Table 1: The clinical condition at different time point of the patient.

Two months later for peritoneal function evaluation, the fastperitoneal equilibrium test revealed peritoneal permeability at low average transport (D/Pcr=0.58) and peritoneal Kt/V urea was 2.08.

Discussion

Peritonitis is a common and important complication in PD patients, but peritonitis due to draining high-temperature peritoneal dialysis fluid into abdominal cavity was rare and no lecture repotted such cases so far. Dialysis fluid culture is a most important examination for peritonitis patient, which is helpful for treatment. When draining high-temperature peritoneal dialysis fluid into abdominal but without any clinical symptom, do dialysis fluid culture is needed? In our case we made the culture instantly and the result was positive which is helpful for our subsequent therapy.

Usually peritoneum with host defence to eliminate some bacteria into the abdominal cavity, so clinical peritonitis may not happened though bacteria into abdominal cavity. There are two approaches of bacteria into abdominal cavity of peritoneal dialysis patients, including exogenous and endogenous ways. Common causes include contamination during dialysate exchange, exit site/ tunnel tract infection, intra-abdominal pathologies or ascending gynaecological infections. In this case, culture of the dialysis effluent yielded streptococcus oralis, which usually existed in oral cavity [1]. So we speculated that peritoneum injured by high-temperature peritoneal dialysis fluid, then not able to eliminate bacteria transferred from gut or contamination during dialysate exchange, finally result in peritonitis. Therefore, when the peritoneum injured by high-temperature peritoneal dialysis fluid we should keep gut function well and perform peritoneal dialysis through a rigorous cleaning process to prevent clinical peritonitis, though initially without fever, abdominal pain and PD fluid became turbid.

Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis [2]. Bennett- Jones 1987 reported that IP antibiotics were superior to IV antibiotics in peritonitis treatment [3]. Coincidentally, the latest recommendation described that IP antibiotics were superior to IV antibiotics in peritoneal dialysis-related infections [4]. In this case, according to peritoneal fluid culture result the patient was treated with intraperitoneal antibiotics, specifically vancomycin. However, after five days therapy the peritonitis still not respond. According to guideline PD catheter removal may be the best treatment for persistent peritonitis [2]. For this patient we did not remove PD catheter but only stopped peritoneal dialysis and replaced by hemodialysis, meanwhile continued intravenous vancomycin therapy. Gradually, fever and abdominal pain improved. Two weeks later, all the clinical symptoms of peritonitis were disappeared and repetitive effluent fluid cultures were all negative. So stopped peritoneal dialysis and replaced by hemodialysis but without PD catheter removal may be a recommended treatment strategy for peritonitis induced by high-temperature peritoneal dialysis fluid.

Conclusion

So far, it is the first reported case that peritonitis induced by highperitoneal dialysis fluid and had a successful treatment. From this case we can extract experience and draw a lesson when peritoneum injured high attention should take and dialysis fluid culture should make instantly, though without clinical symptom, and when peritonitis developed stopping peritoneal dialysis and replaced by hemodialysis but without PD catheter removal may be a recommended method.

Disclosures

The authors have no financial conflicts of interest to declare. This article was supported by grant from the Program of Ke Jiao Xing Wei of Suzhou City (kjxw2015021).

References

1. Do T, Jolley KA, Maiden MC, Gilbert SC, Clark D, et al. (2009) Population structure of streptococcus oralis. Microbiology 155: 2593-2602.
2. Ballinger AE, Palmer SC, Wiggins KJ, Craig JC, Johnson DW, et al. (2014) Treatment for peritoneal dialysis-associated peritonitis. Cochrane Database Syst Rev 26: 5284.
3. Bailie GR, Morton R, Ganguli L, Keaney M, Waldek S (1987) Intravenous or intraperitoneal vancomycin for the treatment of continuous ambulatory peritoneal dialysis associated gram-positive peritonitis? Nephron 46: 316-318.
4. Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, et al. (2010) International society for peritoneal dialysis peritoneal dialysisrelated infections recommendations: Update. Perit Dial Int 30: 393- 423.