Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
Peritonitis is a common complication of peritoneal dialysis. Peritonitis is associated with significant morbidity, catheter loss, transfer to hemodialysis, transient loss of ultrafiltration, possible permanent membrane damage, and occasionally death [1-6].
This topic will review the clinical presentation and diagnosis of peritonitis in patients undergoing peritoneal dialysis. Most of the discussion relates to the presentation and diagnosis of bacterial peritonitis, although a few specific issues unique to fungal and tuberculosis peritonitis are also addressed. Prevention and treatment are discussed separately. (See "Pathophysiology and prevention of peritonitis in peritoneal dialysis" and "Microbiology and therapy of peritonitis in continuous peritoneal dialysis" and "Fungal peritonitis in continuous peritoneal dialysis".)
Among peritoneal dialysis patients, peritonitis may be peritoneal dialysis related or secondary (such as enteric or rarely hematogenous). Peritoneal dialysis-related peritonitis is due to touch contamination with pathogenic skin bacteria or to catheter-related infection. Secondary peritonitis is caused by underlying pathology of the gastrointestinal tract and has rarely been reported due to hematogenous spread, such as postdental procedures.
Gastrointestinal conditions that may lead to secondary peritonitis include cholecystitis, appendicitis, ruptured diverticulum, treatment of severe constipation, perforation during endoscopy, bowel ischemia, and incarcerated hernia. Secondary peritonitis is less common than peritoneal dialysis-related peritonitis. As an example, in one review, intra-abdominal pathology was responsible for less than 6 percent of cases of peritonitis in chronic ambulatory peritoneal dialysis (CAPD) patients . Secondary peritonitis may also be caused by seeding from the blood or vagina, but this is less common compared with the intra-abdominal causes listed above.
The clinical outcome is often much worse in cases of secondary peritonitis [8-10]. In one report, 11 of 26 patients with secondary peritonitis died  compared with an overall peritonitis-associated mortality of approximately 2 to 3 percent among all peritoneal dialysis patients with peritonitis . In the study of secondary peritonitis, mortality correlated with the specific causes of peritonitis (particularly infarcted bowel), the time to diagnosis, and definitive surgical intervention. (See "Gastrointestinal disease in dialysis patients".)
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- CLINICAL FEATURES
- Clinical manifestations
- Laboratory manifestations
- - Peritoneal fluid cell count
- - Peritoneal fluid amylase and lipase levels
- - Peritoneal fluid cultures
- - Peripheral white cell count
- - Blood cultures
- Radiographic findings
- Establishing the diagnosis
- Correct technique for obtaining peritoneal fluid for culture
- DIFFERENTIAL DIAGNOSIS
- EVALUATION AFTER DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS