key: cord-0939159-hoi2x4n4 authors: Candellier, Alexandre; Goffin, Eric title: Can SARS-CoV-2 be found in the effluent from peritoneal dialysis patients? date: 2021-06-11 journal: Clin Kidney J DOI: 10.1093/ckj/sfab099 sha: 8396bb6de1f25b33e95cc5ad20f5998914bfd591 doc_id: 939159 cord_uid: hoi2x4n4 nan Peritoneal dialysis (PD) patients represent a vulnerable population for coronavirus disease 2019 (COVID-19) [1, 2] . Approximately 300 000 patients are currently treated by PD worldwide, which produces large amounts of care-related waste including peritoneal effluent. PD drained fluid has previously been identified as a potential source of contamination with hepatitis B virus (HBV) [3] , hepatitis C virus (HCV) [4] and human immunodeficiency virus (HIV) [5] . The question regarding the contagiousness of spent peritoneal dialysate by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the current COVID-19 pandemic is still debated. In order to investigate this concern, we performed a systematic review of currently available literature. Since the start of the pandemic, seven studies (three cases series and four cases reports) have reported peritoneal dialysate testing (n ΒΌ 52 in 28 patients) for the presence of SARS-CoV-2 using reverse transcriptase-polymerase chain reaction (RT-PCR) ( Table 1) [6] [7] [8] [9] [10] [11] [12] . Only one report analysed the presence of viable viral particles with cytopathic studies [7] . The effluent was tested throughout the clinical course from 0 to 41 days after diagnosis. Most reports involved mild-to-moderate COVID-19 in chronic PD patients, but two studies [7, 9] were performed during acute PD in critical ill patients. None of the PD effluent from the 10 patients in whom cytopathic studies were performed was found positive [7] . Identification of SARS-CoV-2 RNA was reported in only 1 (3.6%) of the 28 patients [11] . In this single case, PCR assay was positive 1 month after COVID-19 diagnosis; unfortunately, viral culture or cytopathic analysis was not performed, and the cycle threshold for the PCR was not mentioned. Peritoneal dialysate effluent from PD patients might theoretically become infective for some viruses either via the catheter, by intra-luminal or peri-luminal routes after touch contamination, or via haematogenous diffusion or viral translocation across injured intestinal loops. Dialysate contamination had indeed been described in PD patients infected by small viruses such as HBV [3] , HCV [4] and HIV [5] who had systemic infection and high viral load, but not during the SARS pandemic in 2003 [13] nor during the Middle East Respiratory Syndrome (MERS) outbreak in 2012. Similarly, the lack of SARS-CoV-2 documentation within spent dialysates, has reviewed here, might thus be accounted for, on one hand, by the scarcity of intact virus circulation in blood (even though SARS-CoV-2 RNA has been detected in serum or plasma from infected patients [14] ), and on the other hand, by a virion size larger than the peritoneum pores diameter. It is also unlikely that RT-PCR assays have missed identifying viral RNA in peritoneal effluent, as fluid centrifugation is commonly performed to enhance their sensibility [6] . A word of caution should however be mentioned. As a prolonged presence of SARS-CoV-2 RNA has been described in faecal samples [15] , viral RNA might be found within the dialysate effluent in PD patients with severe enteric peritonitis, because of transmural translocation. In this context, viral RNA was found on peritoneal fluid from three COVID-19 patients, not on PD, but in whom an open abdominal surgical procedure was performed. Coccolini et al. [16] first reported positive RT-PCR (RdRP, N and E sequences) on intraperitoneal swabs from a 78-year-old male during surgically treated ileal volvulus and from a 71-year-old female who underwent subtotal colectomy for severe colitis with ulceration and bleeding, respectively [17] . Intraoperative fluid sampling was also found positive in a 73-year-old female with small bowel resection due to an incarcerated umbilical hernia and concomitant loop necrosis [18] . In these studies, viral isolation was not performed. To date, strong evidence of intraperitoneal contamination of PD patients by SARS-CoV-2 is lacking as no direct viral culture is available and as viral RNA was found in the PD effluent of only one patient. Still, the presence of RNA does not imply infectivity [19] . The risk of viral transmission by PD effluent thus remains , at most, very low. Imposing special disposal procedures, such as the instillation of hypochlorite in the drainage bags, is probably not necessary. Nevertheless, it still seems prudent to drain spent PD effluent into a toilet that needs to be disinfected thereafter. CKD is a key risk factor for COVID-19 mortality ERACODA: The European database collecting clinical information of patients on kidney replacement therapy with COVID-19 Hepatitis B surface antigen (HBSAg) in peritoneal fluid of HBSAg carriers undergoing peritoneal dialysis Diffusion of HCV through peritoneal membrane in HCV positive patients treated with continuous ambulatory peritoneal dialysis Detection of HIV antigen in peritoneal dialysis fluid Absence of SARS-CoV-2 in the effluent of peritoneal dialysis patients Coronavirus disease 2019 (COVID-19) hospitalized patients with acute kidney injury treated with acute peritoneal dialysis do not have infectious peritoneal dialysis effluent SARS-CoV-2 not detected in peritoneal effluent in COVID-19 end-stage kidney disease (ESKD) peritoneal dialysis patient Peritoneal dialysis for COVID-19-associated acute kidney injury Does SARS-CoV-2 reach peritoneal effluent? SARS-CoV-2 in the peritoneal waste in a patient treated with peritoneal dialysis SARS-CoV-2 in spent dialysate from chronic peritoneal dialysis patients with COVID-19 Severe acute respiratory syndrome in dialysis patients No evidence of SARS-CoV-2 transfusion transmission despite RNA detection in blood donors showing symptoms after donation Prolonged presence of SARS-CoV-2 viral RNA in faecal samples SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients SARS-CoV-2 in peritoneal fluid: an important finding in the Covid-19 pandemic COVID-19 in the peritoneal fluid: does this evidence oblige to introduce new rules? Presentation of a Case Report Virological assessment of hospitalized patients with COVID-2019 None declared.