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| Year : 2010 | Volume
: 21
| Issue : 3 | Page : 501-503 |
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| Relapsing peritonitis in a malnourished female with rheumatoid arthritis on continuous ambulatory peritoneal dialysis |
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Varun Sundaram, Georgi Abraham, Santosh Kumar Mohanraj, Yogesh NV Reddy, Vijaiaboobbathi Sathiah
Department of Nephrology, Madras Medical Mission, Chennai, Tamilnadu, India
Click here for correspondence address and email
| Date of Web Publication | 26-Apr-2010 |
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How to cite this article:
Sundaram V, Abraham G, Mohanraj SK, Reddy YN, Sathiah V. Relapsing peritonitis in a malnourished female with rheumatoid arthritis on continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl 2010;21:501-3 |
How to cite this URL:
Sundaram V, Abraham G, Mohanraj SK, Reddy YN, Sathiah V. Relapsing peritonitis in a malnourished female with rheumatoid arthritis on continuous ambulatory peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Aug 12];21:501-3. Available from: https://www.sjkdt.org/text.asp?2010/21/3/501/62687 |
 Introduction | |  |
Infectious complication such as peritonitis remains a major cause of drop out and death in CAPD patients. [1],[2] Incidence of peritonitis varies from centre to centre and country to country and majority of peritonitis episodes can be effectively treated with no relapses and recurrences. [3] There are certain factors which predispose to peritonitis relapses and recurrences such as malnutrition, exit site and tunnel infection, catheter biofilm and bowel leak. [3],[4] Malnutrition is a major predictor of peritonitis related mortality in these patients. We hereby report a 52 year old vegetarian female with rheumatoid arthritis on CAPD who developed recurrent peritonitis and had inflammation, malnutrition and atherosclerosis.
| Case Report | | |
A 52-year-old female, vegetarian, with rheumatoid arthritis and ESRD on hemodialysis for six months was later switched over to CAPD after implanting a swan neck double cuff tenck-hoff catheter in September 2002. She was on dianeal two liters three exchanges of 2.5% dialysate. She did not turn up for follow up for next four years as her dialysis was going un-interrupted. In September 2006 she was hospitalized for abdominal pain, and on examination her blood pressure was 90/60mmHg. Her exit site and tunnel were normal. Investigations at the time of admission showed hemoglobin 8.2 gm/dL, WBC 6700/mm 3 , serum albumin 0.9 gm/dL, blood urea16 mg/dL, serum creatinine 4.2 mg/dL, potassium 2.1 mmol/L, phosphorous 1 mg/dL, HsCRP 12 mg/L. PD fluid cell count was WBC 1300 cells with predominant neutrophilia and culture was negative. She was treated successfully with intraperitoneal ceftazidime and ampicillin for two weeks. Concurrently she was given fluconazole 150 mg OD as a prophylaxis for fungal peritonitis. A Bioelectrical impedance analysis (BIA) was done which showed total body fat 51.6%, body fat 26.8%, (target fat 2733%), resting metabolic rate 1006 kcal, target weight 32-38 kg, lean body weight 25.2 kg, lean body weight 48.5%, body water 18.4 liters, body water 35.4% (target water 46-53%). She was given dietary advice on discharge. She presented one month later with abdominal pain and cloudy dialysate. Investigations showed again anemia with hemoglobin of 6.8 gm/dL. The dialysate fluid cell count was 350 cells/mm 3 with predominant neutrophils (91%). Dialysate effluent culture grew coagulase negative staphylococci (CONS). She was treated with intraperitoneal ampicillin 250 mg per cycle and oral fluconazole 150 mg OD for fungal prophylaxis. Her dialysis effluent cleared in two days.
One month later she was re-hospitalized with peritonitis causing abdominal pain and hypotension with BP of 70/40 mmHg. Her exit site and tunnel was un-remarkable. She was given intravenous normal saline, and supported with vasopressors. Serum cortisol level was low and received intravenous hydrocortisone 50 mg q6 hourly. Her dialysate cell count was 950 cells with predominant neutrophilia and culture grew CONS (methicillin resistant) and was treated with intraperitoneal teicoplanin 20 mg/L. She continued to receive prophylactic fluconazole 150 mg/day orally. With this regimen her dialysis effluent became clear after five days. Four days after current admission she had sudden onset of hypotension and ECG showed acute anteroseptal myocardial infarction and ECHO revealed severe LV dysfunction (echo previous month was normal). She was treated with low molecular weight heparin and two days later she died of cardiogenic shock.
| Discussion | | |
Several studies suggest that malnutrition is an important factor for morbidity and mortality in dialysis patients. [1] CAPD patients can be confronted with a situation leading to malnutrition secondary to protein loss in dialysate, especially in patients with recurrent peritonitis in addition to the protein caloric malnutrition associated with chronic kidney disease. [2] This patient's course was smooth during the initial few years of CAPD, but subsequently developed relapsing peritonitis following a decline in nutritional status as she was a pure vegetarian. Her malnutrition may be a combination of type 1 and type 2 as shown by the BIA, low serum albumin, low potassium, low phosphorous, low blood urea nitrogen, elevated CRP and globulin levels as this patient had rheumatoid arthritis. Low serum albumin levels were associated with worse peritonitis free survival. [3] Though in some patients recurrent peritonitis could be the primary event and malnutrition a secondary effect, the sequence of events suggests that malnutrition is the risk factor for peritonitis in our patient. However the relapsing peritonitis may also be the result of a biofilm as she had same CONS grown in culture. Catheter removal and reimplantation at the same sitting was planned during her final admission under antibiotic cover when the dialysate effluent cleared up but could not be implemented because of her acute coronary episode. She developed methicillin resistance during the last episode of peritonitis which was effectively treated with intraperitoneal teicoplanin. Female gender, low residual renal function, inflammation (HsCRP) and malnutrition which were considered predictors of poor outcome were evident in this patient. [4] Protein energy malnutrition has been shown to be strongly independent predictor of cause and cardiovascular related mortality in dialysis patients. Most of the traditional risk factors such as hypertension, physical inactivity and nontraditional risk factors such as inflammation, malnutrition and anemia were present in this patient which explains the cardiovascular death in this patient. There is high prevalence of CVD in incident dialysis patients and in stages one to four suggesting that CVD begins before the onset of ESRD. [5] Several studies suggest that high blood pressure is a risk factor for mortality in dialysis dependent patients. The risk of mortality in relationship with blood pressure is U shaped in dialysis patients. Studies have shown that risk was higher in patients with post dialytic systolic blood pressure greater than 180 mmHg but also in those with a predialysis or post dialysis systolic blood pressure less than 110 mmHg as in our patient. [6] The incidence of coronary artery disease in patients undergoing chronic dialysis is 22.5%. Age (> 60 years), underlying diabetic nephropathy and CRP (> 0.5 mg/dL) were predictors of CAD in PD patients whereas underlying diabetic nephropathy and age were predictors of mortality in these patients. [7] The "malnutrition-inflammation-cachexia syndrome" (MICS) is the main cause of worsening atherosclerotic cardiovascular disease in the CKD population. The MICS is associated with low serum cholesterol and homocysteine levels and hence a reverse epidemiology of cardiovascular risk factors is observed in dialysis patients with a paradoxical association of obesity, hypercholesterolemia, and hyperhomocysteinemia with better survival. [8] Both uremic malnutrition and chronic inflammation are also associated with increased oxidative stress, a condition proposed as a unifying concept of CVD in uremia. Although a single common etiology has not been identified in this complex process, nutritional, anti-inflammatory, and antioxidant interventions can provide potential treatment options to improve the high mortality and morbidity in ESRD patients. [9],[10] Observation of vegetarian and malnourished CAPD patients at more frequent intervals such as at least once a month follow up will alert the need for counseling and intensive nutritional therapy, thus reducing morbidity and mortality as seen in our patient.
| References | | |
| 1. | Prasad N, Gupta A, Sharma RK, et al. Impact of nutritional status on peritonitis in CAPD patients. Perit Dial Int 2007;27(1):42-7.  |
| 2. | Cueto-Manzano AM, Gamba G, Correa-Rotter R, et al. Peritoneal protein loss in patients with high peritoneal permeability: Comparison between continuous ambulatory peritoneal dialysis and daytime intermittent peritoneal dialysis. Arch Med Res 2001;32(3):197-201. |
| 3. | Chow KM. A risk analysis of continuous ambulatory peritoneal dialysis-related peritonitis. Perit Dial Int 2005;25(4):374-9. |
| 4. | Perez Fontan M, Rodriguez-Carmona, GarciaNaveiro R. Peritonitis related mortality in patients undergoing chronic peritoneal dialysis. Perit Dial Int 2005;25(3):274-84. |
| 5. | Stack AG, Bloembergen WE. Prevalence and clinical correlates of coronary artery disease among new dialysis patients in the United States: A cross sectional study. J Am Soc Nephrol 2001;12:1516-23. [PUBMED] [FULLTEXT] |
| 6. | Zager PG, Nikolic J, Brown RH, et al. U curve association of blood pressure and mortality in hemodialysis patients. Medical directors of dialysis clinic. Kidney Int 1998;54:561-9. [PUBMED] [FULLTEXT] |
| 7. | Kim SB, Lee SK, Park JS, et al. Prevalence of Coronary artery disease using -201 single photon emission computed tomography among patients newly undergoing chronic peritoneal dialysis and its association with mortality. Am J Nephrol 2004;24:448-52. [PUBMED] [FULLTEXT] |
| 8. | Kamyar KZ. Recent advances in understanding the Malnutrition-Inflammation-Cachexia syndrome in chronic kidney disease patients: What is Next? Semin Dial 2005;18(5):365-9. |
| 9. | Ikizler TA. Role of nutrition for cardiovascular risk reduction in chronic kidney disease patients. Adv Chronic Kidney Dis 2004;11(2): 162-71. |
| 10. | Stenvinkel P, Heimburger O, Paultre F, et al. Strong association between malnutrition, inflammation and atherosclerosis in chronic renal failure. Kidney Int 1999;55(5):1899-911. |
Correspondence Address:
Georgi Abraham
Department of Nephrology, Madras Medical Mission Hospital, Chennai 600037, Tamilnadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 20427876 
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