Persistent Symptomatic Intra-Abdominal Collection after Catheter Removal for Pd-Related Peritonitis

Abstract

♦ ♦ ♦ ♦ ♦ Background: Peritoneal dialysis (PD) patients with severe peritonitis require catheter removal. It is often assumed that this approach, together with antibiotics, would eradicate the infection; however, some patients continue to have problems despite catheter removal. ♦ ♦ ♦ ♦ ♦ Method: We reviewed 30 consecutive PD patients in our center from 1997 to 2008 with recurrent loculated peritoneal collection after catheter removal for severe peritonitis. ♦ ♦ ♦ ♦ ♦ Results: Of the 1928 episodes of peritonitis that occurred in 702 patients during the study period, 11.1% required catheter removal and 1.6% developed recurrent peritoneal collection that required percutaneous drainage. Median time to diagnosis of intra-abdominal collection was 12 days after catheter removal (interquartile range 7 -61 days). In 25 patients (83.3%), aspirate of the abdominal collection was culture negative. In 17 patients (56.7%), the abdominal collection was recurrent and required repeated percutaneous aspiration. Only 3 patients had successful reinsertion of the peritoneal catheter but all had reduced small solute clearance after returning to PD. ♦ ♦ ♦ ♦ ♦ Conclusion: A small but not negligible proportion of patients with PD-related peritonitis develop recurrent intraabdominal collection that requires percutaneous drainage after catheter removal. The chance of a successful return to PD is very low in this group of patients. Direct conversion to long-term hemodialysis may avoid unnecessary attempts at peritoneal catheter reinsertion.

Persistent Sterile Peritoneal Inflammation after Catheter Removal for Refractory Bacterial Peritonitis Predicts Full-Blown Encapsulating Peritoneal Sclerosis

“…In a Korean study by Moon et al (9), persistent elevation of CRP at 72 hours was found to be a significant predictor for the development of EPS in patients after dialysis catheter removal for refractory peritonitis. Another local study by Szeto et al (10) also found that 14% of their patients in the same clinical context experienced persistent symptomatic intra-abdominal collections, and 67% and 70% of the patients also had elevated inflammatory markers and bowel obstruction respectively. Those features are likely the clinical manifestations of the inflammatory phase of EPS.…”

“…In various studies, elevated CRP and the presence of intra-abdominal collections have commonly been observed in patients with technique failure (9,10,15). In a Korean study by Moon et al (9), persistent elevation of CRP at 72 hours was found to be a significant predictor for the development of EPS in patients after dialysis catheter removal for refractory peritonitis.…”

“…Their theory is supported by the fact that 63% of EPS cases develop within 1 year after PD withdrawal (2), and many of the patients experience non-resolving peritoneal inflammation, with persistent elevation of C-reactive protein (CRP) and the presence of ascites after peritoneal catheter removal for refractory peritonitis (3,9,10). Patients who have undergone catheter removal for refractory bacterial peritonitis are therefore in a unique clinical situation, with the coexistence of two putative "second hit" factors rendering these patients at an exceptional risk of developing EPS.…”

An intra-abdominal abscess or "rind" as a consequence of peritoneal dialysis-associated pseudomonas peritonitis

“…The first is the post-peritonitis development of ascites comprised of loculated fluid pockets [4, 5]. The second is the syndrome of encapsulating peritoneal sclerosis [6].…”

“…The former has been reported in 2 – 20% of patients requiring removal of peritoneal catheters consequent to peritoneal infections. 50% of these individuals also require percutaneous catheter drainage of persisting fluid, which is usually culture negative [5]. The latter syndrome has a mortality rate that may be as high as 50% and is associated with increased duration of peritoneal dialysis, but has not been correlated with the frequency or severity of peritonitis episodes [7].…”