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Infectious Diseases

Peritoneal Fluid Analysis in Peritoneal Dialysis–Associated Peritonitis

Educational Objective
To understand how to interpret the results of diagnostic tests and apply them clinically.

1 Credit CME

JAMA

Published Online: November 10, 2022

JAMA Diagnostic Test Interpretation

Article Information and Disclosures

Jeffrey Perl, MD, SM¹;

Ziv Harel, MD, MSc¹;

Sharon J. Nessim, MD, MSc²

Author Affiliations

¹Division of Nephrology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
²Division of Nephrology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada

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A 62-year-old woman undergoing peritoneal dialysis (PD) for kidney failure due to IgA nephropathy presented to the PD clinic with a 1-day history of severe abdominal pain and cloudy PD fluid. Seven days prior, she inadvertently broke aseptic technique when tightening a leaking connection of her PD catheter tubing. On presentation, she was afebrile and had normal vital signs. Physical examination revealed diffuse abdominal tenderness. Cloudy fluid that was drained from her PD catheter was sent for laboratory analysis (Table 1).

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A. Administer empirical broad-spectrum intraperitoneal antibiotics

PD-associated peritonitis occurs in approximately 30% to 40% of patients during their course of PD treatment¹^,2 and develops when infectious organisms gain access to the peritoneal cavity. Infection can occur through “touch contamination,” involving a breach in aseptic technique that introduces infectious organisms in the PD catheter, PD catheter exit site or tunnel infection with skin organisms that migrate into the peritoneal cavity, translocation of organisms from the gastrointestinal or genitourinary tract, or, in less than 1% of cases, hematogenous spread to the peritoneal cavity. After organisms enter the peritoneal cavity, polymorphonuclear leukocytes (PMNs) induce an inflammatory cascade, causing abdominal pain and cloudy dialysate.

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Article Information

Corresponding Author: Jeffrey Perl, MD, SM, Division of Nephrology, St Michael’s Hospital, University of Toronto, 61 Queen St E, Ninth Floor, Toronto, ON, M5C 2T2, Canada (Jeffrey.perl@unityhealth.to).

Published Online: November 10, 2022. doi:10.1001/jama.2022.21289

Conflict of Interest Disclosures: Dr Perl reported receiving grants from the Agency for Healthcare Research and Quality; personal fees from Baxter Healthcare, Fresenius Medical Care, Amgen Canada, US Renal Care, Bayer Canada, Otsuka Canada, LiberDi, DaVita Healthcare, AstraZeneca, Pfizer, and GlaxoSmithKline; and salary support from Arbor Research Collaborative for Health outside the submitted work. Dr Nessim reported receiving personal fees from Baxter Healthcare, Otsuka, and AstraZeneca outside the submitted work. No other disclosures were reported.

References

Perl J , Fuller DS , Bieber BA , et al. Peritoneal dialysis-related infection rates and outcomes: results from the peritoneal dialysis outcomes and practice patterns study (PDOPPS). Am J Kidney Dis. 2020;76(1):42-53. doi:10.1053/j.ajkd.2019.09.016 PubMed Google Scholar Crossref

Nessim SJ , Bargman JM , Austin PC , Nisenbaum R , Jassal SV . Predictors of peritonitis in patients on peritoneal dialysis: results of a large, prospective Canadian database. Clin J Am Soc Nephrol. 2009;4(7):1195-1200. doi:10.2215/CJN.00910209 PubMed Google Scholar Crossref

Li PK , Chow KM , Cho Y , et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110-153. doi:10.1177/08968608221080586 PubMed Google Scholar Crossref

Males BM , Walshe JJ , Amsterdam D . Laboratory indices of clinical peritonitis: total leukocyte count, microscopy, and microbiologic culture of peritoneal dialysis effluent. J Clin Microbiol. 1987;25(12):2367-2371. doi:10.1128/jcm.25.12.2367-2371.1987 PubMed Google Scholar Crossref

Flanigan MJ , Freeman RM , Lim VS . Cellular response to peritonitis among peritoneal dialysis patients. Am J Kidney Dis. 1985;6(6):420-424.PubMed Google Scholar Crossref

Buchanan R , Fan S , NicFhogartaigh C . Performance of gram stains and 3 culture methods in the analysis of peritoneal dialysis fluid. Perit Dial Int. 2019;39(2):190-192. doi:10.3747/pdi.2018.00087 PubMed Google Scholar Crossref

Fung WW , Chow KM , Ng JK , Chan GC , Li PK , Szeto CC . The clinical utility of the neutrophil-to-lymphocyte ratio as a discriminatory test among bacterial, mycobacterium tuberculosis, and nontuberculous mycobacterium peritoneal dialysis-related peritonitis. Kidney360. 2022;3(6):1031-1038. doi:10.34067/KID.0000842022 PubMed Google Scholar Crossref

Vlaanderen K , de Fijter CW , Bos HJ , et al. The effect of dwell time on peritoneal phagocytic defense of chronic peritoneal dialysis patients. Adv Perit Dial. 1989;5:151-153.PubMed Google Scholar

Al Sahlawi M , Zhao J , McCullough K , et al. Variation in peritoneal dialysis-related peritonitis outcomes in the peritoneal dialysis outcomes and practice patterns study (PDOPPS). Am J Kidney Dis. 2022;79(1):45-55.e1. doi:10.1053/j.ajkd.2021.03.022 PubMed Google Scholar Crossref

Park SJ , Lee JY , Tak WT , Lee JH . Using reagent strips for rapid diagnosis of peritonitis in peritoneal dialysis patients. Adv Perit Dial. 2005;21:69-71.PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.