genitourinary disorders
Peritoneal Dialysis
Complications of Peritoneal Dialysis
 (see table Complications of Renal Replacement Therapy ) are Peritonitis Catheter tunnel exit-site infection Peritonitis symptoms and signs include abdominal pain, cloudy peritoneal fluid, fever, nausea, and tenderness to palpation. Diagnosis of peritonitis is made by clinical criteria and testing. A sample of peritoneal fluid is obtained for Gram stain, culture, and white blood cell (WBC) count with differential. Peritonitis is present if a patient has at least 2 of the following criteria: Clinical features consistent with peritonitis (eg, abdominal pain, tenderness, and/or cloudy dialysis effluent) Dialysis effluent WBC>100/mcL with>50% polymorphonuclear cells after a dwell time of at least 2 hours Positive peritoneal fluid culture ( Complications reference ) Gram stain is often unrevealing, but cultures are positive in>90%. About 90% also have>100 WBCs/mcL, usually neutrophils (lymphocytes with fungal peritonitis). Negative cultures and WBC counts<100/mcL do not exclude peritonitis, so treatment is indicated if peritonitis is suspected based on clinical or laboratory criteria and should begin immediately, before culture results are available. Peritoneal fluid studies may be falsely negative due to prior antibiotic use, infection limited to the catheter exit site or tunnel, or sampling of too little fluid. If peritonitis is suspected based on clinical criteria, start treatment immediately regardless of laboratory findings. Empiric treatment should be adapted to microbial resistance patterns of a given facility, but typical recommendations are for initial treatment with drugs active against gram-positive organisms, eg, eithervancomycinor a 1st-generation cephalosporin, plus drugs active against gram-negative organisms, such as a 3rd-generation cephalosporin (eg,ceftazidime) or an aminoglycoside (eg,gentamicin). Doses are adjusted for renal failure. Drugs are adjusted based on the result of peritoneal dialysis fluid culture. Antibiotic therapy is usually given IV or intraperitoneally (IP) for peritonitis and orally for exit-site infections. Patients with peritonitis are admitted to the hospital if IV treatment is necessary or if hemodynamic instability or other significant complications arise. Most cases of peritonitis respond to prompt antibiotic therapy. If peritonitis does not respond to antibiotics within 5 days or is caused by recurrence of the same organism or by fungi, the dialysis catheter is removed. Catheter tunnel exit-site infection manifests as tenderness over the tunnel or at the exit site along with crusting, erythema, or drainage. Diagnosis is clinical. Treatment of infection without drainage is topical antiseptics (eg, povidone iodine,chlorhexidine); if ineffective,vancomycinis usually used empirically, with culture results guiding subsequent therapy. 1.Li PK-T, Chow KM, Cho Y, et al: ISPD (International Society of Peritoneal Dialysis) peritonitis guideline recommendations: 2022 Update on prevention and treatment.Perit Dial Int42(2):110-153, 2022. doi: 10.1177/08968608221080586 