Dialysate cyclophilin A as a predictive marker for historical peritonitis in patients undergoing peritoneal dialysis

Introduction

No markers have been used to diagnose historical peritoneal dialysis (PD)-related peritonitis. Cyclophilin A (CypA) is associated with glucose toxicity and inflammation. We hypothesize that dialysate CypA can be a marker for historical peritonitis (at least 3 months free from peritonitis).

Method

An enzyme-linked immunosorbent assay kit was used to measure the concentration of dialysate CypA. Clinical and laboratory data were collected to correlate with historical peritonitis. Mann-Whitney U test and Chi-square test were used for analysis. Receiver operating characteristic (ROC) analysis was used to evaluate predictive power.

Results

Out of a total of 31 patients who had undergone PD for at least 2 years, 18 had no history of PD-related peritonitis, while 13 had experienced PD-related peritonitis at least once. Overall, the patients in this population were in good health (normal white blood cell count, no anemia, normal electrolyte and serum albumin levels). There were no significant differences between patients with and without a history of peritonitis, except for blood white blood cell count (5650.6 ± 1848.4 vs. 7154.6 ± 2056.8, p = 0.032) and dialysate CypA value (24.27 ± 22.715 vs. 54.41 ± 45.63, p = 0.020). In the univariate analysis, only the dialysate CypA level showed a statistically significant association with historical peritonitis (HR = 1.030, 95 % CI = 1.010-1.062, p = 0.046). The AUC for dialysate CypA (>34.83 ng/mL) was 0.748, with a sensitivity of 0.615 and specificity of 0.833.

Conclusion

PD peritonitis poses a significant threat to the long-term use of peritoneal dialysis. Based on our study, even in the absence of concurrent infection, dialysate CypA can serve as a predictive marker for historical peritonitis, demonstrating high predictive power along with fair sensitivity and good specificity.

Clinical profile and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis-associated peritonitis at a tertiary care center

Background

We present risk factors, clinical profile, and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis who were managed at our center.

Methods

All consecutive patients with CAPD-associated peritonitis who presented to our center between July 2018 and December 2019 were included in the study. Risk factors, microbiological spectrum, clinical profile, and outcome of patients were studied.

Results

Eighty-five patients with CAPD-associated peritonitis and 50 patients who never had peritonitis during the study period were included. Diabetes Mellitus (OR 0.058, 95% CI0.007-0.493, p < 0.05), residence in rural area (OR 3.376, 95% CI 1.084-10.516, p < 0.05), duration of peritoneal dialysis (OR 0.935, 95% CI 0.886-0.987, p < 0.05), mean serum hemoglobin (OR 1.674, 95% CI 1.119-2.502, p < 0.05) and serum albumin (OR 0.148, 95% CI 0.066-0.333, p < 0.05) were associated with higher risk of peritonitis in CAPD patients. Eight-three patients (98.8%) had turbid CAPD fluid and 52 (61.2%) had fever at the time of presentation to the hospital. The mean CAPD fluid TLC on day 1, 3, and 5 were 2034.3 ± 3330.1 cells/cumm, 1049.0 ± 1210.9 cells/cumm, and 605.2 ± 950.5 cells/cumm, respectively. The organisms isolated were two Escherichia coli (2.4%), one Staphylococcus aureus (1.2%), one Klebsiella (1.2%), two Acinetobacter (2.4%), 10 Fungal organisms (11.7%), and in two (2.4%) cases, Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction (PCR) of CAPD fluid. Thirty-seven (43.5%) patients had a complete cure and 48 (56.5%) patients were refractory to treatment; hence catheter was removed in them (catheter loss). Six (7.0%) patients died during the study period.

Conclusion

CAPD-associated peritonitis is an important risk factor for technique failure. The majority of episodes are culture-negative, and PCR can help in detecting fungal and tubercular peritonitis early in the course.

Established risk prediction models for the incidence of a low lean tissue index in patients with peritoneal dialysis

Objective

The objective of this study is to investigate the incidence of low lean tissue index (LTI) and the risk factors for low LTI in peritoneal dialysis (PD) patients, including to establish risk prediction models.

Methods

A total of 104 PD patients were enrolled from October 2019 to 2021. LTI was measured by bioimpedance spectroscopy. Multivariate logistic regression and machine learning were used to analyze the risk factors for low LTI in PD patients. Kaplan–Meier analysis was used to analyze the survival rate of patients with low LTI.

Results

The interleukin-6 (IL-6) level, red cell distribution width (RDW), overhydration, body mass index (BMI), and the subjective global assessment (SGA) rating significantly differed between the low LTI and normal LTI groups (all p < 0.05). Multivariate logistic regression showed that IL-6 (1.10 [95% CI: 1.02–1.18]), RDW (1.87 [95% CI: 1.18–2.97]), BMI (0.97 [95% CI: 0.68–0.91]), and the SGA rating (6.33 [95% CI: 1.59–25.30]) were independent risk factors for LTI. Cox regression analysis showed that low LTI (HR 3.14, [95% CI: 1.12–8.80]) was the only significant risk factor for all-cause death in peritoneal dialysis patients. The decision process to predict the incidence of low LTI in PD patients was established by machine learning, and the area under the curve of internal validation was 0.6349.

Conclusions

Low LTI is closely related to mortality in PD patients. Microinflammatory status, high RDW, low BMI and low SGA rating are risk factors for low LTI in PD patients. The developed prediction model may serve as a useful tool for assessing low LTI in PD patients.

Is there a relationship between oral hygiene and nutritional status in peritoneal dialysis patients?

Brackground: in the early stages of kidney disease, oral manifestations (gingivitis and periodontitis) may cause premature tooth loss and limit food intake. There is scarce evidence of the relationship between oral hygiene and nutritional status in patients on peritoneal dialysis (PD).

OBJECTIVE

we aimed to assess the relationship of oral hygiene with nutritional, clinical, and physical performance parameters in PD patients.

METHODS

this cross-sectional study included outpatients aged 34-69 years. Oral health questionnaire, nutritional, functional, and clinical assessment tools such as malnutrition inflammation score (MIS), subjective global assessment (SGA), handgrip strength, and gastrointestinal symptoms questionnaire (GSQ) were applied. Patients were divided according to debris, calculus, and simplified oral hygiene index (OHI-S) in two groups: "clean-slightly dirty" and "dirty-very dirty".

RESULTS

in total, 41 patients were included, those in the "dirty-very dirty" group had a worse nutritional status with higher scores on the MIS tool and worse nutritional diagnosis with SGA as compared to the "clean-slightly dirty" group. The handgrip strength was higher in patients in the best category of oral hygiene, and those with the worst hygiene presented greater severity of gastrointestinal symptoms. The risks of malnutrition in the three indices of oral hygiene with the worst category were statistically significant.

CONCLUSION

poor oral hygiene was associated with poorer nutritional status, lower handgrip, and worse GSQ. Poor oral hygiene might be related to persistent inflammation status and catabolism that favored protein-energy wasting.

Proton pump inhibitor use and the risk of peritoneal dialysis associated peritonitis

BACKGROUND

The use of proton-pump inhibitors (PPI) has been associated with an increased risk of developing spontaneous bacterial peritonitis in patients with cirrhosis. Whether PPI use confers a similar risk in developing peritonitis in peritoneal dialysis (PD) patients remains unclear.

METHODS

Patients on PD were retrospectively identified. Data such as PPI use during PD, underlying diagnoses, comorbidities, and baseline serum tests were collected. Univariable and multivariable analysis was conducted using logistic regression to assess whether PPI use and other factors were associated with PD peritonitis.

RESULTS

57 patients were identified with a median(interquartile range(IQR)) age of 65.0(51.5-74.0) years. The median(IQR) time on PD was 29.0(17.5-45.0) months. 28 patients were on a PPI during PD. 57% of the PPI group went on to develop peritonitis, compared to 31% of patients without PPI exposure (OR=2.96, 95% CI:[1.00, 8.78], p=0.050). Months on PD (OR=1.03, 95% CI:[1.00, 1.06], p=0.026), serum urea (OR=0.88, 95% CI:[0.80, 0.97], p=0.017), congestive cardiac failure (OR=5.44, 95% CI:[1.29, 23.00], p=0.021) and renovascular disease (OR=14.59, 95% CI:[1.68, 126.67], p=0.015) were identified as possible risk factors for peritonitis on univariable analysis. Following adjustment for covariates, serum urea, but not PPI use, was associated with PD peritonitis (OR=0.87, 95% CI:[0.78,0.98], p=0.020).

CONCLUSION

PPI use during PD was not associated with peritonitis. Due to the small number of patients and the limited number of studies investigating the effect of PPI use on PD peritonitis, further research is needed. This article is protected by copyright. All rights reserved.

Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy)

Approximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.

Association between self-reported appetite and clinical outcomes of peritoneal dialysis patients: Findings from a low middle-income country

AIM

Patient-reported outcome measures (PROM) has gained international recognition as important predictors of clinical outcomes in peritoneal dialysis (PD). We sought to understand the associations between patient-reported appetite and clinical outcomes.

METHODS

In the Thailand Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), 690 of 848 randomly selected PD patients from 22 facilities reported their appetite by using the short form (three items) of the Appetite and Diet Assessment Tool (ADAT), between 2016 and 2018. In this questionnaire, the patients rated their appetite as well as a change in appetite over time. Cox proportional hazards model regression was used to estimating associations between self-reported appetite and clinical outcomes, including mortality, haemodialysis (HD) transfer and peritonitis.

RESULTS

Half of the PD patients reported a good appetite, whereas 34% and 16% reported fair and poor appetites, respectively. Poor appetite was more prevalent among female, diabetic, congestive heart failure, older age and patients who had worse nutritional indicators, including lower time-averaged serum albumin and serum creatinine concentrations, as well as a higher proportions of hypokalaemia and severe hypoalbuminemia (serum albumin <3 g/dl). After adjusting for age, sex, comorbidities, and PD vintage, poor appetite was associated with increased risks of peritonitis (adjusted hazard ratio [HR] 1.73, 95% confidence interval [CI] 1.14-2.62), HD transfer (adjusted HR 2.25, 95% CI 1.24-4.10) and all-cause mortality (adjusted HR 1.60, 95% CI 1.08-2.39) compared to patients with good appetite.

CONCLUSION

Patient-reported poor appetite was independently associated with higher risks of peritonitis, HD transfer and all-cause mortality. This warrants further investigation to identify effective interventions.

Peritoneal Dialysis in India: Current Status and Challenges

With its ambulatory nature and freedom from complicated and expensive technology, chronic peritoneal dialysis (PD) is the ideal renal replacement therapy for resource-poor India. Despite being available for more than 15 years, PD has been limited in its growth because of economic factors, inadequate government policies, nephrologist bias, and lack of adequate pre-dialysis care. The number of patients initiated on therapy has increased in recent years, but the number of early dropouts remains high. Single-center studies suggest that contributors to poor outcome include gram-negative peritonitis, malnutrition, and failure to increase the dialysis dose as residual renal function declines. Development of a national PD registry and increased educational activities to position PD as part of integrated therapy for end-stage kidney disease would improve utilization of the PD modality.

Nutritional Status in Peritoneal Dialysis: Nutritional Guidelines, Adequacy and the Management of Malnutrition

The positive impact of nutritional status on the health and treatment adequacy of peritoneal dialyzed patients has been well established. Protein intake is an important factor used to stratify malnutrition, with inadequate intake leading to protein-energy wasting during the course of therapy. In this review, we discuss the recommendations made by nephrological societies regarding nutrition in this population of dialysis patients. Special attention is given to the intake of protein, and recommendations on the intake of micronutrients are also discussed. Furthermore, factors that may impair nutritional intake and balance are discussed, with mention of the innovative strategies utilized to combat them. In light of inconsistent recommendations that vary between each respective society, as well as a general lack of concise information, it is our intention to call for further research regarding nutritional recommendations in peritoneal dialysis (PD), as well as to advocate for clear and accessible information for patients.

Analysis of risk factors and outcome in peritoneal dialysis patients with early-onset peritonitis: a multicentre, retrospective cohort study

OBJECTIVES

To investigate the risk factors associated with early-onset peritonitis (EOP) and their influence on patients' technique survival and mortality.

STUDY DESIGN

Retrospective, cohort study.

SETTING

Three peritoneal dialysis (PD) units in Shanghai.

PARTICIPANTS

PD patients from 1 June 2006 to 1 May 2018 were recruited and followed up until 31 December 2018. According to time-to-first episode of peritonitis, patients were divided into non-peritonitis (n=144), EOP (≤6 months, n=74) and late-onset peritonitis (LOP) (>6 months, n=139).

PRIMARY AND SECONDARY OUTCOME MEASURES

EOP was defined as the first episode of peritonitis occurring within 6 months after the initiation of PD. The outcomes were all-cause mortality and technique failure.

RESULTS

Of the 357 patients, 74 (20.7%) patients developed their first episode of peritonitis within the first 6 months. Compared with the LOP group, the EOP group had older ages, more female patients, higher Charlson Comorbidity Index (CCI) score, lower serum albumin levels and renal function at the time of initiation of PD, and higher diabetes mellitus and peritonitis rates (p<0.05). Staphylococcus was the most common Gram-positive organism in both EOP and LOP groups. The multivariate logistic regression analysis showed that factors associated with EOP included a higher CCI score (OR 1.285, p=0.011), lower serum albumin level (OR 0.924, p=0.016) and lower Kt/V (OR 0.600, p=0.018) at start of PD. In the Cox proportional-hazards model, EOP was more likely a predictor of technique failure (HR 1.801, p=0.051). There was no difference between EOP and LOP for all-cause mortality.

CONCLUSION

A higher CCI score and lower serum albumin level and Kt/V at PD initiation were significantly associated with EOP. EOP also predicted a high peritonitis rate and poor clinical outcome.

Proton pump inhibitor use increases the risk of peritonitis in peritoneal dialysis patients

Peritonitis is a major and the most significant complication of peritoneal dialysis (PD). Although some predictors of peritonitis in PD patients are known, the association between proton pump inhibitor (PPI) use and peritonitis has not been characterized. Here, we examined whether PPI use is a risk factor for the development of peritonitis, based on a single-center retrospective analysis of 230 consecutive Japanese PD patients at Narita Memorial Hospital. We assessed the association between PPI use and subsequent first episode of peritonitis using multivariate Cox proportional hazards models, following adjustment for clinically relevant factors. The median follow-up period was 36 months (interquartile range, 19–57 months). In total, 86 patients (37.4%) developed peritonitis. Analysis with multivariate Cox proportional hazards models revealed the following significant predictors of peritonitis: PPI use (adjusted hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.11–2.66; P = 0.016) and low serum albumin level (per g/dl adjusted HR = 0.59, 95% CI: 0.39–0.90; P = 0.014). Thus, PPI use was independently associated with PD-related peritonitis. The results suggest that nephrology physicians should exercise caution when prescribing PPIs for PD patients.

Sarcopenia and Frailty in PD: Impact on Mortality, Malnutrition, and Inflammation

BACKGROUND

It is known that sarcopenia is related to malnutrition-inflammation-atherosclerosis (MIA) syndrome and is an important problem in dialysis patients. The notion of frailty includes various physical, psychological, and social aspects. Although it has been reported that sarcopenia is associated with poor prognosis in patients with hemodialysis, reports on peritoneal dialysis (PD) patients are rare. In this study, we examined the morbidity and mortality of sarcopenia and frailty in PD patients. We also investigated the MIA-related factors.

METHODS

We evaluated 119 patients cross-sectionally and longitudinally. The Asian Working Group for Sarcopenia criteria and the Clinical Frailty Scale (CFS) were used to diagnose sarcopenia and frailty. The primary outcome is all-cause mortality with sarcopenia and frailty. The secondary outcome is the relationship between various MIA-related factors.

RESULTS

Morbidity of sarcopenia and frailty in PD patients was 8.4% and 10.9%, respectively. Old age, high values of Barthel Index, Charlson Comorbidity Index, CFS, and low values of body mass index (BMI), muscle strength, muscle mass, and slow walking were associated with sarcopenia. Interleukin-6, albumin, and prealbumin were significantly correlated with muscle mass. During follow-up, the presence of sarcopenia or frailty was associated with the risk of mortality. In multivariate analysis, CFS was related to the mortality rate of PD patients.

CONCLUSIONS

The presence of sarcopenia or frailty was associated with a worse prognosis.

Peritoneal Dialysis-Related Peritonitis: Can We Predict It?

Peritonitis complicating peritoneal dialysis represents a major cause of technique failure, hospitalization, and increased mortality. Peritonitis tends to be recurrent and clustered within particular patients at risk. The aim of this review is to evaluate the potential predictive factors for development of peritoneal dialysis-associated peritonitis based on currently available evidence. Risk factors were divided into medical and non-medical ones, and characterized by a schema of fixed versus modifiable factors. A new direction in the landscape change of the risk factors of peritonitis appears to focus on psychosocial aspects and patient training. Identification of these factors have important clinical implications because of the hitherto lack of well-established strategies to prevent peritonitis complicating peritoneal dialysis. It is hoped that better understanding of the risk factors will allow us to take tangible steps toward minimizing the infectious burden from the Achilles' heel of peritoneal dialysis.

Apoptosis inhibitor of macrophage ameliorates fungus-induced peritoneal injury model in mice

Fungal peritonitis in a patient on peritoneal dialysis (PD) is a refractory injury accompanied by severe inflammation, predisposing patients to a poor prognosis. Defective clearance of necrotic tissue interferes with amelioration of tissue injury and induces abnormal tissue remodeling. In the recent reports, apoptosis inhibitor of macrophage (AIM, also called CD5L) prevents obesity, hepatocellular carcinoma and acute kidney injury. Here, we investigated potential roles of AIM in prevention of progression of fungal peritonitis models. AIM^−/− mice subjected to zymosan-induced peritonitis exhibited progressive inflammation and sustained peritoneal necrosis tissue on day 28 after the disease induction, whereas there was an improvement in AIM^+/+ mice. This appeared to be caused by deposition of AIM at the necrotic peritoneum in AIM^+/+ mice. In vitro, AIM enhanced the engulfment of necrotic debris by macrophages derived from zymosan-induced peritonitis, M1- and M2a-like bone marrow derived macrophages, as well as by mesothelial cells. In addition, administration of recombinant AIM dramatically ameliorated severe inflammation associated with necrosis in zymosan-induced peritonitis of AIM^−/− mice. Our observations suggest that AIM appears to be involved in the repair process of zymosan-induced peritonitis, and thus, could be the basis of development of new therapeutic strategies for PD-related fungal peritonitis.

Peritonitis outcomes in patients with HIV and end-stage renal failure on peritoneal dialysis: a prospective cohort study

BACKGROUND

Few studies have investigated the management of human immunodeficiency virus (HIV)-associated end-stage renal failure particularly in low-resource settings with limited access to renal replacement therapy. We aimed to evaluate the effects of HIV infection on continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis outcomes and technique failure in highly active antiretroviral therapy (HAART)-treated HIV-positive CAPD populations.

METHODS

We conducted a single-center prospective cohort study of consecutive incident CAPD patients recruited from two hospitals in Durban, South Africa from September 2012-February 2015. Seventy HIV-negative and 70 HIV-positive end-stage renal failure patients were followed monthly for 18 months at a central renal clinic. Primary outcomes of peritonitis and catheter failure were assessed for the first 18 months of CAPD therapy. We assessed risk factors for peritonitis and catheter failure using Cox regression survival analysis.

RESULTS

The HIV-positive cohort had a significantly increased rate of peritonitis compared to the HIV-negative cohort (1.86 vs. 0.76 episodes/person-years, respectively; hazard ratio [HR], 2.41; 95% confidence interval [CI], 1.69-3.45, P < 0.001). When the baseline CD4 count was below 200 cells/μL, the peritonitis rate rose to 3.69 episodes/person-years (HR 4.54, 95% CI 2.35-8.76, P < 0.001), while a baseline CD4 count above 350 cells/μL was associated with a peritonitis rate of 1.60 episodes/person-years (HR 2.10, CI 1.39-3.15, P = 0.001). HIV was associated with increased hazards of peritonitis relapse (HR, 3.88; CI, 1.37-10.94; P = 0.010). Independent predictors associated with increased peritonitis risk were HIV (HR, 1.84; CI, 1.07-3.16; P = 0.027), diabetes (HR, 2.09; CI, 1.09-4.03; P = 0.027) and a baseline CD4 count < 200 cells/μL (HR, 3.28; CI, 1.42-7.61; P = 0.006). Catheter failure rates were 0.34 (HIV-positive cohort) and 0.24 (HIV-negative cohort) episodes/person-years (HR, 1.42; 95% CI, 0.73-2.73; P = 0.299). Peritonitis (HR, 14.47; CI, 2.79-75.00; P = 0.001), average hemoglobin concentrations (HR, 0.75; CI, 0.59-0.95; P = 0.016), and average serum C-reactive protein levels were independent predictors of catheter failure.

CONCLUSIONS

HIV infection in end-stage renal disease patients managed by CAPD was associated with increased peritonitis risk; however, HIV infection did not increase the risk for CAPD catheter failure rate at 18 months.

Risk factors and outcomes of high peritonitis rate in continuous ambulatory peritoneal dialysis patients: A retrospective study

Peritonitis remains a major complication of peritoneal dialysis (PD). A high peritonitis rate (HPR) affects continuous ambulatory peritoneal dialysis (CAPD) patients' technique survival and mortality. Predictors and outcomes of HPR, rather than the first peritonitis episode, were rarely studied in the Chinese population. In this study, we examined the risk factors associated with HPR and its effects on clinical outcomes in CAPD patients.This is a single center, retrospective, observational cohort study. A total of 294 patients who developing at least 1 episode of peritonitis were followed up from March 1st, 2002, to July 31, 2014, in our PD center. Multivariate logistic regression was used to determine the factors associated with HPR, and the Cox proportional hazard model was conducted to assess the effects of HPR on clinical outcomes.During the study period of 2917.5 patient-years, 489 episodes of peritonitis were recorded, and the total peritonitis rate was 0.168 episodes per patient-year. The multivariate analysis showed that factors associated with HPR include a quick occurrence of peritonitis after CAPD initiation (shorter than 12 months), and a low serum albumin level at the start of CAPD. In the Cox proportional hazard model, HPR was a significant predictor of technique failure. There were no differences between HPR and low peritonitis rate (LPR) group for all-cause mortality. However, when the peritonitis rate was considered as a continuous variable, a positive correlation was observed between the peritonitis rate and mortality.We found the quick peritonitis occurrence after CAPD and the low serum albumin level before CAPD were strongly associated with an HPR. Also, our results verified that HPR was positively correlated with technique failure. More importantly, the increase in the peritonitis rate suggested a higher risk of all-cause mortality.These results may help to identify and target patients who are at higher risk of HPR at the start of CAPD and to take interventions to reduce peritonitis incidence and improve clinical outcomes.

The Association of Individual and Regional Socioeconomic Status on Initial Peritonitis and Outcomes in Peritoneal Dialysis Patients: A Propensity Score-Matched Cohort Study

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BACKGROUND

Research indicates that the socioeconomic status (SES) of individuals and the area where they live are related to initial peritonitis and outcomes in peritoneal dialysis (PD). We conducted a retrospective, multi-center cohort study in China to examine these associations. ♦

METHODS

Data on 2,171 PD patients were collected from 7 centers, including baseline demographic, socioeconomic, and laboratory data. We explored the potential risk factors for initial peritonitis and outcomes using univariate Cox regression and unadjusted binary logistic regression. Then, we used propensity score matching to balance statistically significant risk factors for initial peritonitis and outcomes, and Kaplan-Meier survival analysis to compare differences in peritonitis-free rates between different groups of participants after matching. ♦

RESULTS

A total of 563 (25.9%) initial episodes of peritonitis occurred during the study period. The Kaplan-Meier peritonitis-free rate curve showed high-income patients had a significantly lower risk than low-income patients (p = 0.007) after matching for age, hemoglobin, albumin, and regional SES and PD center. The risk of treatment failure was significantly lower in the high-income than the low-income group after matching for the organism causing peritonitis and PD center: odds ratio (OR) = 0.27 (0.09 - 0.80, p = 0.018). Regional SES and education were not associated with initial peritonitis and outcomes. ♦

CONCLUSIONS

Our study demonstrates low individual income is a risk factor for the initial onset of peritonitis and treatment failure after initial peritonitis.

Risk Factors for Early-Onset Peritonitis in Southern Chinese Peritoneal Dialysis Patients

♦ BACKGROUND: Early peritonitis was confirmed to be associated with a higher risk of early technique failure. However, literature concerning peritonitis within the first 3 months of peritoneal dialysis (PD) initiation is scarce. The present study was to investigate risk factors associated with early-onset peritonitis in PD patients. ♦ METHODS: In this retrospective observational cohort study, all incident PD patients from January 1, 2006, to December 31, 2013, were recruited and followed up until December 31, 2014. According to time-to-first episode of peritonitis, patients were divided into early-onset (≤ 3 months) peritonitis and late-onset (> 3 months) peritonitis. Baseline demographic, clinical, and laboratory data, as well as episodes of peritonitis, were collected. Risk factors associated with early-onset peritonitis were evaluated using logistic regression model. ♦ RESULTS: Of 1,690 patients on PD, 503 (29.8%) developed at least 1 episode of peritonitis and 118 (7.0%) patients presented the first episodes of peritonitis within the first 3 months. A multivariate logistic analysis showed that higher body mass index (BMI) (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01 - 1.15, p = 0.034), hypoalbuminemia (OR 1.75, 95% CI 1.11 - 2.78, p = 0.017), and catheter exit-site infection (OR 4.14, 95% CI 2.45 - 7.00, p < 0.001) were risk factors independently associated with early-onset peritonitis. Compared to those with late-onset, patients with early-onset peritonitis had a higher overall peritonitis rate (0.76 vs 0.38 per patient-year, p < 0.001) and worse technique survival (p < 0.001), while patient survival did not differ significantly between the 2 groups during the long-term follow-up (p > 0.05). ♦ CONCLUSIONS: Higher BMI, hypoalbuminemia, and catheter exit-site infection were the risk factors associated with early-onset peritonitis in PD patients.

Trajectories of Serum Albumin Predict Survival of Peritoneal Dialysis Patients: A 15-year Follow-Up Study

Although initial serum albumin level is highly associated with overall and cardiovascular mortality in peritoneal dialysis (PD) patients, we consider that the dynamic change and trend of albumin after initiation of PD are also essential.We enrolled patients who received PD for more than 3 months from January 1999 to March 2014. We categorized these patients into 2 groups by the difference in serum albumin level (Δalbumin = difference between peak with initial albumin level = peak albumin level - initial albumin level) after PD. The patients with Δalbumin < 0.2 g/dL (median level) were considered as group A (n, number = 238) and those with Δalbumin ≥ 0.2 g/dL were considered as group B (n = 278). Further, we stratified these patients into quartiles: Q1 Δalbumin < -0.2 g/dL; Q2, -0.2 ≦∼ <0.2 g/dL; Q3, 0.2 ≦∼ <0.6 g/dL; and Q4, ≥0.6 g/dL. Regression analysis was performed to determine the correlation of initial albumin and Δalbumin.Group A patients presented with higher levels of serum albumin (3.71 ± 0.54 vs 3.04 ± 0.55 g/dL; P < 0.001) and hematocrit as well as better initial residual renal function. However, those in group A had lower serum albumin increment and downward-sloped trends after dialysis. In contrast, the albumin trend was upward sloped and the increment of albumin was remarkable in group B, despite the high prevalence of cardiovascular diseases and diabetes. Overtime, group A patients had poorer survival and experienced more frequent and longer hospitalizations. Group Q1 patients with least albumin increment had worst survival. Group Q4 patients with lowest initial albumin also had poor survival. Age, diabetes, cardiovascular diseases, BMI, initial albumin, and Δalbumin could affect patient outcomes independently. Regression analysis showed a better outcome can be obtained if the initial albumin level is at least above 3.15 g/dL. (Initial albumin level = -0.61 × Δalbumin + 3.50.)The increment and trend of albumin especially during early period of PD may be a more crucial determinant for survival.

Continuous ambulatory peritoneal dialysis in Limpopo province, South Africa: predictors of patient and technique survival

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INTRODUCTION AND AIM

Continuous ambulatory peritoneal dialysis (CAPD) is not a frequently used modality of dialysis in many parts of Africa due to several socio-economic factors. Available studies from Africa have shown a strong association between outcome and socio-demographic variables. We sought to assess the outcome of patients treated with CAPD in Limpopo, South Africa. ♦

METHODS

This was a retrospective study of 152 patients treated with CAPD at the Polokwane Kidney and Dialysis Centre (PKDC) from 2007 to 2012. We collected relevant demographic and biochemical data for all patients included in the study. A composite outcome of death while still on peritoneal dialysis (PD) or CAPD technique failure from any cause requiring a change of modality to hemodialysis (HD) was selected. The peritonitis rate and causes of peritonitis were assessed from 2008 when all related data could be obtained. ♦

RESULTS

There were 52% males in the study and the average age of the patients was 36.8 ± 11.4 years. Unemployment rate was high (71.1%), 41.1% had tap water at home, the average distance travelled to the dialysis center was 122.9 ± 78.2 kilometres and half the patients had a total income less than USD ($)180 per month. Level of education, having electricity at home, having tap water at home, body mass index (BMI), serum albumin and hemoglobin were significantly different between those reaching the composite outcome and those not reaching it (p < 0.05). The overall peritonitis rate was 0.82/year with 1-year, 2-year and 5-year survival found to be 86.7%, 78.7% and 65.3% (patient survival) and 83.3%, 71.7% and 62.1% (technique survival). Predictors of the composite outcome were BMI (p = 0.011), serum albumin (p = 0.030), hemoglobin (p = 0.002) and more than 1 episode of peritonitis (p = 0.038). ♦

CONCLUSION

Treatment of anemia and malnutrition as well as training and re-training of CAPD patients and staff to prevent recurrence of peritonitis can have positive impacts on CAPD outcomes in this population.

Serum immunoglobulin G levels and peritonitis in peritoneal dialysis patients

BACKGROUND

Peritonitis is a frequent and serious complication of peritoneal dialysis (PD). Whether low immunoglobulin level is associated with PD-related peritonitis is unknown.

METHODS

We conducted a prospective study to assess whether immunoglobulin levels at PD onset could predict the occurrence of peritonitis. All patients starting peritoneal dialysis between 01/2005 and 12/2010 at the University hospital of Besançon, France, were included in the study.

RESULTS

Of 240 consecutive PD patients enrolled (mean follow-up 25 ± 12 months), 76 (32%) had at least one episode of peritonitis. Mean immunoglobulin (Ig)G level at PD start was lower in patients who subsequently experienced peritonitis (7.9 + 3.4 vs. 9.7 + 3.4 g/l, p = 0.005). An increased IgG level at PD onset was associated with a reduced risk of peritonitis [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.80-0.97 for each increase of 1 g/l in IgG, p = 0.008]. IgG level ≤6.4 g/l ("low IgG") was the best predictive value for the occurrence of subsequent peritonitis: 52 patients (24%) had low IgG levels. At multivariate analysis, both low IgG level (HR 2.49, 95% CI 1.32-4.69, p = 0.005) and diabetes (HR 2.78, 95% CI 1.49-5.20, p = 0.001) were predictive of the occurrence of peritonitis.

CONCLUSION

Low IgG levels predict the occurrence of PD-related peritonitis. Randomized studies should determine whether such patients could benefit from intravenous immunoglobulin administration.

Predictors for and impact of high peritonitis rate in Taiwanese continuous ambulatory peritoneal dialysis patients

AIM

The influence of high peritonitis rate (HPR) on clinical outcomes of continuous ambulatory peritoneal dialysis (CAPD) patients has been far less studied in the Chinese population than in those of the USA, Australia and Europe. Furthermore, concerning the peritonitis risk, most studies primarily examined the risk of developing the first peritonitis episode, rather than a HPR.

METHODS

A single-center, retrospective, observational study was carried out over 10 years in Taiwan. A total of 124 patients with at least one peritonitis episode were the study subjects. The Cox proportional hazard model was used to assess the impact of HPR on clinical outcomes. Multivariate logistic regression was conducted to determine the independent factors associated with a HPR.

RESULTS

In the multivariate Cox regression model, HPR was still a significant predictor for technique failure, patient mortality and dropout from peritoneal dialysis (PD). Factors independently associated with a HPR were peritonitis occurrence during the first year after the start of CAPD and the first peritonitis infected with streptococcus species.

CONCLUSION

Peritonitis during the first year after PD commencement and the first peritonitis infected by streptococcus species were significantly associated with an increased risk of a HPR. Our data also indicate that HPR was correlated with technique failure, patient mortality and dropout from PD, thus highlighting the need and role of future studies to reduce this complication.

Predictors of peritonitis and the impact of peritonitis on clinical outcomes of continuous ambulatory peritoneal dialysis patients in Taiwan--10 years' experience in a single center

OBJECTIVE

Peritoneal dialysis (PD) has become more prevalent as a treatment modality for end-stage renal disease, and peritonitis remains one of its most devastating complications. The aim of the present investigation was to examine the frequency and predictors of peritonitis and the impact of peritonitis on clinical outcomes. ♢

METHODS

Our retrospective observational cohort study enrolled 391 patients who had been treated with continuous ambulatory PD (CAPD) for at least 90 days. Relevant demographic, biochemical, and clinical data were collected for an analysis of CAPD-associated peritonitis, technique failure, drop-out from PD, and patient mortality. ♢

RESULTS

The peritonitis rate was 0.196 episodes per patient-year. Older age (>65 years) was the only identified risk factor associated with peritonitis. A multivariate Cox regression model demonstrated that technique failure occurred more often in patients experiencing peritonitis than in those free of peritonitis (p < 0.001). Kaplan-Meier analysis revealed that the group experiencing peritonitis tended to survive longer than the group that was peritonitis-free (p = 0.11). After multivariate adjustment, the survival advantage reached significance (hazard ratio: 0.64; 95% confidence interval: 0.46 to 0.89; p = 0.006). Compared with the peritonitis-free group, the group experiencing peritonitis also had more drop-out from PD (p = 0.03). ♢

CONCLUSIONS

The peritonitis rate was relatively low in the present investigation. Elderly patients were at higher risk of peritonitis episodes. Peritonitis independently predicted technique failure, in agreement with other reports. However, contrary to previous studies, all-cause mortality was better in patients experiencing peritonitis than in those free of peritonitis. The underlying mechanisms of this presumptive "peritonitis paradox" remain to be clarified.

Lower education level is a major risk factor for peritonitis incidence in chronic peritoneal dialysis patients: a retrospective cohort study with 12-year follow-up

BACKGROUND

Peritoneal dialysis (PD)-related peritonitis remains an important complication in PD patients, potentially causing technique failure and influencing patient outcome. To date, no comprehensive study in the Taiwanese PD population has used a time-dependent statistical method to analyze the factors associated with PD-related peritonitis.

METHODS

Our single-center retrospective cohort study, conducted in southern Taiwan between February 1999 and July 2010, used time-dependent statistical methods to analyze the factors associated with PD-related peritonitis.

RESULTS

The study recruited 404 PD patients for analysis, 150 of whom experienced at least 1 episode of peritonitis during the follow-up period. The incidence rate of peritonitis was highest during the first 6 months after PD start. A comparison of patients in the two groups (peritonitis vs null-peritonitis) by univariate analysis showed that the peritonitis group included fewer men (p = 0.048) and more patients of older age (≥65 years, p = 0.049). In addition, patients who had never received compulsory education showed a statistically higher incidence of PD-related peritonitis in the univariate analysis (p = 0.04). A proportional hazards model identified education level (less than elementary school vs any higher education level) as having an independent association with PD-related peritonitis [hazard ratio (HR): 1.45; 95% confidence interval (CI): 1.01 to 2.06; p = 0.045). Comorbidities measured using the Charlson comorbidity index (score >2 vs ≤2) showed borderline statistical significance (HR: 1.44; 95% CI: 1.00 to 2.13; p = 0.053).

CONCLUSIONS

A lower education level is a major risk factor for PD-related peritonitis independent of age, sex, hypoalbuminemia, and comorbidities. Our study emphasizes that a comprehensive PD education program is crucial for PD patients with a lower education level.

Risk factors associated with peritoneal-dialysis-related peritonitis

Background. Peritonitis represents a major complication of peritoneal dialysis (PD). The aim of this paper was to systematically collect data on patient-related risk factors for PD-associated peritonitis, to analyze the methodological quality of these studies, and to summarize published evidence on the particular risk factors. Methods. Studies were identified by searches of Pubmed (1990–2012) and assessed for methodological quality by using a modified form of the STROBE criteria. Results. Thirty-five methodologically acceptable studies were identified. The following nonmodifiable risk factors were considered valid and were associated with an increased risk of peritonitis: ethnicity, female gender, chronic lung disease, coronary artery disease, congestive heart failure, cardiovascular disease, hypertension, antihepatitis C virus antibody positivity, diabetes mellitus, lupus nephritis or glomerulonephritis as underlying renal disease, and no residual renal function. We also identified the following modifiable, valid risk factors for peritonitis: malnutrition, overweight, smoking, immunosuppression, no use of oral active vitamin D, psychosocial factors, low socioeconomic status, PD against patient's choice, and haemodialysis as former modality. Discussion. Modifiable and nonmodifiable risk factors analyzed in this paper might serve as a basis to improve patient care in peritoneal dialysis.

Geographic and educational factors and risk of the first peritonitis episode in Brazilian Peritoneal Dialysis study (BRAZPD) patients

BACKGROUND AND OBJECTIVES

Peritonitis remains as the most frequent cause of peritoneal dialysis (PD) failure, impairing patient's outcome. No large multicenter study has addressed socioeconomic, educational, and geographic issues as peritonitis risk factors in countries with a large geographic area and diverse socioeconomic conditions, such as Brazil.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Incident PD patients recruited from 114 dialysis centers and reporting to BRAZPD, a multicenter observational study, from December 2004 through October 2007 were included. Clinical, dialysis-related, demographic, and socioeconomic variables were analyzed. Patients were followed up until their first peritonitis. Cox proportional model was used to determine independent factors associated with peritonitis.

RESULTS

In a cumulative follow-up of 2032 patients during 22.026 patient-months, 474 (23.3%) presented a first peritonitis episode. In contrast to earlier findings, PD modality, previous hemodialysis, diabetes, gender, age, and family income were not risk predictors. Factors independently associated with increased hazard risk were lower educational level, non-white race, region where patients live, shorter distance from dialysis center, and lower number of patients per center.

CONCLUSIONS

Educational level and geographic factors as well as race and center size are associated with risk for the first peritonitis, independent of socioeconomic status, PD modality, and comorbidities.

Predictors of long-term survival on peritoneal dialysis in South India: a multicenter study

BACKGROUND

Little is known about survival on peritoneal dialysis (PD) in Indian patients since the initiation of continuous ambulatory PD (CAPD) in India in 1991. Survival data from single centers with small numbers have been published.

OBJECTIVE

A retrospective 4-center analysis for predictors of survival >3 years in south Indian chronic PD patients.

METHODS

A total of 309 patients were trained during the observation period (from 1999 to 2004) and were analyzed in a multicenter study (4 centers), including 150 patients (male:female 109:41) that survived > or = 3 years and 59 patients that did not survive > or = 3 years (nonsurvivors; male: female 43:16) that were taken as controls. The patients were on chronic PD, predominantly CAPD, using double-bag disconnect systems. They were supervised by 4 nephrologists. Mean age in the nonsurvival group was 56.6 +/- 10.6 years. In the survival group, mean age was 50.9 +/- 14.9 years; there were 92 (62%) nondiabetics and 58 (38%) diabetics; the majority were nonvegetarians; 148 patients were doing 6 - 8 L exchanges and 2 were doing >8 L exchanges daily; 93 of 102 patients were average transporters based on peritoneal equilibration testing. At the beginning, mean combined Kt/V was 2.31 and weekly creatinine clearance was 73 L. Patients making one lifetime payment were 46% and 21% belonged to the full reimbursement group.

RESULTS

Body mass index (BMI) was normal in 114 patients (76%). Ultrafiltration volume was 1377 +/- 452 at the start and 1400 +/- 461 mL/day after 3 years. Anuric patients at the start were 12% and after 3 years 44%; urine output decreased from 527 +/- 26 to 253 +/- 14 mL/day from the start to after 3 years. Peritonitis rate was 1 episode/75 patient-months at the beginning and after 3 years it was 1 episode/30 patient-months. Exit-site care was done daily by 88% and 3 times weekly by 12%. Nonsmokers were 92% and smokers were 8%. Those that lived in the city were 62% and rural areas were 38%. Mean blood pressure was 143 +/- 16/88 +/- 10 and 136 +/- 18/85 +/- 9 mmHg, calcium x phosphorus product 44.6 +/- 15.6 and 45.9 +/- 15.7 mg(2)/dL(2), albumin 3.33 +/- 0.5 and 3.25 +/- 0.4 g/dL, hemoglobin 9.18 +/- 2 and 9.48 +/- 1.8 g/dL at the beginning and after 3 years, respectively. Statistical analysis showed a significant fall in both systolic (p < or = 0.001) and diastolic blood pressure (p < or = 0.05), an increase in BMI (p < or = 0.01), and a decrease in blood urea (p < or = 0.001) in the survival group. Those with Hb > or = 11 g/dL survived longer (p < or= 0.001), those with serum albumin > or = 3 g/dL had better survival (p = 0.001), and anuric patients survived longer (p = 0.001).

CONCLUSION

This multicenter cohort study of prevalent continuous PD patients in south India showed nondiabetics, average transporters, nonsmokers with reasonable nutritional status, with Hb 11 g/dL, with low peritonitis rate, with over 1 L ultrafiltration volume per day, the great majority that joined the once per lifetime payment scheme, and the reimbursement group survived for 3 years or longer.

Impact of the bag exchange procedure on risk of peritonitis

OBJECTIVE

We studied whether improper bag exchange predicts the first peritonitis episode in continuous ambulatory peritoneal dialysis (CAPD) patients.

PATIENTS AND METHODS

Our single-center prospective observational study of 130 incident urban CAPD patients who started peritoneal dialysis (PD) between March 2005 and August 2008 aimed to determine the relationship between bag exchange procedures examined at the 6th month of PD and risk for a first peritonitis episode. All patients were followed until a first peritonitis episode, censoring, or the end of the study.

RESULTS

These 130 patients experienced 22 first peritonitis episodes during the 14-month follow-up. During bag exchange evaluation, 51.5% of patients washed their hands improperly, 46.2% failed to check expiration date or bag leakage, and 11.5% forgot to wear a face mask and cap. Patients experiencing peritonitis were more likely to forget to wear a face mask and cap. In multivariate Cox regression model, not wearing a face mask and cap [hazard ratio (HR): 7.26; 95% confidence interval (CI): 2.6 to 20.1; p < 0.001] and having anemia (HR: 0.96; 95% CI: 0.94 to 0.99; p = 0.005) were independent risk factors for a first episode of peritonitis.

CONCLUSIONS

Not wearing a face mask and cap and having anemia were independent risk factors for peritonitis. A further randomized control study needs to verify the correlation between improper bag exchange technique and peritonitis in PD patients.

Fungal peritonitis in peritoneal dialysis: risk factors and prognosis

Although less common than bacterial peritonitis, fungal peritonitis is associated with much higher morbidity and mortality. In this study, we aimed to determine the risk factors for fungal peritonitis in peritoneal dialysis patients. The records of 109 peritoneal dialysis patients were analyzed. A total of 86 episodes of peritonitis attacks were recorded. Nine (10.5%) of these attacks were fungal peritonitis attacks. The fungal peritonitis attack rate of the population was 1 attack per 480.1 patient months. In order to determine predisposing factors for fungal peritonitis patients, patients with bacterial peritonitis and with no peritonitis admitted immediately before and after those with fungal peritonitis were used as controls. There was no statistically significant difference between the bacterial and fungal peritonitis groups with respect to symptoms and signs. Obligatory peritoneal dialysis treatment due to access or other medical problems (p = 0.04) and serum albumin levels (p = 0.01) were found to be significantly related with fungal peritonitis (p = 0.04). The mortality rate was 11.1%. When compared with the mortality rate of bacterial peritonitis (1.8%) during the same period, it was found to be significantly higher (p = 0.0001). The catheter removal was performed within 2-7 days (mean = 5.2 days) of the fungal peritonitis attacks. In conclusion, we decided that because fungal peritonitis attacks end up with high morbidity and mortality, prompt diagnosis and removal of the catheter is mandatory. Diagnosis highly depends on culture results, as signs and symptoms usually do not differ from that of bacterial peritonitis. Low serum albumin levels and obligatory peritoneal dialysis treatment are found to be the risk factors for fungal peritonitis.

Surgical Peritonitis in Patients on Peritoneal Dialysis

In this short review we highlight the diagnostic challenge presented by surgical peritonitis in peritoneal dialysis patients, giving attention to etiology, clinical presentation, diagnosis, and management. Despite improvements in medical imaging and a reduction in overall rates of peritonitis in peritoneal dialysis, the mortality of surgical peritonitis has not changed in recent years and remains a challenge for the clinical team.