Reviewer ’s report  
 
Title: Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dialysis: a 
case report  
 
Version: 2 Date: 24 Apr 2020  
 
Reviewer: Luca Nardelli  
 
Reviewer's report:  
 
34-36 "The  ESRD was caused by chronic nephritis. He has a history of hypertension for 6 years, 
and has no history of diabetes, coronary heart disease; trauma, infectious diseases such as 
hepatitis, tuberculosis, food and drug allergies no tobacco and alcohol addicti on; no special 
personal and family history".  
 
I don't think there is need to state all the pathologic conditions which were absent in patient's 
history. Conversely, it could be more notable to know why a chronic nephritis was suspected 
(even without a spe cific diagnosis, probably because a kidney biopsy was never performed) 
rather than a hypertensive nephrosclerosis which could be hypothesized on the basis of the 
anamnestic info reported.  
 
39 "Repeated peritonitis caused by peritoneal dialysis lasted more  than 4 weeks without regularly 
treatment"  
 
As I pointed out earlier according to the last ISPD guidelines (Szeto C, Li PK, Johnson DW, 
Bernardini J, Dong J, Figueiredo AE, et al. ISPD catheter -related infection recommendations: 
2017 update. Perit Dial Int . 37(2):141 -54) an episode of repeated peritonitis is defined as "an 
episode of peritonitis that occurs more than 4 weeks after completion of therapy of a prior 
episode with the same organism". Hence, the temporal indication in the definition is not relate d 
to the duration of the infection, but to the interval of the time between the occurrence of a new 
episode of peritonitis sustained by the same organism and the previous one. Thus, it was notable 
to have more info concerning the past peritonitis episodes (how many? Sustained by organism?) 
in order to define them correctly. However, if these notions are not available, I suggest to re -
phrase the sentence without the term "repeated peritonitis" and just explain that the patients 
showed in the past several epi sodes of peritonitis. Furthermore, it is very unlikely that those 
episodes were not treated at all. What does it imply the term "without regularly treatment?".  
 
41 "Leakage of peritoneal dialysis fluid was noted at the orifice of the peritoneal dialysis t ube".  
 
Is "the orifice" intended to be the exit -site of the PD catheter? If, so I suggest using the correct 
terminology. Moreover, I asked whether was performed an analysis of the fluid at the orifice. 
Why it was suspected a leakage rather than an exudati ve secretion suggesting, for instance, an 
exit-site/tunnel infection which could have caused a secondary peritonitis diagnosed by ascitic 
fluid analysis after 3 days?  
 
43-44 "After a week of anti -inflammatory treatment, (Imipenem 0.5g Intraperitoneal for 4h once, 
Meropenem 0.5g Intravenous infusion Q12h)".  
 
I suggest changing "anti -inflammatory" with "antibiotic therapy".  
 
88-89 "Catheter insertion methods include perc utaneous needle -guidewire with or without image 
guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy".  
 
The sentence has been well rewritten. I just advise to change "percutaneous needle -guidewire" 
with "percutaneous proc edure" since the needle -guidewire is not the only percutaneous technique 
which can be employed (Scalamogna A, Nardelli L, Zanoni F, Messa P. Double purse -string 
around the inner cuff of the peritoneal catheter  : A novel technique for an immediate initiatio n of 
continuous peritoneal dialysis. Int J Artif Organs. 2019; Dec 19).  
 
77 "extensive peritoneal calcification"  
 
It represents a repetition. See lines above.  
 
91-92 "PA Brown, BB McCormick, G Knoll, Y Su, S Doucette, D Fergusson and S Lavoie"  
 
I suggest  rephrasing "Brown et al" and similarly for the following citations in the discussion.  
 
103-104 "It is often difficult to determine whether clinically suspected peritonitis in patients on 
peritoneal dialysis is due to dialysis".  
 
The statement is not cle ar and generally uncorrect. The cases reported by Brady involved CAPD 
patients who received transplant. According the citation it might be stated that in PD patients 
after transplantation, the immunosuppressive therapy can mask the classic signs of periton itis 
delaying the diagnosis until the disease is widespread.  
 
72-75 / 109 -100 see comment line 39.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does the work include the necessary c ontrols?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
Are you  able to assess any statistics in the manus cript or  would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not releva nt to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents  relating to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If you r reply is yes to any, please give details below.  
 
'I declare that I have no competing interests'  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepte d for publication,  my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.or g/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dialysis: a 
case report  
 
Version: 2 Date: 24 Apr 2020  
 
Reviewer: Luca Nardelli  
 
Reviewer's report:  
 
34-36 "The  ESRD was caused by chronic nephritis. He has a history of hypertension for 6 years, 
and has no history of diabetes, coronary heart disease; trauma, infectious diseases such as 
hepatitis, tuberculosis, food and drug allergies no tobacco and alcohol addicti on; no special 
personal and family history".  
 
I don't think there is need to state all the pathologic conditions which were absent in patient's 
history. Conversely, it could be more notable to know why a chronic nephritis was suspected 
(even without a spe cific diagnosis, probably because a kidney biopsy was never performed) 
rather than a hypertensive nephrosclerosis which could be hypothesized on the basis of the 
anamnestic info reported.  
 
39 "Repeated peritonitis caused by peritoneal dialysis lasted more  than 4 weeks without regularly 
treatment"  
 
As I pointed out earlier according to the last ISPD guidelines (Szeto C, Li PK, Johnson DW, 
Bernardini J, Dong J, Figueiredo AE, et al. ISPD catheter -related infection recommendations: 
2017 update. Perit Dial Int . 37(2):141 -54) an episode of repeated peritonitis is defined as "an 
episode of peritonitis that occurs more than 4 weeks after completion of therapy of a prior 
episode with the same organism". Hence, the temporal indication in the definition is not relate d 
to the duration of the infection, but to the interval of the time between the occurrence of a new 
episode of peritonitis sustained by the same organism and the previous one. Thus, it was notable 
to have more info concerning the past peritonitis episodes (how many? Sustained by organism?) 
in order to define them correctly. However, if these notions are not available, I suggest to re -
phrase the sentence without the term "repeated peritonitis" and just explain that the patients 
showed in the past several epi sodes of peritonitis. Furthermore, it is very unlikely that those 
episodes were not treated at all. What does it imply the term "without regularly treatment?".  
 
41 "Leakage of peritoneal dialysis fluid was noted at the orifice of the peritoneal dialysis t ube".  
 
Is "the orifice" intended to be the exit -site of the PD catheter? If, so I suggest using the correct 
terminology. Moreover, I asked whether was performed an analysis of the fluid at the orifice. 
Why it was suspected a leakage rather than an exudati ve secretion suggesting, for instance, an 
exit-site/tunnel infection which could have caused a secondary peritonitis diagnosed by ascitic 
fluid analysis after 3 days?  
 
43-44 "After a week of anti -inflammatory treatment, (Imipenem 0.5g Intraperitoneal for 4h once, 
Meropenem 0.5g Intravenous infusion Q12h)".  
 
I suggest changing "anti -inflammatory" with "antibiotic therapy".  
 
88-89 "Catheter insertion methods include perc utaneous needle -guidewire with or without image 
guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy".  
 
The sentence has been well rewritten. I just advise to change "percutaneous needle -guidewire" 
with "percutaneous proc edure" since the needle -guidewire is not the only percutaneous technique 
which can be employed (Scalamogna A, Nardelli L, Zanoni F, Messa P. Double purse -string 
around the inner cuff of the peritoneal catheter  : A novel technique for an immediate initiatio n of 
continuous peritoneal dialysis. Int J Artif Organs. 2019; Dec 19).  
 
77 "extensive peritoneal calcification"  
 
It represents a repetition. See lines above.  
 
91-92 "PA Brown, BB McCormick, G Knoll, Y Su, S Doucette, D Fergusson and S Lavoie"  
 
I suggest  rephrasing "Brown et al" and similarly for the following citations in the discussion.  
 
103-104 "It is often difficult to determine whether clinically suspected peritonitis in patients on 
peritoneal dialysis is due to dialysis".  
 
The statement is not cle ar and generally uncorrect. The cases reported by Brady involved CAPD 
patients who received transplant. According the citation it might be stated that in PD patients 
after transplantation, the immunosuppressive therapy can mask the classic signs of periton itis 
delaying the diagnosis until the disease is widespread.  
 
72-75 / 109 -100 see comment line 39.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does the work include the necessary c ontrols?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
Are you  able to assess any statistics in the manus cript or  would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not releva nt to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents  relating to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If you r reply is yes to any, please give details below.  
 
'I declare that I have no competing interests'  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepte d for publication,  my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.or g/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Intestinal fistula accompanied by recurrent peritonitis associa ted with peritoneal dialysis: a 
case report  
 
Version: 2 Date: 24 Apr 2020  
 
Reviewer: Luca Nardelli  
 
Reviewer's report:  
 
34-36 "The  ESRD was caused by chronic nephritis. He has a history of hypertension for 6 years, 
and has no history of diabetes, coronary heart disease; trauma, infectious diseases such as 
hepatitis, tuberculosis, food and drug allergies no tobacco and alcohol addicti on; no special 
personal and family history".  
 
I don't think there is need to state all the pathologic conditions which were absent in patient's 
history. Conversely, it could be more notable to know why a chronic nephritis was suspected 
(even without a spe cific diagnosis, probably because a kidney biopsy was never performed) 
rather than a hypertensive nephrosclerosis which could be hypothesized on the basis of the 
anamnestic info reported.  
 
39 "Repeated peritonitis caused by peritoneal dialysis lasted more  than 4 weeks without regularly 
treatment"  
 
As I pointed out earlier according to the last ISPD guidelines (Szeto C, Li PK, Johnson DW, 
Bernardini J, Dong J, Figueiredo AE, et al. ISPD catheter -related infection recommendations: 
2017 update. Perit Dial Int . 37(2):141 -54) an episode of repeated peritonitis is defined as "an 
episode of peritonitis that occurs more than 4 weeks after completion of therapy of a prior 
episode with the same organism". Hence, the temporal indication in the definition is not relate d 
to the duration of the infection, but to the interval of the time between the occurrence of a new 
episode of peritonitis sustained by the same organism and the previous one. Thus, it was notable 
to have more info concerning the past peritonitis episodes (how many? Sustained by organism?) 
in order to define them correctly. However, if these notions are not available, I suggest to re -
phrase the sentence without the term "repeated peritonitis" and just explain that the patients 
showed in the past several epi sodes of peritonitis. Furthermore, it is very unlikely that those 
episodes were not treated at all. What does it imply the term "without regularly treatment?".  
 
41 "Leakage of peritoneal dialysis fluid was noted at the orifice of the peritoneal dialysis t ube".  
 
Is "the orifice" intended to be the exit -site of the PD catheter? If, so I suggest using the correct 
terminology. Moreover, I asked whether was performed an analysis of the fluid at the orifice. 
Why it was suspected a leakage rather than an exudati ve secretion suggesting, for instance, an 
exit-site/tunnel infection which could have caused a secondary peritonitis diagnosed by ascitic 
fluid analysis after 3 days?  
 
43-44 "After a week of anti -inflammatory treatment, (Imipenem 0.5g Intraperitoneal for 4h once, 
Meropenem 0.5g Intravenous infusion Q12h)".  
 
I suggest changing "anti -inflammatory" with "antibiotic therapy".  
 
88-89 "Catheter insertion methods include perc utaneous needle -guidewire with or without image 
guidance, open surgical dissection, peritoneoscopic procedure, and surgical laparoscopy".  
 
The sentence has been well rewritten. I just advise to change "percutaneous needle -guidewire" 
with "percutaneous proc edure" since the needle -guidewire is not the only percutaneous technique 
which can be employed (Scalamogna A, Nardelli L, Zanoni F, Messa P. Double purse -string 
around the inner cuff of the peritoneal catheter  : A novel technique for an immediate initiatio n of 
continuous peritoneal dialysis. Int J Artif Organs. 2019; Dec 19).  
 
77 "extensive peritoneal calcification"  
 
It represents a repetition. See lines above.  
 
91-92 "PA Brown, BB McCormick, G Knoll, Y Su, S Doucette, D Fergusson and S Lavoie"  
 
I suggest  rephrasing "Brown et al" and similarly for the following citations in the discussion.  
 
103-104 "It is often difficult to determine whether clinically suspected peritonitis in patients on 
peritoneal dialysis is due to dialysis".  
 
The statement is not cle ar and generally uncorrect. The cases reported by Brady involved CAPD 
patients who received transplant. According the citation it might be stated that in PD patients 
after transplantation, the immunosuppressive therapy can mask the classic signs of periton itis 
delaying the diagnosis until the disease is widespread.  
 
72-75 / 109 -100 see comment line 39.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does the work include the necessary c ontrols?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
Are you  able to assess any statistics in the manus cript or  would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not releva nt to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscript, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents  relating to the content 
of the manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If you r reply is yes to any, please give details below.  
 
'I declare that I have no competing interests'  
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepte d for publication,  my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.or g/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant