Case 1
A 71-year-old woman with end-stage kidney disease (ESKD) on CAPD, type 2 diabetes, hypertension, and neurogenic bladder, was admitted to the COVID-19 unit, with a two-week history of shortness of breath, dry cough, and a one-day onset of fever. On admission, she had a low oxygen saturation (88%), she was normotensive, with a respiratory rate of 24 breaths per minute, a heart rate of 89 beats per minute, and a body temperature of 37ºC. A chest X-ray showed diffuse opacities and consolidation in the base of the right lung. A COVID‐19 rapid test of IgG/IgM was positive for IgM; a nasopharyngeal qRT-PCR test for SARS-CoV-2 was negative. Two days after admission, she presented PD catheter dysfunction. Additionally, a bacterial pneumonia infection was also suspected both by the patient's clinical findings and laboratory tests (Table 1). Empirical piperacillin/tazobactam was initiated. Subsequently, she required ventilatory support with supplementary oxygen. A qRT-PCR test for SARS-CoV-2 was performed in the PF that had remained for 48 hours in the peritoneal cavity. The molecular test was positive. [cycle threshold (Ct)=36 and Ct=22 for E, and RNase P genes, respectively]. The RdRP gene did not amplify. RP was used as an endogenous internal amplification control. A time-dependent follow-up of SARS-CoV-2 presence in the PF was performed, and samples of PF that remained in the peritoneal cavity at different periods of time (4, 12, and 24 hours), were analyzed (Table 3).
Three days after hospitalization, the patient's respiratory distress improved, and her PD catheter was working well. A PF culture detected methicillin-sensitive Staphylococcus aureus. She was discharged after 8 days of hospitalization, with antibiotic and isolation indications. Fourteen days after her discharge, her PF culture, leucocyte cells count, and qRT-PCR test for SARS-CoV-2 were negative.
Table 1. Laboratory test during hospital admission and discharge
|
Admission
|
Discharge
|
Hb g/dL
|
8.0
|
8.6
|
Ls x103/mm3
|
9.5
|
9.06
|
Lymph %
|
18.4
|
21.8
|
Plt x103/mm3
|
486.5
|
500
|
LDH U/L
|
-
|
240
|
CRP mg/L
|
98.0
|
30.8
|
sFer ng/mL
PCT ng/mL
LsPF x103/mm3
PMNPF %
sCr mg/dL
sUr mg/dL
|
115.0
1.2
15.8
89
3.3
28.9
|
100.9
0.4
66
91
3.5
40.2
|
|
|
|
|
|
Hb, hemoglobin; Ls, leucocytes; Lymph, lymphocytes; Plt, platelets; LDH, lactic dehydrogenase; CRP, C-reactive protein; sFer, serum ferritin; PCT, procalcitonin; LsPF, leucocytes in peritoneal fluid; PMNPF, polymorphonuclear cells in peritoneal fluid; sCr, serum creatinine; sUr, Serum urea.
Case 2:
A 78-years-old woman with type 2 diabetes, hypertension, chronic obstructive pulmonary disease, and ischemic heart disease, arrived at the COVID-19 unit, referring a two-week history of polypnea; five days before admission, she developed fever, nausea, myalgias, cough, and shortness of breath. Oxygen saturation upon admission was <86%; blood pressure was 205/116 mm/Hg. Bilateral lung crackling without whistling was detected. Her chest X-ray showed global cardiomegaly, with increased density in both upper lung zones, perihilar opacities, and bilateral air bronchograms. A COVID‐19 rapid test of IgG/IgM was positive for both IgG and IgM, as well as a positive nasopharyngeal qRT-PCR test for SARS-CoV-2.
Laboratory tests showed glomerular filtration rate (GFR) of 48 mL/min/1.73m2 estimated with the (CKD-EPI) formula (18), decompensated diabetes, and thrombocytopenia; five days after admission, she developed KDIGO III AKI and uremic encephalopathy (Table 2). A percutaneous tenckhoff catheter was placed at the bedside, and automated cycler PD was started. A PF sample obtained during the catheter placement was positive to qRT-PCR SARS-CoV-2 test (Ct=34, Ct=41, Ct=32 for E, RdRP, and RNase P genes, respectively). Although the presence of SARS-CoV-2 was confirmed in PF (Table 3), the patient never had peritoneal or gastrointestinal symptoms. Fortunately, the patient's kidney function improved, and the catheter was removed on day 12 and discharged the day after.
The PFs of both patients were disposed by infusing chlorinated solution (Amukina ® at 50%) through the tubes and bags (19). Then, the liquid was disposed to a chlorinated septic tank.
Table 2. Laboratory test during hospital admission, PD start day and discharge.
|
Admission
|
PD start
|
Discharge
|
Hb g/dL
|
13
|
15
|
10
|
Ls x103/mm3
|
11.26
|
11.34
|
16.47
|
Lymph %
|
20.1
|
6.7
|
11.0
|
Plt x103/mm3
|
79.6
|
282
|
185
|
LDH U/L
|
177
|
-
|
112
|
CRP mg/L
|
17.4
|
-
|
14.8
|
sFer ng/mL
PCT ng/mL
sCr mg/dL
sUr mg/dL
|
75.5
12.5
1.1
65
|
-
1.16
2.5
317
|
239.4
0.09
0.57
84
|
Hb, hemoglobin; Ls, leucocytes; Lymph, lymphocytes; Plt, platelets; LDH, lactic dehydrogenase; CRP, C-reactive protein; sFer, serum ferritin; PCT, procalcitonin; sCr, serum creatinine; sUr, Serum urea; PD, peritoneal dialysis.
Table 3. Nasopharyngeal and Peritoneal Fluid SARS-CoV-2 PCR
Patient
|
qRT-PCR
NFEx
|
qRT-PCR
PF
|
Hours in
cavity
|
IgG Ab
|
IgM Ab
|
Case 1
Case 2
|
-
+
|
+
+
|
48: +
4: -
12: -
24: -
+
|
-
+
|
+
+
|
|
|
|
|
|
|
qRT-PCR, quantitative Reverse Transcription-Polymerase Chain Reaction; NFEx, nasopharyngeal exudate; PF, peritoneal fluid; IgG, immunoglobulin G; IgM, immunoglobulin M; Ab, antibody, SARS CoV-2, severe acute respiratory syndrome coronavirus 2.