EM@3AM: Peritoneal Dialysis Emergencies

Author: Rachel Bridwell, MD (@rebridwell, EM Attending Physician) // Reviewed by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital); Brit Long, MD (@long_brit, EM Attending Physician, San Antonio, TX)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.


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.

 

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