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insertion in adult peritoneal dialysis patients: case report and literature review A 79-year-old woman on peritoneal dialysis was admitted to hospital on January 14, 2013, for management of bilateral nonhealing heel ulcers. During her hospital stay, her oral intake was very poor and her albumin level progressively declined to 8g/L. On February 15, she underwent percutaneous endoscopic gastrostomy (PEG) tube insertion and was switched to hemodialysis. Prophylactic oral fluconazole and intravenous piperacillin/tazobactam were administered. On February 23, she developed fever, hypotension, and tachycardia, and subsequently had a cardiorespiratory arrest. She was resuscitated and transferred to the intensive care unit. A leak around the PEG tube site was noted and the PD catheter drained turbid fluid with a total white cell count of 9800×10–6/L and effluent culture grew Klebsiella oxytoca, Pseudomonas aeruginosa, Enterococcus species, and Candida albicans. Imaging showed no evidence of bowel perforation. The patient continued to deteriorate and she died on February 24, 2013. A very limited number of case reports [1, 2] indicate that the insertion of peritoneal dialysis catheters in patients who have a preexistent and presumably well-healed PEG may be safe (●" Table1), but that the insertion of gastrostomy tubes in patients receiving peritoneal dialysis is associated with major adverse outcomes including leaks and fatal or nonfatal peritonitis (●" Table2) [2,3]. With our patient, withholding peritoneal dialysis, switching to hemodialysis, and use of prophylactic antimicrobials did not prevent the development of fatal peritonitis. We hypothesize that residual peritoneal fluid may have prevented effective healing of the PEG site with subsequent spillage of gastric contents into the peritoneal space. It is uncertain whether surgical as opposed to endoscopic placement or a longer healing time would have resulted in a better outcome. We conclude that gastrostomy tubes should not be placed in adult patients on peritoneal dialysis, because of a very high rate of fatal peritonitis.

High mortality following gastrostomy tube insertion in adult peritoneal dialysis patients: case report and literature review