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Néphrologie & Thérapeutique

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Peritoneal dialysis catheter sterilization by urokinase administration in case of relapsing peritonitis: About four observations Volume 17, issue 2, Avril 2021

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Authors

Introduction

There is no feasible benchmark in daily routine to estimate the hydration status of haemodialysis patients, which is essential to their management.

Objective

We performed a study in haemodialysis patients to assess the diagnostic performance of pulmonary ultrasound and clinical examination for the evaluation of fluid overload using transthoracic echocardiography as a gold standard.

Methods

Thirty-one patients receiving chronic haemodialysis patients were included. Evaluation of hydration status was assessed weekly before haemodialysis sessions using clinical and Echo Comet Score from pulmonary ultrasound and transthoracic echocardiography (reference method).

Results

Five patients had a transthoracic echocardiography overload. Compared with transthoracic echocardiography, the diagnostic performance of the clinical overload score has a sensitivity of 100%, a specificity of 77%, a positive predictive value of 50% and a negative predictive value of 100% with a κ of 0.79. Only orthopnoea (P=0.008), jugular turgor (P=0.005) and hepatic-jugular reflux (P=0.008) were significantly associated with transthoracic echocardiography overload diagnosis. The diagnostic performance of Echo Comet Score by pulmonary ultrasound has a sensitivity of 80%, a specificity of 58%, a positive predictive value of 26% and a negative predictive value of 94%. Ten patients (32.3%) had an increase of extravascular pulmonary water without evidence of transthoracic echocardiography or clinical overload.

Conclusions

Our clinical score has a convincing diagnostic performance compared to transthoracic echocardiography and could be easily used in daily clinical routine to adjust dry weight. The evaluation of the overload using pulmonary ultrasound seems poorly correlated with the overload evaluated by transthoracic echocardiography. Extravascular pulmonary water undetected by clinical examination and transthoracic echocardiography remains a parameter that requires further investigation.

La présence d’un biofilm dans le cathéter de dialyse péritonéale où les bactéries sont encapsulées, inaccessibles au traitement antibiotique, et relarguées régulièrement, à bas bruit, dans le dialysat, explique le mieux le caractère récidivant d’une péritonite infectieuse à l’arrêt de l’antibiothérapie, chez des patients en dialyse péritonéale. Nous rapportons ici quatre cas cliniques où l’injection d’urokinase dans le cathéter de dialyse péritonéale, en complément du traitement antibiotique, a permis d’éradiquer une péritonite récidivante à Staphylocoque epidermidis dans deux cas, à Acinetobacter johnsonii dans un cas et à Staphylocoque haemolyticus dans un cas. Ce traitement adjuvant, dénué d’effets secondaires, a permis la guérison de l’épisode infectieux, d’éviter l’ablation du cathéter de dialyse péritonéale et le transfert en hémodialyse, chez ces patients en dialyse péritonéale présentant une péritonite récidivante.

The presence of a biofilm within the peritoneal dialysis catheter where bacteria are encapsulated, protected from the action of antibiotics and insidiously liberated within the dialysate, best explains the relapse of the infectious peritonitis, when antibiotics are withdrawn. We here report a serie of four clinical cases in whom the administration of urokinase within the peritoneal catheter in addition to the current antibiotherapy, has cured relapsing peritonitis due to Staphylococcus epidermidis in two cases, Acinetobacter johnsonii in one case and Staphylococcus haemolyticus in one case, respectively. This approach, safe and easy, allowed the infection eradication and did prevent a catheter removal and a potential transfer of the patients to hemodialysis.