Rothia dentocariosa Repeat and Relapsing Peritoneal Dialysis-Related Peritonitis: A Case Report and Literature Review

Peritonitis is well recognized as the Achilles tendon of peritoneal dialysis (PD). Reoccurrence of peritonitis due to the same organism, defined as either repeat or relapsing peritonitis under the 2005 guidelines by the International Society for Peritoneal Dialysis, often results in PD technique failure. Rothia dentocariosa, a low-virulent human oropharynx commensal, is a rarely reported pathogen in human infection, particularly infective endocarditis. R. dentocariosa PD-related peritonitis is exceedingly uncommon yet potentially results in repeat or relapsing peritonitis which requires catheter removal. We report a case of R. dentocariosa repeat and relapsing peritonitis in a PD patient who was treated successfully with antimicrobial therapy.     

持续非卧床腹膜透析患者腹膜炎的临床分析

目的：通过分析影响持续非卧床腹膜透析（CAPD）患者发生腹膜炎的因素,为腹膜炎的防治制定合理的方案。方法：调查2005年2月1日～2009年10月31日行CAPD患者的临床资料,以单因素方差分析及COX回归法分析影响患者发生腹膜炎的因素。结果：105例患者中有35例发生53次腹膜炎。致病菌中革兰阳性菌多见。术后1月内培养出的致病菌均是球菌类,而术后1月后杆菌类占43.5%。在导致腹膜炎的原因中,操作因素及消化道因素占67.9%。糖尿病患者腹膜炎发生率为36.8%,非糖尿病患者腹膜炎发生率为32.6%。白蛋白浓度下降与患者发生腹膜炎相关（P〈0.01）。结论：腹膜透析相关性腹膜炎最常见的细菌仍是球菌类。术后早期发生的腹膜炎均是球菌类,可能与早期操作不熟练相关;术后1月后杆菌类比例迅速增加,可能为消化道因素增多所致。相对于非糖尿病患者,糖尿病腹膜透析患者腹膜炎的发生率高,无腹膜炎生存时间短。白蛋白浓度降低为腹膜炎发生的高危因素。     

Initial Experiences with Continuous Ambulatory Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) has been initiated on 51 patients: 27 females (mean age -- 43.9 years) and 24 males (mean age -- 46.4 years). This group has been observed for a total of 1420 patient weeks of treatment (27.3 patient years). Thirty-six episodes of peritonitis have been noted among 19 patients. The overall incidence was one episode per 39.4 patient weeks. Recurrent episodes of peritonitis resulted in discontinuation of CAPD in five (9.8%) of the patients. Three (5.9%) of the patients were unable to continue with CAPD because of its inability to control extracellular fluid balance. In the patients who transferred from intermittent peritoneal dialysis to CAPD, there was a 4.5 mg/dl drop in serum creatinine and a 34 mg/dl drop in mean BUN values. There was a rise of approximately 2 gm in the hemoglobin levels of this group of patients. If the problem of peritonitis can be solved, CAPD will become the dialytic treatment of choice for the majority of patients with end-stage renal disease.     

Comparison of Blood and Peritoneal Lymphocytes from Continuous Ambulatory Peritoneal Dialysis Patients,Asymptomatic and with Peritonitis

Objective. The purpose of this study was to compare the characteristics of the blood immunophenotype of CAPD patients with and without peritonitis and to compare the phenotypes of peripheral blood lymphocytes (PBL) and peritoneal lymphocytes (PL) in CAPD patients with peritonitis. Methods. Fifty-seven CAPD patients (20 with peritonitis and 37 without peritonitis) were recruited in the study (mean age 66,88 ± 13,48, male/female 16/21). Lymphocyte subsets (CD2+, CD3+, CD3+/4+, CD3+/8+, CD3-/16 + 56+, CD4/CD8 ratio) were quantitated by using monoclonal antibodies and dual-color flow cytometric analysis. With the above method we measured PBL in patients with and without peritonitis. In patients with peritonitis we also measured PL. Results. CD2 were slightly decreased in patients with peritonitis. Those patients also had more intense CD3 + /CD4+ lymphopenia (p < 0.05) and larger expansion of NK cells (p < 0.05). Patients with peritonitis appeared to have a lower ratio of CD4/CD8 (p < 0.05). All the above results are shown to . Following the onset of peritonitis, a consistent finding in all patients was a significant increase in CD2 population of PL compared with PBL (85.71 ± 9.20 versus 82.60 ± 7.34, p < 0.05) as well as in CD3 population (77.01 ± 13.09 versus 68.74 ± 13.43, p < 0.05). An increased number of CD3/8 in PL compared with PBL (33.70 ± 9.34 versus 27.98 ± 10.77, p < 0.05) was also noted. Conclusions. In the present study, we found important immune activation in asymptomatic CAPD patients. The activation increases during peritonitis. The causes and the clinical consequences of chronic activation remain unknown.     

腹膜炎对CAPD患者腹膜小分子物质转运与超滤功能的影响

目的观察了腹透时间、腹膜炎对连续非卧床腹膜透析(CAPD)患者腹膜转运与超滤功能的影响.方法观察对象为1998年～2001年在我透析中心行CAPD患者101例,其中发生腹膜炎者12例,为观察组;无腹膜炎发作史者89例,为对照组.于开始腹透后第1、6、12、18、24月分别进行腹膜平衡实验(PET),用于评价腹膜的小分子溶质转运(D/Pcreat)及超滤能力(UF).结果在无腹膜炎发作史的89例患者中,其D/Pcreat比值随腹透的进行而逐渐缓慢上升,至12个月时达到最大值(0.65±0.05),与透析第1个月相比无显著性差异(0.61±0.06,P=0.065);在伴有腹膜炎发作史者,其D/Pcreat比值上升幅度较大,并于腹透的第12个月也达到高峰值(0.74±0.056),与对照组相比有显著性差异(P＜0.05);在开始CAPD后,所有患者超滤量(UF)随透析时间延长,呈快速下降过程,特别是在伴有腹膜炎发作史的患者更为明显.无腹膜炎发作史的患者于透析第18个月达到最低水平(351±48 ml),与透析第1个月相比有显著性差异(382±42 ml,P＜0.05),而伴有腹膜炎发作史的患者则于开始透析后的第12个月达最低水平(326±57 ml),两组的差别具有统计学意义(P＜0.05).经线性回归分析,累积腹膜炎发作时间与腹膜肌酐转运水平(D/Pcreat)呈明显正相关(r=0.83),与腹膜超滤量(UF)呈负相关(r=-0.75).结论以糖为基质的常规CAPD对腹膜转运功能与超滤功能具有一定的负面影响,而腹膜炎则明显加剧或恶化常规CAPD对腹膜功能的负面作用.因此,进一步提高CAPD技术与方法,降低腹膜炎发生率仍是肾科工作者所面临的主要问题之一.     

Sclerosing Peritonitis: Report of Three Cases

Sclerosing peritonitis is a dramatic complication of continuous ambulatory peritoneal dialysis and chronic peritoneal inflammation. Both visceral and parietal surfaces of the peritoneal cavity are involved. A thickened peritoneum encloses the small intestine in a «cocoon» formation which often leads to intestinal occlusion. CT scan may help obtaining an early diagnosis but diagnosis is often established with some delay or even at the time of laparotomy. Our report describes three cases of this uncommon peritoneal fibrosis syndrome which caused intestinal obstruction requiring surgical intervention.     

Mycobacterium chelonae Peritonitis in a Patient on Peritoneal Dialysis

Non-tuberculous mycobacteria peritonitis is uncommon with the majority of cases reported in patients on peritoneal dialysis with diagnostic and therapeutic challenges. Here we present a case of Mycobacterium chelonae peritonitis and review other cases in the literature to discuss the clinical spectrum, diagnostics, regimens and duration of treatment, and outcome.     

Fas Expression on Peritoneal Macrophages during Continuous Ambulatory Peritoneal Dialysis Peritonitis

Background. Peritonitis is a common complication of end stage renal failure (ESRF) patients receiving continuous ambulatory peritoneal dialysis (CAPD). Peritoneal macrophage may participate in the activation of specific T cells and in the generation of local cell-mediated immunity to various pathogens. The purpose of this study is to investigate the possible role of macrophage in CAPD patients with peritonitis. Methods. We evaluated the expression of Fas receptor (CD95), ICAM-1 (CD54), CD25, and CD69 by two-color flow cytometry on extravasted macrophages from 16 ESRF patients on CAPD with peritonitis (peritonitis-positive) and compared them to 11 ESRF patients on CAPD without peritonitis (peritonitis-negative) and normal controls. Results. We found an increased expression of CD95, CD54, and CD25 on macrophage in peritonitis-positive group compared to controls (all p < 0.001). In the peritonitis-positive group, the CD95 expression was significantly higher than that of the peritonitis-negative group (p < 0.001). The expression of CD54, CD25, and CD69, however, was not significantly different between the peritonitis-positive and peritonitis-negative CAPD subgroups. Conclusion. We found an abnormally increased percentage of macrophage-expressing Fas receptor and ICAM-1, and the percentage of CD95+ macrophage, but not those of other markers, were increased among the subset of CAPD patients with peritonitis. The later finding suggests that this macrophage phenotype is associated with peritonitis occurring in CAPD.     

Candida parapsilosis Peritonitis Has More Complications Than Other Candida Peritonitis in Peritoneal Dialysis Patients

Candida parapsilosis is the most prevalent pathogen of fungal peritonitis in peritoneal dialysis (PD). The difference between C. parapsilosis peritonitis and other C. species for clinical outcomes and treatment responses to fungal peritonitis remains unclear. This retrospective study of fungal peritonitis attempts to answer that question. A total 22 patients with fungal peritonitis in 762 PD patients were enrolled in this study. The mean age of the 22 patients, 9 males and 13 females, was 54.7 ± 12.5 years with a mean PD duration of 39.7 ± 33.4 months. Candida species accounted for 86% (19 cases) of fungal peritonitis and 41% (9 cases) were C. parapsilosis. Thirteen (59%) patients received fluconazole as monotherapy; others received either amphotericin B alone or in combination with fluconazole. Catheters were removed for all patients. The mean duration from peritonitis onset to catheter removal was 5.8 ± 4.1 days. Eleven (50%) patients developed severe complications, with abscess formation or persistent peritonitis after catheter removal. C. parapsilosis peritonitis had a higher complication rate than other Candida species (78% versus 20%, p = 0.012). In patients who received fluconazole as monotherapy, the rate of severe complications of C. parapsilosis peritonitis was statistically higher than those of other Candida species (100% versus 29%, p = 0.013). Because of different severity and prognosis, C. parapsilosis peritonitis in PD patients should be treated more aggressively than other Candida species.     

The Effect of Peritoneal Dialysate on DXA Bone Densitometry Results in Patients with End-Stage Renal Disease

The bone mineral density of patients undergoing peritoneal dialysis (PD) is low compared to a healthy population. No studies have been conducted to investigate whether the presence of peritoneal dialysate affects dual-energy X-ray absorptiometry (DXA) results. We hypothesized that the presence of peritoneal dialysate would not affect the measurement of bone mineral density (BMD) or bone mineral content (BMC) in the spine. Thirty patients on PD had DXA scans of the lumbar spine and hip completed before and after the drainage of peritoneal dialysate. A paired t-test was used to compare the difference in area, BMC, and BMD before and after drainage of dialysate. A significant difference was found in the BMC of the spine before and after the drainage of dialyzate. We recommend that peritoneal dialyzate be removed prior to scanning patients on PD and that densitometry technologists should be observant about the presence of peritoneal dialysate.     

Temporary Peritoneal Dialysis in Newborns and Children: A Single-Center Experience over Five Years

Aim: To evaluate the indications, complications, and outcomes of temporary peritoneal dialysis (TPD) in children with acute renal failure (ARF). Patients and methods: All patients undergoing TPD between February 2006 and January 2011 in a children’s hospital were included in the study. Patient characteristics, indications, complications, and duration of TPD (DPD), requirement of re-operation, length of stay, presence of sepsis, and outcome were recorded. Results: There were 21 newborns (14 prematures), 9 infants, and 9 children. The main nephrotoxic agents were gentamicin (n = 7), netilmisin (n = 5), vancomycin (n = 3), and ibuprophen (n = 3). Patients with multiorgan failure (n = 9) had significantly higher blood urea nitrogen (BUN) and creatinine levels than those without multiorgan failure (n = 30) [BUN: 94 ± 27.3 vs. 34.3 ± 4.9) and creatinine: 4.1 ± 0.8 vs. 1.9 ± 0.2)]. The mean DPD was longer in mature patients than in prematures (newborn: 3.7; children: 7.1). Nine complications were observed (23%) (leakage in three and poor drainage in six patients). Twenty-five patients (64.1%) responded to TPD treatment and were discharged, and 14 patients (10 newborns and 7 of them were premature) died (35.9%). Mortality rate was higher in prematures (n = 7) and patients with a history of nephrotoxic agent (n = 10). Conclusion: TPD is effective especially in neonates with ARF and it is a reliable alternative to the hemodialysis or other continuous renal replacement therapies but it is not free of complications. It has limited effects, particularly in patients with multiorgan failure.     

Icodextrin Dialysate Improves Nutritional and Inflammatory Profiles in Peritoneal Dialysis Patients

Background. Previous studies demonstrate that icodextrin is superior to 4.25%?dextrose for fluid removal in patients with high and high-average transport membrane. Recent studies reveal that controlling volume status improves malnutrition in peritoneal dialysis (PD) patients. This study hypothesized that icodextrin enhances nutritional and inflammatory status by improving fluid balance. Methods. This retrospective case-control study investigated the effects of icodextrin on patient nutritional profiles over a one-year period. Thirty-two patients who used icodextrin for more than one year were classified as the “icodextrin group.” Ten patients who used glucose-containing dialysate without icodextrin were classified as the control group. Clinical and laboratory parameters were compared between groups. Demographic and laboratory parameters were analyzed at baseline, 3 months, 6 months, and 12 months after starting icodextrin dialysis. Results. Ultrafiltration of icodextrin per exchange in the icodextrin group was 66%?higher than that for 4.25%?dextrose exchange in the icodextrin group (icodextrin vs. 4.25%?dextrose: 492.1?±?204.5 vs. 296.1?±?115.3 mL/exchange; p?<?0.0001, paired t-test). The increased albumin and normalized protein catabolic rate (nPCR) after icodextrin for one year was unique for the icodextrin group (p?<?0.0001 and p?<?0.0001, respectively). The inflammatory marker high sensitivity C-reactive protein (hsCRP) decreased significantly only in the icodextrin group (p?=?0.0048). Conclusion. Icodextrin dialysate may improve nutritional and inflammatory status in PD patients. However, the long-term clinical effects of icodextrin require further study.     

The clinical course of peritoneal dialysis-related peritonitis caused by Corynebacterium species.

BACKGROUND: Corynebacterium species are part of the normal skin flora. The incidence of nosocomial infections caused by Corynebacterium species have increased substantially over the past two decades. However, the clinical course of Corynebacterium peritonitis complicating peritoneal dialysis remains unclear. METHOD: We reviewed all the Corynebacterium peritonitis in our dialysis unit from 1995 to 2002. During this period, there were 1485 episodes of peritonitis recorded; 27 (1.8%) of which were caused by Corynebacterium species. RESULTS: The underlying renal diagnosis and prevalence of comorbid conditions of the 27 patients were similar to our whole dialysis population. The bacteria isolated were resistant to penicillin in 8 cases (29.6%). Three cases (11.1%) had concomitant exit-site infection. The overall primary response rate was 74.1%; the complete cure rate was 37.0%. Episodes that received vancomycin as initial antibiotic had a marginally higher primary response rate (9 in 10 vs 11 in 17 episodes, P = 0.2) and complete cure rates (7 in 10 vs 3 in 17 episodes, P = 0.12) than the episodes that received cephalosporins, although neither of the differences was statistically significant. Thirteen cases (48.1%) had recurrent peritonitis after antibiotic therapy, 8 of which had the recurrent episode at least 30 days after stopping antibiotics (median 54 days, range 43-60 days). Eight recurrent cases (61.5%) were successfully cured by another 3 week course of intra-peritoneal vancomycin. CONCLUSIONS: Recurrent Corynebacterium peritonitis is common after a 2 week course of antibiotics. Recurrent Corynebacterium peritonitis may be delayed up to 2 months after the antibiotic is stopped. Recurrent peritonitis can usually be cured with a 3 week course of intra-peritoneal vancomycin, which is probably the preferred antibiotic regimen for Corynebacterium peritonitis.     

Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids.

BACKGROUND: Icodextrin dialysate used for peritoneal dialysis contains an iso-molar glucose polymer solution, which provides sustained ultrafiltration over long dwell times and is considered a valuable approach to reduce intraperitoneal glucose exposure. However, several side effects have been described, including abdominal pain and allergic and hypersensitivity reactions. Also, reactions compatible with chemical peritonitis have been reported. Over the period of a few months (January 2002-May 2002), a remarkable increase in the number of continuous ambulatory peritoneal dialysis (CAPD) patients using icodextrin dialysate diagnosed with sterile peritonitis was observed in our unit. METHODS: Five of the CAPD patients using icodextrin dialysate in our unit and diagnosed with sterile peritonitis were screened for leucocyte count and leucocyte differentiation during a follow-up period of 77 +/- 23 days. In addition, expression of CD14, a receptor for lipopolysaccharide (LPS), on the peripheral and peritoneal monocyte population was analysed. These results were compared to CAPD patients suffering from bacterial peritonitis. RESULTS: The peritoneal leucocyte count of CAPD patients using icodextrin dialysate and diagnosed with sterile peritonitis did not decrease significantly before treatment with icodextrin dialysate was interrupted, whereas it currently disappeared within 2-4 days in proven bacterial peritonitis. The sterile, cloudy icodextrin effluent contained an excess of macrophages on the day of diagnosis, whereas in bacterial peritonitis essentially an increase in the granulocyte population was observed. No elevation in the eosinophil population was observed. In contrast to bacterial peritonitis, we observed no increase in CD14 expression on the peripheral and peritoneal macrophages on the day of presentation and during the follow-up period. CONCLUSIONS: Specific batches of the icodextrin CAPD fluids contain a macrophage chemotactic agent, which causes a sustained inflammatory state in the peritoneal cavity. Because no increase in the expression of the LPS receptor CD14 could be observed, the increased peritoneal leucocyte count is probably not caused by LPS or LPS-like (possibly peptidoglycan-like) contamination.     

Peritoneal Dialysis in Acute Renal Failure

The definition of adequate dialysis in acute renal failure (ARF) is complex and involves the time of referral to dialysis, dose, and dialytic method. Nephrologist experience with a specific procedure and the availability of different dialysis modalities play an important role in these choices. There is no consensus in literature on the best method or ideal dialysis dose in ARF.

Peritoneal dialysis (PD) is used less and less in ARF patients, and is being replaced by continuous venovenous therapies. However, it should not be discarded as a worthless therapeutic option for ARF patients. PD offers several advantages over hemodialysis, such as its technical simplicity, excellent cardiovascular tolerance, absence of an extracorporeal circuit, lack of bleeding risk, and low risk of hydro-electrolyte imbalance. PD also has some limitations, though: it needs an intact peritoneal cavity, carries risks of peritoneal infection and protein losses, and has an overall lower effectiveness. Because daily solute clearance is lower with PD than with daily HD, there have been concerns that PD cannot control uremia in ARF patients. Controversies exist concerning its use in patients with severe hypercatabolism; in these cases, daily hemodialysis or continuous venovenous therapy have been preferred.

There is little literature on PD in ARF patients, and what exists does not address fundamental parameters such as adequate quantification of dialysis and patient catabolism. Given these limitations, there is a pressing need to re-evaluate the adequacy of PD in ARF using accepted standards. Therefore, new studies should be undertaken to resolve these problems.     

Streptococcus gordonii Peritonitis in a Patient on CAPD

We report the first case of Streptococcus gordonii-related continuous ambulatory peritoneal dialysis (CAPD) peritonitis. He is a 69-year-old man with end-stage renal failure due to chron ic glomerulonephritis who had been put on CAPD for 1 year. He was successfully treated with a 2-week course of cefazolin. This case highlights the emerging threat that S. gordonii can be the source of infection in patients on CAPD.