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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

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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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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
1.
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.2019.09.016PubMedGoogle ScholarCrossref
2.
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.00910209PubMedGoogle ScholarCrossref
3.
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:10.1177/08968608221080586PubMedGoogle ScholarCrossref
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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.25.12.2367-2371.1987PubMedGoogle ScholarCrossref
5.
Flanigan  MJ , Freeman  RM , Lim  VS .  Cellular response to peritonitis among peritoneal dialysis patients.   Am J Kidney Dis. 1985;6(6):420-424.PubMedGoogle ScholarCrossref
6.
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.2018.00087PubMedGoogle ScholarCrossref
7.
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.0000842022PubMedGoogle ScholarCrossref
8.
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.PubMedGoogle Scholar
9.
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.2021.03.022PubMedGoogle ScholarCrossref
10.
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.PubMedGoogle Scholar
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