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[Resumen] Las infecciones peritoneales siguen constituyendo una complicación muy relevante de la diálisis peritoneal, por su incidencia todavía elevada y por sus importantes consecuencias clínicas, en términos de mortalidad, fracaso de la técnica y costes para el sistema sanitario. Las prácticas de prevención y tratamiento de esta complicación muestran una notable heterogeneidad derivada, entre otros factores, de la complejidad del problema y de la escasez de evidencia clínica que permitan responder de manera clara a muchas de las dudas planteadas. El propósito de este documento es proporcionar una revisión completa y actualizada de los métodos de diagnóstico, prevención y tratamiento de estas infecciones. El documento se ha elaborado tomando como referencia de partida la guía más reciente de la Sociedad Internacional de Diálisis Peritoneal (2016). Mientras que para el capítulo diagnóstico se ha adoptado una estructura más narrativa, el análisis de las medidas de prevención y tratamiento ha seguido una metodología sistemática (Grading of Recommendations, Assessment, Development and Evaluation [GRADE]), que especifica el nivel de evidencia y la fuerza de las sugerencias y recomendaciones propuestas, y facilita actualizaciones futuras de la guía. La gran extensión y numerosas recomendaciones o sugerencias emanadas de la revisión ponen de manifiesto la complejidad y gran número de facetas a tener en cuenta para un adecuado abordaje de esta importante complicación de la diálisis peritoneal., [Abstract] Peritoneal infections still represent a most feared complication of chronic peritoneal dialysis, due to their high incidence and relevant clinical consequences, including direct mortality, technique failure and a significant burden for the health system. The practices for prevention and treatment of this complication show a remarkable heterogeneity emerging, among other factors, from the complexity of the problem and from a paucity of quality evidence which could permit to respond clearly to many of the raised questions. The purpose of this document is to provide a complete and updated review of the main methods of diagnosis, prevention and treatment of these infections. The document has been elaborated taking as a reference the most recent guidelines of the International Society of Peritoneal Dialysis (2016). The diagnostic considerations are presented in a narrative style while, for prevention and therapy, we have used a systematic methodology (Grading of Recommendations, Assessment, Development and Evaluation [GRADE]), which specifies the level of evidence and the strength of the proposed suggestions and recommendations and facilitates future updates of the document. The length of the document and the many suggestions and recommendations coming out of the review underline the large number and the complexity of the factors to be taken into consideration for an adequate approach to this complication of peritoneal dialysis.

[Abstract] Preservation of the peritoneal membrane is an essential determinant of the long-term outcome of peritoneal dialysis (PD). Epithelial-to-mesenchymal transition (EMT) plays a central role in the pathogenesis of PD-related peritoneal membrane injury. We hypothesized that mitochondria may be implicated in the mechanisms that initiate and sustain peritoneal membrane damage in this setting. Hence, we carried out ex vivo studies of effluent-derived human mesothelial cells, which disclosed a significant increase in mitochondrial reactive oxygen species (mtROS) production and a loss of mitochondrial membrane potential in mesothelial cells with a fibroblast phenotype, compared to those preserving an epithelial morphology. In addition, in vitro studies of omentum-derived mesothelial cells identified mtROS as mediators of the EMT process as mitoTEMPO, a selective mtROS scavenger, reduced fibronectin protein expression induced by TGF-ß1. Moreover, we quantified mitochondrial DNA (mtDNA) levels in the supernatant of effluent PD solutions, disclosing a direct correlation with small solute transport characteristics (as estimated from the ratio dialysate/plasma of creatinine at 240 min), and an inverse correlation with peritoneal ultrafiltration. These results suggest that mitochondria are involved in the EMT that human peritoneal mesothelial cells suffer in the course of PD therapy. The level of mtDNA in the effluent dialysate of PD patients could perform as a biomarker of PD-induced damage to the peritoneal membrane.

[Abstract] Introduction: Prior abdominal surgery may result in peritoneal membrane adhesions and fibrosis, compromising the success of peritoneal dialysis (PD). The impact of this factor on peritoneal membrane function and PD technique survival has not been adequately investigated. Methods: Following an observational, retrospective design, we studied 171 incident PD patients, with the main objective of analyzing the influence of prior abdominal surgical procedures (main study variable) on baseline and evolutionary peritoneal transport characteristics (main outcome) and PD patient and technique survival (secondary outcomes). Abdominal surgeries were categorized according to the degree of presumed injury to the peritoneal membrane. We also considered the additive effect of aggressions to the membrane during the first year on PD therapy. Results: All patients had a baseline peritoneal equilibration test with complete drainage at 60′, and 113 patients had a second study at the end of the first year. Sixty-one patients (35.7%) had a record of prior abdominal surgery, including 29 patients with at least one major intraperitoneal surgery, 22 having undergone minor intraperitoneal procedures, and 21 with a background of major abdominopelvic extraperitoneal surgery. We did not observe differences, at baseline or after 1 year, among patients with or without previous abdominal procedures regarding small solute transport, overall capacity of ultrafiltration, free water transport, small pore ultrafiltration, or peritoneal protein excretion. Stratified analysis, considering prior and first-year-on-PD peritoneal aggressions, did not reveal any differences, although in this case our analysis was hampered by a limited statistical power. Abdominal surgical events did not influence patient or PD technique survival. Conclusion: Prior abdominal surgical procedures do not appear to compromise peritoneal membrane function or technique survival in patients successfully started on PD.

[Abstract} Background. The selective impact of strategies for prevention of PD-related peritonitis (PDrP) may have modified, in the long term, the causal spectrum, clinical presentation and outcomes of these infections. Objectives. To compare trends in the incidence of PDrP by different microorganisms during a 30-year period, with a particular focus on streptococcal infections. To analyze the clinical presentation and outcomes of these infections. Secondarily, to investigate how the isolation of different species of streptococci can influence the clinical course of PDrP by this genus of bacteria. Method. Following a retrospective, observational design we investigated 1061 PDrP (1990–2019). We used joinpoint regression analysis to explore trends in the incidence of PDrP by different microorganisms, and compared the risk profile (Cox), clinical presentation and outcomes (logistic regression) of these infections. Main results. Our data showed a progressive decline in the incidence of PDrP by staphylococci and Gram negative bacteria, while the absolute rates of streptococcal (average annual percent change +1.6%, 95% CI -0.1/+3.2) and polymicrobial (+1.8%, +0.1/+3.5) infections tended to increase, during the same period. Remarkably, streptococci were isolated in 58.6% of polymicrobial infections, and patients who suffered a streptococcal PDrP had a 35.8% chance of presenting at least one other infection by the same genus. The risk profile for streptococcal infections was comparable to that observed for PDrP overall. Streptococcal PDrP were associated with a severe initial inflammatory response, but their clinical course was generally nonaggressive thereafter. We did not observe a differential effect of different groups of streptococci on the clinical presentation or outcome of PDrP. Conclusions. Time trends in the incidence of PDrP by different microorganisms have granted streptococci an increasing relevance as causative agents of these infections, during the last three

[Abstract] Background: Overhydration (OH) complicates frequently the clinical course of Peritoneal Dialysis (PD) patients, and keeps a controversial association with the risk of peritoneal infection. The main objective of this study was to disclose an association between persistent OH and the risk of enteric peritonitis in a relatively large sample of patients undergoing PD. Method: Following a prospective design, we monitorized systematically body composition of patients treated with PD in our unit (2011–2016), searching for a correlation with the ensuing risk of peritonitis, with an emphasis on the association between persistent OH (main study variable) and the risk of infection by enteric pathogens (main outcome). Essential demographic, clinical and laboratory variables with a potential influence on the risk of peritonitis were recorded. We used multivariate survival analysis to clarify the specific effect of different body composition parameters on the main outcome. Main results: We included 139 patients for analysis (mean follow-up 24 months). Sixty-three patients suffered at least one peritonitis, and 17 had at least one diagnosis of enteric peritonitis. Univariate analysis disclosed a general trend to an increased risk of enteric peritonitis in overhydrated patients, as evidenced by associations of this outcome with mean extracellular water/intracellular water (ECW/ICW)(p = 0007), OH/ECW (p = 0033) and ECW/total body water (ECW/TBW)(p = 0004) ratios, but not with absolute OH values. Multivariate analysis confirmed similar associations or trends (RR 3,48, 95 % CI 1,03–14,59, p = 0,046, highest versus lowest tertile of ECW/ICW, RR 2,31, 95 % CI 0,98-6,56, p = 0,061, highest versus lowest tertile of OH/ECW, and RR 6,33, 95 % CI 1,37-19,37, p = 0,011, highest versus lowest tertile of ECW/TBW). On the contrary, no apparent association was detected between OH and the overall risk of peritoneal infection., [Resumen] Antecedentes y objetivos. La sobrehidratación (SH) es frecuente, y a menudo persistente, en pacientes tratados con diálisis peritoneal (DP), y mantiene una asociación controvertida con el riesgo de infección peritoneal. El objetivo principal de este estudio fue desvelar una posible asociación entre la presencia de SH y el riesgo subsiguiente de infección peritoneal por gérmenes entéricos, en una población relativamente amplia de pacientes tratados con DP. Método Según diseño prospectivo, monitorizamos de manera sistemática la composición corporal de pacientes tratados con DP en nuestra unidad (2011-2016), buscando una posible correlación con el riesgo de peritonitis durante el seguimiento, con un interés particular en la asociación entre SH persistente (variable de estudio principal) y el riesgo de infección peritoneal por patógenos entéricos (variable resultado principal). Para el análisis tuvimos en cuenta variables demográficas, clínicas y de laboratorio con influencia potencial en el riesgo de infección peritoneal. Utilizamos técnicas de análisis multivariante para clarificar el efecto específico de diferentes parámetros de composición corporal sobre la variable resultado principal. Resultados principales. Incluimos 139 pacientes, con seguimiento medio de 24 meses. Sesenta y tres pacientes sufrieron al menos una peritonitis, y 17 al menos una infección por gérmenes entéricos. El análisis univariante mostró una tendencia general a mayor riesgo de infección peritoneal entérica en pacientes sobrehidratados, que se hacía evidente cuando se usaba el cociente agua extracelular/agua intracelular (AEC/AIC) (p=0,007), el cociente SH/AEC (SH/AEG) (p=0,033), o el cociente AEC/agua corporal total (AEC/ACT) (p=0,004), pero no cuando se usaba la SH absoluta, como variable de estudio. El análisis multivariante confirmó estas asociaciones o tendencias (RR: 3,48; IC 95%: 1,03-14,59; p=0,046, tercil mayor versus menor para AEC/AIC, RR: 2,31; IC 95%: 0,98-6,56; p=0,061

[Abstract] Background Preservation of residual kidney function (RKF) is a relevant objective in peritoneal dialysis (PD) patients. The influence of dietary protein intake (PI) on this variable has not been adequately investigated. Methods Following an observational design, we studied 336 patients incident on PD, with a minimum follow-up of 6 months. The main study variable was the mean PI [normalized rate of protein nitrogen appearance (nPNA)] during the first 4 months on PD. The main outcome variables were the absolute rate of decline of RKF and the proportion of patients presenting a >50% decay of their RKF during the first year of follow-up. We applied univariate and multivariate strategies of analysis, taking into consideration the main control variables bearing a correlation with nPNA and/or RKF. Results Mean nPNA (first 4 months) was 1.23 ± 0.33 g/kg/day, while the overall rate of decline of RKF was −0.13 ± 0.29 mL/min/month; 69 patients (25.1%) had lost >50% of their initial RKF by the end of the first year. Univariate analysis disclosed consistent associations between the main study variable on one hand and baseline RKF (r = 0.32, P < 0.0005) and its rate of decline (r = −0.23, P < 0.0005) on the other. The latter two variables were also significantly correlated (r = −0.36, P < 0.0005). Multivariate analysis identified mean nPNA as an independent predictor of the rate of decline of RKF [odds ratio 1.09 per 0.10 g/kg/day, 95% confidence interval (CI) 0.99–1.19, P = 0.058] and, in particular, of the probability of losing >50% of the baseline RKF during the first year of treatment (odds ratio 1.15 per 0.10 g/kg/day, 95% CI 1.04–1.27, P = 0.006). Conclusion Higher rates of PI during the first months of therapy are associated with a faster decline of RKF among patients incident on PD. Our results underline the convenience of keeping an adequate balance between sufficient protein ingestion, to prevent malnutrition and wasting, and sensible restriction in stable, a

El trabajo es una aproximación descriptiva que pretende conocer los Programas de Mejora del Aprendizaje y del Rendimiento (PMAR), según la visión del alumnado, profesorado de los ámbitos y orientadores pertenecientes a 6 IES de la Provincia de Sevilla. Se utilizaron cuestionarios y entrevistas para la recogida de datos, que, posteriormente, fueron sometidos a un análisis de contenido y categorización. Los resultados obtenidos muestran que, en algunos casos, no se sigue la legislación de forma exhaustiva en la selección del alumnado y las valoraciones de los agentes implicados difieren notablemente respecto al programa, siendo las más favorables las de los estudiantes. En conclusión, son necesarias otras medidas para atender a todo el alumnado que no reúne algunos de los requisitos de acceso al PMAR., The following work is a descriptive approach that seeks to know the Programs for the Improvement of Learning and Performance (PMAR), according to the vision of the students, teachers of the fields and counselors belonging to 6 IES of the Province of Seville. Questionnaires and interviews were used to collect data, which were subsequently subjected to content analysis and categorization. The results obtained show that, in some cases, the legislation is not followed exhaustively in the selection of students and the assessments of the agents involved differ markedly with respect to the program, being the most favorable those of the students. In conclusion, other measures are necessary to attend to all students who do not meet some of the requirements for access to PMAR.

The following work is a descriptive approach that seeks to know the Programs for the Improvement of Learning and Performance (PMAR), according to the vision of the students, teachers of the fields and counselors belonging to 6 IES of the Province of Seville. Questionnaires and interviews were used to collect data, which were subsequently subjected to content analysis and categorization. The results obtained show that, in some cases, the legislation is not followed exhaustively in the selection of students and the assessments of the agents involved differ markedly with respect to the program, being the most favorable those of the students. In conclusion, other measures are necessary to attend to all students who do not meet some of the requirements for access to PMAR, El trabajo es una aproximación descriptiva que pretende conocer los Programas de Mejora del Aprendizaje y del Rendimiento (PMAR), según la visión del alumnado, profesorado de los ámbitos y orientadores pertenecientes a 6 IES de la Provincia de Sevilla. Se utilizaron cuestionarios y entrevistas para la recogida de datos, que, posteriormente, fueron sometidos a un análisis de contenido y categorización. Los resultados obtenidos muestran que, en algunos casos, no se sigue la legislación de forma exhaustiva en la selección del alumnado y las valoraciones de los agentes implicados difieren notablemente respecto al programa, siendo las más favorables las de los estudiantes. En conclusión, son necesarias otras medidas para atender a todo el alumnado que no reúne algunos de los requisitos de acceso al PMAR

[Abstract] Background: Peritoneal infections of enteric origin (EntP) have been classically investigated using partial strategies, focused on particular subgroups of microorganisms. A more comprehensive approach may facilitate the definition of the nomenclature and clinical presentation of these infections. Objectives: To investigate the clinical presentation and outcomes of a full spectrum of EntP, with a particular interest in the comparison between single-organism and polymicrobial infections. Method: Following an observational design, we investigated 165 single-organism and 83 polymicrobial peritonitis episodes with isolation of at least 1 enteric bacteria (Enterobacteriaceae, Enterococcus spp. and/or intestinal anaerobics). We compared the risk of treatment failure for these 2 types of infection and explored the significance of the isolation of specific microorganisms and of their antibacterial susceptibility patterns. Results: Polymicrobial EntP was associated with higher rates of hospitalization, more changes to initial antibiotic therapy, more surgical explorations, and higher mortality and treatment failure rates than monobacterial EntP. However, stratified and multivariate analyses revealed that the burden of these differences rested on the isolation of intestinal anaerobics (odds ratio [OR] 12.05, 95% confidence interval [CI] 2.53–31.09, p < 0.001) and/or Enterococcus faecium (OR 3.37, 95% CI 1.02–11.30, p = 0.046), while other polymicrobial infections were more comparable with single-organism peritonitis, except for even higher mortality rates in the former group. Lower antibiotic susceptibility of the isolations (OR 1.18, 95% CI 0.51–2.70, p = 0.70) did not perform as a predictor of treatment failure. Conclusion: A comprehensive approach to peritoneal infections by intestinal microorganisms may provide a focused perspective of the clinical presentation and outcomes of these complications of peritoneal dialysis.