HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Akpolat, T. Search for Related Content PubMed PubMed Citation Articles by Akpolat, T.

TUBERCULOUS PERITONITIS

Ondokuz Mayis University, School of Medicine, Department of Nephrology, Samsun, Turkey

Correspondence to: T. Akpolat, Ondokuz Mayis Üniversitesi, Tip Fakültesi, Nefroloji Bilim Dali, Samsun 55139 Turkey. tekinakpolat{at}yahoo.com

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

Compared with the general population, dialysis patients are at higher risk of acquiring mycobacterial infections. The aim of the present article is to review case reports and studies published since the report by Talwani and Horvath (2000) and to discuss the main problems that arise in daily practice. After a comprehensive review of the literature, cumulative data about peritoneal dialysis and peritoneal tuberculosis from reports of 98 patients in 21 papers were analyzed.

The clinical and laboratory findings of peritoneal tuberculosis are nonspecific. Diagnosis requires a high index of suspicion. The most difficult cases present as culture-negative peritonitis or culture-positive peritonitis resistant to appropriate antibiotics without any additional clues of tuberculosis. The sensitivity of smears and cultures can be enhanced by centrifuging a 50 – 150 mL dialysate sample.

KEY WORDS: End-stage renal disease; peritonitis; tuberculosis.

Peritoneal dialysis (PD) is one of the treatment options for patients with end-stage renal disease (ESRD). Although peritonitis rates have declined in parallel with advances in PD technology, peritonitis remains a leading complication of PD (1,2). The most common infectious complication of PD is bacterial peritonitis. As compared with the general population, dialysis patients are at higher risk of acquiring mycobacterial infections. For various reasons, peritoneal tuberculosis (TB) has an important significance for PD patients.

The first case of continuous ambulatory PD (CAPD) complicated by Mycobacterium tuberculosis was reported in 1980. In 2000, Talwani and Horvath reviewed 52 published cases dealing with PD and peritoneal TB (3). The guidelines from the International Society for Peritoneal Dialysis (ISPD) about PD-related infections briefly discuss the main issues concerning peritoneal TB (1,2). The aim of the present article is to review case reports and studies published since the Talwani and Horvath report, and to discuss the main problems that arise in daily practice.

	MATERIALS AND METHODS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
After a comprehensive review of the literature, cumulative data about PD and peritoneal TB were analyzed. The report by Talwani and Horvath (3) investigated cases published before 1999. For the present review, the PubMed database was searched using the terms "tuberculosis" and "peritoneal dialysis," looking for papers published after 1999. Pertinent articles cited as references in the identified papers were also reviewed. The papers cited in the report of Talwani and Horvath (3) were excluded. The literature review focuses on problems seen in daily practice, and the main findings are compared with the report of Talwani and Horvath (3). Interesting or important cases are also presented. To homogenize the data, approximate values have been used or assumed in a few cases.

	RESULTS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
A total of 98 patients were identified in 21 papers (4–24). At least 20 more patients were reported in three papers, but one paper could not be acquired, and the other two papers made no data available.

The average age for 74 of the 98 patients was 51.2 years (range: 12 – 76 years), and 39 of the 74 (53%) were males. The mean duration of PD therapy was 19 months (range: 2 – 84 months). Concomitant bacterial and fungal peritonitis was present in 6 of 31 patients (19%). In 25 of 26 patients (96%), antibiotics were administered before the diagnosis of peritoneal TB. All remaining data are presented in the Discussion section.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Most of the cases of peritoneal TB were reported from Hong Kong (Table 1). The increase in the number of cases with peritoneal TB in that territory parallels the increase in the number of patients receiving PD in Turkey.

Only one cumulative analysis about PD and peritoneal TB (Talwani and Horvath) has been published in the literature (3). Chau et al. (4) discussed the diagnostic challenges of peritoneal TB in 33 patients with end-stage renal disease (ESRD). Because the report by Chau et al. (4) includes the highest number of PD patients having peritoneal TB in a single study, important findings from that study are presented separately.

The issues important in daily practice are these:

• What are the clinical findings in peritoneal TB?
  
• Is a peritoneal fluid cell count helpful in the differential diagnosis?
  
• Does a tuberculin test help in the diagnosis?
  
• What is the interval between presentation of the disease and diagnosis and initiation of treatment?
  
• What diagnostic methods are used?
  
• How does the presence of extraperitoneal TB affect diagnosis and treatment?
  
• What medical treatment is used for peritoneal TB?
  
• What is the outcome of peritoneal TB?
  
• Is removal of the catheter necessary?
  

Clinical findings in peritoneal TB are indistinguishable from those in bacterial peritonitis. Fever, abdominal pain, and cloudy fluid are the most common presenting symptoms (Table 2). Ultrafiltration failure, anorexia, nausea, vomiting, diarrhea, weight loss, generalized weakness, and paraplegia are other nonspecific symptoms related to peritoneal TB. Peritoneal TB was diagnosed in 1 patient (14) who was asymptomatic, and in another patient, the peritoneal fluid was clear (19). Cell count cannot be used to differentiate peritoneal TB from other forms of peritonitis (1–4). More than 60% of peritoneal TB cases have a predominance of polymorphonuclear neutrophils (Table 2). The predictive value of the tuberculin (PPD) test in the diagnosis of TB is not clear in CAPD patients. For the present review, PPD status was available for 11 patients, 10 of whom (91%) were anergic. Talwani and Horvath (3) reported positive PPD tests in 48% of patients (11/23).

Tuberculosis is an infrequent cause of peritonitis, and it can be difficult to diagnose. Early diagnosis and timely initiation of antituberculosis drugs is key to the management of peritoneal TB. The average interval between presentation with disease and diagnosis and initiation of treatment was about 6.8 weeks in the literature reviewed for the present report (n = 27). That interval is similar to the interval given in the Talwani and Horvath report (mean: 6.7 weeks; median: 5 weeks), but longer than the interval observed by Chau et al. [mean: 37 days (unpublished data); median: 32 days] (3,4).

Many methods are useful in making the diagnosis (Table 2). Each method has advantages, disadvantages, and limitations (Table 3). Because negative results were not mentioned in some of the studies and case reports reviewed here, the sensitivity of the diagnostic methods is hard to determine. The usefulness of a diagnostic method depends mainly on the experiences of TB in nonuremic patients. Extraperitoneal TB was present in 8% (21) of 38 patients, a value similar to those seen in the studies cited earlier: 17% (3) and 28% (4).

Data about antituberculosis treatment was available in 60 of the 98 cases identified. All regimens included at least 3 drugs (isoniazid, rifampin, pyrazinamide). Quinolones or ethambutol were a 4th agent in most of the cases reviewed here. The ISPD 2005 peritonitis guideline briefly outlines the basic principles in the management of peritoneal TB (2). The treatment protocol is based on the experience of extraperitoneal TB in ESRD. The ISPD guideline recommends four drugs: rifampin, isoniazid, pyrazinamide, and ofloxacin (2). Pyrazinamide and ofloxacin must be stopped after 3 months; the rifampin and isoniazid should be continued for a total of 12 months. The usual dosage of these drugs in a PD patient are rifampin 10 mg/kg daily (maximum 600 mg); isoniazid 3 – 5 mg/kg daily; pyrazinamide 30 mg/kg 3 times weekly; and ofloxacin 200 mg daily. Table 4 summarizes some practical issues in the management of peritoneal TB in PD patients.

Mortality is high in cases of TB. Talwani and Horvath (3) reported a mortality rate of 25% at 9 months after diagnosis, and 8 of the 13 fatalities they reported were related to peritoneal TB. The only statistically significant variable predicting death attributable to TB was treatment delay (3). In the present review, the mortality rate and causes of death were similar (Table 5).

In 2000, the ISPD guideline about peritonitis mentioned that "catheter removal appears to be necessary in all cases" (1). The approach to the catheter removal has changed in the 2005 ISPD guideline (2). Table 6 shows the outcome for PD catheters among 94 of the cases included here. In the past, tuberculous peritonitis was itself an indication for catheter removal (9). Today, many patients are treated without removal of the catheter. Current data suggest that tuberculous peritonitis is not an indication for catheter removal; patients can continue PD treatment unless another complication occurs.

	CONCLUSIONS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The clinical and laboratory findings of peritoneal TB are nonspecific, and the diagnosis requires a high index of suspicion. The hardest cases to diagnose are those with culture-negative peritonitis or culture-positive peritonitis resistant to appropriate antibiotics without any additional clues suggesting TB. The sensitivity of smears and cultures can be enhanced by centrifuging 50 – 150 mL of a dialysate sample. A fluid culture medium reduces the time required for growth of mycobacteria. Laparoscopy with biopsy should be considered at an early stage when peritoneal TB is suspected.

Further studies are needed to investigate

• the effects of aminoglycosides and quinolones used for treatment of bacterial peritonitis on growth of mycobacteria in the culture.
  
• the cost-effectiveness of routine culture for mycobacteria in all peritonitis episodes.
  
• the potential usefulness of adenosine deaminase levels in peritoneal fluid.
  
• the cause of polymorphonuclear neutrophils in peritoneal fluid.
  

	REFERENCES

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 

1. Keane WF, Bailie GR, Boeschoten E, Gokal R, Golper TA, Holmes CJ, et al. on behalf of the International Society for Peritoneal Dialysis. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int2000; 20:396 -411.[Free Full Text]
2. Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, et al. on behalf of the ISPD Ad Hoc Advisory Committee. Peritoneal dialysis–related infections recommendations: 2005 update. Perit Dial Int 2005;25 : 107-31.[Free Full Text]
3. Talwani R, Horvath JA. Tuberculous peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: case report and review. Clin Infect Dis 2000;31 : 70-5.[Medline]
4. Chau TN, Leung VK, Wong S, Law ST, Chan WH, Luk IS, et al. Diagnostic challenges of tuberculosis peritonitis in patients with and without end-stage renal failure. Clin Infect Dis2007; 45:e141 -6.[Medline]
5. Karayaylali I, Seyrek N, Akpolat T, Ates K, Ozener C, Yilmaz ME, 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 : 819-27.[Medline]
6. Dervisoglu E, Yilmaz A, Sengul E. The spectrum of tuberculosis in dialysis patients. Scand J Infect Dis2006; 38:1040 -4.[Medline]
7. Dervisoglu E, Sayan M, Sengul E, Yilmaz A. Rapid diagnosis of Mycobacterium tuberculous peritonitis with real-time PCR in a peritoneal dialysis patient. APMIS 2006;114 : 656-8.[Medline]
8. Abraham G, Mathews M, Sekar L, Srikanth A, Sekar U, Soundarajan P. Tuberculous peritonitis in a cohort of continuous ambulatory peritoneal dialysis patients. Perit Dial Int 2001;21 (Suppl 3):S202 -4.[Abstract/Free Full Text]
9. Quantrill SJ, Woodhead MA, Bell CE, Hutchison AJ, Gokal R. Peritoneal tuberculosis in patients receiving continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2001;16 : 1024-7.[Abstract/Free Full Text]
10. Ferrara E, Lemire J, Grimm PC, Reznik VM, Mendoza SA, Leake JA, et al. Mycobacterial peritonitis in pediatric peritoneal dialysis patients. Pediatr Nephrol 2004;19 : 114-17.[Medline]
11. 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.[Medline]
12. Prakash KC. Tuberculous peritonitis. Perit Dial Int 1999; 19(Suppl 2):S283 -5.[Abstract/Free Full Text]
13. Lui SL, Lam MF, Tse KC, Lo WK. Reactivation of systemic lupus erythematosus in a dialysis patient after tuberculous peritonitis. Lupus 2002; 11:49 -51.[Abstract/Free Full Text]
14. Gupta N, Prakash KC. Asymptomatic tuberculous peritonitis in a CAPD patient. Perit Dial Int 2001;21 : 416-17.[Free Full Text]
15. Chow KM, Chan NP, Chui KL, Szeto CC. Pancytopenia in a patient with tuberculous peritonitis. Intern Med J2007; 37:277 -8.[Medline]
16. Canbakan B, Ergun I, Ekmekci Y, Ates K, Karatan O. Pulmonary and peritoneal tuberculosis in a CAPD patient. Int Urol Nephrol 2007; 39:975 -8.[Medline]
17. Dogukan A, Cinar S, Taskapan H, Ozcan O, Oymak O, Utas C. Mycobacterium tuberculosis as a cause of peritonitis in a patient undergoing continuous ambulatory dialysis [Turkish]. Turk Nefrol Diyal Transplant Derg 1998;4 : 217-19.
18. Hung SC, Yang WC, Tarng DC. Fistulizing TB peritonitis during CAPD. Nephrol Dial Transplant 2003;18 : 1226-7.[Free Full Text]
19. Ogütmen B, Tuglular S, Al Ahdab H, Akoglu E, Ozener C. Tuberculosis peritonitis with clear fluid accompanying systemic disseminated tuberculosis in a CAPD patient. Perit Dial Int2003; 23:95 -6.[Free Full Text]
20. Vadivel N, Tucker JK, Trikudanathan S, Heher E, Singh AK. Tuberculous peritonitis: a race against time. Kidney Int 2006; 70:969 -72.[Medline]
21. Sahin G, Kiraz N, Sahin I, Soydan M, Akgün Y. Tuberculous peritonitis in a case receiving continuous ambulatory peritoneal dialysis (CAPD) treatment. Ann Clin Microbiol Antimicrob2004; 3:19 .[Medline]
22. Lui SL, Chan TM, Lai KN, Lo WK. Tuberculous and fungal peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. Perit Dial Int 2007;27 (Suppl 2):S263 -6.[Abstract/Free Full Text]
23. Lui SL, Tang S, Li FK, Choy BY, Chan TM, Lo WK, et al. Tuberculosis infection in Chinese patients undergoing continuous ambulatory peritoneal dialysis. Am J Kidney Dis2001; 38:1055 -60.[Medline]
24. Hung YM, Chan HH, Chung HM. Tuberculous peritonitis in different dialysis patients in Southern Taiwan. Am J Trop Med Hyg 2004; 70:532 -5.[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Akpolat, T. Search for Related Content PubMed PubMed Citation Articles by Akpolat, T.