What are the other Names for this Condition? (Also known as/Synonyms)

• Dialysis-Associated Peritonitis
• Peritoneal Dialysis Catheter-Associated Peritonitis
• Peritonitis Secondary to Peritoneal Dialysis

What is Peritoneal Dialysis-Associated Peritonitis? (Definition/Background Information)

• The peritoneum is a thin double-layered membrane that lines the inside of the abdominal cavity, covering organs within it. Peritonitis is inflammation of the peritoneum, which may be caused by bacteria, fungi, or even by chemicals
• When the inflammation results from a procedure known as peritoneal dialysis (PD), the condition is termed Peritoneal Dialysis-Associated Peritonitis. Peritoneal dialysis is a way to remove unfiltered waste products from the body, when the kidneys can no longer function adequately
• Peritoneal dialysis involves filling the abdomen with a dialysis fluid (called dialysate), which filters waste products using peritoneal membrane as a filter. The fluid is left in the abdomen for a while, after which it is removed, along-with all the waste products it contains
• The process is continuous and is often repeated many times daily (3-5 times per day including once or twice during the night). Moreover, since the patient can go about their normal activities, this procedure is termed continuous ambulatory peritoneal dialysis (CAPD)
• Peritoneal Dialysis-Associated Peritonitis is the most common and serious complication of peritoneal dialysis. It can occur while handling dialysis catheters or due to unhygienic conditions, while performing dialysis. Diabetes, obesity, immunosuppression, and certain comorbid conditions (such as heart and lung disease, diabetes, etc.) are also important risk factors
• The signs and symptoms of Peritoneal Dialysis-Associated Peritonitis include fever, abdominal pain, decreased urination, inability to pass stool or gas, nausea and vomiting, and presence of a cloudy fluid on dialysis
• The condition is a medical emergency and prompt diagnosis is critical. Careful evaluation of medical history, physical examination and symptom assessment guide the diagnosis, which can be confirmed by blood tests and testing the dialysis fluid for bacteria and other pathogens
• Peritoneal Dialysis-Associated Peritonitis can lead to severe complications including multi-organ failure due to widespread infection or sepsis, lung conditions (such as acute respiratory distress syndrome), disseminated intravascular coagulation (DIC), and peritoneal scarring that may render the peritoneum useless for future dialysis
• The treatment involves the administration of intravenous or intra-peritoneal antibiotics (medications) and resting the abdomen with hemodialysis, until the membrane heals. However, with timely diagnosis and treatment, the prognosis of Peritoneal Dialysis-Associated Peritonitis is generally good; a complete recovery is observed in most affected individuals
• Peritoneal Dialysis-Associated Peritonitis can be prevented by proper washing of hands and sanitizing techniques during dialysis and using prophylactic antibiotics prior to catheter insertion

Who gets Peritoneal Dialysis-Associated Peritonitis? (Age and Sex Distribution)

• Peritoneal Dialysis-Associated Peritonitis is common among individuals (of all age groups and both male and female genders) who undergo peritoneal dialysis
• Among all patients on continuous ambulatory peritoneal dialysis, children were found to have a higher rate of developing Dialysis-Associated Peritonitis than adults
• The condition is seen in individuals belonging to all races and ethnicities
• However, among individuals on CAPD, the incidence rate is higher in African-Americans, for some unknown reason, when compared to individuals of Caucasian descent

What are the Risk Factors for Peritoneal Dialysis-Associated Peritonitis? (Predisposing Factors)

The risk factors for Peritoneal Dialysis-Associated Peritonitis may include:

• Any infection at the exit site of a catheter
• Belonging to African-American or aboriginal ethnic group
• Transferring from hemodialysis (kidney) to peritoneal dialysis
• Uncontrolled diabetes (especially in women)
• Obesity
• Previous episode of peritonitis
• Smoking
• Malnutrition
• Immunosuppression causing decreased immunity
• Certain pre-existing conditions including heart diseases and heart failure, chronic lung disease, and systemic lupus erythematosus (SLE)

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Peritoneal Dialysis-Associated Peritonitis? (Etiology)

Peritoneal Dialysis-Associated Peritonitis is caused predominantly by a bacterial infection. This may occur in the following manner:

• Touch contamination: Bacteria gain entry into the peritoneum when the open ends of the catheter are in contact with a non-sterile surface during bag change. Infections are known to occur occasionally, even if standard and recommended practices are strictly adhered to
• Contamination at the catheter exit site through skin infection, which subsequently spreads to the peritoneal membrane

The most common pathogens causing infections include:

• Bacteria
• Staphylococcus epidermidis
• Staphylococcus aureus
• Streptococcus spp
• Micrococcus spp
• Escherichia coli
• Klebsiella spp
• Acinetobacter spp
• Fungi
• Aspergillus fumigatus
• Candida spp
• Neosartorya hiratsukae

What are the Signs and Symptoms of Peritoneal Dialysis-Associated Peritonitis?

The common signs and symptoms of Peritoneal Dialysis-Associated Peritonitis include:

• Abdominal pain
• Distended abdomen: Bloated abdomen or feeling of fullness in the stomach
• Nausea and vomiting
• Fever and chills
• Decreased urination and reduced stool output

The signs and symptoms of the underlying condition necessitating peritoneal dialysis may be observed.

How is Peritoneal Dialysis-Associated Peritonitis Diagnosed?

The diagnosis of Peritoneal Dialysis-Associated Peritonitis is made on the basis of the following tests and exams:

• A thorough physical examination which may show the following:
• Tenderness of the abdomen
• Discharge from the spot where the catheter is inserted for dialysis
• Cloudy color of the dialysis fluid
• Assessment of the presenting symptoms
• Evaluation of medical history
• Other tests such as:
• Complete blood count; increased white blood cells may be indicative of and infection
• Blood culture, to check for or rule out a bacterial infection
• Peritoneal fluid detailed report and culture (to identify the pathogen)
• X-ray or computed tomography (CT) scan to rule out perforation of organs

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Peritoneal Dialysis-Associated Peritonitis?

Peritoneal Dialysis-Associated Peritonitis may be a life-threatening emergency. The potential complications include:

• Intra-abdominal abscess formation: Fluid or pus collecting in the abdominal cavity
• Sepsis: Infection that spreads to the bloodstream causing multi-organ failure that can be fatal
• Acute respiratory distress syndrome (ARDS) or severe infection of the lungs
• Disseminated intravascular coagulation (DIC): It is a clotting disorder that can progress to septic shock and multi-organ failure
• Recurrence of infection after treatment

Repeated bouts of infection can damage the peritoneal membrane and cause thickening or sclerosis (scarring). Under these circumstances, the peritoneum may no longer be useful for dialysis, and individuals may be placed on hemodialysis instead.

How is Peritoneal Dialysis-Associated Peritonitis Treated?

Peritoneal Dialysis-Associated Peritonitis is a medical emergency and must not be treated at home. The options for treatment may include the following:

• Administering antibiotics through the vein or into the lining of the abdomen. Some studies have demonstrated better outcomes with intra-peritoneal administration of antibiotics
• Anti-fungal treatment, if the pathogen is a fungus
• Removal of the dialysis catheter may be required
• Placing an individual on hemodialysis until the peritoneum has healed. If the infection persists, the option of hemodialysis may become permanent
• Surgery to remove infected tissue and prevent infection from spreading (considered on rare occasions)

How can Peritoneal Dialysis-Associated Peritonitis be Prevented?

The following are some methods to prevent Peritoneal Dialysis-Associated Peritonitis:

• Practicing proper and recommended techniques to maintain the dialysis equipment sterile
• Use of appropriate equipment designed to minimize contamination
• Adequate and proper education and training for use of catheter: This includes effective hand washing techniques, use of antiseptics, storage of supplies, including keeping pets away, when such dialysis procedures are underway
• Checking, if an individual carries Staphylococcus aureus in his/her nasal passages; recommending treatment for the bacteria, in such cases. There is evidence to show that those with the bacteria in their nasal passages have a substantially higher rate of exit site infections, when compared to those who do not harbor this bacterial species
• Managing constipation; constipations can increase the risks for a colonic infection
• If necessary, prophylactic application of topical antibiotic before insertion of catheters
• Switching to hemodialysis, if one experiences recurrent infections

What is the Prognosis of Peritoneal Dialysis-Associated Peritonitis? (Outcomes/Resolutions)

The prognosis of Peritoneal Dialysis-Associated Peritonitis is determined by the overall health of the affected individual and the infection type.

• In approximately 96% of the individuals, the prognosis is good with suitable treatment
• The type of pathogen also dictates outcomes. Individuals with fungal infections (such as Candida spp) are reported to have poorer outcomes in comparison to individuals with bacterial infections
• Additionally, the outcomes for infection by Pseudomonas spp is poorer when compared to infection by other bacterial species

Peritoneal Dialysis-Associated Peritonitis is a common complication seen in patients on peritoneal dialysis. Prompt diagnosis and treatment can help improve prognosis and prevent serious life-threatening complications. The treatment involves a use of antibiotics and safe and hygienic dialysis practices.

Additional and Relevant Useful Information for Peritoneal Dialysis-Associated Peritonitis:

Peritoneal Dialysis-Associated Peritonitis is a type of secondary peritonitis, which occurs when the peritoneum is infected from the gastrointestinal or biliary tract, or through perforation of the abdominal wall.