Staphylococcus lugdunensis Peritoneal Dialysis-Related Peritonitis: A Matched Comparative Analysis

Rationale & Objective

Staphylococcus lugdunensis (S lugdunensis) is a coagulase-negative staphylococcus species that has been increasingly recognized to cause serious infections with virulence resembling Staphylococcus aureus (S aureus). No studies have evaluated the characteristics and outcomes of patients with S lugdunensis peritoneal dialysis-related peritonitis compared with those with S aureus peritonitis. We aim to evaluate the clinical course of peritonitis as caused by these organisms.

Study Design

A retrospective matched comparative analysis involving a single tertiary center from July 2000 to July 2020.

Setting & Participants

Forty-eight episodes of S aureus peritonitis were matched to 19 cases of S lugdunensis peritonitis.

Analytical Approach

The cases were individually matched for year of peritonitis, sex, age (±10 years), and Charlson Comorbidity Index (±3). A comparative analysis was performed between the 2 organisms. The outcome includes responses at day 5 of peritonitis and the rate of complete response.

Results

There is a higher predilection of diabetes in those with S aureus peritonitis than in those with S lugdunensis (64.6% vs 31.6%; P = 0.03). Patients with S aureus peritonitis also have a much higher total cell count at presentation (4,463.9 ± 5,479.5 vs 1,807.9 ± 3,322.7; P = 0.05); a higher prevalence of poor response at day 5 (50.0% vs 15.8%; P = 0.03); a lower rate of complete response (64.6% vs 94.7%; P = 0.01) and are more prone to relapse with the same organism (29.2% vs 0%, respectively; P = 0.01) as compared to those with S lugdunensis.

Limitations

The result of this small retrospective study involving a single center may not be generalizable to other centers. There is also no data for comparative analysis on other coagulase-negative staphylococci such as Staphylococcus epidermidis, which belongs to the same family as S lugdunensis.

Conclusions

Although S aureus peritonitis is more virulent with significant morbidity, S lugdunensis can cause similarly serious peritonitis. This largest case series of S lugdunensis peritonitis enabled better characterization of clinical features and outcomes of patients with S lugdunensis peritonitis.

Dermoid cyst management and outcomes: A review of over 1,000 cases at a single institution

BACKGROUND

Mature cystic teratomas represent nearly 60% of benign ovarian neoplasms across all age groups. We aim to update existing descriptive studies of ovarian teratomas including the epidemiology, rate of torsion/malignancy, and treatment modalities in a large modern cohort of patients.

STUDY DESIGN

This is a retrospective cross-sectional study of all pathology-confirmed cases of ovarian teratoma who underwent surgery at one tertiary care institution from 2004-2015. Patient demographics, ovarian cyst characteristics, surgical approach and timing, rate of spillage, and surgical complications were examined.

RESULTS

1,054 cases of ovarian teratoma were identified during the study period. There were 113 cases of bilateral teratoma (10.7%). Mean age at diagnosis was 38 years. Average cyst size was 6.26cm. The overall rate of torsion was 5.6%, with a higher rate of torsion with increasing cyst size. Over 70% of cases were treated with minimally invasive surgery, which was associated with decreased perioperative complications but an increased risk of cyst spillage. Among 394 patients with cyst spillage, only one developed chemical peritonitis. The malignant transformation rate of mature cystic teratoma in this cohort was 1.1%. This cohort included 100 pregnant women with mature teratoma. Pregnant patients were more likely to have minimally invasive surgery in the 1st trimester and more likely to undergo laparotomy in the 2nd or 3rd trimester.

CONCLUSIONS

In this large modern cohort, we found similar rates of bilaterality, torsion, malignant transformation, and struma ovarii in ovarian teratomas when compared to previous literature. Most cases of ovarian teratoma can be managed laparoscopically, which is associated with a lower surgical complication rate. Despite increased risk of cyst spillage with a minimally invasive approach, chemical peritonitis is a rare complication.

NLRP3 Cys126 palmitoylation by ZDHHC7 promotes inflammasome activation

Nucleotide oligomerization domain (NOD)-like receptor protein 3 (NLRP3) inflammasome hyperactivation contributes to many human chronic inflammatory diseases, and understanding how NLRP3 inflammasome is regulated can provide strategies to treat inflammatory diseases. Here, we demonstrate that NLRP3 Cys126 is palmitoylated by zinc finger DHHC-type palmitoyl transferase 7 (ZDHHC7), which is critical for NLRP3-mediated inflammasome activation. Perturbing NLRP3 Cys126 palmitoylation by ZDHHC7 knockout, pharmacological inhibition, or modification site mutation diminishes NLRP3 activation in macrophages. Furthermore, Cys126 palmitoylation is vital for inflammasome activation in vivo. Mechanistically, ZDHHC7-mediated NLRP3 Cys126 palmitoylation promotes resting NLRP3 localizing on the trans-Golgi network (TGN) and activated NLRP3 on the dispersed TGN, which is indispensable for recruitment and oligomerization of the adaptor ASC (apoptosis-associated speck-like protein containing a CARD). The activation of NLRP3 by ZDHHC7 is different from the termination effect mediated by ZDHHC12, highlighting versatile regulatory roles of S-palmitoylation. Our study identifies an important regulatory mechanism of NLRP3 activation that suggests targeting ZDHHC7 or the NLRP3 Cys126 residue as a potential therapeutic strategy to treat NLRP3-related human disorders.

Resilience and challenges of peritoneal dialysis survivors in the aftermath of the 2023 Kahramanmaraş earthquake

INTRODUCTION

Peritoneal dialysis (PD) remains understudied in disaster nephrology. This retrospective multicenter study explores the experiences of PD survivors following the February 6, 2023, Kahramanmaraş Earthquake.

METHODS

Adult PD patients from 11 affected cities were analyzed to assess challenges faced during and postearthquake, alongside clinical outcomes.

RESULTS

Among 101 participants (median age: 45 years, median PD duration: 24 months), 57 were female, with 79 on continuous ambulatory PD. Challenges included power outages and water shortages, with primary shelter in kin's houses (33%) and homes (28%). Twelve patients experienced PD program delays, and three lacked assistance postdisaster. Sixteen patients changed PD modalities, with seven experiencing postearthquake peritonitis. Clinical parameters remained stable, except for a slight decrease in hemoglobin levels.

CONCLUSION

Despite challenges, PD survivors exhibited resilience, highlighting the importance of addressing peritonitis and unusual pathogens in disaster preparedness initiatives.

Apramycin efficacy against carbapenem- and aminoglycoside-resistant Escherichia coli and Klebsiella pneumoniae in murine blood stream infection models

BACKGROUND

The aminoglycoside apramycin has been proposed as a drug candidate for the treatment of critical Gram-negative systemic infections. However, its potential in the treatment of drug-resistant bloodstream infections (BSIs) has yet to be assessed.

METHODS

The resistance gene annotations of 40 888 blood culture isolates were analyzed. In vitro profiling of apramycin comprised cell-free translation assays, broth microdilution, and frequency of resistance determination. The efficacy of apramycin was studied in a mouse peritonitis model for nine Escherichia coli and Klebsiella pneumoniae isolates.

RESULTS

Genotypic aminoglycoside resistance was identified in 87.8% of all 6973 carbapenem-resistant Enterobacterales blood-culture isolates, in comparison to 46.4% of colistin and 2.1% of apramycin resistance. Apramycin activity against methylated ribosomes was > 100-fold higher than other aminoglycosides. Frequencies of resistance were < 10-9 at 8  ×  MIC. Tentative epidemiological cutoffs (ECOFFs) were determined as 8 µg/mL for E. coli and 4 µg/mL for K. pneumoniae. A single dose of 5 to 13 mg/kg resulted in a 1-log CFU reduction in the blood and peritoneum. Two doses of 80 mg/kg, resulting in an exposure that resembles the AUC observed for a single 30 mg/kg dose in humans, resulted in complete eradication of carbapenem- and aminoglycoside-resistant bacteremias.

CONCLUSION

Encouraging coverage and potent in vivo efficacy against a selection of highly drug-resistant Enterobacterales isolates in the mouse peritonitis model warrants further consideration of clinical studies to validate apramycin as a drug candidate for the treatment and prophylaxis of BSI.

A Novel IRAK4 Inhibitor DW18134 Ameliorates Peritonitis and Inflammatory Bowel Disease

IRAK4 is a critical mediator in NF-κB-regulated inflammatory signaling and has emerged as a promising therapeutic target for the treatment of autoimmune diseases; however, none of its inhibitors have received FDA approval. In this study, we identified a novel small-molecule IRAK4 kinase inhibitor, DW18134, with an IC50 value of 11.2 nM. DW18134 dose-dependently inhibited the phosphorylation of IRAK4 and IKK in primary peritoneal macrophages and RAW264.7 cells, inhibiting the secretion of TNF-α and IL-6 in both cell lines. The in vivo study demonstrated the efficacy of DW18134, significantly attenuating behavioral scores in an LPS-induced peritonitis model. Mechanistically, DW18134 reduced serum TNF-α and IL-6 levels and attenuated inflammatory tissue injury. By directly blocking IRAK4 activation, DW18134 diminished liver macrophage infiltration and the expression of related inflammatory cytokines in peritonitis mice. Additionally, in the DSS-induced colitis model, DW18134 significantly reduced the disease activity index (DAI) and normalized food and water intake and body weight. Furthermore, DW18134 restored intestinal damage and reduced inflammatory cytokine expression in mice by blocking the IRAK4 signaling pathway. Notably, DW18134 protected DSS-threatened intestinal barrier function by upregulating tight junction gene expression. In conclusion, our findings reported a novel IRAK4 inhibitor, DW18134, as a promising candidate for treating inflammatory diseases, including peritonitis and IBD.

Peritoneal Inflammation in PD-Related Peritonitis Induces Systemic Eryptosis: In Vitro and In Vivo Assessments

Erythrocytes (RBCs) have a highly specialized and organized membrane structure and undergo programmed cell death, known as eryptosis. Our preliminary data show a significant increase in the eryptosis during peritoneal dialysis (PD)-associated peritonitis. The objectives of the present study were assessment of the incrementation of eryptosis in PD patients with peritonitis, evaluation of the relationship between systemic eryptosis in peritonitis and specific peritonitis biomarkers in PD effluent (PDE), and confirmation of the induction of eryptosis by peritonitis in a vitro setting. We enrolled 22 PD patients with peritonitis and 17 healthy subjects (control group, CTR). For the in vivo study, eryptosis was measured in freshly isolated RBCs. For the in vitro study, healthy RBCs were exposed to the plasma of 22 PD patients with peritonitis and the plasma of the CTR group for 2, 4, and 24 h. Eryptosis was evaluated by flow cytometric analyses in vivo and in vitro. PDE samples were collected for biomarkers analysis.The percentage of eryptotic RBCs was significantly higher in PD patients with peritonitis than in CTR (PD patients with peritonitis: 7.7; IQR 4.3-14.2, versus CTR: 0.8; IQR 0.7-1.3; p < 0.001). We confirmed these in vivo results by in vitro experiments: healthy RBCs incubated with plasma from PD patients with peritonitis demonstrated a significant increase in eryptosis compared to healthy RBCs exposed to plasma from the control group at all times. Furthermore, significant positive correlations were observed between eryptosis level and all analyzed peritoneal biomarkers of peritonitis. We investigated a potential connection between systemic eryptosis and peritoneal biomarkers of peritonitis. Up-regulation of inflammatory markers could explain the increased rate of systemic eryptosis during PD-related peritonitis.

Diagnostic and surgical treatment for traumatic bile peritonitis in dogs and cats

OBJECTIVE

To describe short-term outcomes of dogs and cats undergoing surgery for traumatic bile peritonitis.

ANIMALS

13 dogs and 4 cats.

METHODS

Multi-institutional, retrospective study. Medical records from 6 institutions were reviewed for cases of traumatic bile peritonitis between 2006 and 2022. Clinical presentation, additional injuries, surgical treatment, and outcome were recorded.

RESULTS

Trauma occurred a median of 2 (range, 1 to 22) and 4 (range, 1 to 22) days prior to presentation in dogs and cats, respectively. Total bilirubin was increased in 11 of 13 dogs and 2 of 4 cats. Rupture occurred at the common bile duct (CBD) in 10 dogs and 1 cat, gallbladder in 3 dogs, cystic duct in 2 cats, and hepatic duct in 1 dog and 1 cat. The most common surgeries were cholecystoduodenostomy and CBD repair in dogs and cholecystectomy in cats. Eleven of 13 dogs and all cats survived to hospital discharge (88.2% overall survival). Median follow-up in surviving dogs and cats was 35 days (range, 14 to 401) and 30 days (range, 14 to 90), respectively. One dog that underwent cholecystectomy experienced recurrent bile peritonitis 20 days postoperatively. Short-term survival following surgical treatment of traumatic bile peritonitis was excellent and recurrence appears uncommon. The most frequent site of rupture was the CBD in dogs and the cystic duct in cats.

CLINICAL RELEVANCE

Measurement of peritoneal bilirubin should be considered in dogs and cats with peritoneal effusion following trauma. Surgeons should be prepared to identify and address ruptures in locations other than the gallbladder.

The effect of hand fine motor skills on peritoneal dialysis-related peritonitis

INTRODUCTION

We aimed to evaluate the relationship between the hand fine motor skills of peritoneal dialysis (PD) practitioners and PD-related peritonitis.

METHODS

This multicenter prospective observational study was conducted with 120 incident PD patients. Patients were divided into two groups who had PD-related peritonitis within the first year as Group 1, and those who did not as Group 2. Hand fine motor skills were evaluated by Nine-Hole Peg Test (NHPT) and Nut Screwing Test (NST).

RESULTS

Initial NHPT (28.5 ± 6.0 s vs. 25.8 ± 5.0 s, p = 0.011) and NST (82.3 (61.5-102.8) s versus 65.3 (52.3-88.5) s p = 0.023) scores were significantly higher in Group 1 than Group 2. In multivariate logistic regression analysis, NHPT, Body Mass Index, Mini-Mental Test, self PD practitioner, and catheter complications were found to be independent variables in predicting PD-related peritonitis.

CONCLUSION

Decreased hand fine motor skills of PD patients is a risk factor for peritonitis.

Unusual and complicated peritonitis: Your questions answered

Effective treatment of infections is a growing challenge owing to antimicrobial resistance. Peritoneal dialysis (PD) patients experience more frequent hospitalisations than the general population and have greater exposure to antibiotics, making them particularly vulnerable to this threat. Over the last decade, we have noted a surge in cases of complicated peritoneal dialysis-associated peritonitis (PD peritonitis) caused by antimicrobial-resistant organisms, including extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase-producing Enterobacterales, Pseudomonas aeruginosa and fungi. Practitioners must be alert to these organisms, seek early recognition of these resistance patterns and make timely adjustments in order to avoid delay in treatment that may increase risk of PD catheter removal and technique failure. We present a case of successful treatment of ESBL peritonitis, highlight its challenges, while providing guidance on management of other unusual and complicated PD peritonitis.

Species-specific NLRP3 regulation and its role in CNS autoinflammatory diseases

The NLRP3 inflammasome is essential for caspase-1 activation and the release of interleukin (IL)-1β, IL-18, and gasdermin-D in myeloid cells. However, research on species-specific NLRP3's physiological impact is limited. We engineer mice with the human NLRP3 gene, driven by either the human or mouse promoter, via syntenic replacement at the mouse Nlrp3 locus. Both promoters facilitate hNLRP3 expression in myeloid cells, but the mouse promoter responds more robustly to LPS. Investigating the disease impact of differential NLRP3 regulation, we introduce the D305N gain-of-function mutation into both humanized lines. Chronic inflammation is evident with both promoters; however, CNS outcomes vary significantly. Despite poor response to LPS, the human promoter results in D305N-associated aseptic meningitis, mirroring human pathology. The mouse promoter, although leading to increased CNS expression post-LPS, does not induce meningitis in D305N mutants. Therefore, human-like NLRP3 expression may be crucial for accurate modeling of its role in disease pathogenesis.

Percutaneous Gastrostomies: Associated Complications in PUSH vs. PULL Techniques over 12 Years in a Referral Centre

Objectives: To compare complications associated with percutaneous gastrostomies performed using PUSH and PULL techniques, whether endoscopic (PEG) or radiological (PRG), in a tertiary-level hospital. Methods: This was a prospective observational study. Adult patients who underwent percutaneous PULL or PUSH gastrostomy using PEG or PRG techniques at the Virgen del Rocio University Hospital and subsequently followed up in the Nutrition Unit between 2009-2020 were included. X2 tests or Fisher's test were used for the comparison of proportions when necessary. Univariate analysis was conducted to study risk factors for PRG-associated complications. Results: n = 423 (PULL = 181; PUSH = 242). The PULL technique was associated with a higher percentage of total complications (37.6% vs. 23.8%; p = 0.005), exudate (18.2% vs. 11.2%; p = 0.039), and irritation (3.3% vs. 0%; p = 0.006). In the total sample, there were 5 (1.1%) cases of peritonitis, 3 (0.7%) gastrocolic fistulas, and 1 (0.2%) death due to complications associated with gastrostomy. Gender, age, and different indications were not risk factors for a higher number of complications. The most common indications were neurological diseases (35.9%), head and neck cancer (29%), and amyotrophic lateral sclerosis (17.2%). Conclusions: The PULL technique was associated with more total complications than the PUSH technique, but both were shown to be safe techniques, as the majority of complications were minor.

Spontaneous cecal perforation in a cat diagnosed with ultrasonography

An 8-year-old cat was presented for an acute history of anorexia, marked abdominal pain, and hyperthermia. Ultrasonography showed a cecal perforation with focal steatitis and adjacent free gas bubbles, consistent with focal peritonitis. Surgery confirmed the imaging findings. An enterectomy was performed with the removal of the cecum and ileocolic valve, and anastomosis between the ileum and colon was performed. Histology revealed transmural enteritis and chronic severe pyogranulomatous peritonitis with intralesional plant fragments.

Rapid point-of-care test for diagnosis of peritonitis in peritoneal dialysis patients

BACKGROUND

Periplex® is a rapid point-of-care test based on the detection of interleukin-6 (IL-6) or matrix metalloproteinase-8 (MMP-8) to diagnose peritonitis in peritoneal dialysis (PD) patients.

METHODS

This single-centre study was conducted in Singapore General Hospital from 2019 to 2022. The study recruited PD patients suspected of having peritonitis. Periplex was performed at the presentation and recovery of peritonitis. Primary outcomes were sensitivity and specificity of Periplex at presentation. The positive and negative predictive values of tests were also performed.

RESULTS

A total of 120 patients were included in the study. The mean age was 60.9 ± 14.9 years, 53% were male, 79% were Chinese and 47.5% had diabetes mellitus. Periplex was positive in all patients with peritonitis (n = 114); sensitivity of 100%; 95% confidence interval (CI): 100-100%. Periplex was falsely positive in three patients with non-infective eosinophilic peritonitis, resulting in a low specificity of 50%; 95% CI: 41.1-59.0%. Periplex had a positive predictive value of 97.4% and a negative predictive value of 100%. During recovery from peritonitis, Periplex had high specificity (93.6%) and negative predictive value (98.7%) to indicate the resolution of infection. MMP-8 was more sensitive than IL-6 in detecting peritonitis. Periplex was positive in all patients with peritonitis regardless of the types of PD solutions used.

CONCLUSIONS

Periplex had high sensitivity, and positive and negative predictive values in the diagnosis of peritonitis can be considered as a screening tool for peritonitis. Given its high specificity and negative predictive value, it may also be used to document the resolution of peritonitis.

Baker's Yeast Might not always be Good for Everyone - A Case of Percutaneous Gastrostomy Tube Induced Saccharomyces Cerevisiae Peritonitis in an Immunocompromised Patient

Peritonitis, the inflammation of the protective membrane surrounding parts of the abdominal organs, is a common clinical pathology with multifactorial aetiologies. While bacterial infections are well-recognised as a cause of peritonitis, fungal infections remain relatively uncommon especially Saccharomyces cerevisiae, which is commonly used for breadmaking and as a nutritional supplement. This fungus has been reported to induce peritonitis in patients on peritoneal dialysis. However, it has never been reported as secondary to percutaneous endoscopic gastrostomy (PEG) tube insertion in immunocompromised patients. We present a 64-year-old female with a history of human immunodeficiency virus (HIV) who developed S. cerevisiae peritonitis following PEG tube insertion. The case highlights the importance of considering rare organisms when treating immunocompromised patients with peritonitis, especially after gastrointestinal tract penetration or peritoneal membrane disruption.

LEARNING POINTS

Fungal infection can be a cause of peritonitis especially in an immunocompromised patient.Saccharomyces cerevisiae can be a pathological organism and induce serious infections.Early recognition of the cause of peritonitis and controlling the source is critical to prevent complications.

Vancomycin flushing reaction after intraperitoneal vancomycin: A case report

Vancomycin has been reported to cause vancomycin flushing reaction (VFR), a hypersensitivity reaction that mostly occurs after intravenous administration. The incidence of VFR in a patient receiving intraperitoneal vancomycin is rare. We report a case of a female peritoneal dialysis (PD) patient with a PD-related peritonitis who developed VFR after intraperitoneal administration of 2000 mg vancomycin. Seventy-five minutes after instillation, she developed flushing, a pruritic erythema on the upper body and swelling of the lips. Blood results revealed a vancomycin plasma concentration of 54.8 mg/L and a normal tryptase level. During a relapse of her PD-related peritonitis, vancomycin was successfully reintroduced in a 50% reduced dose. No symptoms of VFR developed, and the corresponding vancomycin plasma concentration was 33.6 mg/L. Intraperitoneal treatment was continued with 500 mg vancomycin every 2-3 days with frequently measured, adequate trough levels ranging from 15-22 mg/L. This case illustrates the risk factors for the development of VFR after intraperitoneal administration of vancomycin, namely a high and concentrated loading dose together with a low body weight, a fast peritoneal transport state and peritonitis. Reintroduction of vancomycin after occurrence of VFR is safe, but a lower loading dose or a slower instillation rate is recommended.

[Mechanism of Fushen Granules treat peritoneal dialysis-related peritonitis by regulating TLR4/NF-κB pathway:based on network pharmacology and animal experiments]

Network pharmacology was employed to probe into the mechanism of Fushen Granules in treating peritoneal dialysis-rela-ted peritonitis(PDRP) in rats. The main active components of Fushen Granules were searched against the Traditional Chinese Medicine Systems Pharmacology Database and Analysis Platform, and their targets were predicted. PDRP-related targets were retrieved from DisGeNET and other databases. The common targets shared by the drug and the disease were identified by the online tool, and protein-protein interaction(PPI) network of the common targets. The obtained 276 common targets were imported into DAVID for GO function enrichment and KEGG pathway enrichment. The main signaling pathway of Fushen Granules in the treatment of PDRP was predicted as Toll-like receptor 4(TLR4)/nuclear factor(NF)-κB. The rat model of uremia was induced by 5/6 nephrectomy. From two weeks after operation, the rat model of peritoneal dialysis(PD) was established by intraperitoneal injection of 20 mL dialysate with 1.25% glucose every day. The sham operation group and model group received 2 mL normal saline by gavage every day. The rats in Fushen Gra-nules groups were administrated with 2 mL solutions of low-(0.54 g·kg~(-1)), medium-(1.08 g·kg~(-1)) and high-dose(2.16 g·kg~(-1)) Fushen Granules every day. The bifico group received 2 mL(113.4 mg·kg~(-1)) of bifico solution every day. At the end of the 8th week, the levels of serum creatinine(Scr) and blood urea nitrogen(BUN) in each group were measured. The serum levels of hypersensitive C reactive protein(hs-CRP), tumor necrosis factor(TNF)-α, and interleukin(IL)-6 were measured, and the pathological changes in the colon tissue were observed by hematoxylin-eosin(HE) staining. The serum levels of lipopolysaccharide(LPS) and lipopolysaccharide-binding protein(LBP) of rats were measured, and the expression levels of LBP, TLR4, NF-κB p65, inhibitor of κB kinase α(IκBα), TNF-α, and IL-1β in the colon tissue were determined. Compared with sham operation group, the model group had abnormal structure of all layers of colon tissue, sparse and shorter intestinal villi, visible edema in mucosal layer, wider gap, obvious local inflammatory cell infiltration, significantly decreased body weight(P<0.01), and significantly increased kidney function index(Scr, BUN) content(P<0.01). Serum levels of inflammatory cytokines(hs-CRP, TNF-α, IL-6), LPS and LBP were significantly increased(P<0.01), protein expressions of LBP, TLR4, NF-κB p65, TNF-α and IL-1β were significantly increased(P<0.01), and protein expressions of IκBα were significantly decreased(P<0.01). Compared with model group, intestinal villi damage in colonic tissue of rats in low-, medium-and high-dose Fushen Granules groups and bifico group were alleviated to different degrees, edema in submucosa was alleviated, space was narrowed, and inflammatory cell infiltration in lamina propria was reduced. The contents of renal function index(Scr, BUN) and serum inflammatory factors(hs-CRP, TNF-α, IL-6) were significantly decreased(P<0.05 or P<0.01) in medium-and high-dose Fushen Granules groups and bifico group(P<0.05 or P<0.01). Serum LPS and LBP contents in Fushen Granules group and bifico group were significantly decreased(P<0.01), protein expressions of LBP, TLR4, NF-κB p65, TNF-α and IL-1β in Fushen Granules group were significantly decreased(P<0.05 or P<0.01), and protein expressions of IκBα were significantly increased(P<0.01). The expression of LBP protein in bifico group was significantly decreased(P<0.01). The results suggest that Fushen Granules can protect the residual renal function of PD rats, reduce the inflammatory response, and protect the colon tissue. Based on network pharmacology, TLR4/NF-κB pathway may be the main signaling pathway of Fushen granule in the treatment of PDRP. The results showed that Fushen Granules could improve intestinal inflammation and protect intestinal barrier to prevent PDRP by regulating the expression of key factors in TLR4/NF-κB pathway in colon of PD rats.

Gastric Acid Suppression Therapy and Its Association with Peritoneal Dialysis-Associated Peritonitis in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Key Points

In a large multinational cohort of PD patients, any GAS use was not associated with an increased risk of all-organism peritonitis. For peritonitis, risks were particularly high among certain classes of organisms particularly for Gram-negative, enteric, and streptococcal peritonitis episodes. The association with enteric peritonitis appeared to be stronger among H2RA users.

Background

Peritonitis is a major peritoneal dialysis–related complication. We determined whether gastric acid suppression (GAS) (proton pump inhibitor [PPI] or histamine-2 receptor antagonists [H2RAs]) use was associated with all-cause and organism-specific peritonitis in peritoneal dialysis patients.

Methods

In the Peritoneal Dialysis Outcomes and Practice Patterns Study (595 facilities, eight countries, years 2014–2022), associations between GAS use and time to first episode of all-cause peritonitis were examined using Cox proportional hazards models. The primary exposure of interest was GAS and secondarily PPI or H2RA use. Secondary outcomes were organism-specific peritonitis, peritonitis cure rates, and death.

Results

Among patients (N =23,797) at study baseline, 6020 (25.3%) used PPIs, and 1382 (5.8%) used H2RAs. Overall risks of GAS use and peritonitis risk (adjusted hazard ratio [AHR]=1.05, 95% confidence interval [CI], 0.98 to 1.13]) and use of PPI (AHR 1.06 [95% CI, 0.99 to 1.14]) or H2RA (AHR 1.02 [95% CI, 0.88 to 1.18]) did not reach statistical significance. In organism-specific analyses, GAS users displayed higher peritonitis risks for Gram-negative (AHR 1.29, 95% CI, 1.05 to 1.57), Gram-positive (AHR 1.15, 95% CI, 1.01 to 1.31), culture-negative (AHR 1.20, 95% CI, 1.01 to 1.42), enteric (AHR 1.23, 95% CI, 1.03 to 1.48), and particularly Streptococcal (AHR 1.47, 95% CI, 1.15 to 1.89) peritonitis episodes. GAS was also associated with higher overall mortality (AHR 1.13 [95% CI, 1.05 to 1.22]).

Conclusion

The association between GAS use and peritonitis risk was weaker (hazard ratio [HR] 1.05 [0.98 to 1.13]) than for streptococcal (HR 1.57 [1.15 to 1.89]) and Gram-negative (HR 1.29 [1.05 to 1.57]) peritonitis. A better understanding of mechanisms surrounding the differential effects of GAS subtype on peritonitis risks is needed. Clinicians should be cautious when prescribing GAS. The impact of GAS deprescribing on peritonitis risk requires further evaluation.

Acute Peritonitis and Pelvic Abscess Secondary to Abdominal Tuberculosis

Tuberculosis (TB), caused by Mycobacterium tuberculosis, continues to be a global health concern with high morbidity and mortality rates. Extrapulmonary TB (EPTB), which affects various organs beyond the lungs, presents a diagnostic challenge due to its diverse clinical and radiological manifestations. Herein, we describe the case of a middle-aged woman with severe lower abdominal pain, vomiting, night fevers, and other symptoms. Clinical and radiological examinations revealed pelvic abscesses and peritonitis. Exploratory laparoscopy uncovered intraabdominal adhesions, a pus-containing abscess cavities, and biopsies confirmed Mycobacterium tuberculosis infection. Post-operative pulmonology consultations comprising sputum cultures for TB detection were conducted, and the patient was started on anti-tuberculosis medications. This case highlights the complexity of diagnosing abdominal TB and the importance of a comprehensive diagnostic approach.

Relationship between number of daily exchanges at CAPD start with clinical outcomes

BACKGROUND

Peritoneal dialysis (PD) continues to be demanding for patients affected by kidney failure. In kidney failure patients with residual kidney function, the employment of incremental PD, a less onerous dialytic prescription, could translate into a decrease burden on both health systems and patients.

METHODS

Between 1st January 2009 and 31st December 2021, 182 patients who started continuous ambulatory peritoneal dialysis (CAPD) at our institution were included in the study. The CAPD population was divided into three groups according to the initial number of daily CAPD exchanges prescribed: one or two (50 patients, CAPD-1/2 group), three (97 patients, CAPD-3 group) and four (35 patients, CAPD-4 group), respectively.

RESULTS

Multivariate analysis showed a difference in term of peritonitis free survival in CAPD-1/2 in comparison to CAPD-3 (hazard ratio (HR): 2.20, p = 0.014) and CAPD-4 (HR: 2.98, p < 0.01). A tendency towards a lower hospitalisation rate (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.11 and 0.13, respectively) and decreased mortality (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.13 and 0.22, respectively) in patients who started PD with less than three daily exchanges was detected. No discrepancy of the difference of the mean values between baseline and 24 months residual kidney function was observed among the three groups (p = 0.33).

CONCLUSIONS

One- or two-exchange CAPD start was associated with a lower risk of peritonitis in comparison to three- or four-exchange start. Furthermore, an initial PD prescription with less than three exchanges may be associated with an advantage in term of hospitalisation rate and patient survival.

Comparative Analysis of Demographic and Clinical Findings in Spontaneous, Peritoneal Dialysis-Related, and Secondary Bacterial Peritonitis

Background This study aims to contribute to peritonitis management strategies by comparing the demographic, clinical, and laboratory characteristics of patients diagnosed with spontaneous bacterial peritonitis (SBP), peritoneal dialysis-related peritonitis (PDrP), and secondary peritonitis. Methods This study included 86 patients diagnosed with peritonitis between 2016 and 2022. Patients were categorized and compared as SBP, PDrP, and secondary peritonitis. Results SBP was diagnosed in 36% of patients, secondary peritonitis in 36% and PDrP in 28%. The mean age of patients with PDrP is 43.71 ± 14.74, which is significantly lower compared to those with SBP and secondary peritonitis (p<0.001). Patients with hypertension (HT), chronic kidney disease (CKD), and those undergoing dialysis most commonly have PDrP whereas those without HT, without CKD, and not undergoing dialysis are most often diagnosed with secondary peritonitis (p=0.002, p<0.001, p<0.001). In peritoneal fluid cultures, the growth of Gram-positive bacteria was most commonly identified in patients with PDrP, while the growth of Gram-negative bacteria was most frequently seen in patients with secondary peritonitis (p=0.018). CRP levels and sedimentation rates were found to be higher in patients with secondary peritonitis (p<0.001, p=0.003). Conclusion The distinct characteristics observed across different types of peritonitis underscore the importance of tailored approaches to diagnosis and treatment. Parameters such as CRP levels, sedimentation rates, and patient age could serve as valuable indicators in discerning between various types of peritonitis. When selecting empirical antibiotic therapy, it's crucial to consider coverage for Gram-positive pathogens in cases of PDrP and Gram-negative pathogens in secondary peritonitis.

Diagnostic utility of the total nucleated cell count for differentiation of septic and sterile peritoneal effusions in dogs

BACKGROUND

Rapid and accurate diagnosis of septic peritonitis is critical for initiating appropriate medical and surgical management.

OBJECTIVES

The aim of this study was to determine the diagnostic utility of the total nucleated cell count (TNCC), absolute neutrophil count, neutrophil percentage, and total protein (TP) to distinguish septic versus non-septic peritoneal effusions in dogs.

METHODS

Electronic medical records were retrospectively searched for peritoneal fluid samples from 2008 to 2018 and classified as septic or non-septic based on bacterial culture and/or cytology results. Receiver operator characteristic curves (ROCs) were used to describe the overall diagnostic utility of each test, with optimal cutpoints analyzed to dichotomize continuous variables. Positive and negative likelihood ratios were calculated at these cutpoints.

RESULTS

A total of 166 unique samples, including 87 septic and 79 non-septic peritoneal effusions, were included. There were no significant differences in dog sex, age, or days hospitalized between groups. Septic effusions had significantly higher TP, TNCC, absolute neutrophil count, and neutrophil percentage compared with non-septic effusions. The area under the curve of the ROC curves was TNCC (0.80), absolute neutrophil count (0.80), neutrophil percentage (0.64), and TP (0.63). For TNCC and absolute neutrophil count, optimal cutoffs were 17.13 × 103  cells/μL and 19.88 × 103  cells/μL, resulting in positive and negative likelihood ratios of 2.39 and 0.28 and 2.85 and 0.28, respectively.

CONCLUSIONS

Total nucleated cell counts and absolute neutrophil counts aid in the differentiation of septic and non-septic peritoneal effusions with similar diagnostic utility but are not sufficiently sensitive or specific to use without concurrent microscopic evaluation.

Educational interventions and identification of risk factors to prevent and reduce peritonitis in peritoneal dialysis: A scoping review

BACKGROUND

Peritonitis is a common and serious complication of peritoneal dialysis and is one of the main causes of peritoneal dialysis technique failure and long-term hemodialysis conversion.

OBJECTIVES

The aim of the review was to identify and clarify peritonitis risk factors and learn about strategies employed at international level to prevent and reduce the occurrence of peritoneal dialysis associated infections and their complications.

DESIGN

A scoping review.

PARTICIPANTS

Adults in pertitoneal dialysis.

MEASUREMENTS

The methodology framework of Arksey and O'Malley and PRISMA for Scoping Reviews guidelines were applied. A search was conducted of PubMed, Scopus and CINAHL using terms to identify peritoneal dialysis -associated risk factors and interventions carried out for the prevention and reduction of peritonitis in adult persons living at home.

RESULTS

The 17 studies selected were based on work carried out in nine different countries. Eleven articles analysed modifiable risk factors (low educational level, being a foreigner and low adherence to aseptic technique) and non-modifiable risk factors (age and comorbidities) that predispose to peritonitis in peritoneal dialysis. The other six studies applied an intervention to improve the prevalence of peritonitis considering educational practices adapted to patient characteristics and the application of retraining.

CONCLUSIONS

Personalised patient training and the identification of risk factors for peritonitis are key to reducing complications and enhancing the survival of peritoneal dialysis patients and the effectiveness of the technique.

Evolution of Peritoneal Dialysis-Associated Peritonitis: Pathogen, Antibiotic Resistance, and the Impact of Lymphocyte Count on Treatment Outcomes

Purpose

Antibiotic administration leads to alterations in pathogenic organisms and antibiotic resistance, posing a significant risk to peritoneal dialysis patients' health. This study aimed to investigate changes in the cause-specific peritonitis, pathogen profiles, antibiotic resistance, and the prognostic factors among patients with peritoneal dialysis-associated peritonitis (PDAP) at our center.

Patients and Methods

We included 463 PDAP patients who attended Peking University Shenzhen Hospital between 2002 and 2023. We analyzed the effects of empirical treatment regimens with cefazolin and ceftazidime or gentamicin.

Results

From 2002 to 2023, we observed that gram-positive staphylococci emerged as the primary causative agents, while the proportion of gram-negative bacillary, enteric peritonitis, and catheter-associated peritonitis decreased significantly. However, the overall cure rate for PDAP and gram-negative bacillary peritonitis declined significantly from 2014 to 2023. Notably, we observed no increase in antibiotic resistance associated with antibiotic drugs use. In addition, reduced lymphocyte counts due to the prevalence of 2019 coronavirus disease (COVID-19) emerged as an independent risk factor for treatment failure in cases of gram-negative bacillary peritonitis.

Conclusion

We did not observe elevated antibiotic resistance in our center when employing empirical dosing strategies involving cefazolin, ceftazidime, or gentamicin. Additionally, we found that a decrease in lymphocyte count due to the COVID-19 epidemic was a significant risk factor for treatment failure in cases of gram-negative bacillary peritonitis at our center. This study provides a foundation for developing clinical treatment strategies for PDAP.

Draft genome sequence of emm103/ST1363 Streptococcus pyogenes strain AB1, isolated from the blood of a woman with peritonitis and toxic shock syndrome

We report the draft genome sequence of Streptococcus pyogenes strain AB1 isolated from the blood of a woman with peritonitis-toxic shock syndrome. The genome measured 1.855 Mbp, with a G + C content of 38.3%. Sequences unmapped to the reference genome sequence of M1 SF370 (GenBank accession number AE004092.2) were characterized.

Cell surface RNAs control neutrophil recruitment

RNAs localizing to the outer cell surface have been recently identified in mammalian cells, including RNAs with glycan modifications known as glycoRNAs. However, the functional significance of cell surface RNAs and their production are poorly known. We report that cell surface RNAs are critical for neutrophil recruitment and that the mammalian homologs of the sid-1 RNA transporter are required for glycoRNA expression. Cell surface RNAs can be readily detected in murine neutrophils, the elimination of which substantially impairs neutrophil recruitment to inflammatory sites in vivo and reduces neutrophils' adhesion to and migration through endothelial cells. Neutrophil glycoRNAs are predominantly on cell surface, important for neutrophil-endothelial interactions, and can be recognized by P-selectin (Selp). Knockdown of the murine Sidt genes abolishes neutrophil glycoRNAs and functionally mimics the loss of cell surface RNAs. Our data demonstrate the biological importance of cell surface glycoRNAs and highlight a noncanonical dimension of RNA-mediated cellular functions.

Case Report: The acute appendicitis and incarcerated umbilical hernia: a rare association

Introduction

One of the most prevalent congenital wall abnormalities in children, umbilical hernias are often linked to premature or small-for-gestational-age babies. In cases of intestinal malrotation or if the cecum is very movable, generalized peritonitis may facilitate the imprisonment of these hernias.

Case report

We described a case of a 4-month-old baby who had a prior reducible umbilical hernia with a history of fever, vomiting, poor appetite, and constipation for around 48 h. The patient experienced significant intestinal bloating, vomiting, irreducibility of the umbilical hernia, skin pigmentation, and erythema at the umbilical site within 2 days after hospitalization. When there was no free abdominal air, a direct abdominal x-ray revealed evidence of hydro-gas stasis and various hydro-aerial levels that were pertinent to the ileum. In order to reduce the hernia, the patient had an emergency surgical treatment where the hernia sac was isolated and released from the ileal loop, which was securely attached to a fibrin plate. When the herniary sac was opened, a gangrenous and perforated appendix was found inside. On the seventh postoperative day, the patient was released from the hospital after an uncomplicated postoperative stay.

Conclusion

Our patient's clinical presentation is similar to that of only one other case report involving a 25-day-old male patient. Our case presented with a variant of the clinical symptoms of the previously described umbilical hernia, which became unfixable and strangulated as a result of appendix inflammation. The appendix was discovered inside the hernia sac during surgery.

Multi-Drug-Resistant Tuberculosis Peritonitis: A Case Report

The increasing incidence of tuberculosis raises concerns globally, impacting both developing and developed nations. Abdominal tuberculosis stands out as the most prevalent form of extrapulmonary tuberculosis. This case report details the diagnostic journey of a young male with abdominal TB complicated by concurrent HIV infection. The patient presented with night sweats and substantial weight loss, concurrently receiving a naive human immunodeficiency virus (HIV) diagnosis with an undetectable CD4 count. Imaging revealed abdominal lymphadenopathy concealing the pancreatic head while bronchoscopy unveiled TB in the lung. The patient faced septic shock and bilateral pulmonary embolism, possibly due to immune reconstitution inflammatory syndrome (IRIS). The patient then developed ascites, and a diagnosis of TB peritonitis was made based on low serum ascites albumin gradient (SAAG) and a positive acid-fast bacillus (AFB) result in the para-aortic lymph node. Treatment complexity arose from drug resistance to isoniazid and ethambutol.

Benign or by Chance: A Case Report on Incidental Appendectomy Revealing a Neuroendocrine Tumor During Traumatic Exploratory Laparotomy

Incidental appendectomies (IAs) are often performed in laparotomies to prevent future complications caused by the buildup of scar tissue. Although neoplastic findings are rare, all appendectomy specimens should be sent for histopathological analysis. We present the case of a 38-year-old man found to have an appendiceal neuroendocrine tumor (NET) after receiving an IA secondary to a traumatic rectal perforation requiring exploratory laparotomy. Well-differentiated NETs isolated to the appendix have an excellent prognosis. Appendectomies are considered curative for NETs smaller than 2 cm that have not metastasized beyond the appendix. Appendiceal NETs are capable of secreting vasoactive substances and, therefore, causing carcinoid syndrome. However, the progression to carcinoid syndrome generally coincides with metastasis to the liver, indicating a poor prognosis. While histopathological analysis of appendectomy specimens rarely yields atypical findings, this analysis is crucial to ensure that the proper treatment is selected based on tumor progression in an appendectomy specimen staining positive for somatotropin and chromogranin.

Micrococcus Peritonitis Complicating Peritoneal Dialysis

Peritonitis, a serious complication of peritoneal dialysis (PD), can be caused by opportunistic pathogens like Micrococcus species on rare occasions. We present a case of Micrococcus sp peritonitis in a 55-year-old female with end-stage kidney disease on continuous cycling peritoneal dialysis for one year who presented with cloudy effluent. Initial treatment against Micrococcus sp with vancomycin, gentamicin, and prophylactic oral nystatin was successful. However, one month later, the patient presented with abdominal pain and dialysate culture again grew Micrococcus sp. Treatment with vancomycin was unsuccessful in resolving culture positivity. The patient was transitioned to hemodialysis for non-medical reasons and then was later restarted on PD without further peritonitis episodes. Micrococcus sp peritonitis in PD poses treatment challenges due to limited guidelines. Intraperitoneal vancomycin is commonly used to target Micrococcus isolates although there is a high incidence of treatment failure. This case report highlights the need for continued reporting to enhance identification, prevention, and patient outcomes in Micrococcus sp peritonitis during PD.

Associations of neutral pH, low-GDP peritoneal dialysis solutions with patient survival, transfer to haemodialysis and peritonitis

BACKGROUND

Peritoneal dialysis (PD) solutions containing low levels of glucose degradation products (GDPs) are associated with attenuation of peritoneal membrane injury and vascular complications. However, clinical benefits associated with neutral-pH, low-GDP (N-pH/L-GDP) solutions remain unclear.

METHODS

Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the associations between N-pH/L-GDP solutions and all-cause mortality, cause-specific mortality, transfer to haemodialysis (HD) for ≥30 days and PD peritonitis in adult incident PD patients in Australia and New Zealand between 1 January 2005 and 31 December 2020 using adjusted Cox regression analyses.

RESULTS

Of 12 814 incident PD patients, 2282 (18%) were on N-pH/L-GDP solutions. The proportion of patients on N-pH/L-GDP solutions each year increased from 11% in 2005 to 33% in 2017. During the study period, 5330 (42%) patients died, 4977 (39%) experienced transfer to HD and 5502 (43%) experienced PD peritonitis. Compared with the use of conventional solutions only, the use of any form of N-pH/L-GDP solution was associated with reduced risks of all-cause mortality {adjusted hazard ratio [aHR] 0.67 [95% confidence interval (CI) 0.61-0.74]}, cardiovascular mortality [aHR 0.65 (95% CI 0.56-0.77)], infection-related mortality [aHR 0.62 (95% CI 0.47-0.83)] and transfer to HD [aHR 0.79 (95% CI 0.72-0.86)] but an increased risk of PD peritonitis [aHR 1.16 (95% CI 1.07-1.26)].

CONCLUSIONS

Patients who received N-pH/L-GDP solutions had decreased risks of all-cause and cause-specific mortality despite an increased risk of PD peritonitis. Studies assessing the causal relationships are warranted to determine the clinical benefits of N-pH/L-GDP solutions.

Rapid and Effective Treatment of Peritonitis in Peritoneal Dialysis Patients with Intravenous Dalbavancin

BACKGROUND Peritonitis is a complication associated with peritoneal dialysis (PD), which carries a significant morbidity and mortality risk. Empiric therapy must include coverage of gram-positive organisms; vancomycin is a recommended treatment option, particularly when MRSA infection is a risk. Vancomycin is cumbersome for patients, requiring therapeutic drug monitoring and re-administration by a healthcare provider. Dalbavancin, administered as a one-time intravenous dose, is a convenient potential treatment option for PD patients to cover gram-positive organisms without the need for routine drug monitoring. CASE REPORT We present 2 patients effectively treated with dalbavancin for infectious peritonitis. The first patient, a 73-year-old woman with end-stage renal disease (ESRD) on PD, presented to the hospital with fever, elevated white blood cells (WBCs), and cloudy peritoneal fluid with elevated nucleated cell counts (88% neutrophils). This patient was given 1 dose of 1500 mg IV dalbavancin. Within 3 days, her fever resolved, WBCs returned to normal, and peritoneal fluid results improved. The second patient was a 36-year-old woman presenting to an outpatient clinic with abdominal pain and cloudy peritoneal fluid with elevated nucleated cell counts (53% neutrophils) treated with dalbavancin 1500 mg IV once. Within 4 days, this patient's pain had resolved, and peritoneal fluid results returned to baseline. No adverse effects were noted for either patient. CONCLUSIONS These cases illustrate the potential of dalbavancin as a convenient option for patients with PD-associated peritonitis. Both patients demonstrated rapid and complete response to a single dose of dalbavancin without complications. Further prospective studies are needed to establish dalbavancin as an option for peritonitis.

Transjugular intrahepatic portosystemic shunts for adults with hepatorenal syndrome

BACKGROUND

Hepatorenal syndrome is a condition that occurs in people with chronic liver disease (such as alcoholic hepatitis, advanced cirrhosis, or fulminant liver failure) and portal hypertension. The prognosis is dismal, often with a survival of weeks to months. Hepatorenal syndrome is characterised by the development of intense splanchnic vasodilation favouring ascites and hypotension leading to renal vasoconstriction and acute renal failure. Therefore, treatment attempts focus on improving arterial pressure through the use of vasopressors, paracentesis, and increasing renal perfusion pressure. Several authors have reported that the placement of transjugular intrahepatic portosystemic shunts (TIPS) may be a therapeutic option because it decreases portal pressure and improves arterial and renal pressures. However, the evidence is not clearly documented and TIPS may cause adverse events. Accordingly, it is necessary to evaluate the evidence of the benefits and harms of TIPS to assess its value in people with hepatorenal syndrome.

OBJECTIVES

To evaluate the benefits and harms of transjugular intrahepatic portosystemic shunts (TIPS) in adults with hepatorenal syndrome compared with sham, no intervention, conventional treatment, or other treatments.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 2 June 2023.

SELECTION CRITERIA

We included only randomised clinical trials with a parallel-group design, which compared the TIPS placement with sham, no intervention, conventional therapy, or other therapies, in adults aged 18 years or older, regardless of sex or ethnicity, diagnosed with chronic liver disease and hepatorenal syndrome. We excluded trials of adults with kidney failure due to causes not related to hepatorenal syndrome, and we also excluded data from quasi-randomised, cross-over, and observational study designs as we did not design a separate search for such studies.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. morbidity due to any cause, and 3. serious adverse events. Our secondary outcomes were 1. health-related quality of life, 2. non-serious adverse events, 3. participants who did not receive a liver transplant, 4. participants without improvement in kidney function, and 5. length of hospitalisation. We performed fixed-effect and random-effects meta-analyses using risk ratio (RR) or Peto odds ratio (Peto OR), with 95% confidence intervals (CI) for the dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for the continuous outcomes. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included two randomised clinical trials comparing TIPS placement (64 participants) versus conventional treatment (paracentesis plus albumin 8 g/L of removed ascites) (66 participants). The co-interventions used in the trials were dietary treatment (sodium less than 60 mmoL/day), spironolactone (300 mg/day to 400 mg/day), and furosemide (120 mg/day). Follow-up was up to 24 months. Both were multicentre trials from Spain and the USA, and Germany, conducted between 1993 and 2002. Most participants were men (aged 18 to 75 years). We are uncertain about the effect of TIPS placement compared with conventional treatment, during the first 24 months of follow-up, on all-cause mortality (RR 0.88, 95% CI 0.55 to 1.38; 2 trials, 130 participants; I2 = 58%; very low-certainty evidence) and on the development of any serious adverse event (RR 1.60, 95% CI 0.10 to 24.59; 2 trials, 130 participants; I2 = 78%; very low-certainty evidence). The use of TIPS may or may not result in a decrease in overall morbidity such as bacterial peritonitis, encephalopathy, or refractory ascites, during the first 24 months of follow-up, compared with the conventional treatment (RR 0.95, 95% CI 0.77 to 1.18; 2 trials, 130 participants; I2 = 0%; low-certainty evidence). We are uncertain about the effect of TIPS placement versus conventional treatment on the number of people who did not receive a liver transplant (RR 1.03, 95% CI 0.93 to 1.14; 2 trials, 130 participants; I2 = 0%; very low-certainty evidence) or on the length of hospitalisation (MD -20.0 days, 95% CI -39.92 to -0.08; 1 trial, 60 participants; very low-certainty evidence). Kidney function may improve in participants with TIPS placement (RR 0.53, 95% CI 0.27 to 1.02; 1 trial, 70 participants; low-certainty evidence). No trials reported health-related quality of life, non-serious adverse events, or number of participants with improvement in liver function associated with the TIPS placement. Funding No trials reported sources of commercial funding or conflicts of interest between researchers. Ongoing studies We found one ongoing trial comparing TIPS with conventional therapy (terlipressin plus albumin) and listed one study as awaiting classification as no full-text article could be found.

AUTHORS' CONCLUSIONS

TIPS placement was compared with conventional treatment, with a follow-up of 24 months, in adults with hepatorenal syndrome type 2. Based on two trials with insufficient sample size and trial limitations, we assessed the overall certainty of evidence as low or very low. We are unsure if TIPS may decrease all-cause mortality, serious adverse events, the number of people who did not receive a liver transplant, and the days of hospitalisation because of the very low-certainty evidence. We are unsure if TIPS, compared with conventional treatment, has better effects on overall morbidity (bacterial peritonitis, encephalopathy, or refractory ascites). TIPS may improve kidney function, but the certainty of evidence is low. The trials included no data on health-related quality of life, non-serious adverse events, and liver function associated with the TIPS placement. We identified one ongoing trial and one study awaiting classification which may contribute to the review when information becomes available.

Random forest can accurately predict the technique failure of peritoneal dialysis associated peritonitis patients

Instructions

Peritoneal dialysis associated peritonitis (PDAP) is a major cause of technique failure in peritoneal dialysis (PD) patients. The purpose of this study is to construct risk prediction models by multiple machine learning (ML) algorithms and select the best one to predict technique failure in PDAP patients accurately.

Methods

This retrospective cohort study included maintenance PD patients in our center from January 1, 2010 to December 31, 2021. The risk prediction models for technique failure were constructed based on five ML algorithms: random forest (RF), the least absolute shrinkage and selection operator (LASSO), decision tree, k nearest neighbor (KNN), and logistic regression (LR). The internal validation was conducted in the test cohort.

Results

Five hundred and eight episodes of peritonitis were included in this study. The technique failure accounted for 26.38%, and the mortality rate was 4.53%. There were resignificant statistical differences between technique failure group and technique survival group in multiple baseline characteristics. The RF prediction model is the best able to predict the technique failure in PDAP patients, with the accuracy of 93.70% and area under curve (AUC) of 0.916. The sensitivity and specificity of this model was 96.67 and 86.49%, respectively.

Conclusion

RF prediction model could accurately predict the technique failure of PDAP patients, which demonstrated excellent predictive performance and may assist in clinical decision making.

A Case of Successfully Treated Roseomonas mucosa-induced Peritonitis Diagnosed by Mass Spectrometry

Roseomonas mucosa is difficult to identify using routine analytical techniques. We herein report a case of peritoneal dialysis (PD)-related peritonitis caused by R. mucosa identified using matrix-assisted laser desorption/ionization-time-of-flight (MALDI-TOF) mass spectrometry (MS). A 70-year-old woman was admitted to our hospital with PD-related peritonitis. Blood agar medium of dialysate culture derived colony pale pink in color, and the organism was identified as R. mucosa using MALDI-TOF MS. She was successfully treated with ciprofloxacin and meropenem without catheter removal. To our knowledge, this is the first case of R. mucosa peritonitis in which technique failure has been avoided.

Poncet's disease and tubal tuberculosis: A case report

A 25-year-old female patient was admitted to the hospital with abdominal pain, loss of appetite, and weight loss for the last 5 months. The patient underwent paracentesis five times and was referred to our clinic after peritonitis findings were detected. Tubal tuberculosis was detected during her hospitalization. The patient, who also developed joint pain, was diagnosed with Poncet's disease. She was given quadruple antituberculosis treatment. After the treatment, the patient's joint pain regressed, and the adnexal mass due to tubal tuberculosis disappeared. In this case report, we wanted to present a rare case of Poncet's disease with tubal tuberculosis.

Isolated Perforation of Multiple Jejunal Diverticulae: A Very Rare Cause of Acute Abdomen

Isolated jejunal diverticular (JD) perforation is extremely rare; it usually presents as a diagnostic dilemma and is often discovered incidentally on laparotomy. Most of these perforations are single. Literature has revealed only one case of multiple small bowel diverticular perforations. We report the first case of simultaneous perforation of four jejunal diverticulae in an 85-year-old male. Small bowel resection and primary anastomosis were performed. The patient had an uneventful post-operative recovery. This case highlights the importance of prompt diagnosis and timely management to reduce the morbidity and mortality of these patients. It should be included in the differential diagnosis in all elderly patients presenting with acute abdomen.

The influence of different peritoneal dialysis techniques on wound infection in patients with peritoneal dialysis tube

More and more research has started to investigate the effect of peritoneal dialysis treatment on the incidence of pericatheter wound complications in chronic kidney disease (CKD). This meta-study evaluated the effect of emergency peritoneal dialysis (EPD) with conventional peritoneal dialysis (CPD) in patients with catheter-related complications. We looked up 4 databases: PubMed, EMBASE, Cochrane, and Web of Science, and analysed the data with RevMan 5. There were a total of 15 studies with 3034 participants. While the quality of the research included was fairly good, the evidence was mediocre. In the meta-analyses, the risk of leak in the conduit with PD was very high (OR, 2.48; 95% CI, 1.72, 3.59, p < 0.00001). However, for those treated with urgent medical method prior to initiation of PD, the risk for peritonitis, catheter dysfunction and bleeding was similar compared with CPD. Based on limited information, immediate initiation of PDs is advised in order to increase the quality of life for people in urgent need, except if there is no consideration for loss of fluid. The low quality of the evidence is holding up the evidence. This research, however, is also informative because of the large number of available data. Consequently, additional high quality, large, randomized controlled studies are required to establish.

Oral vitamin D supplementation on the prevention of peritoneal dialysis-related peritonitis: A pilot randomised controlled trial

OBJECTIVE

Peritoneal dialysis (PD)-related peritonitis is independently associated with low serum 25-hydroxy vitamin D [25(OH)D] levels. Our objective is to examine the feasibility of conducting a large, randomised controlled trial to determine the effects of vitamin D supplementation on the risk of PD-related peritonitis.

DESIGN

Pilot, prospective, open-label randomised controlled trial.

SETTING

Peking University First Hospital, China.

PARTICIPANTS

Patients receiving PD who had recovered from a recent episode of peritonitis between 30 September 2017 and 28 May 2020.

INTERVENTIONS

Oral natural vitamin D supplementation (2000 IU per day) versus no vitamin D supplementation for 12 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were feasibility (recruitment success, retention, adherence, safety) and fidelity (change in serum 25(OH)D level during follow-up) for a large, randomised controlled trial in the future to determine the effects of vitamin D on PD-related peritonitis. Secondary outcomes were time to peritonitis occurrence and outcome of subsequent peritonitis.

RESULTS

Overall, 60 among 151 patients were recruited (recruitment rate was 39.7%, 95% CI 31.9-47.5%, recruitment rate among eligible patients was 61.9%, 95% CI 52.2-71.5%). Retention and adherence rates were 100.0% (95% CI 100.0-100.0%) and 81.5% (95% CI 66.8-96.1%), respectively. During follow-up, serum 25(OH)D levels increased in the vitamin D (VD) group (from 19.25 ± 10.11 nmol/L to 60.27 ± 23.29 nmol/L after 6 months, p < 0.001, n = 31), and remained higher (p < 0.001) than those in the control group (n = 29). No differences were observed between the two groups with respect to time to subsequent peritonitis (hazard ratio 0.85, 95% CI 0.33-2.17) or any of the peritonitis outcomes. Adverse events were uncommon.

CONCLUSIONS

A randomised controlled trial of the effect of vitamin D supplementation on peritonitis occurrence in patients receiving PD is feasible, safe and results in adequate serum 25(OH)D levels.

Peritoneal Dialysis-Associated Peritonitis Caused by Achromobacter xylosoxidans: A Case Report and Literature Review

Achromobacter xylosoxidans is a gram-negative bacterium that is responsible for rare peritonitis associated with peritoneal dialysis (PD). We present a case of a 64-year-old woman with a medical history of end-stage renal disease undergoing PD who was admitted to the emergency department with abdominal pain and nausea. Physical examination and laboratory studies revealed peritoneal signs and laboratory abnormalities consistent with peritonitis. Intraperitoneal catheter dysfunction was identified and subsequently resolved via laparoscopy. Following a peritoneal fluid culture, A xylosoxidans was identified, leading to the initiation of intraperitoneal meropenem treatment. After an initial improvement, the patient developed an ileus and recurrent abdominal symptoms, and further peritoneal cultures remained positive for A xylosoxidans. Subsequent treatment included intravenous meropenem and vancomycin for Clostridium difficile colitis. Owing to the high likelihood of biofilm formation on the PD catheter by A xylosoxidans, the catheter was removed, and the patient transitioned to hemodialysis. Intravenous meropenem was continued for 2 weeks post-catheter removal. This case highlights the challenges in managing recurrent peritonitis in PD patients caused by multidrug-resistant A xylosoxidans. A high index of suspicion, appropriate microbiological identification, and targeted intraperitoneal and systemic antibiotic treatment, along with catheter management, are crucial in achieving a favorable outcome in such cases.

Primary sclerosing encapsulating peritonitis

Sclerosing encapsulating peritonitis also known as cocoon abdomen is a rare chronic inflammatory condition of the peritoneum in which the bowel loops are encircled by a membrane (cocoon formation) within the peritoneal cavity leading to intestinal obstruction. It can be primary (idiopathic) or secondary (chemotherapy, beta-blockers, peritoneal dialysis, shunts, tuberculosis, systemic lupus erythematosus, etc.). The symptomatology report includes recurrent episodes of abdominal pain and vomiting. We present here a case of a 32-year-old male who presented with complaints of being unable to pass stools, vomiting (3-4 times), and abdomen pain for 4 days. This case is considered worth mentioning due to its rarity, lack of identification of secondary causes, and diminutive mention of histopathological aspect.

A case report: Infection-related glomerulonephritis and mantle cell lymphoma due to mycobacterium avium complex infection

RATIONALE

Mycobacterium avium complex (MAC) infection is common in lung, liver and skin. However, MAC presenting with peritonitis is uncommon and is particularly rare in immunocompetent patients. We report a case of infection-associated glomerulonephritis and mantle cell lymphoma caused by peritonitis due to MAC.

PATIENT CONCERNS

We report a case of a 73-year-old elderly man with fever and abdominal pain for 2 days and gradually developed anuria, ascites, and abdominal lymphadenopathy.

DIAGNOSES

The initial diagnosis was peritonitis and acute renal failure. There was no significant relief of symptoms after empirical anti-infective therapy and hemodialysis. infection-associated glomerulonephritis, mantle cell lymphoma, and peritonitis due to MAC were diagnosed by renal biopsy, abdominal lymph node biopsy, and metagenomics next-generation sequencing.

INTERVENTIONS

The patient received empirical antibiotic therapy, hemodialysis, and anti-MAC therapy.

OUTCOMES

Unfortunately, the patient eventually died of septic shock after the 21st day of admissiom.

LESSONS

Early diagnosis of MAC infection is essential. When the cause of fever is unknown, metagenomics next-generation sequencing can be considered.

Entrectinib inhibits NLRP3 inflammasome and inflammatory diseases by directly targeting NEK7

Excessive inflammation caused by abnormal activation of the NLRP3 inflammasome contributes to the pathogenesis of multiple human diseases, but clinical drugs targeting the NLRP3 inflammasome are still not available. In this study, we identify entrectinib (ENB), a US Food and Drug Administration (FDA)-approved anti-cancer agent, as a target inhibitor of the NLRP3 inflammasome to treat related diseases. ENB specifically blocks NLRP3 without affecting activation of other inflammasomes. Furthermore, we demonstrate that ENB directly binds to arginine 121 (R121) of NEK7 and blocks the interaction between NEK7 and NLRP3, thereby inhibiting inflammasome assembly and activation. In vivo studies show that ENB has a significant ameliorative effect on mouse models of NLRP3 inflammasome-related diseases, including lipopolysaccharide (LPS)-induced systemic inflammation, monosodium urate (MSU)-induced peritonitis, and high-fat diet (HFD)-induced type 2 diabetes (T2D). These data show that ENB is a targeted inhibitor of NEK7 with strong anti-NLRP3 inflammasome activity, making it a potential candidate drug for the treatment of inflammasome-related diseases.

Sterility of antibiotic-admixed peritoneal dialysis solution over time

BACKGROUND

Intraperitoneal antibiotics may be required daily for up to three weeks to treat peritoneal dialysis (PD)-related peritonitis. In some jurisdictions, antibiotic-admixed PD solutions are required to be used within 24 h due to concerns regarding microbial contamination and growth. This requires patients to attend the PD unit daily or alternatively for staff to perform home delivery with associated transport, staffing and cost implications.

OBJECTIVE

The aim of this study was to determine if significant microbial growth occurs in PD solutions following their injection with antibiotic or sterile water.

METHODS

Twelve PD solution bags were admixed with cefazolin sodium 1 g, diluted in 10 mL sterile water, while a further 12 PD solution bags were admixed with 10 mL sterile water using aseptic technique (AT) under supervision. All bags were stored at room temperature. Three bags from each experimental group were sampled for microbiologic culture at 0-, 24-, 48- and 72-h intervals.

RESULTS

One sterile water admixed bag sampled at 24 h yielded a Corynebacterium spp. after microbiologic culture. A repeat specimen from the same bag at day nine returned a negative culture result. All other sterile water and cefazolin admixed bags returned negative culture results at all time points.

CONCLUSIONS

Antibiotic-admixed PD solutions prepared using AT and stored at room temperature remained sterile for up to 72 h. This suggests that patients can be safely issued with a supply of antibiotic-admixed PD bags for up to three days at a time.

Complement terminal pathway inhibition reduces peritoneal injuries in a rat peritonitis model

Peritonitis and the resulting peritoneal injuries are common problems that prevent long-term peritoneal dialysis (PD) therapy in patients with end-stage kidney diseases. Previously, we have analyzed the relationship between the complement system and progression of peritoneal injuries associated with PD, particularly focusing on the early activation pathways and effects of the anaphylatoxins. We here utilized a novel mAb 2H2 that blocks assembly of the membrane attack complex (MAC) to investigate roles of the complement terminal pathway in PD-associated peritoneal injury. We intraperitoneally injected mAb 2H2 anti-C5b-7 (2.5 or 5 mg/rat) once or twice over the five-day course of the experiment to investigate the effects of inhibiting formation of MAC in a fungal rat peritonitis model caused by repeated intraperitoneal administration of zymosan after methylglyoxal pretreatment (Zy/MGO model). Rats were sacrificed on day 5 and macroscopic changes in both parietal and visceral peritoneum evaluated. Peritoneal thickness, the abundance of fibrinogen and complement C3 and MAC deposition in tissue and accumulation of inflammatory cells were pathologically assessed. The results showed that mAb 2H2, but not isotype control mAb, reduced peritoneal thickness and accumulation of inflammatory cells in a dose and frequency-dependent manner in the Zy/MGO model. These effects were accompanied by decreased C3, MAC, and fibrinogen deposition in peritoneum. In conclusion, in the rat Zy/MGO model, complement terminal pathway activation and MAC formation substantially contributed to development of peritoneal injuries, suggesting that MAC-targeted therapies might be effective in preventing development of peritoneal injuries in humans.

Optimized Treatment of Nosocomial Peritonitis

This comprehensive review aims to provide a practical guide for intensivists, focusing on enhancing patient care associated with nosocomial peritonitis (NP). It explores the epidemiology, diagnosis, and management of NP, a significant contributor to the mortality of surgical patients worldwide. NP is, per definition, a hospital-acquired condition and a consequence of gastrointestinal surgery or a complication of other diseases. NP, one of the most prevalent causes of sepsis in surgical Intensive Care Units (ICUs), is often associated with multi-drug resistant (MDR) bacteria and high mortality rates. Early clinical suspicion and the utilization of various diagnostic tools like biomarkers and imaging are of great importance. Microbiology is often complex, with antimicrobial resistance escalating in many parts of the world. Fungal peritonitis and its risk factors, diagnostic hurdles, and effective management approaches are particularly relevant in patients with NP. Contemporary antimicrobial strategies for treating NP are discussed, including drug resistance challenges and empirical antibiotic regimens. The importance of source control in intra-abdominal infection management, including surgical and non-surgical interventions, is also emphasized. A deeper exploration into the role of open abdomen treatment as a potential option for selected patients is proposed, indicating an area for further investigation. This review underscores the need for more research to advance the best treatment strategies for NP.