Peritonitis in peritoneal dialysis

Peritonitis is the most serious infectious complication associated with peritoneal dialysis (PD) therapy.1 Peritonitis rates have shown significant improvement over the years, with recent data reporting infection-related hospitalizations experienced by 16% of peritoneal dialysis patients.2 However, infection-related deaths accounted for 10% of PD patients versus 7% of conventional hemodialysis (IHD) patient deaths.3 Secondary complications of PD-related infections significantly compromise long-term use of the peritoneal membrane, patient well-being, and longevity.4-6 For the long-term success of PD patients, focused strategies to reduce risk and to ensure therapeutic antibiotic dose are essential.7-9

Factors associated with increased and decreased risk of peritonitis

Exit-site and catheter-tunnel infections are major predisposing factors to PD-related peritonitis.10 A number of improvements in PD over the past several years, including better disconnect systems, have resulted in decreased peritonitis rates.11 Training, retraining, and home visits are necessary to guarantee training efficacy.12-14 Potential sources for increased risk should also be considered.

  • Increased exposure to glucose in combination with loss of residual kidney function (RKF) increased peritonitis risk.5,16,17
  • Obese patients have higher risk of complications than non-obese patients and may be biased toward increased peritoneal infections.15
  • Use of immunosuppressive drugs and glucose exposure per 100 g/24h at 6-months was associated with a nearly a 3.5 and >twofold increased risk of peritonitis respectively.16
  • Preservation of RKF and higher serum albumin decreased the risk of peritonitis by 47% and 11% respectively.16
  • Center-level predictors of lower peritonitis rates included smaller center size and high proportion of patients on PD.18,19

Association with all-cause, infection-related, and cardiovascular-related mortality 

Observational studies have shown a range of between 3% and 10% of PD-related infections result in death.20-23 An episode of peritonitis has been reported to be a cofactor for mortality in an additional 16% of affected patients.24

  • In patients on PD therapy for over 2 years, peritonitis was independently associated with 95% increased risk of all-cause mortality, ninefold increased risk of cardiovascular mortality, and near 4-fold increased risk of infection-related mortality.24
  • Early onset peritonitis (EOP), defined as peritonitis within 6 months of initiating PD, was independently and multivariately associated with increased risk of technique failure and mortality.15
    • EOP was independently associated with a >2-fold increased risk of mortality and technique failure.25
    • Multivariate analysis did not reduce risk dramatically; risk remained between 1.7 and 2 times higher with occurrence of EOP.25

Peritonitis and technique survival

Since peritonitis is one of the more common complications of PD, it has caused patients to switch from this modality to hemodialysis. 

  • In an analysis of 855 episodes of peritonitis in 435 PD patients, 25.2% of the episodes resulted in technique failure.26
  • Renal clearance of antibiotics should be paid attention to, and the monitoring of antibiotic levels is paramount to ensure therapeutic dose is achieved.7-9
  • Peritonitis in patients with creatinine clearance of 0-5 mL/min had 6.8 higher odds of treatment failure than episodes experienced by anuric participants.8
    • Episodes experienced by participants with creatinine clearance 0-5ml/min also had significantly higher odds; 2.9 increased odds of treatment failure than episodes experienced by anuric participants.8
    • The odds of relapse and recurrent peritonitis among participants with creatinine clearance >5 ml/min was also 7 times higher compared with anuric participants.8

Conclusion

Peritonitis was independently associated with increased risk of all-cause, cardiovascular, EOP, and infection-related mortality. The duration of peritoneal dialysis also has an increased risk of mortality combined with infection. Focused strategies to reduce peritonitis risk, prompt and appropriate management, and measures to assure therapeutic antibiotic dosing are essential for the long-term success of PD in all patients.7

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References

  1. Guest S. Handbook of Peritoneal Dialysis. Createspace Independent Pub; 2014. https://books.google.com/books?id=eLnqnQEACAAJ
  2. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in the United States. Reference Tables, Section G: Hospitalization. Am J Kidney Dis. 2020;75(1):A6-A7. doi:10.1053/j.ajkd.2019.09.003
  3. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2019 Annual Data Report: Epidemiology of Kidney Disease in the United States. Reference Tables, Section H: Mortality & Causes of Death. Am J Kidney Dis. 2020;75(1):A6-A7. doi:10.1053/j.ajkd.2019.09.003
  4. Mujais S, Story K. Patient and technique survival on peritoneal dialysis in patients with failed renal allograft: A case-control study. Kidney Int. 2006;70(SUPPL. 103):S133-S137. doi:10.1038/sj.ki.5001930
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  7. Salzer WL. Peritoneal dialysis-related peritonitis: challenges and solutions. Int J Nephrol Renovasc Dis. 2018;Volume 11:173-186. doi:10.2147/IJNRD.S123618
  8. Whitty R, Bargman JM, Kiss A, Dresser L, Lui P. Residual kidney function and peritoneal dialysis–associated peritonitis treatment outcomes. Clin J Am Soc Nephrol. 2017;12(12):2016-2022. doi:10.2215/CJN.00630117
  9. Brown EA, Blake PG, Boudville N, et al. International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis. Perit Dial Int. 2020;40(3):244-253. doi:10.1177/0896860819895364
  10. Li PKT, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int. 2016;36(5):481-508. doi:10.3747/pdi.2016.00078
  11. Raimann JG. Handbook of Dialysis Fifth Edition by John T. Daugirdas, Peter G. Blake and Todd S. Ing. Philadelphia, PA: Lippincott Williams & Wilkins, 2014, 900 pp. (ISBN-13: 978-1451144291). Daugirdas JT, Blake PG, Ing TS, eds. Hemodial Int. 2015;19(4):609-610. doi:10.1111/hdi.12322
  12. Zhang L, Hawley CM, Johnson DW. Focus on peritoneal dialysis training: Working to decrease peritonitis rates. Nephrol Dial Transplant. 2016;31(2):214-222. doi:10.1093/ndt/gfu403
  13. Hsu CK, Lee CC, Chen YT, et al. Multidisciplinary predialysis education reduces incidence of peritonitis and subsequent death in peritoneal dialysis patients: 5-year cohort study. PLoS One. 2018;13(8):1-12. doi:10.1371/journal.pone.0202781
  14. Ljungman S, Jensen JE, Paulsen D, et al. Retraining for prevention of peritonitis in peritoneal dialysis patients: A randomized controlled trial. Perit Dial Int. 2020;40(2):141-152. doi:10.1177/0896860819887626
  15. Ma X, Shi Y, Tao M, et al. Analysis of risk factors and outcome in peritoneal dialysis patients with early-onset peritonitis: A multicentre, retrospective cohort study. BMJ Open. 2020;10(2):1-9. doi:10.1136/bmjopen-2019-029949
  16. Uiterwijk H, Franssen CFM, Kuipers J, Westerhuis R, Nauta FL. Glucose Exposure in Peritoneal Dialysis Is a Significant Factor Predicting Peritonitis. Am J Nephrol. 2020;51(3):237-243. doi:10.1159/000506324
  17. Guo A, Mujais S. Patient and technique survival on peritoneal dialysis in the United States: Evaluation in large incident cohorts. Kidney Int Suppl. 2003;64(88):3-12. doi:10.1046/j.1523-1755.2003.08801.x
  18. Htay H, Cho Y, Pascoe EM, et al. Center Effects and Peritoneal Dialysis Peritonitis Outcomes: Analysis of a National Registry. Am J Kidney Dis. 2018;71(6):814-821. doi:10.1053/j.ajkd.2017.10.017
  19. Nadeau-Fredette AC, Johnson DW, Hawley CM, et al. Center-specific factors associated with peritonitis risk—a multi-center registry analysis. Perit Dial Int. 2016;36(5):509-518. doi:10.3747/pdi.2015.00146
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  21. Ghali JR, Bannister KM, Brown FG, et al. Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients. Perit Dial Int. 2011;31(6):651-662. doi:10.3747/pdi.2010.00131
  22. Boudville N, Kemp A, Clayton P, et al. Recent peritonitis associates with mortality among patients treated with peritoneal dialysis. J Am Soc Nephrol. 2012;23(8):1398-1405. doi:10.1681/ASN.2011121135
  23. Krishnan M, Thodis E, Ikonomopoulos D, et al. Predictors of outcome following bacterial peritonitis in peritoneal dialysis. Perit Dial Int. 2002;22(5):573-581. doi:10.1177/089686080202200508
  24. Ye H, Zhou Q, Fan L, et al. The impact of peritoneal dialysis-related peritonitis on mortality in peritoneal dialysis patients. BMC Nephrol. 2017;18(1):1-9. doi:10.1186/s12882-017-0588-4
  25. Feng S, Wang Y, Qiu B, et al. Impact of early-onset peritonitis on mortality and technique survival in peritoneal dialysis patients. Springerplus. 2016;5(1). doi:10.1186/s40064-016-3369-9
  26. Nochaiwong S, Ruengorn C, Koyratkoson K, et al. A Clinical Risk Prediction Tool for Peritonitis-Associated Treatment Failure in Peritoneal Dialysis Patients. Sci Rep. 2018;8(1):1-11. doi:10.1038/s41598-018-33196-2

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