A 47-year-old man with end-stage renal disease (ESRD), type 2 diabetes mellitus, hypertension, and coronary artery disease was started on peritoneal dialysis (PD) 2 years prior after a renal allograft failed. Six months previously, he underwent a renal allograft nephrectomy after the renal allograft became inflamed and caused pain. After the operation, he was briefly on hemodialysis and then transitioned back to PD. For the past few months, he has been doing well with no issues on PD. However, during the most recent clinic visit, he was found to have purulent discharge from the PD catheter exit site associated with induration near the exit site. A stat ultrasound showed hypoechoic fluid along the PD catheter tract consistent with abscess. An exit-site culture grew methicillin-sensitive Staphylococcus aureus. He was treated with oral cephalexin 500 mg twice a day.
Three days later, he underwent surgery to remove the abdominal wall abscess. The infected subcutaneous portion of the PD catheter was removed. The remaining portion of the catheter was connected to the new external catheter using a titanium adaptor. A new cutaneous exit site was created away from the prior exit site. He was discharged home to resume his usual prescription of continuous cycling peritoneal dialysis (CCPD) with a dwell volume of 2.5L. Three days later, the patient noticed his shirt and exit-site dressing was wet following dialysis and he presented to the emergency room. He also noted increased abdominal swelling and 3 kg weight gain since the surgery. Ultrafiltration on dialysis has been variable 200 to 600 mL a day, which is lower than usual. On exam, his abdomen was non-tender but it was moderately distended with pitting edema, worse in the bilateral flank area. The PD catheter exit-site dressing was wet. There was clear fluid draining around the exit site. A computed tomography scan showed diffuse soft tissue anasarca in the abdominal wall with a small amount of free intraperitoneal fluid (Figure 1). The PD catheter tip was in the deep pelvis.