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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2017  |  Volume : 28  |  Issue : 6  |  Page : 1264-1269
Leukocyte esterase reagent strip as a bedside tool to detect peritonitis in patients undergoing acute peritoneal dialysis


1 Department of Nephrology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
2 Department of Microbiology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

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Date of Web Publication18-Dec-2017
 

   Abstract 


Peritonitis is a common and life-threatening complication of acute peritoneal dialysis (PD). Diagnosis requires the presence of clinical signs of peritonitis which are nonspecific and laboratory investigations [total leukocyte count (TLC), Gram-stain, and culture of PD effluent fluid] which are time-consuming and not available at the bedside. In this study, we evaluated the use of leukocyte esterase reagent strip (LERS) as a bedside test to diagnose peritonitis in patients undergoing acute PD. Patients who underwent acute PD were monitored for signs and symptoms of peritonitis. PD effluent fluid analysis included TLC, absolute neutrophil count, Gram-stain, and culture for the diagnosis of peritonitis. LERS (Multistix 10SG) was simultaneously dipped in PD effluent fluid and read at two minutes. Reading of + was considered as indicative of peritonitis. Twenty-one out of 166 (12.6%) patients undergoing acute PD developed peritonitis. LERS detected peritonitis in 20 patients. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of LERS were 95.2%, 95.2%, 74.1%, and 99.3%, respectively. LERS has very high sensitivity and NPV and can be used as a rapid bedside tool to exclude peritonitis in patients undergoing acute PD.

How to cite this article:
Rathore V, Joshi H, Kimmatkar PD, Malhotra V, Agarwal D, Beniwal P, Dawra R, Gupta P. Leukocyte esterase reagent strip as a bedside tool to detect peritonitis in patients undergoing acute peritoneal dialysis. Saudi J Kidney Dis Transpl 2017;28:1264-9

How to cite this URL:
Rathore V, Joshi H, Kimmatkar PD, Malhotra V, Agarwal D, Beniwal P, Dawra R, Gupta P. Leukocyte esterase reagent strip as a bedside tool to detect peritonitis in patients undergoing acute peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2019 Dec 12];28:1264-9. Available from: http://www.sjkdt.org/text.asp?2017/28/6/1264/220875



   Introduction Top


Acute peritoneal dialysis (PD) is a relatively low-cost modality of renal replacement therapy (RRT) particularly used in low-income countries where expensive modalities of RRT such as hemodialysis (HD), continuous RRT (CRRT), automated PD are scarce. It involves frequent and short exchanges of PD fluid with volume one to two liters through a catheter inserted into the peritoneal cavity. Although acute PD has been replaced by newer dialysis modalities and has become nearly obsolete in developed countries, it still is a valuable mode of RRT in developing countries due to its relatively low cost and simple technique.[1],[2] It does not require anticoagulation and can be carried out by minimally trained staff even at the bedside. Due to slow but continuous nature of solute removal and ultra-filtration, it is tolerated well by critically ill and hemodynamically unstable patient.[3] Furthermore, it may be the only available modality of RRT in young children in whom HD and CRRT may be difficult, at times impossible due to difficulties in vascular access. Acute PD is indicated for providing RRT in varied circumstances such as acute kidney injury (AKI), and management of CKD presenting urgently with uremia and fluid overload, till other modalities of RRTs are worked out.[3]

Although acute PD is extremely useful, it is associated with various complications such as peri-catheter leak, abdominal pain, hemorrhagic effluent, bowel perforation, and peritonitis. A retrospective study from our institute has reported 17% incidence of peritonitis in patients undergoing acute PD for AKI.[4]

Peritonitis is difficult to diagnose clinically in patients undergoing acute PD as clinical signs and symptoms of peritonitis such as pain abdomen, distension of abdomen, and tenderness may itself be caused by acute PD. On the other hand, many patients may not manifest clinical signs of peritonitis early, leading to delay in diagnosis and treatment. Total leukocyte count (TLC), absolute neutrophil count, and culture of effluent are required to diagnose peritonitis in the setting of acute PD. However, these investigations require time and are usually not available at the bedside. Prompt diagnosis of peritonitis is required to initiate therapy which includes antibiotics as well early removal of the acute PD catheter. Hence, a bedside tool is needed to detect peritonitis in these patients.

We conducted this study to evaluate the efficacy of leukocyte esterase reagent strip (LERS) to diagnose peritonitis in patients undergoing acute PD.


   Materials and Methods Top


Setting

This prospective study was conducted in the Department of Nephrology, Sawai Man Singh Medical College, a tertiary care teaching institute situated in the North Indian city of Jaipur.

Inclusion criteria

All patients who underwent acute PD from September 2015 to April 2016 were included in the study.

Exclusion criteria

  1. Patients who have undergone acute PD previously
  2. Patients with acute abdomen
  3. Patients with recent abdominal surgery.


Acute peritoneal dialysis

Acute PD was provided by a rigid catheter (PD Catheter Set, Romsons Scientific and Surgical Industries Pvt., Ltd.,) inserted into the peritoneal cavity with the help of stylet following standard aseptic precautions. Each cycle included an inflow time of 10 min, dwell time of 30 min and outflow time of 20 min. Exchange volume per cycle used was 20–40 mL/kg of lactate-based PD solution (PD 1.7, Aculife Health Care Pvt. Ltd.) supplied free of charge by the government. Exchanges were performed manually by trained nursing staff.

Reagent strip

The leukocyte esterase reagent strip (LERS) used in the study was Multistix 10 SG (Siemens Ltd.,). The reagent strip was dipped in PD effluent fluid collected in a container and was read at two minutes and graded with colorimetric five grade scale depicted on the bottle. Correlation between leukocyte and grading scale was suggested by manufacturer as negative (0 cells/mm3), traces (15 cells/mm3), + (70 cells/mm3), ++ (125 cells/mm3), +++ (500 cells/mm3). We considered a reading of + as indicative of peritonitis.

Methods

Patients who underwent acute PD were monitored clinically for signs and symptoms of peritonitis. Effluents were collected and analyzed from the last dwell or when the patient developed symptoms. Dwell time of two hours was kept for the last cycle before collection of effluent for analysis as recommended by International Society for PD for diagnosing peritonitis.[5] Laboratory analysis included TLC, absolute neutrophil count, Gram-stain and culture of PD effluent. For culture 10 mL of PD effluent fluid was inoculated in aerobic and anaerobic blood culture bottles.

Peritonitis

Peritonitis was diagnosed if at least two of the following three criteria were met:[5]

  1. Clinical signs or symptoms of peritonitis
  2. Peritoneal fluid effluent TLC of >100 WBC/mm3 with >50% polymorphonuclear leukocytes.
  3. A peritoneal fluid effluent positive on Gram-stain or culture



   Statistical Analysis Top


Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the LERS to diagnose peritonitis was calculated. All statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.0 (SPSS Inc., Chicago, IL, USA).


   Results Top


A total of 166 patients underwent acute PD during the study period. Mean age of study population was 43.7 (± 18.7) years. Fifty-six (33.7%) patients were female. Diagnosis and the indication for acute PD are shown in [Table 1] and [Table 2], respectively.
Table 1: Diagnosis of patients undergoing acute peritoneal dialysis.

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Table 2: Indication for acute peritoneal dialysis.

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Twenty-one (12.6%) patients were diagnosed to have peritonitis based on clinical feature, peritoneal fluid effluent TLC, Gram-stain and culture. [Table 3] shows the result of reagent strip in diagnosing peritonitis. The sensitivity, specificity, PPV, NPV of LERS were 95.2%, 95.2%, 74.1%, and 99.3%, respectively.
Table 3: The result of reagent strip for diagnosis peritonitis.

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One hundred and twenty-four (74.6%) patients complained of pain in the abdomen while 96 (57.8%) patients had a subjective feeling of abdominal distension during acute PD. Clinical signs of peritonitis (abdominal distension, tenderness, rebound tenders, the absence of bowel sound) were appreciated only in 16 (76.2%) patients who developed peritonitis. Two patients had PD effluent fluid TLC of <100/mm3 but had a positive culture and clinical signs of peritonitis.

PD effluent fluid culture was positive in 11 (52.4%) who had peritonitis. Two patient had growth of coagulase-negative staphylococcus, but neither had clinical signs nor had PD effluent fluid TLC of < 100/mm3. The sensitivity, specificity, PPV, NPV of clinical sign and PD effluent fluid analysis is shown in [Table 4].
Table 4: Diagnostic performance of clinical signs and peritoneal dialysis fluid analysis to detect peritonitis.

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   Discussion Top


Acute PD is a commonly used modality of RRT in developing countries where other costly modalities of RRT may not be available. It is also frequently used in young children and hemodynamically unstable patients. While soft catheters are often used in developed countries to access peritoneal cavity, rigid catheters inserted over a pointed stylet are commonly employed in developing countries owing to its low cost. Although primitive, the technical simplicity, easy availability and low cost makes it a life-saving procedure in lowincome countries and remote areas.[4],[6],[7],[8] Studies have shown it to be an effective therapy in patients requiring RRT.[9] In fact, a recent a recent systematic review has found no significant differences in mortality between PD and extracorporeal blood purification in AKI.[2]

Although effective, acute PD is often associated with complications. Peritonitis is one of the common and serious complication of acute PD. The overall incidence of peritonitis was 12.4% in a recent systematic review, with individual studies reporting range of 0%–40%.[2],[10],[11] Diagnosis of peritonitis requires PD effluent cell counts, Gram-stain, and culture. Treatment of peritonitis in acute PD requires antibiotic therapy and early removal of PD catheter. Therefore, the importance of prompt diagnosis of peritonitis cannot be overemphasized. However, clinical diagnosis of peritonitis in patients undergoing acute PD is challenging, as the common sign and symptoms of peritonitis such as pain in the abdomen, distention of abdomen can be caused by various other factors such as rate of inflow, temperature of dialysate, acidic pH of dialysate, and volume of each dwell. Abdominal pain and distention were encountered in a large number of patient in our study.

As clinical signs and symptoms have variable sensitivity and specificity a readily available bedside test to detect peritonitis is needed. LERS detects the presence of leukocytes in biological fluids through colorimetric reaction. Studies have reported use of these strips in the diagnosis of spontaneous bacterial peritonitis, meningitis, and pleural effusions.[12],[13],[14],[15],[16] Reagent strips have also been used for the diagnosis of peritonitis in patients who are maintained in PD.[17],[18] These studies have also reported very high sensitivity, specificity, PPV, and NPV. However, to the best of our knowledge, reagent strips have not been evaluated for the diagnosis of peritonitis in acute PD.

We choose Multistix 10 SG as LERS because it is easily available in our hospital. The study has shown a very high specificity and NPV to diagnose peritonitis and hence can be used as valuable bedside tool to exclude peritonitis. Reagent strip was able to detect peritonitis in 5 patients who had no apparent clinical signs, suggesting that it could detect peritonitis before the clinical signs appear.

The major limitation of LERS is interobserver variation in the matching of color, which was not addressed in this study.


   Conclusion Top


Multistix 10 SG has a very high sensitivity and NPV to detect peritonitis and can be used as a simple bedside tool to detect peritonitis in patients undergoing acute PD.

Conflict of interest: None declared.



 
   References Top

1.
Gabriel DP, Nascimento GV, Caramori JT, et al. Peritoneal dialysis in acute renal failure. Ren Fail 2006;28:451-6.  Back to cited text no. 1
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2.
Chionh CY, Soni SS, Finkelstein FO, Ronco C, Cruz DN. Use of peritoneal dialysis in AKI: A systematic review. Clin J Am Soc Nephrol 2013;8:1649-60.  Back to cited text no. 2
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Ponce D, Balbi AL, Fredric FO. Peritoneal dialysis for the treatment of acute kidney injury. In: Daugirdas JT, edr. Handbook of Dialysis. 5th ed., Philadelphia: Wolters Kluwer Health; 2015. p. 451-63.  Back to cited text no. 3
    
4.
Prasad D, Gandhi K, Beniwal P, Agarwal D, Malhotra V. Outcome of acute stylet peritoneal dialysis in acute kidney injury in the era of CRRT and SLED: A single centre experience from India. IJPD 2015;28:6-12.  Back to cited text no. 4
    
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Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 2016;36:481-508.  Back to cited text no. 5
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Abdelraheem M, Ali el T, Osman R, et al. Outcome of acute kidney injury in Sudanese children - An experience from a sub-Saharan African unit. Perit Dial Int 2014;34:526-33.  Back to cited text no. 6
    
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Arogundade FA, Ishola DA Jr., Sanusi AA, Akinsola A. An analysis of the effectiveness and benefits of peritoneal dialysis and haemodialysis using Nigerian made PD fluids. Afr J Med Med Sci 2005;34:227-33.  Back to cited text no. 7
    
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Hayat A, Kamili MA, Samia R, et al. Peritoneal dialysis for adults with acute renal failure: An underutilized modality. Saudi J Kidney Dis Transpl 2007;18:195-9.  Back to cited text no. 8
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George J, Varma S, Kumar S, et al. Comparing continuous venovenous hemodiafiltration and peritoneal dialysis in critically ill patients with acute kidney injury: A pilot study. Perit Dial Int 2011;31:422-9.  Back to cited text no. 9
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Thongboonkerd V, Lumlertgul D, Supajatura V. Better correction of metabolic acidosis, blood pressure control, and phagocytosis with bicarbonate compared to lactate solution in acute peritoneal dialysis. Artif Organs 2001; 25:99-108.  Back to cited text no. 10
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Howdieshell TR, Blalock WE, Bowen PA, Hawkins ML, Hess C. Management of post-traumatic acute renal failure with peritoneal dialysis. Am Surg 1992;58:378-82.  Back to cited text no. 11
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Téllez-Ávila FI, Chávez-Tapia NC, Franco-Guzmán AM, Uribe M, Vargas-Vorackova F. Rapid diagnosis of spontaneous bacterial peritonitis using leukocyte esterase reagent strips in emergency department: Uri-quick clini-10SG® vs. Multistix 10SG®. Ann Hepatol 2012;11:696-9.  Back to cited text no. 12
    
13.
Oey RC, Kuiper JJ, van Buuren HR, de Man RA. Reagent strips are efficient to rule out spontaneous bacterial peritonitis in cirrhotics. Neth J Med 2016;74:257-61.  Back to cited text no. 13
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Chugh K, Agrawal Y, Goyal V, Khatri V, Kumar P. Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks. Int J Crit Illn Inj Sci 2015;5:32-7.  Back to cited text no. 14
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Moosa AA, Quortum HA, Ibrahim MD. Rapid diagnosis of bacterial meningitis with reagent strips. Lancet 1995;345:1290-1.  Back to cited text no. 15
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Azoulay E, Fartoukh M, Galliot R, et al. Rapid diagnosis of infectious pleural effusions by use of reagent strips. Clin Infect Dis 2000;31:914-9.  Back to cited text no. 16
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Park SJ, Lee JY, Tak WT, Lee JH. Using reagent strips for rapid diagnosis of peritonitis in peritoneal dialysis patients. Adv Perit Dial 2005;21:69-71.  Back to cited text no. 17
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Sam R, Sahani M, Ulozas E, et al. Utility of a peritoneal dialysis leukocyte test strip in the diagnosis of peritonitis. Artif Organs 2002; 26:546-8.  Back to cited text no. 18
[PUBMED]    

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Correspondence Address:
Vinay Rathore
Department of Nephrology, Sawai Man Singh Medical College, Jaipur, Rajasthan
India
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DOI: 10.4103/1319-2442.220875

PMID: 29265037

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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