Complications of Peritoneal Dialysis Part II: Nonmechanical Complications

Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in many countries. Unlike mechanical complications that typical arise early in the course of treatment, noninfectious, nonmechanical complications often present late in patients who are established on PD. In this review, we first discuss abnormal-appearing drained dialysate, including hemoperitoneum, chyloperitoneum, and noninfectious cloudy dialysate. The underlying cause is frequently unrelated to PD. We then discuss encapsulating peritoneal sclerosis, a rare complication of PD. Finally, we review metabolic changes associated with PD and methods to mitigate its effects.

Peritoneal dialysis related eosinophilic peritonitis: a case report and review of the literature

BACKGROUND

Overt eosinophilic peritonitis (EP) is a relatively uncommon complication of peritoneal dialysis (PD), although not rare. Here we reported a case of EP relieved after changing dialysate.  CASE PRESENTATION: A 28-year old male patient developed cloudy PD effluents within the first month after PD started. Cytological study of PD effluents showed elevated white blood cells and polynuclear cells. Bacteria culture of PD effluents repeated for several times were all negative, and no pathogen was found by metagenomics next generation sequencing (mNGS). Antibiotic therapy for 28-day was ineffective. Based on these and increased eosinophils in peritoneal fluid, he was finally diagnosed as EP. PD dialysate was changed (consists of the same buffer agent and electrolytes, but is packed in bags that do not contain PVC), and the patient's PD effluent became clear. Of note, EP did not relapse 5 months later when the patient started to use the former PD solution again.

CONCLUSION

Although PD effluent turbidity almost always represents infectious peritonitis, there are other differential diagnoses including EP. For patients with cloudy fluid accompanied by mild symptoms who do not response to antibiotic therapy, it is reasonable to consider the possibility of this disease. EP tends to heal spontaneously, however, antihistamines or glucocorticoids are required sometimes to avoid catheter obstruction. For patients with no obvious incentives, replacement of dialysate may be useful.

Eosinophilic peritonitis in children undergoing maintenance peritoneal dialysis: A case report and literature review

Eosinophilic peritonitis (EP) constitutes a significant number of culture-negative peritonitis cases that can affect 16-60% of the patients who are treated with maintenance peritoneal dialysis (PD). Although it is mainly considered to be the hypersensitivity response of the peritoneum to foreign substances, it can also develop following culture-positive peritonitis attacks. Besides the presence of more than 100 white blood cells (WBC)/ml, the diagnosis is made with the high number of eosinophils in the dialysate fluid (>10%), usually accompanied by peripheral eosinophilia. In this study, a 12-year-old male patient, who was diagnosed as EP as early as in the first week of PD catheter placement and treated with systemic antihistamines was reported. Additionally, clinical aspects and treatment modalities of EP are presented with a detailed literature review. Although EP is usually a self-limiting clinical manifestation with a benign outcome, it can be overlooked due to the lack of a routine reporting of the count and percentage of peritoneal eosinophils in most centers. For this reason, a detailed examination in culture-negative peritonitis cases for EP in order to avoid unnecessary antibiotic use for these patients should be the strategy.

Cefoperazone and sulbactam-related eosinophilic peritonitis: a case report and literature review

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis that occurs because of an overreaction to constituents that are related to the catheter or tubing, peritoneal dialysate, pathogenic infection, or intraperitoneal drug use. EP caused by antibiotic use is rare. We present the case of a patient with cefoperazone and sulbactam-related EP. A 59-year-old woman who was undergoing peritoneal dialysis presented with peritonitis with abdominal pain and turbid peritoneal dialysis. Empiric intraperitoneal cefazolin in combination with cefoperazone and sulbactam was started after peritoneal dialysis effluent cultures were performed. Her peritonitis achieved remission in 2 days with the help of cephalosporin, but she developed EP 1 week later, when her dialysate eosinophil count peaked at 49% of the total dialysate white blood cells (absolute count, 110/mm³). We excluded other possible causes and speculated that cefoperazone and sulbactam was the probable cause of EP. The patient continued treatment with cefoperazone and sulbactam for 14 days. EP resolved within 48 hours after stopping cefoperazone and sulbactam. Thus, EP can be caused by cefoperazone and sulbactam use. Physicians should be able to distinguish antibiotic-related EP from refractory peritonitis to avoid technique failure.

Eosinophilic peritonitis in children on chronic peritoneal dialysis

BACKGROUND

Eosinophilic peritonitis (EP) is sometimes difficult to distinguish from bacterial peritonitis (BP) at onset, as they are often overlapping. Previous reports show EP occurs more frequently in infants, although the reason is unknown.

METHODS

The study population was 77 pediatric patients receiving chronic peritoneal dialysis (PD) in our center. We compared clinical and laboratory data at onset of EP with those of BP. We also investigated age distribution at onset of EP and PD-related surgery.

RESULTS

Eleven patients developed EP (18 episodes) and 19 patients developed BP (38 episodes). EP patients showed lower rate of cloudy dialysate (44.4% vs. 74.4%; p = 0.04), lower rate of fever (38.9% vs. 56.4%), lower frequency of abdominal pain (16.7% vs. 38.5%), higher peripheral blood eosinophil counts (/μL) (514 vs. 160; p < 0.001), and lower serum C-reactive protein level (mg/dL) (0.4 vs. 4.7; p < 0.001) than BP patients. Thirteen EP events were observed after 169 surgical interventions. Age at surgery-related EP was similar to age at surgery without EP (2.6 vs. 2.1; p = 0.65). There was no significant difference in postoperative EP occurrence between groups <2 years and ≥ 2 years (6.2% vs. 9.1%; p = 0.48). However, infants received more operations than older children.

CONCLUSION

Clinical symptoms in children and laboratory data of EP in children were less severe than those of BP. As incidence of postoperative EP did not differ by age, we speculate that higher incidence of EP in infants might be associated with higher incidence of surgery, although further validation is necessary.

Eosinophilic peritonitis induced by sucroferric oxyhydroxide

A 49-year-old woman developed eosinophilic peritonitis 2 months after starting continuous ambulatory peritoneal dialysis because of congenital right kidney hypoplasia and chronic glomerulonephritis. This was shown to have been induced by sucroferric oxyhydroxide, an iron-based phosphate binder, using a drug-induced lymphocyte stimulation test. Her eosinophilic peritonitis was improved after stopping the administration of sucroferric oxyhydroxide without providing any immunosuppressive agents.

Increase of Eosinophil in Dialysate during Induction of Peritoneal Dialysis

As a rare complication in patients on peritoneal dialysis (PD), increase of eosinophil (peritoneal dialysate fluid [PDF] eosinophilia), including eosinophilic peritonitis, was observed in PDF. The majority of eosinophilic peritonitis cases are detected during the early phase of PD induction. However, the frequency of and mechanisms underlying PDF eosinophilia remain unclear. We therefore investigated the frequency of PDF eosinophilia and what mechanisms, specifically complement activation, might contribute to its occurrence. In 48 patients, eosinophil counts and concentrations of complement activation products, such as C3a, C5a, and sC5b-9, interleukin (IL)-5, and IL-6 in PDF were evaluated on days 1, 2, and 4 after starting PD therapy. We focused on the relationships between patient background characteristics and eosinophil counts and levels of C3a, C5a, and sC5b-9 as complement activation products in PDF. In 33.3% of PD patients, increased PDF eosinophils were observed on day 1. Eosinophil counts correlated with PDF levels of C3a on days 1 and 2, IL-5 on days 1, 2, and 4, and IL-6 on day 1. In terms of background characteristics, only the duration the PD catheter was left in place differed significantly between PDF eosinophilia and non-PDF eosinophilia. Notably, PDF levels of C3a differed significantly between patients with and without eosinophilia, suggesting that C3a might be a candidate for induction of increased eosinophil.

PDF eosinophilia was frequently observed during PD initiation. Our results suggest that PD catheter insertion and complement activation might be related to increases in eosinophils in PDF during PD initiation.

Chryseobacterium indologenesperitonitis in a peritoneal dialysis patient

Peritonitis remains an important complication of peritoneal dialysis. The Gram-negative bacillusChryseobacterium indologenescauses infection mostly in immunocompromised patients with severe underlying disease, mainly in Asia. Herein, we report the first case in Europe and the second case in an immunocompetent patient of peritoneal dialysis-associatedC. indologenesperitonitis. Our patient presented with abdominal pain and a cloudy effluent and was started on intraperitoneal antibiotics. The organism cultured from the peritoneal fluid was later identified asC. indologenesand antibiotic therapy was adjusted accordingly. Despite this, the peritonitis followed a relapsing course, requiring Tenckhoff catheter removal, temporary transfer to haemodialysis and intravenous antibiotics. Subsequently, a new Tenckhoff catheter was inserted and peritoneal dialysis was restarted. The patient remains peritonitis free after 18 months of follow-up. This case highlights the need to consider rare causes of peritonitis in peritoneal dialysis patients as well as the heterogeneous clinical course ofC. indologenesperitonitis.

Vancomycin-induced eosinophilic peritonitis

PURPOSE

A case of eosinophilic peritonitis (EP) with severe cardiovascular compromise in a patient receiving intraperitoneal vancomycin therapy is described.

SUMMARY

A woman with a medical history including hypertension, end-stage renal disease, and anemia of chronic disease was hospitalized for complaints of severe abdominal pain and loss of appetite over the preceding four days; she had been undergoing peritoneal dialysis for about one year. Bacterial infection was diagnosed on the basis of peripheral blood and peritoneal fluid analyses showing highly elevated neutrophil and total nucleated cell (TNC) counts. Vancomycin was added to the peritoneal dialysis bags, with subsequent dramatic TNC and neutrophil reductions over two days, but the woman's condition continued to worsen; she developed severe hypotension and on hospital day 13 was transferred to the intensive care unit for central line placement and vasopressor support. The clinician team determined that conversion from bacterial peritonitis to EP had occurred. After the exclusion of other potential causes of EP (e.g., a reaction to dialysis equipment, antihypertensive medication use), intraperitoneal administration of vancomycin was deemed to be the probable cause. Within days of discontinuation of vancomycin use, the patient's hypotension abated, her abdominal symptoms resolved, and she was discharged home. In this case, the diagnosis of EP was complicated by the initial presentation of bacterial peritonitis (confirmed by laboratory and culture data). A literature search identified one other published report of vancomycin-induced EP.

CONCLUSION

A 37-year-old woman developed EP after receiving vancomycin intraperitoneally. The infection resolved after discontinuation of vancomycin.

Flow cytometry for the microscopy of body fluids in patients with suspected infection

Automating the microscopy of body fluids is challenging, due to the wider range and lower concentrations of cells in these fluids, as opposed to blood, while the viscous nature of some of these fluids can also be problematic. This review shows that there have been major improvements and that newer flow cytometers can have remarkably low limits of quantitation for WBCs. Accurate counting of RBCs is still problematic with many flow cytometers, but this is of no clinical significance. Many flow cytometers can give reasonably accurate WBC differential counts, but detection of eosinophils and neoplastic or other nucleated cells which are not blood cells can still be problematic, hence fail-safe measures are recommended. Cerebrospinal fluid is the most challenging body fluid as it requires the ability to count and differentiate WBCs down to a 'normal range', which is much lower than the diagnostic cut-off values used for serous fluids; precision at or around the cerebrospinal fluid WBC normal range is reduced even with the best flow cytometers, but manual microscopy is even less precise.

American Society of Nephrology Quiz and Questionnaire 2014: RRT

The Nephrology Quiz and Questionnaire (NQ&Q) remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology (ASN). Once again, the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, end-stage renal disease/dialysis, and transplantation. Complex cases representing each of these categories along with single best answer questions were prepared and submitted by the panel of experts. Prior to the meeting, program directors of U.S. nephrology training programs and nephrology fellows answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by experts. They compared their answers in real time using audience response devices with the answers of the nephrology fellows and training program directors (TPDs). The correct and incorrect answers were then discussed after the audience responses and the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this educational session. This article recapitulates the session and reproduces its educational value for the readers of the Clinical Journal of the American Society of Nephrology. Enjoy the clinical cases and expert discussions.

Montelukast: a novel therapeutic option in eosinophilic peritonitis

BACKGROUND

Eosinophilic peritonitis is a recognised complication of peritoneal dialysis and has an incompletely understood pathophysiology. Current treatment options, including change of dialysate, change of peritoneal dialysis modality, steroids or antihistamines, are supported only by case reports with a lack of controlled trials or evidence-based guidelines. Leukotrienes are proinflammatory arachidonic acid metabolites produced by leucocytes and are involved in eosinophil chemotaxis. Montelukast is an orally administered leukotriene receptor antagonist commonly used in managing childhood atopic illnesses and theoretically safe for use in patients with renal failure.

CASE DIAGNOSIS AND TREATMENT

We describe the first reported case of recurrent, symptomatic, eosinophilic peritonitis in a 15-year-old girl successfully treated with leukotriene receptor antagonist montelukast after changes in dialysate and treatment with antihistamines failed to adequately control eosinophilic peritoneal infiltrates or symptoms.

CONCLUSIONS

Current scientific understanding of leukotrienes and eosinophil migration suggest that montelukast may be a well-tolerated, safe and efficacious treatment for eosinophilic peritonitis complicating peritoneal dialysis. Further cases and comparative studies are required to develop an evidence base for treatment of this condition.

Regulation of chemokine CCL5 synthesis in human peritoneal fibroblasts: a key role of IFN-γ

Peritonitis is characterized by a coordinated influx of various leukocyte subpopulations. The pattern of leukocyte recruitment is controlled by chemokines secreted primarily by peritoneal mesothelial cells and macrophages. We have previously demonstrated that some chemokines may be also produced by human peritoneal fibroblasts (HPFB). Aim of our study was to assess the potential of HPFB in culture to release CCL5, a potent chemoattractant for mononuclear leukocytes. Quiescent HPFB released constitutively no or trace amounts of CCL5. Stimulation of HPFB with IL-1β and TNF-α resulted in a time- (up to 96 h) and dose-dependent increase in CCL5 expression and release. IFN-γ alone did not induce CCL5 secretion over a wide range of concentrations (0.01–100 U/mL). However, it synergistically amplified the effects of TNF-α and IL-1β through upregulation of CCL5 mRNA. Moreover, pretreatment of cells with IFN-γ upregulated CD40 receptor, which enabled HPFB to respond to a recombinant ligand of CD40 (CD40L). Exposure of IFN-γ-treated HPFB, but not of control cells, to CD40L resulted in a dose-dependent induction of CCL5. These data demonstrate that HPFB synthesise CCL5 in response to inflammatory mediators present in the inflamed peritoneal cavity. HPFB-derived CCL5 may thus contribute to the intraperitoneal recruitment of mononuclear leukocytes during peritonitis.

Intestinal Strongyloides causing peritoneal eosinophilia in peritoneal dialysis

A 59-year-old Laotian male with a past medical history of multiple myeloma on peritoneal dialysis (PD) presented with abdominal pain and peritoneal eosinophilia. He was treated empirically for bacterial peritonitis and discharged although his PD fluid did not isolate any pathogens. He soon developed a partial small bowel obstruction and his serum Strongyloides IgG was positive. After treatment with ivermectin, stool microscopic examination showed Strongyloides stercoralis larvae. This case illustrates that the differential diagnosis of peritoneal eosinophilia should include typical and atypical infections in addition to an allergic or hypersensitivity type reaction.

Vancomycin-related eosinophilic peritonitis

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis and is often associated with either a reaction to a constituent of the dialysis system (tubing, sterilant, or solution) or an underlying bacterial or fungal reaction. EP has also been described in the setting of icodextrin use. We report a case of EP associated with intraperitoneal vancomycin used in the treatment of peritonitis secondary to methicillin-resistant Staphylococcus epidermidis. Causation was based upon temporal association, negative cultures, concomitant peripheral eosinophilia, and resolution with cessation of vancomycin. Vancomycin allergy should be considered in the differential diagnosis of EP in the right clinical context. Negative bacterial and fungal cultures are essential to exclude other etiologies.

Eosinophilic peritonitis in children on chronic peritoneal dialysis

Eosinophilic peritonitis is a response of the peritoneum to foreign substances. It presents as cloudy dialysate and may be missed because not all laboratories report the eosinophil count, giving only the total number of polymorphonuclear cells. Over a 2-year period, eight children developed 13 episodes of eosinophilic peritonitis. Three episodes were asymptomatic other than cloudy fluid, five followed surgery and two were associated with gastroenteritis. Despite recurrent episodes, there were no adverse outcomes, although a raised peritoneal eosinophil count persisted in most cases. Eosinophilic peritonitis is under-diagnosed and may lead to unnecessary antibiotic therapy.