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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 1  |  Page : 65-69
Tuberculous Peritonitis in Patients on Chronic Peritoneal Dialysis: Case Reports


Division of Nephrology, Department of Internal Medicine, Security Forces Hospital Program, Riyadh, Saudi Arabia

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   Abstract 

Two cases of tuberculous (TB) peritonitis on chronic peritoneal dialysis (PD) are described. The cases were diagnosed by positive acid fast bacilli (AFB) culture from the PD fluid effluent. Catheter removal and transfer to hemodialysis were needed in one, while the other remained on continuous ambulatory peritoneal dialysis. The patients recovered with antituberculous therapy. A high index of suspicion for early diagnosis and treatment is emphasized. A six-month course of anti-TB drugs for TB peritonitis is a viable option of therapy.

Keywords: Tuberculosis, Peritonitis, Continuous ambulatory peritoneal dialysis.

How to cite this article:
Malik GH, Al-Harbi AS, Al-Mohaya S, Kechrid M, Sheita MS, Azhari O. Tuberculous Peritonitis in Patients on Chronic Peritoneal Dialysis: Case Reports. Saudi J Kidney Dis Transpl 2003;14:65-9

How to cite this URL:
Malik GH, Al-Harbi AS, Al-Mohaya S, Kechrid M, Sheita MS, Azhari O. Tuberculous Peritonitis in Patients on Chronic Peritoneal Dialysis: Case Reports. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2020 Dec 3];14:65-9. Available from: https://www.sjkdt.org/text.asp?2003/14/1/65/33090

   Introduction Top


Peritoneal dialysis (PD) is one of the modalities of renal replacement therapy for patients with end-stage renal disease. [1] Mycobacterium tuberculosis, is isolated in less than 1% of patients with continuous ambulatory peritoneal dialysis (CAPD) associated peritonitis. However, it is an important infective complication in the dialysis patients. [2],[3] Antituberculous therapy with successful outcome has been reported in many cases without removing the PD catheter. [4],[5],[6],[7] Nevertheless, the removal of the PD catheter has been advised in addition to anti-tuberculosis drugs in patients with tuberculous (TB) peritonitis. [8]

We describe two cases of TB peritonitis; one on intermittent peritoneal dialysis (IPD) and the other on CAPD. Their clinical course, methods of diagnosis, response to antituber­culous therapy and outcome are discussed.

Case 1

A 57-year-old Saudi man with hypertension, coronary artery disease, congestive heart failure and chronic renal failure, was initiated on IPD in 1995. IPD was performed in hospital as 2-liter hourly cycles for 20 hours, twice a week. He sustained a non-Q anteroseptal myocardial infarction two months after starting peritoneal dialysis. This was eventually treated by a coronary artery by­pass surgery. During 1996-1997, the patient had two episodes of pseudomonas peritonitis that were treated successfully by antibiotics. The PD catheter was not removed during these episodes.

One year later, the patient was admitted again with turbid PD fluid that had white blood cell count of 1270/µL with 70% lymphocytes. His body weight was 42.5 kg. The chest x-ray was unremarkable. Adenine deaminase (ADA) in the PD fluid was 4.8 u/L (normal 5-25 u/L), and the direct smear for acid fast bacilli (AFB) was negative. No organisms were grown on the regular bacterial culture of PD fluid and there was no response to broad spectrum antibiotics. The PD catheter was removed and no organisms were grown from the catheter tip. A new catheter insertion failed because of multiple peritoneal adhesions, so maintenance hemodialysis was initiated. Culture of PD fluid for AFB was positive and anti-tuberculosis therapy was started with Rifampicin 600 mg daily, Isoniazid 300 mg daily, Ethambutol 400 mg daily, Pyrazinamide 1000 mg daily and Pyridoxin 100 mg daily. Ethambutol and Pyrazinamide were discontinued after two months and a total of six- months' course was completed with a satisfactory response. The patient is currently maintained on hemodialysis and is doing well and has gained 7 kg of body weight.

Case 2

A 71-year old Saudi man had type 2 diabetes mellitus for 30 years with chronic renal failure, severe retinopathy and neuropathy. He also had osteoarthritis of both knees and was wheel chair bound. He was admitted in 1999 with hematemesis and melena. The clinical examination did not reveal new medical problems and vital signs were stable. The patient was found to have advanced renal failure. The upper gastroscopy showed only gastritis. He was started on CAPD and his wife was trained to perform the procedure at home; 2-liter cycles four times daily.

Six months later, the patient was admitted with an episode of peritonitis secondary to Klebsiella pneumoniae Scientific Name Search  that responded to Ciprofloxacin. Three weeks later, he was readmitted with a relapse of peritonitis but responded partially to the same antibiotic.

The direct smear for acid fast bacilli was negative and the ADA titer was 4.5u/L, but Mycobacterium tuberculosis was cultured from the PD fluid and the patient was started on antituberculous medication: Rifampicin 600 mg daily, Isoniazid 300 mg daily, Ethambutol 400 mg daily, Pyrazinamide 1 gm/day and Pyridoxin 100 mg daily. Ethambutol and Pyrazinamide were discontinued after 2 months. He completed successfully the course of anti-B therapy for six-months without a need for interruption of CAPD.


   Discussion Top


The incidence and mortality of tuberculosis (TB) are high in patients undergoing dialysis, particularly in the developing countries. [9] Furthermore, tuberculosis is 6-25 times higher in the dialysis patients than in the general population, even in the developed countries such as Japan and USA. [10],[11],[12],[13] In Saudi Arabia, the incidence of TB varies from 4.8 to 28%. [14],[15],[16]

The first case of TB peritonitis in a CAPD patient was reported in 1980. [17] Talwani and Horvath found 50 more cases reported up to 1999 in the English language medical literature, in addition to their reported case and provided a comprehensive review of these cases. [18] Quantrill et al from Manchester Royal Infirmary reported eight more cases. [19]

The causes of increased risk of TB in dialysis patients have been attributed to impaired cellular immunity, [20] suppressed mitogenic response to lymphocytes, [21] protein malnutrition and Zinc and Pyridoxine deficiency. [22] Extrapulmonary TB occurs in 40% of dialysis patients with TB. [10],[11] In CAPD patients, local derangements in the intraperitoneal immune defense most likely predisposes to reactivation of peritoneal TB. Alterations in pH, osmolality and dilution by peritoneal fluid volume may hinder both phagocytic and lymphocytic activity locally and lead to infection by a few micro­organisms. [23]

The CAPD patients with TB peritonitis usually have abdominal pain and cloudy peritoneal fluid effluent, which are similar to bacterial peritonitis. The peritoneal differential WBC count is not helpful in differentiating these two conditions since 76% of patients reviewed by Talwani and Horvath showed predominance of neutro­phils. [18] In our cases, there was an initial predominance of neutrophils but subsequently the lymphocytes pre-dominated in the perito­neal fluid.

Concomitant or antecedent peritonitis was noted in 14 out of 50 patients of TB peritonitis in CAPD patients. [18] Our cases had antecedent episodes of peritonitis.

The AFB smear of PD fluid is not sensitive in diagnosing AFB peritonitis. [24] The diagnosis of TB peritonitis has to rely on a positive AFB culture from the PD fluid. Out of 59 cases smear was positive in 11 whereas culture was positive in 34. [19],[23] In our cases, the smear for AFB was negative but the culture was positive. AFB culture takes however, several weeks which usually causes delay in diagnosis and initiation of anti­tuberculous therapy.

The use of laparoscopy and peritoneal biopsy in the diagnosis of TB peritonitis has been suggested. [25],[26],[27] However, these are invasive procedures and are not without risk, so we did not attempt them in our patients.

The raised levels of ascitic fluid adenosine deaminase activity (ADA) in the PD fluid has been found to be useful in the diagnosis of TB peritonitis in nonuremic patients. [28] In our patients, the ADA in the PD fluid was low, which might have been due to the dilution by the PD fluid.

One of our patients needed removal of catheter before the diagnosis of TB peritonitis was made and was transferred to hemodialysis due to peritoneal adhesions. Out of 51 case reports catheter was removed in 27 (53%) before the completion of therapy. [18] In the rest of the cases, the removal of the PD catheter was not required if symptoms abated and adequate dialysis could be achieved.

Both of our cases were treated with anti-TB drugs for 6 months and recovered, supporting the view that short course (6 months) anti-TB therapy is a viable option.


   Acknowledgment Top


The authors feel grateful to Ms. Sesita J. Benedicto for her secretarial assistance and Ms. Arlene Montero and her team for managing the patients during peritoneal dialysis.

 
   References Top

1.Popovich RP, Moncrief JW, Decherd JF, Bomar JB, Pyle WK. The definition of a novel portable-wearable equilibrium peritoneal technique. Trans Am Soc Artif Int Organs, Abstract 1976;5:64.  Back to cited text no. 1    
2.Leehey DJ, Gandhi VC, Daugirdas JT. Peritonitis and Exit site infection. Hand-book of Dialysis. Daugirdas JT, Blake PG, Ing TS (eds). Lippincott Williams and Wilkins, Phila­delphia 1976, p. 374.  Back to cited text no. 2    
3.Kwan JT, Hart PD, Raftery MJ, Cunningham J, Marsh FP. Mycobacte-rial infection is an important infective compli­cation in British Asian dialysis patients. J Hosp Infect 1991; 19:249-55.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Cheng IK, Chan PC, Chan MK. Tuber­culous peritonitis complicating long-term peritoneal dialysis. Report of 5 cases and review of the literature. Am J Nephrol 1989;9:155-61.  Back to cited text no. 4    
5.Baumgartner DD, Arterbery VE, Hale AJ, Gupta RK, Bradley SF. Peritoneal dialysis associated tuberculous peritonitis in an intravenous drug user with acquired immuno­deficiency syndrome. Am J Kidney Dis 1989;14:154-7.  Back to cited text no. 5  [PUBMED]  
6.Mallat SG, Brensilver JM. Tuberculous peritonitis in a CAPD patient cured without catheter removal: Case Report, review of the literature and guidelines for treatment and diagnosis. Am J Kidney Dis 1989;13:154-7.  Back to cited text no. 6  [PUBMED]  
7.Tan D, Fein PA, Jordan A, Avram MM. Successful treatment of tuberculous peritonitis while maintaining patient on CAPD. Adv Perit Dial 1991;7:102-4.  Back to cited text no. 7    
8.Vas SI. Renaissance of tuberculosis in the 1990's. Lessons for the nephrologist. Perit Dial Int 1994;14:209-14.  Back to cited text no. 8    
9.Cengiz K. Should tuberculosis prophyla-xis be given for the chronically dialyzed patients. Nephron 1994;86:411-3.  Back to cited text no. 9    
10.Sasaki S, Akiba T, Suenaga M, et al. Ten years' survey of dialysis associated tubercu­losis. Nephron 1994;24:141-6.  Back to cited text no. 10    
11.Andrew OT, Schoenfeld PY, Hopewell PC, Humphreys MH. Tuberculosis in patients with end stage renal disease. Am J Med 1980;68:59-65.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Simon TA, Paul S, Watenberg D, Takars JI. Tuberculosis in hemodialysis patients in New Jersey: a Statewide study. Infect Control Hosp Epidemio 1999;20:607-9.  Back to cited text no. 12    
13.Chia S, Karim M, Elwood RK, Fitzgerald JM. Risk of tuberculosis in dialysis patients: a population bases study. Int J Tuberc Lung Dis 1998; 2(12):989-91.  Back to cited text no. 13    
14.Mitwalli A. Tuberculosis in patients on maintenance dialysis. Am J Kidney Dis 1991;18:579-82.  Back to cited text no. 14  [PUBMED]  
15.Al-Homrany M. Successful therapy of tuberculosis in hemodialysis patients. Am J Nephrol 1997;17:32-5.  Back to cited text no. 15  [PUBMED]  
16.Shohaib S, Scrimgeour EM, Shaerya F. Tuberculosis in active dialysis patients in Jeddah. Am J Nephrol 1999;19:34-7.  Back to cited text no. 16    
17.Khanna R, Fentou SS, Cattran DC, Thompson D, Deitel M, Oreopoulos DG. Tuberculous peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Perito­neal Dial Bull 1980;1:10-2.  Back to cited text no. 17    
18.Talwani R, Horvath JA. Tuberculous Peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: Case report and review: Clin Infect Dis 2000;31:70-5.  Back to cited text no. 18    
19.Quantrill SJ, Woodhead MA, Bell CE, Hutchison AJ, Gokal R. Peritoneal tuberculosis in patients receiving continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2001; 6:1024-7.  Back to cited text no. 19    
20.Byron PR, Mallick NP, Taylor G. Immune potential in human uraemia: changes after regular haemodialysis therapy. J Clin Pathol 1976;29:770-2.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]
21.Newberry WM, Sanford JP. Defective cellular immunity in renal failure: depre-ssion of reactivity of lymphocytes to phytohemag­glutinin renal failure serum. J Clin Invest 1971;50:1262-71.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Tolkoff-Rubin NE, Rubin RH. Uremia and host defences. N Engl J Med 1990;322:770-2.  Back to cited text no. 22  [PUBMED]  
23.Rapoport J, Hausmann MJ, Chaimovitz C. The peritoneal immune system and continuous ambulatory peritoneal dia-lysis. Nephron 1999;81:373-80.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Ahijado F, Luno J, Soto I, et al. Tuber-culous peritonitis in patients on CAPD. Contrib Nephrol 1991;89:79-86.  Back to cited text no. 24    
25.Kluge GH. Tuberculous peritonitis in a patient undergoing chronic ambulatory peritoneal dialysis (CAPD). Perit Dial Bull 1983;3:189-90.  Back to cited text no. 25    
26.Ong AC, Scoble JE, Baillod RA, Fernando ON, Sweny P, Moorhead JF. Tuberculous peritonitis complicating peritoneal dialysis: a case for early diagnostic laparotomy? Nephrol Dial Transplant 1992;7:443-6.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]
27.Jenkins PF, Ward MJ. The role of peritoneal biopsy in the diagnosis of ascites. Postgrad Med J 1980;56:702-3.  Back to cited text no. 27  [PUBMED]  
28.Sathar MA, Simjee AE, Coovadia YM, et al. Ascitic fluid gamma interferon concentrations and adenosine deaminase activity in tuberculous peritonitis. Gut 1995; 36:419-21.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]

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Correspondence Address:
Ghulam Hassan Malik
Consultant Nephrologist, Security Forces Hospital Program, P.O. Box 3643, Riyadh 11481
Saudi Arabia
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    Abstract
    Introduction
    Discussion
    Acknowledgment
    References
 

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