Clostridium difficile infection was identified as the major cause of antibioticassociated diarrhea and cause wide manifestations include asymptomatic, fulminant disease and unusual manifestations such as protein-losing enteropathy. The incidence and severity of healthcare-associated clostridium difficile have been dramatically increased. A 25-years old male with end-stage renal disease who on hemodialysis complained of nonbloody watery diarrhea and abdominal pain for a month. Also, he had a hospital admission due to secondary peritonitis with negative investigations and was treated with antibiotics with no improvement. Abdominal CT scan revealed a moderate amount of ascites with wall thickening of transverse colon and culture of ascites was negative. A stool examination was positive for clostridium difficile toxins (A+B) and cured by 21 days of oral vancomycin. A literature review for ascites- induced by clostridium difficile yielded only one patient with end-stage renal disease on hemodialysis. First-line clinicians may not be familiar with such a rare manifestation and may not initially consider it when making differential diagnosis related to secondary peritonitis. Clostridium difficile should be suspected in all cases of diarrhea in patients with chronic kidney disease and should be considered in the presence of ascites in the context of diarrhea with no obvious source.