Sepsis- PD peritonitis

74 yr female with ESRD secondary to reflux nephropathy elected to have peritoneal dialysis as her preferred mode of renal replacement therapy. 4 weeks following insertion of her Tenckhoff PD catheter, she notices mild abdominal pain. She claims her PD fluid looks clear. She is having problems with draining fluid out of her abdomen and this is causing increasing fluid retention. You send off a PD fluid sample for analysis, which returns showing: 6000 polymorphs/ul. No organisms seen. What is your diagnosis and how would you approach treatment?

Ans: PD Peritonitis. Gram positive, gram negative and pseudomonal cover. In most units, IP vancomycin, IP gentamicin and Ciprofloxacin. Once cultures are back, then tailor as per culture result. Relevant guidelines include ISPD guidelines.

Which specialties do you think it might be necessary to involve in the care of this patient?

Ans: Micro and potentially Surgeons. Staph aureus infection usually necessitates removal of tube. Fungal infection always necessitates removal of tube. Failure to improve with standard antibiotics would also require tube removal.

The patients’ infection failed to improve, with her PD fluid cell count on day 5 of therapy showing 10 000 polymorphs/ul. The PD tube was removed and she improved clinically a few days later. Now that her PD catheter has been removed, what options has she left for renal replacement therapy?

Ans: It is not unreasonable to consider another PD tube, provided that you ensure her technique is correct and was not the reason for the infection. Haemodialysis is an option. Transplantation is an option, although, she would need to be fit for a major operation to undergo a transplant.