Blackwell Science, LtdOxford, UKNEPNephrology1320-53582004 Asian Pacific Society of NephrologyOctober 20049S3S56S58MiscIndications for the use of urokinase in peritoneal dialysis–associated

peritonitisThe CARI Guidelines

NEPHROLOGY 2004; 9, S56–S58

5. Indications for the use of urokinase in peritoneal

dialysis–associated peritonitis
Date written: February 2003
Final submission: July 2004

GUIDELINES

The use of antibiotics with catheter replacement is superior to antibiotics with urokinase to treat peritoneal
dialysis-associated peritonitis. (Level II evidence)

BACKGROUND who received urokinase compared with 1 who received

antibiotics alone.2
The use of urokinase seems logical, because of its poten- A prospective randomised trial of 80 peritoneal dial-
tial to dissolve fibrin clots causing the obstruction of ysis patients (40 in each group) that compared treat-
peritoneal dialysis (PD) catheters and to dissolve biofilm ment with antibiotics and intraperitoneal urokinase
lining the inside of PD catheters, which harbour micro- 5000 IU against treatment with antibiotics alone
organisms in patients with peritonitis. showed no statistically significant difference in out-
The purpose of this guideline is to identify the comes between the two treatment groups. Outcomes
circumstances in which that procedure might be used. included duration of peritonitis, severity of symptoms
and signs of peritonitis, and peritonitis recurrence or
relapse rate.3
SEARCH STRATEGY

Databases searched: MeSH terms and text words for peri- SUMMARY OF THE EVIDENCE
toneal dialysis were combined using ‘and’ with MeSH
terms and text words for catheters. These were then com- The evidence to date neither supports nor rejects the use
bined using ‘and’ with MeSH terms and text words for of urokinase in PD-associated peritonitis.
urokinase. The search was carried out in Medline (1966
– October Week 5 2002). The Cochrane Renal Group
Trials Register was also searched for trials not indexed in SUGGESTIONS FOR CLINICAL CARE
Medline.
Date of searches: 26 November 2002. (Suggestions are based on Level III and IV evidence)
• Urokinase may lyse some fibrin thrombi that
obstruct catheters
WHAT IS THE EVIDENCE? 7000 IU of urokinase infused into the obstructed
PD catheters of 10 CAPD patients (4 of whom had
Williams et al. performed a randomised controlled peritonitis) restored flow without causing complica-
trial in which 17 patients received intraperitoneal tions.4
urokinase (5000 IU) on the second and fourth days Urokinase or streptokinase combined with antibiotic
of appropriate antibiotic treatment for CAPD perito- therapy succeeded in curing peritonitis in 8/16 patients
nitis; 14 patients underwent catheter replacement.1 but failed in another 8 patients treated with the same
A further 6 patients who had a recurrence of perito- regimen.5
nitis after urokinase treatment underwent catheter Intraluminal urokinase treatment repeated daily for
replacement. Peritonitis subsequently recurred in sig- 3 days in conjunction with intensive antibiotic treat-
nificantly more patients after urokinase treatment ment cured peritonitis in 9 paediatric CAPD patients
(41%) than after catheter replacement (5%). whereas relapses occurred in 75.8% of events in
In a randomised prospective trial, 24 patients with controls.6
persistent or recurring CAPD peritonitis received treat- A literature review of largely anecdotal reports of
ment with antibiotics for 14 days; 12 also received intra- streptokinase and urokinase treatment of PD peritoni-
peritoneal urokinase. Treatment succeeded in 8 patients tis concluded that streptokinase had an unacceptably
Indications for the use of urokinase in peritoneal dialysis–associated peritonitis
high adverse reaction rate and that catheter removal
was a more effective therapy than thrombolysis. The
authors proposed that clinicians should reserve uroki-
nase treatment for antibiotic-compliant patients who
develop two or more episodes of recurrent or persistent
peritonitis and in whom dialysis catheter removal is
contraindicated.7
WHAT DO THE OTHER GUIDELINES SAY?
Kidney Disease Outcomes Quality Initiative: No
recommendation.
British Renal Association: Refers to Gokal et al.8: If out-
flow obstruction occurs shortly after catheter placement
or after peritonitis, it may be due to a clot or fibrin. Flush-
ing with streptokinase or urokinase and heparin may
restore the flow immediately.
Canadian Society of Nephrology: No recommendation.
European Best Practice Guidelines: Refer to the Inter-
national Guidelines.
International Guidelines: Adults: Re Outflow/Inflow
Obstruction
1 Conservative or non-invasive approaches such as
body position change, walk on staircases, laxatives,
flushing with heparinized saline (‘push-and-suck’
manoeuvre) should be undertaken. If these fail, then
instillation of fibrinolytic agents (urokinase, streptoki-
nase 10 000 U in 2 mL left in the catheter for
2 hours) may be tried.9
IMPLEMENTATION AND AUDIT
Document the outcome of urokinase-treated PD
patients.
S57
SUGGESTIONS FOR FUTURE RESEARCH
Establish a registry of urokinase-treated PD patients and
their outcomes.
REFERENCES
1. Williams AJ, Boletis I, Johnson BF et al. Tenckhoff catheter replace-
ment or intraperitoneal urokinase: A randomised trial in the
management of recurrent continuous ambulatory peritoneal dialysis
(CAPD) peritonitis. Perit. Dial. Int. 1989; 9: 65–7.
2. Innes A, Burden RP, Finch RG et al. Treatment of resistant perito-
nitis in continuous ambulatory peritoneal dialysis with intraperito-
neal urokinase: A double-blind clinical trial. Nephrol. Dial.
Transplant. 1994; 9: 797–9.
3. Gadallah MF, Tamayo A, Sandborn M et al. Role of intraperitoneal
urokinase in acute peritonitis and prevention of catheter loss in
peritoneal dialysis patients. Adv. Perit. Dial. 2000; 16: 233–6.
4. Strippoli P, Pilolli D, Mingrone G et al. A hemostasis study in
CAPD patients during fibrinolytic intraperitoneal therapy with
urokinase (UK). Adv. Perit. Dial. 1989; 5: 97–9.
5. Murphy G, Tzamaloukas AH, Eisenberg B et al. Intraperitoneal
thrombolytic agents in relapsing or persistent peritonitis of patients
on continuous ambulatory peritoneal dialysis. Int. J. Artif. Organs
1991; 14: 87–91.
6. Klaus G, Schafer F, Querfeld U et al. Treatment of relapsing
peritonitis in pediatric patients on peritoneal dialysis. Adv. Perit.
Dial. 1992; 8: 302–5.
7. Worland MA, Radabaugh RS, Mueller BA. Intraperitoneal throm-
bolytic therapy for peritoneal dialysis-associated peritonitis. Ann.
Pharmacother. 1998; 32: 1216–20.
8. Gokal R, Ash SR, Helfrich GB et al. Peritoneal catheters and exit-
site practices: Toward optimum peritoneal access. Perit. Dial. Int.
1993; 13: 29–39.
9. Gokal R, Alexander S, Ash S et al. Peritoneal catheters and exit-
site practices toward optimum peritoneal access: 1998 update. Offi-
cial report from the International Society for Peritoneal Dialysis.
Perit. Dial. Int. 1998; 18: 11–33.
APPENDIX S58

Table 1 Characteristics of randomised controlled trial evidence

Study ID Intervention Intervention Follow up
(author, year) N Study Design Setting Participants (experimental group) (control group) (months) Comments
Gadallah et al. 2000 80 Randomised controlled University PD patients who developed a Intraperitoneal urokinase No urokinase 36 None
clinical trial first episode of peritonitis; (5000 IU)
32.5% diabetic on first day of diagnosis
Innes et al. 1994 24 Randomised controlled Teaching CAPD patients with resistant Urokinase 5000 Ploug Placebo plus Unclear None
clinical trial hospital peritonitis (persistent or units in 5 mL of N saline antibiotic
recurrent infection) at onset of 3rd peritonitis (same as for
episode within 6 months experimental
(recurrent infection) or intervention)
after 4 days of antibiotic
treatment with no
resolution (persistent
infection); antibiotic
treatment continued for
14 days
Williams et al. 1989 37 Randomised controlled Teaching CAPD patients with Intraperitoneal urokinase One stage 3–12 months None
clinical trial hospital peritonitis (5000 IU) intravenous removal and re-
plus antibiotic insertion of
Tenckhoff
catheter plus
antibiotic

Table 2 Quality of randomised trials

Study ID Method of allocation Blinding

(author, year) concealment (participants) (investigators) (outcome assessors) Intention-to-treat analysis Loss to follow up (%)
Gadallah et al. 2000 Unclear No No No Unclear 0
Innes et al. 1994 Unclear Yes Not stated Not stated Yes 0
Williams et al. 1989 Unclear No No No No Unclear

Table 3 Results for dichotomous outcomes

Intervention group (number of Control group (number of
Study ID patients with events/number patients with events/number Relative risk (RR) Risk difference (RD)
(author, year) Outcomes of patients exposed) of patients not exposed) [95% CI] [95% CI]
Gadallah et al. 2000 Catheter loss 3/40 6/40 0.50 (0.13–1.86) -0.08 (-0.21–0.06)
Innes et al. 1994 Failure of treatment of peritonitis 4/12 11/12 0.36 (0.16–0.82) -0.58 (-0.89 to –0.27)
Williams et al. 1989 Recurrent peritonitis at <1 month 7/17 1/20 8.24 (1.12–60.43) 0.36 (0.11–0.61)
The CARI Guidelines