Peritonitis as a complication of peritoneal dialysis.

Abstract

Peritonitis continues to be a serious complication for patients on peritoneal dialysis (PD). Peritonitis is one of the major causes of hospitalization, accounting for 23% of admissions in the CANUSA study (1). Peritonitis is the leading cause of technique failure and catheter loss (2,3). Patients with frequent peritonitis are at increased risk of dying, independent of other factors (4). Although the rates of peritonitis have decreased dramatically from the inception of CAPD, rates above 0.5 episodes per year still commonly occur. The success of this dialysis technique is closely tied to the ability of the dialysis team to reduce the risk of peritonitis, and when it occurs, manage the patient appropriately. Clinical Presentation The usual presentation of peritonitis is abdominal pain, cloudy effluent or, most often, both. The pain can range from extremely severe to nonexistent. In the inexperienced patient, the absence of pain may lead him/her to ignore the cloudy effluent initially, leading to a delay in presentation and subsequent treatment. All patients must be instructed to call immediately if the effluent is even slightly cloudy. Peritonitis is present if the white blood cell (WBC) count in the effluent is b00/p.b or greater, with at least 50% polymorphonuclear cells. If the specimen is collected from a short cycle, an aspirate from a drained abdomen, or obtained from a patient already on antibiotics, the percentage of polymorphonuclear cells (i.e., more than 50%) is a more reliable marker for peritonitis than the absolute number of WBC. Occasionally, blood-tinged effluent will be confused with cloudiness, but trained personnel can readily detect the differenee. Other causes of cloudy effluent include chylous ascites, which have a milky appearance, intra-abdominal malignancy, diagnosed by cell cytology, and pancreatitis, which can be differentiated by an effluent amylase level of >50 UIL. Also included in the differential diagnosis is eosinophilie peritonitis, which is rarely associated with unusual fungi, but more often is idiopathic; recent reports suggest that treatment with steroids is effective in reducing the cellularity. In up to 6% of the episodes of peritonitis, the patient presents with abdominal pain but has clear effluent (5). Koopmans et a!. reported 60 such episodes of peritonitis, all with positive