneous and surgical insertion of peritoneal catheter in patients starting in chronic dialysis therapy: a comparative study. Semin Dial 2014; 27:E32–7.
[13] Al-Hwiesh AK. Percutaneous versus laparoscopic placement of peritoneal dialysis catheters: simplicity and favorable outcome. Saudi J Kidney Dis Transpl 2014; 25:1194–201.
[14] Sun C, Zhang M, Jiang C. Vertical tunnel-based low-site peritoneal dialysis catheter implantation decreases the incidence of catheter malfunction. Am Surg 2015; 81:1157–62.
[15] Ejlersen E, Steven K, Lokkegaard H. Paramedian versus midline incision for the insertion of permanent peritoneal dialysis catheters. A randomized clinical trial. Scand J Urol Nephrol 1990; 24:151–4.
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[17] Brum S, Rodrigues A, Rocha S, Carvalho MJ, Nogueira C, Magalhães C, et al. Moncrief-Popovich technique is an advantageous method of peritoneal dialysis catheter implantation. Nephrol Dial Transplant 2010; 25:3070–5.
[18] Park MS, Yim AS, Chung SH, Lee EY, Cha MK, Kim JH, et al. Effect of pro- longed subcutaneous implantation of peritoneal catheter on peritonitis rate during CAPD: a prospective randomized study. Blood Purif 1998; 16:171–8.
[19] Danielsson A, Blohme L, Tranaeus A, Hylander B. A prospective randomized study of the effect of a subcutaneously ‘buried’ peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection. Perit Dial Int 2002; 22:211–9.
[20] Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Am JKidneyDis2004;44:591–603.
[21] Wikdahl AM, Engman U, Stegmayr BG, Sorenssen JG. One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion. Nephrol Dial Transplant 1997; 12:157–60.
[22] Lye WC, Lee EJ, Tan CC. Prophylactic antibiotics in the insertion of Tenckhoff catheters. Scand J Urol Nephrol 1992; 26:177–80.
[23] Bennet-Jones DN, Martin JB, Barratt AJ, Duffy TJ, Naish PF, Aber GM. Prophylactic gentamicin in the prevention of early exit-site infections and peritonitis in CAPD. Adv PeritDial1988;4:147–50.
[24] Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L, Tatro S. Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Am J Kidney Dis 2000; 36:1014–9.
[25] Liu Y, Zhang L, Lin A, Ni Z, Qian J, Fang W. Impact of break-in period on the short-term outcomes of patients started on peritoneal dialysis. Perit Dial Int 2014; 34:49–56.
[26] Povlsen JV, Ivarsen P. How to start the late referred ESRD patient urgently on chronic APD. Nephrol Dial Transplant 2006; 21(Suppl 2):ii56–9.
[27] Sharma AP, Mandhani A, Daniel SP, Filler G. Shorter break-in period is a viable option with tighter PD catheter securing during the insertion. Nephrology (Carlton) 2008; 13:672–6.
[28] Yang YF, Wang HJ, Yeh CC, Lin HH, Huang CC. Early initiation of continuous ambulatory peritoneal dialysis in patients undergoing surgical implantation of Tenckhoff catheters. Perit Dial Int 2011; 31:551–7.
[29] Mupirocin Study Group. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group. J Am Soc Nephrol 1996; 7:2403–8.
[30] Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis 2003; 37:1629–38.
[31] Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kidney Dis 1996; 27:695–700.
[32] Chu KH, Choy WY, Cheung CC, Fung KS, Tang HL, Lee W, et al. A prospective study of the efficacy of local application of gentamicin versus mupirocin in the prevention of peritoneal dialysis catheter-related infections. Perit Dial Int 2008; 28:505–8.
[33] Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2010; 25:587–92.
[34] Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, et al. Effect of local mupirocin application on exit-site infection and peritonitis in an Indian peritoneal dialysis population. Perit Dial Int 2005; 25:473–7.
[35] Lim CT, Wong KS, Foo MW. The impact of topical mupirocin on peritoneal dialysis infection in Singapore General Hospital. Nephrol Dial Transplant 2005; 20:2202–6.
[36] Davenport A. Do topical antibiotics reduce exit-site infection rates and peritonitis episodes in peritoneal dialysis patients? The Pan Thames Renal Audit. J Nephrol 2012; 25:819–24.
[37] Wong C, Luk IW, Ip M, You JH. Prevention of gram-positive infections in peritoneal dialysis patients in Hong Kong: a cost-effectiveness analysis. Am J Infect Control 2014; 42:412–6.
[38] Lobbedeez T, Gardam M, Dedier H, Burdzy D, Chu M, Izatt S, et al. Rou- tine use of mupirocin at the peritoneal catheter exit site and mupirocin resistance: still low after 7 years. Nephrol Dial Tranplant 2004; 19:3140–3.
[39] Perez-Fontan M, Rosales M, Rodriguez-Carmona A, Falcon TG, Valdes F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis 2002; 39:337–41.
[40] Annigeri R, Conly J, Vas S, Dedier H, Prakashan KP, Bargman JM, et al. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int 2001; 21:554–9.
[41] Piraino B. Mupirocin for preventing peritonitis and exit site infections in patients undergoing peritoneal dialysis. Was it effective? Nephrol Dial Transplant 2010; 25:349–52.
[42] Mahaldar A, Weisz M, Kathuria P. Comparison of gentamicin and mupirocin in the prevention of exit-site infection and peritonitis in peritoneal dialysis. Adv Perit Dial 2009; 25:56–9.
[43] Pierce DA, Williamson JC, Mauck VS, Russell GB, Palavecino E, Burkart JM. The effect on peritoneal dialysis pathogens of changing topical antibiotic prophylaxis. Perit Dial Int 2012; 32:525–30.
[44] Lo MW, Mak SK, Wong YY, Lo KC, Chan SF, Tong GM, et al. Atypical mycobacterial exit-site infection and peritonitis in peritoneal dialysis patients on prophylactic exit-site gentamicin cream. Perit Dial Int 2013; 33:267–72.
[45] Chen SS, Sheth H, Piraino B, Bender F. Long-term exit-site gentamicin prophylaxis and gentamicin resistance in a peritoneal dialysis program. Perit Dial Int 2016; 36(4):387–9.
[46] Thokhonelidze I, Maglakelidze N, Sarishvili N, Kasradze T, Dalakishvili K. Single-center experience in successful prevention of exit-site infection in patients on peritoneal dialysis. Georgian Med News 2015; 241:54–8.
[47] Fuchs J, Gallagher E, Jackson-Bey D, Krawtz D, Schreiber MJ. A prospective randomized study of peritoneal catheter exit-site care. Nephrol Hypertens 1990; 19:81–4.
[48] Jones LL, Tweedy L, Warady BA. The impact of exit-site care and catheter design on the incidence of catheter-related infections. Adv Perit Dial 1995; 11:302–5.
[49] Shelton DM. A comparison of the effects of two antiseptic agents on Staphylococcus epidermidis colony forming units at the peritoneal dialysis catheter exit site. Adv Perit Dial 1991; 7:120–4.
[50] Firanek C, Guest S. Hand hygiene in peritoneal dialysis. Perit Dial Int 2011; 31:399–408.
[51] Mushahar L, Mei LW, Yusuf WS, Sivathasan S, Kamaruddin N, Idzham NJ. Exit-site dressing and infection in peritoneal dialysis: a randomized controlled pilot trial. Perit Dial Int 2016; 36:135–9.
[52] Prowant BF, Warady BA, Nolph KD. Peritoneal dialysis catheter exit-site care: results of an international survey. Perit Dial Int 1993; 13:149–54.
[53] Twardowski ZJ, Prowant BF. Current approach to exit-site infection in patients on peritoneal dialysis. Nephrol Dial Transplant 1997;12:1284–95.
[54] Figueiredo AE, Bernardini J, Bowes E, et al. A syllabus for teaching peritoneal dialysis patients and caregivers. Perit Dial Int. 2016, 36:592–605. 94. Piraino B, Bernardini J, Brown E, et al. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int. 2011;31:614–630).
[2] Flanigan MJ, Hochstetler LA, Langholdt D, Lim VS. Continuous ambulatory peritoneal dialysis catheter infections: diagnosis and management. Perit Dial Int 1994; 14:248–54.
[3] Plum J, Sudkamp S, Grabensee B. Results of ultrasound-assisted diagnosis of tunnel infections in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1994; 23:99-104.
[4] Holley JL, Bernardini J, Piraino B. Risk factors for tunnel infections in continuous peritoneal dialysis. Am J Kidney Dis 1991; 18:344–8.
[5] Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Catheter-related interventions to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. J Am Soc Nephrol 2004; 15:2735–46.
[6] Ejlersen E, Steven K, Lokkegaard H. Paramedian versus midline incision for the insertion of permanent peritoneal dialysis catheters. A randomized clinical trial. Scand J Urol Nephrol 1990; 24:151–4.
[7] Rubin J, Didlake R, Raju S, Hsu H. A prospective randomized evaluation of chronic peritoneal catheters. Insertion site and intraperitoneal segment. ASAIO Trans 1990; 36: M497–500.
[8] Restrepo CA, Buitrago CA, Holguin C. Implantation of peritoneal catheters by laparotomy: nephrologists obtained similar results to general surgeons. Int J Nephrol Renovasc Dis 2014; 7:383–90.
[9] de Moraes TP, Campos RP, de Alcântara MT, Chula D, Vieira MA, Riella MC, et al. Similar outcomes of catheters implanted by nephrologists and surgeons: analysis of the Brazilian peritoneal dialysis multicentric study. Semin Dial 2012; 25:565–8.
[10] Cox TC, Blair LJ, Huntington CR, Prasad T, Kercher KW, Heniford BT, et al. Laparoscopic versus open peritoneal dialysis catheter placement. Surg Endosc 2016; 30:899–905.
[11] Xie H, Zhang W, Cheng J, He Q. Laparoscopic versus open catheter placement in peritoneal dialysis patients: a systematic review and meta- analysis. BMC Nephrol 2012; 13:69.
[12] Chula DC, Campos RP, de Alcântara MT, Riella MC, do Nascimento MM. Percutaneous and surgical insertion of peritoneal catheter in patients starting in chronic dialysis therapy: a comparative study. Semin Dial 2014; 27:E32–7.
[13] Al-Hwiesh AK. Percutaneous versus laparoscopic placement of peritoneal dialysis catheters: simplicity and favorable outcome. Saudi J Kidney Dis Transpl 2014; 25:1194–201.
[14] Sun C, Zhang M, Jiang C. Vertical tunnel-based low-site peritoneal dialysis catheter implantation decreases the incidence of catheter malfunction. Am Surg 2015; 81:1157–62.
[15] Ejlersen E, Steven K, Lokkegaard H. Paramedian versus midline incision for the insertion of permanent peritoneal dialysis catheters. A randomized clinical trial. Scand J Urol Nephrol 1990; 24:151–4.
[16] Rubin J, Didlake R, Raju S, Hsu H. A prospective randomized evaluation of chronic peritoneal catheters. Insertion site and intraperitoneal segment. ASAIO Trans 1990; 36: M497–500.
[17] Brum S, Rodrigues A, Rocha S, Carvalho MJ, Nogueira C, Magalhães C, et al. Moncrief-Popovich technique is an advantageous method of peritoneal dialysis catheter implantation. Nephrol Dial Transplant 2010; 25:3070–5.
[18] Park MS, Yim AS, Chung SH, Lee EY, Cha MK, Kim JH, et al. Effect of pro- longed subcutaneous implantation of peritoneal catheter on peritonitis rate during CAPD: a prospective randomized study. Blood Purif 1998; 16:171–8.
[19] Danielsson A, Blohme L, Tranaeus A, Hylander B. A prospective randomized study of the effect of a subcutaneously ‘buried’ peritoneal dialysis catheter technique versus standard technique on the incidence of peritonitis and exit-site infection. Perit Dial Int 2002; 22:211–9.
[20] Strippoli GF, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents to prevent peritonitis in peritoneal dialysis: a systematic review of randomized controlled trials. Am JKidneyDis2004;44:591–603.
[21] Wikdahl AM, Engman U, Stegmayr BG, Sorenssen JG. One-dose cefuroxime i.v. and i.p. reduces microbial growth in PD patients after catheter insertion. Nephrol Dial Transplant 1997; 12:157–60.
[22] Lye WC, Lee EJ, Tan CC. Prophylactic antibiotics in the insertion of Tenckhoff catheters. Scand J Urol Nephrol 1992; 26:177–80.
[23] Bennet-Jones DN, Martin JB, Barratt AJ, Duffy TJ, Naish PF, Aber GM. Prophylactic gentamicin in the prevention of early exit-site infections and peritonitis in CAPD. Adv PeritDial1988;4:147–50.
[24] Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L, Tatro S. Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Am J Kidney Dis 2000; 36:1014–9.
[25] Liu Y, Zhang L, Lin A, Ni Z, Qian J, Fang W. Impact of break-in period on the short-term outcomes of patients started on peritoneal dialysis. Perit Dial Int 2014; 34:49–56.
[26] Povlsen JV, Ivarsen P. How to start the late referred ESRD patient urgently on chronic APD. Nephrol Dial Transplant 2006; 21(Suppl 2):ii56–9.
[27] Sharma AP, Mandhani A, Daniel SP, Filler G. Shorter break-in period is a viable option with tighter PD catheter securing during the insertion. Nephrology (Carlton) 2008; 13:672–6.
[28] Yang YF, Wang HJ, Yeh CC, Lin HH, Huang CC. Early initiation of continuous ambulatory peritoneal dialysis in patients undergoing surgical implantation of Tenckhoff catheters. Perit Dial Int 2011; 31:551–7.
[29] Mupirocin Study Group. Nasal mupirocin prevents Staphylococcus aureus exit-site infection during peritoneal dialysis. Mupirocin Study Group. J Am Soc Nephrol 1996; 7:2403–8.
[30] Tacconelli E, Carmeli Y, Aizer A, Ferreira G, Foreman MG, D’Agata EM. Mupirocin prophylaxis to prevent Staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clin Infect Dis 2003; 37:1629–38.
[31] Bernardini J, Piraino B, Holley J, Johnston JR, Lutes R. A randomized trial of Staphylococcus aureus prophylaxis in peritoneal dialysis patients: mupirocin calcium ointment 2% applied to the exit site versus cyclic oral rifampin. Am J Kidney Dis 1996; 27:695–700.
[32] Chu KH, Choy WY, Cheung CC, Fung KS, Tang HL, Lee W, et al. A prospective study of the efficacy of local application of gentamicin versus mupirocin in the prevention of peritoneal dialysis catheter-related infections. Perit Dial Int 2008; 28:505–8.
[33] Xu G, Tu W, Xu C. Mupirocin for preventing exit-site infection and peritonitis in patients undergoing peritoneal dialysis. Nephrol Dial Transplant 2010; 25:587–92.
[34] Mahajan S, Tiwari SC, Kalra V, Bhowmik DM, Agarwal SK, Dash SC, et al. Effect of local mupirocin application on exit-site infection and peritonitis in an Indian peritoneal dialysis population. Perit Dial Int 2005; 25:473–7.
[35] Lim CT, Wong KS, Foo MW. The impact of topical mupirocin on peritoneal dialysis infection in Singapore General Hospital. Nephrol Dial Transplant 2005; 20:2202–6.
[36] Davenport A. Do topical antibiotics reduce exit-site infection rates and peritonitis episodes in peritoneal dialysis patients? The Pan Thames Renal Audit. J Nephrol 2012; 25:819–24.
[37] Wong C, Luk IW, Ip M, You JH. Prevention of gram-positive infections in peritoneal dialysis patients in Hong Kong: a cost-effectiveness analysis. Am J Infect Control 2014; 42:412–6.
[38] Lobbedeez T, Gardam M, Dedier H, Burdzy D, Chu M, Izatt S, et al. Rou- tine use of mupirocin at the peritoneal catheter exit site and mupirocin resistance: still low after 7 years. Nephrol Dial Tranplant 2004; 19:3140–3.
[39] Perez-Fontan M, Rosales M, Rodriguez-Carmona A, Falcon TG, Valdes F. Mupirocin resistance after long-term use for Staphylococcus aureus colonization in patients undergoing chronic peritoneal dialysis. Am J Kidney Dis 2002; 39:337–41.
[40] Annigeri R, Conly J, Vas S, Dedier H, Prakashan KP, Bargman JM, et al. Emergence of mupirocin-resistant Staphylococcus aureus in chronic peritoneal dialysis patients using mupirocin prophylaxis to prevent exit-site infection. Perit Dial Int 2001; 21:554–9.
[41] Piraino B. Mupirocin for preventing peritonitis and exit site infections in patients undergoing peritoneal dialysis. Was it effective? Nephrol Dial Transplant 2010; 25:349–52.
[42] Mahaldar A, Weisz M, Kathuria P. Comparison of gentamicin and mupirocin in the prevention of exit-site infection and peritonitis in peritoneal dialysis. Adv Perit Dial 2009; 25:56–9.
[43] Pierce DA, Williamson JC, Mauck VS, Russell GB, Palavecino E, Burkart JM. The effect on peritoneal dialysis pathogens of changing topical antibiotic prophylaxis. Perit Dial Int 2012; 32:525–30.
[44] Lo MW, Mak SK, Wong YY, Lo KC, Chan SF, Tong GM, et al. Atypical mycobacterial exit-site infection and peritonitis in peritoneal dialysis patients on prophylactic exit-site gentamicin cream. Perit Dial Int 2013; 33:267–72.
[45] Chen SS, Sheth H, Piraino B, Bender F. Long-term exit-site gentamicin prophylaxis and gentamicin resistance in a peritoneal dialysis program. Perit Dial Int 2016; 36(4):387–9.
[46] Thokhonelidze I, Maglakelidze N, Sarishvili N, Kasradze T, Dalakishvili K. Single-center experience in successful prevention of exit-site infection in patients on peritoneal dialysis. Georgian Med News 2015; 241:54–8.
[47] Fuchs J, Gallagher E, Jackson-Bey D, Krawtz D, Schreiber MJ. A prospective randomized study of peritoneal catheter exit-site care. Nephrol Hypertens 1990; 19:81–4.
[48] Jones LL, Tweedy L, Warady BA. The impact of exit-site care and catheter design on the incidence of catheter-related infections. Adv Perit Dial 1995; 11:302–5.
[49] Shelton DM. A comparison of the effects of two antiseptic agents on Staphylococcus epidermidis colony forming units at the peritoneal dialysis catheter exit site. Adv Perit Dial 1991; 7:120–4.
[50] Firanek C, Guest S. Hand hygiene in peritoneal dialysis. Perit Dial Int 2011; 31:399–408.
[51] Mushahar L, Mei LW, Yusuf WS, Sivathasan S, Kamaruddin N, Idzham NJ. Exit-site dressing and infection in peritoneal dialysis: a randomized controlled pilot trial. Perit Dial Int 2016; 36:135–9.
[52] Prowant BF, Warady BA, Nolph KD. Peritoneal dialysis catheter exit-site care: results of an international survey. Perit Dial Int 1993; 13:149–54.
[53] Twardowski ZJ, Prowant BF. Current approach to exit-site infection in patients on peritoneal dialysis. Nephrol Dial Transplant 1997;12:1284–95.
[54] Figueiredo AE, Bernardini J, Bowes E, et al. A syllabus for teaching peritoneal dialysis patients and caregivers. Perit Dial Int. 2016, 36:592–605. 94. Piraino B, Bernardini J, Brown E, et al. ISPD position statement on reducing the risks of peritoneal dialysis-related infections. Perit Dial Int. 2011;31:614–630).
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Silva FS, Tavares J, Correia SO, Freitas C, santos O, Carvalho MJ, Malheiro J, Cabrita A, Rodrigues A. Exit site infection in peritoneal dialysis : predictive factors for adverse outcome. Bull Dial Domic [Internet]. 2019 Sep. 14 [cited 2024 Nov. 22];2(3):127-34. Available from: https://bdd.rdplf.org/index.php/bdd/article/view/21333
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Copyright (c) 2019 Filipa Sofia Silva, Joana Tavares, Sofia O Correia, Cristina Freitas, Olivia Santos, Maria João Carvalho, Jorge Malheiro, António Cabrita, Anabela Rodrigues
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