EM@3AM: Peritoneal Dialysis Emergencies

A 42 year-old male presents with abdominal pain and fevers for 72 hours, with nausea and vomiting for 24 hours. He has a history of end stage renal disease and has been on peritoneal dialysis for 5 years. He also has a history of hypertension, hyperlipidemia, and diabetes.

Triage vital signs (VS): BP 105/60, HR 121, T 101.4 temporal, RR 24, SpO2 98% on room air. Pertinent physical examination findings include a tender peritoneal dialysis site and diffuse abdominal tenderness, but no erythema overlying the PD site.

What’s the next step in your evaluation and treatment?

Answer: Peritonitis secondary to peritoneal dialysis (PD)

Epidemiology of PD:

• Less expensive, at home dialysis option compared to hemodialysis
• Less dietary restriction, greater independence and mobility
• Improved preservation of renal function

Types of PD Emergencies:

• Infectious
  • Bacterial Peritonitis
    • Most common PD complication – 1 case per patient per year
    • Contributes to morbidity and mortality – accounts for 1.9% of PD related deaths
      • Risk Factors: Obesity, depression, hypokalemia, recent invasive interventions (e.g. colonoscopy), lack of vitamin D supplementation, wet contamination, prior hemodialysis, nasal aureus carrier, previous exit site infection
    • Tuberculoid Peritonitis
      • Occurs from rupture of a scrofula
        • Only 14% of these patients will demonstrate chest radiographic evidence of tuberculosis
      • Develops within 12 months of starting PD
      • Occurs secondary to decreased cellular immunity
    • Catheter Exit Site and Tunnel Infections
      • 39% of catheter removals occur because of recalcitrant infections
•   Structural—PD catheter should be located in a dependent area, in females the rectouterine pouch and in males the retrovesical pouch
  • Malposition
    • Migration occurs usually within the first 12 months
      • Reduces drainage, increases risk of peritonitis, localized pain, and fluid overload
  •  Kinking
    • Difficulty instilling dialysate
  •  Hernias
    • Sudden increase in abdominal pressure (e.g. coughing)
    • Most common in those with polycystic kidney disease
    • Usually from umbilicus
    • 25% will occur from abdominal wall
    • Can migrate thoracically from Morgagni and Bochdalek’s hernias
    • Present with dialysate infusion, weight gain, edema
  • Leakage
    • Occurs in up to 5% of PD patients
    • Can present with genital swelling or abdominal swelling from extension along Scarpa’s fascia
  • Entrapment
    • Adhesions or abdominal organs decrease the surface area available for dialysis
      • In history of peritonitis, more likely to be secondary to loculations
•  Other
  • Sclerosing Encapsulating Peritonitis—Inflammatory process in which thick fibrous connective tissue surrounds bowels with dilated lymphatics
    • Occurs in 0.9-7.3% of PD patients, more common in those with a history of peritonitis
    • Presents with abdominal pain or cramping, weight loss, anorexia, loss of ultrafiltration, bloody effluent
  • Hepatic Steatosis
    • Present in 62% of patients undergoing PD with intraperitoneal insulin for patients with diabetes mellitus
      • Intraperitoneal insulin provides better glycemic control but with the risk of hepatic steatosis

Evaluation:

• Assess ABCs and obtain VS
  • May demonstrate fever, tachycardia, hypotension if infectious complication, edema seen in obstructive or other mechanical issues
    • Weight loss and night sweats may be seen in tuberculoid peritonitis
  • Perform a complete physical examination
    • PD site: Exit site infections may demonstrate erythema and purulence, while tunnel infections may demonstrate tenderness or may be clinically undetectable
    • Abdomen: Tenderness in peritonitis as well as mechanical complications, hepatomegaly in hepatic steatosis
    • Lower extremities: Assess for edema
•  Laboratory evaluation:
  • Complete blood count with differential, electrolytes, renal/liver function, blood gas with lactate
  • Peritoneal fluid culture if concern for infectious complications, consider fungal culture
    • Establishes causative organism in 75% of cases within 3 days
    • In bacterial peritonitis, cell count>100 cells/mm³ with > 50% neutrophils clinch diagnosis in proper clinical picture
• Imaging
  • Ultrasound
    • May demonstrate increased echogenicity of infected dialysate in bacterial peritonitis
    • Can aid in finding tunnel site infections with fluid and a hypoechoic area surrounding the thin hyperechoic bands of the catheter
    • Can demonstrate subcapsular hepatic steatosis
  • Abdominal radiographs
    • Will demonstrate catheter kinking
  • Computed Tomography
    • May demonstrate loculations or isolated fluid collections in bacterial peritonitis
    • Can show enhanced mesenteric thickness of >15 mm or enlarged lymph nodes in tuberculoid peritonitis
    • Helpful in detecting hernias as well as leakages
    • Diagnostic imaging of choice for sclerosing encapsulating peritonitis with peritoneal enhancement/calcifications, bowel tethering posterior to fluid collections
  • Magnetic Resonance Imaging
    • Dialysate is often used as contrast agent to mitigate risk for nephrogenic systemic fibrosis

Treatment:

• ABCs—Resuscitation in the setting of any infectious complications
• Antibiotics—Bacterial peritonitis
  • Intraperitoneal antibiotics without interruption of PD
  • Vancomycin (15-30 mg/kg) + Cefepime (1 g daily) or ceftazidime (1-5 grams daily) OR
  • Vancomycin + ciprofloxacin
    • Intermittent vancomycin dosing is equivalent to continuous vancomycin
  • Allergies
    • Aztreonam for MRSA coverage
    • Can also use aminoglycosides for gram negative coverage in those with cephalosporin allergies, does not appear to affect residual renal function
      • Pharmacy consultation for intraperitoneal antibiotic dosing
    • Anti-tuberculoid:
      • 4 drug regimen of rifampicin, isoniazid (with pyridoxine), pyrazinamide, ofloxacin
    • In sclerosing encapsulating peritonitis, early cessation of PD is paramount as well as surgery to relieve bowel obstruction and consideration of prednisolone and cyclosporin for mitigation of inflammation
•  Consultation:
  • Nephrology for PD recommendations
  • IR may aid in removal or assessment of catheter malfunction or infection
    • In malposition, any repositioning must occur under sterile conditions
  • Can consider discharge some peritonitis patients but many of these patients will require admission with expert consultation for mechanical issues

Pearls:

• Peritonitis is common, occurring nearly annually for PD patients
• Peritonitis predisposes PD patients to a myriad of further infections and mechanical complications
• Catheter complications may present with edema and/or reduced dialysate yield
• Sclerosing Encapsulating Peritonitis carries a high mortality and can be prevented with early recognition and cessation of PD

References:

1. Stuart S, Booth TC, Cash CJ, Hameeduddin A, Goode JA, Harvey C, Malhotra A. Complications of continuous ambulatory peritoneal dialysis. Radiographics. 2009 Mar-Apr;29(2):441-60. doi: 10.1148/rg.292085136. PMID: 19325058.
2. Feriani M, Dell’Aquila R, La Greca G. The treatment of diabetic end-stage renal disease with peritoneal dialysis. Nephrol Dial Transplant 1998;13 (suppl 8):53–56.
3. Khalili K, Lan FP, Hanbidge AE, Muradali D, Oreopoulos DG, Wanless IR. Hepatic subcapsular steatosis in response to intraperitoneal insulin delivery: CT findings and prevalence. AJR Am J Roentgenol 2003;180(6):1601–1604.
4. Slingeneyer A. Preliminary report on a cooperative international study on sclerosing encapsulating peritonitis. Contrib Nephrol 1987;57:239–247.
5. Niaudet P, Berard E, Revillon Y, Lothon M, Broyer M. Sclerosing encapsulating peritonitis in children. Contrib Nephrol 1987;57:230–238.
6. Gokal R, Jakubowski C, King J, et al. Outcome in patients on continuous ambulatory peritoneal dialysis and haemodialysis: 4-year analysis of a prospective multicentre study. Lancet 1987;2(8568): 1105–1109.
7. Cho Y, Johnson DW. Peritoneal dialysis-related peritonitis: towards improving evidence, practices, and outcomes. Am J Kidney Dis2014; 64:278–89.
8. Lui SL, Cheng SW, Ng F, Ng SY, Wan KM, Yip T, et al. Cefazolin plus netilmicin versus cefazolin plus ceftazidime for treating CAPD peritonitis: effect on residual renal function. Kidney Int2005; 68:2375–80.
9. Wong KM, Chan YH, Cheung CY, Chak WL, Choi KS, Leung SH, et al. Cefepime versus vancomycin plus netilmicin therapy for continuous ambulatory peritoneal dialysis associated peritonitis. Am J Kidney Dis 2001; 38:127–31.
10. Goffin E, Herbiet L, Pouthier D, Pochet JM, Lafontaine JJ, Christophe JL, et al. Vancomycin and ciprofloxacin: systemic antibiotic administration for peritoneal dialysis-associated peritonitis. Perit Dial Int2004; 24:433–9.
11. Baker RJ, Senior H, Clemenger M, Brown EA. Empirical aminoglycosides for peritonitis do not affect residual renal function. Am J Kidney Dis2003; 41:670–5.
12. Li PK, Szeto CC, Piraino B, et al. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment [published correction appears in Perit Dial Int. 2018 Jul-Aug;38(4):313]. Perit Dial Int. 2016;36(5):481-508. doi:10.3747/pdi.2016.00078
13. Hanbidge AE, Lynch D, Wilson SR. US of the peritoneum. RadioGraphics 2003;23(3):663–684; discussion 684–685.
14. Lindblad AS. Complications of peritoneal catheters. In: Lindblad AS, Novak JW, Nolph KD, eds. Continuous ambulatory dialysis in the USA: final report of the National CAPD Registry. Dordrecht, the Netherlands: Kluwer Academic, 1989; 157–166.
15. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial 2001;14(1):50–54.
16. Tzamaloukas AH, Gibel LJ, Eisenberg B, et al. Early and late peritoneal dialysate leaks in patients on CAPD. Adv Perit Dial 1990;6:64–71.
17. Slingeneyer A. Preliminary report on a cooperative international study on sclerosing encapsulating peritonitis. Contrib Nephrol 1987;57:239–247.
18. Wanless IR, Bargman JM, Oreopoulos DG, Vas SI. Subcapsular steatonecrosis in response to peritoneal insulin delivery: a clue to the pathogenesis of steatonecrosis in obesity. Mod Pathol 1989;2(2): 69–74.
19. Torun D, Oguzkurt L, Sezer S, et al. Hepatic sub-capsular steatosis as a complication associated with intraperitoneal insulin treatment in diabetic peri-toneal dialysis patients. Perit Dial Int 2005;25(6): 596–600.