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

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 3 years, 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 6.3 mg/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 4 days, 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 47 days. 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.

Comparison of clinical outcomes between culture-negative and positive peritonitis in patients undergoing maintenance peritoneal dialysis: a prospective cohort study

BACKGROUND

Culture-negative peritonitis is a serious complication in patients undergoing maintenance peritoneal dialysis (PD) and occurs in up to 40% of all peritonitis episodes. Despite its high incidence, data regarding treatment response and prognosis remain poorly defined. This study compared the clinical outcomes of patients with culture-negative and positive peritonitis.

METHOD

This prospective cohort study was conducted between 2021 and 2022. Patients treated with maintenance PD who developed PD-associated peritonitis were included and received standard treatment. The primary endpoint was the primary response (resolution of peritonitis 10 days after the initiation of treatment).

RESULTS

Of the 81 patients who developed PD-associated peritonitis during the study, 35 and 46 had culture-negative and culture-positive peritonitis, respectively. Overall, 52 (64.2%) patients achieved the primary response: 24 (68.6%) in the culture-negative group and 28 (60.9%) in the culture-positive group (p = 0.630). There were no significant differences between the two groups in the incidence of complete cure (complete resolution of peritonitis without the need for Tenckhoff catheter removal or salvage antibiotic therapy or peritonitis within 120 days after treatment) (culture-negative vs. culture-positive group, 57.1% vs. 45.7%), refractory peritonitis (28.6% vs. 41.3%), relapse peritonitis (8.6% vs. 2.2%), repeat peritonitis (11.4% vs. 10.9%), salvage antibiotics (40.0% vs. 50.0%), permanent hemodialysis transfer (11.4% vs. 10.9%), Tenckhoff catheter removal (25.7% vs. 41.3%), or mortality (2.9% vs. 2.2%) (all p > 0.05).

CONCLUSION

This study offers valuable insights into the clinical outcomes of culture-negative peritonitis versus culture-positive peritonitis. However, caution must be exercised in interpreting these findings due to the limitations of the small sample size.

CLINICAL TRIAL REGISTRATION

The study was retrospectively registered in the Thai Clinical Trials Registry (TCTR20221130006).

Variability in Culture-Negative Peritonitis Rates in Pediatric Peritoneal Dialysis Programs in the United States

BACKGROUND AND OBJECTIVES

International guidelines suggest a target culture-negative peritonitis rate of <15% among patients receiving long-term peritoneal dialysis. Through a pediatric multicenter dialysis collaborative, we identified variable rates of culture-negative peritonitis among participating centers. We sought to evaluate whether specific practices are associated with the variability in culture-negative rates between low- and high-culture-negative rate centers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Thirty-two pediatric dialysis centers within the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative contributed prospective peritonitis data between October 1, 2011 and March 30, 2017. Clinical practice and patient characteristics were compared between centers with a ≤20% rate of culture-negative peritonitis (low-rate centers) and centers with a rate >20% (high-rate centers). In addition, centers completed a survey focused on center-specific peritoneal dialysis effluent culture techniques.

RESULTS

During the 5.5 years of observation, 1113 patients had 1301 catheters placed, totaling 19,025 patient months. There were 620 episodes of peritonitis in 378 patients with 411 catheters; cultures were negative in 165 (27%) peritonitis episodes from 125 (33%) patients and 128 (31%) catheters. Low-rate centers more frequently placed catheters with a downward-facing exit site and two cuffs (P<0.001), whereas high-rate centers had more patients perform dialysis themselves without the assistance of an adult care provider (P<0.001). The survey demonstrated that peritoneal dialysis effluent culture techniques were highly variable across centers. No consistent practice or technique helped to differentiate low- and high-rate centers.

CONCLUSIONS

Culture-negative peritonitis is a frequent complication of maintenance peritoneal dialysis in children. Despite published recommendations for dialysis effluent collection and culture methods, great variability in culture techniques and procedures exists among individual dialysis programs and respective laboratory processes.

Sterile Peritonitis in the Peritoneal Dialysis Patient

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

Association between peritoneal dialysate effluent leukocytosis and amlodipine besylate

Dialysate effluent leukocytosis is consistent with a greater degree of infection or inflammation in patients receiving peritoneal dialysis. This study describes a girl aged 2 years 9 months with end-stage renal disease resulting from crescent glomerulonephritis and severe interstitial nephritis who developed leukocytosis with a predominance of lymphocytes in the dialysate effluent, and in whom the effluent cell count normalized 1 week after discontinuation of amlodipine besylate therapy. Rechallenge confirmed that amlodipine was the offending agent causing effluent leukocytosis.

Pseudomyxoma Peritonei as a Cause of Culture-Negative Peritonitis for a Patient Undergoing Peritoneal Dialysis

Culture-negative peritonitis accounts for up to 20% of all peritoneal dialysis-related peritonitis, the causes of which include culture-associated technical errors, prior use of antibiotics, infection caused by certain unusual or fastidious microorganisms, the development of abdominal or retroperitoneal organ inflammation, and the presence of malignancies. Here, we report a patient with end-stage renal disease receiving peritoneal dialysis who presented with culture-negative peritonitis and ultrafiltration failure caused by the rare pseudomyxoma peritonei. For cases of culture-negative peritonitis such as this, early imaging studies may help recognize intraperitoneal/retroperitoneal visceral inflammation and malignant conditions.