Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review

Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review Tonghuan Liu, Ruizhi Yu, Lixin Wang, Junjie Lin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8448620/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 26 You are reading this latest preprint version Abstract Introduction: The incidence of peritonitis caused by intestinal perforation in patients undergoing peritoneal dialysis (PD) is low, but it often leads to delayed diagnosis and poor prognosis. Case presentation: We report a case of a 63-year-old patient on combined PD and hemodialysis (HD) who presented with abdominal pain, turbid peritoneal fluid, and bloody ascites. Abdominal CT revealed extensive atherosclerosis of the superior mesenteric artery. The patient was diagnosed with PD-related peritonitis, and ascites cultures grew Enterococcus. Despite anti-infective treatment, the patient's condition did not improve. On the tenth day of admission, fecal ascites were drained, and a repeat abdominal CT showed new pneumoperitoneum, suggesting intestinal perforation. Emergency laparotomy confirmed superior mesenteric artery ischemia leading to small bowel perforation. Postoperative ascites cultures grew Candida krusei and Enterococcus faecium. The patient was transferred to the ICU for aggressive treatment but ultimately succumbed to septicemia. Conclusion: Currently, it is difficult to distinguish clinically between perforative peritonitis and PD-related peritonitis in PD patients, and imaging findings are often non-specific. Laparoscopic catheter removal or early laparotomy for refractory or fungal peritonitis may aid in early identification. Case Report perforative peritonitis PD-related peritonitis intestinal perforation peritoneal dialysis Figures Figure 1 Figure 2 Figure 3 Introduction Peritoneal dialysis is a widely used renal replacement therapy for end-stage renal disease patients[1]，PD-related peritonitis is a common complication, while peritonitis secondary to intestinal perforation is relatively rare. However, due to similarities in clinical symptoms and characteristics with PD-related peritonitis, it often leads to delayed diagnosis, resulting in higher mortality and technical failure rates[2]. The causes and risk factors of intestinal perforation in PD patients are not well understood, and reports on this topic are limited. Here, we present a rare case of refractory peritonitis diagnosed as small bowel perforation through laparotomy and review relevant literature to further discuss the clinical manifestations, diagnosis, and treatment of intestinal perforation in PD patients. Case Presentation A 63-year-old male patient with hypertension, diabetes, coronary heart disease, and cerebral infarction underwent PD catheter placement on March 19, 2013. Due to inadequate PD, the patient underwent left forearm arteriovenous fistula formation on April 27, 2020, combined with HD treatment (twice a week) from June 24, 2020. The PD regimen consisted of DAPD with 1.5% low-calcium PD fluid (2000ml, dwell time 4h * 2 cycles) and 2.5% low-calcium PD fluid (2000ml, dwell time 4h * 2 cycles). On March 22, 2022, The colonoscopy showed no diverticular lesions. The patient presented with abdominal distension on July 27, 2023, and was admitted for treatment. Initial ascites fluid analysis was negative, and abdominal X-ray suggested intestinal stagnation. The patient's condition improved after defecation and gastric protection treatment and was discharged. On September 18, 2023, the patient presented to the emergency department with ‘abdominal pain for 10 days, worsened for 1 day.’ On physical examination, abdominal pain was strong, and rebound tenderness was positive Abdominal CT revealed extensive atherosclerosis of the superior mesenteric artery (Figure 1a), and cloudy mesentery with increased density suggesting peritonitis. Procalcitonin was 1.95 ng/ml, white blood cell count was 16.15*10E 9 /L, and the neutrophil percentage was 83.4%.Peritoneal dialysis-related peritonitis was suspected. The patient was treated with intravenous ceftriaxone 1g and intraperitoneal cefazolin 1g once daily and ceftazidime 1g. On September 19, 2023, the patient was admitted to the renal unit with red and turbid ascites (see Figure 2a), fever (temperature 38.3℃), pulse 122 beats per minute, blood pressure 108/71 mmHg, and respiratory rate 20 breaths per minute. Ascites fluid analysis showed 7208*10 6 /L nucleated cells, 98% neutrophils, and 1000*10 6 /L red blood cells. The diagnosis was peritoneal dialysis-related peritonitis initially. Treatment included intravenous sulperazon (1.5g every 12 hours) and intraperitoneal cefazolin (1g) + ceftazidime (1g). On September 20, 2023, at 10:40 am, a repeat ascites fluid analysis revealed 6415*10 6 /L nucleated cells, 95% neutrophils, and 1000*10 6 /L red blood cells. In the afternoon, the patient's condition worsened, presenting with lethargy,manifesting a persistent fever (maximum temperature: 39.9 ℃), chest tightness , and shortness of breath. oxygen saturation was 75-80%, heart rate of 156 beats per minute, blood pressure of 157/79mmHg, CRP was 208mg/L, blood albumin was 29.9g/L, and procalcitonin was 68.23ng/ml. Blood routine tests showed white blood cell count of 6.61×10 9 /L, neutrophil percentage of 77.2%, hemoglobin of 151g/L, platelet count of 180×10 9 /L, and an oxygenation index of 251. Considering sepsis, PMseq-DNA high-throughput genetic testing for pathogenic microorganisms in bloodstream infections was performed. The anti-infection regimen was adjusted to include amikacin sulfate (0.12g qd) and vancomycin (1g q3d) for intraperitoneal, along with imipenem-cilastatin (1g q12h ivgtt). The patient was transferred to the ICU for monitoring and treatment. After transfer to the ICU, PMseq-DNA high-throughput genetic testing revealed Klebsiella oxytoca, Enterococcus faecalis, Clostridium perfringens, Atypical Veillonella, and Escherichia coli. Bloody ascites was drained (Figure 2b). Routine ascites reexamination showed a nucleated cell count of 367*10 6 /L, neutrophil percentage of 93%, and red blood cell count of 1000*10 6 /L. On September 22, abdominal CT was unchanged compared to previous scans. On September 25, 2023, CRP was 156.7mg/L, procalcitonin was 50.67ng/ml. Blood routine tests showed a white blood cell count of 14.82×10 9 /L, neutrophil percentage of 86.7%, hemoglobin of 117g/L, platelet count of 99×10 9 /L. Routine ascites analysis revealed a nucleated cell count of 6497*106/L, neutrophil percentage of 95%, red blood cell count of 3000*10 6 /L, and an oxygenation index of 152.6 On September 27, 2023, CT showed a new pneumoperitoneum (Figure 1b), and the drained ascites appeared fecal-like (see Figure 2c), suggesting intestinal perforation. An emergency laparotomy was performed, revealing a large amount of yellow fecal ascites and pus in the abdominal cavity (Figure 3a). There was widespread adhesion in the abdominal cavity, with the omentum and intestinal tract wrapped around and adherent to the peritoneal dialysis tube. The small intestinal mesentery was contracted and stiff, and the small intestinal wall was widely adherent and edematous. Multiple segmental ischemic necrosis and perforation were observed in the jejunum approximately 60cm from the Treitz ligament (Figure 3b). The necrotic segment was about 60cm long, with no diverticulum-like changes. Small bowel partial resection (necrotic jejunum segment, see Figure 3c), abdominal adhesion lysis, and peritoneal dialysis tube removal were performed. Double-lumen drainage tubes were placed in the left pelvic cavity and right paracolic sulcus. Intraoperative bacterial culture of the pus grew Enterococcus faecium, which was sensitive to vancomycin. On September 28, ascites bacterial culture results returned, showing a large amount of Enterococcus faecium sensitive to vancomycin but resistant to penicillin, along with Candida krusei (isolated on the 25th). On the 13th day after surgery, brownish-yellow fluid leaked from the patient's right paracolic sulcus drainage tube incision. Surgical consultation suggested intestinal fistula, but the patient's family refused further surgery. On the 15th day after surgery, the patient died of sepsis and septic shock. A detailed chronological summary of the patient’s clinical course is presented in Table 2. Literature review: Peritoneal dialysis (PD) is widely used in patients with end-stage renal disease (ESRD) due to its economic and simplicity. Peritonitis is a common complication of PD, clinical features consistent with peritonitis, that is, abdominal pain and/or cloudy dialysis effluent. The 2022 ISPD guidelines define peritonitis caused by intestinal perforation as enteric peritonitis[3]. Intestinal perforation in PD patients often presents as a chronic process without obvious acute abdominal symptoms, leading to secondary peritonitis or intra-abdominal abscesses ,which is similar to PD-related peritonitis. The use of antibiotics in the peritoneal cavity to alleviate peritonitis symptoms often results in delayed diagnosis and increased mortality[4]. Currently, there are relatively few reports on peritonitis caused by intestinal perforation in PD patients. We searched PubMed using the keywords "Peritoneal dialysis-related peritonitis" and "intestinal perforation" for articles published up to July 2024. After excluding articles with incomplete information or unavailable full texts, we identified 14 case reports, with 30 patients including ours. Based on the retrieved literature, including the case we reported, and excluding incomplete data, we summarized the epidemiological information as follows: Male to female ratio was 16:14, with a maximum age of 83 years, a minimum age of 19 years, and an average age of 58 years. Nine patients (30%) died. The duration of PD ranged from 1 month to 12 years, with an average of 3.8 years. The longest delay in diagnosis was 63 days, with an average delay of 14.75 days. The main site of intestinal perforation was the colon (20 cases, including 16 sigmoid colon, 2 large intestine, 1 cecum, and 1 transverse colon), followed by appendicitis perforation (5 cases), small intestine perforation (4 cases), and ileocecal perforation (1 case).Only 5 patients showed signs of intestinal perforation by abdominal CT when they were admitted to hospital.23 patients showed multi-bacterial peritonitis.The statistical results are shown in Table 1. Discussion The abdominal clinical manifestations of intestinal perforation in patients undergoing peritoneal dialysis are non-specific compared to those of peritoneal dialysis-related peritonitis, often leading to delayed diagnosis, which is a significant risk factor for patient death[5-7]. The average time of delayed diagnosis is 14.75 days, and the case we reported was delayed for 10 days. Previous literature suggests that the role of abdominal CT in predicting intestinal perforation in peritoneal dialysis patients is uncertain[8], as pneumoperitoneum can also occur in CAPD patients[9]. Wellington, J.L. reported that imaging studies were not suggestive in 7 surgical patients[10], and in a review of 15 articles, only 5 patients had positive findings on initial abdominal CT. In our reported case, abdominal CT did not initially suggest intestinal perforation at the time of admission. However, after anti-infective treatment, the patient's peritonitis symptoms worsened, and fecal ascites appeared. A repeat abdominal CT scan revealed new pneumoperitoneum, suggesting intestinal perforation. Considering that imaging studies may not aid in early diagnosis, laparoscopy or surgical exploration may be necessary when symptoms do not resolve with antibiotic treatment or when peritonitis symptoms recur after treatment. The ISPD guidelines suggest that the presence of multiple microorganisms in peritoneal dialysate indicates intra-abdominal pathology[3], In our review of 30 patients, 23 had multiple microorganisms cultured, with one case of intestinal perforation caused by a single fungus. Our reported patient also had fungi cultured, and fungi were also cultured in 4 other cases of polymicrobial peritonitis.Shima,H[11] reported a case of intestinal perforative peritonitis with non-specific clinical manifestations, fungal cultures were positive in the ascites, and the peritoneal dialysis catheter was found to be the cause of intestinal perforation during its removal. In the general population, fungal infection in perforative peritonitis is a poor prognostic factor[12].The ISPD guidelines recommend immediate removal of the peritoneal dialysis catheter when fungi are detected in the dialysate or when refractory peritonitis is diagnosed[3]. Our patient was clinically diagnosed with refractory peritonitis, and the second ascites culture confirmed fungal infection postoperatively. Clinical symptoms and inflammatory markers did not improve, If the peritoneal dialysis catheter had been removed laparoscopically in a timely manner, intestinal perforation could have been detected early, possibly avoiding an unfavorable outcome. Therefore, patients with fungal peritonitis or refractory peritonitis should be alert to the possibility of intestinal perforation, and early laparoscopic catheter removal can be used to explore abdominal conditions and diagnose potential intestinal perforation. It is noteworthy that in this case, a discrepancy was observed between the PMseq-DNA results (showing multiple bloodstream pathogens) and the subsequent ascitic fluid culture (growing only Enterococcus faecium and Candida krusei). This may reflect the higher sensitivity of molecular testing to detect non-viable or low-burden organisms, antimicrobial suppression of culturable bacteria, and potential compartmentalization of infection following perforation. In complex abdominal infections, integrating both molecular and conventional culture methods may provide a more complete microbiological profile. Patients with end-stage renal disease (ESRD) are at a higher risk of intestinal perforation, with colonic diverticulosis, chronic constipation, history of abdominal surgery, and appendicitis being the main risk factors for peritoneal dialysis (PD) patients[13]; The primary site of perforation is the colon, while small bowel perforation is rare.The incidence of small bowel perforation in the general population is relatively low[14], and the mortality rate of non-traumatic small bowel perforation is high, with common etiologies including typhoid, specific inflammation, tuberculosis, and malignant tumors[15]. The cause of small bowel perforation in dialysis patients remains unclear,Fujii,K[7] eported a case of perforation due to small bowel adhesive intestinal obstruction, while another case was possibly related to extensive peritoneal calcification[16]. Currently, there are no reported cases of intestinal perforation in patients undergoing combined PD and hemodialysis (HD). We report a case of a patient who maintained PD treatment for 10 years and received combined HD due to inadequate peritoneal dialysis. On admission, CT revealed extensive atherosclerosis in the thoracoabdominal aorta, coronary arteries, splenic artery, superior mesenteric artery, bilateral renal arteries, and bilateral iliac arteries. A repeat CT scan during the patient's deterioration indicated pneumoperitoneum, suggesting intestinal perforation. Exploratory laparotomy revealed multi-segmental ischemic necrosis and perforation of the jejunum. Despite surgical treatment, the patient died of sepsis finally. We hypothesize that this patient developed chronic mesenteric ischemia due to superior mesenteric artery atherosclerosis, which progressed to intestinal necrosis and perforation. This is supported by several factors: firstly, the patient was admitted one month prior with abdominal pain and distension, but the ascites test was negative; secondly, after admission, the drained ascites was bloody, suggesting intra-abdominal small vessel hemorrhage. Chronic mesenteric ischemia refers to intermittent or persistent insufficient perfusion of the small intestine, often caused by mesenteric atherosclerosis[17],and necrosis and perforation are severe complications. The increased risk of atherosclerosis can be observed in the early stages of chronic kidney disease[18]. The NEFRONA study indicated an increased prevalence of atherosclerosis in patients with moderate CKD, and the progression of atherosclerosis is closely related to the progression of CKD[19], Hemodialysis accelerates atherosclerosis in patients with CKD[20], and diabetes can also accelerate its progression.[21]. Most cases of chronic mesenteric ischemia are asymptomatic, but symptomatic patients may experience abdominal pain related to eating. Previous literature has reported that the risk of mesenteric ischemia in ESRD patients is 44.1 times higher than in the general population, compared to hemodialysis, peritoneal dialysis is associated with a higher risk of mesenteric ischemia, independent risk factors include older age, diabetes, peripheral vascular disease, heart failure, and peritoneal dialysis[22]. Mesenteric ischemia in peritoneal dialysis patients can manifest similarly to peritonitis, leading to delayed diagnosis and high mortality[23]. Therefore, in long-term dialysis patients, considering the increased prevalence of atherosclerosis, it is crucial to be vigilant about the possibility of small bowel perforation caused by superior mesenteric artery atherosclerosis. This case report has several limitations. First, it is a retrospective study of a single patient, which limits the generalizability of our findings. Second, the diagnosis of intestinal perforation was delayed, reflecting the inherent difficulty in distinguishing between PD-related peritonitis and perforative peritonitis based on clinical and imaging features alone. Third, although we reviewed relevant literature, the sample size of reported cases remains small, which may affect the strength of our epidemiological summary. Finally, the patient’s complex comorbidities and combined dialysis modality may represent a unique clinical scenario, and further case reports are needed to validate our observations and recommendations. Conclusion Intestinal perforation leading to enteric peritonitis is relatively rare in peritoneal dialysis patients and can be difficult to distinguish from peritoneal dialysis-related peritonitis. The rate of delayed diagnosis is high, and the prognosis is poor. In patients with peritonitis who show poor response to anti-infective treatment, recurrent symptoms, or positive ascitic fluid cultures indicating polybacterial infection, intestinal perforation should be suspected, given the low diagnostic yield of abdominal CT, laparoscopy or surgical laparotomy should be considered to improve early diagnosis. Declarations Acknowledgments: The authors would like to thank our patient’s family for allowing for his case to be presented. Ethical approval: Ethical approval was obtained from Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine, in accordance with the ethical guidelines of the 1975 Declaration of Helsinki (ethical approval number: G2024-33). Consent for publication: We have obtained written informed consent from the patient's family for the publication of this case report, including all clinical details, imaging findings, and surgical photographs (including identifiable images), and for their use in academic journals. Author contributions: Tonghuan Liu conceived and designed the study, drafted the original manuscript, and performed the literature review. Lixin Wang supervised the research, provided critical revisions to the manuscript, and contributed to study design and data collection. Junjie Lin and Ruizhi Yu participated in manuscript review and editing, and provided intellectual input throughout the writing process.Ruizhi Yu contributed to the creation and optimization of figures and tables. All authors reviewed and approved the final version of the manuscript. Disclosure statement: No potential conflict of interest was reported by the author(s). Funding: Zhang Daning’s Academic Experience Inheritance Studio, Guangdong Provincial Hospital of Traditional Chinese Medicine (E43714), the Traditional Chinese Medicine Bureau of Guangdong Province (grant number:20232051) Data availability statement: All data generated or analyzed during this study are included in this published article. References Yu X, Yang X. Peritoneal dialysis in China: meeting the challenge of chronic kidney failure. Am J Kidney Dis. 2015;65(1):147–51. Wakeen MJ, Zimmerman SW, Bidwell D. Viscus perforation in peritoneal dialysis patients: diagnosis and outcome. Perit Dial Int. 1994;14(4):371–7. Li PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110–53. Rotellar C, et al. Bowel perforation in CAPD patients. Perit Dial Int. 1992;12(4):396–8. Kurultak I, Altay M, Duranay M. Fatal cecal perforation complicating PD peritonitis. Perit Dial Int. 2008;28(4):329–30. Wang R, et al. Delayed bowel perforation in a peritoneal dialysis patient: a case report and literature review. Perit Dial Int. 2014;34(4):460–6. Fujii K, et al. Adhesive intestinal obstruction increases the risk of intestinal perforation in peritoneal dialysis patients: a case report. BMC Nephrol. 2018;19(1):153. Mizuno M, et al. Perforative peritonitis caused by appendicitis in a patient on peritoneal dialysis. Intern Med. 2013;52(11):1177–81. Chang FC, et al. Intestinal perforation in a patient with continuous ambulatory peritoneal dialysis. QJM. 2009;102(7):495–6. Wellington JL, Rody K. Acute abdominal emergencies in patients on long-term ambulatory peritoneal dialysis. Can J Surg. 1993;36(6):522–4. Shima H, et al. Intestinal perforation by a peritoneal dialysis catheter in which fungal peritonitis led to diagnosis: a rare case report. CEN Case Rep. 2018;7(2):208–10. Prakash A, et al. Effect of Candida infection on outcome in patients with perforation peritonitis. Indian J Gastroenterol. 2008;27(3):107–9. Inaguma Y, Kaito H, Tanaka R. A rare case of peritonitis in a young woman on peritoneal dialysis. CEN Case Rep. 2020;9(4):448–9. Freeman HJ. Spontaneous free perforation of the small intestine in adults. World J Gastroenterol. 2014;20(29):9990–7. Jain BK, et al. Insight into the management of non-traumatic perforation of the small intestine. J Infect Dev Ctries. 2010;4(10):650–4. Tu HY, et al. Extensive peritoneal calcification and small intestinal perforation in a peritoneal dialysis patient: a case report. Kaohsiung J Med Sci. 2011;27(5):199–202. Acosta S. Epidemiology of mesenteric vascular disease: clinical implications. Semin Vasc Surg. 2010;23(1):4–8. Valdivielso JM, et al. Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol. 2019;39(10):1938–66. Junyent M, et al. [Usefulness of imaging techniques and novel biomarkers in the prediction of cardiovascular risk in patients with chronic kidney disease in Spain: the NEFRONA project]. Nefrologia. 2010;30(1):119–26. Lindner A, et al. Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med. 1974;290(13):697–701. Zhao N, et al. Diabetes Mellitus to Accelerated Atherosclerosis: Shared Cellular and Molecular Mechanisms in Glucose and Lipid Metabolism. J Cardiovasc Transl Res. 2024;17(1):133–52. Li SY, et al. Mesenteric ischemia in patients with end-stage renal disease: a nationwide longitudinal study. Am J Nephrol. 2012;35(6):491–7. Archodovassilis F, et al. Nonocclusive mesenteric ischemia: a lethal complication in peritoneal dialysis patients. Perit Dial Int. 2007;27(2):136–41. Wen YK. Diagnostic dilemma of bowel perforation in a peritoneal dialysis patient with encapsulating peritoneal sclerosis. Clin Nephrol. 2023;100(4):193–4. Adames H, et al. Peritonitis due to Microbacterium sp in a patient on cycler peritoneal dialysis. Perit Dial Int. 2010;30(6):669–70. Nakamura H, et al. Stercoral perforation of the sigmoid colon in a patient undergoing CAPD: case report. Perit Dial Int. 2004;24(4):399–401. Morimoto H, et al. [A rare case illustrating the difficulty of diagnosing and treating elderly patient with CAPD-related peritonitis caused by the perforation of sigmoid colon diverticulum]. Nihon Ronen Igakkai Zasshi. 2002;39(3):314–7. Carmeci C, et al. Emergency laparotomy in patients on continuous ambulatory peritoneal dialysis. Am Surg. 2001;67(7):615–8. Imai H, Satoh K. Perforated diverticulitis after barium enema examination in a patient on CAPD. Nephrol Dial Transpl. 1997;12(12):2758–60. Tables Table 1: Clinical characteristics of peritoneal dialysis patients with intestinal perforation No. Study Patients Age/Sex Duration of CAPD,y Results of culture CT scans results Duration from onset to surgery,d Perforation site Outcome 1 This case 63/M 10 Enterococcus faecium, Enterococcus avian, Candida krusei Negative 10 Small intestine Died 2 Wen, Y.K 2023[24] 59/F 11 E.coli, Klebsiella pneumoniae, Enterococcus faecalis, Parabacteroides distasonis encapsulating peritoneal sclerosis 63 Sigmoid colon Survived 3 Inaguma,Y, 2020[13] 19/F 5 three bacteria types, including anaerobic bacteria sigmoid colon perforation and fecal mass N/A Sigmoid colon N/A 4 Fujii, K，2018[7] 73/M 8 Enterococcus faecalis and Bacteroides caccae localized dilation of the intestine 23 Small intestine Survived 5 Mizuno,M，2013[8] 46/M 2.5 Klebsiella pneumonia, Citrobacter freundii, Enterococcus faecium and Fusobacterium nucleatum Negative 0 Appendix Survived 6 Tu, H.Y, 2011[16] 56/F 12 N/A extensive calcification of the abdominal aorta and small arteries. 5 Small intestine Died(sepsis) 7 Adames,H, 2010[25] 57/F 8 Microbacterium sp N/A 24 Transverse colon Died(septic shock) 8 Chang,F.C, 2009[9] 69/F 4 Candida albicans minimal free air pockets in the peritoneal cavity/a focal asymmetric wall defect of the distal ileum N/A Small intestine N/A 9 Kurultak,I, 2008[5] 54/F 3 methicillin-susceptible Staphylococcus aureus N/A 6 Cecal Died 10 Nakamura,H,2004[26] 72/F 1 N/A N/A 1 Sigmoid colon Survived 11 Morimoto,H, 2002[27] 67/M 3 Enterococcus,E.coli an abscess in the Douglas pouch 36 Sigmoid colon Survived 12 Carmeci,C, 2001[28] 51/M 2 Pseudomonas aeruginosa,Candida albicans,Enterobacter cloacae,Citrobacter freundii Subhepatic and periportal abcesses 3 Appendix Survived 34/F 0.33 Candida albicans,Escherichia coli,Staphylococcus aureus Fluid consistent with CAPD 9 Appendix Survived 46/M 5 Clostridium difficile,C. freundii,C. albicans,S.aureus Fluid consistent with CAPD 14 Appendix Died(septic shock) 50/M N/A E.coli(two species) Sigmoid diverticulitis 7 Sigmoid colon Survived 71/F 0.17 E.coli,S.aureus Negative 21 Sigmoid colon Survived 13 H. Imai，1997[29] 64/M 7 Enterococcus faecalis, E.coli N/A 30 Sigmoid colon Died(septic shock) 14 Wellington, J. L,1993[10] 63/M 8.83 Multiple enteric organisms N/A 2 Sigmoid colon Survived 83/M 0.08 Multiple enteric organisms N/A 5 Sigmoid colon Survived 57/M 1.33 Multiple enteric organisms (Bacteroides fragilis) N/A 27 Sigmoid colon Died(sepsis) 66/F 3.75 Multiple enteric organisms N/A 5 Colon Died(sepsis) 77/M 2.25 Multiple enteric organisms N/A No surgery Sigmoid colon Died 69/F 2.83 Multiple enteric organisms N/A 6 Sigmoid colon Survived 15 Rotellar,C, 1992[4] 22/M 0.67 gm-rods bacteroides N/A N/A Sigmoid colon Survived 69/F 0.67 proteus Enterococci klebsiella N/A N/A Sigmoid colon Survived 36/M 4.25 S.epidermidis S.aureus,bacteroides,E.coli N/A N/A Right colon Survived 80/M 0.67 gm-gm+cocci bacteroides,clostridium N/A N/A Sigmoid colon Survived 54/M 1.25 Anaerobes N/A N/A Sigmoid colon Survived 54/F 0.25 klebsiella,Enterococci,Pseudomonas N/A N/A Ileocecal area Survived 53/F 1.42 Enterococci, S.aureus,Candida N/A N/A Sigmoid colon Survived F, female; M, male; N/A, Not Applicable. Table 2: Clinical Timeline of the Case Date Event / Finding Management / Outcome 2013/3/19 Initiation of Peritoneal Dialysis (PD) PD catheter placement. 2020/4/27 Addition of Hemodialysis (HD) Left forearm arteriovenous fistula created due to inadequate PD. 2020/6/24 Combined Dialysis Regimen HD twice weekly added to PD. 2022/3/22 Colonoscopy No diverticular lesions found. 2023/7/27 Admission for abdominal distension Initial ascites fluid negative. Discharged after symptomatic improvement. 2023/9/18 Emergency presentation with abdominal pain for 10 days, worsening for 1 day CT showed extensive atherosclerosis of superior mesenteric artery. Suspected PD-related peritonitis. Initial antibiotic therapy (ceftriaxone IV, intraperitoneal cefazolin and ceftazidime). 2023/9/19 Admission to renal unit Red/turbid ascites, fever, elevated inflammatory markers. Diagnosis: PD-related peritonitis. Antibiotics changed to IV sulperazon， intraperitoneal cefazolin and ceftazidime. 2023/9/20 Clinical deterioration (fever, lethargy, respiratory distress) Sepsis suspected. PMseq-DNA testing performed. Antibiotics adjusted (IV imipenem-cilastatin，intraperitoneal amikacin and vancomycin). Transfer to ICU. 2023/9/22 Abdominal CT Unchanged from previous. 2023/9/25 Ascites specimen sent for bacterial culture 2023-09-28 Formal culture: Enterococcus faecium (vancomycin-sensitive, penicillin-resistant) and Candida krusei confirmed. 2023/9/27 New CT findings and ascites appearance New pneumoperitoneum; fecal-like ascites drained. Intestinal perforation suspected. Emergency laparotomy Findings: jejunal ischemic necrosis and perforation. Small bowel resection, adhesion lysis, PD catheter removal. 2023/10/10 Postoperative complication Brownish-yellow fluid leakage from drainage site; suspected intestinal fistula. Family declined further surgery. 2023/10/12 Outcome Patient died of sepsis and septic shock. Additional Declarations No competing interests reported. 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Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIie3RPQrCMBiA4a8U0iVp14iiV0gJiJtXSRGcxMXFQSRS6OQFCv7cQhxTCp1yAEers9AjWB3EqekomHdK4HtIQgBsth/MdwEYAMLgbaQSS9ofmAj6EJxnqtIjHkoT+azodJKlyTICZSIeUQty9nsBzFhODlQ40i1vl8aL+YITjXBH6pqc6NwDxPmskWDGSYIwy7ZvsnAkRt1WZJzjmuxoJFVbwhASWSpbknBfE6pdpaqC8jA2vCUI9JA9kmIcHMu4Eqt1f+DF5b2JvA6qv7L42rvN4++RK8DKPGaz2Wz/2xMAY0IouEV6JgAAAABJRU5ErkJggg==","orcid":"","institution":"Second Affiliated Hospital of Guangzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Junjie","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2025-12-25 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06:56:18","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":90276,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8448620/v1/ae5ed4988ec0058e579456ad.html"},{"id":100855509,"identity":"d5755b80-7c81-4a50-bfcb-45775a99ab97","added_by":"auto","created_at":"2026-01-22 06:56:20","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":251807,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8448620/v1/906e842a3b900fc4c1f38cb6.jpeg"},{"id":100855353,"identity":"85fbc8cd-3f62-46b5-96d9-d959e7931c93","added_by":"auto","created_at":"2026-01-22 06:55:55","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":325721,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"floatimage1Copy.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8448620/v1/00d50d975cae64bf48fa95d1.jpeg"},{"id":100855330,"identity":"661a1441-2e60-4687-9f22-611592094270","added_by":"auto","created_at":"2026-01-22 06:55:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":702813,"visible":true,"origin":"","legend":"\u003cp\u003eSurgical findings during laparotomy\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8448620/v1/b7b705f6f8fe6b0c2cd84734.png"},{"id":100856017,"identity":"7cd87a9a-228f-44bb-8f9c-5e4443d323f0","added_by":"auto","created_at":"2026-01-22 06:57:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2118889,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8448620/v1/4fc2e865-414b-49ae-8755-dfa5a12dc8c7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeritoneal dialysis is a widely used renal replacement therapy for end-stage renal disease patients[1]，PD-related peritonitis is a common complication, while peritonitis secondary to intestinal perforation is relatively rare. However, due to similarities in clinical symptoms and characteristics with PD-related peritonitis, it often leads to delayed diagnosis, resulting in higher mortality and technical failure rates[2]. The causes and risk factors of intestinal perforation in PD patients are not well understood, and reports on this topic are limited. Here, we present a rare case of refractory peritonitis diagnosed as small bowel perforation through laparotomy and review relevant literature to further discuss the clinical manifestations, diagnosis, and treatment of intestinal perforation in PD patients.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 63-year-old male patient with hypertension, diabetes, coronary heart disease, and cerebral infarction underwent PD catheter placement on March 19, 2013. Due to inadequate PD, the patient underwent left forearm arteriovenous fistula formation on April 27, 2020, combined with HD treatment (twice a week) from June 24, 2020. The PD regimen consisted of DAPD with 1.5% low-calcium PD fluid (2000ml, dwell time 4h * 2 cycles) and 2.5% low-calcium PD fluid (2000ml, dwell time 4h * 2 cycles). On March 22, 2022, The colonoscopy showed no\u0026nbsp;diverticular lesions. The patient presented with abdominal distension on July 27, 2023, and was admitted for treatment. Initial ascites fluid analysis was negative, and abdominal X-ray suggested intestinal stagnation. The patient's condition improved after defecation and gastric protection treatment and was discharged. On September 18, 2023, the patient presented to the emergency department with ‘abdominal pain for 10 days, worsened for 1 day.’ On physical examination, abdominal pain was strong, and rebound tenderness was positive Abdominal CT revealed extensive atherosclerosis of the superior mesenteric artery (Figure 1a), and cloudy mesentery with increased density suggesting peritonitis. Procalcitonin was 1.95 ng/ml, white blood cell count was 16.15*10E\u003csup\u003e9\u003c/sup\u003e/L, and the neutrophil percentage was 83.4%.Peritoneal dialysis-related peritonitis was suspected. The patient was treated with intravenous ceftriaxone 1g and intraperitoneal cefazolin 1g once daily and ceftazidime 1g. On September 19, 2023, the patient was admitted to the renal unit with red and turbid ascites (see Figure 2a), fever (temperature 38.3℃), pulse 122 beats per minute, blood pressure 108/71 mmHg, and respiratory rate 20 breaths per minute. Ascites fluid analysis showed 7208*10\u003csup\u003e6\u003c/sup\u003e/L nucleated cells, 98% neutrophils, and 1000*10\u003csup\u003e6\u003c/sup\u003e/L red blood cells. The diagnosis was peritoneal dialysis-related peritonitis initially. Treatment included intravenous sulperazon (1.5g every 12 hours) and intraperitoneal cefazolin (1g) + ceftazidime (1g). On September 20, 2023, at 10:40 am, a repeat ascites fluid analysis revealed 6415*10\u003csup\u003e6\u003c/sup\u003e/L nucleated cells, 95% neutrophils, and 1000*10\u003csup\u003e6\u003c/sup\u003e/L red blood cells. In the afternoon, the patient's condition worsened, presenting with lethargy,manifesting a persistent fever (maximum temperature: 39.9 ℃), chest tightness , and shortness of breath. oxygen saturation was 75-80%, heart rate of 156 beats per minute, blood pressure of 157/79mmHg, CRP was 208mg/L, blood albumin was 29.9g/L, and procalcitonin was 68.23ng/ml. Blood routine tests showed white blood cell count of 6.61×10\u003csup\u003e9\u003c/sup\u003e/L, neutrophil percentage of 77.2%, hemoglobin of 151g/L, platelet count of 180×10\u003csup\u003e9\u003c/sup\u003e/L, and an oxygenation index of 251. Considering sepsis, PMseq-DNA high-throughput genetic testing for pathogenic microorganisms in bloodstream infections was performed. The anti-infection regimen was adjusted to include amikacin sulfate (0.12g qd) and vancomycin (1g q3d) for intraperitoneal, along with imipenem-cilastatin (1g q12h ivgtt). The patient was transferred to the ICU for monitoring and treatment. After transfer to the ICU, PMseq-DNA high-throughput genetic testing revealed Klebsiella oxytoca, Enterococcus faecalis, Clostridium perfringens, Atypical Veillonella, and Escherichia coli. Bloody ascites was drained (Figure 2b). Routine ascites reexamination showed a nucleated cell count of 367*10\u003csup\u003e6\u003c/sup\u003e/L, neutrophil percentage of 93%, and red blood cell count of 1000*10\u003csup\u003e6\u003c/sup\u003e/L. On September 22, abdominal CT was unchanged compared to previous scans. On September 25, 2023, CRP was 156.7mg/L, procalcitonin was 50.67ng/ml. Blood routine tests showed a white blood cell count of 14.82×10\u003csup\u003e9\u003c/sup\u003e/L, neutrophil percentage of 86.7%, hemoglobin of 117g/L, platelet count of 99×10\u003csup\u003e9\u003c/sup\u003e/L. Routine ascites analysis revealed a nucleated cell count of 6497*106/L, neutrophil percentage of 95%, red blood cell count of 3000*10\u003csup\u003e6\u003c/sup\u003e/L, and an oxygenation index of 152.6 On September 27, 2023, CT showed a new pneumoperitoneum (Figure 1b), and the drained ascites appeared fecal-like (see Figure 2c), suggesting intestinal perforation. An emergency laparotomy was performed, revealing a large amount of yellow fecal ascites and pus in the abdominal cavity (Figure 3a). There was widespread adhesion in the abdominal cavity, with the omentum and intestinal tract wrapped around and adherent to the peritoneal dialysis tube. The small intestinal mesentery was contracted and stiff, and the small intestinal wall was widely adherent and edematous. Multiple segmental ischemic necrosis and perforation were observed in the jejunum approximately 60cm from the Treitz ligament (Figure 3b). The necrotic segment was about 60cm long, with no diverticulum-like changes. Small bowel partial resection (necrotic jejunum segment, see Figure 3c), abdominal adhesion lysis, and peritoneal dialysis tube removal were performed. Double-lumen drainage tubes were placed in the left pelvic cavity and right paracolic sulcus. Intraoperative bacterial culture of the pus grew Enterococcus faecium, which was sensitive to vancomycin. On September 28, ascites bacterial culture results returned, showing a large amount of Enterococcus faecium sensitive to vancomycin but resistant to penicillin, along with Candida krusei (isolated on the 25th). On the 13th day after surgery, brownish-yellow fluid leaked from the patient's right paracolic sulcus drainage tube incision. Surgical consultation suggested intestinal fistula, but the patient's family refused further surgery. On the 15th day after surgery, the patient died of sepsis and septic shock. A detailed chronological summary of the patient’s clinical course is presented in Table 2.\u003c/p\u003e\n\u003cp\u003eLiterature review:\u003c/p\u003e\n\u003cp\u003ePeritoneal dialysis (PD) is widely used in patients with end-stage renal disease (ESRD) due to its economic and simplicity. Peritonitis is a common complication of PD, clinical features consistent with peritonitis, that is, abdominal pain and/or cloudy dialysis effluent. The 2022 ISPD guidelines define peritonitis caused by intestinal perforation as enteric peritonitis[3]. Intestinal perforation in PD patients often presents as a chronic process without obvious acute abdominal symptoms, leading to secondary peritonitis or intra-abdominal abscesses ,which is similar to PD-related peritonitis. The use of antibiotics in the peritoneal cavity to alleviate peritonitis symptoms often results in delayed diagnosis and increased mortality[4]. Currently, there are relatively few reports on peritonitis caused by intestinal perforation in PD patients. We searched PubMed using the keywords \"Peritoneal dialysis-related peritonitis\" and \"intestinal perforation\" for articles published up to July 2024. After excluding articles with incomplete information or unavailable full texts, we identified 14 case reports, with 30 patients including ours. Based on the retrieved literature, including the case we reported, and excluding incomplete data, we summarized the epidemiological information as follows: Male to female ratio was 16:14, with a maximum age of 83 years, a minimum age of 19 years, and an average age of 58 years. Nine patients (30%) died. The duration of PD ranged from 1 month to 12 years, with an average of 3.8 years. The longest delay in diagnosis was 63 days, with an average delay of 14.75 days. The main site of intestinal perforation was the colon (20 cases, including 16 sigmoid colon, 2 large intestine, 1 cecum, and 1 transverse colon), followed by appendicitis perforation (5 cases), small intestine perforation (4 cases), and ileocecal perforation (1 case).Only 5 patients showed signs of intestinal perforation by abdominal CT when they were admitted to hospital.23 patients showed multi-bacterial peritonitis.The statistical results are shown in Table 1.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe abdominal clinical manifestations of intestinal perforation in patients undergoing peritoneal dialysis are non-specific compared to those of peritoneal dialysis-related peritonitis, often leading to delayed diagnosis, which is a significant risk factor for patient death[5-7]. The average time of delayed diagnosis is 14.75 days, and the case we reported was delayed for 10 days. Previous literature suggests that the role of abdominal CT in predicting intestinal perforation in peritoneal dialysis patients is uncertain[8], as pneumoperitoneum can also occur in CAPD patients[9]. Wellington, J.L. reported that imaging studies were not suggestive in 7 surgical patients[10], and in a review of 15 articles, only 5 patients had positive findings on initial abdominal CT. In our reported case, abdominal CT did not initially suggest intestinal perforation at the time of admission. However, after anti-infective treatment, the patient's peritonitis symptoms worsened, and fecal ascites appeared. A repeat abdominal CT scan revealed new pneumoperitoneum, suggesting intestinal perforation. Considering that imaging studies may not aid in early diagnosis, laparoscopy or surgical exploration may be necessary when symptoms do not resolve with antibiotic treatment or when peritonitis symptoms recur after treatment. The ISPD guidelines suggest that the presence of multiple microorganisms in peritoneal dialysate indicates intra-abdominal pathology[3], In our review of 30 patients, 23 had multiple microorganisms cultured, with one case of intestinal perforation caused by a single fungus. Our reported patient also had fungi cultured, and fungi were also cultured in 4 other cases of polymicrobial peritonitis.Shima,H[11] reported a case of intestinal perforative peritonitis with non-specific clinical manifestations, fungal cultures were positive in the ascites, and the peritoneal dialysis catheter was found to be the cause of intestinal perforation during its removal. In the general population, fungal infection in perforative peritonitis is a poor prognostic factor[12].The ISPD guidelines recommend immediate removal of the peritoneal dialysis catheter when fungi are detected in the dialysate or when refractory peritonitis is diagnosed[3]. Our patient was clinically diagnosed with refractory peritonitis, and the second ascites culture confirmed fungal infection postoperatively. Clinical symptoms and inflammatory markers did not improve, If the peritoneal dialysis catheter had been removed laparoscopically in a timely manner, intestinal perforation could have been detected early, possibly avoiding an unfavorable outcome. Therefore, patients with fungal peritonitis or refractory peritonitis should be alert to the possibility of intestinal perforation, and early laparoscopic catheter removal can be used to explore abdominal conditions and diagnose potential intestinal perforation. It is noteworthy that in this case, a discrepancy was observed between the PMseq-DNA results (showing multiple bloodstream pathogens) and the subsequent ascitic fluid culture (growing only Enterococcus faecium and Candida krusei). This may reflect the higher sensitivity of molecular testing to detect non-viable or low-burden organisms, antimicrobial suppression of culturable bacteria, and potential compartmentalization of infection following perforation. In complex abdominal infections, integrating both molecular and conventional culture methods may provide a more complete microbiological profile.\u003c/p\u003e\n\u003cp\u003ePatients with end-stage renal disease (ESRD) are at a higher risk of intestinal perforation, with colonic diverticulosis, chronic constipation, history of abdominal surgery, and appendicitis being the main risk factors for peritoneal dialysis (PD) patients[13]; The primary site of perforation is the colon, while small bowel perforation is rare.The incidence of small bowel perforation in the general population is relatively low[14], and the mortality rate of non-traumatic small bowel perforation is high, with common etiologies including typhoid, specific inflammation, tuberculosis, and malignant tumors[15]. The cause of small bowel perforation in dialysis patients remains unclear,Fujii,K[7] eported a case of perforation due to small bowel adhesive intestinal obstruction, while another case was possibly related to extensive peritoneal calcification[16]. Currently, there are no reported cases of intestinal perforation in patients undergoing combined PD and hemodialysis (HD). We report a case of a patient who maintained PD treatment for 10 years and received combined HD due to inadequate peritoneal dialysis. On admission, CT revealed extensive atherosclerosis in the thoracoabdominal aorta, coronary arteries, splenic artery, superior mesenteric artery, bilateral renal arteries, and bilateral iliac arteries. A repeat CT scan during the patient's deterioration indicated pneumoperitoneum, suggesting intestinal perforation. Exploratory laparotomy revealed multi-segmental ischemic necrosis and perforation of the jejunum. Despite surgical treatment, the patient died of sepsis finally. We hypothesize that this patient developed chronic mesenteric ischemia due to superior mesenteric artery atherosclerosis, which progressed to intestinal necrosis and perforation. This is supported by several factors: firstly, the patient was admitted one month prior with abdominal pain and distension, but the ascites test was negative; secondly, after admission, the drained ascites was bloody, suggesting intra-abdominal small vessel hemorrhage. Chronic mesenteric ischemia refers to intermittent or persistent insufficient perfusion of the small intestine, often caused by mesenteric atherosclerosis[17],and necrosis and perforation are severe complications. The increased risk of atherosclerosis can be observed in the early stages of chronic kidney disease[18]. The NEFRONA study indicated an increased prevalence of atherosclerosis in patients with moderate CKD, and the progression of atherosclerosis is closely related to the progression of CKD[19], Hemodialysis accelerates atherosclerosis in patients with CKD[20], and diabetes can also accelerate its progression.[21]. Most cases of chronic mesenteric ischemia are asymptomatic, but symptomatic patients may experience abdominal pain related to eating. Previous literature has reported that the risk of mesenteric ischemia in ESRD patients is 44.1 times higher than in the general population, compared to hemodialysis, peritoneal dialysis is associated with a higher risk of mesenteric ischemia, independent risk factors include older age, diabetes, peripheral vascular disease, heart failure, and peritoneal dialysis[22]. Mesenteric ischemia in peritoneal dialysis patients can manifest similarly to peritonitis, leading to delayed diagnosis and high mortality[23]. Therefore, in long-term dialysis patients, considering the increased prevalence of atherosclerosis, it is crucial to be vigilant about the possibility of small bowel perforation caused by superior mesenteric artery atherosclerosis.\u003c/p\u003e\n\u003cp\u003eThis case report has several limitations. First, it is a retrospective study of a single patient, which limits the generalizability of our findings. Second, the diagnosis of intestinal perforation was delayed, reflecting the inherent difficulty in distinguishing between PD-related peritonitis and perforative peritonitis based on clinical and imaging features alone. Third, although we reviewed relevant literature, the sample size of reported cases remains small, which may affect the strength of our epidemiological summary. Finally, the patient’s complex comorbidities and combined dialysis modality may represent a unique clinical scenario, and further case reports are needed to validate our observations and recommendations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIntestinal perforation leading to enteric peritonitis is relatively rare in peritoneal dialysis patients and can be difficult to distinguish from peritoneal dialysis-related peritonitis. The rate of delayed diagnosis is high, and the prognosis is poor. In patients with peritonitis who show poor response to anti-infective treatment, recurrent symptoms, or positive ascitic fluid cultures indicating polybacterial infection, intestinal perforation should be suspected, given the low diagnostic yield of abdominal CT, laparoscopy or surgical laparotomy should be considered to improve early diagnosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments: The authors would like to thank our patient’s family for allowing for his case to be presented.\u003c/p\u003e\n\u003cp\u003eEthical approval: Ethical approval was obtained from Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine, in accordance with the ethical guidelines of the 1975 Declaration of Helsinki (ethical approval number: G2024-33).\u003c/p\u003e\n\u003cp\u003eConsent for publication: We have obtained written informed consent from the patient's family for the publication of this case report, including all clinical details, imaging findings, and surgical photographs (including identifiable images), and for their use in academic journals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions: Tonghuan Liu conceived and designed the study, drafted the original manuscript, and performed the literature review. Lixin Wang supervised the research, provided critical revisions to the manuscript, and contributed to study design and data collection. Junjie Lin and Ruizhi Yu participated in manuscript review and editing, and provided intellectual input throughout the writing process.Ruizhi Yu contributed to the creation and optimization of figures and tables. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eDisclosure statement: No potential conflict of interest was reported by the author(s).\u003c/p\u003e\n\u003cp\u003eFunding: Zhang Daning’s Academic Experience Inheritance Studio, Guangdong Provincial Hospital of Traditional Chinese Medicine (E43714), the Traditional Chinese Medicine Bureau of Guangdong Province (grant number:20232051)\u003c/p\u003e\n\u003cp\u003eData availability statement: All data generated or analyzed during this study are included in this published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYu X, Yang X. Peritoneal dialysis in China: meeting the challenge of chronic kidney failure. Am J Kidney Dis. 2015;65(1):147\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWakeen MJ, Zimmerman SW, Bidwell D. Viscus perforation in peritoneal dialysis patients: diagnosis and outcome. Perit Dial Int. 1994;14(4):371\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRotellar C, et al. Bowel perforation in CAPD patients. Perit Dial Int. 1992;12(4):396\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKurultak I, Altay M, Duranay M. Fatal cecal perforation complicating PD peritonitis. Perit Dial Int. 2008;28(4):329\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang R, et al. Delayed bowel perforation in a peritoneal dialysis patient: a case report and literature review. Perit Dial Int. 2014;34(4):460\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFujii K, et al. Adhesive intestinal obstruction increases the risk of intestinal perforation in peritoneal dialysis patients: a case report. BMC Nephrol. 2018;19(1):153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMizuno M, et al. Perforative peritonitis caused by appendicitis in a patient on peritoneal dialysis. Intern Med. 2013;52(11):1177\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChang FC, et al. Intestinal perforation in a patient with continuous ambulatory peritoneal dialysis. QJM. 2009;102(7):495\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWellington JL, Rody K. Acute abdominal emergencies in patients on long-term ambulatory peritoneal dialysis. Can J Surg. 1993;36(6):522\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShima H, et al. Intestinal perforation by a peritoneal dialysis catheter in which fungal peritonitis led to diagnosis: a rare case report. CEN Case Rep. 2018;7(2):208\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrakash A, et al. Effect of Candida infection on outcome in patients with perforation peritonitis. Indian J Gastroenterol. 2008;27(3):107\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInaguma Y, Kaito H, Tanaka R. A rare case of peritonitis in a young woman on peritoneal dialysis. CEN Case Rep. 2020;9(4):448\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeman HJ. Spontaneous free perforation of the small intestine in adults. World J Gastroenterol. 2014;20(29):9990\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJain BK, et al. Insight into the management of non-traumatic perforation of the small intestine. J Infect Dev Ctries. 2010;4(10):650\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTu HY, et al. Extensive peritoneal calcification and small intestinal perforation in a peritoneal dialysis patient: a case report. Kaohsiung J Med Sci. 2011;27(5):199\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcosta S. Epidemiology of mesenteric vascular disease: clinical implications. Semin Vasc Surg. 2010;23(1):4\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValdivielso JM, et al. Atherosclerosis in Chronic Kidney Disease: More, Less, or Just Different? Arterioscler Thromb Vasc Biol. 2019;39(10):1938\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJunyent M, et al. [Usefulness of imaging techniques and novel biomarkers in the prediction of cardiovascular risk in patients with chronic kidney disease in Spain: the NEFRONA project]. Nefrologia. 2010;30(1):119\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindner A, et al. Accelerated atherosclerosis in prolonged maintenance hemodialysis. N Engl J Med. 1974;290(13):697\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao N, et al. Diabetes Mellitus to Accelerated Atherosclerosis: Shared Cellular and Molecular Mechanisms in Glucose and Lipid Metabolism. J Cardiovasc Transl Res. 2024;17(1):133\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi SY, et al. Mesenteric ischemia in patients with end-stage renal disease: a nationwide longitudinal study. Am J Nephrol. 2012;35(6):491\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArchodovassilis F, et al. Nonocclusive mesenteric ischemia: a lethal complication in peritoneal dialysis patients. Perit Dial Int. 2007;27(2):136\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWen YK. Diagnostic dilemma of bowel perforation in a peritoneal dialysis patient with encapsulating peritoneal sclerosis. Clin Nephrol. 2023;100(4):193\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdames H, et al. Peritonitis due to Microbacterium sp in a patient on cycler peritoneal dialysis. Perit Dial Int. 2010;30(6):669\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura H, et al. Stercoral perforation of the sigmoid colon in a patient undergoing CAPD: case report. Perit Dial Int. 2004;24(4):399\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorimoto H, et al. [A rare case illustrating the difficulty of diagnosing and treating elderly patient with CAPD-related peritonitis caused by the perforation of sigmoid colon diverticulum]. Nihon Ronen Igakkai Zasshi. 2002;39(3):314\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarmeci C, et al. Emergency laparotomy in patients on continuous ambulatory peritoneal dialysis. Am Surg. 2001;67(7):615\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImai H, Satoh K. Perforated diverticulitis after barium enema examination in a patient on CAPD. Nephrol Dial Transpl. 1997;12(12):2758\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"962\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 962px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Table 1: Clinical characteristics of peritoneal dialysis patients with intestinal perforation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eStudy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003ePatients Age/Sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eDuration of CAPD,y\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eResults of culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eCT scans results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eDuration from onset to surgery,d\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003ePerforation site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eThis case\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e63/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eEnterococcus faecium, Enterococcus avian,\u003c/p\u003e\n \u003cp\u003eCandida krusei\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSmall intestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eWen, Y.K\u003c/p\u003e\n \u003cp\u003e2023[24]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e59/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eE.coli, Klebsiella pneumoniae, Enterococcus faecalis, Parabacteroides distasonis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eencapsulating peritoneal sclerosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eInaguma,Y,\u003c/p\u003e\n \u003cp\u003e2020[13]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e19/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003ethree bacteria types, including anaerobic bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003esigmoid colon perforation and fecal mass\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eFujii, K，2018[7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e73/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eEnterococcus faecalis and Bacteroides caccae\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003elocalized dilation of the intestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSmall intestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eMizuno,M，2013[8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e46/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eKlebsiella pneumonia, Citrobacter freundii, Enterococcus faecium and Fusobacterium nucleatum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eAppendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eTu, H.Y,\u003c/p\u003e\n \u003cp\u003e2011[16]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e56/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eextensive calcification of the abdominal aorta and small arteries.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSmall intestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(sepsis)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eAdames,H,\u003c/p\u003e\n \u003cp\u003e2010[25]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e57/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMicrobacterium sp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eTransverse colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(septic shock)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eChang,F.C,\u003c/p\u003e\n \u003cp\u003e2009[9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e69/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eCandida albicans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eminimal free air pockets in the peritoneal cavity/a focal asymmetric wall defect of the distal ileum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSmall intestine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eKurultak,I,\u003c/p\u003e\n \u003cp\u003e2008[5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e54/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003emethicillin-susceptible Staphylococcus aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eCecal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eNakamura,H,2004[26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e72/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eMorimoto,H,\u003c/p\u003e\n \u003cp\u003e2002[27]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e67/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eEnterococcus,E.coli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003ean abscess in the Douglas pouch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eCarmeci,C,\u003c/p\u003e\n \u003cp\u003e2001[28]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e51/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003ePseudomonas aeruginosa,Candida albicans,Enterobacter cloacae,Citrobacter freundii\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eSubhepatic and periportal abcesses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eAppendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e34/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eCandida albicans,Escherichia coli,Staphylococcus aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eFluid consistent with CAPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eAppendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e46/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eClostridium difficile,C. freundii,C. albicans,S.aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eFluid consistent with CAPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eAppendix\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(septic shock)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e50/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eE.coli(two species)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eSigmoid diverticulitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e71/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eE.coli,S.aureus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eH. Imai，1997[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e64/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eEnterococcus faecalis, E.coli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(septic shock)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eWellington, J. L,1993[10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e63/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e8.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e83/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e57/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms (Bacteroides fragilis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(sepsis)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e66/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eColon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied(sepsis)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e77/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eNo surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eDied\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e69/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e2.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eMultiple enteric organisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003eRotellar,C,\u003c/p\u003e\n \u003cp\u003e1992[4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e22/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003egm-rods bacteroides\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e69/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eproteus Enterococci klebsiella\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e36/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e4.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eS.epidermidis S.aureus,bacteroides,E.coli\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eRight colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e80/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003egm-gm+cocci bacteroides,clostridium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e54/M\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e1.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eAnaerobes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e54/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eklebsiella,Enterococci,Pseudomonas\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eIleocecal area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e53/F\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 52px;\"\u003e\n \u003cp\u003e1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp\u003eEnterococci, S.aureus,Candida\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003eSigmoid colon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eSurvived\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" style=\"width: 962px;\"\u003e\n \u003cp\u003eF, female; M, male; N/A, Not Applicable.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"107%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 100px;\"\u003e\n \u003cp\u003eTable 2: Clinical Timeline of the Case\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003eDate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eEvent / Finding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eManagement / Outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2013/3/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eInitiation of Peritoneal Dialysis (PD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003ePD catheter placement.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2020/4/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAddition of Hemodialysis (HD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eLeft forearm arteriovenous fistula created due to inadequate PD.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2020/6/24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eCombined Dialysis Regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eHD twice weekly added to PD.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2022/3/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eColonoscopy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eNo diverticular lesions found.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/7/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAdmission for abdominal distension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eInitial ascites fluid negative. Discharged after symptomatic improvement.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eEmergency presentation with abdominal pain for 10 days, worsening for 1 day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eCT showed extensive atherosclerosis of superior mesenteric artery. Suspected PD-related peritonitis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eInitial antibiotic therapy (ceftriaxone IV, intraperitoneal cefazolin and ceftazidime).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAdmission to renal unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eRed/turbid ascites, fever, elevated inflammatory markers. Diagnosis: PD-related peritonitis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eAntibiotics changed to IV sulperazon，\u0026nbsp;intraperitoneal cefazolin and ceftazidime.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eClinical deterioration (fever, lethargy, respiratory distress)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eSepsis suspected. PMseq-DNA testing performed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eAntibiotics adjusted (IV imipenem-cilastatin，intraperitoneal amikacin and vancomycin). Transfer to ICU.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAbdominal CT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eUnchanged from previous.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eAscites specimen sent for bacterial culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003e2023-09-28 Formal culture: Enterococcus faecium (vancomycin-sensitive, penicillin-resistant) and Candida krusei confirmed.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/9/27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eNew CT findings and ascites appearance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eNew pneumoperitoneum; fecal-like ascites drained. Intestinal perforation suspected.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eEmergency laparotomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eFindings: jejunal ischemic necrosis and perforation. Small bowel resection, adhesion lysis, PD catheter removal.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/10/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003ePostoperative complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003eBrownish-yellow fluid leakage from drainage site; suspected intestinal fistula. Family declined further surgery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e2023/10/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003eOutcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 55px;\"\u003e\n \u003cp\u003ePatient died of sepsis and septic shock.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Case Report, perforative peritonitis, PD-related peritonitis, intestinal perforation, peritoneal dialysis","lastPublishedDoi":"10.21203/rs.3.rs-8448620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8448620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: The incidence of peritonitis caused by intestinal perforation in patients undergoing peritoneal dialysis (PD) is low, but it often leads to delayed diagnosis and poor prognosis.\u003c/p\u003e \u003cp\u003eCase presentation: We report a case of a 63-year-old patient on combined PD and hemodialysis (HD) who presented with abdominal pain, turbid peritoneal fluid, and bloody ascites. Abdominal CT revealed extensive atherosclerosis of the superior mesenteric artery. The patient was diagnosed with PD-related peritonitis, and ascites cultures grew Enterococcus. Despite anti-infective treatment, the patient's condition did not improve. On the tenth day of admission, fecal ascites were drained, and a repeat abdominal CT showed new pneumoperitoneum, suggesting intestinal perforation. Emergency laparotomy confirmed superior mesenteric artery ischemia leading to small bowel perforation. Postoperative ascites cultures grew Candida krusei and Enterococcus faecium. The patient was transferred to the ICU for aggressive treatment but ultimately succumbed to septicemia.\u003c/p\u003e \u003cp\u003eConclusion: Currently, it is difficult to distinguish clinically between perforative peritonitis and PD-related peritonitis in PD patients, and imaging findings are often non-specific. Laparoscopic catheter removal or early laparotomy for refractory or fungal peritonitis may aid in early identification.\u003c/p\u003e","manuscriptTitle":"Small Intestinal Perforation Leading to Peritonitis in a Patient Undergoing Peritoneal Dialysis Combined with Hemodialysis: A Rare Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 06:53:29","doi":"10.21203/rs.3.rs-8448620/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-10T09:00:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T12:14:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T13:18:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-02T10:56:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-29T07:50:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T22:34:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-26T12:08:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52505301372430954981594789172811810833","date":"2026-01-24T08:57:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T07:57:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"219970005148579337984935737918682127162","date":"2026-01-24T06:14:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266309688050399843692406558246410288035","date":"2026-01-23T08:46:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112196151676067172991785855112406957570","date":"2026-01-23T01:24:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T17:36:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"23704157802582259547943528453796129042","date":"2026-01-21T17:20:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61968027723103173062844879264192490566","date":"2026-01-21T08:02:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T03:24:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T02:39:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93372733661584991071349854443056752289","date":"2026-01-21T02:33:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125616676781010094165886699758673557029","date":"2026-01-21T02:13:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315262580365958619778019010214768848343","date":"2026-01-19T16:08:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305363241500355737654481669650726094037","date":"2026-01-19T11:54:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-19T02:08:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-15T05:28:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-07T04:11:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-06T13:59:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2026-01-06T13:48:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"07363563-fce6-48d3-8c64-eef5a70f1647","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-02-10T09:09:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 06:53:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8448620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8448620","identity":"rs-8448620","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}