Peritonitis in Patients with Peritoneal Dialysis

Definition and Classification

The International Society of Peritoneal Dialysis defines peritonitis associated with peritoneal dialysis as a diffuse bacterial infection of the peritoneum, typically caused by a single organism, without loss of integrity of the gastrointestinal tract, usually seen in patients with a peritoneal dialysis catheter 1
Peritonitis is classified as primary, secondary (resulting from gastrointestinal perforation), or tertiary (recurrent infection >48 hours after surgical control) 1, 2

Peritonitis represents a major cause of morbidity in patients with peritoneal dialysis, associated with mortality, hospitalizations, and termination of peritoneal dialysis therapy 3, 4, 5

Diagnostic criteria include cloudy peritoneal fluid, abdominal pain, and evidence of infection in the analysis of peritoneal effluent, although these criteria are not always present 6

The American Journal of Kidney Diseases recommends empirical treatment with intraperitoneal antibiotics that cover both Gram-positive and Gram-negative organisms, including Pseudomonas species, as soon as possible after obtaining appropriate microbiological samples 3, 4
The International Society of Peritoneal Dialysis suggests that all diagnostic tests should be performed when the patient is clinically stable and at least 1 month after the resolution of any previous episode of peritonitis 6

The American Journal of Kidney Diseases indicates that catheter removal and temporary support with hemodialysis are recommended for refractory peritonitis, recurrent peritonitis, fungal peritonitis, and refractory exit-site or tunnel infections 3, 4, 7, 8, 9

The International Society of Peritoneal Dialysis has established treatment guidelines, and each unit should monitor peritonitis rates, causative organisms, and develop strategies to understand the reasons for peritonitis 3, 4, 5

The translocation of bacteria from the intestine is the probable mechanism in cases of peritonitis associated with diarrhea, especially with enteric organisms, as stated by the American Journal of Kidney Diseases 10, 11

The American Journal of Kidney Diseases recommends reevaluating renal residual function after an episode of peritonitis, as it can have a significant negative impact 12, 13
According to the American Journal of Kidney Diseases, peritonitis temporarily changes the patient to a high transporter state and decreases ultrafiltration, which can underestimate or overestimate clearances 12, 13

Maintaining adequate antimicrobial drug levels throughout treatment is crucial for effective peritonitis management in patients with peritoneal dialysis catheters 14

Diagnostic assessments of peritoneal membrane function should be performed only when the patient is clinically stable and at least one month after complete resolution of any previous peritonitis episode. 15

Peritonitis induces a temporary shift of peritoneal transport characteristics toward a high‑transporter state, which can confound interpretation of transport studies if measurements are taken too early. 15
In the immediate post‑peritonitis period, ultrafiltration capacity is reduced, leading to potentially misleading clearance values. 15
Performing peritoneal function testing during the early recovery phase may result in over‑ or under‑estimation of true peritoneal function, compromising clinical decision‑making. 15