Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature

Background

The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal.

Methods

A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients.

Results

There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter.

Conclusion

Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic ‘sterile’ peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.     

Pseudomonas peritonitis in CAPD patients: characteristics and outcome of treatment

Twenty-five episodes of Pseudomonas peritonitis which occurred over a five-and-a-half-year period were reviewed. Pseudomonas peritonitis accounted for 25/516 (4.8%) of all episodes of peritonitis. Nine of the episodes were first infections in that the patient had not experienced peritonitis before. The rest were repeat peritonitis. There was no difference in any demographic factors between the first episodes and the repeat episodes except exit site infection which was more common among patients who had repeat infections. Overall cure rate of Pseudomonas peritonitis was 20/25 (80%). Five catheters had to be removed, all in patients who had to be transferred permanently to haemodialysis. In general, ceftazidime in combination with an aminoglycoside was an effective regimen. Oral ofloxacin was not useful despite in vitro sensitivity of the pathogen to the antibiotic.     

Fungal peritonitis in patients on peritoneal dialysis: incidence, clinical features and prognosis

Fungal peritonitis occurred in 17 patients on chronic peritoneal dialysis. The incidence of infection per 100 patient-dialysis months was 0.36 for patients on intermittent peritoneal dialysis and 1.6 for patients on continuous ambulatory dialysis (p less than 0.005). Initial clinical findings included abdominal pain (76%), fever (59%), cloudy dialysate (76%) and poor dialysate outflow (6%). 15 patients received antibiotics within 4 weeks of developing peritonitis. All infections were caused by yeasts, with Candida parapsilosis and Candida albicans as the most common species. 14 patients were unable to continue peritoneal dialysis due to persistent or relapsing infection or the development of complications. 2 of the 3 patients who were able to continue peritoneal dialysis were treated with catheter replacement, intraperitoneal miconazole and oral ketoconazole.     

鲎试验对腹膜透析并发腹膜炎诊断价值的探讨

为寻求简便，快速诊断腹膜透析并发腹膜炎的有效方法，对６例持续性非卧床腹膜透析患者隔夜腹透液进行了６６次鲎试验观察。结果２１次为腹膜炎，其中鲎试验阳性７次，占３３．３％，用抗革兰阴性菌抗生素疗效佳。认为鲎试验是ＣＡＰＤ并发革兰阴性菌性腹膜炎的简便，快速的诊断方法，为及时使用有效抗生素提供了有力证据。     

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.     

Incidence of CAPD peritonitis in patients using UVXD or O-set systems

Eighty-one patients were placed either on the O-set (39) or the UVXD germicidal system (42). Total experience was 13.7 +/- 8.0 and 17.8 +/- 14.8 months, respectively. There were 48 and 85 new episodes of peritonitis in 24 and 28 patients, respectively, and an additional 11 and 28 episodes of relapse or probable relapse. The peritonitis rate was 1 episode each 11.14 and 8.83 patient months, which was not significantly different. There was no significant difference between the 2 groups in terms of the mean numbers of peritonitis-free days (393.7 versus 503.8) or in the mean time to the first episode of peritonitis (6.60 versus 6.54 months). The odds ratio of relative risk of peritonitis with the two systems was 1:1.17 (O-set:UVXD). There appears to be no difference in ability of the two systems to prevent peritonitis.     

The effect of peritonitis on the transperitoneal transport of cefuroxime in patients on CAPD treatment

The pharmacokinetics and transperitoneal transport of cefuroxime were investigated in CAPD patients without peritonitis (n = 6), receiving 500 mg of the drug intravenously (i.v.) and intraperitoneally (i.p.) on separate occasions. CAPD patients with peritonitis were also investigated after i.p. administration of an initial dose of 500 mg cefuroxime followed by repeated doses of 250 mg. Routine hospital CAPD procedures and dwell-time schedules were followed during the study, and frequent blood and dialysate samples were collected. Cefuroxime was analysed by HPLC methods, and pharmacokinetic parameters were calculated. In the patients without peritonitis, the following pharmacokinetic parameters after i.v. and i.p. administration did not differ significantly (mean +/- SD): elimination half-life, 15.1 +/- 1.9 h; apparent volume of distribution 27.9 +/- 2.91; and total clearance, 21.5 +/- 1.2 ml/min. In contrast, the transperitoneal transport of cefuroxime differed significantly in the three studies. After i.v. administration the apparent transperitoneal clearance was low and time dependent, ranging from 4.2 +/- 1.2 to 1.4 +/- 0.4 ml/min. After i.p. administration the apparent transperitoneal clearance increased to 10.9 +/- 2.4 ml/min, whereas in the peritonitis patients a further increase to 21.5 +/- 3.5 ml/min was observed. In all patients we found cefuroxime concentrations in serum and dialysate, greatly exceeding MIC values of most pathogens involved in CAPD peritonitis and other systemic bacterial infections.     

Vancomycin and tobramycin in the treatment of CAPD peritonitis

Seventy-five episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied during a 1 year period at the Queen Elizabeth Hospital, Birmingham. When two simple culture methods were used in parallel, the causative organisms were identified in 97% of cases. Nearly two thirds of episodes of peritonitis were caused by coagulase-negative staphylococci (C-NS), many of which were multiply antibiotic-resistant. On the basis of detailed antibiotic sensitivities, intraperitoneal vancomycin and tobramycin were chosen for the initial treatment of CAPD peritonitis. With this regime, a cure was achieved in 32 of 38 episodes, compared with 15 of 27 episodes when cefuroxime was used. All but 1 of 24 episodes caused by C-NS were cured by vancomycin.     

Vancomycin and ceftazidime in the treatment of CAPD peritonitis

102 episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied prospectively during a 288-day period at The Queen Elizabeth Hospital, Birmingham. Organisms were isolated from 76% of the episodes, with coagulase-negative staphylococci, being the most commonly encountered organism (55%). Initial treatment consisted of intraperitoneal vancomycin and ceftazidime with subsequent adjustment on the basis of antibiotic sensitivities. With this regimen, 83% of the positive cultures became negative by 72 h, 9.8% of cases relapsed and removal of the CAPD catheter was necessary in 8 patients (7.8%). Overall, 92% of cases were cured. No adverse drug reactions were seen. This combination of antibiotics appears effective and safe in the treatment of CAPD peritonitis.     

Lipopolysaccharide-binding protein is present in effluents of patients with Gram-negative and Gram-positive CAPD peritonitis

Background: Bacterial peritonitis is a frequent complication during treatment of end-stage renal failure by continuous ambulatory peritoneal dialysis. Local host defence mechanisms including the secretion of proinflammatory cytokines by peritoneal macrophage are of particular importance in the pathogenesis of infectious complications. LPS-binding protein (LBP) and soluble CD14 (sCD14) are serum factors known to regulate the endotoxin-induced cellular immune response. However, it is still unknown whether LBP and sCD14 are also present in the peritoneal effluent of CAPD patients. Methods: Using specific immunoassays, we examined the concentration of LBP, sCD14 and the proinflammatory cytokines TNF=&agr;, IL-1{beta} and IL-6 in the dialysis effluents of 31 patients with CAPD-associated peritonitis. Twenty patients without peritonitis served as controls. Intraperitoneal LPS concentrations were determined using the limulus amebocyte lysate assay. Results: Bacterial lipopolysaccharide could be detected in 42% of the infected dialysis effluents. In comparison to controls (0.2±0.05 &mgr;g/ml), LBP was significantly elevated in both Gram-negative/LPS-positive (1.03±0.3 &mgr;g/ml) and Gram-positive infections (0.5±0.14 &mgr;g/ml) (P<0.05). No significant differences were detected concerning the intraperitoneal sCD14 levels in the three patient groups. Levels of TNF-&agr;, IL-1{beta} and IL-6 were significantly increased in the effluents of patients with bacterial peritonitis compared to non-infected controls. Moreover the respective cytokine concentrations were significantly higher in the Gram-negative/LPS-positive compared to the gram-positive bacterial infections (P<0.01). Conclusion: Our data demonstrate that LBP is significantly elevated in the dialysis effluents of patients with CAPD-associated peritonitis caused by both Gram-negative and Gram-positive bacteria and might be used as a marker of intraperitoneal infection. Moreover, our findings support the concept that LBP enhances the effects of LPS on cytokine production by peritoneal macrophages. The function of LBP in Gram-positive infection remains to be further elucidated. Key words: CAPD-associated peritonitis; cytokines; lipopolysaccharide-binding protein; macrophages; peritoneal dialysis; soluble CD14      

尿素动力学模型在持续性非卧床腹膜透析中的应用

对２０例ＥＳＲＤ患者先后给予持续性非卧床膜腹膜透析（ＣＡＰＤ）１Ｌ×５／ｄ和２Ｌ×４／ｄ方案透析，测定其尿素清除指数（ＫＴ／Ｖ）和标化每日蛋白质分解率（ＮＰＣＲ），同时应用１２个临床参数对两方案进行疗效评价．结果显示由ＩＬ×５／ｄ改为２Ｌ×４／ｄ时，ＫＴ／Ｖ和ＮＰＣＲ分别上升０．７４±０．２１和０．１２±０．０９（Ｐ＜０．００１），临床有效率上升８０％（Ｐ＜０．００５）；ＮＰＣＲ和ＫＴ／Ｖ呈正相关（ｒ＝０．４９，Ｐ＜０．０５）．ＮＰＣＲ与每日蛋白质摄入量（ＤＰＩ）呈高度正相关（ｒ＝０．９１，Ｐ＜０．００１），ＫＴ／Ｖ与临床评分也呈正相关（ｒ＝０．６１，Ｐ＜０．０１）．结果表明尿素动力学模型对评价ＣＡＰＤ治疗具有重要意义．     

Timing and characteristics of multiple peritonitis episodes: a report of the National CAPD Registry

Patterns of recurrent peritonitis episodes were examined in 6,335 new continuous ambulatory peritoneal dialysis (CAPD) patients entered into the National CAPD Registry. Forty-six percent of all peritonitis episodes were initial occurrences, with 8% of the patients reporting four or more episodes. The proportion of gram-positive and gram-negative infections was constant across episodes. In patients with multiple infections, negative organisms were found to have increased risk of recurring as gram-negative infection. A similar observation was made for fungal infections. Of patients with multiple peritonitis episodes, more than 40% of those who transferred to other maintenance renal replacement therapy identified peritonitis as the reason for transfer. A discrete time logistic model was used to estimate peritonitis risk in 4-month follow-up periods. Patients like those on the registry are estimated to have a 22% risk of developing peritonitis during any 4-month period. This risk was increased 4% for patients aged less than 21 years, 7% for nonwhite patients, and 19% in the period following a peritoneal infection.     

Larsen syndrome: clinical features and treatment--a report of two cases

The literature on reported clinical and radiographic findings of Larsen syndrome is reviewed in detail. Two patients with Larsen syndrome who exhibited previously unreported skeletal deformities and such characteristic features as flattened facies, palate defects, and multiple joint dislocations are reported. Persistent difficulties in wound healing are discussed.     

The Prevalence and Clinical Features of Tuberculous Peritonitis in CAPD Patients in Turkey,Report of Ten Cases from Multi-centers

Objective.?To determine the rate, risk factors and outcome of Tuberculous Peritonitis (TBP) in patients treated with continuous ambulatory peritoneal dialysis (CAPD) in our units. Design.?Retrospectively, we reviewed the medical data of all CAPD patients from 12 centers for TBP, covering the period between 1986 and 12 2002. Setting.?All patients were from 12 renal clinics at tertiary-care university hospitals. Results.?Ten cases of TBP were identified among the CAPD patients in our centers. There were five male and five female patients with a mean age of 37.2 years. None of the patients had tuberculosis history, 6 patients had predominance of PNL. One patient had coincidental bacterial peritonitis. Two patients were successfully treated without the removal of the Tenckhoff catheter. Conclusion.?TBP in CAPD patients is a very rare complication. In contrast to predominance of lymphocytes in nonuremic patients with tuberculous peritonitis, CAPD patients with tuberculous peritonitis may have predominance of PNL on examination of the peritoneal fluid. Since TBP has high morbidity and mortality, early diagnosis and treatment of disease are extremely important for improving outcome.     

Intraperitoneal vancomycin and ceftazidime in the treatment of CAPD peritonitis

The use of intraperitoneal vancomycin and ceftazidime in the treatment of 64 episodes of CAPD peritonitis is reported. Serum and dialysate antibiotic concentrations were measured in 19 of these and the maximum serum vancomycin level recorded was 30 mg/l. Culture of the dialysate was sterile in 52% of the cases, staphylococci were isolated in 30% and the infection rate during 1983 was 2.22 episodes per patient-year. This antibiotic combination has proven safe and effective and easily administered by the patients.     

Differing prognostic significance of reinfection and relapse in CAPD peritonitis

All episodes of recurrent infection in a CAPD unit over a 26-monthperiod have been analysed to discover whether relapse and reinfectionhave different prognostic importance. Relapse and reinfectionwere distinguished by detailed microbiological investigation.Prognosis was expressed in terms of outcome of treatment andthe fate of the Tenckhoff catheter. Twenty-nine patients suffered recurrent infections (i.e. morethan one infection during a 12-month period). Nine (6 male,3 female, age range 42–73 years) had relapses, and 20(16 male, 4 female, age range 42–74 years) reinfections.The characteristics of the two groups of patients were indistinguishable. Relapse was of graver prognostic consequence: patients who relapsedwere significantly less likely to respond to antibiotic treatment(78% versus 20%) and have to have their catheters removed (78%versus 10%) than those with reinfections. Thus it is importantto differentiate relapse from reinfection in CAPD peritonitis.In addition to being helpful for the management of individualpatients, this is essential if results of therapeutic trialsare to be interpreted correctly.     

腹腔镜技术在结核性腹膜炎诊断中的应用

目的:探讨腹腔镜技术用于诊断结核性腹膜炎的价值,总结结核性腹膜炎的镜下特点及诊断要点。方法:回顾分析2002年7月至2010年7月27例结核性腹膜炎患者的临床资料。患者均行腹腔镜检查,术中取腹水及病灶标本行生化、病理学等检查。结果:27例患者均获确诊,手术时间30～140 min,平均40.2 min,术中出血量10～110 ml,平均12.3 ml。术中及术后均未出现肝、肠管等器官损伤。结论:腹腔镜检查诊断结核性腹膜炎具有患者创伤小、阳性率高、痛苦小等优点,可作为诊断结核性腹膜炎的优选术式。     

Hereditary renal tubular disorders in Turkey: demographic,clinical, and laboratory features

Background  

The Turkish Renal Tubular Disorders Working Group aimed to form a patient registry database and gathered demographic, clinical, and laboratory data in various hereditary renal tubular disorders (HRTDs).     

Takayasu arteritis: clinical features and management: report of 272 cases

BACKGROUND: Takayasu's arteritis is a condition of unknown aetiology with an unpredictable natural history. Most of the literature available has originated from Asia, with a few contributions from Africa where the pattern of the disease may be different. This is a single institution's experience review. METHODS: Data were obtained retrospectively from the angiographic and medical records of patients treated at Groote Schuur Hospital over the period 1952-2002. The criteria for inclusion were those proposed by the Aortitis Syndrome Research Committee of Japan and the American College of Rheumatology. RESULTS: Two hundred and seventy-two patients were identified. The mean age at presentation was 25 years (range 14-66 years) and 75% were female. Only 8% were Caucasian. Hypertension was the most common presentation (77%) and was usually a consequence of renal artery stenosis or aortic coarctation. Cardiac failure was the most common problem. Cerebrovascular symptoms were recorded in 20%. Convincing evidence of tuberculosis was present in 20%. The entire aorta was involved in 70% of cases. Thirty per cent had aortic bifurcation involvement. Occlusions were noted in 93% and aneurysms in 46%. Vascular reconstruction was performed on 115 occasions in 99 patients, with an operative mortality of 4%. Cardiac failure was the usual cause of death. One hundred and six patients (39%) were followed for a minimum of 5 years. No further progression of disease was noted in 70 patients. CONCLUSION: The natural history and prognosis of Takayasu's arteritis still remain poorly defined.