CORRESPONDENCE
SEPTEMBER 2017 – VOL. 37, NO. 5 PDI
extended or continuous versus short-term intravenous infusion of carbapenems and piperacillin/tazobactam: a systematic review and meta-analysis. Clin Infect Dis 2013; 56(2):272–82. 7. Deslandes G, Gregoire M, Bouquie R, Le MA, Allard S, Dailly E, et al. Stability and compatibility of antibiotics in peritoneal dialysis solutions applied to automated peritoneal dialysis in the pediatric population. Perit Dial Int 2016; 36(6):676–9. 8. Turnidge JD. The pharmacodynamics of beta-lactams. Clin Infect Dis 1998; 27(1):10–22. https://doi.org/10.3747/pdi.2017.00055
Concerns Regarding ISPD Recommendations for Peritonitis in Relation to Imipenem/Cilastatin—In Reply
DISCLOSURES The authors have no financial conflicts of interest to declare.
C.-C. Szeto* P.K.-T. Li 585
*email: [email protected] REFERENCES 1. van Gelder MK, van Eck van der Sluijs A, van Maarseveen EM, Klein Klouwenberg PMC, Abrahams AC. Response letter to the “ISPD peritonitis recommendations: 2016 update on prevention and treatment”. Perit Dial Int 2017; 37(5):584. 2. Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 2016; 36:481–508. 3. Brown EA, Bargman JM, Li PK. Managing older patients on peritoneal dialysis. Perit Dial Int 2015; 35:609–11. 4. Szeto CC. Peritoneal dialysis-related infection in the older population. Perit Dial Int 2015; 35:659–62. 5. Deslandes G, Grégoire M, Bouquié R, Le Marec A, Allard S, Dailly E, et al. Stability and compatibility of antibiotics in peritoneal dialysis solutions applied to automated peritoneal dialysis in the pediatric population. Perit Dial Int 2016; 36:676–9. 6. Anwar N, Merchant M, Were T, Tooth A, Uttley L, Gokal R. A prospective, randomized study of the comparative safety and efficacy of intraperitoneal imipenem versus vancomycin and netilmicin in the treatment of peritonitis on CAPD. Perit Dial Int 1995; 15:167–71. https://doi.org/10.3747/pdi.2017.00071
Post-Transplant Lymphoproliferative Disorder Presenting as Cloudy Peritoneal Dialysate Editor: A recent encounter with post-transplant lymphoproliferative disorder (PTLD) manifesting as cloudy peritoneal dialysate prompted a review of the literature which we feel may be of interest to clinicians finding themselves in similar circumstances. A 63-year-old female patient presented acutely with culturenegative peritonitis, having recently commenced peritoneal dialysis (PD). Pertinently, she had developed skin-limited PTLD 2 years previously, which had been treated successfully with rituximab. Peritoneal dialysate fluid microscopy showed a white cell count of 5,680 × 109/L, with 20% polymorphs, 80% lymphocytes, and no organisms on gram staining. Microscopic analysis described “atypical, unidentified white cells.” We found advanced imaging of limited utility as both computed tomography and positron emission tomography of the abdomen demonstrated non-specific panniculitis and peritoneal and omental thickening and stranding. The diagnosis was made via cytological analysis of the PD fluid showing numerous markedly pleomorphic cells with large vesicular nuclei, multiple prominent nucleoli and abundant cytoplasm. The overall appearances were consistent with a PTLD, monomorphic type, with features similar to those seen in the previous skin biopsy. Epstein Barr Virus (EBV) was noted in the PD fluid, and quantitative polymerase chain reaction of serum demonstrated raised EBV levels of 47,456 IU/mL.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at Goteborgs universitet on September 30, 2017
Editor: We appreciate the comments from van Gelder et al. (1) on the use of intraperitoneal (IP) imipenem/cilastatin described in the recent recommendations by the International Society for Peritoneal Dialysis (ISPD) (2). We fully agree with their comment that continuous IP dosing of the beta-lactam group of antibiotics offers a theoretical advantage and should be the preferred regimen. As van Gelder clearly points out, continuous IP dosing ensures an adequate IP drug level throughout the day, facilitates bacterial killing by agents whose activity is time-dependent (i.e., the reduction in bacterial density being proportional to the time above minimal inhibitory concentration [MIC]), takes away the concern regarding drug stability in the peritoneal dialysis (PD) solution, and requires a lower daily dose, which is less expensive and has a lower risk of neurotoxicity. Nonetheless, we believe it is valuable to describe intermittent dosing regimens that have been found to be reasonably effective. With the rising prevalence of elderly PD patients (3), many would require helpers or healthcare visitors for the administration of IP antibiotics (4), and intermittent dosage may be the only practical solution, especially when the injection could only be performed once or twice daily and drug stability in the PD solution is a concern (5). Intermittent dosage is also the only possible means of administering antibiotics for patients treated with automated PD (APD) when temporary conversion to continuous ambulatory peritoneal dialysis (CAPD) is not feasible (2). Since extrapolation of pharmacokinetic data from CAPD to APD may result in significant underdosing in APD patients when antibiotics are given IP intermittently (2), a higher daily dose is generally required. As illustrated by Anwar et al. (6) and rightly pointed out by van Gelder et al. (1), the dosage to be administered depends on the intricate balance between adequate therapeutic response and the risk of toxicity.
Department of Medicine & Therapeutics Prince of Wales Hospital The Chinese University of Hong Kong Shatin, Hong Kong, China
PDI
SEPTEMBER 2017 – VOL. 37, NO. 5 CORRESPONDENCE
TABLE 1 All Cases of Malignancy Presenting as Cloudy Dialysate Case
Morphology
Malignancy
PD
1
5,680×109/L 20% polymorphs, 80% lymphocytes
Pleomorphic cells with large vesicular nuclei, multiple prominent nucleoli and abundant cytoplasm
PTLD: Plasmablastic lymphoma
Continued
21
450×109/L “unidentified cells”
Atypical multi-nucleated lymphoid-like cells
Hodgkin’s lymphoma
Withdrawn
32
N/A
Atypical epithelioid cells with finely vacuolated cytoplasm, ovoid nuclei, and small prominent nucleoli
Prostatic adenocarcinoma
Continued
43
300×109/L 84% atypical cells, 4% lymphocytes, 12% neutrophils
“adenocarcinoma cells”
Endometrial adenocarcinoma
Continued
54
700 leukocytes×109/L 80% mononuclear, 20% polymorphonuclear
Atypical lymphocytes
Large B cells non-Hodgkin lymphoma
Continued
65
SEPTEMBER 2017 – VOL. 37, NO. 5 PDI
extended or continuous versus short-term intravenous infusion of carbapenems and piperacillin/tazobactam: a systematic review and meta-analysis. Clin Infect Dis 2013; 56(2):272–82. 7. Deslandes G, Gregoire M, Bouquie R, Le MA, Allard S, Dailly E, et al. Stability and compatibility of antibiotics in peritoneal dialysis solutions applied to automated peritoneal dialysis in the pediatric population. Perit Dial Int 2016; 36(6):676–9. 8. Turnidge JD. The pharmacodynamics of beta-lactams. Clin Infect Dis 1998; 27(1):10–22. https://doi.org/10.3747/pdi.2017.00055
Concerns Regarding ISPD Recommendations for Peritonitis in Relation to Imipenem/Cilastatin—In Reply
DISCLOSURES The authors have no financial conflicts of interest to declare.
C.-C. Szeto* P.K.-T. Li 585
*email: [email protected] REFERENCES 1. van Gelder MK, van Eck van der Sluijs A, van Maarseveen EM, Klein Klouwenberg PMC, Abrahams AC. Response letter to the “ISPD peritonitis recommendations: 2016 update on prevention and treatment”. Perit Dial Int 2017; 37(5):584. 2. Li PK, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 2016; 36:481–508. 3. Brown EA, Bargman JM, Li PK. Managing older patients on peritoneal dialysis. Perit Dial Int 2015; 35:609–11. 4. Szeto CC. Peritoneal dialysis-related infection in the older population. Perit Dial Int 2015; 35:659–62. 5. Deslandes G, Grégoire M, Bouquié R, Le Marec A, Allard S, Dailly E, et al. Stability and compatibility of antibiotics in peritoneal dialysis solutions applied to automated peritoneal dialysis in the pediatric population. Perit Dial Int 2016; 36:676–9. 6. Anwar N, Merchant M, Were T, Tooth A, Uttley L, Gokal R. A prospective, randomized study of the comparative safety and efficacy of intraperitoneal imipenem versus vancomycin and netilmicin in the treatment of peritonitis on CAPD. Perit Dial Int 1995; 15:167–71. https://doi.org/10.3747/pdi.2017.00071
Post-Transplant Lymphoproliferative Disorder Presenting as Cloudy Peritoneal Dialysate Editor: A recent encounter with post-transplant lymphoproliferative disorder (PTLD) manifesting as cloudy peritoneal dialysate prompted a review of the literature which we feel may be of interest to clinicians finding themselves in similar circumstances. A 63-year-old female patient presented acutely with culturenegative peritonitis, having recently commenced peritoneal dialysis (PD). Pertinently, she had developed skin-limited PTLD 2 years previously, which had been treated successfully with rituximab. Peritoneal dialysate fluid microscopy showed a white cell count of 5,680 × 109/L, with 20% polymorphs, 80% lymphocytes, and no organisms on gram staining. Microscopic analysis described “atypical, unidentified white cells.” We found advanced imaging of limited utility as both computed tomography and positron emission tomography of the abdomen demonstrated non-specific panniculitis and peritoneal and omental thickening and stranding. The diagnosis was made via cytological analysis of the PD fluid showing numerous markedly pleomorphic cells with large vesicular nuclei, multiple prominent nucleoli and abundant cytoplasm. The overall appearances were consistent with a PTLD, monomorphic type, with features similar to those seen in the previous skin biopsy. Epstein Barr Virus (EBV) was noted in the PD fluid, and quantitative polymerase chain reaction of serum demonstrated raised EBV levels of 47,456 IU/mL.
This single copy is for your personal, non-commercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, contact Multimed Inc. at [email protected]
Downloaded from http://www.pdiconnect.com/ at Goteborgs universitet on September 30, 2017
Editor: We appreciate the comments from van Gelder et al. (1) on the use of intraperitoneal (IP) imipenem/cilastatin described in the recent recommendations by the International Society for Peritoneal Dialysis (ISPD) (2). We fully agree with their comment that continuous IP dosing of the beta-lactam group of antibiotics offers a theoretical advantage and should be the preferred regimen. As van Gelder clearly points out, continuous IP dosing ensures an adequate IP drug level throughout the day, facilitates bacterial killing by agents whose activity is time-dependent (i.e., the reduction in bacterial density being proportional to the time above minimal inhibitory concentration [MIC]), takes away the concern regarding drug stability in the peritoneal dialysis (PD) solution, and requires a lower daily dose, which is less expensive and has a lower risk of neurotoxicity. Nonetheless, we believe it is valuable to describe intermittent dosing regimens that have been found to be reasonably effective. With the rising prevalence of elderly PD patients (3), many would require helpers or healthcare visitors for the administration of IP antibiotics (4), and intermittent dosage may be the only practical solution, especially when the injection could only be performed once or twice daily and drug stability in the PD solution is a concern (5). Intermittent dosage is also the only possible means of administering antibiotics for patients treated with automated PD (APD) when temporary conversion to continuous ambulatory peritoneal dialysis (CAPD) is not feasible (2). Since extrapolation of pharmacokinetic data from CAPD to APD may result in significant underdosing in APD patients when antibiotics are given IP intermittently (2), a higher daily dose is generally required. As illustrated by Anwar et al. (6) and rightly pointed out by van Gelder et al. (1), the dosage to be administered depends on the intricate balance between adequate therapeutic response and the risk of toxicity.
Department of Medicine & Therapeutics Prince of Wales Hospital The Chinese University of Hong Kong Shatin, Hong Kong, China
PDI
SEPTEMBER 2017 – VOL. 37, NO. 5 CORRESPONDENCE
TABLE 1 All Cases of Malignancy Presenting as Cloudy Dialysate Case
Morphology
Malignancy
PD
1
5,680×109/L 20% polymorphs, 80% lymphocytes
Pleomorphic cells with large vesicular nuclei, multiple prominent nucleoli and abundant cytoplasm
PTLD: Plasmablastic lymphoma
Continued
21
450×109/L “unidentified cells”
Atypical multi-nucleated lymphoid-like cells
Hodgkin’s lymphoma
Withdrawn
32
N/A
Atypical epithelioid cells with finely vacuolated cytoplasm, ovoid nuclei, and small prominent nucleoli
Prostatic adenocarcinoma
Continued
43
300×109/L 84% atypical cells, 4% lymphocytes, 12% neutrophils
“adenocarcinoma cells”
Endometrial adenocarcinoma
Continued
54
700 leukocytes×109/L 80% mononuclear, 20% polymorphonuclear
Atypical lymphocytes
Large B cells non-Hodgkin lymphoma
Continued
65
