Abdominal catastrophes and other unusual events in continuous ambulatory peritoneal dialysis patients

Sterile Peritonitis in the Peritoneal Dialysis Patient

Peritonitis is a serious and common problem in the peritoneal dialysis (PD) population. Abdominal pain, fever, and cloudy PD fluid usually heralds the onset of infective peritonitis. However, in up to 20% of cases, no organism is identified. In these situations, diagnosis can be made only by excluding a microbiological cause and performing a cytological examination of the PD fluid to determine the cellular or noncellular constituents. This review examines the differential diagnosis of sterile peritonitis and uses cytological examination to facilitate the appropriate diagnosis.

Peritonitis Associated with Intra-Abdominal Pathology in Continuous Ambulatory Peritoneal Dialysis Patients

Features helpful in diagnosis and associated with death were evaluated In 26 episodes of peritonitis associated with intra-abdominal pathology (IAP) In continuous ambulatory peritoneal dialysis (CAPD) patients. Culture of multiple enteric pathogens, or of a single unusual enteric pathogen, from the dialysate was useful for diagnosis in 22/26 instances. Other diagnostic features (fecal material in dialysate, diarrhea containing dialysate, Increasing free air in the abdominal cavity) were infrequently found. A comparison of patients who died (n=11, 42%) and those who survived revealed that death was associated with bowel gangrene (5/6 died), recovery of bacteroides from the dialysate, more frequent and severe comorbid conditions (bacteremia, pneumonia, intra-abdominaland intracerebral bleeding, septic shock, hepatic failure), the development of severe malnutrition and thrombocytopenia during infection, and multiple surgical procedures until the diagnosis was established. Peritonitis associated with intra-abdominal pathology In CAPD patients is a severe infection with considerable diagnostic difficulty and high mortality. Early exploratory laparotomy upon suspicion of the nature of the peritonitis, usually raised by the recovery of enteric pathogens from the dialysate, may improve mortality.

CAPD and Pancreatitis: No Connection

Autopsy studies have shown that approximately 56% of patients on long-term continuous ambulatory peritoneal dialysis (CAPD) develop various pancreatic abnormalities, such as acute and chronic pancreatitis, fibrosis, and acinar dilatation. This prevalence of anatomical abnormalities is similar to that observed in patients on hemodialysis and higher than that in those with normal renal function. However, clinical acute pancreatitis is an uncommon complication of CAPD (0.9%), and this prevalence is similar to that (1.7%) of patient son hemodialysis.

We can attribute acute pancreatitis in CAPD patients to no single factor. Perhaps preexisting anatomical abnormalities of the pancreas make the CAPD patient susceptible to acute pancreatitis when exposed to a variety of physiological and non physiological influences.

The diagnosis of acute pancreatitis in CAPD patients is difficult, because symptoms and signs are similar to those of dialysis-associated peritonitis. Serum amylase values three times greater than the upper limit of normal and effluent amylase greater than 100 U/L suggest the diagnosis of acute pancreatitis. Serum lipase, isoamylase, and pancreatic secretory trypsin inhibitor are not helpful. In confirming the diagnosis, a computed tomography (CT) scan is more helpful than ultrasound, although it is positive in only 50–60% of cases.

One should harbor a high index of suspicion concerning acute pancreatitis if a CAPD patient presenting with suspected peritonitis has either a negative effluent culture or does not respond to antibiotic therapy.

Viscus Perforation in Peritoneal Dialysis Patients: Diagnosis and Outcome

Objective

To determine the incidence and outcome of spontaneous viscus perforation in peritoneal dialysis (PD) patients and which factors could facilitate early diagnosis.

Design

A retrospective chart review was done on all patients with viscus perforation and on a control group with peritonitis secondary to gram-negative organisms.

Setting

A tertiary care University Hospital Peritoneal Dialysis program.

Patients

All patients with surgically proven spontaneous viscus perforation from 1978 to June 1992 (n = 15). A group of control patients (n = 15) with gram-negative bacterial peritonitis was also reviewed for comparison.

Interventions

None.

Main Outcome Measures

Hospital days, patient survival after perforation, and return to peritoneal dialysis were the main outcomes measured. Peripheral white blood cell (WBC) count, PD fluid WBC count with differential, PD fluid cultures, radiologic information, and surgical intervention were also evaluated. Data were analyzed using the Mann-Whitney test to determine significant differences between the two groups.

Results

Viscus perforation occurred in 15 of the 431 patients on PD from 1978 to June 1992 (3.5%). In comparison to the control group, patients with viscus perforation had a significantly higher peripheral WBC count (p = .016), a higher mean PD fluid WBC count (p = .006), and a higher mean percentage of polymorphonuclear cells in the PD effluent (p = .038). Multiple organisms on PD fluid cultures were noted in 12 of 15 patients with perforation and in only 3 control patients. Pneumoperitoneum was seen on abdominal or chest radiograph or computerized tomographic (CT) scan in 10 of 15 patients with perforation and in only 1 of 15 patients in the control group. All patients with viscus perforation required surgery and 6 expired. Only 1 death occurred in the control group. Only 1 of the 9 patients surviving perforation was able to resume PD, in contrast to 13 of 14 surviving control patients.

Conclusion

We conclude that viscus perforation is associated with high morbidity, mortality, and technique failure. Diagnosis may be made by repeatedly searching for intraperitoneal free air on radiograph or CT scan in patients with persistently elevated peripheral and PD fluid WBC count, and for multiple organisms on PD fluid culture.

Surgical Peritonitis in Patients on Peritoneal Dialysis

In this short review we highlight the diagnostic challenge presented by surgical peritonitis in peritoneal dialysis patients, giving attention to etiology, clinical presentation, diagnosis, and management. Despite improvements in medical imaging and a reduction in overall rates of peritonitis in peritoneal dialysis, the mortality of surgical peritonitis has not changed in recent years and remains a challenge for the clinical team.

Determinants of Catheter Loss following Continuous Ambulatory Peritoneal Dialysis Peritonitis

Background

Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis.

Patients and Methods

We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal ( n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved.

Results

The incidence of PD catheter loss increased as the number of organisms cultured increased ( p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level ( p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/μL ( p < 0.001), those with concomitant tunnel infection ( p < 0.001), those with concomitant exit-site infection ( p = 0.005), and those with presence of catastrophic intra-abdominal visceral events ( p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance ( p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi ( p < 0.001), anaerobes ( p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095).

Conclusion

PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/μL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.

Noninfectious complications of peritoneal dialysis

Peritoneal dialysis is an established form of renal replacement therapy. With its increasing popularity, we are now encountering a variety of complications. Noninfectious complications are usually less common as compared with infectious complications. In this review, we discuss some of the common noninfectious complications of peritoneal dialysis such as hernias, hydrothorax, hemoperitoneum, pancreatitis, ischemic colitis and necrotizing enterocolitis, pneumoperitoneum, GERD, subcapsular steatosis and hypokalemia. The awareness of these complications will help in early diagnosis and treatment.

Diagnosis of peritonitis using near-infrared optical imaging of in vivo labeled monocytes-macrophages

Peritonitis is an inflammatory process characterized by massive monocytes-macrophages infiltration. Since early diagnosis is important for a successful therapeutic outcome, the feasibility for a selective labeling and imaging of macrophages for highly sensitive optical imaging was assessed. After in vitro incubation of mouse macrophages J774A.1 with the far-red/near-infrared fluorochrome DY-676, distinct fluorescence intensities (1026+/-142 a.u.) were detected as compared to controls (552+/-54 a.u.) using a whole-body small animal near-infrared fluorescence (NIRF) imaging system. Macrophage labeling was confirmed by confocal laser scanning microscopy (CLSM) and fluorescence-activated cell sorting, (FACS). The fluorochrome was also found to be predominantly distributed within compartments in the cytoplasm. Additionally, peritonitis was induced in mice by intraperitoneal injection of zymosanA. After intravenous injection of fluorochrome (55 nmol/kg) and using whole-body fluorescence imaging, higher fluorescence intensities (869+/-151 a.u.) were detected in the peritoneal area of diseased mice as compared to controls (188+/-41 a.u.). Furthermore, cells isolated from peritoneal lavage revealed the presence of labeled monocytes-macrophages. The results indicate that in vivo diagnosis of peritonitis by near-infrared optical imaging of labeled monocytes-macrophages is feasible. Possibly, early stages of other inflammatory diseases could also be detected by the proposed diagnostic method in the long term.

An unusual complication of peritoneal dialysis

Abdominal pain during peritoneal dialysis can be due to an inflow pain or most frequently be associated with peritonitis. However, other unusual pathologies can also occur in patients with peritoneal dialysis. Herein, pelvic inflammatory disease in a pediatric peritoneal dialysis patient is presented. After exclusion of the most common causes, abdominal ultrasonography and laparoscopy will guide clinicians for the diagnosis of the other rare diseases in patients with peritoneal dialysis.

A peritoneal dialysis patient with fatal culture-negative peritonitis. Case Discussion

Culture-negative peritoneal inflammation accounts for between 5 and 20% of cases of peritonitis in peritoneal dialysis patients. Diagnostic yields may be enhanced considerably by reculturing dialysate effluents using appropriate collection methods and optimal laboratory techniques (including prolonged low-temperature and anaerobic incubations). In patients with persistent culture-negative peritonitis, consideration should be given to the possibilities of unusual or fastidious microorganisms (especially fungi and mycobacteria) and non-infective causes (especially drug reactions, malignancy, visceral inflammation and retroperitoneal inflammation). In this paper, an illustrative case of persistent culture-negative peritonitis is presented followed by a discussion of the investigative approach to such patients, with particular emphasis on differential diagnosis and the limitations of currently available tests.

Peritonitis in peritoneal dialysis

Peritonitis, an infectious complication of peritoneal dialysis, continues to account for much of the morbidity associated with this techniques. The clinical presentation and laboratory data used in diagnosis the peritonitis, as well as its differential diagnosis will be reviewed in this article. The distribution of pathogens is an important outcome determinant, Gram-negative infections being associated with greater rates of catheter loss and higher death rates. Among the five routes of peritoneal contamination, intraluminal and periluminal contamination account for most of the infections. Due to the two prevention methods implemented in the care of the PD population, the incidence of peritonitis has decreased over the last two decades. The recommendations for empiric treatment of peritonitis have changed over the years, as more was learnt about antibiotic resistance and drug toxicity. Future research to address enteric peritonitis, as well as biocompatible dialysis solution or biocompatible catheter materials is needed to further reduce the incidence of PD peritonitis.

Noninfectious causes of cloudy peritoneal dialysate

The appearance of cloudy dialysate fluid in combination with the clinical manifestations of peritonitis usually heralds infectious peritonitis. Diagnosis is readily established in most cases by routine culture of the turbid dialysate. However, an occasional patient presents with culture-negative, cloudy dialysate. After ruling out atypical infectious etiologies, a diverse set of aseptic causes remains in the differential diagnosis. Herein we review these causes and suggest an organizational scheme, based on identifying the cellular or noncellular constituent producing the dialysate turbidity, to facilitate appropriate diagnostic and therapeutic interventions.

Polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients

We retrospectively evaluated 232 continuous ambulatory peritoneal dialysis (CAPD) patients entering our program from January 1, 1987, to December 31, 1997, for polymicrobial peritonitis. Polymicrobial peritonitis occurred in 16% of the patients (polymicrobial-peritonitis group), whereas 52% of the patients had peritonitis episodes with only a single organism (single-organism group), and 32% of the patients had no episode of peritonitis. Polymicrobial peritonitis accounted for 8% of the 554 peritonitis episodes, occurred after 23 +/- 20 months on peritoneal dialysis (PD), and was preceded by greater than three episodes of peritonitis in 73% of the patients. Peritonitis rates were greater in the polymicrobial-peritonitis group compared with patients in the single-organism group (1.8 versus 1.2 episodes/patient-year; P: < 0.001). The majority of polymicrobial infections involved gram-negative and/or fungal pathogens, but in 21% of the episodes, only gram-positive organisms were identified. An intra-abdominal process was identified in only 7% of the patients. Catheter loss overall was greatest in the polymicrobial-peritonitis group (65% versus single-organism group, 30% versus patients without peritonitis, 5%; P < 0.001), but only 33% of the polymicrobial infections resulted in catheter loss. At last follow-up, 70% of the patients in the polymicrobial-peritonitis group had permanently transferred to hemodialysis compared with 25% from the single-organism group and 15% from the no-peritonitis group (P < 0.001). In conclusion, polymicrobial peritonitis is an infrequent but serious complication of CAPD that occurs late in the course of PD and is often preceded by recurrent episodes of peritonitis. Polymicrobial peritonitis is rarely the result of a catastrophic intra-abdominal process, and although the majority of patients can be successfully treated without catheter removal, the long-term prognosis is poor, with a high rate of transfer to hemodialysis.

Peritoneal dialysis. Prevention and control of infection

In spite of the reduction in peritonitis and catheter-related infection rates in patients undergoing peritoneal dialysis, these infections remain major sources of morbidity and transfer to haemodialysis. Touch contamination at the time of doing the exchanges is still a major cause of peritonitis and leads to Gram-positive organisms (coagulation-negative staphylococcus) being the most common pathogens. Newer exchange techniques have reduced this incidence but the more serious pathogens (Staphylococcal aureus, pseudomonas and fungi) remain a major problem. Treatment has to be immediate, and hence empirical, giving adequate cover for both Gram-positive and Gram-negative organisms. The use of vancomycin as an initial antibacterial has been discontinued because of the problem of vancomycin-resistant enterococcus. Recent guidelines advocate the use of a first generation cephalosporin combined with ceftazidime (if the urine output is >100 ml/day) or an aminoglycoside in anuric patients. Subsequent therapy changes are made upon bacterial isolation and sensitivities. Vancomycin is reserved for methicillin-resistant staphylococcus. Peritoneal catheter-related infections (exit site and tunnel) are predominantly caused by S. aureus and pseudomonal organisms and can be difficult to eradicate. Tunnel infections invariably involve the catheter dacron cuffs and therefore are more likely to lead to peritonitis; in this situation catheter removal is the treatment of choice. Treatment of exit-site infections is with oral antibacterials (penicillinase-resistant penicillins, cefalexin). Vancomycin is avoided if possible. The identification that nasal carriage of S. aureus predisposes to exit-site and tunnel infections has led to prophylactic regimens to combat this problem. Mupirocin applied at the exit site leads to a reduction in catheter-related infections and peritonitis.

Thoracic complications of peritoneal dialysis

Approximately 20% of the 100,000 patients in the United States currently undergoing dialysis therapy for end-stage renal disease use the technique of peritoneal dialysis. We present a patient on peritoneal dialysis who developed a large posterior mediastinal mass, which on surgical exploration was found to be a paraesophageal hernia sac filled with omentum and dialysis fluid. We use this case as an introduction to review the thoracic complications of peritoneal dialysis.

Emergency department evaluation and management of dialysis patient complications

The number of dialysis patients in the United States has markedly increased in recent years to more than 100,000. An emergency physician is increasingly likely to be presented with the challenge of handling the emergent problems of the dialysis patient. This article is a review of the complications seen in the population of hemodialysis and peritoneal dialysis patients, with recommendations for emergency department evaluation and management.

Hemoperitoneum complicating chronic peritoneal dialysis: single-center experience and literature review

Hemoperitoneum is a well-recognized, if uncommon, complication of chronic peritoneal dialysis. In this review of 424 patients maintained on peritoneal dialysis at a single center during an 11-year period, 26 patients (6.1%) developed one or more episodes of hemoperitoneum. Three patients had hemoperitoneum on two separate occasions with different etiologies. One additional patient was seen on a hospital consultative service. Three types of bleeding episodes were observed. Twenty-one of 30 (70%) were benign, consisting of pink-tinged dialysate with little clinical consequence (group 1). Three (10%) consisted of minor hemoperitoneum associated with significant intra-abdominal pathology (group 2), and six (20%) required active intervention (group 3). The most frequent cause of hemoperitoneum was bleeding related to menstruation or ovulation; hemoperitoneum was more common in women than in men. Two patients had hemoperitoneum occurring after more than 6 years on dialysis. In both, the etiology was sclerosing peritonitis, an association not previously noted. The less common etiologies of hemoperitoneum encountered in our patients were similar to those in reports from other centers and are compiled here.