Twenty-one episodes of peritonitis in a continuous ambulatory peritoneal dialysis patient: What is the root cause?

A 51-year-old female, with non-alcoholic liver cirrhosis, portal hypertension, type 2 diabetes mellitus, autosomal dominant polycystic kidney disease with a clipped cerebral aneurysm and chronic kidney disease stage 5 was on continuous ambulatory peritoneal dialysis (CAPD) for 6.5 years elsewhere. She came for opinion on continuation of CAPD as she had 21 episodes of peritonitis in 76 months. Her blood pressure was 80/50 mmHg. She was on haemodialysis with a temporary central access for 2 weeks. She had no abdominal tenderness, and exit site looked normal. Fluid was negative for Mycobacterium tuberculosis. Laparoscopically, we replaced the catheter with a new swan-neck Tenckhoff double-cuff catheter through a different exit site in the same sitting. Catheter-tip biofilm culture isolated Enterococcus casseliflavus. Peritoneal sampling biopsy showed evidence of fibrosis. She has adequate ultrafiltration and is currently on automated peritoneal dialysis for 5 months.