Peritoneal Dialysis Catheter Removal Research Articles

Peritoneal dialysis-associated peritonitis, caused by superior mesenteric artery thrombosis with intestinal necrosis: a case report.

Peritoneal dialysis (PD)-associated peritonitis is a common complication of PD. Enteric peritonitis is defined as peritonitis arising from an intestinal or intra-abdominal organ source. The delay in the diagnosis or treatment of enteric peritonitis has been reported to increase mortality. Therefore, the early consideration of enteric peritonitis, particularly in cases of culture-negative peritonitis, is imperative. A 67-year-old Japanese man who had been undergoing PD for 3years, was admitted to our hospital with a diagnosis of PD-associated peritonitis. A month previously, he experienced a bleeding gastric ulcer, which led to severe anemia (hemoglobin 6.3mg/dL), followed by thrombocytosis. On admission, peritoneal fluid analysis showed a high white blood cell count (WBC: 8,570 /µL), with neutrophils predominating (74.5%). Cultures of both his dialysis effluent and blood were negative. After admission, the WBC count of the dialysis effluent gradually decreased alongside antibiotic therapy, but the patient's abdominal pain did not improve. After 4days, enhanced computed tomography showed superior mesenteric artery (SMA) thrombosis and intestinal necrosis. Therefore, emergency intestinal resection and PD catheter removal were performed, and then antithrombosis therapy was initiated. Because the patient's abdominal pain was improved and platelet count and D-dimer concentration were reduced by these treatments, he was discharged from the hospital after 47days. Thus, we report a rare case of culture-negative PD-associated peritonitis, which was caused by SMA thrombosis and intestinal necrosis. It is likely that combination of severe calcification of SMA and prolonged thrombocytosis secondary to the severe anemia contributed to the thrombosis.

Empyema associated with peritoneal dialysis peritonitis.

A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae. However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae. Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space.

#1245 Standard or personalized policy of peritoneal catheter removal at kidney transplantation?

Abstract Background and Aims The presence of peritoneal dialysis (PD) catheter in an immunosuppressed kidney transplant recipient can increment the risk of infectious complications after transplant. For this reason, it is thought that management of PD catheters at the time of transplant can have an impact on patient and graft outcomes. However, there is no agreement when to remove peritoneal dialysis catheter after transplantation. According to European Guidelines, the catheter can be left in situ for 3-4 months despite a functional graft. Our aim was to review the data from our center regarding infectious PD associated complications after kidney transplant. Method We retrospectively reviewed all 132 patients that were previously on PD and were admitted to our center for renal transplantation between January of 2013 and June of 2023, and had information regarding timing of removal of PD access. Simple descriptive and inferential statistics were used to generate results. Categorical data were described using frequency and percentage. Our main outcome was to assess the PD infectious catheter-associated complications. Our secondary outcomes were the timing of removal of PD catheter after renal transplantation, number of episodes of dialysis post transplantation, and kidney replacement therapy (KRT) used. Our follow up included the time from kidney transplantation (KT) until they removed PD catheter. Those who removed PD catheter at the timing of renal transplantation were excluded when evaluating the infectious complications. Results From the 132 kidney transplant recipients eight patients removed PD catheter at the time of the transplant due to ongoing PD associated infection. Sixty-nine patients were men (52.3%), with a median (IQR) age at transplantation of 48.4 years (41-57). Regarding donors’ characteristics, 88 (33.3%) were deceased, 21 of which were expanded criteria donors, and 44 (66.7%) were living donors. A total of 19 (14.4%) patients had history of PD infectious complications in the three months before transplantation. From the 124 patients that remained with the PD catheter after KT the adverse event infection occurred in 19 (15.3%) patients and two of these had previous access related infection in the 3 months interval before transplantation. The adverse events were: exit-site infection (ESI) 10.4% (n = 19), peritonitis 3% (n = 4) and tunnel infection 1.6% (n = 2). Half required hospitalization mainly due to center logistics for catheter removal. No deaths were registered. The identified microorganisms are present in Table 1. The median (IQR) time of removal of the PD catheter was 4 (3-5) months. Sixteen patients (12.9%) required KRT due to delayed graft function: ten patients used the Tenckhoff catheter and the rest performed haemodialysis (four using central venous catheter and two using arteriovenous fistula). Three patients remained dialysis dependent. When analysing the living donor group the rate of KRT was even lower, with three (6.8%) patients requiring dialysis, and only one used the PD catheter. Conclusion Despite the timing of PD catheter removal was according to the European Guidelines, the risk of PD catheter associated infections is not negligible (15.3%), not to mention the burden for the patient to keep an abdominal device demanding routinely care of the exit site. Peritonitis rate was low and comparable to previous studies. Considering the utility of remaining with the catheter, the risk of needing KRT, namely in living donor KT, was low. We postulate whether PD catheter removal at the time of KT should be considered, especially when the risk of late graft function is low, as in living donors, and/or the risk of PD catheter related infections is high. For this reason, we call for an individualized policy regarding catheter removal in the transition to KT.

#593 Prevalence and outcomes of tuberculous peritonitis among CAPD patients in National Kidney and Transplant Institute from January 2016 to January 2023

Abstract Background Continuous ambulatory peritoneal dialysis is a cost effective and efficient modality of renal replacement therapy. However, infectious processes such as peritonitis may lead to peritoneal membrane failure necessitating shift to hemodialysis. Tuberculous peritonitis is an unusual cause of peritonitis, which may lead to risk of hospitalization and significant morbidity and mortality. Aims To determine the prevalence and outcomes of tuberculous peritonitis among patients on continuous ambulatory peritoneal dialysis Method A retrospective, descriptive study of patients on continuous ambulatory peritoneal dialysis with tuberculous peritonitis from January 2016 to January 2023 in National Kidney and Transplant Institute. Demographic, clinical and laboratory data of patients with TB peritonitis were collected via chart review. Results Among 1182 patients on continuous ambulatory peritoneal dialysis, 2.03% had tuberculous peritonitis. Average length of time from development of symptoms to diagnosis is 24.5 days. Majority of presenting symptoms were hazy drain and abdominal pain. 66.7% retained their peritoneal dialysis catheter. PD catheter was removed in 33% of TB peritonitis due to peritoneal dialysis failure and unresolving peritonitis. Mortality was 37.5% after diagnosis of tuberculous peritonitis. Only significant factor associated with mortality was length of time on continuous ambulatory peritoneal dialysis to development of TB peritonitis (p = 0.0332). Conclusion Relative high prevalence of tuberculous peritonitis could be related to high background occurrence of tuberculosis in the country. Majority of cases had resolution of symptoms and effective dialysis during course of anti-tuberculous treatment and did not warrant peritoneal dialysis catheter removal.

Pyogenic liver abscesses in peritoneal dialysis patients: A single-centre retrospective case series.

Peritoneal dialysis (PD)-related infection rates have improved, but serious complications such as liver abscesses remain an issue, posing unique management challenges including safety of continuing PD versus early PD catheter removal. Current literature describing this is unfortunately limited. This study aims to describe the characteristics, management and outcomes of liver abscesses in PD patients from a retrospective review of prevalent PD patients on follow-up at Tan Tock Seng Hospital between 1st January 2016 and 30th June 2021. A total of 11/383 PD patients (2.9%) were treated for liver abscesses. Most were diabetic (n =10, 90.9%), with a median PD vintage of 541 days (interquartile range: 310-931 days). Fever (n = 7, 63.6%), bacteraemia (n = 7, 63.6%) and concomitant PD peritonitis (n = 7, 63.6%) were the most common presenting symptoms. Majority of patients underwent radiological aspiration of abscess in addition to antibiotics (n = 7, 63.6%). PD catheter was removed in eight patients (72.7%), with the most common indications being empirical removal due to intra-abdominal abscess (n = 5, 62.5%) followed by septic shock (n = 2, 25%) and refractory PD peritonitis (n = 1, 12.5%). Only three patients (37.5%) remained on PD, as they did not develop PD peritonitis during their course of treatment. The overall mortality remains high with three patients (27.3%) passing away within 6 months of presentation. Liver abscesses in PD patients is associated with poor technique and overall survival. Absence of PD peritonitis appears to be a good prognostic factor, but larger studies are required to guide the optimal management of liver abscesses in PD patients.

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.

Green Nails, Red Alert: An Unusual Exit site infection Presentation.

Green nail syndrome is an infectious nail disorder caused most commonly by Pseudomonas aeruginosa. We report a rare case of peritoneal dialysis (PD) exit site infection (ESI) accompanied by P. aeruginosa-associated green nail syndrome. The patient was treated with oral and topical antibiotics without the need for PD catheter removal. We aim to emphasise the importance of nail assessment for ESI in patients undergoing PD.

Peritoneal Dialysis Catheter Complications after Insertion by Surgeons, Radiologists, or Nephrologists.

The Advancing American Kidney Health Initiative aims to increase rates of utilization of peritoneal dialysis (PD) in the United States. One of the first steps to PD is successful catheter placement, which can be performed by surgeons, interventional radiologists, or nephrologists. We examined the association between operator subspecialty and risk of needing a follow-up procedure in the first 90 days after initial PD catheter implantation. Overall, we found that 15.5% of catheters required revision, removal, or a second catheter placement within 90 days. The odds of requiring a follow-up procedure was 36% higher for interventional radiologists and 86% higher for interventional nephrologists compared with general surgeons. Further research is needed to understand how to optimize the function of catheters across different operator types. The US government has implemented incentives to increase the use of PD. Successful placement of PD catheters is an important step to increasing PD utilization rates. Our objective was to compare initial outcomes after PD catheter placement by different types of operators. We included PD-naïve patients insured by Medicare who had a PD catheter inserted between 2010 and 2019. We examined the association between specialty of the operator (general surgeon, vascular surgeon, interventional radiologist, or interventional nephrologist) and odds of needing a follow-up procedure, which we defined as catheter removal, replacement, or revision within 90 days of the initial procedure. Mixed logistic regression models clustered by operator were used to examine the association between operator type and outcomes. We included 46,973 patients treated by 5205 operators (71.1% general surgeons, 17.2% vascular surgeons, 9.7% interventional radiologists, 2.0% interventional nephrologists). 15.5% of patients required a follow-up procedure within 90 days of the initial insertion, of whom 2.9% had a second PD catheter implanted, 6.6% underwent PD catheter removal, and 5.9% had a PD catheter revision within 90 days of the initial insertion. In models adjusted for patient and operator characteristics, the odds of requiring a follow-up procedure within 90 days were highest for interventional nephrologists (HR, 1.86; 95% confidence interval [CI], 1.56 to 2.22) and interventional radiologists (odds ratio, 1.36; 95% CI, 1.17 to 1.58) followed by vascular surgeons (odds ratio, 1.06; 95% CI, 0.97 to 1.14) compared with general surgeons. The probability of needing a follow-up procedure after initial PD catheter placement varied by operator specialty and was higher for interventionalists and lowest for general surgeons.

Efficacy and safety of removing peritoneal dialysis catheters using the pull technique.

To study the efficacy and safety of peritoneal dialysis (PD) catheter removal using the pull technique. We conducted a retrospective analysis of 36 patients in whom the pull technique was used to remove a PD catheter. We evaluated the efficacy, safety, and health economic benefits of this technique by analyzing the pain score, duration of the procedure, complications during or after the procedure, and cost. The mean age (± standard deviation) of the 36 patients was 51 ± 14years involving 27 males and 9 females with a mean body mass index was 23.4 ± 2.6. The mean duration of PD was 28months (range 4-96months). The site of the pull technique for peritoneal dialysis catheter removal was at the bedside or in the treatment room, with local anesthesia or no anesthesia. The mean duration of the procedure (from anesthesia to complete removal of the PD catheter) was 5-15min. Only one patient experienced catheter rupture and no patients developed procedural or post-procedural bleeding or abdominal wall leakage. Infection did not occur at the inner or outer cuffs, tunnel, or outlet. Pain scores analyzed by a 10-point visual analogue scoring technique both immediately and 24h after the procedure were 3.5 ± 1.7 and 1.2 ± 0.8, respectively. The pull technique is simple to perform, takes a short time, results in few complications and small wounds, causes only mild pain, enables fast recovery, and results in low medical costs.

Laparoscopic observations of adhesions between peritoneal dialysis catheters and intraperitoneal organs: A retrospective, observational study.

Laparoscopy provides extensive data for the decannulation of a peritoneal dialysis catheter and is being increasingly used to diagnose encapsulating peritoneal sclerosis. However, there are few reports on the methods of decannulation of peritoneal dialysis catheters. In this study, we examined the laparoscopic findings and postoperative complications of patients undergoing peritoneal dialysis catheter removal. A total of 119 laparoscopic decannulations of peritoneal dialysis catheters were performed between 2003 and 2018 at the Juntendo University Hospital and Juntendo University Nerima Hospital. Laparoscopy was performed during peritoneal dialysis catheter removal by a gastrointestinal surgeon. Patient characteristics such as age, sex, duration of peritoneal dialysis, history of peritonitis and age at the time of peritoneal dialysis termination were assessed. Of these 119 cases, 19 (16.0%) showed adhesion between the peritoneal dialysis catheter and intraperitoneal organs. There were 13 (10.9%) cases involving a tangled omentum, 4 (3.4%) cases involving the small intestine and 2 (1.7%) cases of adhesions extending from the bowels to the abdominal wall. No postoperative complications were associated with the laparoscopic surgery. In these cases, blind decannulation of the peritoneal dialysis catheter may result in injury to the gastrointestinal tract in patients with adhesions. Therefore, we need to pay attention to adhesions between peritoneal dialysis catheters and intraperitoneal organs, and laparoscopy could be a valuable tool in detecting such adhesions and ensuring patient safety.

Peritoneal Expression of Membrane Complement Regulators Is Decreased in Peritoneal Dialysis Patients with Infected Peritonitis.

In peritoneal dialysis (PD) patients, fungi and Pseudomonas aeruginosa are considered important causative microorganisms for peritonitis with poor prognosis. Our objective was to explore expressions of membrane complement (C) regulators (CRegs) and tissue injuries in the peritoneum of patients with PD-related peritonitis, including fungal and Pseudomonas aeruginosa peritonitis. In peritoneal biopsy tissues obtained at PD catheter removal, we investigated the severity of peritonitis-associated peritoneal injuries and the expression of CRegs, CD46, CD55, and CD59 against peritoneal tissues without any episode of peritonitis. In addition, we evaluated peritoneal injuries among fungal and Pseudomonas aeruginosa-peritonitis (P1) and Gram-positive bacterial peritonitis (P2). We also observed deposition of C activation products such as activated C and C5b-9 and measured sC5b-9 in the PD fluid of patients. As a result, the severity of peritoneal injuries correlated inversely with the expression of peritoneal CRegs. Peritoneal CReg expression in peritonitis was significantly reduced compared to no peritonitis. Peritoneal injuries were more severe in P1 than in P2. CReg expression was further decreased and C5b-9 further increased in P1 than in P2. In conclusion, severe peritoneal injuries due to fungal and Pseudomonas aeruginosa-peritonitis decreased CReg expression and increased deposition of activated C3 and C5b-9 in the peritoneum, suggesting that peritonitis, particularly fungal and Pseudomonas aeruginosa-peritonitis, might induce susceptibility to further peritoneal injuries due to excessive C activation.

Clinical characteristics and outcomes of peritoneal dialysis (PD)-related peritonitis after colonoscopy.

Colonoscopy is known to be associated with peritonitis in peritoneal dialysis (PD) patients. Antibiotic prophylaxis is recommended before colonoscopy. This study aims to investigate the clinical characteristics and outcomes of patients with PD-related peritonitis after colonoscopy. PD patients who were followed up in Pamela Youde Nethersole Eastern Hospital, with colonoscopy done from 1 January 2009 to 31 December 2019, were included for record review retrospectively. During this period, 74 patients underwent 115 colonoscopies. Fourteen patients (12.2%) developed PD-related peritonitis within 1 week after colonoscopy. There was no statistically significant difference in mean age, PD vintage, PD modality and history of PD-related peritonitis between patients with or without colonoscopy-related peritonitis. Polypectomy was more common in patients who developed peritonitis (78.6%) compared to those without peritonitis (35.6%) (p = 0.006). Ten of the 14 PD patients who had colonoscopy-related peritonitis responded to medical treatment while 4 patients required PD catheter removal. Two patients converted to maintenance haemodialysis and two died. Only 33% of Gram-negative bacteria isolated were sensitive to intravenous cefuroxime which was given as prophylactic antibiotic before colonoscopy. In conclusion, the overall risk of PD patients developing peritonitis post colonoscopy was 12.2%. Polypectomy was associated with higher risk of colonoscopy-related peritonitis. Large-scale study is needed to delineate effective antibiotic prophylaxis for colonoscopy-related peritonitis.

Analysis of the impact of peritoneal dialysis catheter tail-end design on catheter-related complications.

Evaluate the impact of peritoneal dialysis catheter (PDC) tail-end design variations on PDC-related complications. Effective data were extracted from databases. The literature was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions, and a meta-analysis was conducted. Analysis revealed that the straight-tailed catheter was superior to the curled-tailed catheter in minimizing catheter displacement and complication-induced catheter removal (RR = 1.73, 95%CI:1.18-2.53, p = 0.005). In terms of complication-induced PDC removal, the straight-tailed catheter was superior to the curled-tailed catheter (RR = 1.55, 95%CI: 1.15-2.08, p = 0.004). Curled-tail design of the catheter increased the risk of catheter displacement and complication-induced catheter removal, whereas the straight-tailed catheter was superior to the curled-tailed catheter in terms of reducing catheter displacement and complication-induced catheter removal. However, the analysis and comparison of factors such as leakage, peritonitis, exit-site infection, and tunnel infection did not reveal a statistically significant difference between the two designs.

Peritoneal dialysis-related peritonitis with encapsulated ascites due to Mycobacterium abscessus subsp. massilience and subsp. bolletii: a case series and literature review

BackgroundAs there is no established standard of care for non-tuberculous mycobacterium (NTM) peritoneal dialysis (PD)-related peritonitis, its treatments have to be case-dependent, which is often difficult. Additionally, several reported cases were accompanied by encapsulated ascites, adhesive ileus, and encapsulating peritoneal sclerosis, suggesting treatment difficulties. We report two cases of PD-related peritonitis with encapsulated ascites due to Mycobacterium abscessus subsp. massilience and subsp. bolletii. To the best of our knowledge, this is the first case series to report PD-related peritonitis caused by Mycobacterium abscessus subsp. bolletii.Case presentationThe first case is that of a 74-year-old male patient who started PD six years ago for end-stage renal failure due to diabetic nephropathy. In February 2021, he presented with signs of infection at the exit-site and swelling of the tunnel. Mycobacterium abscessus subsp. massilience was detected in the culture of the exit-site exudate; thus, he was diagnosed with tunnel infection (caused by NTM). Subsequently, fever, abdominal pain, and increased cell counts in the PD drainage fluid were observed, and he was judged to have NTM peritonitis. His general condition improved after PD catheter removal in addition to antimicrobial treatment and encapsulated ascites drainage. The second case is that of a 52-year-old man who commenced PD for end-stage renal failure due to nephrosclerosis 12 years ago. In May 2022, he was diagnosed with PD-related peritonitis based on signs of infection at the exit-site, encapsulated ascites on computed tomography, and a cloudy PD drainage fluid. Mycobacterium abscessus subsp. bolletii was detected in the culture of the exit-site exudate, which led to the diagnosis of NTM peritonitis. In addition to antimicrobial treatment, PD catheter removal and encapsulated ascites drainage were performed. The patient also had adhesive bowel obstruction due to peritonitis and required decompression therapy with the insertion of a gastric tube.ConclusionsPD catheter removal and encapsulated ascites drainage might have improved inflammation and treatment outcomes. Additionally, Mycobacterium abscessus might be prone to forming encapsulated cavities and/or intestinal adhesions; however, further accumulation of cases clarifying “subspecies” of Mycobacterium abscessus is necessary to confirm this hypothesis.

Stenotrophomonas maltophilia: A Case Series and Review for an Uncommon Cause of Peritoneal Dialysis-Associated Infection

Peritonitis is a common and potentially serious complication of peritoneal dialysis (PD). Common organisms include Staphylococcus Aureus, enterococci, and coagulase-negative staphylococcus. However, Stenotrophomonas maltophilia (S. maltophilia) is an uncommon cause of PD-related infection. We describe a series of three cases of S. maltophilia PD infection (two cases of PD peritonitis and one case of PD exit-site infection) that were identified over a seven-week period in a single centre. The cases were treated with antibiotics (the primary antibiotic being co-trimoxazole) for a mean duration of 30 ± 7.9 days. All of the patients required PD catheter removal due to treatment failure with antibiotics. Hospital admission was required in two of the cases and one case resulted in mortality, with the cause of death directly associated with complications from S. maltophilia infection. A multi-disciplinary team using root-cause analysis did not identify a common link between our cases but highlighted possible risk factors contributing to these presentations. Given the relative rarity of S. maltophilia, evidence on its management options remains limited. In this article, we draw upon our own experiences and examine the literature available from previously published case reports and series. These reports highlight S. maltophilia as a complex and challenging organism to treat. Our experience demonstrated the importance of early PD catheter removal in S. maltophilia PD infection, as this is likely more effective than prolonged antibiotic therapy and hence a safer management option, considering the resistant nature of S. maltophilia.

Tuberculous peritonitis in patients on peritoneal dialysis: a 35-year experience from a large medical center in Northern Taiwan

Introduction Tuberculous peritonitis (TBP) is a rare but fatal complication in patients on peritoneal dialysis (PD). In this study, we aimed to determine the demographic features, clinical features, laboratory parameters, and clinical outcomes of PD patients with TBP and to clarify possible risk factors for mortality. Materials and methods We retrospectively reviewed 2084 PD patients from January 1985 to December 2019. The diagnosis of TBP was established by positive peritoneal fluid culture for Mycobacterium tuberculosis. Results 18 patients were diagnosed with TBP. The incidence was 2.029 episodes per 1000 patient-years. The most common symptom was fever (94.4%), followed by cloudy effluent (83.3%) and abdominal pain (83.3%). The average peritoneal dialysis effluent (PDE) white blood cell (WBC) count was 172.7 cells/μL. Nine patients (50%) had WBC counts lower than 100 cells/μL and 13 patients (72.2%) had neutrophilic predominant WBC counts. Acid fast stain (AFS) was positive in 7 patients (38.9%). Only 2 patients (11.1%) continued with PD after TB infection, while 10 patients (55.6%) changed to hemodialysis. Seven patients (38.9%) died within 1 year. Significant differences were observed in sex (p = 0.040), the presence of diabetes mellitus (p = 0.024), and PD catheter removal (p < 0.001) between TBP patients with and without mortality. However, none of them was a significant factor for 1-year mortality in multivariate Cox regression model. Conclusion Physicians should pay attention to the unusual presentations of peritonitis, especially if symptoms include fever or an initial low PDE WBC count. Catheter removal is not mandatory if early diagnosis and appropriate therapy are available.

Relapsing and refractory peritoneal dialysis peritonitis caused by Corynebacterium amycolatum

BackgroundPeritonitis is an important complication and cause of morbidity in patients undergoing peritoneal dialysis (PD). Corynebacterium species, often considered skin and mucosal contaminants, are a rare cause of PD-associated peritonitis and have been acknowledged in published guidelines for the diagnosis and treatment of PD peritonitis only over the last decade.Case-Diagnosis/TreatmentWe present two children with difficult-to-treat episodes of PD peritonitis due to Corynebacterium amycolatum. Episodes were associated with fever, abdominal pain and cloudy dialysate, high dialysate polymorphonuclear leukocyte counts, and elevated serum C-reactive protein and procalcitonin concentrations. Symptoms persisted beyond 5 days in 4 of 5 peritonitis episodes, and peritonitis relapsed despite in vitro sensitivity of the bacterial isolates to guideline-recommended antibiotics. C. amycolatum was cultured from the PD catheter tip despite 4 weeks of intraperitoneal glycopeptide therapy and clinical peritonitis resolution suggestive of efficient biofilm formation. Our systematic literature search identified three previous (adult) case descriptions of C. amycolatum peritonitis, all with repeat episodes by the same organism. The incidence of C. amycolatum as a cause of PD peritonitis has not yet been established but is likely underreported due to challenges in species differentiation.ConclusionsC. amycolatum is a rarely identified cause of refractory and/or relapsing PD peritonitis. Species differentiation of non-diphtheriae Corynebacterium isolates is critical, and prolonged antibiotic treatment, preferably with a glycopeptide antibiotic, is recommended, with a low threshold for PD catheter change or removal in case of repeat peritonitis.

High C-reactive protein and number of previous episodes at diagnosis increase the risk of catheter removal in peritoneal dialysis-related peritonitis in children.

A minority of patients with peritonitis require removal of peritoneal dialysis (PD) catheters. We examined risk factors at diagnosis that could predict the removal of PD catheter before obtaining the results of treatment success in children with peritonitis. We analyzed 156 peritonitis episodes in 57 pediatric PD patients. The peritonitis rate was 0.68 peritonitis episode per patient year. Catheter removal was required in 22 of 156. C-reactive protein (CRP) ≥ ×10 of upper limit at diagnosis and increased previous episode number were found to be associated with catheter removal (OR [95% CI] 6.4 [2.3-18.1], p= 0.001 and 3.8 [1.4-10.6], p= 0.009). These findings supported that CRP could be an early marker in predicting catheter removal even before obtaining the results of treatment success. Furthermore, it should be kept in mind that the risk of catheter removal is high in patients with high number of previous episodes especially of three or more.

Relationship between laparoscopic and microscopic findings of peritoneum in peritoneal dialysis patients

Long-term exposure to the peritoneal dialysis solution (PDS) causes functional and morphological alterations that diminish the efficacy of peritoneal dialysis (PD). Macroscopic and microscopic findings, submesothelial compact zone (SMC) thickness and vascular patency, were associated with PD duration. The relationship between microscopic and laparoscopic morphological findings in PD patients was determined. A total of 78 laparoscopic intraperitoneal findings were recorded during PD catheter removal and 45 peritoneal tissues were obtained from the anterior parietal peritoneum. We examined macroscopic morphological findings in both parietal and visceral peritoneums and bowel movement and assessed the score semiquantitatively. SMC thickness and vascular patency were examined as microscopic findings. Total laparoscopic finding’s score (LFS) and microscopic findings, SMC thickness and vascular patency, were associated with PD duration. Total LFS was related to SMC thickness in both visceral and parietal peritoneum, whereas it was related to vascular patency in parietal but not in visceral peritoneum. There was no relationship between microscopic findings and peritoneal surface color, properties, vasculopathy, and adhesion. Total LFS in patients with newly formed membrane and omentum atrophy was higher than in those without. There was a significant relationship between microscopic and laparoscopic findings in PD patients. It is important to evaluate laparoscopic findings in more PD patients to find the predictive findings of encapsulating peritoneal sclerosis development.

Beware of a duplicate superior vena cava

A duplicate superior vena cava (SVC) with a persistent left SVC (PLSVC) is present in 0.3% of the population with an incidence as high as 10-11% in patients with congenital heart disease. While a PLSVC is rare and usually asymptomatic, clinicians should be aware of this anomaly during central line placement due to potential complications. Our case involves a 76-year-old man with end-stage renal disease, on peritoneal dialysis (PD), who was admitted to our hospital for treatment of generalized peritonitis secondary to a descending colon perforation. He underwent left hemicolectomy and removal of an infected PD catheter. During preparation for discharge, he underwent hemodialysis catheter replacement. During the procedure, it was noted that the wire did not traverse the midline. A subsequent venogram with contrast showed a duplicate SVC draining into the coronary sinus. The catheter was inserted into the proximal left SVC and verified with fluoroscopy. One hour later, the patient went into atrial fibrillation and death ensued. Persistent superior vena cava, if known or suspected, requires additional caution in central venous line placement to avoid potentially fatal complications, such as arrhythmias. Immediate removal and reassessment of an alternative access site should be pursued to avoid secondary complications.