A 74-year-old woman with stage 5 chronic kidney disease (CKD) attributed to nephroangioes-clerosis, with a history of hypertension, secondary hyperparathyroidism, anemic syndrome and chronic lymphocytic leukemia was treated with PD.
She has four children but lives with two, takes care of her grandchildren, cannot read or write, but she is independent for daily and instrumental activities:
(January 2014)= Barthel 100%, Lawton-Brody 8/8, Quality of Life (sf-12): PCS 50.6, MCS 59.7
On 04/10/2013 a peritoneal catheter was placed and CAPD started at home on May 22, 2013, being the patient the main caregiver.
Initial CAPD treatment was: 3 exchanges/ day (2 with Phisioneal 35 1.36% glucose and 1 with Extraneal, with volumes of 2000 ml).
Daily ultrafiltered 500 ml with exchanges and maintained a diuresis volume of 1500 ml.
The result of the peritoneal membrane study before the last peritonitis showed a peritoneal membrane AH (high medium carrier).
In 8 months she presented 4 episodes of peritonitis, of which 3 were recurrent, with positive culture of the same bacterium (Staphylococcus epidermis).
A protocolized antibiotic treatment was administered: Vancomycin 1gr/72h intraperitoneal (IP) for 15 days and Fluconazole orally (vo) for 21 days.
After the resolution of the last peritoneal infection, it was decided to seal the catheter with Daptomycin (35 mg in 7.2 ml ringer/24h after the last exchange of the day) medication that was prepared at the last day self-medication.
Fungal peritonitis episode:
During the sealing period (14/8/2014) the patient informed the emergency telephone by cloudy liquid, abdominal pain and general malaise.
A protocolized peritoneal fluid culture was performed and she was admitted waiting for results.
After cell count, empirical antibiotic treatment was initiated with Vancomycin 1gr/72h and Ceftazidime 1gr/24h IP.
Culture showed growth of BGN (Klebsiellar arrhythmia and Acinetobacter sp multisenmicina), so treatment was continued with Ceftazidima 1gr/24h/IP, adding 40mg G/24h
Clinical improvement (clear effluent without drainage problems) was discharged home.
The technique was re-trained and the home antibiotic medication was managed (IP treatment for 21 days).
Eight days later, the patient came back to the emergency department with turbid liquid, and a new pathogen (Challucinda andlos) appeared in the culture. A new pathogen was admitted to the treatment Fluconazole 200 mg/24h.
Due to the poor response to treatment, it was decided to remove the Tenckoff catheter, as recommended by the protocol, and transfer it to haemodialysis definitively.
A provisional bilumen venous catheter (right jugular) was placed, awaiting surgery for internal arteriovenous fistula in the right elbow (5/09/2014).
Five days later, the venous catheter was replaced due to dysfunction and it was visualized by CT angiography, a significant thrombus in the jugular vein, requiring surgery, admission to intensive care and placement of a new catheter (or femoral access).
This new catheter also presented nonsteroidal venous thrombosis, requiring anticoagulation and withdrawal within 2-3 weeks.
Despite the use of internal arteriovenous fistula one month after surgery, poor adaptation to HD treatment was observed due to continuous hypotensive episodes, difficulty in venous cannulation and limb pain.
The quality of life of the patient had significantly worsened after admission of 74 days and transfer to hemodialysis:
(Octubre 2014)= Barthel 95%, Lawton-Brody 6/8, Quality of Life (sf-12): PCS 20,1, MCS 40,3
Due to complications, poor adaptation to HD and at the request of the patient, the patient was re-evaluated with nocturnal cycling treatment.
Return to Peritoneal Dialysis:
Thus, on December 19, 14, a Tenckoff catheter was placed (laparoscopy to assess possible adhesions, which may appear after fungal peritonitis) and automatic as there were no problems, the patient restarted peritoneal dialysis at 1 month).
The minor daughter of the patient was the main caregiver, who, although not living with her, performed the assembly and connection displacing herself at home daily.
Disconnection, night alarm solution and disassembly of the machine is performed by the patient without supervision.
The cycling treatment consisted of: 8 cycles, 4 cycles of 2000 ml (Pioneal junction 35 1.36%), 80 minutes of permanence and dry day.
Every day, the patient has an ultrafilament with treatment of 400-500 ml and maintains a diuresis volume of 1500 ml.
The peritoneal balance test remained the same as at the beginning.
Currently it has been > 1 year without any problem, practically recovering the autonomy and quality of life of the beginning:
(September 2015)= Barthel 100%, Lawton-Brody 8/8, Quality of Life (sf-12): PCS 43.6, MCS 51.5
SEN guidelines recommend retraining after each episode of peritonitis.
The objective is to seek possible causes, evaluate the training of the responsible and correct those wrong procedures.
This methodology helps us to reveal the possible cause of the infection.
In our case, the result indicated that the patient had not followed the recommended aseptic measures in handling the antibiotic for sealing.
Bacterial peritonitis was diagnosed with the first result of peritoneal fluid culture, but fungal peritonitis was also added.
Thus, the fungal infection conditioned the removal of the peritoneal catheter and the abandonment of the peritoneal dialysis program.
The multidisciplinary team decided to transfer it to HD definitively after the diagnosis of fungal peritonitis.
Many authors describe that the survival of the technique after fungal peritonitis due to Candida non-its walls is very low, and there are few patients who can return to PD therapy again after the event, as described by García-Martos.
The reasons for considering that the patient had volatilized PD were: poor adaptation to HD, complications during transfer to hemodialysis and the request of the patient.
The recommendation of the guidelines on the possibility of reinsertion of a new peritoneal catheter 4-6 weeks after resolution of the clinical picture was also taken into account.
Once the decision was made to return to the PD program, it was clear that a change of strategy was necessary, so that it was proposed to start as an automatic cycler, in order to reduce the number of manipulations of the patient/family.
However, it was also essential to avoid new episodes of infection, so we decided to seek a new person responsible for performing the technique and all this in the home with restarting the training process with the daughter and starting the technique.
