Peritoneal Dialysis-Associated Peritonitis

Is cloudy peritoneal dialysate associated with adverse drug reactions to benidipine?

Cloudiness in peritoneal dialysate is a key clinical indicator of peritonitis. However, distinguishing between turbidity caused by peritonitis and that induced by drug administration can be challenging. To better understand this phenomenon, data were collected between April 2020 and March 2023 from 287 peritoneal dialysis (PD) patients undergoing benidipine-controlled blood pressure management in our PD center. Among these patients, 25 cases (8.71%) developed non-infectious chyloperitoneum as an adverse reaction to benidipine. Turbidity appeared, on average, 25.28 ± 60.55 days after starting benidipine. Switching to another antihypertensive drug cleared the dialysate within 12 to 36 hours. Laboratory results, including smears and cultures, were consistent with a non-infectious state. Elevated triglyceride (TG) levels were observed in the turbid dialysate (p < 0.0001), with a mean TG of 0.28 ± 0.17 mmol/L in cloudy samples, compared to 0.07 ± 0.03 mmol/L in clear samples. No significant changes in cholesterol or peripheral blood TG levels were found before or after the occurrence of turbidity. This study confirms that benidipine can cause non-infectious chyloperitoneum, underscoring the need for attention to adverse drug reactions to avoid unnecessary resource use. Further investigation is required to guide antihypertensive medication choices in PD patients.

The "Silent" Threat: Group G Streptococcus Peritonitis in Peritoneal Dialysis

Peritoneal dialysis (PD) is a therapy for patients with end-stage renal disease (ESRD). PD carries an increased risk of peritonitis, often secondary to poor technique. A small subset of patients may present with "silent" peritonitis, or peritonitis in the absence of fever and abdominal pain, making diagnosis and treatment challenging. Identification of a causative organism can be an added barrier further delaying care. We present the case of a 95-year-old female with a history of ESRD on PD who presented with fatigue, confusion, and a lower leg wound found to have group G Streptococcus bacteremia. Treatment with intravenous antibiotics did not yield significant improvement, prompting the investigation of PD dialysate as a potential source. The patient was afebrile with persistent leukocytosis and no clinical signs of peritonitis. Yet, peritoneal fluid analysis confirmed peritonitis. This case underscores the importance of remaining cognizant of PD peritonitis in patients receiving PD therapy even in the absence of classic symptomatology. Risk factors such as advanced age, dementia, altered mentation from sepsis, or uncommon organisms may create an atypical presentation, delaying diagnosis and treatment. High rates of morbidity in peritonitis with concomitant bacteremia make early treatment even more crucial.

The impact of cat-related peritonitis on peritoneal dialysis outcomes: Results from the RDPLF

BACKGROUND

Cat ownership is common in peritoneal dialysis (PD) patients, even with recent guidelines recommending avoiding domestic animals during PD exchanges to limit the risk of peritonitis due to pet contamination. We analysed the outcomes of patients who experienced cat-related peritonitis compared with those who experienced peritonitis due to other causes.

METHODS

This retrospective study based on the Registre de Dialyse Peritoneale de Langue Française data analysed the outcomes of 52 patients experiencing cat-related peritonitis from the beginning of the database (1986) until 21 June 2022 compared with those of 208 matched patients experiencing peritonitis due to other causes. A Cox regression model examined the association between cat-related peritonitis and the composite end point of death in PD or transfer to haemodialysis (HD), death in PD and transfer to HD.

RESULTS

Among patients with an episode of cat-related peritonitis, 11 (21.1%) died, 19 (36.5%) were transferred to HD and 11 (21.1%) were transplanted. In the group with other causes of peritonitis, these numbers were 67 (32%), 81 (39%) and 26 (12.5%), respectively. In multivariate survival analysis, age (hazard ratio (HR): 1.39; 95% confidence interval (CI): 1.13-1.70) and use of assisted PD (HR: 4.07; 95% CI: 2.11-7.86) were associated with the risk of death. Having experienced cat-related peritonitis was not significantly associated with any of the three outcomes (death, transfer to HD or PD cessation).

CONCLUSIONS

Patients on PD should be aware that cats may cause a peritoneal infection, which results in similar consequences to those of other causes of peritonitis. However, pets at home should not be considered a contraindication to PD.

Linking clinical manifestations and causative organisms may provide clues for the treatment of peritoneal dialysis-associated peritonitis

INTRODUCTION

Different initial manifestations of peritoneal dialysis-associated peritonitis (PDAP) may depend on the type of pathogenic organism. We investigated the association between the clinical characteristics of PDAP and susceptibility to vancomycin and investigated the possibility of using vancomycin monotherapy alone as an initial treatment regimen for some PDAP patients to avoid unnecessary antibiotic exposure and secondary infection.

METHODS

Patients with culture-positive PDAP were retrospectively analyzed and divided into two groups: peritonitis with only cloudy effluent (PDAP-cloudy) or with cloudy effluent, abdominal pain and/or fever (PDAP-multi). The bacterial culture of PD effluent and antibiotic sensitivity test results were compared between groups. Logistic regression was used to investigate factors predicting susceptibility to vancomycin.

RESULTS

Of 162 episodes of peritonitis which had a positive bacterial culture of PD fluid, 30 peritonitis were in the PDAP-cloudy group, and 132 peritonitis were in the PDAP-multi group. Thirty (100%) peritonitis in the PDAP-cloudy group had gram-positive bacterial infections, which was significantly greater than that in the PDAP-multi group (51.5%) (P < 0.001). Twenty-nine (96.7%) peritonitis in the PDAP-cloudy group were susceptible to vancomycin, compared to 67 (50.8%) in the PDAP-multi group (P < 0.001). The specificity of PDAP-cloudy for vancomycin-sensitive peritonitis was 98.48%. Only one patient (3.3%) in the PDAP-cloudy group experienced vancomycin-resistant peritonitis caused by Enterococcus gallinarum, which could neither be covered by vancomycin nor by the initial antibiotic regimen recommended by the current ISPD guidelines. The presence of only cloudy effluent was an independent predictor of susceptibility to vancomycin according to multivariate analysis (OR = 27.678, 95% CI 3.191-240.103, p = 0.003), in addition to PD effluent WBC counts (OR = 0.988, 95% CI 0.980-0.996, p = 0.004), diabetes mellitus (OR = 3.646, 95% CI 1.580-8.416, p = 0.002), first episode peritonitis (OR = 0.447, 95% CI 0.207-0.962, p = 0.039) and residual renal creatinine clearance (OR = 0.956, 95% CI 0.918-0.995, p = 0.027). Addition of these characteristics increased the AUC to 0.813 (95% CI 0.0.749-0.878, P < 0.001). The specificity of presenting with only cloudy effluent for vancomycin-sensitive peritonitis was 98.48%.

CONCLUSIONS

Cloudy dialysate, as the only symptom at PDAP onset, was an independent predictor of vancomycin-sensitive PDAP, which is an important new insight that may guide the choice of initial antibiotic treatment.

Pathogenic microorganism DNA high-throughput genetic sequencing to diagnose peritoneal dialysis-associated peritonitis due to Mycobacterium tuberculosis infection

Peritoneal dialysis-associated peritonitis is a serious complication of peritoneal dialysis, and the prevention and treatment of this condition are important for improving the long-term survival and quality of life of patients. However, peritoneal dialysis-associated peritonitis due to Mycobacterium tuberculosis infection is relatively rare and not easily diagnosed. Here, we present a case of peritoneal dialysis-associated peritonitis caused by Mycobacterium tuberculosis identified by pathogenic microbial DNA high-throughput genetic sequencing. This case demonstrates that pathogenic microbial DNA high-throughput genetic sequencing could be used to improve the detection rate of pathogenic microorganisms in patients with complex conditions, thereby allowing for earlier initiation of treatment.

11 cases of peritoneal dialysis catheter penetrating into the intestinal cavity: case series

The penetration of a peritoneal dialysis catheter into the intestinal cavity is a clinically rare complication. In the present retrospective clinical case series, 11 patients with uraemia who received continuous ambulatory peritoneal dialysis and attended hospital between 2019 and 2023 are described. The median patient age was 61.91 ± 11.33 years. All patients had previously experienced peritoneal dialysis-related peritonitis and were clinically cured by infusing sensitive antibiotics into the abdominal cavity. Colonoscopy was utilised to locate the penetrating catheter and close the perforation with a titanium clip once the catheter had been removed via an external approach. Following a 2-4-week fast, the perforations healed in all 11 patients. The present authors' experience illustrates that directly removing the catheter and clamping the perforation opening under the guidance of colonoscopy is simple to operate with few complications compared with traditional open surgery.

Astragalus membranaceus and its monomers treat peritoneal fibrosis and related muscle atrophy through the AR/TGF-β1 pathway

Background: To anticipate the potential molecular mechanism of Astragalus membranaceus (AM) and its monomer, Calycosin, against peritoneal fibrosis (PF) and related muscle atrophy using mRNA-seq, network pharmacology, and serum pharmacochemistry. Methods: Animal tissues were examined to evaluate a CKD-PF mice model construction. mRNA sequencing was performed to find differential targets. The core target genes of AM against PF were screened through network pharmacology analysis, and CKD-PF mice models were given high- and low-dose AM to verify common genes. Serum pharmacochemistry was conducted to clarify which components of AM can enter the blood circulation, and the selected monomer was further validated through cell experiments for the effect on PF and mesothelial mesenchymal transition (MMT) of peritoneal mesothelial cells (PMCs). Results: The CKD-PF mice models were successfully constructed. A total of 31,184 genes were detected in the blank and CKD-PF groups, and 228 transcription factors had significant differences between the groups. Combined with network pharmacology analysis, a total of 228 AM-PF-related targets were identified. Androgen receptor (AR) was the remarkable transcription factor involved in regulating transforming growth factor-β1 (TGF-β1). AM may be involved in regulating the AR/TGF-β1 signaling pathway and may alleviate peritoneal dialysis-related fibrosis and muscle atrophy in CKD-PF mice. In 3% peritoneal dialysis solution-stimulated HMrSV5 cells, AR expression levels were dramatically reduced, whereas TGF-β1/p-smads expression levels were considerably increased. Conclusion: AM could ameliorate PF and related muscle atrophy via the co-target AR and modulated AR/TGF-β1 pathway. Calycosin, a monomer of AM, could partially reverse PMC MMT via the AR/TGF-β1/smads pathway. This study explored the traditional Chinese medicine theory of "same treatment for different diseases," and supplied the pharmacological evidence of "AM can treat flaccidity syndrome."

Analysis of risk factors for refractory peritonitis in patients undergoing peritoneal dialysis

OBJECTIVE

To explore the risk factors for refractory peritonitis in patients undergoing peritoneal dialysis.

METHODS

We retrospectively collected data from 130 patients who underwent peritoneal dialysis (PD) and received peritonitis treatment at the Renal Disease Center of Beijing Luhe Hospital affiliated with Capital Medical University from January 1, 2016 to January 30, 2023. According to clinical treatment results, patients with refractory peritonitis were classified as the refractory group (n=52 cases), and those with non-refractory peritonitis were classified as the non-refractory group (n=78 cases). Baseline information and laboratory indicators of patients in each group were collected, and Logistic regression model was used to identify the risk factors for the poor prognosis of peritonitis patients.

RESULTS

There were statistically significant differences in dialysis time, dialysate sugar concentration and inducement type between the refractory group and the non-refractory group (P<0.05). The values of peripheral white blood cells (pWBC), T helper 2 cell (Th2), T regulatory cell (Treg), Treg/Th17 and C-reactive protein (CRP) in the refractory group were significantly higher than those in the non-refractory group, while the values of T helper 17 cell (Th17) and albumin (ALB) were significantly lower (all P<0.05). There were no significant differences in serum creatinine, blood urea, Th1, hemoglobin (Hb) and blood calcium levels between the two groups (all P>0.05). Gram-positive bacteria were the main pathogenic bacteria of peritonitis in all groups. The proportion of enterococcus/streptococcal peritonitis in the refractory group was higher than that in the non-refractory group (P<0.05). Logistic regression identified elevated pWBC, higher dialysate sugar concentration, exit-site infection and gram-negative bacteria infection as independent risk factors for refractory peritonitis in patients undergoing PD (all P<0.05).

CONCLUSION

Elevated pWBC, high glucose dialysate concentration, exit-site infection, and gram-negative bacteria infection are risk factors for refractory peritonitis in patients undergoing PD.

Protective effect of Cyclo(His-Pro) on peritoneal fibrosis through regulation of HDAC3 expression

Peritoneal dialysis is a common treatment for end-stage renal disease, but complications often force its discontinuation. Preventive treatments for peritoneal inflammation and fibrosis are currently lacking. Cyclo(His-Pro) (CHP), a naturally occurring cyclic dipeptide, has demonstrated protective effects in various fibrotic diseases, yet its potential role in peritoneal fibrosis (PF) remains uncertain. In a mouse model of induced PF, CHP was administered, and quantitative proteomic analysis using liquid chromatography-tandem mass spectrometry was employed to identify PF-related protein signaling pathways. The results were further validated using human primary cultured mesothelial cells. This analysis revealed the involvement of histone deacetylase 3 (HDAC3) in the PF signaling pathway. CHP administration effectively mitigated PF in both peritoneal tissue and human primary cultured mesothelial cells, concurrently regulating fibrosis-related markers and HDAC3 expression. Moreover, CHP enhanced the expression of nuclear factor erythroid 2-related factor 2 (Nrf2) while suppressing forkhead box protein M1 (FOXM1), known to inhibit Nrf2 transcription through its interaction with HDAC3. CHP also displayed an impact on spleen myeloid-derived suppressor cells, suggesting an immunomodulatory effect. Notably, CHP improved mitochondrial function in peritoneal tissue, resulting in increased mitochondrial membrane potential and adenosine triphosphate production. This study suggests that CHP can significantly prevent PF in peritoneal dialysis patients by modulating HDAC3 expression and associated signaling pathways, reducing fibrosis and inflammation markers, and improving mitochondrial function.

Rare Pathogens in Peritoneal Dialysis-Associated Peritonitis: A Comprehensive Case Study and Guideline Review

BACKGROUND Peritoneal dialysis (PD) serves as a critical renal replacement therapy for individuals with end-stage renal disease (ESRD), leveraging the peritoneum for fluid and substance exchange. Despite its effectiveness, PD is marred by complications such as peritonitis, which significantly impacts patient outcomes. The novelty of our report lies in the presentation of a rare case of PD-associated peritonitis caused by 2 unusual pathogens, emphasizing the importance of rigorous infection control measures. CASE REPORT We report on an 80-year-old African-American female patient with ESRD undergoing PD, who was admitted twice within 8 months for non-recurring episodes of peritonitis. These episodes were attributed to the rare pathogens Achromobacter denitrificans/xylosoxidans and Carbapenem-resistant Acinetobacter baumannii. Despite presenting with similar symptoms during each episode, such as abdominal pain and turbid dialysis effluent, the presence of these uncommon bacteria highlights the intricate challenges in managing infections associated with PD. The treatment strategy encompassed targeted antibiotic therapy, determined through susceptibility testing. Notably, the decision to remove the PD catheter followed extensive patient education, ensuring the patient comprehended the rationale behind this approach. This crucial step, along with the subsequent shift to hemodialysis, was pivotal in resolving the infection, illustrating the importance of patient involvement in the management of complex PD-related infections. CONCLUSIONS This case underscores the complexities of managing PD-associated peritonitis, particularly with uncommon and resistant bacteria. It emphasizes the importance of rigorous infection control measures, the need to consider atypical pathogens, and the critical role of patient involvement in treatment decisions. Our insights advocate for a more informed approach to handling such infections, aiming to reduce morbidity and improve patient outcomes. The examination of the literature on recurrent peritonitis and treatment strategies provides key perspectives for navigating these challenging cases effectively.

Red cell distribution width to albumin ratio predicts treatment failure in peritoneal dialysis-associated peritonitis

BACKGROUND

This study aims to investigate the potential correlation between baseline red cell distribution width (RDW) to albumin ratio (RAR) levels and treatment failure in peritoneal dialysis-associated peritonitis (PDAP) patients.

METHODS

A retrospective single-center study was conducted on 286 PDAP patients. Logistic regression and generalized estimation equation (GEE) analyses were employed to assess the relationship between RAR and treatment failure.

RESULTS

RAR emerged as a robust predictor of treatment failure in PDAP patients. Elevated RAR levels were associated with an increased risk of treatment failure, exhibiting a linear relationship. Even after adjusting for demographic and clinical variables, this association remained statistically significant. ROC analysis revealed that RAR outperformed RDW and albumin individually in predicting PDAP prognosis.

CONCLUSION

This study highlights RAR as a superior prognostic marker for treatment failure in PDAP patients, offering new insights into risk assessment and management strategies for this challenging condition.

A rare case of successful treatment of peritoneal dialysis patient with Serratia marcescens peritonitis without catheter removal: case report and literature review

Serratia marcescens, as a Gram-negative opportunistic pathogen, is a rare cause of peritonitis and has worse clinical outcomes than Gram-positive peritonitis. In this case report, we describe a case of Serratia marcescens associated peritonitis that was successfully cured without catheter removal. A 40-year-old male patient with peritoneal dialysis who worked in the catering industry was admitted to the hospital for 16 hours after the discovery of cloudy peritoneal dialysate and abdominal pain. Ceftazidime and cefazolin sodium were immediately given intravenously as an empirical antibiotic regimen. After detecting Serratia marcescens in the peritoneal diasate culture, the treatment was switched to ceftazidime and levofloxacin. The routine examination of peritoneal dialysate showed a significant decrease in white blood cells, the peritoneal dialysate became clear, and the peritoneal dialysis catheter was retained. The patient was treated for 2 weeks and treated with oral antibiotics for 1 week. It is necessary to further strengthen the hygiene of work environment to prevent Serratia marcescens infection in peritoneal dialysis patients. We recommend that patients with Serratia marcescens associated peritonitis should be treated with a combination of antibiotics as early as possible empirically, and at the same time, the peritoneal dialysis fluid culture should be improved, and the antibiotic regimen should be timely adjusted according to the drug sensitivity results. For patients with clinical symptoms for more than 3 days, considering the strong virulence of Serratia marcescens, whether to use meropenem directly or not can provide a reference for clinical decision-making. Further clinical studies are needed to achieve more precise anti-infective treatment.

Characteristics of patients and facility of peritoneal dialysis in Korea: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) Korea

BACKGROUND

Varying peritoneal dialysis (PD)-related clinical outcomes have been reported in different countries. As a participant of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), this study investigated the characteristics of Korean PD patients, PD facilities and the incidence rates of clinical outcomes including mortality and PD-related outcomes.

METHODS

From July 2019 to December 2021, a total of 766 Korean PD patients were included for analysis. Poisson regression analysis was used to explore the incidence rates of various clinical events including mortality, modality transfer, exit site or catheter tunnel infection and peritonitis.

RESULTS

Among the 766 patients (median age 55.5 years, males 59.5%), 276 were incident and 490 were prevalent PD patients. The incidence rates of events were as follows: all-cause mortality (0.048), modality transfer (0.051), exit site or catheter tunnel infection (0.054) and peritonitis (0.136) events per person year. The most common causative organism for exit site or tunnel infection was staphylococcus species (47%) and that for peritonitis was streptococcus (28%) followed by staphylococcus (27%) species.

CONCLUSIONS

Up to now, PDOPPS Korea has recruited 766 Korean PD patients and started documentation of major PD-related outcomes which occurred during the follow-up period. The overall incidence rates of clinical outcomes in Korean PD patients were relatively favourable. There was no statistically significant difference in the incidence rates of clinical outcomes according to both facility and patient factors.

Staphylococcus aureus small colony variants: A potentially underestimated microbiological challenge in peritoneal dialysis

INTRODUCTION

Peritonitis remains the major infectious complication in the setting of peritoneal dialysis (PD). Despite known only moderate pathogenicity, the most frequently detected pathogens in PD-related peritonitis are surprisingly coagulase-negative staphylococci. However, this could be explained, at least in part, by Staphylococcus aureus small colony variants (SCVs) induced by PD fluids (PDFs) and misidentified by routinely used microbiological methods.

MATERIAL AND METHODS

Bacteria were exposed to commonly used PDFs in various regimens designed to simulate daily use as closely as possible. Wild-type isolates and SCVs were subsequently used to determine minimum inhibitory concentrations (MICs), in vitro biofilm formation capacities, and auxotrophies. Underlying genetic alterations were investigated using whole-genome sequencing, and various microbial identification methods were tested to determine their performance for wild-types and SCVs.

RESULTS

Stable SCVs could be isolated most successfully after exposure to glucose-containing PDFs alone. The reading of MICs was significantly affected by the reduced growth of SCVs, resulting in lower MIC values in 44% of all tests. Nonsynonymous mutations were found in all but one SCV, while only two isolates showed typical auxotrophic responses. While MALDI-TOF, PCR and Pastorex Staph-Plus correctly identified all S. aureus SCVs, API-Staph and VITEK-2 yielded identification rates of only 40% and 10%, respectively.

CONCLUSIONS

Overall, the present study has shown that commercially available PDFs induce S. aureus SCVs in vitro, which are difficult to identify and test for antimicrobial susceptibility and can potentially lead to recurrent or persistent infections. Thus, they represent a potentially underappreciated challenge not only for microbiologists, but also for clinicians.

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.

The association between new inflammation markers and frequent peritoneal dialysis-associated peritonitis

OBJECTIVE

To validate an association between new inflammation and frequent peritoneal dialysis-associated peritonitis (PDAP).

MATERIALS AND METHODS

In China, retrospective clinical data were collected on 208 patients who received continuous ambulatory peritoneal dialysis (CAPD) between 2010 and 2021. The patients were divided into two groups: non-frequent PDAP (the interval between two peritonitis episodes of more than one year) and frequent PDAP (the interval between two peritonitis episodes of less than one year). Patients with their first episode of peritonitis had their age, gender, history of hypertension, diabetic disease, underlying renal disease, bacterial infection, and laboratory data collected. The outcomes of bacterial dispersion, systemic immune-inflammation index (SII), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), and risk variables associated with frequent PDAP were analyzed.

RESULTS

There are differences between the two groups in dialysis time (p = 0.006), hypertensive nephropathy (p = 0.038), staphylococcus (p = 0.035), white blood cells (p = 0.001), neutrophil (p < 0.01), lymphocyte (p < 0.01), platelet(p = 0.01), SII(p < 0.01), CRP/HDL-C (p = 0.002), CRP (p < 0.001), serum creatinine (p = 0.007), blood urea nitrogen (p = 0.05), serum magnesium (0.03), serum potassium (p = 0.007), and dialysate polymorphonuclear cells (p = 0.004). Multifactorial logistic regression analysis found that SII (p < 0.001), CRP/HDL-C (p = 0.041), and Diabetes mellitus (p = 0.027) were independent risk factors for frequent PDAP. The ROC curve analysis revealed that combining SII with CRP/HDL-C resulted in the largest AUC area (AUC = 0.814).

CONCLUSIONS

Our findings offer clinical proof of the combination of SII and CRP/HDL-C in patients with frequent PDAP.

A population-based study on the incidence and aetiology of infectious complications in peritoneal dialysis in South Sweden

BACKGROUND

Peritonitis is a major cause of morbidity in peritoneal dialysis (PD) and an independent risk factor for elevated all-cause mortality. The aims of this study were to report the incidence, trend, aetiology, and antimicrobial susceptibility of PD-associated peritonitis and catheter-related infections in South Sweden between 2011-2020.

METHODS

This population-based observational cohort study included all patients with PD between the years 2011-2020 in the county of Skåne. Data was accessed through the Swedish Renal Registry and the Department of Clinical Microbiology in Lund. Definitions issued by the International Society for Peritoneal Dialysis were implemented to assess PD-associated infections.

RESULTS

Medical records of 675 paediatric and adult PD patients were eligible for inclusion. Of those, 208 (31%) were female and the median age was 67 years (range 0-91). The overall rate of PD-peritonitis was 0.38 episodes per year at risk. Out of 484 episodes of peritonitis, 61% (n = 295) were caused by Gram-positive bacteria. There were 289 occurrences of exit site infections, of which most (n = 152, 53%) were Gram-positive. Tunnel infections occurred in 16 episodes and were caused by S. aureus or P. aeruginosa. Among all isolates, 37 were of MRSE, four of ESBL-producing E. coli, and one of MRSA.

CONCLUSION

The crude rate of PD-peritonitis was stable during the study period. Gram-positive bacteria dominated the microbial aetiology, and antibiotic resistance was limited. It is important to monitor the aetiology, incidence, and resistance rates in PD-associated infections, to base empirical antibiotic regimens and facilitate prevention.

Analysis of a nurse-provided on-call peritoneal dialysis support in an outpatient reference care centre

BACKGROUND

To analyse the nature of medical or technical emergency issues of ambulatory peritoneal dialysis (PD) patients calling a nurse-provided emergency PD support service of a reference centre that is provided all year in the after-hours.

METHODS

We retrospectively analysed patients' chief complaint, urgency, resolution of and association to current PD treatment and modality directed to an on-call nurse-provided PD support service from 2015-2021 based on routinely collected health data. Calls were systematically categorized being technical/procedural-, medical-, material-related or type of correspondence. Call urgency was categorized to have "immediate consequence", inquiry was eligible for "processing next working day" or whether there was "no need for further action". Call outcomes were classified according to whether patients were able to initiate, resume or finalize their treatments or whether additional interventions were required. Unexpected adverse events such as patients' acute hospitalization or need for nurses' home visits were evaluated and quantified.

RESULTS

In total 753 calls were documented. Most calls were made around 7:30 a.m. (5:00-9:00; median, 25-75th CI) and 6:30 p.m. (5:00-8:15). 645 calls were assigned to continuous ambulatory- (CAPD) or automated PD (APD). Of those, 430 calls (66.7%) had an "immediate consequence". Of those 77% (N = 331) were technical/procedural-, 12.8% (N = 55) medical- and 6.3% (N = 27) material related issues. 4% (N = 17) were categorized as other correspondence. Issues disrupting the course of PD were identified in 413 cases. In 77.5% (N = 320) patients were able to initiate, resume or finalize their treatment after phone consultation. Last-bag exchange was used in 6.1% enabling continued therapy in 83.6%. In 35 cases a nurse visit at patients' home or patients' visit to the practice at the earliest possible date were required, while hospitalization was required in seven medical category cases (5.4% and 1.09% of total assessed calls, respectively).

CONCLUSION

The on-call PD-nurse provides patient support for acute and imminent issues enabling them to successfully initiate, resume or finalize their prescribed treatment. Nurses triage of acute conditions facilitated rapid diagnostics and therapy. Maintaining quality PD homecare, the provision of trained personnel is indispensable. The information gathered in this study may therefore be used as a foundation to tailor educational programs for nephrology nurses and doctors to further develop their competencies in PD.

Persistent peritonitis in peritoneal dialysis: a comphrenesive review of recurrent, relapsing, refractory, and repeat peritonitis

Peritonitis is a major cause of morbidity and technique failure in patients receiving peritoneal dialysis. Complicated peritonitis that manifests as multiple or unresolving episodes is classified as refractory, recurrent, relapsing, or repeat peritonitis, and often possesses higher risk of technique failure and mortality as well as lower complete cure rates than primary or uncomplicated episodes. While these peritonitis subtypes affect a considerable portion of PD patients, details regarding their epidemiology, pathogenesis, diagnosis, clinical sequelae, and management have not yet been fully elucidated. Improved clinical awareness and understanding of complicated peritonitis subtypes is crucial to ensure optimal management for these patients; thus, we consolidate and report the pertinent findings of recent literature on these four entities.

Exploring the Therapeutic Potential of Peritoneal Dialysis (PD) in the Treatment of Neurological Disorders

Peritoneal dialysis (PD) is a well-established renal replacement therapy commonly employed in clinical practice. While its primary application is in the treatment of kidney disease, its potential in addressing other systemic disorders, including neurological diseases, has garnered increasing interest. This study provides a comprehensive overview of the related technologies, unique advantages, and clinical applications of PD in the context of neurological disorders. By exploring the mechanism underlying PD, its application in neurological diseases, and associated complications, we addressed the feasibility and benefits of PD as an adjunct therapy for various neurological conditions. Our study aims to highlight its role in detoxification and symptom management, as well as its advantages over other universally accepted methods of renal replacement therapy. Our goal is to bring to the spotlight the therapeutic potential of PD in neurological diseases, such as stroke, stimulate further research, and broaden the scope of its application in the clinical setting.

Calculated inflammatory markers derived from complete blood count results, along with routine laboratory and clinical data, predict treatment failure of acute peritonitis in chronic peritoneal dialysis patients

BACKGROUND & AIMS

Complete blood count (CBC)-derived inflammatory markers are predictive biomarkers for the prognosis of many diseases. However, there was no study on patients with peritoneal dialysis-associated peritonitis (PDAP). We aimed to investigate the value of these markers in predicting treatment failure of acute peritonitis in chronic PD patients.

METHODS

The records of 138 peritonitis episodes were reviewed and divided into treatment success or failure groups in a single center for 10 years. CBC-derived markers and other routine data were recorded before peritonitis treatment was initiated. Univariate and multivariate regression analyses and the receiver operating characteristic (ROC) curve about the predictors of treatment outcomes were performed.

RESULTS

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), and derived NLR were significantly higher in the failure group. Univariate logistic regression results showed that NLR and PLR were risk factors of treatment outcomes. The backward stepwise multivariate logistic regression results demonstrated that NLR [adjusted odds ratio (aOR), 1.376; 95% confidence intervals (CI), 1.105-1.713; p = .004], PLR (aOR, 1.010; 95%CI, 1.004-1.017; p = .002) were risk factors, but hemoglobin-to-lymphocyte ratio (HLR) (aOR, 0.977; 95%CI, 0.963-0.991; p = .001), and SII (aOR, 0.999; 95%CI, 0.998-1.000; p = .040) were protective factors. A combination of age, PD vintage, Gram-positive peritonitis, staphylococcus aureus, culture-negative, NLR, PLR, HLR, and SII would improve prognostic performance. The area under this ROC curve was 0.85, higher than other factors.

CONCLUSIONS

NLR, PLR, HLR, and SII were associated with PDAP outcomes. Age, PD vintage, NLR, and PLR were significant risk factors in PDAP patients.

Influencing factors for residual kidney function in incident peritoneal dialysis patients: a systematic review and meta-analysis

BACKGROUND

Residual kidney function (RKF) impacts patients' survival rate and quality of life when undergoing peritoneal dialysis (PD). This meta-analysis was conducted to systematically identify risk and protective factors associated with RKF decline and loss.

METHODS

We searched three English and one Chinese databases from inception to January 31, 2023, for cohort and cross-sectional studies exploring factors associated with RKF decline or loss. The random effects model was employed to aggregate risk estimates and 95% confidence intervals (CIs) from multivariate analysis. Sensitivity and subgroup analyses were performed to explore the heterogeneity among the studies.

RESULTS

Twenty-seven studies comprising 13549 individuals and 14 factors were included in the meta-analysis. Based on the meta-analysis results, risk factors involving male gender (hazard ratio (HR) 1.689, 95%CI 1.385-2.061), greater body mass index (BMI) (odds ratio (OR) 1.081, 95% confidence interval (CI) 1.029-1.135), higher systolic blood pressure (SBP) (HR 1.014, 95%CI 1.005-1.024), diabetes mellitus (DM) (HRRKF loss 1.873, 95%CI 1.475-2.378), DM (ORRKF decline 1.906, 95%CI 1.262-2.879), peritonitis (relative ratio (RR) 2.291, 95%CI 1.633-3.213), proteinuria (OR 1.223, 95%CI 1.117-1.338), and elevated serum phosphorus (RR 2.655, 95%CI 1.679-4.201) significantly contributed to the risk of RKF decline and loss in PD patients. Conversely, older age (HR 0.968, 95%CI 0.956-0.981), higher serum albumin (OR 0.834, 95%CI 0.720-0.966), weekly Kt/V urea (HR 0.414, 95%CI 0.248-0.690), baseline urine volume (UV) (HR 0.791, 95%CI 0.639-0.979), baseline RKF (HR 0.795, 95%CI 0.739-0.857) exhibited protective effects. However, diuretics use, automatic peritoneal dialysis (APD) modality and baseline RKF did not significantly impact RKF decline.

CONCLUSIONS

Patients with male gender, greater BMI, higher SBP, DM, peritonitis, proteinuria, and elevated serum phosphorus might have a higher risk of RKF decline and loss. In contrast, older age, higher serum albumin, weekly Kt/V urea, baseline UV, and baseline RKF might protect against RKF deterioration.

Rapid detection of pathogens of peritoneal dialysis-related peritonitis, especially in patients who have taken antibiotics, using metagenomic next-generation sequencing: a pilot study

INTRODUCTION

Peritoneal dialysis (PD)-related peritonitis is a serious complication of PD. Improving the diagnostic rate of peritonitis pathogens may substantially benefit peritonitis patients.

METHODS

The study was conducted in the People's Liberation Army (PLA) General Hospital from 1 June 2021 to 31 May 2022. Information about peritonitis, culture and metagenomic next-generation sequencing (mNGS) results and so on were collected. Patients were divided into antibiotic-use and antibiotic-free groups. The culture and mNGS results were compared using the paired χ2 test.

RESULTS

Data from 26 patients with peritonitis were collected. 50% of the patients had used antibiotics before samples were obtained (antibiotic-use group). The positivity rate using culture was 92.3% (12 cases) in the antibiotic-free group and 38.5% (5 cases) in the antibiotic-use group (p = 0.011). However, the positivity rate using mNGS was 92.3% (12 cases) regardless of whether antibiotics were used (p = 1.000). After revising the mNGS results, the positivity rate was 84.6% (11 cases) in both groups (p = 1.000). A significant difference between culture and mNGS results of all groups was observed (p = 0.039). The difference no matter between culture and mNGS (p = 0.016) or between culture and modified mNGS (p = 0.031) of the antibiotic-use group was observed.

CONCLUSION

For patients with PD-related peritonitis who previously received antibiotics, mNGS is suggested. For other patients, mNGS testing can be performed, but the results should be interpreted with caution. Much more research should be done to identify a powerful and ideal tool to detect pathogens underlying PD-related peritonitis.

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).

Antimicrobial-loaded biodegradable nanoemulsions for efficient clearance of intracellular pathogens in bacterial peritonitis

Intracellular pathogenic bacteria use immune cells as hosts for bacterial replication and reinfection, leading to challenging systemic infections including peritonitis. The spread of multidrug-resistant (MDR) bacteria and the added barrier presented by host cell internalization limit the efficacy of standard antibiotic therapies for treating intracellular infections. We present a non-antibiotic strategy to treat intracellular infections. Antimicrobial phytochemicals were stabilized and delivered by polymer-stabilized biodegradable nanoemulsions (BNEs). BNEs were fabricated using different phytochemicals, with eugenol-loaded BNEs (E-BNEs) affording the best combination of antimicrobial efficacy, macrophage accumulation, and biocompatibility. The positively-charged polymer groups of the E-BNEs bind to the cell surface of macrophages, facilitating the entry of eugenol that then kills the intracellular bacteria without harming the host cells. Confocal imaging and flow cytometry confirmed that this entry occurred mainly via cholesterol-dependent membrane fusion. As eugenol co-localized and interacted with intracellular bacteria, antibacterial efficacy was maintained. E-BNEs reversed the immunosuppressive effects of MRSA on macrophages. Notably, E-BNEs did not elicit resistance selection after multiple exposures of MRSA to sub-therapeutic doses. The E-BNEs were highly effective against a murine model of MRSA-induced peritonitis with better bacterial clearance (99 % bacteria reduction) compared to clinically-employed treatment with vancomycin. Overall, these findings demonstrate the potential of E-BNEs in treating peritonitis and other refractory intracellular infections.

Elevated triglyceride-glucose index predisposes to the initial episode of peritonitis in chronic peritoneal dialysis patients

OBJECTIVE

The serum triglyceride-glucose (TyG) index is a marker of inflammation. However, the relationship between TyG index and peritoneal dialysis-related peritonitis (PDRP) is unclear. This study aimed to investigate the potential relationship between the baseline TyG index and the initial episode of PDRP.

METHODS

A total of 208 peritoneal dialysis (PD) patients were enrolled from January 1, 2012, to December 31, 2019 and followed up until December 31, 2022. They were divided into 2 groups according to the median TyG. The primary outcome was the occurrence of the initial episode of PDRP while on PD therapy. Kaplan-Meier curves and Cox regression analyses were used to examine the association between them.

RESULTS

Eighty-five initial episodes of PDRP were identified. The risk of PDRP was higher in the high-TyG index group (p = 0.030). Multivariate Cox regression analysis showed a higher risk of PDRP in patients with a high TyG index (HR = 1.800, 95% CI 1.511-2.815, p = 0.010).

CONCLUSION

The baseline serum TyG index was an independent risk factor for the initial episode of PDRP in chronic PD patients.

Body surface area and treatment failure in peritoneal dialysis-associated peritonitis

INTRODUCTION

This study mainly discussed the relationship between body surface area (BSA) and treatment failure of peritoneal dialysis-associated peritonitis (PDAP).

METHODS

The exposures were BSA grouped by the tertiles of BSA levels. The association between BSA and the risk of treatment failure in PDAP, defined as the temporary or permanent switch to hemodialysis and kidney transplantation, was evaluated in Cox proportional hazards models.

RESULTS

A total of 483 episodes in 285 patients were recorded in our center. As a three-level categorical variable, in reference to G3, the G1 of BSA displayed a 4.054-fold increased venture of treatment failure in a fully adjusted model. In sensitivity analysis, a lower value of BSA (G1) was identified as an independent risk factor for peritonitis episodes (odds ratio = 2.433, 95% confidence interval: 1.184-4.999, p = 0.015).

CONCLUSION

A lower level of body surface area was remarkably associated with a higher incidence of treatment failure among peritoneal dialysis-associated peritonitis episodes.

Current Utilization of Antifungal Agents for Intra-abdominal Infections Categorized by Patient Risk Factors During Surgical Procedures: A Literature Review

The high morbidity and mortality rates associated with invasive fungal infections have led to the overutilization of empiric antifungal therapies. With increasing antibiotic resistance, the careful consideration of prophylactic or empiric antifungal use is critical. The purpose of this review is to evaluate the available literature regarding the current practice of utilizing antifungal agents for intra-abdominal infections based on specific surgical procedures and patient risk factors. Relevant articles were identified through a comprehensive literature search of several databases using the keywords antifungal agents, postoperative period, preoperative care, surgical procedures, and intra-abdominal infections. Only articles that evaluated the use of empiric antifungals for suspected or confirmed intra-abdominal infections and surgical procedures were included in this review. Based on the available literature, antifungal prophylaxis is appropriate in patients who meet the criteria for high-risk invasive candidiasis, kidney or liver transplant recipients, severely-immunocompromised patients with perforated peptic ulcer, peritonitis, and patients on peritoneal dialysis who are failing on a therapeutic antibiotic regimen. We acknowledge that the evidence for using antifungal therapy empirically for all surgical procedures is lacking, and the following review is based on available literature and current guidelines.

Peritonitis-associated with peritoneal dialysis following Ureaplasma parvum infection: A case report and literature review

We report a patient diagnosed with peritonitis due to a rare infection of Ureaplasma parvum after receiving peritoneal dialysis for two years. This microorganism rarely causes peritoneal dialysis-associated peritonitis (PDAP). This is the first case of PDAP caused by Ureaplasma parvum. In the present case, the pathogen was identified through next-generation sequencing of PD fluid samples. The patient was treated with intraperitoneal (IP) levofloxacin combined with vancomycin and oral clarithromycin which effectively improved her symptoms. This case creates awareness that Ureaplasma parvum can cause PDAP and can be diagnosed using next-generation sequencing(NGS).

Population pharmacokinetics of meropenem in patients undergoing automated peritoneal dialysis

BACKGROUND

Meropenem is a second-line agent for the treatment of peritoneal dialysis-associated peritonitis (PD peritonitis), while information on pharmacokinetics (PK) of intraperitoneal (i.p.) meropenem is limited in this patient group. The objective of the present evaluation was to assess a pharmacokinetic rationale for the selection of meropenem doses in automated PD (APD) patients based on population PK modelling.

METHODS

Data were available from a PK study in six patients undergoing APD who received a single 500 mg dose of meropenem intravenous or i.p. A population PK model was developed for plasma and dialysate concentrations (n = 360) using Monolix. Monte Carlo simulations were carried out to assess the probability of achieving meropenem concentrations above minimum inhibitory concentrations (MICs) of 2 and 8 mg/L, representing susceptible and less susceptible pathogens respectively, for at least 40% of the dosing interval (T >MIC ≥ 40%).

RESULTS

A two-compartment model for each plasma and dialysate concentrations with one transit compartment for the transfer from plasma to dialysate fluid described the data well. An i.p. dose of 250 and 750 mg, for an MIC of 2 and 8 mg/L respectively, was sufficient to attain the pharmacokinetic/pharmacodynamic target (T >MIC ≥ 40%) in more than 90% patients in plasma and dialysate. Additionally, the model predicted that no relevant meropenem accumulation in plasma and/or peritoneal fluid would occur with prolonged treatment.

CONCLUSION

Our results suggest that an i.p. dose of 750 mg daily is optimal for pathogens with an MIC 2-8 mg/L in APD patients.

Potential clinical value of catheters impregnated with antimicrobials for the prevention of infections associated with peritoneal dialysis

INTRODUCTION

Peritoneal dialysis (PD) is a widely used dialysis modality, which offers the advantage of being a home therapy but is associated with a risk of potentially serious infections, including exit site infection, catheter tunnel infection, and peritonitis that may result in morbidity, technique failure, and increased mortality. Catheters impregnated with antimicrobials hold promise as a novel technique to reduce PD associated infections.

AREAS COVERED

We describe PD modalities, catheters, technique, complications, and the microbiology of associated infections, as well as standard measures to reduce the risk of infection. A novel technique for the impregnation of silicone devices with antimicrobial agents has been used to produce antimicrobial impregnated ventricular shunt catheters with proven clinical efficacy that have now been adopted as the standard of care to reduce neurosurgical infections. Using the same technology, we have developed PD and urinary catheters impregnated with sparfloxacin, triclosan, and rifampicin. Safety and tolerability have been demonstrated in urinary catheters, and a similar study is planned in PD catheters.

EXPERT OPINION

Catheters impregnated with antimicrobials offer a simple technique to reduce PD associated infections and thereby enable more people to enjoy the advantages of PD. Clinical trials are needed to establish efficacy.

Autophagy in peritoneal fibrosis

Peritoneal dialysis (PD) is a widely accepted renal replacement therapy for patients with end-stage renal disease (ESRD). Morphological and functional changes occur in the peritoneal membranes (PMs) of patients undergoing long-term PD. Peritoneal fibrosis (PF) is a common PD-related complication that ultimately leads to PM injury and peritoneal ultrafiltration failure. Autophagy is a cellular process of "self-eating" wherein damaged organelles, protein aggregates, and pathogenic microbes are degraded to maintain intracellular environment homeostasis and cell survival. Growing evidence shows that autophagy is involved in fibrosis progression, including renal fibrosis and hepatic fibrosis, in various organs. Multiple risk factors, including high-glucose peritoneal dialysis solution (HGPDS), stimulate the activation of autophagy, which participates in PF progression, in human peritoneal mesothelial cells (HPMCs). Nevertheless, the underlying roles and mechanisms of autophagy in PF progression remain unclear. In this review, we discuss the key roles and potential mechanisms of autophagy in PF to offer novel perspectives on future therapy strategies for PF and their limitations.

A Repertoire of Clinical Non-Dermatophytes Moulds

Humans are constantly exposed to micromycetes, especially filamentous fungi that are ubiquitous in the environment. In the presence of risk factors, mostly related to an alteration of immunity, the non-dermatophyte fungi can then become opportunistic pathogens, causing superficial, deep or disseminated infections. With new molecular tools applied to medical mycology and revisions in taxonomy, the number of fungi described in humans is rising. Some rare species are emerging, and others more frequent are increasing. The aim of this review is to (i) inventory the filamentous fungi found in humans and (ii) provide details on the anatomical sites where they have been identified and the semiology of infections. Among the 239,890 fungi taxa and corresponding synonyms, if any, retrieved from the Mycobank and NCBI Taxonomy databases, we were able to identify 565 moulds in humans. These filamentous fungi were identified in one or more anatomical sites. From a clinical point of view, this review allows us to realize that some uncommon fungi isolated in non-sterile sites may be involved in invasive infections. It may present a first step in the understanding of the pathogenicity of filamentous fungi and the interpretation of the results obtained with the new molecular diagnostic tools.

Relationship between serum iPTH and peritonitis episodes in patients undergoing continuous ambulatory peritoneal dialysis

Background

Peritonitis is considered as one of the most serious complications that cause hospitalization in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). There is limited evidence on the impact of the parathyroid hormone (PTH) on the first peritoneal dialysis (PD)-associated peritonitis episode. We aimed to investigate the influence of serum intact parathyroid hormone (iPTH) on peritonitis in patients undergoing PD.

Methods

This was a retrospective cohort study. Patients undergoing initial CAPD from a single center in China were enrolled. The baseline characteristics and clinical information were recorded. The primary outcome of interest was the occurrence of the first PD-associated peritonitis episode. Five Cox proportional hazard models were constructed in each group set. In group set 1, all participants were divided into three subgroups by tertiles of the serum concentration of iPTH; in group set 2, all participants were divided into three subgroups based on the serum concentration of iPTH with 150 pg/ml interval (<150, 150-300, and >300 pg/ml). Hazard ratios and 95% confidence intervals (CIs) were calculated for each model. The multivariate linear regression analysis elimination procedure assessed the association between the clinical characteristics at baseline and the iPTH levels. Restricted cubic spline models were constructed, and stratified analyses were also conducted.

Results

A total of 582 patients undergoing initial PD (40% women; mean age, 45.1 ± 11.5 years) from a single center in China were recruited. The median follow-up duration was 25.3 months. Multivariate Cox regression analysis showed that, in the fully adjusted model, a higher serum iPTH level (tertile 3, iPTH >300 pg/ml) was significantly associated with a higher risk of PD-associated peritonitis at 3 years [tertile 3: hazard ratio (HR) = 1.53, 95%CI = 1.03-2.55, p = 0.03; iPTH > 300 pg/ml: HR = 1.57, 95%CI = 1.08-2.27, p = 0.02]. The hazard ratio for every 100 pg/ml increase in serum iPTH level was 1.12 (95%CI = 1.05-1.20, p < 0.01) in the total cohort when treating iPTH as a continuous variable.

Conclusions

An elevated iPTH level was significantly associated with an increased risk of peritonitis in patients undergoing CAPD.

Pre-Peritoneal Dialysis Peritonitis After Saline Infusion Sonohysterogram in a Patient With an Embedded Catheter: A Case Report

Rationale

Clear guidelines currently exist regarding antibiotic prophylaxis for patients on peritoneal dialysis (PD) prior to common diagnostic procedures. However, these guidelines do not include patients with subcutaneously embedded PD catheters who are awaiting PD initiation although both these populations share a great deal of risk factors for infections. Issues regarding antibiotic prophylaxis and avoidable infections are bound to keep occurring if physicians are not conscious of the risks of infections shared by all patients suffering from renal failure.

Presenting concerns

Two weeks after a saline infusion sonohysterography (SIS), a 48-year-old woman with chronic kidney disease (CKD) G5 ND, type 2 diabetes, a subcutaneously embedded PD catheter, and prior abnormal uterine bleeding presented to the emergency department complaining of nausea, vomiting, diarrhea, weakness, and abdominal pain. The patient received no antibiotic prophylaxis prior to her SIS.

Diagnoses

The final diagnosis of peritonitis was established after acute kidney injury, gastroenteritis, and small bowel obstruction were considered and ruled out. A delay in the final diagnosis occurred because of the complex presentation, the fact that the patient had not yet initiated PD, and the presence of concomitant anion gap metabolic acidosis and an acute elevation of the patient's creatinine.

Interventions

The patient was started on broad-spectrum intravenous antibiotics when the diagnosis of peritonitis was established. Insulin and intravenous bicarbonate infusions were used to correct the patient's anion gap metabolic acidosis. Surgical debridement of the necrotic subcutaneous tissue and removal of the embedded PD catheter were necessary.

Outcomes

The patient's infection resolved completely as did her anion gap metabolic acidosis. The patient had to transfer permanently from PD to hemodialysis for her renal replacement therapy.

Teaching points

This case report serves as a good reminder that physicians should keep in mind the possibility of peritonitis in patients with embedded PD catheters. As these patients are also at risk of infections, antibiotic prophylaxis should be used in patients with embedded catheters in the same way it is used for PD patients prior to obstetrical, gynecological, or gastrointestinal procedures.

Time-dependent incidence rates and risk factors for transferring to hemodialysis in patients on peritoneal dialysis under the Thai PD-First Policy

BACKGROUND

Haemodialysis (HD) transfer (HDT) is the major challenge of peritoneal dialysis (PD). This study aimed to analyse the time-dependent incidence rates and risk factors for permanent HDT in patients under Thailand's PD First policy.

METHODS

The records of 20,545 patients from January 2008 to June 2018 were studied. The time on therapy (TOT) was divided into 0-3, 3-12, 12-24, 24-36, 36-48 and more than 48 months. The time-dependent incidence rates and causes of PD dropout were investigated. The risk factors for HDT were analysed by multivariable Poisson regression model and presented as incidence rate ratios (IRRs) and 95% confidence intervals (CIs).

RESULTS

The main cause of PD dropout was death (45.7%) with 17.4% of the patients transferred to HD. The median (25th to 75th interquartile range) dialysis vintage was 1.4 (0.5-2.7) years. The incidence rates of HDT increased with TOT. Patients with universal coverage were transferred to HD less frequently than those with other health schemes. Patients who were illiterate or only had primary school education had a higher risk of being transferred to HD after 48 months of TOT (IRR 1.41 (95% CI 1.07-1.89)). Peritonitis within the first year of PD was the risk for HDT during 13-48 months of PD. The reasons for HDT changed with TOT. Mechanical complications followed by peritonitis were the main causes of HDT during the first 3 months, and after that peritonitis was the main reason.

CONCLUSIONS

The incidence of HDT increased with TOT. The risks for HDT changed over time on PD.

Platelet-to-lymphocyte ratio and the first occurrence of peritonitis in peritoneal dialysis patients

BACKGROUND

Platelet-to-lymphocyte ratio (PLR) has been used as a potential biomarker of inflammation-related diseases, but its role in the peritoneal dialysis-related peritonitis (PDRP) is still uncertain. This study was aimed to investigate the association between PLR and the new-onset PDRP in peritoneal dialysis (PD) patients.

METHODS

In this multicenter retrospective study, 1378 PD Chinese PD patients were recruited from four centers, who were divided into the high PLR group (HPG) and the low PLR group (LPG) according to the cutoff value of PLR. The correlation between PLR and the new-onset PDRP was assessed using the Cox regression model analysis.

RESULTS

During follow-up, 121 new-onset PDRP events were recorded. Kaplan-Meier survival curve showed a higher risk of new-onset PDRP in the HPG (log-rank test, P < 0.001). After adjusting for confounding factors, the Cox regression model showed the risk of new-onset PDRP was higher in the HPG than that in the LPG (HR 1.689, 95%CI 1.096-2.602, P = 0.017). Competitive risk model analysis showed that significant differences still existed between the two PLR groups in the presence of other competitive events (P < 0.001).

CONCLUSION

PLR is independently associated with the new-onset PDRP in PD patients.

The impact of Propolis on catheter exit site infection and peritonitis in peritoneal Dialysis patients: a clinical trial

BACKGROUND

Peritonitis is one of the major complications of peritoneal dialysis. The most common cause of peritonitis is infection at the catheter exit site. This study aimed to determine the effect of propolis on the incidence of catheter exit site infection and peritonitis in peritoneal dialysis patients.

METHOD

This study was a double-blind clinical trial (2019-2020) with peritoneal dialysis patients. Ninety peritoneal dialysis patients were allocated to three groups (placebo, control, intervention) using block randomization method. Catheter exit site was washed with 0.9% normal saline and dressing was done every other day after the morning peritoneal dialysis exchange by use of normal saline in placebo, mupirocin in control, and propolis in intervention group, for 6 months.

DISCUSSION

10% of the patients in the placebo and 6.7% in the control group developed catheter Exit Site Infection, but none patient in the intervention group developed this infection (P = 0.469). Whereas 6.7% in both the placebo and control groups developed peritonitis, but none patient in the intervention group contracted peritonitis (P = 0.997). No significant differences in the incidence of catheter exit site infection and peritonitis among the three groups were observed. Considering that mupirocin is of chemical origin and may lead to drug resistance whereas propolis is of plant origin and does not produce drug resistance, the use of propolis is recommended.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials [ IRCT20110427006318N10 ] (17/01/2019).

Comparison of risk of peritoneal dialysis-associated peritonitis between roxadustat and recombinant human erythropoietin in peritoneal dialysis patients: a retrospective comparative cohort study

Background

Roxadustat and recombinant human erythropoietin (rhuEPO) have been approved for the treatment of renal anemia in patients undergoing dialysis. The comparison of risk of peritoneal dialysis (PD)-associated peritonitis between roxadustat and rhuEPO in PD patients remains uncertain. We aimed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO and examine possible modifiers for the comparison in PD patients.

Methods

A total of 437 PD patients with renal anemia (defined as hemoglobin ≤10.0 g/dL) from 4 centers were selected. Participants were scheduled for follow-up every 1-3 months at each center. We compared differences in baseline characteristics by medication group and 1:1 matching group based on propensity scores. PD-associated peritonitis was defined according to the International Society for Peritoneal Dialysis guidelines. Univariable and multivariable Cox proportional hazard analyses were performed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO in PD patients. Propensity score matching method was used to examine the robustness of results.

Results

A total of 437 participants, including 291 in roxadustat group and 146 in rhuEPO group, were included in the current study, respectively. During a median follow-up of 13.0 (25th-75th, 10.0-15.0) months, PD-associated peritonitis occurred in 68 patients, including 26 of 291 (0.10 episodes per patient-year) patients in the roxadustat group and 42 of 146 (0.27 episodes per patient-year) patients in the rhuEPO group. Overall, compared to patients in the rhuEPO group, the roxadustat group (hazard ratio, 0.345; 95% confidence interval: 0.202-0.589) was associated with a lower risk of PD-associated peritonitis with adjustment of use of roxadustat medication, age, sex, hypertension status, diabetes status, dialysis vintage, serum potassium, hemoglobin, and albumin. Furthermore, the results were consistent with the propensity score analysis. None of the variables, including age, sex, body mass index, PD vintage, presence of residual renal function, hemoglobin, albumin, serum potassium, and C-reactive protein levels, significantly modified the associations.

Conclusions

Our study demonstrated that compared with rhuEPO, roxadustat may reduce the risk of PD-associated peritonitis in PD patients, highlighting the importance of roxadustat for the prevention of PD-associated peritonitis in PD patients.

In Vitro Study of the Effect of Inhibition of Quorum Sensing by Brominated Furanone on Peritoneal Dialysis-Associated Peritonitis Associated with Escherichia Coli Infection

In recent years, the occurrence of peritoneal dialysis (PD)-associated peritonitis (PDAP) with Escherichia coli infection has gradually increased. The presence of quorum sensing (QS) among bacteria facilitates the expansion of antibiotic resistance. Brominated furanone (BMF), a halogenated furanone compound isolated from macroalgae, is a new type of quorum-sensing inhibitor that can inhibit bacterial quorum sensing and reduce bacterial resistance. In this study, we established an in vitro peritoneal dialysis-associated peritonitis biofilm model. After intervention with BMF, the biofilm was destroyed, as shown by scanning electron microscopy, and the number of viable bacteria was reduced. Crystal violet semiquantitative determination showed that biofilm absorption significantly decreased, and RT-PCR showed that luxS expression was downregulated after drug intervention. Therefore, we propose that BMF can effectively inhibit E. coli QS by disrupting the bacterial biofilm and downregulating QS gene expression to reduce the bacterial resistance, providing a direction for the development of novel antibacterial drugs.

Microbiology and outcomes of polymicrobial peritonitis associated with peritoneal dialysis: a register-based cohort study from the French Language Peritoneal Dialysis Registry (RDPLF)

BACKGROUND

Previous studies have reported that polymicrobial peritonitis in peritoneal dialysis (PD) is associated with poor outcomes, but recent data from European cohorts are scarce.

METHODS

We included from the French Language Peritoneal Dialysis Registryall patients ≥ 18 years who started PD between January 2014 and November 2020. We compared microbiology and patient characteristics associated with mono- and polymicrobial peritonitis. We assessed patient outcomes after a first polymicrobial peritonitis using survival analysis with competing events. We differentiated microorganisms isolated from dialysis effluent as enteric or non-enteric pathogens.

RESULTS

8848 patients contributed 13 023 patient-years of follow-up and 3348 culture-positive peritonitis, including 251 polymicrobial ones. This corresponded to rates of 0.32 and 0.02 episodes/patient-year, respectively. For most patients (72%) who experienced polymicrobial peritonitis, this was their first peritonitis episode. Enteric pathogens were more frequently isolated in poly- than in monomicrobial peritonitis (57 vs 44%, P < 0.001). In both cases of peritonitis with or without enteric pathogens, the poly- versus monomicrobial character of the peritonitis was not associated with mortality in patients who did not switch to hemodialysis (adjusted cause-specific hazard ratio, a.cs-HR, 1.2 [95% CI, 0.3-5.0], P = 0.78 and 1.1 [0.7-1.8], P = 0.73, respectively). However, the risks of death and switch to hemodialysis were higher for monomicrobial peritonitis with enteric pathogens, compared to those without (a.cs-HR, 1.3 [1.1-1.7], P = 0.02 and 1.9 [1.5-2.4], P < 0.0001, respectively).

CONCLUSION

Isolation of enteric pathogens, rather than the polymicrobial character of the peritonitis, is associated with poorer outcomes.

Card9 protects fungal peritonitis through regulating Malt1-mediated activation of autophagy in macrophage

Fungal peritonitis is an inflammatory condition of the peritoneum which occurs secondary to peritoneal dialysis. Most cases of peritonitis are caused by microbial invasion into the peritoneal cavity, resulting in high morbidity and mortality. Unlike bacterial peritonitis, little is known on fungal peritonitis. Card9, an adapter protein, plays a critical role in anti-fungal immunity. In this study, by using zymosan-induced peritonitis and C. albicans-induced peritonitis mouse model, we demonstrated that fungal peritonitis was exacerbated in Card9^-/- mice, compared with WT mice. Next, we found the autophagy activation of peritonealmacrophages was impaired in Card9^-/- peritonitis mice. The autophagy agonist, MG132, ameliorated peritonitis in Card9^-/- mice. The result of microarray analysis indicates Malt1 was significantly decreased in Card9^-/- peritonitis mice. Furthermore, we demonstrated that Malt1 interacts with P62 and mediates the function of P62 to clear ubiquitinated proteins. After overexpression of Malt1, impaired autophagy activation caused by Card9 deficient was significantly rescued. Together, our results indicate that Card9 protects fungal peritonitis by regulating Malt1-mediated autophagy in macrophages. Our research provides a new idea for the pathogenesis of fungal peritonitis, which is of great significance for the clinical treatment of fungal peritonitis.

Excessive risk and poor outcome of hospital-acquired peritoneal dialysis-related peritonitis

Background

Peritoneal dialysis (PD) is a home-based renal replacement therapy. Since hospital staff are not often familiar with PD and its complications, PD patients may have an excess risk of developing PD-related peritonitis during hospital admission for unrelated reasons, and the outcome may be affected.

Methods

We reviewed 371 episodes of hospital-acquired PD-peritonitis in our center from 2000 to 2019. Their clinical characteristics and outcome were compared to 825 episodes that required hospital admission, and 1964 episodes that were treated as out-patient.

Result

Hospitalized PD patients had a significantly higher risk of developing peritonitis than out-patient ones (incident rate ratio 4.41, 95% confidence interval [CI] 3.95–4.91). Hospital-acquired peritonitis episodes were more commonly culture negative. Bacterial isolates from the hospital acquired episodes were more likely resistant to ceftazidime (p &lt; 0.0001) than the other groups. The primary response rate, complete cure rate, and overall mortality of the hospital-acquired episode were 66.6%, 62.0%, and 23.2% respectively, all worse than episodes that developed outside the hospital (p &lt; 0.0001 for all).

Conclusion

PD patients admitted to the hospital had a 4-fold increase in the risk of developing peritonitis. Hospital-acquired peritonitis episodes were more likely culture negative, be resistant to antibiotics. They also had a lower primary response rate, lower complete cure rate, and a higher mortality than episodes that developed outside hospital.

Obesity, Weight Gain, and Fluid Overload in Peritoneal Dialysis

Obesity is a global epidemic that has a complicated pathogenesis as well as impact on the outcome of peritoneal dialysis (PD) patients. In this review, the prevalence of obesity in incident PD patients as well as the phenomenon of new-onset glucose intolerance after PD will be reviewed. Published literature on the effect of obesity on the survival and incidence of cardiovascular disease in PD patients will be discussed. Particular emphasis would be put on literature that compared the impact of obesity on the outcome of hemodialysis and PD, and the confounding effect of dialysis adequacy. Next, the complex concept of obesity and its relevance for PD will be explored. The focus would be put on the methods of assessment and clinical relevance of central versus general obesity, as well as visceral versus subcutaneous adipose tissue. The relation between obesity and systemic inflammation, as well as the biological role of several selected adipokines will be reviewed. The confounding effects of metabolic syndrome and insulin resistance will be discussed, followed by the prevalence and prognostic impact of weight gain during the first few years of PD. The differences between weight gain due to fluid overload and accumulation of adipose tissue will be discussed, followed by the current literature on the change in body composition after patients are put on chronic PD. The methods of body composition will be reviewed, and the clinical relevance of individual body component (fluid, fat, muscle, and bone) will be discussed. The review will conclude by highlighting current gaps of knowledge and further research directions in this area.

Peritoneal dialysis and peritoneal fibrosis: molecular mechanisms, risk factors and prospects for prevention

Peritoneal dialysis (PD) leads to structural and functional changes in the peritoneal membrane, the endpoint of which is peritoneal fibrosis. Peritoneal fibrosis is diagnosed in 50% and 80% of PD patients within 1 and 2 years of treatment initiation, respectively. A key role in the development of peritoneal fibrosis is played by mesothelial-mesenchymal transformation, a complex biological process of transition from mesothelium to mesenchyme. This review summarizes the current knowledge on the changes in peritoneal function and morphology, the molecular mechanisms of peritoneal fibrosis development, and its clinical consequences during PD. Special attention is given to established and potential risk factors for peritoneal fibrosis, and existing prevention strategies are considered.

Astragaloside IV Alleviates Intestinal Barrier Dysfunction via the AKT-GSK3β-β-Catenin Pathway in Peritoneal Dialysis

Background and aims: Long-term peritoneal dialysis (PD) causes intestinal dysfunction, including constipation, diarrhea, or enteric peritonitis. However, the etiology and pathogenesis of these complications are still unclear and there are no specific drugs available in the clinic. This study aims to determine whether Astragaloside IV (AS IV) has therapeutic value on PD-induced intestinal epithelial barrier dysfunction in vivo and in vitro.

Methods: We established two different long-term PD treatment mice models by intraperitoneally injecting 4.25% dextrose-containing peritoneal dialysis fluid (PDF) in uremia mice and normal mice, which were served as controls. In addition, PDF was applied to T84 cells in vitro. The therapeutic effects of AS IV on PD-induced intestinal dysfunction were then examined by histopathological staining, transmission electron microscopy, western blotting, and reverse transcription polymerase chain reaction. The protein levels of protein kinase B (AKT), glycogen synthase kinase 3β (GSK-3β) and β-catenin were examined after administration of AS IV.

Results: In the present study, AS IV maintained the intestinal crypt, microvilli and desmosome structures in an orderly arrangement and improved intestinal epithelial permeability with the up-regulation of tight junction proteins in vivo. Furthermore, AS IV protected T84 cells from PD-induced damage by improving cell viability, promoting wound healing, and increasing the expression of tight junction proteins. Additionally, AS IV treatment significantly increased the levels of phosphorylation of AKT, inhibited the activity GSK-3β, and ultimately resulted in the nuclear translocation and accumulation of β-catenin.

Conclusion: These findings provide novel insight into the AS IV-mediated protection of the intestinal epithelial barrier from damage via the AKT-GSK3β-β-catenin signal axis during peritoneal dialysis.

Pull technique versus open surgical removal of the catheter for peritoneal dialysis: a retrospective cohort study

BACKGROUND

The open surgical technique (OST) is the main modality for peritoneal dialysis (PD) catheter removal; however, the pull technique (PT) is emerging as a minimally invasive alternative. At present, the safety and relative equivalence of PT and OST are unclear.

METHODS

In this retrospective study, we reviewed the medical records of consecutive patients who underwent PD catheter removal via PT or OST at the Xinyang Central Hospital from April 2015 to October 2019. Complication-free survival (CFS) and surgical outcomes 365 days after PD catheter removal were evaluated and compared between groups.

RESULTS

The PD catheter was removed in 89 patients. The final sample of 80 patients was selected based on eligibility for inclusion and exclusion criteria. Ten patients experienced complications (PT group, n = 2; OST group, n = 8), including death (n = 6), dialysate leak (n = 3), and incisional dehiscence (n = 1). Epidemiological and preoperative clinical characteristics were similar in all patients. Kaplan-Meier plots for CFS revealed significant differences in prognostic outcomes between the groups. Multivariate analysis revealed that CFS was similar in both groups (with OST as a reference; hazard ratio, 0.21; 95% confidence interval [CI], 0.03-1.27; P = 0.09). We observed significant differences in the operative time, blood loss, operative pain score, and anesthetic use between the groups (all P < 0.001). The length and cost of hospitalization were similar in both the groups.

CONCLUSIONS

PT is superior to OST in terms of blood loss, anesthetic use, operative pain score, and operating time without sacrificing safety and survival benefits.

Association of Abnormal Iron Status with the Occurrence and Prognosis of Peritoneal Dialysis-Related Peritonitis: A Longitudinal Data-Based 10-Year Retrospective Study

This retrospective study investigated the effect of iron status on peritonitis by analyzing longitudinal iron parameters in peritoneal dialysis (PD) patients. Patients who received PD at our center from 1 January 2006 to 31 December 2015 were included and followed up until 31 December 2017. According to the joint quartiles of baseline transferrin saturation and ferritin, iron status was categorized as reference iron status (RIS), absolute iron deficiency (AID), functional iron deficiency (FID), and high iron status (HIS). Generalized estimating equations and Cox regression models with time-dependent covariates were used. A total of 1258 PD patients were included; 752 (59.8%) were male, with a mean (±standard deviation) age of 47.4 (±14.9) years. During a median follow-up period of 35.5 (interquartile range, 18.4–60.0) months, 450 (34.3%) patients had 650 episodes of peritonitis. By analyzing longitudinal data, patients with AID were independently positively associated with the occurrence (adjusted odds ratio (AOR) = 1.45) and treatment failure of peritonitis (adjusted hazard ratio (AHR) = 1.85). Patients with HIS were positively associated with the treatment failure of peritonitis (AHR = 2.70). Longitudinal AID and HIS were associated with the episodes and poor prognosis of peritonitis. Active clinical monitoring and correction of iron imbalance in patients with PD are needed.

The Clinical Utility of the Neutrophil-to-Lymphocyte Ratio as a Discriminatory Test among Bacterial, Mycobacterium Tuberculosis, and Nontuberculous Mycobacterium Peritoneal Dialysis-Related Peritonitis

Background

Distinguishing Mycobacterium tuberculosis (TB) and nontuberculous Mycobacterium (NTM) from bacterial peritoneal dialysis (PD)-related peritonitis (peritonitis) is often very challenging and can lead to a significant delay in diagnosis and treatment. The neutrophil-to-lymphocyte ratio (NLR) is readily calculable and has been shown to be useful in differentiating pulmonary TB from bacterial pneumonia. We are the first group to demonstrate the predictive efficacy of peritoneal dialysate (PDE) NLR in distinguishing TB/NTM peritonitis from bacterial causes in the PD population.

Methods

We retrospectively reviewed the clinical and laboratory characteristics of all patients with TB/NTM peritonitis, methicillin-sensitive Staphylococcus aureus (MSSA) peritonitis, and culture-negative peritonitis in our tertiary center between July 2000 and July 2020. The diagnostic ability of the blood and PDE NLR for differential diagnosis was evaluated.

Results

In total, 258 episodes, 38 episodes, and 27 episodes were caused by MSSA, TB, and NTM species, respectively; 364 episodes were culture negative. The PDE NLR level taken at presentation were lowest in the TB peritonitis, followed by the NTM, culture-negative, and MSSA groups, (9.44±13.01, 16.99±23.96, 36.63±32.33, 48.51±36.01; P<0.001, respectively). The area under the receiver operating characteristic curve for the NLR taken at presentation was 0.83 (95% confidence interval, 0.77 to 0.89; P<0.001). A PDE NLR <15 was an optimal cut-off value with sensitivity, specificity, positive predictive value, and negative predictive values of 81%, 70%, 97%, and 22%, respectively.

Conclusions

The PDE NLR obtained at presentation is a useful and easily accessible marker to discriminate TB/NTM peritonitis from bacterial peritonitis, especially in areas with intermediate TB/NTM burden. The NLR may enable early prompting of TB/NTM peritonitis, allowing specific investigation and treatment to be instigated earlier.