#2905 Recurrent liver cyst infections in an ADPKD patient on peritoneal dialysis

Abstract Background and Aims Autosomal dominant polycystic kidney disease (ADPKD) is frequently associated with liver manifestations, and liver cyst infection is a serious complication. We present the case of a patient who experienced recurrent liver cyst infections over eight months while undergoing peritoneal dialysis. Results A 59-year-old male with a history of ADPKD and chronic automated peritoneal dialysis for 4 years presented four times to our institution in 2024 with hepatic cyst infections, with an average interval of two months between admissions. Common clinical features included high-grade fever, epigastric pain, nausea, vomiting, leukocytosis, elevated C-reactive protein, and positive blood cultures for gram-negative bacilli. The first episode was initially treated as septicemia with two weeks of intravenous antibiotics, as imaging findings were inconclusive. In the second episode, MRI confirmed the presence of an infected cyst, and antibiotic therapy was extended to 6 weeks. Notably, there was no evidence of peritonitis, as peritoneal dialysis effluent cultures were negative for infection each time, and there were no signs of diverticulitis on imaging. During the third episode, common bile duct dilation and intrahepatic stones were noted on MRI without clear evidence of cholangitis. PET-CT scan performed to search for a potential source of infection, revealed an ill-defined, radiotracer-avid hypodense mass in hepatic segment VI, along with fusiform dilation of the biliary ducts, particularly on the left side. Further evaluation with echo-endoscopy suggested cholangitis, revealing hyperechoic material in the main bile duct (likely pus/sludge under pressure), a dilated common bile duct (8 mm), and a 4 cm hepatic abscess. An ERCP with sphincterotomy and balloon sweeping was performed, retrieving thickened bile and some whitish debris. A plastic stent was placed, and antibiotic therapy continued for 6 weeks, with resolution of the infection confirmed by imaging. However, two months later, the patient experienced another cyst infection. The stent was removed, and ursodeoxycholic acid therapy was initiated. Following this intervention, no further infections were observed during follow-up. Of note, infection affected cysts at different locations at each time and the liver function tests were mildly elevated. Conclusion This case highlights the need to consider cholangitis as a potential cause of liver cyst infections in ADPKD patients undergoing peritoneal dialysis. In this patient, intrahepatic stones likely contributed to the recurrent infections, and the combination of endoscopic treatments and ursodeoxycholic acid effectively prevented further episodes. While hepatic abscesses in peritoneal dialysis patients are typically linked to peritonitis or diverticular disease, cholangitis should also be considered as a possible source of infection in ADPKD patients.