| Abstract|| |
Even though rare, tuberculous peritonitis (TBP) in patients on continuous ambulatory peritoneal dialysis (CAPD) is a perilous condition. Physicians worry about continuing treatment of their patients, whether to continue this modality of dialysis or switch to hemodialysis. A retrospective cohort study of 89 patients undergoing CAPD over a 12-year period was carried out for any episode of peritonitis with the objectives to find out the incidence of TBP in these patients, evaluation of patients' 3-year survival, possibility of retention of Tenckhoff catheter, and modality of dialysis post-infection. One hundred and three episodes of peritonitis occurred in our patients. Most of them were bacterial and occasionally fungal. We identified four cases of TBP, with one patient having concurrent bacterial infection in the peritoneal fluid. The clinical presentation was insidious with cloudy fluid in all cases. The diagnosis was established by the polymerase chain reaction (PCR) technique in one case, by positive peritoneal fluid culture for Mycobacterium tuberculosis in two cases, and clinically in the fourth one that responded well to anti-tuberculous therapy. All four patients survived their mycobacterial infection. Removal of catheter was necessary in all four patients and all were converted to hemodialysis. Three patients remained on hemodialysis thereafter, and one patient had to be re-implanted with a new catheter and was restarted on CAPD. TBP in patients undergoing CAPD in Jeddah remains a real concern, especially with the evidence of high prevalence of tuberculosis and with the emergence of drug-resistant tuberculosis. We recommend early initiation of anti-tuberculous therapy and removal of the Tenckhoff catheter for better survival. Most of these patients probably will require conversion to hemodialysis, but in a selected few CAPD can be restarted.
|How to cite this article:|
Waness A, Al Shohaib S. Tuberculous peritonitis associated with peritoneal dialysis. Saudi J Kidney Dis Transpl 2012;23:44-7
|How to cite this URL:|
Waness A, Al Shohaib S. Tuberculous peritonitis associated with peritoneal dialysis. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2022 Sep 28];23:44-7. Available from: https://www.sjkdt.org/text.asp?2012/23/1/44/91299
| Introduction|| |
Even after we reaching the 21 st century, tuberculosis remains a disease of serious concern for both patients and physicians. This is compounded by the recent advent of multi-drug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. Certain categories of people are more prone to these infections and among them are patients with chronic renal failure. Their risk of extrapulmonary tuberculosis is reported to be ten times more than that in any other group.  The incidence and prevalence of tuberculosis in patients with chronic renal disease in the city of Jeddah was found to be higher than that in the rest of Saudi Arabia. The possible explanations are overcrowding and the yearly Hajj (Muslim Pilgrimage) season.  A particular form of tuberculosis that affects some of these patients is tuberculous peritonitis (TBP) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). It is a rare complication, but a serious one. It usually starts within the first year of the dialysis initiation and is of extra-pulmonary origin. 
| Patients and Methods|| |
This was a retrospective study carried on 89 patients undergoing CAPD at the King Abdulaziz University Hospital in Jeddah, Saudi Arabia, between January 1994 and December 2006. The objectives of this study were to find the following:
- the occurrence of any episode of TBP,
- 3-year-survival after initiation of anti-tuberculous therapy,
- possibility of retention of Tenckhoff catheter, and
- modality of dialysis in these patients, postinfection.
The proposal for the study was approved by the institutional review board.
| Results|| |
During the period of 12 years, 103 episodes of peritonitis occurred in our patients. Most of them were bacterial or occasionally fungal. All patients were treated with Aminoglycosides, Cephalosporins, Vancomycin; or an antifungal agent when fungal peritonitis was diagnosed. None of them received Quinolone derivatives.
We identified four cases (three males and one female) of TBP, with one patient having concurrent bacterial infection in the peritoneal fluid. All the findings are summarized in [Table 1].
The clinical presentation was insidious with only one patient experiencing fatigue and decreased appetite. The peritoneal fluid was cloudy in all cases; cytologic examinations showed neutrophilic predominance. Smear for acid fast bacilli (AFB) was negative in all cases. The Mantoux skin test was not done on any patient because of its unreliability as reported by Al-Hajjaj et al in their study from Western Saudi Arabia. 
The diagnosis was established by the polymerase chain reaction (PCR) technique in one case, by positive peritoneal fluid culture for Mycobacterium tuberculosis in two cases, and clinically in the fourth one that responded well to anti-tuberculous therapy. All patients were treated with triple anti-tuberculous therapy (INH, Rifampin, Pyrazinamide) for nine months each. Ethambutol was not given since three of our four patients had stigmata of diabetic retinopathy. Clinical improvement was observed within six weeks of starting anti-tuberculous therapy in all patients.
All four patients survived their respective mycobacterial infection for a period of three years each. Removal of catheter was necessary in all four patients and all were converted to hemodialysis initially. Three patients remained on hemodialysis thereafter and one patient had to be re-implanted with a new Tenckhoff catheter, six months after she was diagnosed with TBP and was reinstated on CAPD.
| Discussion|| |
In our series, the incidence of TBP was about 3.88% among the 103 episodes of peritonitis in that particular period of 12 years. It is relatively high compared to the incidence of 2.58% reported by Abraham et al in their series of 155 patients.  This confirms earlier reports of high rates of tuberculosis in patients with chronic renal disease in general  and in those undergoing dialysis in Jeddah. 
TBP usually occurs within the first year of starting dialysis, but can also occur later. Two of our patients developed TBP within the first year after starting CAPD, while the other two patients had TBP after two years of CAPD initiation. Abdominal pain and fever are the most frequently occurring symptoms.  In our series, three out of our four patients had no symptoms at presentation. The dialysate was usually cloudy with predominance of polymorphonuclear cells in the peritoneal fluid.  All these patients had negative AFB smear of the peritoneal fluid. The sensitivity of this test in the literature widely varies from 3.8  to 80%. , A recent study by Bandyopadhyay et al showed that PCR is clearly more effective than AFB smear in the diagnosis of TBP.  Only one of our patients (25%) had positive gene amplification for M. tuberculosis DNA complex by PCR; this test offers a fast and reliable way to diagnose TBP.  Mycobacterial peritoneal fluid culture offers another diagnostic way for this condition. However, it takes weeks to be available; that is why some authors advocate invasive approach with laparoscopy and peritoneal biopsy as the most effective diagnostic tool for TBP. ,
All of our patients received initial antibiotic coverage for bacterial peritonitis. They were switched to triple anti-tuberculous treatment when the diagnosis was established by PCR or when their condition was clearly refractory to conventional therapy for peritonitis. All four patients were alive for three years after their bout of TBP. No relapse or recurrent TBP was observed in these patients.
The removal of the Tenckhoff catheter during TBP is controversial. Some authors advocate its removal,  while others prefer keeping it in place after initiation of the anti-tuberculous chemotherapy. , A Saudi Arabian study, done in the city of Riyadh, reported the removal of 50% (one out of two) of the Tenckhoff ca-theter.  In our series, all of our patients (100% of cases) had their respective catheters removed. We feel that this intervention was helpful in the cure and survival of all our patients, with a mortality rate of 0% compared to the average of 30% in the same category of patients.  In our opinion, removing the Tenckhoff catheter is a better option while treating TBP.
In the City of Jeddah, the incidence of TBP in patients undergoing CAPD is high. In the era of emerging resistance to anti-tuberculous therapy, we urge physicians in general and nephrologists in particular to keep a high index of suspicion in aggressively diagnosing and treating this worrisome condition. We also recommend removal of Tenckhoff catheter as part of possible successful intervention and survival improvement. Most of these patients will require conversion to hemodialysis, but in a selected few, CAPD can be resumed.
| References|| |
|1.||Mousson C, Bonnin A, Dumas M, Chevet D, Rifle G. Peritoneal tuberculosis and continuous ambulatory peritoneal dialysis. Nephrologie 1993;14(3):139-42. |
|2.||Al Shohaib S. Tuberculosis in chronic renal failure in Jeddah. Int Urol Nephrol 1999;31(4):571-5. |
|3.||Quantrill SJ, Woodhead MA, Bell CE, Hutchison AJ, Gokal R. Peritoneal tuberculosis in patients receiving continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2001;16(5):1024-7. |
|4.||Al-Hajjaj MS, El-Kassimi FA, Al-Orainey IO, Abdullah AK, Bener A. Prevalence of tuberculosis in the Western Region of Saudi Arabia. J KAU Med Sci 1992;2:59-69. |
|5.||Abraham G, Mathews M, Sekar L, Srikanth A, Sekar U, Soundarajan P. Tuberculosis peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. Peritoneal Dial Int 2001;21(3):S202-4. |
|6.||Al Shohaib S, Scrimgeour EM, Shaerya F. Tuberculosis in active dialysis patients in Jeddah. Am J Nephrol 1999;19:34-7. |
|7.||Talwani R, Horvath JA. Tuberculous peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: Case report and review. Clin Infect Dis 2000;31:70-5. |
|8.||Karayaylali I, Seyrek N, Akpolat T, et al. The prevalence and clinical features of tuberculous peritonitis in CAPD patients in Turkey, report of ten cases from multi-centers. Ren Fail 2003;25(5):819-27. |
|9.||Demir K, Okten A, Kaymakoglu S, et al. Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems. Eur J Gastroenterol Hepatol 2001;13(5):581-5. |
|10.||Verspyck E, Struder C, Wendum D, Bourgeois D, Lariven S, Marpeau L. Peritoneal tuberculosis. Ann Chir 1997;51(4):375-8. |
|11.||Bandyopadhyay D, Gupta S, Banerjee S, et al. Adenosine deaminase estimation and multiplex polymerase chain reaction in diagnosis of extra-pulmonary tuberculosis. Int J Tuberc Lung Dis 2008;12(10):1203-8. |
|12.||Lye WC. Rapid diagnosis of Mycobacterium tuberculous peritonitis in two continuous ambulatory peritoneal dialysis patients, using DNA amplification by polymerase chain reaction. Adv Perit Dial 2002;18:154-7. |
|13.||Hung YM, Chan HH, Chung HM. Tuberculous peritonitis in different dialysis patients in Southern Taiwan. Am J Trop Med Hyg 2004;70(5):532-5. |
|14.||Chow KM, Chow VC, Szeto CC. Indication for peritoneal biopsy in tuberculous peritonitis. Am J Surg 2003;185(6):567-73. |
|15.||Vas SI. Renaissance of tuberculosis in the 1990s: lessons for the nephrologist. Perit Dial Int 1994;14(3):209-14. |
|16.||Tan D, Fein PA, Jorden A, Avram MM. Successful treatment of tuberculous peritonitis while maintaining patient on CAPD. Adv Perit Dial 1991;7:102-4. |
|17.||Lui SL, Lo CY, Choy BY, Chan TM, Lo WK, Cheng IK. Optimal treatment and long-term outcome of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1996; 28(5):747-51. |
|18.||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. |
|19.||Lui SL, Chan TM, Lai KN, Lo WK. Tuberculous and fungal peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int 2007;27Suppl 2:S263-6. |
SKMC - Research Center Director, Consultant, Department of Internal Medicine, Sheikh Khalifa Medical City, P.O. Box 51900, Abu Dhabi
United Arab Emirates
Source of Support: None, Conflict of Interest: None