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Although conventional wisdom advises removal of the Tenckhoff catheter as part of the therapy for tuberculous peritonitis, there are a few recent reports of cases successfully treated while maintaining the patients on CAPD. We wish to report three cases treated without interrupting CAPD. In two of the patients, cultures were positive for Mycobacterium tuberculosis and in the third case, although the cultures were negative, the patient improved on anti-Tb medications. Smear for AFB was positive in one patient; and two had a positive PPD. All had predominance of lymphocytes and monocytes in effluent. The total WBC count was 160-300 and two patients had fever. All had abdominal pain. One patient was treated with INH and ethambutol; one with INH and rifampin and one (who was suspected of being HIV+) also received pyrazinamide (PZA) until culture was available. Cultures grew in 4-6 weeks. All were started on therapy prior to having the culture results, and all showed clinical improvement within two weeks. One patient had his catheter replaced two months later because of pseudomonas peritonitis, continued on CAPD for an additional five months, then changed to HD because of recurrent bacterial peritonitis. One patient died of complications of diabetic vascular disease three months later with no evidence of peritonitis. One patient has remained on anti-Tb treatment for seven months and is doing well on CAPD.
Adv Perit Dial 1991
PMID:Successful treatment of tuberculous peritonitis while maintaining patient on CAPD. 168 Apr 1

In this study we evaluate the effectiveness of a newly available peroxyacetic acid solution (Dialox) as a disinfecting agent in the re-use of highly permeable dialysers. The germicidal properties of Dialox were tested in an in vitro trial on previously used haemodiafilters (HF80, Fresenius) highly contaminated with Pseudomonas aeruginosa, Mycobacterium smegmatis or sporulated Bacillus cereus. Complete freedom from bacterial contamination was observed 5 min after the reprocessing treatment on a Renatron reprocessing machine, using the currently marketed Dialox concentrate.
Nephrol Dial Transplant 1989
PMID:Germicidal effectiveness of Dialox, a new stable peroxyacetic acid solution, in the re-use of high-flux dialysers. 251 80

The aim of this study was to verify whether the replacement of the peritoneal catheter in a single operation and during infectious complications of peritoneal dialysis is effective and safe. Sixty-eight infectious complications refractory to appropriate antibiotic therapy were treated by this technique: 26 tunnel infections, 22 peritonitis-complicating tunnel infections, 12 refractory peritonitis, and 8 recurrent peritonitis. Operations were successful in all cases of tunnel infection and recurring peritonitis, and in all cases but one of peritonitis-complicating tunnel infection. Ten failures occurred among the 12 catheters removed for refractory peritonitis. Microorganisms cultured in these 10 failures were: Fungi (3 cases), Mycobacterium (2 cases), Pseudomonas (2 cases), Acinetobacter (1 case), Acinetobacter+Pseudomonas (1 case), and Enterococcus (1 case). Complications were 3 one-way obstructions and 2 external dialysate leaks. This study supports the simultaneous catheter replacement-removal procedure during infectious complications of peritoneal dialysis (PD) with the exception of refractory peritonitis; this technique spares the patient the temporary vascular access, the shift to hemodialysis, and a second operation to insert a new catheter. There are few complications.
Adv Perit Dial 1994
PMID:Simultaneous catheter replacement-removal during infectious complications in peritoneal dialysis. 799 30

Exit-site infections (ESI) and/or tunnel infections (TI) are common causes of peritoneal catheter loss. Catheter-related infection can be characterized by ultrasonographic examination (UE) of the exit site and the tunnel. This study was done to determine if the UE is useful in predicting catheter loss. Records from 1990 to 1992 of all continuous ambulatory peritoneal dialysis (CAPD) patients with an ESI or TI who had an UE performed were reviewed for causative organism, loss of catheter, and infection resolution. ESI was defined as redness or induration of exit site with or without the presence of drainage. TI was defined as induration or redness along tunnel or incision site with or without the presence of drainage. The presence of a pericatheter sonolucent fluid collection was considered a positive (+) UE, and the absence of fluid a negative (-) UE. Eleven CAPD patients had 12 UE performed within a week of starting antibiotic therapy. Ten were (+) and 2 (-); 7 catheters were removed, all with (+) UE. Of those removed, 6 were due to S. aureus, and 1 due to mycobacterial infection. Of the 3 (+) catheters not removed, 2 infections resolved clinically: both reverted to (-) UE after treatment. We conclude that a (+) UE is a useful predictor of catheter loss.
Adv Perit Dial 1993
PMID:Is ultrasonography useful in predicting catheter loss? 810 31

Peritoneal dialysis (PD) success depends on adequate renal function replacement. Reports in adult dialysis populations indicate the risk of ultrafiltration failure (UF) increases with the time on dialysis. Type 1 UF is the most common. For children, dialysis modalities are temporizing measures until renal transplantation, considered optimal therapy for end-stage renal disease in children, can be performed. Children are frequently on dialysis for less than 2 years prior to transplantation. Thus if type 1 UF frequency increases with time on dialysis, it would be expected to occur less frequently in children, because they often are on dialysis for shorter periods. A retrospective chart review was performed to determine the cause of ultrafiltration failure in children; 172 children, mean age 8.0 +/- 5.5 (SD) years received a mean of 15 +/- 11.9 (SD) months of chronic PD; 39 patients received only continuous ambulatory peritoneal dialysis, 18 received only continuous cycling peritoneal dialysis, 22 received only tidal PD, and 94 received more than one type of PD. Ten patients (5.8%) developed type 2 UF failure as sequellae of atypical peritonitis, Candida albicans (6 patients), Mycobacterium foruitum (2), Achromatium spp. (1), and Pseudomonas aeruginosa (1). There was no significant difference in time on dialysis for children who developed membrane failure. No patients with type 1 or type 3 UF could be identified. It appears that the causes of peritoneal membrane failure in children are different from those in adults.
Adv Perit Dial 1995
PMID:Peritoneal membrane failure in children on peritoneal dialysis. 853 22

Peritoneoscopic placement of peritoneal dialysis catheters, although accomplished in only about 10% of dialysis centers, is a nonsurgical technique that fulfills requirements for safety and dependability. Over a 40-month period, 136 catheters were placed with the peritoneoscope, 135 of which were double-cuffed, Swan neck curled catheters, with a uniform radiopaque stripe. Patients were followed longitudinally for outcome. Catheters were placed in 44 diabetic patients, 1 human immunodeficiency virus (HIV)-positive patient, and 18 morbidly obese patients. No complications occurred as a direct result of placement. Catheters were used, on average, nine days after placement (many on days 1 to 4) usually with 1.5 to 2 L exchanges. With 1183 patient-months' experience, complications were few: 28 patients experienced catheter-related infections, and there were five leaks that resolved with supine, low-volume dialysis for several days. Leakage did not correlate with time of usage after placement. Of ten outflow/mechanical problems that required catheter removal, nine involved catheter migration, probably due to lack of attention during placement to orientation of the radiopaque stripe. One was due to a preperitoneal placement early in this institution's experience with the peritoneoscope. Five of the migrated catheters were removed and then successfully replaced with the peritoneoscope at the same sitting. Four patients requested surgical removal and replacement. Sixteen catheters were removed because of catheter-related infections: five refractory Staphylococcus aureus, six Pseudomonas aeruginosa, two fungal, two Serratia species, and one Mycobacterium chelonei. Actuarial life-table analysis showed that at the end of the 40-month follow-up, 62% of the catheters were expected to survive. Because more than 50% survived, median catheter survival could not be calculated. The adverse responses were removal because of infection or catheter migration. Peritoneal dialysis catheter implantation with the peritoneoscope represents a safe and dependable method for catheter placement. Literature review and comparison indicate that catheter-related complications are fewer and catheter longevity is better with peritoneoscopic placement than with surgical placement. Our experience with prompt postplacement utilization suggests the need for further evaluation of catheter break-in procedure with the peritoneoscope.
Perit Dial Int 1996
PMID:Peritoneoscopic placement of Swan neck peritoneal dialysis catheters. 872 18

Exit-site infections (ESIs) are frequently due to gram-positive organisms and occasionally to gram-negative organisms. Initial empiric antibiotic therapy is therefore directed against these organisms until culture reports are available. Two cases of ESI associated with Mycobacterium are here reported. The first patient, a 63-year-old man with type 2 diabetes, recently treated for Staphylococcus epidermidis peritonitis, presented with acute purulent drainage at the catheter exit site, accompanied by pain and erythema. No tunnel abscess was identified by ultrasound. Empiric antibiotic therapy was initiated with ofloxacin and vancomycin. A rapid-growing acid-fast bacillus (AFB) noted four days after culture was eventually identified as Mycobacterium fortuitum. Ofloxacin was continued, vancomycin was discontinued, and clarithromycin was added. The ESI initially showed improvement; therapy was therefore continued for several months. However, cultures remained positive for M. fortuitum, and the catheter was removed 5 months after therapy was initiated. The second patient, a 28-year-old woman, presented with severe pain and tenderness at the exit site without erythema or drainage. Empiric therapy with cefazolin, gentamicin, and cephalexin was initiated. Gram-positive cocci and an AFB were identified from the exit-site culture, and antibiotics were initially changed to clarithromycin, trimethoprim/sulfamethoxazole, and ofloxacin. The organisms were subsequently identified as M. chelonae-M. abscessus complex and coagulase-negative Staphylococcus. The patient continued to improve after 3 weeks of antibiotic therapy. However, despite the initial improvement in the ESI, the M. chelonae-M. abscessus complex continued to grow, and amikacin was added intravenously. Despite continued treatment, the ESI did not resolve, and the catheter was removed after 4 months of therapy. Despite unusual exist-site infections with rapidly growing AFBs, both patients continued continuous ambulatory peritoneal dialysis (CAPD) while undergoing treatment for ESI. Catheters were left intact, as improvement was initially seen with no evidence of tunnel infection or peritonitis. Rapid-growing AFB should be considered another possible causative agent for ESI. Two cases of atypical mycobacterial exit-site infection are presented to illustrate the difficulties in managing this complication of peritoneal dialysis. Ofloxacin--or other quinolones--may provide a better spectrum of coverage when choosing empiric therapy in patients presenting with ESI.
Adv Perit Dial 2001
PMID:Treatment of mycobacterial exit-site infections in patients on continuous ambulatory peritoneal dialysis. 1151 Feb 69

Among 155 patients who were initiated on continuous ambulatory peritoneal dialysis (CAPD), 4 patients (2 men, 2 women) developed tuberculous peritonitis. They had been on PD for between 2 months and 84 months when they developed the peritonitis. The Mantoux test was negative in all of them. The diagnosis was made by a variety of means in the various cases: demonstration of Mycobacterium tuberculosis in the peritoneal cavity; presence of caseating granuloma in a peritoneal biopsy; Mycobacterium tuberculosis in a cold abscess adjacent to the peritoneal cavity; and demonstration of IS6110 and MPB64 genes of Mycobacterium tuberculosis by polymerase chain reaction (PCR) technique. Two of the patients developed ultrafiltration failure. Among 3 patients who were switched to hemodialysis, 2 died and 1 continues on maintenance dialysis. The last patient, whose catheter was removed, was reimplanted with a new catheter and continues on PD without ultrafiltration failure. Any patient with peritonitis unresponsive to conventional therapy should be investigated for tuberculous peritonitis. Institution of chemotherapy without delay will preserve peritoneal membrane integrity.
Perit Dial Int 2001
PMID:Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. 1188 21

Tuberculous peritonitis is not an uncommon cause of continuous ambulatory peritoneal dialysis (CAPD) peritonitis in endemic countries. The diagnosis is usually delayed because peritoneal fluid smears for acid-fast bacilli (AFB) are insensitive, and cultures for Mycobacterium tuberculosis require weeks. The present paper reports two cases of tuberculous CAPD peritonitis that were rapidly diagnosed using gene amplification for M. tuberculosis DNA complex by polymerase chain reaction with the commercial Amplicor M. tuberculosis nucleic acid amplification test (Roche Diagnostic Systems, Branchburg, NJ, U.S.A.). A 18-year-old man and a 50-year-old man, both on CAPD, developed culture-negative peritonitis. Empirical therapy with intraperitoneal vancomycin and gentamicin failed. Peritoneal fluid AFB smears were negative. In both patients, M. tuberculosis DNA complex was detected by nucleic acid amplification using the Amplicor test. Anti-tuberculosis treatment was unsuccessful and their catheters were removed. Six weeks later, their peritoneal fluid cultures isolated M. tuberculosis. The use of molecular techniques to assist in the diagnosis of pulmonary tuberculosis is well accepted. Little information exists regarding the use of molecular techniques in the diagnosis of tuberculous CAPD peritonitis. The diagnosis of tuberculous peritonitis in CAPD patients is frequently delayed and may cause increased morbidity and mortality. Molecular diagnosis of tuberculous peritonitis using nucleic acid amplification tests may allow more rapid diagnosis. Further studies are required to determine the sensitivity and specificity of the technique in CAPD patients with tuberculous peritonitis.
Adv Perit Dial 2002
PMID:Rapid diagnosis of Mycobacterium tuberculous peritonitis in two continuous ambulatory peritoneal dialysis patients, using DNA amplification by polymerase chain reaction. 1240 9

While nontuberculous mycobacterial peritonitis is uncommon among peritoneal dialysis (PD) patients, these infections have serious consequences. They present a significant diagnostic and therapeutic challenge for clinicians. Diagnosis can be delayed due to the slow growth rate of some mycobacterial species. These organisms can also be overlooked when adequate culture media are not used in the microbiological evaluation process. The choice of antimicrobial therapy depends upon isolation and speciation of the infecting Mycobacterium species, and prompt catheter removal is essential. Because serious intra-abdominal complications may follow infection, identifying patient risk factors for nontuberculous mycobacterial peritonitis and initiating prompt diagnosis and treatment are essential. We report three cases of peritonitis associated with Mycobacterium chelonae and Mycobacterium gordonae, each with a unique presentation, and discuss the appropriate diagnosis and treatment strategies for the management of PD-associated mycobacterial infections.
Semin Dial
PMID:Nontuberculous mycobacterial peritonitis in peritoneal dialysis patients. 1755 95


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