Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations and diagnosis of peritonitis in peritoneal dialysis

John M Burkart, MD
Section Editor
Thomas A Golper, MD
Deputy Editor
Alice M Sheridan, MD


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 [7]. 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 [8] compared with an overall peritonitis-associated mortality of approximately 2 to 3 percent among all peritoneal dialysis patients with peritonitis [11]. 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 "Unique aspects of gastrointestinal disease in dialysis patients".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Aug 19, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Holley JL, Praino BM. Complications of peritoneal dialysis: Diagnosis and management. Semin Dial 1990; 3:245.
  2. Schreiber M, Burkart JM, et al. Peritonitis remains the leading cause of transfer from PD to HD (abstract). Perit Dial Int 1996.
  3. Woodrow G, Turney JH, Brownjohn AM. Technique failure in peritoneal dialysis and its impact on patient survival. Perit Dial Int 1997; 17:360.
  4. Pérez Fontan M, Rodríguez-Carmona A, García-Naveiro R, et al. Peritonitis-related mortality in patients undergoing chronic peritoneal dialysis. Perit Dial Int 2005; 25:274.
  5. Sipahioglu MH, Aybal A, Unal A, et al. Patient and technique survival and factors affecting mortality on peritoneal dialysis in Turkey: 12 years' experience in a single center. Perit Dial Int 2008; 28:238.
  6. Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis: gram negatives versus gram positives in the Network 9 Peritonitis Study. Kidney Int 1997; 52:524.
  7. Tzamaloukas AH, Obermiller LE, Gibel LJ, et al. Peritonitis associated with intra-abdominal pathology in continuous ambulatory peritoneal dialysis patients. Perit Dial Int 1993; 13 Suppl 2:S335.
  8. Tzamaloukas AH, Murata GH, Fox L. Peritoneal catheter loss and death in continuous ambulatory peritoneal dialysis peritonitis: correlation with clinical and biochemical parameters. Perit Dial Int 1993; 13 Suppl 2:S338.
  9. Harwell CM, Newman LN, Cacho CP, et al. Abdominal catastrophe: visceral injury as a cause of peritonitis in patients treated by peritoneal dialysis. Perit Dial Int 1997; 17:586.
  10. Kern EO, Newman LN, Cacho CP, et al. Abdominal catastrophe revisited: the risk and outcome of enteric peritoneal contamination. Perit Dial Int 2002; 22:323.
  11. Ghali JR, Bannister KM, Brown FG, et al. Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients. Perit Dial Int 2011; 31:651.
  12. Vas, SI. Peritonitis. In: Peritoneal Dialysis, 3rd ed, Nolph, KD (Eds), Kluwer Academic Publishers, Dordrecht 1989. p.261.
  13. Oliveira LG, Luengo J, Caramori JC, et al. Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center. Int Urol Nephrol 2012; 44:1529.
  14. Shrestha BM, Brown P, Wilkie M. Surgical peritonitis in patients on peritoneal dialysis. Perit Dial Int 2008; 28:331.
  15. Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393.
  16. Voinescu CG, Khanna R. Peritonitis in peritoneal dialysis. Int J Artif Organs 2002; 25:249.
  17. Piraino B, Bailie GR, Bernardini J, et al. Peritoneal dialysis-related infections recommendations: 2005 update. Perit Dial Int 2005; 25:107.
  18. Tranaeus A, Heimbürger O, Lindholm B. Peritonitis in continuous ambulatory peritoneal dialysis (CAPD): diagnostic findings, therapeutic outcome and complications. Perit Dial Int 1989; 9:179.
  19. Koopmans JG, Boeschoten EW, Pannekeet MM, et al. Impaired initial cell reaction in CAPD-related peritonitis. Perit Dial Int 1996; 16 Suppl 1:S362.
  20. Flanigan MJ, Freeman RM, Lim VS. Cellular response to peritonitis among peritoneal dialysis patients. Am J Kidney Dis 1985; 6:420.
  21. Twardowski ZJ, Schreiber MJ Jr, Burkart JM. A 55-year-old man with hematuria and blood-tinged dialysate. Perit Dial Int 1992; 12:61.
  22. Eisenberg ES, Leviton I, Soeiro R. Fungal peritonitis in patients receiving peritoneal dialysis: experience with 11 patients and review of the literature. Rev Infect Dis 1986; 8:309.
  23. Cheng IK, Fang GX, Chan TM, et al. Fungal peritonitis complicating peritoneal dialysis: report of 27 cases and review of treatment. Q J Med 1989; 71:407.
  24. Holley HP Jr, Tucker CT, Moffatt TL, et al. Tuberculous peritonitis in patients undergoing chronic home peritoneal dialysis. Am J Kidney Dis 1982; 1:222.
  25. Dunmire RB 3rd, Breyer JA. Nontuberculous mycobacterial peritonitis during continuous ambulatory peritoneal dialysis: case report and review of diagnostic and therapeutic strategies. Am J Kidney Dis 1991; 18:126.
  26. Keane WF, Bailie GR, Boeschoten E, et al. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000; 20:396.
  27. Johnson CA. Intraperitoneal vancomycin administration. Perit Dial Int 1991; 11:9.
  28. Charney DI, Gouge SF. Chemical peritonitis secondary to intraperitoneal vancomycin. Am J Kidney Dis 1991; 17:76.
  29. Ejaz AA, Fitzpatrick PM, Durkin AJ, et al. Pathophysiology of peritoneal fluid eosinophilia in peritoneal dialysis patients. Nephron 1999; 81:125.
  30. Fontán MP, Rodríguez-Carmona A, Galed I, et al. Incidence and significance of peritoneal eosinophilia during peritoneal dialysis-related peritonitis. Perit Dial Int 2003; 23:460.
  31. Caruana RJ, Burkart J, Segraves D, et al. Serum and peritoneal fluid amylase levels in CAPD. Normal values and clinical usefulness. Am J Nephrol 1987; 7:169.
  32. Burkart JM, Khanna R. A 69-year-old male with elevated amylase in bloody and cloudy dialysate. Perit Dial Int 1993; 13:142.
  33. Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003; 42:1082.
  34. Morduchowicz G, van Dyk DJ, Wittenberg C, et al. Bacteremia complicating peritonitis in peritoneal dialysis patients. Am J Nephrol 1993; 13:278.
  35. Szeto CC, Wong TY, Chow KM, et al. The clinical course of culture-negative peritonitis complicating peritoneal dialysis. Am J Kidney Dis 2003; 42:567.
  36. Eisele G, Adewunni C, Bailie GR, et al. Surreptitious use of antimicrobial agents by CAPD patients. Perit Dial Int 1993; 13:313.
  37. Sewell DL, Golper TA, Hulman PB, et al. Comparison of large volume culture to other methods for isolation of microorganisms from dialysate. Perit Dial Int 1990; 10:49.
  38. Lye WC, Wong PL, Leong SO, Lee EJ. Isolation of organisms in CAPD peritonitis: a comparison of two techniques. Adv Perit Dial 1994; 10:166.
  39. Alfa MJ, Degagne P, Olson N, Harding GK. Improved detection of bacterial growth in continuous ambulatory peritoneal dialysis effluent by use of BacT/Alert FAN bottles. J Clin Microbiol 1997; 35:862.
  40. Rocklin MA, Teitelbaum I. Noninfectious causes of cloudy peritoneal dialysate. Semin Dial 2001; 14:37.
  41. de Freitas DG, Gokal R. Sterile peritonitis in the peritoneal dialysis patient. Perit Dial Int 2005; 25:146.
  42. Yoshimoto K, Saima S, Nakamura Y, et al. Dihydropyridine type calcium channel blocker-induced turbid dialysate in patients undergoing peritoneal dialysis. Clin Nephrol 1998; 50:90.
  43. Bargman JM, Zent R, Ellis P, et al. Diagnosis of lymphoma in a continuous ambulatory peritoneal dialysis patient by peritoneal fluid cytology. Am J Kidney Dis 1994; 23:747.
  44. Pérez Fontán M, Pombo F, Soto A, et al. Chylous ascites associated with acute pancreatitis in a patient undergoing continuous ambulatory peritoneal dialysis. Nephron 1993; 63:458.
  45. Rocklin MA, Quinn MJ, Teitelbaum I. Cloudy dialysate as a presenting feature of superior vena cava syndrome. Nephrol Dial Transplant 2000; 15:1455.
  46. Streather CP, Carr P, Barton IK. Carcinoma of the kidney presenting as sterile peritonitis in a patient on continuous ambulatory peritoneal dialysis. Nephron 1991; 58:121.
  47. Vlahakos D, Rudders R, Simon G, Canzanello VJ. Lymphoma-mimicking peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1990; 10:165.
  48. MacGinley R, Cooney K, Alexander G, et al. Relapsing culture-negative peritonitis in peritoneal dialysis patients exposed to icodextrin solution. Am J Kidney Dis 2002; 40:1030.
  49. Tintillier M, Pochet JM, Christophe JL, et al. Transient sterile chemical peritonitis with icodextrin: clinical presentation, prevalence, and literature review. Perit Dial Int 2002; 22:534.
  50. Boer WH, Vos PF, Fieren MW. Culture-negative peritonitis associated with the use of icodextrin-containing dialysate in twelve patients treated with peritoneal dialysis. Perit Dial Int 2003; 23:33.
  51. Glorieux G, Lameire N, Van Biesen W, et al. Specific characteristics of peritoneal leucocyte populations during sterile peritonitis associated with icodextrin CAPD fluids. Nephrol Dial Transplant 2003; 18:1648.
  52. Martis L, Patel M, Giertych J, et al. Aseptic peritonitis due to peptidoglycan contamination of pharmacopoeia standard dialysis solution. Lancet 2005; 365:588.
  53. Rozenberg R, Magen E, Weissgarten J, Korzets Z. Icodextrin-induced sterile peritonitis: the Israeli experience. Perit Dial Int 2006; 26:402.
  54. Bunke M, Brier ME, Golper TA. Culture-negative CAPD peritonitis: the Network 9 Study. Adv Perit Dial 1994; 10:174.
  55. Choi P, Nemati E, Banerjee A, et al. Peritoneal dialysis catheter removal for acute peritonitis: a retrospective analysis of factors associated with catheter removal and prolonged postoperative hospitalization. Am J Kidney Dis 2004; 43:103.
  56. Royse VL, Jensen DM, Corwin HL. Pancreatic enzymes in chronic renal failure. Arch Intern Med 1987; 147:537.
  57. Akriviadis EA, Runyon BA. Utility of an algorithm in differentiating spontaneous from secondary bacterial peritonitis. Gastroenterology 1990; 98:127.
  58. Suresh KR, Port FK. Air under the diaphragm in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989; 9:309.
  59. Yehia M, de Zoysa JR, Collins JF. Is computerized tomography useful in identifying abdominal catastrophes in patients presenting with peritonitis? Perit Dial Int 2008; 28:385.