GASTROINTESTINAL MUCORMYCOSIS IN A PERITONEAL DIALYSIS PATIENT WITH END STAGE RENAL FAILURE SECONDARY TO AA AMYLOIDOSIS: A CASE REPORT

B ZAHOROWSKA1, K ISMAIL2, G NARAYANAN1

1Liverpool Hospital, Liverpool, New South Wales; 2Department of Anatomical Pathology, Liverpool Hospital, Liverpool, New South Wales

Background: Gastrointestinal mucormycosis is a rare opportunistic infection predominately affecting individuals with immune deficiency and predisposing conditions including gastric ulcers and severe malnutrition. It is acquired by ingestion of fungal-contaminated food and initial manifestations include abdominal pain, distention and haematochezia. The diagnosis of gastrointestinal mucormycosis is often delayed, with only 25% of cases diagnosed ante-mortem and 85% mortality rate.

Case Report: We report a unique case of gastrointestinal mucormycosis caused by Rhizopus species resulting in splenic, stomach and colonic infarction diagnosed post-mortem in a peritoneal dialysis patient. A 50 year old female initially presented with Acinetobacter baumanni peritonitis ten months post commencement of peritoneal dialysis (PD) for renal failure secondary to systemic AA amyloidosis of unknown underlying aetiology. Her amyloidosis had previously manifested with intermittent non-bloody diarrhoea and had been treated with low-dose prednisone. The peritonitis episode presented with typical abdominal pain and cloudy effluent complicated by septic shock due to delayed presentation and resulted in PD catheter removal. Her abdominal pain persisted and was investigated with a CT mesenteric angiogram, which was unremarkable. The patient developed new dysphagia and gastroscopy identified a large ulcerated lesion in the gastric fundus comprised of amyloid deposition. The patient deteriorated with further septic shock and underwent laparotomy with findings of necrotic stomach, spleen and colonic splenic flexure and she deceased post-operatively, three weeks after the initial peritonitis diagnosis.  Amyloid vasculopathy and superimposed angioinvasive mucormycosis was identified post-mortem as the cause of organ infarction.

Conclusions: This rare case of mucormycosis in an immunosuppressed patient demonstrates the high index of suspicion required for diagnosis, particularly in the setting of presentation with overlapping symptoms from PD peritonitis.

RETAINED PERITONEAL DIALYSIS CATHETER TUNNELING DEVICE SEGMENT ASSOCIATED WITH RECURRENT PERITONITIS: A CASE REPORT

B ZAHOROWSKA1, I DE GUZMAN1, B CLELAND1, A ARAVINDAN1, J WONG1

1Liverpool Hospital, Liverpool, New South Wales

Background: Peritoneal dialysis (PD) catheter insertion can be performed by percutaneous Seldinger technique with ultrasound guidance and image intensification to confirm intraperitoneal positioning. Disposable catheter insertion kits are used by our institution and have the advantage of simplicity and portability of pre-packaged sterile equipment. A significant disadvantage of certain pre-assembled kits is the inclusion of radiolucent components that are at risk of displacement and inadvertent retention in the peritoneal cavity or insertion wound.

Case Report: We report a unique case of a 60 year old female with recurrent PD peritonitis on a background of diabetic nephropathy and hypertension. Her PD catheter had been inserted using percutaneous Seldinger technique and the CovidienTM PD Catheter kit in 2013. Since PD commencement, the patient was treated for six episodes of peritonitis comprising of two staphylococcus haemolyticus, and four culture-negative episodes. In 2017 she presented with multiple organism peritonitis (K. Oxytoca, E.Faecalis and Streptococcus species) and was found to have an erythematous wound with purulent discharge superomedial to her peritoneal catheter exit site. An abdominal computer tomography scan was unremarkable whereas abdominal wall ultrasound identified a subcutaneous, 3.4cm plastic blind-ending foreign body immediately adjacent to the PD catheter. Surgical exploration of the wound retrieved a pus-filled plastic cap which was identified as a component of the CovidienTM blunt tunneling stylet.

Conclusions: This case demonstrates the risk of retained radiolucent components of PD catheter insertion equipment resulting in recurrent peritonitis. The foreign body was not identified until four years post insertion due to initial lack of superficial skin and exit site changes and was only found with dedicated ultrasound imaging. Our institution no longer uses the aforementioned tunneling stylet.

PERITONEAL DIALYSIS CATHETERS FOR RECURRENT/REFRACTORY ASCITES DRAINAGE

E TAN1, S GODDARD1

1Regional Renal Unit, Waikato Hospital, Hamilton, New Zealand

Aim: To describe a case series of Peritoneal Dialysis Catheter (PDC) Insertions (PDCI)s for recurrent Ascites Drainage (AD)

Background: Interventional nephrologists insert 60 PDCs annually (50%) in Waikato Renal Unit. Expanding the scope of practice involved inserting PDCs for non-dialysis reasons: AD. These patients’ outcomes were analysed.

Methods: Data was retrospectively collected for patients with PDCIs for ascites (2013-2017) and included age at insertion, gender, frequency of prior paracentesis, initial renal function, initial albumin levels and ascites diagnosis. Major endpoints analysed: complications (including PDC malfunction and infection: peritonitis/exit-site infection), catheter survival and mortality. All insertions were physician-led, using modified Fluoroscopic Seldinger technique.

Results: 5 patients were identified and all required at least fortnightly paracentesis. All reported immediate symptom-relief from AD post-PDCI. Patient demographics: mean age (55.35±6.49years), male/female ratio (2:3), mean creatinine (118.80±41.52umol/L), mean eGFR (64.40±15.76ml/min) and mean Albumin (22.80±3.12g/L). The underlying diagnoses were malignancy (melanoma, pancreatic and breast) and heart failure (ischaemic heart disease and amyloidosis). Complications:  none were catheter-related (malfunction or infectious), 1 patient developed acute kidney injury and 2 patients developed symptomatic hypotension at home. Catheter and patient survival: both 41.60±20.76days (range 1-104 days). 3 patients died within 3 weeks. All died with PDCs in situ.

Conclusions: PDCs (inserted quickly and safely by physicians) is a viable solution to problematic ascites, avoiding repeated paracentesis. Most patients were medically and nutritionally poorly by the referral/insertion time, possibly resulting in the above complications and short survival.

Discussion: Patients with ascites may benefit from earlier referrals for PDCIs. One patient (not included here) even died 2 days before the planned PDCI. Local guidelines for PDCIs for AD are called for; covering referral criteria and pre/post-insertion management.

MORGANELLA MORGANII PD-RELATED PERITONITIS IN A LUNG TRANSPLANT PATIENT

K HAWKE1, I ISMAIL1, A LEE1, M FAHIM2, A GUPTA1

1Department of Nephrology, Toowoomba Hospital, Queensland; 2Department of Nephrology, Princess Alexandra Hospital, Queensland

Aim: We present a lung transplant patient with a diagnosis of sepsis secondary to M morganii PD peritonitis, requiring PD catheter removal despite prompt antimicrobial therapy.

Background: Morganella morganii is a rare cause of peritoneal dialysis (PD) peritonitis. Resistant strains of this opportunistic pathogen have emerged with widespread use of third-generation cephalosporins.

Methods: A 59 year old man had been on peritoneal dialysis for eight weeks because of end-stage renal disease secondary to calcineurin inhibitor toxicity. His background was bilateral lung transplant seven years prior, with current immunosuppressant regimen comprising cyclosporine, azathioprine and prednisolone.

While admitted for pulmonary fungal infection, he developed abdominal pain and turbid PD fluid. Physical examination revealed a tender abdomen, tachycardia and erythematous catheter exit site. Peritoneal effluent contained white cells 9000 x 106/L (83% polymorphonuclear leukocytes), which increased to 26 400 (95% polymorphs) the following day. Computed tomography of the abdomen showed greater omentum fat stranding and sigmoid diverticulitis, but no perforation.

Results: We diagnosed PD-related peritonitis and gave empiric antibiotic therapy (intraperitoneal gentamicin and vancomycin). Cultures of the peritoneal fluid yielded M. morganii (sensitive to gentamicin) and low numbers of Enterococcus faecium (sensitive to vancomycin). PD catheter was removed after three days of clinical deterioration and new haemodynamic instability. Catheter tip was culture-positive for M. morganii.

Conclusions: To our knowledge, this is the first case of M. morganii PD peritonitis in a transplant setting. It supports a high index of suspicion for rare organisms in immunocompromised hosts. The organism’s sensitivity to gentamicin suggests current empiric therapy guidelines are appropriate in transplant patients. The clinical course was more severe than those described previously, highlighting M. morganii’s pathogenic potential in transplant recipients.

CLOUDY BAG: NOT ALWAYS PERITONITIS

V KHELGI1, 2 A GUPTA1, 2,

1Renal unit, Toowoomba Hospital, Toowoomba, Queensland; 2Rural School of Medicine, University of Queensland Toowoomba, Queensland

Background: Chylous ascitis (CA) in peritoneal dialysis (PD) patients is a very rare complication. Due to its milky appearance, it can be confused with peritonitis. There are case reports of CA in patients on PD associated with drugs (calcium channel blockers, everolimus), infections (tuberculosis), malignancy and anatomic disruptions to chyle-containing lymphatic channels. We present a case of a young male who developed CA after insertion of right internal jugular Permcath and resolved completely after removal of the same with no further recurrences.

Case Report: A 23 year-old male acutely developed abdominal discomfort after right internal jugular Permcath insertion. His background includes end stage kidney disease secondary (ESKD) to CAKUT and solute failure on PD. As tenckhoff catheter was in situ, fluid was drained and sent for analysis. He was commenced on IP antibiotics as per the protocol. Initial cell count was high (196, with predominant mononuclear cells) but the repeat counts were down to 5 cells. However the bags continued to be very cloudy and had unusual milky appearance. Triglyceride levels was high consistent with CA (2.3 mmol/L).  There were no eosinophils in the dialysate fluid and Quantiferon gold test was negative. CT chest/abdomen/pelvis did not reveal any blockages. Permcath tip was located appropriately. Lymphscintigram also did not reveal any blockages. After further discussions with patient; Permcath was removed and is back on PD since then. Since the removal of the catheter, PD dilysate bags have been clear with reduced triglyceride levels.

Conclusion: CA is an extremely rare complication in the setting of PD and remains an important differential diagnosis in patients presenting with cloudy bag.

USE OF DEFERASIROX (EXJADE) FOR IRON OVERLOAD IN PERITONEAL DIALYSIS PATIENTS.

E YII4*, JCG DOERY3,4, Z KAPLAN2,4, PG KERR1,4.

1Department of Nephrology, 2Haematology; 3Pathology – Monash Health; 4Department of Medicine, Monash University, Clayton, Victoria. (* medical student).

Aim: To determine the efficay and safety of desferasirox in PD patients.

Background: A 54 year old male with b-Thalassemia major developed ESRD and was managed with CAPD. Despite being untransfusable, he required concomitant management of iron overload. The iron chelator Deferasirox (Exjade) was administered orally. There was concern that excretion of iron via the peritoneal dialysate may raise the risk of iron-dependent infections (Yersinia and Rhizopus).

Methods: Whilst receiving Exjade 1000mg /day, a total collection of 12.7L of peritoneal dialysate was collected over a 24 hour period. The dialysate total iron levels were measured by ICP-mass spectrometry at 0.46mmol/L which equates to 0.33mg of Fe in total. Over a 6 month period his serum ferritin fell from 3869ug/l to 1545ug/l. There were no episodes of peritonitis.

Results: According to the deferasirox product information, 1000mg/day in this man accounts for just under the 20mg/kg/day dosage, hence giving an expected 18-20mg excretion of Fe per day (predominantly via the GIT). Since only 7-8% of the deferasirox and iron complex is excreted through the urine, the amount of Fe seen in the patient’s dialysate might be expected to be up to 1.5-1.6mg. Yet, the results of the Fe levels in the patient’s PD fluid was a meagre 0.33mg, about five times lower than expected.

Conclusion: Thus, deferasirox appears to be a safe and effective agent for iron chelation in iron overloaded peritoneal dialysis patients.

AN UNUSUAL CASE OF CATHETER MIGRATION IN A PERITONEAL DIALYSIS PATIENT

S CROCKER1

1John Hunter Hospital, Newcastle, New South Wales

Background: Peritoneal dialysis (PD) continues to remain a viable dialysis modality with at least 60-90% of home-based patients performing PD across Australia. PD allows patients to maintain greater independence and a more normal lifestyle to participate in usual activities of daily living. Complications of peritonitis, catheter migration and exit site infections are not uncommon and often lead to membrane failure.

Case Report: A 49 year-old lady on peritoneal dialysis presented to hospital with diffuse abdominal pain, fevers and cloudy dialysate. Her underlying renal disease was diabetic nephropathy and the peritoneal dialysis catheter had been laparoscopically inserted 6 months prior to this presentation. Dialysis had been complicated by an episode of uncomplicated Staphylococcus epidermidis peritonitis and a pleural leak. Initial treatment in hospital began with empiric intra-peritoneal antibiotics after a PD fluid sample demonstrated a white cell count of 213 x 106 (98% neutrophils) with growth of mixed anaerobes on fluid culture which was concerning for secondary peritonitis. Upon performing directly observed manual exchanges the patient had instantaneous faecal incontinence of clear fluid and dipstick analysis of this fluid was positive for glucose suggestive of dialysate solution. A contrast-enhanced CT of the abdomen revealed penetration of the PD catheter into the rectosigmoid colon and a likely colovesical fistula. Prompt laparoscopic catheter removal was performed via a suprapubic incision whereby the catheter was noted to be covered in faecal material. The patient recovered uneventfully after catheter removal but required change in dialysis modality.

Conclusions: Despite the ongoing utility of peritoneal dialysis migration of the PD catheter can occur which can rarely cause intra-abdominal viscus penetration and fistula formation.

RAPID ASSESSMENT OF BACTERIAL LOAD AND RESISTANCE PHENOTYPE IN PERITONEAL DIALYSIS EFFLUENT BY FLOW CYTOMETRY

K MULRONEY1, T INGLIS2, A CHAKERA1, 3,

1Translational Renal Research Group, Harry Perkins Institute of Medical Research, Perth, Western Australia; 2Department of Microbiology, PathWest Laboratory Medicine, Perth, Australia; 3Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia

Aim: To use flow cytometry to identify bacterial load and antimicrobial resistance in a patient with peritonitis who had received antibiotics prior to sample collection.

Background: Culture-negative peritonitis cases are common, with rates as high as 20% in some centres. We have developed a novel flow cytometry application allowing identification and quantification of bacterial load, as well as direct determination of antimicrobial sensitivity using our in-house flow-assisted susceptibility testing (FAST) assay. We present a case study using the FAST assay to assess a dialysate sample received after empirical antibiotic therapy had been administered, invalidating standard microbiology techniques.

Methods: Dialysate was analysed by flow cytometry on an Attune NxT flow cytometer. 10 μM SYTO® 9 and 2× Fixable Near-IR amine-reactive viability dye were used for specific identification of cellular (host and bacterial) populations. An enriched sub-specimen was subjected to our FAST assay. Transmission electron microscopy was used to confirm the morphology of the bacterial population found in the dialysate.

Results: A leucocyte population (CD45 positive) at a density of 1.12 x 106 /mL, and a bacterial population at 1.2 x 106 / mL, were detected within 2 hours of sample collection. The FAST assay, gave an invalid result consistent with previous antibiotic exposure, with results available within 4 hours. Transmission electron microscopy studies showed cell carcasses consistent with a Gram positive, spore forming bacillus, with the characteristic features of Micrococcus spp.

Conclusions: We present evidence for the substantial time-benefits of assessment of PD effluent by flow cytometry over traditional culture-based testing, demonstrate a workflow for validating the findings of bacterial flow assays, and highlight some of the difficulties with adopting this technology for routine clinical use.

DEVELOPING AN ASSISTED AUTOMATED PERITONEAL DIALYSIS PROGRAM IN WESTERN AUSTRALIA

D FORTNUM1, N HAWKINS2, G VANDEPEER3, A CHAKERA1,4

1Translational Renal Research Group, Harry Perkins Institute of Medical Research, Perth, Western Australia; 2Hospital in the Home, Sir Charles Gairdner Hospital, Perth, Western Australia; 3Fresenius Medical Care, Perth, Australia; 4Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia

Aim: To develop an assisted automated peritoneal dialysis program in Western Australia

Background: Assisted peritoneal dialysis provides a model of care that has been successfully used to support patient choice and enable patients to stay on peritoneal dialysis. It also has the potential to provide significant cost saving. We describe the develop and initial results of an assisted automated peritoneal dialysis program developed in Western Australia

Methods: The assisted automated peritoneal dialysis model was developed in conjunction with the hospital in the home nursing service, the home dialysis provider (Fresenius Medical Care) and peritoneal dialysis staff. Evaluation methods included patient and staff questionnaires, assessment of dialysis complications and economic analyses.

Results: 15 participants received 594 episodes of care between 13th August 2015 and February 2017. The major reason for requiring assisted automated peritoneal dialysis was respite. Over 90% of patients and staff rated the service as valuable. Clinical outcomes reflected Charlson comorbidity scores (high score = poor outcome). 2 peritonitis episodes occurred during the study period. Initial calculations estimate that by using assisted automated peritoneal dialysis savings of over $600,000 were realised for WA health

Conclusions: Assistance with automated peritoneal dialysis provided by a visiting nursing service daily is a valuable treatment option for patients reducing the need for both hospital bed days and transfers to HD, providing significant cost savings.

CULTURE-INDEPENDENT IDENTIFICATION OF BACTERIA CAUSING PERITONEAL DIALYSIS ASSOCIATED PERITONITIS

K MULRONEY1, J HALL2, T INGLIS2, A CHAKERA1, 3,

1 Translational Renal Research Group, Harry Perkins Institute of Medical Research, Perth, Western Australia; 2Department of Microbiology, PathWest Laboratory Medicine, Perth, Australia; 3Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia

Aim: To assess the sensitivity and specificity of flow cytometry to directly identify bacteria in peritoneal dialysate from patients with suspected peritoneal dialysis associated peritonitis.

Background: Current diagnostic testing of dialysate from patients with suspected peritonitis is based on traditional culture-dependent microbiology. These assays take 1-3 days to become positive and culture-negative rates of over 20% are reported. There has been limited use of culture-independent microbiology techniques for detection of bacteria in dialysate, and none have been routinely adopted in a clinical setting. Flow cytometry based assessment of dialysate may provide a more rapid and accurate tool to detect bacteria in dialysate.

Methods: Dialysate samples from 10 patients with peritonitis were analysed by two PCR-based methods (16S PCR, and BioFire FilmArray®) and flow cytometry using an Attune NxT flow cytometer with 10 μM SYTO® 9, 2× Fixable Near-IR amine-reactive viability dye for identification of bacterial cell populations. Results were compared to traditional culture using BacTec bottles with bacterial identification confirmed by MALDI-TOF Biotyper analysis. Results: 16S PCR was accurate in 30% of samples, whereas the BioFire FilmArray® was accurate in 20% of cases. Flow cytometry was accurate in 90% of cases, with no false negative results. Direct detection of bacteria in dialysate substantially reduces the time for confirm infection compared to traditional culture.

Conclusions: Flow cytometry is an accurate technique for the detection of bacteria in dialysate samples that provides significant advantages over nucleic-acid based detection methods in terms of accuracy and traditional culture with regards to the time to obtain a result.

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