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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of cloudy peritoneal fluid &#40;PF&#41; in patients on peritoneal dialysis &#40;PD&#41; usually occurs in the context of infectious peritonitis&#46; For this diagnosis&#44; two of the following three criteria must be met&#58; &#40;1&#41; the presence of abdominal pain&#44; &#40;2&#41; cloudy fluid with more than 100 leukocytes&#47;&#956;L and more than 50&#37; of them polymorphonucleocytes&#44; and &#40;3&#41; positive culture from PF&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> There are many causes of cloudy PF due to a high cell count&#46; Inflammation of juxtaperitoneal organs &#40;pancreatitis&#44; cholecystitis&#44; splenic infarct&#44; appendicitis&#44; etc&#46;&#41; can increase the number of polymorphonuclear lymphocytes in PF&#46; An increase in PF lymphocytes has also been described with the use of icodextrin&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> tuberculous peritonitis&#44; viral gastroenteritis&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and in one case of acute rejection in graft failure&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> all with negative PF culture&#46; We describe a new case of cloudy PF with a predominance of lymphocytes and negative culture in a patient with a non-functioning renal graft on PD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 67-year-old man with chronic kidney disease of unknown aetiology&#44; who started haemodialysis in 2005&#44; and in January 2009 received a renal graft from a cadaveric donor&#46; Six months post-transplant&#44; a renal biopsy was done because of graft dysfunction and a diagnosis was made of nephritis secondary to BK polyomavirus&#46; The patient continued with the dysfunctional graft until March 2012 when he restarted haemodialysis&#46; After 3 months of haemodialysis&#44; the patient expressed his wish to be transferred to PD and in July 2012 he started continuous ambulatory PD &#40;CAPD&#41;&#46; At that time&#44; the patient was receiving 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day of tacrolimus &#40;blood level 4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; prednisolone had been stopped 2 months before starting PD&#44; and he had a residual diuresis of 500&#8211;700<span class="elsevierStyleHsp" style=""></span>mL&#47;day&#46; As the patient had had viraemia positive for BK virus&#44; and therefore could not be re-added to the waiting list&#44; we decided to stop tacrolimus to try to get a negative viral load&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Two months later&#44; the patient presented with symptoms of diffuse abdominal pain&#44; worst in the zone of the graft&#44; with a low-grade fever&#44; and cloudy PF&#46; Diuresis had decreased to 400<span class="elsevierStyleHsp" style=""></span>mL&#47;day&#44; and there was no failure of ultrafiltration with his regular CAPD routine&#46; Physical exam revealed mild tenderness on palpation of the graft&#44; with no peritonism&#46; Blood tests showed anaemia despite high doses of erythropoietic agents and a CRP of 185<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; and there were no signs of systemic infection&#46; Urine had minimal proteinuria and haematuria without leukocyturia&#46; The PF cell count showed 300 leukocytes&#47;&#956;L with 35&#46;7&#37; polymorphonucleocytes and 64&#46;3&#37; lymphocytes&#46; Doppler-echo confirmed the presence of graft flow&#46; Due to the apparent clinical picture of graft intolerance and lack of criteria for a diagnosis of infectious peritonitis&#44; we decided to start treatment with corticoids at a dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day without adding intraperitoneal antibiotics&#46; Forty-eight hours later&#44; the patient showed a significant clinical improvement with resolution of pain at the graft site and resolution of the cloudy PF&#46; Subsequently&#44; all cultures&#44; including PF&#44; were confirmed negative&#46; Peritoneal fluid cytology was performed with immunohistochemistry techniques and flow cytometry&#44; showing a predominance of T lymphocytes &#40;CD-3 positive&#41;&#46; Finally&#44; in March 2013 we performed graft embolisation&#44; after a biopsy&#46; The biopsy showed humoral rejection with vasculitis&#44; tubulitis&#44; and presence of C4d in the peritubular capillaries&#46; Following a reducing dose of steroids and graft embolisation&#44; the patient had no further cloudy PF&#44; and negative cultures as long as he remained on PD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Cloudy PF in PD can be due to multiple causes&#46; Although the most common cause is infectious peritonitis&#44; other possibilities should be considered&#46; The management of immunosuppression in transplant patients starting PD is controversial&#59; maintenance immunosuppression can increase the incidence of infection and neoplasia&#44; but its withdrawal leads to accelerated loss of residual renal function and the possible occurrence of graft intolerance syndrome&#46; In this patient with significant cumulative immunosuppression&#44; as soon as cloudy PF was noted&#44; infectious peritonitis was the main diagnosis of suspicion&#46; However&#44; as we have seen&#44; if not all the criteria for infectious peritonitis are present&#44; and above all&#44; there is a predominance of lymphocytes in the PF&#44; we must look for other causes of cloudy PF&#46; We think that graft intolerance must be in the differential diagnosis of cloudy PF in patients with a dysfunctional renal graft on PD&#46;</p></span></span>"
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Letter to the Editor
Cloudy peritoneal dialysate effluent due to graft intolerance syndrome
Efluente peritoneal turbio debido a un síndrome de intolerancia al injerto renal
Sandra Beltrán-Catalán
Corresponding author
sanbelca@gmail.com

Corresponding author.
, Belén Vizcaino-Castillo, Pablo Molina-Vila, Marco Montomoli, Luis Manuel Pallardó-Mateu, Ana Ávila-Bernabeu
Servicio de Nefrología, Hospital Universitario Dr. Peset, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of cloudy peritoneal fluid &#40;PF&#41; in patients on peritoneal dialysis &#40;PD&#41; usually occurs in the context of infectious peritonitis&#46; For this diagnosis&#44; two of the following three criteria must be met&#58; &#40;1&#41; the presence of abdominal pain&#44; &#40;2&#41; cloudy fluid with more than 100 leukocytes&#47;&#956;L and more than 50&#37; of them polymorphonucleocytes&#44; and &#40;3&#41; positive culture from PF&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> There are many causes of cloudy PF due to a high cell count&#46; Inflammation of juxtaperitoneal organs &#40;pancreatitis&#44; cholecystitis&#44; splenic infarct&#44; appendicitis&#44; etc&#46;&#41; can increase the number of polymorphonuclear lymphocytes in PF&#46; An increase in PF lymphocytes has also been described with the use of icodextrin&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> tuberculous peritonitis&#44; viral gastroenteritis&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> and in one case of acute rejection in graft failure&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> all with negative PF culture&#46; We describe a new case of cloudy PF with a predominance of lymphocytes and negative culture in a patient with a non-functioning renal graft on PD&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was a 67-year-old man with chronic kidney disease of unknown aetiology&#44; who started haemodialysis in 2005&#44; and in January 2009 received a renal graft from a cadaveric donor&#46; Six months post-transplant&#44; a renal biopsy was done because of graft dysfunction and a diagnosis was made of nephritis secondary to BK polyomavirus&#46; The patient continued with the dysfunctional graft until March 2012 when he restarted haemodialysis&#46; After 3 months of haemodialysis&#44; the patient expressed his wish to be transferred to PD and in July 2012 he started continuous ambulatory PD &#40;CAPD&#41;&#46; At that time&#44; the patient was receiving 1<span class="elsevierStyleHsp" style=""></span>mg&#47;day of tacrolimus &#40;blood level 4<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; prednisolone had been stopped 2 months before starting PD&#44; and he had a residual diuresis of 500&#8211;700<span class="elsevierStyleHsp" style=""></span>mL&#47;day&#46; As the patient had had viraemia positive for BK virus&#44; and therefore could not be re-added to the waiting list&#44; we decided to stop tacrolimus to try to get a negative viral load&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Two months later&#44; the patient presented with symptoms of diffuse abdominal pain&#44; worst in the zone of the graft&#44; with a low-grade fever&#44; and cloudy PF&#46; Diuresis had decreased to 400<span class="elsevierStyleHsp" style=""></span>mL&#47;day&#44; and there was no failure of ultrafiltration with his regular CAPD routine&#46; Physical exam revealed mild tenderness on palpation of the graft&#44; with no peritonism&#46; Blood tests showed anaemia despite high doses of erythropoietic agents and a CRP of 185<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#44; and there were no signs of systemic infection&#46; Urine had minimal proteinuria and haematuria without leukocyturia&#46; The PF cell count showed 300 leukocytes&#47;&#956;L with 35&#46;7&#37; polymorphonucleocytes and 64&#46;3&#37; lymphocytes&#46; Doppler-echo confirmed the presence of graft flow&#46; Due to the apparent clinical picture of graft intolerance and lack of criteria for a diagnosis of infectious peritonitis&#44; we decided to start treatment with corticoids at a dose of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day without adding intraperitoneal antibiotics&#46; Forty-eight hours later&#44; the patient showed a significant clinical improvement with resolution of pain at the graft site and resolution of the cloudy PF&#46; Subsequently&#44; all cultures&#44; including PF&#44; were confirmed negative&#46; Peritoneal fluid cytology was performed with immunohistochemistry techniques and flow cytometry&#44; showing a predominance of T lymphocytes &#40;CD-3 positive&#41;&#46; Finally&#44; in March 2013 we performed graft embolisation&#44; after a biopsy&#46; The biopsy showed humoral rejection with vasculitis&#44; tubulitis&#44; and presence of C4d in the peritubular capillaries&#46; Following a reducing dose of steroids and graft embolisation&#44; the patient had no further cloudy PF&#44; and negative cultures as long as he remained on PD&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Cloudy PF in PD can be due to multiple causes&#46; Although the most common cause is infectious peritonitis&#44; other possibilities should be considered&#46; The management of immunosuppression in transplant patients starting PD is controversial&#59; maintenance immunosuppression can increase the incidence of infection and neoplasia&#44; but its withdrawal leads to accelerated loss of residual renal function and the possible occurrence of graft intolerance syndrome&#46; In this patient with significant cumulative immunosuppression&#44; as soon as cloudy PF was noted&#44; infectious peritonitis was the main diagnosis of suspicion&#46; However&#44; as we have seen&#44; if not all the criteria for infectious peritonitis are present&#44; and above all&#44; there is a predominance of lymphocytes in the PF&#44; we must look for other causes of cloudy PF&#46; We think that graft intolerance must be in the differential diagnosis of cloudy PF in patients with a dysfunctional renal graft on PD&#46;</p></span></span>"
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