Managing Recurrent Peritonitis in Long-Term Dialysis Patients: Treatment Options

Peritoneal dialysis patients develop peritonitis?

Hello Dr.
Ke,
My father has been undergoing peritoneal dialysis for 15 years and has experienced several episodes of peritonitis during this time, which were successfully treated.
At the end of last year, he developed peritonitis again.
The first treatment with antibiotics was successful, but two weeks later, he had another episode of peritonitis, which was also successfully treated with antibiotics.
A month later, he experienced peritonitis again, and it was discovered that he also had gallstones.
During the treatment for peritonitis, his gallbladder was removed, and he was on antibiotics for a month, but the peritonitis was still not resolved.
It was suspected that the dialysis catheter might be infected, so it was removed and he switched to hemodialysis.

Two months later, an abdominal ultrasound revealed fluid accumulation in the abdomen.
After drainage, it was found to be bloody fluid.
Upon further testing, the doctor indicated signs of purulent peritonitis and noted adhesions.
The doctor mentioned that the surgical risks are very high.
I would like to ask if you would recommend surgery or if we should continue with antibiotic treatment, or if you could recommend a specialist in this field.
Thank you very much.

Chen Yan Chi, 20~29 year old female. Ask Date: 2021/04/29

Dr. Ke Fangxu reply Surgery

Peritonitis is the most troublesome complication of peritoneal dialysis because it is difficult to treat and prone to recurrence.
Switching to hemodialysis is the correct approach; however, patients with renal failure often have compromised immune systems, making them more susceptible to recurrent infections.
Surgical intervention is indicated when antibiotic treatment is ineffective and there is the presence of sepsis.
Of course, the surgical risks are also very high.
An alternative approach is to use peritoneal drainage to reduce intra-abdominal abscesses, combined with the use of potent antibiotics, which may provide a better chance of avoiding surgery.
However, the recurrence rate remains quite high.

Reply Date: 2021/04/29

More Info

Managing recurrent peritonitis in long-term dialysis patients, especially those undergoing peritoneal dialysis (PD), can be quite challenging. Your father's case illustrates the complexities involved, particularly given his history of multiple episodes of peritonitis and the recent complications with gallstones and the need for surgical intervention.

Peritonitis is a common complication in patients on peritoneal dialysis, often caused by bacterial infections. The management typically involves the use of antibiotics, but recurrent infections can indicate underlying issues such as catheter-related infections, inadequate dialysis technique, or even the presence of biofilm on the catheter. In your father's case, the recurrent nature of his peritonitis suggests that there may be a persistent source of infection or inflammation that has not been adequately addressed.

Treatment Options
1. Antibiotic Therapy: The first line of treatment for peritonitis is usually empirical antibiotic therapy, tailored based on the culture results if available. Given that your father has had multiple episodes, it may be beneficial to consider a broader spectrum of antibiotics or a combination therapy, especially if there is a suspicion of resistant organisms.

2. Catheter Management: Since you mentioned the possibility of the dialysis catheter being a source of infection, it is crucial to evaluate the catheter's condition. If there is suspicion of infection related to the catheter, catheter removal may be necessary. Transitioning to hemodialysis, as has been done in your father's case, can be a reasonable alternative if peritoneal dialysis is no longer viable.

3. Surgical Intervention: The decision to proceed with surgery should be carefully weighed against the risks, especially given your father's history of complications. If there is evidence of abscess formation or significant intra-abdominal pathology that cannot be managed conservatively, surgical intervention may be warranted. However, this should be discussed in detail with a surgeon who specializes in abdominal or gastrointestinal surgery, particularly one experienced with dialysis patients.

4. Fluid Management: The presence of fluid accumulation in the abdomen (as noted in the ultrasound) may indicate ongoing infection or complications such as an abscess. Drainage of this fluid may provide symptomatic relief and help in the management of infection. However, the nature of the fluid (whether it is infected or sterile) should be determined through analysis.

5. Consultation with Specialists: Given the complexity of your father's case, it would be beneficial to involve a multidisciplinary team, including nephrologists, infectious disease specialists, and surgeons. They can collaboratively assess the situation and determine the best course of action.

Risks and Considerations
Surgical intervention carries inherent risks, especially in patients with a history of chronic illness and previous surgeries. The potential for complications such as infection, bleeding, and delayed recovery must be considered. Additionally, the patient's overall health status, nutritional status, and ability to tolerate surgery should be evaluated.

Conclusion
In summary, managing recurrent peritonitis in long-term dialysis patients requires a comprehensive approach that includes antibiotic therapy, careful evaluation of the dialysis catheter, and consideration of surgical options if necessary. Given your father's complex medical history, it is crucial to have a thorough discussion with his healthcare team to determine the most appropriate and safe treatment plan moving forward. If you are looking for specialists, consider reaching out to a nephrologist with experience in managing peritoneal dialysis complications, as well as a surgeon who specializes in abdominal surgeries related to dialysis patients.

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