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SummaryLithium-induced nephrogenic diabetes insipidus (Li-NDI) is a rare and difficult-to-treat condition. A study in mice and two recent papers describe the use of acetazolamide in Li-NDI in 7 patients (a case report and a 6 patient series). We describe the case of a 63-year-old woman with bipolar disorder treated with lithium and no previous history of diabetes insipidus. She was hospitalized due to a bowel obstruction and developed severe dehydration after surgery when she was water deprived. After desmopressin administration and unsuccessful thiazide and amiloride treatment, acetazolamide was administrated to control polyuria and hydroelectrolytic disorders without significant side effects. To our knowledge, this is the third publication on acetazolamide use in Li-NDI patients.Learning points:Treatment of lithium-induced nephrogenic diabetes insipidus might be challenging.Vasopressin, amiloride and thiazide diuretics have been used in lithium-induced nephrogenic diabetes insipidus treatment.Acetazolamide might be an option to treat lithium-induced nephrogenic diabetes insipidus patients who fail to respond to standard treatment.The use of acetazolamide in lithium-induced nephrogenic diabetes insipidus must be monitored, including its effects on glomerular filtration rate.

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Introduction: Peritonitis is a common complication in peritoneal dialysis, playing a weighty role in patient morbidity and a major cause of transfer to hemodialysis Relapsing or repeat episodes are associated with the development of a biofilm -trapping bacteria, and catheter removal is recommended in these cases. Since October of 2013 our peritoneal dialysis unit has developed a protocol that adds a fibrinolytic agent to an intraperitoneal antibiotic, aiming to reduce the number of relapsing/repeat episodes.Objective: To demonstrate the efficacy and safety of associating a fibrinolytic agent to intraperitoneal antibiotics in the prevention of relapsing or repeat peritonitis.Methodology: Observational study comparing the number of relapsing/repeat peritonitis events between two groups during a four -year period: a historic one, treated with intraperitoneal antibiotics only (control group) and one group that received an association of intraperitoneal antibiotics with alteplase (alteplase group). Secondary and fungi peritonitis were excluded from this study.Results: During the study period, a total of 103 peritonitis episodes were registered (control group: 61 episodes; alteplase group: 42 episodes) corresponding to 17 relapsing/repeat events, with statistical significance between groups (control group: 15 episodes (24.6%); alteplase group: 2 episodes (4,7%); p=0.008). There was no difference in demographic characteristics or the presence of exit site infection between the groups. The microorganisms most frequently involved in relapsing/repeat episodes were S.epidermidis and E.coli. Regarding the outcomes of the treatment, no patient in the alteplase group had to undergo catheter removal due to relapsing/repeat episodes of peritonitis. There were no adverse events following alteplase administration. Three deaths due to peritonitis -related sepsis were registered.Conclusion: Although relapsing/repeat peritonitis are still an important cause of catheter removal, this study demonstrates the potential benefit of fibrinolytic association with intraperitoneal antibiotics in preventing these events and potentially reducing modality drop -out.