Lymphoma-mimicking peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD)

Cloudy dialysate in a patient on continuous ambulatory peritoneal dialysis (CAPD) most commonly reflects an increased number of leukocytes secondary to bacterial peritonitis. In the absence of infection, increased quantities of eosinophils, red blood cells, fibrin, or chyle may produce cloudy dialysate in these patients. We report the case of a CAPD patient presenting with cloudy dialysate and symptoms suggestive of bacterial peritonitis. Analysis of the dialysate revealed no microorganisms. The turbidity of the dialysate was related to an increased number of atypical lymphocytes consistent with a B cell lymphoma. Peritoneal dialysis continued uneventfully despite neoplastic disease within the peritoneum. It is recommended that malignant involvement of the peritoneum be added to the differential diagnosis of cloudy dialysate occurring in CAPD patients.     

An analysis of peritonitis rates with bagless continuous ambulatory peritoneal dialysis (CAPD)

This study was performed to evaluate if the increased number of connections needed to perform bagless continuous ambulatory peritoneal dialysis (CAPD) with the Delmed system was associated with an increased incidence of peritonitis. All patients, from April 1986 through October 1988, using the Delmed bagless connection system, the Delmed bag system, and the Abbott spike system were included. Fifty patients (42.7 years at risk) received bagless CAPD (53 episodes of peritonitis; 1.24 episodes/patient year of dialysis); 56 patients (46.8 years at risk) utilized the Delmed bag technique (76 episodes of peritonitis; 1.63 episodes/patient year); and 45 patients (66.7 years at risk) utilized the Abbott system (155 episodes of peritonitis; 2.36 episodes/patient year of dialysis). The time to the first peritonitis episode was not significantly different between groups. Fifteen patients were switched from the Abbott system (2.3 episodes/patient years) to the Delmed bagless system (0.9 episodes/patient year, peritonitis; p less than 0.05) and 9 patients were switched from the Abbott spike system (2.3 episodes/patient years) to the Delmed bag system (1.4 episodes/patient years; p less than 0.01). It is concluded that the Delmed bagless system is not associated with an increased incidence of peritonitis and that the Delmed system is at least as good as the spike connection devices.     

Campylobacter jejuni peritonitis during chronic ambulatory peritoneal dialysis (CAPD)

A patient treated with chronic ambulatory peritoneal dialysis developed recurrent peritonitis. During a fourth episode, Campylobacter jejuni was cultured from the dialysate. She responded well to streptokinase and imipenem.     

Fluconazole therapy for fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD): a case report

Fluconazole proved effective in treating fungal peritonitis caused by Trichosporon cutaneum. Fluconazole seems to offer several advantages over other antifungal drugs in the treatment of fungal peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients.     

Treatment of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) with intraperitoneal cefazolin and gentamicin

Between 1983 and 1988 57 peritonitis episodes in an unselected patient population were initially treated with intraperitoneal cefazolin and gentamicin. The loading dose consisted of 500 mg cefazolin/L dialysate and 40 mg gentamicin/L dialysate. The maintenance dosage was 125 mg cefazolin and 8 mg gentamicin per liter dialysate. Forty-five (78.9%) patients were primarily cured with this regimen (responder group = RG). Twelve patients (21.1%) did not respond to the initial therapy (nonresponder group = NG). Eight peritonitis episodes in the NG (14.0% of all patients) were caused by tunnel infections and 2 by diverticulitis (3.5%). The cure rate in patients without tunnel infection or bowel disease was 95.7%. A relapse occurred in 2 patients (3.5%). Duration of therapy was assessed by daily white blood cell count (WBC) in the effluent and treatment was discontinued when the WBC was less than 100/microliters for 3 days. The mean duration of therapy with cefazolin and gentamicin was 8.1 days in the RG and 6.0 days in the NG. Nonresponders were subsequently treated with a modified antibiotic regimen on an average 11.9 days.     

Trimethoprim-sulfamethoxazole pharmacokinetics during continuous ambulatory peritoneal dialysis (CAPD)

Ten adult patients on continuous ambulatory peritoneal dialysis (CAPD) received one dose of trimethoprim-320 mg (TMP) and sulfamethoxazole 1600 mg (SMX) orally (p.o.), intravenously (i.v.), and intraperitoneally (i.p.) on three separate occasions to characterize the pharmacokinetics of both drugs. Concentrations of both TMP and SMX were measured in serum and dialysate by HPLC to 48 h. Half-life, total body clearance (TBC), and peritoneal clearance (PCl) were determined. The mean half-life of TMP was 28 h, while for SMX it was 12.5 h. Relative to the i.v. dose, the bioavailability following oral administration for TMP was 98% and 87% for SMX. Intraperitoneal bioavailability was 73% for TMP and 65% for SMX after a 4-h dwell. After 24 h, regardless of the route of administration, less than 3% of TMP and less than 6% of SMX appeared in dialysate. We conclude that peritoneal losses contribute insignificantly to TMP/SMX elimination during CAPD.     

Recurrent bacterial peritonitis caused by Neisseria cinerea in a chronic ambulatory peritoneal dialysis (CAPD) patient

We present an unusual case of recurrent (chronic ambulatory peritoneal dialysis) CAPD-associated peritonitis caused by Neisseria cinerea. Using DNA restriction fragment length polymorphism (RFLP) analysis, we determined that the recurrent infection was caused by reinfection with a different N. cinerea strain rather than relapse with the index strain and that the probable origin of the reinfecting organism was the patient's upper respiratory tract.     

Loss of ultrafiltration in continuous ambulatory peritoneal dialysis (CAPD)

Fifteen patients on long-term continuous ambulatory peritoneal dialysis (CAPD) were assessed with respect to net ultrafiltration capacity. Eight patients were defined as having good and seven as having poor ultrafiltration on the basis of net ultrafiltrate obtained/mmol glucose infused. Subsequently, dialysate was sampled at times 0, 1, 15, 30, 60, 90, 120, 180, and 240 min. No difference in residual volume was observed between the groups. A significantly greater decrease in dialysate sodium during the initial dialysis period in those patients with good as compared to those with poor ultrafiltration occurred, reflecting a greater transcapillary movement of electrolyte poor ultrafiltrate. In those with good ultrafiltration, glucose transfer was normal in five and rapid in three, suggesting the latter had low rates of lymphatic reabsorption. Five of seven patients with poor ultrafiltration had no fall in dialysate sodium in association with a high rate of glucose transfer, suggesting a low rate of transcapillary water movement and normal to high lymphatic absorption. Two patients with low ultrafiltration had an initial fall in dialysate sodium with a normal glucose transfer and thus net ultrafiltration is low due to elevated lymphatic reabsorption. We thus propose that the relative contribution of transcapillary water movement and lymphatic reabsorption can be determined by assessing net ultrafiltration and dialysate sodium concentration in conjunction with solute transfer.     

Beta-2 microglobulin amyloidosis in a patient on long-term continuous ambulatory peritoneal dialysis (CAPD)

A 61-year-old female patient with ESRD due to analgesic nephropathy and treated solely with CAPD for 81 months is described. During this period she developed peritonitis 4 times. She eventually died of acute pulmonary edema due to coronary heart disease. The autopsy showed an analgesic nephropathy with contracted kidneys, diffuse peritoneal fibrosis, and articular and periarticular amyloidosis of AB2m-type. This form of amyloidosis is well known after hemodialysis; it was, however, not observed heretofore after sole long-term CAPD.     

Peritonitis-related deaths in continuous ambulatory peritoneal dialysis (CAPD) patients

A total of 636 episodes of peritonitis occurred in 440 patients who entered our continuous ambulatory peritoneal dialysis (CAPD) program from September 1977 to February 1988. Sixteen patients (8 male and 8 female, aged 37-77 years) died during an episode of peritonitis (fatality rate 2.5%). They had been on CAPD for 3 to 105 (average 39) months. Six of them were diabetics. The peritonitis rate among these 16 patients were 1 episode per 12 patient months, while the corresponding figure for the whole (440) CAPD population was 14 patient months. Risk factors present in the 16 patients were: cardiovascular disease (12), cerebrovascular accident (2) peripheral artery disease (1) and pulmonary fibrosis (1). Fever and leukocytosis were present on admission in 11 patients, while total serum proteins and albumin were significantly lower (p less than 0.001) than the corresponding values before peritonitis (56 +/- 8 vs. 65 +/- 5). Staph. aureus was isolated in 8 patients (50%), multiple organisms in 6, Pseudomonas and Candida albicans in 1 each. An abdominal abscess was found in 4 (25%) patients. The peritoneal catheter was removed between the 5th and 10th day in 6 and after the 10th day in 7 patients. Peritonitis with sepsis was the cause of death in 13 patients. Contributing factors were cardiovascular accident in 9, uremic coma in 2, extensive GI bleeding in 2, GI perforation in 2, intestinal infarction in 1, and pneumonia in 2 patients. We conclude that the risk of peritonitis-related death in CAPD patients is increased with Staph. aureus or multibacterial peritonitis. Contributing factors are concomitant cardiovascular disease and delayed (greater than 5 days) catheter removal.     

Intraperitoneal ciprofloxacin for the treatment of peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD)

Ciprofloxacin was evaluated as single-agent therapy for the empirical treatment of patients presenting with CAPD peritonitis in an open, uncontrolled trial. Seventy-five episodes of peritonitis in 44 patients receiving continuous ambulatory peritoneal dialysis were entered in the study. The antibiotic was administered intraperitoneally, at a dose of 50 mg/l in each bag of dialysate, for seven days. Treatment with ciprofloxacin was appropriate (organisms isolated sensitive to ciprofloxacin) and successful (clinical and bacteriological cure of peritonitis) in 62 (83%) of the 75 episodes. The mean ciprofloxacin concentrations in serum and effluent were 1.1 mg/l (range 0-2.9 mg/l) and 10.0 mg/l (range 0.2-33.4 mg/l), respectively, with no evidence of accumulation. Side effects were seen in two patients only, and were mild and transitory.     

The management of hydrothorax in continuous ambulatory peritoneal dialysis (CAPD)

Four patients on continuous ambulatory peritoneal dialysis (CAPD) developed large, symptomatic pleural effusions after commencing peritoneal dialysis. Pleuroperitoneal fistula in each case was diagnosed by the presence of a high glucose content in pleural fluid, with a normal corresponding blood sugar, and was confirmed by isotope or contrast peritoneography. Two patients had their effusions drained percutaneously, and then underwent pleural sclerosis with intracavitary tetracycline. Two patients had a thoracotomy performed, of which no fistula was identified in one case, and the other patient underwent pleurectomy. All four patients successfully recommenced CAPD several weeks after therapy, without recurrence of effusions. We conclude that pleuroperitoneal connections associated with CAPD do not mandate cessation of peritoneal dialysis and conversion to maintenance haemodialysis. Definitive diagnosis requires aspiration of pleural effusions for glucose estimation. Contrast or isotopic peritoneography is helpful in localising the fistula, but in our experience did not alter management. Simple sclerotherapy is effective and avoids the need for a formal thoracotomy.     

Peritoneal surface-active material in continuous ambulatory peritoneal dialysis (CAPD) patients

Phospholipids have been demonstrated to be present in the peritoneal dialysis effluent of 34 patients on continuous ambulatory peritoneal dialysis (CAPD). The phospholipids present have been characterized by chromatography and their relative concentrations are fairly consistent from patient to patient. The predominant phospholipid is phosphatidylcholine (81%). Surface activity of this phospholipid has been demonstrated. The concentration of total phospholipid correlates with the time the patient had been on CAPD. It is lower in those patients who have been on dialysis longer.     

Oral neostigmine and lymphatic absorption in a myasthenia gravis patient on continuous ambulatory peritoneal dialysis (CAPD)

The effects of oral neostigmine on peritoneal lymph absorption and transcapillary and net ultrafiltration were studied in a myasthenia gravis patient on continuous ambulatory peritoneal dialysis (CAPD). Oral neostigmine decreased lymphatic absorption, but only up to a threshold dose. The effect on net ultrafiltration however was nullified to some extent by a concurrent decrease in cumulative transcapillary ultrafiltration.     

Beta-2 microglobulin removal during continuous ambulatory peritoneal dialysis (CAPD)

Beta-2 microglobulin (B2M) handling in continuous ambulatory peritoneal dialysis (CAPD) was characterized in acute and chronic clinical studies. Average clearance rate was 0.7 mL/min and mean mass transfer coefficient, KoA, was calculated to be 0.95 cm2/min; these values are in the range expected from extrapolation of published data for other large solutes. In chronic studies with both anuric and oliguric populations, CAPD was shown to be much more effective than conventional hemodialysis in removing B2M and, in fact, CAPD removal rates were equivalent to those reported for high flux dialysis therapies. However, this greater extraction was not associated with any clinically significant reduction in circulating plasma concentrations. These trends remained valid in both the anuric and oliguric subsets of the study population.