We had a PD patient whom presented to the Emergency Department with abdominal pain x one week (he never contacted us- Home Dialysis). He subsequently had an appendectomy. His PD catheter is in the lower right quadrant. Our on call Nephrologist requested the PD catheter be removed; the surgeon continues to disagree and wants to save the catheter. The pathology report is below: Gross Description (See result below) Received in formalin labeled “appendix” is a 6.2 x 1.6 x 1.5 cm tubular tan appendix with abundant attached mesoappendix and proximal staple line. The serosa is pink-tan. The lumen is focally dilated to 0.8 cm and contains no fecaliths. The soft tissue immediately adjacent to stapled margin is inked black and representative sections are submitted labeled (A1-A2). Microscopic Description (See result below) Sections show an edematous appendix with acute inflammation on the peritoneal surfaces. No inflammation is present in the appendiceal wall or the mucosa of the appendix . No true appendicitis or perforation is identified. The appearance is consistent with acute peritonitis of unknown cause. Home Dialysis was requested to obtain cell count, cultures and gram stain. Small volume (500 ml) was utilized to obtain these specimens as follows: 9/11: WBC’s 658 (91% neutrophils); no growth in cultures (he has been receiving IV antibiotic since his surgery on 9/9- Zosyn) (1.5% Dialysate used for flush) 9/13: WBC’s 840 (81% neutrophils); on call Nephrologist ordered Vancomycin for today and it was hung around the time I was obtaining specimens today. (Normal Saline used for flush) 9/14 specimen obtained as well but no results so far. We would appreciate any Best Practice Recommendations concerning removal or preservation of this PD catheter.

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A.Clark, Nurse from NY, USA asked
We had a PD patient whom presented to the Emergency Department with abdominal pain x one week (he never contacted us- Home Dialysis). He subsequently had an appendectomy. His PD catheter is in the lower right quadrant. Our on call Nephrologist requested the PD catheter be removed; the surgeon continues to disagree and wants to save the catheter. The pathology report is below: Gross Description (See result below) Received in formalin labeled “appendix” is a 6.2 x 1.6 x 1.5 cm tubular tan appendix with abundant attached mesoappendix and proximal staple line. The serosa is pink-tan. The lumen is focally dilated to 0.8 cm and contains no fecaliths. The soft tissue immediately adjacent to stapled margin is inked black and representative sections are submitted labeled (A1-A2). Microscopic Description (See result below) Sections show an edematous appendix with acute inflammation on the peritoneal surfaces. No inflammation is present in the appendiceal wall or the mucosa of the appendix . No true appendicitis or perforation is identified. The appearance is consistent with acute peritonitis of unknown cause. Home Dialysis was requested to obtain cell count, cultures and gram stain. Small volume (500 ml) was utilized to obtain these specimens as follows: 9/11: WBC’s 658 (91% neutrophils); no growth in cultures (he has been receiving IV antibiotic since his surgery on 9/9- Zosyn) (1.5% Dialysate used for flush) 9/13: WBC’s 840 (81% neutrophils); on call Nephrologist ordered Vancomycin for today and it was hung around the time I was obtaining specimens today. (Normal Saline used for flush) 9/14 specimen obtained as well but no results so far. We would appreciate any Best Practice Recommendations concerning removal or preservation of this PD catheter.

1 answer

Fadhlina MD February 7, 2019

Generally,  any patient with inflammation  of the intestines is at increased risk of translocation of organisms across the bowel wall into the peritoneal cavity. Early treatment to control the inflammation is important. In this case the suspected inflamed appendicitis has been removed and appropriate antibiotics has been given. Chances  of the patient to developed peritonitis is high once there is any inflammation in the abdomen in general. Therefore, it is not a surprise that the patient had developed peritonitis subsequently. 
Treatment of the peritonitis is following the  ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment.  (Li et al. Perit Dial Int. 2016 Sep 10;36(5):481-508)
There are no data on whether holding PD temporarily would decrease the risk of enteric peritonitis, but if a patient has severe colitis and adequate residual renal function, holding PD for 24-48 hours could be considered. Removal of catheter is considered in refractory peritonitis or if the patient is at risk of septic shock, at the discretion of the  managing nephrologists. 

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