Improved Outcome of Enteric Peritonitis in Peritoneal Dialysis Patients Aged 50 Years and Older with Temporary Discontinuation of Peritoneal Dialysis and Intravenous Meropenem.

♦ BACKGROUND: Peritonitis is a major cause of morbidity, mortality, and technique failure in peritoneal dialysis (PD) patients, especially when caused by enteric microorganisms (EM). We have implemented a treatment protocol specifically aimed at improving the outcome in EM peritonitis. The adapted protocol was applied in all PD patients 50 years and older presenting with peritonitis who were considered to be at risk of EM peritonitis and involves 3 interventions: 1) temporary discontinuation of PD without removing the catheter (peritoneal rest), 2) intravenous meropenem, and 3) meropenem intracatheter as lock (Mero-PerRest protocol). ♦ METHODS: In this observational study, we compared the outcome of 203 peritonitis episodes in 71 patients treated with the Mero-PerRest protocol, with 217 episodes in 104 patients treated with a more traditional intraperitoneal gentamicin-rifampicin-based regimen. ♦ RESULTS: In EM peritonitis episodes, the Mero-PerRest protocol resulted in a higher primary cure rate (90.0% vs 65.3%, adjusted odds ratio [OR] 4.54 [95% confidence interval (CI) 1.46 - 14.15]) and better technique survival (90.0% vs 69.4%, adjusted OR 3.41 [95% CI 1.07 - 10.87]). This effect was most distinct in patients with polymicrobial EM peritonitis (cure rate 87.5% vs 34.8%, p = 0.0003). Interestingly, primary cure rate (95.6% vs 84.7%, adjusted OR 3.92 [95% CI 1.37 - 11.19]) and technique survival (95.6% vs 85.6%, adjusted OR 3.60 [95% CI 1.25 - 10.32]) were also excellent in non-EM peritonitis episodes. Patient survival did not differ significantly. ♦ CONCLUSION: The poor outcome of peritonitis caused by EM in PD patients aged 50 years and older could be improved by applying a treatment protocol involving temporary discontinuation of PD without catheter removal and intravenous and intracatheter meropenem.

Similar peritonitis outcome in CAPD and APD patients with dialysis modality continuation during peritonitis.

BACKGROUND: As few data exist on treatment of peritonitis in patients on automated peritoneal dialysis (APD), and as pharmacokinetics of several antibiotics are reported to be unfavorable in APD, some favor switching to continuous ambulant PD (CAPD) while treating APD-related peritonitis. We explored whether treating peritonitis with patients continuing their usual PD modality had an effect on outcome. METHODS: We performed a retrospective analysis of the 508 episodes of PD-associated peritonitis seen in 205 patients in our center from January 1993 to January 2007. During this period, the standard initial therapy for PD-related peritonitis was a combination of intraperitoneal gentamicin and rifampicin. RESULTS: There was no difference in cure rate between CAPD and APD groups. Likewise, initial and maximal leukocyte counts in the PD fluid (PDF), relapse rates, catheter removal rates, and death during treatment of peritonitis were similar in the CAPD and APD groups. Median (interquartile range) duration of elevated leukocyte count in PDF was longer in APD: 5.0 (3.0 - 9.0) days versus 4.0 (2.5 - 7.0) days in CAPD (p <0.001). APD patients were treated with antibiotics longer than CAPD patients: 16.0 (12.5 - 21.0) versus 15.0 (12.0 - 18.0) days (p = 0.036). Also, after correction for possible confounders, odds ratios for death and for the combined end point death or catheter removal showed no difference when patients treated for peritonitis stayed on their own modality. CONCLUSION: Regarding rate of relapse, mortality, or the combined end point mortality plus catheter removal, we found no difference between CAPD and APD patients continuing their own PD modality during treatment of PD-related peritonitis. Intermediate end points such as duration of elevated PDF leukocyte count and duration of antibiotic treatment were longer in APD patients.

Reversible renal failure due to bilateral renal sarcoma in a patient with acute myeloid leukemia.

A 68-year-old male presented with acute myeloid leukemia, renal failure, hypokalemia, and enlarged kidneys on renal ultrasound. Renal biopsy revealed massive leukemic infiltration of the kidney. After systemic chemotherapy, the patient developed tumor lysis syndrome followed by a phase of proximal tubule dysfunction presenting as polyuria and diverse electrolyte abnormalities. In time, renal function returned to normal, as did kidney size. This report shows that renal failure, enlargement of the kidneys, and tubule dysfunction in the course of AML infiltrating the kidneys can be reversed by treatment of the hematological disease.