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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 501-503
Relapsing peritonitis in a malnourished female with rheumatoid arthritis on continuous ambulatory peritoneal dialysis

Department of Nephrology, Madras Medical Mission, Chennai, Tamilnadu, India

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Date of Web Publication26-Apr-2010

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 Top

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 Top

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 Top

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 Top

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.  Back to cited text no. 1      
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.  Back to cited text no. 2      
3.Chow KM. A risk analysis of continuous ambu­latory peritoneal dialysis-related peritonitis. Perit Dial Int 2005;25(4):374-9.  Back to cited text no. 3      
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.  Back to cited text no. 4      
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.  Back to cited text no. 5  [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.  Back to cited text no. 6  [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.  Back to cited text no. 7  [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.  Back to cited text no. 8      
9.Ikizler TA. Role of nutrition for cardiovascular risk reduction in chronic kidney disease pa­tients. Adv Chronic Kidney Dis 2004;11(2): 162-71.  Back to cited text no. 9      
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.  Back to cited text no. 10      

Correspondence Address:
Georgi Abraham
Department of Nephrology, Madras Medical Mission Hospital, Chennai 600037, Tamilnadu
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Source of Support: None, Conflict of Interest: None

PMID: 20427876

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