We prospectively followed-up new patients of tuberculosis while on maintenance hemodialysis at a State Government-run tertiary care institute. Between 2000 and 2010, 1237 new patients were initiated on maintainence hemodialysis. The number of patients diagnosed with tuberculosis after initiation of hemodialysis was 131 (10.5% of 1237). The age was 46.4 ± 10.4 (range 8-85) years and there were 90 (68.7%) males. The number of patients diagnosed with tuberculosis on the basis of organ involvement were: Pulmonary-60, pleural effusion-31, lymph node-21, meningitis-8, pericardial effusion-7, peritoneum-2, latent tuberculosis-2. The incidence of tuberculosis in hemodialysis was found to be 105.9 per 1000 patient years. Male gender, diabetes mellitus, past history of tuberculosis, mining as an occupation, low serum albumin, and duration of hemodialysis more than 24 months, and unemployment were found to be significant risk-factors on univariate analysis.

Editor:A 55-year-old man with hypertension, coronary artery disease, and end-stage renal disease was initiated on automated peritoneal dialysis with 2.5% Dianeal solution [Baxter (India) Private, Haryana, India] 14 days after Tenckhoff catheter placement. On day 0 of initiation, the peritoneal effluent was cloudy. Newspaper print was not visible through the effluent (Figure 1). The patient had no complaints of abdominal pain, fever, loose stools, or vomiting. No fibrin clots were evident, and there were no cells in the effluent. Gram stain, Ziehl-Neelsen stain, and KOH mount of the effluent were negative. Cultures for bacteria and fungi were sterile.The effluent remained cloudy for the next few days, but the patient had no symptoms. There were still no cells on repeat examination, and repeat staining and cultures of the effluent were also negative. The patient's pulse was 78 bpm and his blood pressure was 130/80 mmHg. A clinical examination, including abdominal exam, was unremarkable. There were no clinical features suggestive of acute pancreatitis, solid-organ malignancy, or lymphoma.Effluent triglycerides were measured. The levels were high at 54 mg/dL, 61 mg/dL, and 52 mg/dL on 3 consecutive days. Serum triglycerides were 134 mg/dL. Serum and effluent amylase levels were 12 U/dL and 10 U/dL respectively. In other investigations, serum creatinine was 8.8 mg/dL; blood urea nitrogen, 213 mg/dL; hemoglobin, 9.8 g/dL; and 24-hour urine protein, 230 mg. Contrast-enhanced computed tomography imaging of the abdomen revealed a normal pancreas. Effluent was also negative for malignant cells on repeat examination.The surgeon reported that the catheter insertion had been atraumatic. The patient's medications during this phase of cloudy peritoneal fluid were sevelamer carbonate, injection calcitriol, diltiazem, isosorbide mononitrate, aspirin, and vitamins.Diltiazem, although not a dihydropyridine calcium channel blocker, was stopped. The next day, the effluent became translucent. There were no cells in the effluent. Effluent triglycerides fell to a normal level of 1.0 mg/ dL. After 3 days, the diltiazem was added back to the patient's medications. The effluent became cloudy again, and effluent triglycerides were now 55 mg/dL.Cloudy peritoneal fluid is not always infection (1). An absence of cells excludes infection, intra-or juxta-peritoneal inflammation, allergic reaction to constituents of the dialysis system, air, and pharmaceuticals. Our patient

Automated peritoneal dialysis (APD) is increasingly being used for the treatment of end stage renal disease. We present our experience of APD at a government run tertiary care institute. APD was initiated for 22 patients between 2002 and 2010. On comparing APD and continuous ambulatory peritoneal dialysis (CAPD) patients, no difference in patient survival and technique survival was observed. CAPD patients had higher number of peritonitis episodes, greater decline in the serum albumin and a greater number of patients failed to achieve adequacy targets compared to APD.

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