Non-tuberculous and tuberculous mycobacterial peritonitis in peritoneal dialysis patients

Introduction: Peritoneal dialysis (pd)-associated mycobacterium peritonitis is an important clinical entity in patients with end stage renal disease. They present a significant diagnostic and therapeutic challenge for clinicians because clinical findings and laboratory investigations can not be differentiated from symptoms caused by non-tuberculous mycobacterium (ntm), Mycobacterium tuberculosis (tb) or other bacteria. The aim of the present article is to know the differences between the clinical manifestations and laboratory investigations, the appropriate diagnosis, treatment strategies and prognosis for tb and ntm disease in patients with pd-associated mycobacterial infections. Methods: This was a retrospective observational study conducted over a period of 25 years. Out of 1737 patients, only 7 were diagnosed with mycobacterial peritonitis. Result: Evaluable data showed that there were three patients diagnosed with ntm peritonitis and four patients with tuberculous peritonitis. The mean age of the patients was 53.9?±?11.8 years. Although all patients developed abdominal pain and cloudy dialysate, only four patients (57.1%) had fever. Two patients (28.6%) suffered severe sepsis and septic shock. Therefore, the patient survival rates for ntm and tuberculous peritonitis were 100.0% and 75.0%, respectively. Two patients were shifted to long-term hemodialysis; therefore, the technical survival rates for ntm and tuberculous peritonitis were 66.7% and 50.0%, respectively. Notably, recurrence of mycobacterial infection was found in one patient with both pulmonary tuberculosis and tuberculous peritonitis. Conclusion: The diagnosis of mycobacterial peritonitis remains a challenge to medical staffs because of its insidious nature, the variability of its presentation and the limitations of available diagnostic test.     

Cellular response to peritonitis among peritoneal dialysis patients

White blood cell counts and differential cell counts were performed on 249 peritoneal dialysis effluents from 48 patients using chronic peritoneal dialysis. The finding of more than 50% polymorphonuclear leukocytes in the dialysate was a more sensitive indicator of peritonitis than was an absolute cell count of 100 cells/microL. This finding was true for patients using intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis, and continuous cycling peritoneal dialysis.     

Efficacy of a non-vancomycin-based peritoneal dialysis peritonitis protocol

BACKGROUND: Peritonitis has a significant impact upon morbidity and mortality of peritoneal dialysis (PD) patients. Gram-positive organisms account for the majority of infections and vancomycin is a cost effective broad-spectrum antimicrobial treatment for PD peritonitis, but this may lead to the emergence of multiple antibiotic-resistant organisms. The purpose of the present paper was to evaluate the efficacy of a non-vancomycin-based protocol comprising cephazolin and gentamicin, which was introduced in the present PD population as empirical treatment for peritonitis. METHODS: The study involved 82 peritonitis episodes over a 4-year period in 58 patients, excluding those with previous methicillin-resistant staphylococcal peritonitis. RESULTS: With cephazolin and gentamicin there was no apparent difference in response or relapse rates in comparison to reported studies using vancomycin-based first-line therapy protocols. CONCLUSION: We advocate initial treatment of PD peritonitis with non-vancomycin-based therapy given similar efficacy and the potential for reduction of resistant organisms.     

Pantoea peritonitis in a patient receiving chronic ambulatory peritoneal dialysis

Pantoea agglomerans is usually the most common organism transmitted through plant thorn injuries. This report is of a female patient maintained on chronic ambulatory peritoneal dialysis (CAPD) who developed peritonitis attributed to P. agglomerans. Peritonitis is an uncommon complication of P. agglomerans and there is no previous report of peritonitis associated with this organism in a CAPD patient. The source of infection was thought to be due to rose-thorn injury. Antibiotic therapy with ceftazidime and amikacin i.p. led to a clinical improvement, with disappearance of the organism in the peritoneal fluid.     

The changing trends of peritoneal dialysis related peritonitis and novel risk factors

Abstract

Aim: Continuous ambulatory peritoneal dialysis (PD) has become a treatment modality for end stage renal disease with a peak of its use in 1990s. The aim of this study was to examine the peritonitis rates, causative organisms and the risk factors of peritonitis in a large group of patients in our center. Methods: The study was conducted in the Nephrology Department of a University Hospital in Turkey. Patients in the PD programme between January 2000 and January 2006 were included. Cohort-specific and subject specific peritonitis incidence, and peritonitis-free survival were calculated. Causative organisms and risk factors were evaluated. Results: Totally 620 episodes of peritonitis occurred in 440 patients over the six years period. Peritonitis rates showed a decreasing trend through the years (0.79 episodes/patient-year 2000–2003 and 0.46 episodes/patient-year 2003–2006). Cohort-specific peritonitis incidence was 0.62 episodes/patient-years and median subject-specific peritonitis incidence was 0.44 episodes/patient-years. The median peritonitis-free survival was 15.25 months (%95 CI, 9.45–21.06 months). The proportion of gram-negative organisms has increased from 9.8% to 17.3%. There was a significant difference in the percentage of culture negative peritonitis between the first three and the last three years (53.1% vs. 43.2%, respectively). Peritonitis incidence was higher in patients who had been transferred from HD, who had catheter related infection and who had HCV infection without cirrhosis. Conclusions: Our study showed significant trends in the peritonitis rates, causative organisms and antibiotic resistance. Prior HD therapy, catheter related infections and HCV infection were found to be risk factors for peritonitis.     

Peritoneal nitric oxide is a marker of peritonitis in patients on continuous ambulatory peritoneal dialysis

Nitric oxide plays an important role in mediating the inflammatoryprocess. The aim of this study was to evaluate if nitric oxideproduction was increased during peritonitis in patients receivingcontinuous ambulatory peritoneal dialysis (CAPD), and the associationwith the prognosis. The study population comprised 21 patientswith 22 episodes of peritonitis. Fifteen patients without peritonitiswere controls. Nitrate was measured by HPLC and nitrite by theGriess method, to reflect nitric oxide production. Peritonealdialysate effluent and plasma were collected from six patientsduring peritonitis and 1 week after treatment to study changesin dialysate:plasma ratio. In 15 patients, nitrite was measuredduring peritonitis and every 3 days for 2 weeks or until normalizedfor evolutional changes. The dialysate plasma ratios of nitrateand nitrite during peritonitis were reduced 26% and 41.5%, respectively,after 1 week of treatment, indicating the peritoneal productionof nitric oxide during peritonitis. In the evolutional study,a 5.1-fold increase of peak nitrite levels in bacterial peritonitis(n=13) and a 2.5-fold increase in fungal peritonitis (n=3) wereobserved compared to controls. Nitrite gradually declined tocontrol levels (9.3±7.2 days) after effective antibiotictreatment, but took longer than to normalize leukocyte countin the peritoneal dialysate effluent (3.9±1.9 days).In four patients with refractory peritonitis (Candida infectionin three, Acinetobacter infection in one), the nitrite levelsremained elevated 2-fold despite treatment, and the catheterswere removed. It is concluded that nitrite levels in peritonealdialysate effluent may serve as a marker to assess treatmentefficacy in CAPD patients with peritonitis.     

Aspergillus fumigatus peritonitis in ambulatory peritoneal dialysis: a case report and notes on the therapeutic approach

Aspergillus peritonitis is a rare disease in continuous peritoneal dialysis. It is a severe form of peritonitis, which is frequently lethal. We report a case of Aspergillus fumigatus peritonitis in a female patient on automated peritoneal dialysis (APD), who was successfully treated with intravenous amphotericin B and the removal of the peritoneal catheter. As delayed treatment has an increased mortality rate, it is mandatory to remove the catheter and to start intravenous treatment with amphotericin B empirically.     

Longitudinal changes in peritoneal kinetics: the effects of peritoneal dialysis and peritonitis

BACKGROUND.: Peritoneal infection and poor ultrafiltration continue to bethe major causes of treatment failure in CAPD. The combinedeffects of peritonitis and the continuous exposure to dialysisfluid remain the most likely candidates affecting the peritoneumin the long term. The purpose of this study was to observe theeffects of peritonitis and dialysis on longitudinal peritonealfunction. METHODS.: The peritoneal equilibration test (PET) was utilized to quantifylongitudinal changes in low-molecular-weight solute transfer(D/P_creat) and ultrafiltration (UF) in 233 patients treatedwith CAPD. Of these, 166 represented an unselected cohort (Group1) studied prospectively from commencing treatment for up to54 months, and 67 were selected patients (Group 2) with PETdata available at commencement of the study, having been ondialysis for a minimum of 18 months. PETs were performed either6-monthly or following peritonitis episodes. RESULTS.: Data on the short-term effect of peritonitis kinetics were pooledfor groups 1 and 2. Single, isolated episodes (n = 86) had nosignificant effect on D/P_creat or UF, whereas recurrences orclusters of infection (n = 70) caused increases in D/Pcreatand reductions in UF, the significance of which increased withthe number of episodes. There were significant correlationsbetween both changes in D/P_creat and UF with the cumulativedialysate leukocyte count, regardless of infecting organism,suggesting that intensity of peritoneal inflammation is alsoimportant. Those organisms associated with greater change inperitoneal kinetics, e.g. S. aureus, Pseudomonas, also had thehighest neutrophil counts. The longitudinal changes in peritoneal kinetics were analysedfor patients in group 1 only. There was a highly significantincrease in D/P_creat after 6 months treatment; this increasedfurther with time on treatment, reaching further significanceat 42 and 48 months. There was an associated reduction in UF.In view of the short-term effects of peritonitis on kineticsgroup 1 was further subdivided into patients who were eitherperitonitis free or only experienced isolated infections, group1a, and those that had multiple infection episodes, group 1b.Treatment drop-out, due to death or technical failure occurredat double the rate in group 1b, who also had significantly higherD/P_creat and lower UF at 1, 6, 12, 18 and 24 months of treatment.Group 1a subsequently caught up, however, indicating that peritonitisis not the only factor influencing long-term changes in peritonealkinetics. CONCLUSIONS.: These data suggest that solute transfer increases and UF declineswith time on peritoneal dialysis. This process is exacerbatedand accelerated by peritonitis, and appears to be proportionalto the degree of associated inflammation and number of infectionsin close proximity.     

Gel clot LAL assay in the initial management of peritoneal dialysis patients with peritonitis: a retrospective study.

BACKGROUND: Indiscriminate use of broad-spectrum antibiotic treatment of peritonitis in peritoneal dialysis patients may have either unwanted side-effects or contribute to the development of antibiotic resistance. This may be avoided by improved diagnosis at presentation. The Limulus amoebocyte lysate assay is a convenient test detecting bacterial endotoxins or fungal beta glucans. This study evaluates a qualitative Limulus amoebocyte lysate test as a diagnostic tool used at presentation of a peritoneal dialysis patient with peritonitis. METHODS: One-hundred and eleven episodes of peritonitis in peritoneal dialysis patients have been analysed retrospectively. Limulus amoebocyte lysate results at presentation were compared with culture results. A Limulus amoebocyte lysate assay was performed using a commercial kit by incubating a mixture of dialysate effluent and Limulus amoebocyte lysate reagent at 37 degrees C. The development of a stable solid clot was considered positive. The specificity and sensitivity of the test were calculated. RESULTS: The specificity of the Limulus amoebocyte lysate assay was found to be 98% and the sensitivity 74%. Limulus amoebocyte lysate assay was false-negative in 13 cases of Gram-negative peritonitis (22%). Limulus amoebocyte lysate was positive in three of seven cases of fungal peritonitis. The study included one case each with false-positive Limulus amoebocyte lysate and with culture-negative peritonitis. CONCLUSIONS: The Limulus amoebocyte lysate assay is a convenient and valuable diagnostic tool for excluding Gram-positive peritonitis in peritoneal dialysis patients. This allows more specific antibiotic treatment at presentation and may avoid the development of bacterial resistance. A negative Limulus amoebocyte lysate test is not reliable for the exclusion of Gram-negative peritonitis. In the absence of a positive culture result 48 h after presentation, accompanied by a delayed response to treatment, a positive Limulus amoebocyte lysate assay may indicate the presence of fungus. This justifies early empiric antifungal treatment before definitive culture results are made available. Routine Limulus amoebocyte lysate assay of dialysate effluent from continuous ambulatory peritoneal dialysis patients presenting with peritonitis is recommended.     

Factors influencing peritoneal transport parameters during the first year on peritoneal dialysis: peritonitis is the main factor.

BACKGROUND: Studies on the evolution of peritoneal transport during the first year of peritoneal dialysis (PD) are scarce and their results are contradictory. The aim of the present study was to analyse the evolution of peritoneal transport and residual renal function during the first year on PD, and to determine the factors that may influence them. METHODS: We studied 249 patients on continuous ambulatory PD with glucose exchange solutions (117 men, 132 women, mean age 51.9+/-16 years) 59 of whom had diabetes (25 type I). At baseline and after 1 year, we determined the mass transfer coefficients of urea (U-MTAC) and creatinine (Cr-MTAC), net ultrafiltration and residual renal function. RESULTS: Residual renal function decreased significantly during the first year (from 3.9+/-2.8 to 2.4+/-2.2 ml/min, P<0.001). Both U-MTAC and Cr-MTAC decreased after 1 year [U-MTAC from 22.7+/-7.8 to 20.7+/-6.6 ml/min (P<0.001), Cr-MTAC from 10.5+/-5.3 to 10.1+/-4.6 ml/min (NS)]. The ultrafiltration capacity increased significantly (from 923+/-359 to 987 U 341 ml/4 h, P<0.001). The evolution of MTAC values was independent of age, sex, diabetes and amount of hypertonic glucose used. When patients were grouped according to their initial Cr-MTAC, we observed a tendency toward normalization of the parameters of peritoneal function. Patients with peritonitis (n = 88) showed a first year increase in Cr-MTAC, which was significantly higher than in patients without peritonitis (11.1+/-5 vs 9.5+/-4.2, P<0.01). Ultrafiltration decreased in patients with more than four accumulated days of peritonitis (from 1062+/-447 to 1024+/-340 ml/4 h, NS); it increased in patients without peritonitis. CONCLUSIONS: The peritoneal transport parameters tended toward normalization during the first year on PD, mainly with a decrease of small solute transport and an increase of ultrafiltration capacity. This evolution is independent of age, gender, diabetes and higher exposure to glucose in PD solutions. Peritonitis was the only independent factor that affected peritoneal function during the first year on peritoneal dialysis.     

Relapsing Bacillus licheniformis peritonitis in a continuous ambulatory peritoneal dialysis patient

Bacillus licheniformis is a rare pathogen in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Only one case of B. licheniformis peritonitis has been previously reported but relapsing peritonitis by same species has not been reported. A 31-year-old man undergoing CAPD was admitted to our hospital with diarrhoea and turbid peritoneal effluent. Although B. licheniformis was cultured at his previous admission, we did not consider the species as a pathogen. After the same species was cultured twice consecutively at the subsequent admission, we confirmed that B. licheniformis was a pathogen of CAPD peritonitis. After appropriate intraperitoneal antibiotics therapy, the patient improved. He is currently undergoing CAPD without catheter removal.     

Encapsulating peritoneal sclerosis in paediatric peritoneal dialysis patients

Encapsulating peritoneal sclerosis (EPS) is a serious complication of chronic peritoneal dialysis (CPD). In contrast to the adult population, there are few studies regarding EPS in paediatric CPD patients, and the majority of reported patients are from Japan. The aim of the present report is to define the incidence of EPS in our paediatric CPD patients and to describe the clinical and laboratory characteristics. A total of 104 paediatric patients were followed from November 1989 to November 2003 and two were diagnosed as EPS (1.9%). The dialysis periods of these patients were 45 and 53 months with 6 and 8 peritonitis episodes, respectively. Clinical signs of EPS developed 7 and 14 days after the removal of the dialysis catheter, and CPD was replaced by haemodialysis because of persistent peritonitis. One patient was well after surgical management but died 6 months later. The second patient who was treated with prednisolone remained well at 16 months. In conclusion, EPS is a rare but important complication of CPD. We recommend that all patients on CPD who develop ultrafiltration failure be evaluated radiologically for the occurrence of EPS. Management should be tailored to the individual patient.     

Role of rosiglitazone in lipopolysaccharide-induced peritonitis: A rat peritoneal dialysis model

Aim: The aim of this study was to demonstrate the efficacy of the peroxisome proliferator‐activated receptor (PPAR)‐γ agonist, rosiglitazone, in the amelioration or prevention of inflammation including peritoneal fibrosis secondary to the peritonitis in a peritoneal dialysis (PD) model of non‐uraemic rats. Methods: Thirty male Sprague–Dawley rats were assigned to six groups according to treatment. A 90 min peritoneal equilibrium test, dialysate cellular components, peritoneal thickness and cellularity were assessed on day 21. Additionally, immunohistochemical stains of peritoneal membrane, such as PPAR‐γ, vascular endothelial growth factor (VEGF), transforming growth factor (TGF)‐β1, collagen‐1 and monocyte chemoattractant protein‐1 were performed Results: The dialysate neutrophil count and peritoneal thickness in the high‐dose rosiglitazone group was significantly decreased compared to the lipopolysaccharide (LPS)‐only group. The peritoneal membrane from the LPS‐only group showed marked cellular proliferation in the area of the submesothelial compact zone compared with the PD‐only group, the rosiglitazone‐only group, and the high‐dose rosiglitazone group. The 90 min peritoneal equilibrium test (PET) results showed no statistical difference among the six groups excluding dialysate‐to‐plasma urea ratio. The number of PPAR‐γ expressing cells and the expression of TGF‐β1 were decreased in the high‐dose rosiglitazone group compared to the LPS‐only group. There were no differences in the expression of VEGF and collagen‐1 among the six groups. Interestingly, the number of PPAR‐γ‐positive cells was correlated with expression of VEGF, TGF‐β1, collagen‐1 and monocyte chemoattractant protein‐1 irrespective of the study group. Conclusion: The results of this study showed that rosiglitazone ameliorated peritoneal inflammation induced by LPS and reduced the TGF‐β1 expression in the peritoneal membranes.     

Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis.

BACKGROUND: Automated peritoneal dialysis (APD) and twin-bag (TB) systems are two major peritoneal dialysis (PD) modalities. Published data comparing the infectious complications of these modalities is limited. Subjects and methods. Ninety-five patients using APD (the APD group) and 117 patients using TB system (the TB group) were recruited. Among them, 35 patients used both modalities. The two groups' clinical characteristics, incidences of infectious complications, and the time intervals to first PD-related infection were compared. RESULTS: Clinical characteristics, incidence of exit-site infection (ESI), and time intervals to first ESI were similar in the TB and APD groups. The incidence of peritonitis in the APD group (1.22 episodes/100 patient-months) was significantly (P < 0.001) lower than that of the TB group (2.28 episodes/100 patient-months). Using the Cox proportional hazard model, APD was found to have a lower risk of peritonitis relative to TB systems, with marginal significance (RR 0.58, P = 0.051). CONCLUSION: APD was found to have a lower peritonitis rate than the TB system. Since reducing the peritonitis rate helps to maintain technical survival during PD, from this viewpoint, APD may be preferred for patients undergoing PD, unless contraindicated.     

Treatment of resistant peritonitis in continuous ambulatory peritoneal dialysis with intraperitoneal urokinase: a double-blind clinical trial

Resistant peritonitis in continuous ambulatory peritoneal dialysis(CAPD) is an indication for catheter removal, followed by interimhaemodialysis and subsequent catheter replacement. This involvestwo surgical procedures using general anaesthetic and the availabilityof adequate hospital haemodialysis facilities. Urokinase isan alternative therapy but evidence of its effect is anecdotaland it has not been studied in a double-blind manner. Patients with resistant peritonitis (either no resolution ofperitonitis within 4 days of appropriate antibiotic therapyor a third episode of peritonitis within 6 months) were randomizedto receive intraperi toneal urokinase or placebo (saline) followedby 14 days of antibiotics in this double-blind prospective study.Treatment success was resolution of peritonitis within 4 daysof giving urokinase/placebo (persistent infection) and no recurrencewith the same organism for 6 months (recurrent infection). Twelvepatients received urokinase and 12 placebo. Treatment was successfulin 8/12 in the urokinase group and 1/12 in the placebo group(Fisher's exact test; P=0.0047). Urokinase was successful in 8/12 patients with resist ant peritonitisand significantly better than placebo. Urokinase is an effectiveand simple treatment that may avoid the need for catheter removaland interim haemodialysis in patients with resistant CAPD peritonitis.     

Aspergillus Niger peritonitis in a peritoneal dialysis patient treated with eculizumab

The complement system plays a vital role in preventing life-threatening infections by ensuring optimal functioning of the host immune system. Its dysregulation has been implicated in causing glomerular, hematological, and transplant-related disorders. Eculizumab a novel monoclonal antibody against complement component C5 has emerged in the recent past as the standard of care offering an effective rescue and maintenance therapy against many of these disorders. Its use has been associated with increased risk of infections predominantly with encapsulated organisms. There is no data in the literature on its effects in end-stage kidney disease (ESKD) or dialysis patients. We describe here a very rare case of Aspergillus Niger peritonitis in an ESKD patient on peritoneal dialysis (PD) receiving maintenance eculizumab therapy for atypical hemolytic uremic syndrome. Given that murine models with the same defect as that induced by eculizumab is vulnerable to invasive Aspergillosis, it is suggested that the fungal peritonitis in this patient was the result of the eculizumab therapy.     

Higher rate and earlier peritonitis in Aboriginal patients compared to non-Aboriginal patients with end-stage renal failure maintained on peritoneal dialysis in Australia: analysis of ANZDATA

BACKGROUND: Aboriginal patients maintained on peritoneal dialysis (PD) have a higher rate of technique failure than any other racial group in Australia. Peritonitis accounts for the bulk of these technique failures, but it is uncertain whether the increased risk of peritonitis in Aboriginal patients was independent of associated comorbid conditions, such as diabetes mellitus. METHODS: Using data collected by the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), peritonitis rates and time to first peritonitis were compared between Aboriginal (n = 238) and non-Aboriginal patients (n = 2924) commencing PD in Australia between 1 April 1999 and 31 March 2003. RESULTS: Aboriginal PD patients were younger, and had a higher incidence of diabetes than their non-Aboriginal counterparts. Mean peritonitis rates were significantly higher among Aboriginal (1.15 episodes/year; 95% confidence interval (CI): 1.03-1.28) than non-Aboriginal patients (0.60 episodes/year; 95% CI: 0.57-0.62, P < 0.05). Using multivariate negative binomial regression, independent predictors of higher peritonitis rates include Aboriginal racial origin (adjusted odds ratio 1.78; 95% CI: 1.45-2.19), obesity, age and absence of a recorded dialysate : plasma creatinine ratio (D/P creatinine) measurement. Aboriginal racial origin was also associated with a shorter median time to first peritonitis (9.9 vs 19.3 months, P < 0.05), which remained statistically significant in a multivariate Cox proportional hazards model (adjusted hazard ratio 1.76; 95% CI: 1.47-2.11, P < 0.05). CONCLUSION: Aboriginal and obese PD patients have a higher rate of peritonitis and a shorter time to first peritonitis, independent of demographic and comorbid factors. Further investigation of the causes of increased peritonitis risk in Aboriginal patients is needed.