SARS-CoV-2 in the peritoneal waste in a patient treated with peritoneal dialysis.

To the editor:

We describe for the first time the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the peritoneal waste of a patient with coronavirus disease 2019 and end-stage kidney disease on peritoneal dialysis. A 53-year-old Caucasian female affected by fibrillary glomerulonephritis and on peritoneal dialysis since November 2019 was admitted to our hospital on March 9 with fever, cough, headache, myalgia, and mild hypoxemia. Chest computed tomography showed bilateral multiple ground-glass opacities but the initial nasopharyngeal swab for SARS-CoV-2 was negative. Her laboratory tests showed mild lymphopenia (0.87 × 109) and increased C-reactive protein (128 mg/l) and D-dimer (2213 ng/ml) levels. Because her computed tomography, clinical, and laboratory findings were highly suspicious for coronavirus disease 2019, the patient was isolated and treated with lopinavir and (with) ritonavir, hydroxychloroquine, low-molecular weight heparin, and tocilizumab. One month after admission, a second nasopharyngeal swab was positive. During this period, she became anuric. Despite increasing the osmolarity of peritoneal dialysis solutions, she developed pulmonary edema. At that time, we tested her peritoneal dialysate for SARS-CoV-2 by polymerase chain reaction, and this was positive. She received 8 hemodialysis treatments and following 40 days of hospitalization, the patient was discharged and peritoneal dialysis was gradually resumed although her nasopharyngeal swab and peritoneal dialysate remained positive on discharge. Seven days after discharge, SARS-CoV-2 testing was negative in the peritoneal dialysate and nasopharyngeal swab. To our knowledge, this is the first case in the literature demonstrating SARS-CoV-2 positivity in peritoneal dialysate. Notably, SARS-CoV-2 positivity corresponded with peritoneal dialysis failure, suggesting a potential effect of the virus on the peritoneal membrane.

We hope this interesting case will motivate the nephrology community to look at our patients on peritoneal dialysis and consider testing their dialysate. We suggest that it will be of critical importance to go beyond polymerase chain reaction testing and actually attempt to culture the virus from the fluid. At this time it is not clear whether a positive polymerase chain reaction for SARS-CoV-2 means contagious virus is present.