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Servicio de Nefrología, Hospital Clínico Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Nefrología Clínica, Hospital Clínico Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Jefe del Servicio de Nefrología, Hospital Clínico Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Efluente peritoneal turbio y diarrea por Clostridium difficile" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor:</span></p><p class="elsevierStylePara">Intraperitoneal viscera inflammation favours the translocation of polymorphonuclear leukocytes to the peritoneal cavity, with some cases of cloudy peritoneal effluent being reported alongside infection of the colon by <span class="elsevierStyleItalic">Clostridium difficile</span><span class="elsevierStyleItalic">.</span><span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">We report the case of an 87-year-old male with a good quality of life, who had long-term high blood pressure, chronic obstructive pulmonary disease with bronchiectasis and stage 5 chronic kidney disease secondary to nephroangiosclerosis, with a baseline glomerular filtration rate of 15ml/min. He came to our hospital due to deterioration in his general condition, asthenia and anorexia, and his blood tests revealed a decrease in his glomerular filtration rate (7ml/min). There was no change in his normal medication or focal infection. In the following days, he did not respond to conservative measures and, with the patient’s consent, we started renal replacement therapy by peritoneal dialysis, with a double-cuff straight Tenckhoff peritoneal catheter being introduced, without complications during the procedure. In the hours following the procedure, the patient presented with fever and increasing coughing and expectoration. The X-ray was suggestive of right lower pulmonary lobe consolidation, and as such, given the suspicion of nosocomial pneumonia, we started treatment with meropenem and ciprofloxacin. He started automatic peritoneal dialysis (APD) a week later, given the progressive deterioration of kidney function. He was discharged ten days later having recovered his baseline clinical condition, with oral antibiotic treatment and the indication of continuing APD in the peritoneal dialysis unit while awaiting training. The microorganism was not isolated in the blood cultures or in the sputum analysis.</p><p class="elsevierStylePara">Four days later, after the weekend period, he came to the hospital complaining of watery diarrhoea, without pathological products, lasting 24 hours. He had abdominal discomfort and fever and cloudy peritoneal effluent was observed. The fluid analysis revealed 408 cells/ul with a predominance of polymorphonuclear cells (79%). Using clinical and cytological criteria, the patient was diagnosed with peritonitis and empirical treatment was started with intraperitoneal ceftazidime and vancomycin.<span class="elsevierStyleSup">2</span> Given the lack of response to treatment or growth of the microorganism in the peritoneal dialysate culture, after three days we received the stool culture result, which revealed the presence of <span class="elsevierStyleItalic">Clostridium difficile </span><span class="elsevierStyleItalic">toxin and antigen.</span></p><p class="elsevierStylePara">Given the absence of clinical improvement and the persistence of cloudy dialysate, the case was reassessed and we considered other causes of cloudy peritoneal effluent with polymorphonuclear predominance.<span class="elsevierStyleSup">3</span> We unsuccessfully searched for fungi and mycobacteria. The patient had not received treatment with vancomycin or amphotericin B before symptoms started. The results of the studies to determine the presence of <span class="elsevierStyleItalic">Clostridium difficile</span> toxins or antigens in peritoneal dialysate were negative. Other symptoms that may include the presence of sterile cloudy liquid with eosinophil predominance<span class="elsevierStyleSup">3</span> were not suggestive in this patient, based on the chronology with regard to catheter insertion. The X-ray of the abdomen did not display pneumoperitoneum. The existence of an inflammatory intestinal process and the negative results of tests carried out led us to consider the presence of sterile cloudy peritoneal dialysate to be secondary to colitis due to<span class="elsevierStyleItalic"> </span><span class="elsevierStyleItalic">Clostridium difficile</span>. We discontinued intraperitoneal antibiotic administration and started the patient on 500mg of metronidazole administered orally every 8 hours, with little response. As such, we decided to combine it with 500mg of vancomycin administered orally every 8 hours, with the patient displaying a gradual improvement of the process, a decrease in the frequency of bowel movements and an increase in density of stools. The transparency of the peritoneal dialysate was simultaneously recovered.</p><p class="elsevierStylePara">The fact that no<span class="elsevierStyleItalic"> Clostridium difficile </span>toxins or antigens were detected in the peritoneal dialysate suggests that the aetiology of the cloudy dialysate corresponds to the passage of leukocytes and not to phenomena of bacterial translocation with secondary peritonitis. The fact that symptoms only improved with the introduction of oral vancomycin in the treatment supports this hypothesis. There are studies that report that the exposure of intestinal epithelial cells to the toxin <span class="elsevierStyleItalic">Clostridium difficile</span> modulates the epithelial expression of IL-8 and the intercellular adhesion molecule 1 (ICAM-1), involved in the chemoattraction and adhesion of leukocytes.<span class="elsevierStyleSup">4</span> Furthermore, the data suggest that the transmigration of leukocytes to the peritoneal cavity is related to the upward regulation of ICAM-1 receptors.<span class="elsevierStyleSup">5</span> These results together may offer an explanation of the pathophysiology of the symptoms described.</p><p class="elsevierStylePara"><span class="elsevierStyleBold"> </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p>" "pdfFichero" => "P1-E565-S4505-A12283-EN.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439274" "palabras" => array:1 [ 0 => "Clostridium difficile" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439276" "palabras" => array:1 [ 0 => "Diarrhoea" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439278" "palabras" => array:1 [ 0 => "Sterile peritonitis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439280" "palabras" => array:1 [ 0 => "Cloudy peritoneal effluent" ] ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sakao Y, Kato A, Sugiura T, Fujikura T, Misaki T, Tsuji T, et al. Cloudy dialysate and pseudomembranous colitis in a patient on CAPDl. Perit Dial Int 2008;28(5):562-3. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18708558" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Li PK, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010;30:393-423. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20628102" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Freitas DG, Gokal R. Sterile peritonitis in the peritoneal dialysis patient. Perit Dial Int 2005;25(2):146-51. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15796141" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Canny G, Drudy D, Macmathuna P, O'farrelly C, Baird AW. Toxigenic C. difficile induced inflammatory marker expression by human intestinalepithelial cells is asymmetrical. Life Sci 2006;78:920-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16185718" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Liberek T, Chmielewski M, Lichodziejewska-Niemierko M, Lewandowski K, Rutkowski B. Transmigration of blood leukocites into the peritoneal cavity is related to the upregulation of ICAM-1(CD54) and MAC-1 (CD11b/CD18) adhesion molecules. Perit Dial Int 2004;24(2):139-46. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15119634" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003400000001/v0_201502091619/X2013251414053521/v0_201502091620/en/main.assets" "Apartado" => array:4 [ "identificador" => "35437" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003400000001/v0_201502091619/X2013251414053521/v0_201502091620/en/P1-E565-S4505-A12283-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251414053521?idApp=UINPBA000064" ]
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2022 October | 56 | 58 | 114 |
2022 September | 56 | 32 | 88 |
2022 August | 44 | 42 | 86 |
2022 July | 39 | 56 | 95 |
2022 June | 49 | 42 | 91 |
2022 May | 39 | 24 | 63 |
2022 April | 43 | 52 | 95 |
2022 March | 47 | 41 | 88 |
2022 February | 45 | 47 | 92 |
2022 January | 52 | 29 | 81 |
2021 December | 82 | 37 | 119 |
2021 November | 59 | 26 | 85 |
2021 October | 54 | 39 | 93 |
2021 September | 35 | 39 | 74 |
2021 August | 60 | 44 | 104 |
2021 July | 44 | 25 | 69 |
2021 June | 43 | 24 | 67 |
2021 May | 56 | 37 | 93 |
2021 April | 136 | 50 | 186 |
2021 March | 81 | 28 | 109 |
2021 February | 65 | 12 | 77 |
2021 January | 46 | 21 | 67 |
2020 December | 46 | 19 | 65 |
2020 November | 40 | 11 | 51 |
2020 October | 28 | 18 | 46 |
2020 September | 19 | 11 | 30 |
2020 August | 51 | 13 | 64 |
2020 July | 47 | 10 | 57 |
2020 June | 37 | 15 | 52 |
2020 May | 45 | 5 | 50 |
2020 April | 46 | 11 | 57 |
2020 March | 39 | 15 | 54 |
2020 February | 42 | 19 | 61 |
2020 January | 60 | 22 | 82 |
2019 December | 60 | 27 | 87 |
2019 November | 52 | 24 | 76 |
2019 October | 33 | 13 | 46 |
2019 September | 46 | 19 | 65 |
2019 August | 34 | 16 | 50 |
2019 July | 34 | 22 | 56 |
2019 June | 44 | 17 | 61 |
2019 May | 27 | 11 | 38 |
2019 April | 79 | 32 | 111 |
2019 March | 41 | 21 | 62 |
2019 February | 37 | 16 | 53 |
2019 January | 48 | 17 | 65 |
2018 December | 102 | 34 | 136 |
2018 November | 121 | 11 | 132 |
2018 October | 106 | 14 | 120 |
2018 September | 69 | 7 | 76 |
2018 August | 50 | 14 | 64 |
2018 July | 45 | 10 | 55 |
2018 June | 55 | 16 | 71 |
2018 May | 46 | 17 | 63 |
2018 April | 59 | 9 | 68 |
2018 March | 42 | 12 | 54 |
2018 February | 64 | 12 | 76 |
2018 January | 40 | 8 | 48 |
2017 December | 74 | 13 | 87 |
2017 November | 47 | 8 | 55 |
2017 October | 32 | 6 | 38 |
2017 September | 34 | 8 | 42 |
2017 August | 45 | 10 | 55 |
2017 July | 54 | 15 | 69 |
2017 June | 50 | 27 | 77 |
2017 May | 47 | 14 | 61 |
2017 April | 36 | 13 | 49 |
2017 March | 20 | 5 | 25 |
2017 February | 30 | 9 | 39 |
2017 January | 23 | 6 | 29 |
2016 December | 81 | 19 | 100 |
2016 November | 71 | 20 | 91 |
2016 October | 98 | 12 | 110 |
2016 September | 151 | 2 | 153 |
2016 August | 211 | 5 | 216 |
2016 July | 219 | 7 | 226 |
2016 June | 131 | 0 | 131 |
2016 May | 157 | 0 | 157 |
2016 April | 121 | 0 | 121 |
2016 March | 101 | 0 | 101 |
2016 February | 130 | 0 | 130 |
2016 January | 107 | 0 | 107 |
2015 December | 139 | 0 | 139 |
2015 November | 109 | 0 | 109 |
2015 October | 100 | 0 | 100 |
2015 September | 87 | 0 | 87 |
2015 August | 85 | 0 | 85 |
2015 July | 82 | 0 | 82 |
2015 June | 52 | 0 | 52 |
2015 May | 50 | 0 | 50 |
2015 April | 19 | 0 | 19 |