Subcutaneous embedding of a peritoneal dialysis (PD) catheter at the time of PD discontinuation has been proposed as a strategy to avoid invasive catheter removal while preserving the option of resuming PD in the future. However, the risk of peritonitis after catheter embedding remains poorly understood. We describe all six patients treated at our institution, focusing on the two who developed peritonitis. Since 2020, six patients (four men; age range, 32–88 years) underwent secondary catheter embedding at PD discontinuation. PD duration ranged from 3 to 96 months, and five patients had prior PD-related peritonitis. At embedding, three had hypoalbuminemia and three had mildly elevated serum C-reactive protein levels. Embedding was selected to preserve a possible future PD option or reduce procedural burden because of frailty, comorbidity, or refusal of further surgery. During 14–63 months of follow-up, two patients developed three episodes of presumed endogenous peritonitis, whereas four had no documented peritonitis; no catheter was re-exteriorized. Both affected patients had discontinued PD because of ultrafiltration failure after long-term PD and had persistent ascites. Case 1 developed culture-negative, neutrophil-predominant peritonitis after antimicrobial exposure. Case 2 developed Campylobacter enteritis-associated peritonitis and later culture-positive peritonitis with Streptococcus mitis despite a low ascitic cell count. Antibiotics improved the acute inflammatory findings in both patients; persistent ascites and gastrointestinal symptoms prompted corticosteroid treatment for suspected evolving encapsulating peritoneal sclerosis (EPS). This small, heterogeneous series cannot estimate peritonitis incidence or establish risk factors. Nevertheless, the occurrence of presumed endogenous peritonitis in two patients with persistent ascites after PD discontinuation suggests that careful patient selection and monitoring may be warranted.
Peritoneal dialysis (PD) catheter-related infections can lead to catheter loss, peritonitis, and technique failure. Although nontuberculous mycobacteria are increasingly recognized as causative pathogens, optimal management of infections caused by the Mycobacterium abscessus complex (MABC) remains unclear, particularly when isolates are identified to the subspecies level. This report presents a pediatric PD catheter-related infection caused by M. abscessus subsp. massiliense, in which PD was temporarily continued after simultaneous catheter removal and replacement and prolonged multidrug therapy. A 14-year-old girl with Sensenbrenner syndrome developed end-stage renal disease and was started on PD. At 8 months after initiation, she developed localized pain and purulent discharge at the catheter exit site. Initial cultures were negative; however, repeated cultures detected acid-fast bacilli, and MABC was identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Magnetic resonance imaging (MRI) showed a small abscess adjacent to the catheter. Intravenous imipenem/cilastatin, oral linezolid, and an oral macrolide were initiated. On hospital day 4, the catheter was completely removed and replaced through a separate contralateral tissue tract; PD was resumed 1 week later. Intraoperative findings revealed purulent drainage from the subcutaneous tunnel. Amikacin was added for persistent drainage but discontinued after audiometry demonstrated worsening hearing thresholds. Multiplex polymerase chain reaction (PCR) identified M. abscessus subsp. massiliense. The patient was discharged on hospital day 103. After 6 months, MABC was reisolated from the new exit site without abscess formation on MRI, and subsequent mycobacterial cultures were negative. Antimicrobial therapy was continued for approximately 30 months and discontinued at deceased-donor kidney transplantation and PD catheter removal. No clinical recurrence was observed during approximately 20 months of post-transplant immunosuppression. Repeated cultures and rapid identification methods may be useful for persistent or initially culture-negative PD catheter-related infections. Subspecies-level identification may inform antimicrobial selection. In this patient with localized infection and no overt peritonitis, prompt catheter exchange and prolonged macrolide-containing multidrug therapy enabled temporary continuation of PD until kidney transplantation. However, microbiological eradication could not be established while the catheter remained in situ, and this strategy should not be generalized.
Abstract Background Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by transient plasma extravasation from the intravascular space into surrounding tissues, resulting in hemoconcentration, hypoalbuminemia, and hypotension. Although SCLS most commonly affects otherwise healthy middle-aged individuals, it can cause life-threatening complications such as hypovolemic shock and compartment syndrome. We report a case of severe SCLS that became clinically manifest shortly after the initiation of maintenance online hemodiafiltration, leading to cardiac arrest, in which prompt diagnosis and early intensive treatment resulted in successful resuscitation and recovery. Case presentation A 78-year-old woman with end-stage kidney disease who had been on maintenance online hemodiafiltration for 5 years was subsequently diagnosed with SCLS after developing sudden circulatory collapse shortly after the initiation of a routine online hemodiafiltration session. She had been in her usual state of health prior to dialysis; however, 7 min after the initiation of online hemodiafiltration, she abruptly lost consciousness and subsequently developed cardiac arrest. Immediate cardiopulmonary resuscitation was initiated, and return of spontaneous circulation was achieved after intravenous administration of 1 mg of epinephrine. Upon admission to the intensive care unit, laboratory testing revealed marked hemoconcentration and hypoalbuminemia, and computed tomography demonstrated generalized edema predominantly affecting the extremities. Based on the characteristic triad of acute hypotension, hemoconcentration, and hypoalbuminemia, a diagnosis of SCLS was established. Alternative causes of shock, including sepsis and anaphylaxis, were considered unlikely based on clinical, laboratory, and imaging findings. Supportive therapy with aggressive fluid resuscitation was initiated, resulting in stabilization of hemodynamics and full recovery of consciousness. Maintenance online hemodiafiltration was resumed two days later without recurrence of SCLS, and the patient was discharged without further complications. Conclusions SCLS may become clinically manifest during maintenance online hemodiafiltration and may rapidly progress to profound hypovolemic shock and cardiac arrest. Early recognition of the characteristic clinical triad and prompt initiation of appropriate supportive therapy are crucial for survival in patients who develop SCLS in the dialysis setting.
Abstract Background Bloodstream infection is a leading cause of hospitalization and death in maintenance dialysis, with the vascular access and foreign material as principal portals of entry. Staphylococcus lugdunensis is a coagulase-negative staphylococcus resembling Staphylococcus aureus , yet its epidemiology in dialysis patients is unknown. Methods We retrospectively analyzed 5826 blood culture sets from dialysis patients with suspected bacteremia between April 2020 and December 2022 at a hospital managing more than 700 hemodialysis patients. Identification and susceptibility testing used the MicroScan WalkAway system with Clinical and Laboratory Standards Institute breakpoints. Sets, episodes, and patients were analyzed as distinct units. The set-level yearly trend was explored with the Cochran–Armitage test. Results Of the 5826 sets, 980 were culture-positive, and S. lugdunensis was detected in 42 (0.7% of all sets; 4.3% of positive sets), corresponding to 23 episodes in 21 patients. Among the 288 patients with at least one positive set, S. lugdunensis was recovered from 21 (7.3%), and from 12 (4.2%) when required in two or more sets. Three patients died; one death was unrelated, and the organism’s contribution to two deaths from polymicrobial sepsis could not be established. Seven episodes were vascular access infections; foreign material was present in 13 and involved in 7. A single set was positive in ten episodes; in five, a clinically suspected infection at a compatible site was recorded, with local access or graft signs at presentation in four and infective endocarditis diagnosed on subsequent evaluation in one; organism-specific attribution was not confirmed. Penicillin resistance was found in 16 of 23 isolates (69.6%); all isolates were phenotypically methicillin-susceptible. The organism’s share of culture-positive sets rose from 2.1% to 7.2% (exploratory set-level P = 0.003), whereas episodes numbered three, ten, and ten. Conclusions At this dialysis facility, S. lugdunensis accounted for 4.3% of culture-positive sets, was associated with vascular access or involved foreign material in 8 of 23 episodes, and was mostly penicillin-resistant. Whether this proportion exceeds that elsewhere, and whether it is increasing, requires confirmation in other dialysis units. A single positive set should not be dismissed without clinical assessment.
Abstract Background Peritonitis is a major complication of peritoneal dialysis (PD). Early identification of the causative organism is critical for selecting appropriate antimicrobial therapy in PD-associated peritonitis. However, species-level identification can be challenging when the infection is caused by an uncommon pathogen. Case presentation We report a case of an 84-year-old man undergoing PD who developed peritonitis with concomitant exit-site infection. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) identified the organism as Mycobacterium wolinskyi , a rare rapidly growing mycobacterium, enabling prompt modification of antimicrobial therapy to a targeted regimen. After 6 weeks of antimicrobial therapy and PD catheter exit-site relocation, the patient showed clinical improvement and was discharged. At 1 month later, however, peritonitis due to M. wolinskyi recurred, necessitating removal of the PD catheter. Conclusions This case suggests that MALDI-TOF MS may facilitate timely species-level identification and help to determine initial antimicrobials for the causative organism in PD-associated peritonitis.
