Impact of hypokalemia on peritonitis in peritoneal dialysis patients: a systematic review

Risk factors of peritoneal dialysis-related peritonitis in the Japan Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Background

Peritoneal dialysis (PD)-related peritonitis is a major complication of PD. Wide variations in peritonitis prevention, treatment strategies and consequences are seen between countries. These between-country differences may result from modifiable risk factors and clinical practices.

Methods

A total of 1225 Japanese PD patients were included and prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study phase 1 (2014-2018) and phase 2 (2018-2022). Associations between PD-related peritonitis and various risk factors were assessed by Cox proportional hazards survival models.

Results

During follow-up (median 1.52 years), 539 peritonitis episodes were experienced by 364 patients. The country crude peritonitis rate was 0.27 episodes/patient-year. In the fully adjusted model, noticeable patient-level factors associated with experiencing any peritonitis included age {hazard ratio [HR] 1.07 per 5-year increase [95% confidence interval (CI) 1.01-1.14]}, serum albumin level [HR 0.63 per 1 g/dl higher (95% CI 0.48-0.82)] and continuous ambulatory peritoneal dialysis (PD) [HR 1.31 versus automated PD (95% CI 1.05-1.63)]. The adoption of antibiotic prophylaxis practice at the time of PD catheter insertion [HR 0.63 (95% CI 0.51-0.78)] or when having complicated dental procedures [HR 0.74 (95% CI 0.57-0.95)] or lower endoscopy [HR 0.69 (95% CI 0.54-0.89)] were associated with lower hazards of any peritonitis, while a routine facility practice of having more frequent regular medical visits was associated with a higher hazard.

Conclusion

Identification of risk factors in Japan may be useful for developing future versions of guidelines and improving clinical practices in Japan. Investigation of country-level risk factors for PD-related peritonitis is useful for developing and implementing local peritonitis prevention and treatment strategies.

Peritoneal Dialysis-Related Peritonitis Caused by Lysinibacillus sphaericus

Peritonitis is the major complication of peritoneal dialysis (PD) patients. Staphylococcus is the leading causative organism of PD-related peritonitis. However, there were more reports of unusual organisms causing peritonitis. Clinical features, management, and outcome of peritonitis from unusual organisms are important information. We reported herein a 72-year-old female patient who presented with fever, abdominal pain, and cloudy dialysate for 3 days. Upon admission, ceftazidime and vancomycin were given intraperitoneally. A preliminary report of blood and PD fluid culture showed the presence of Gram-positive bacilli. Her clinical status improved 48 hours after the commencement of the antibiotics. Subsequently, culture reports of blood and PD fluid showed Lysinibacillus sphaericus which was susceptible to vancomycin at a minimal inhibitory concentration of less than 0.25 μg/mL. The patient was given intraperitoneal vancomycin for a total of 14 days. Then, the PD effluent was clear, and its cell count was below 100 cells/mm3 in 3 days. The patient did not have a recurrence of peritonitis after antibiotic discontinuation. The possibility of this organism infection is environmental contamination related to the patient's gardening activities.

Rescue plan for CAPD peritonitis: Using ultrasonography as a guide on when to remove the catheter

INTRODUCTION

Ultrasound has been found to facilitate early identification of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

A retrospective analysis was carried out to evaluate the effectiveness of ultrasonography-guided removal of the Tenckhoff catheter in reducing complications like a shift to hemodialysis or death in CAPD patients.

RESULTS

The "peritonitis rescue plan" supported timely decision-making for the removal of the infected catheter and resulted in a lower peritonitis episode per patient per month ratio (from 1:36 to 1:122) in 2021, a lower death rate (from 19% to 6.6%) and lower incidences of shifts to hemodialysis (from 2%-9% to 0%) as compared to that before the implementation of the plan in 2019.

CONCLUSION

The implementation of the "peritonitis rescue plan" and the removal of the infected catheter within 3 days of peritonitis being detected was successful in improving the standard of care for patients undergoing CAPD.

Efficacy of Potassium Supplementation in Hypokalemic Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial

RATIONALE & OBJECTIVE

Hypokalemia is a common electrolyte abnormality in patients on peritoneal dialysis (PD) and has been associated with increased risks of peritonitis and death. Whether correction of hypokalemia improves these outcomes is unknown.

STUDY DESIGN

Multicenter, open-label, prospective, randomized controlled trial.

SETTING & PARTICIPANTS

Adult (aged ≥18 years) PD patients with hypokalemia (defined as at least 3 values or an average value <3.5 mEq/L in the past 6 months). Randomization was stratified according to center and residual urine output (≤100 or >100 mL/day).

INTERVENTIONS

Random assignment to either protocol-based potassium supplementation (titratable dose of oral potassium chloride to maintain serum potassium of 4-5 mEq/L) or conventional potassium supplementation (reactive supplementation when serum potassium is <3.5 mEq/L) over 52 weeks. Treatment groups were compared using intention-to-treat analyses implemented using Cox proportional hazards regression.

OUTCOME

The primary outcome was time from randomization to first peritonitis episode (any organism). Secondary outcomes were all-cause mortality, cardiovascular mortality, hospitalization, and conversion to hemodialysis.

RESULTS

A total of 167 patients with time-averaged serum potassium concentrations of 3.33 ± 0.28 mEq/L were enrolled from 6 PD centers: 85 were assigned to receive protocol-based treatment, and 82 were assigned to conventional treatment. The median follow-up time was 401 (IQR, 315-417) days. During the study period, serum potassium levels in the protocol-based treatment group increased to 4.36 ± 0.70 mEq/L compared with 3.57 ± 0.65 mEq/L in the group treated conventionally (mean difference, 0.66 [95% CI, 0.53-0.79] mEq/L; P < 0.001). The median time to first peritonitis episode was significantly longer in the protocol-based group (223 [IQR, 147-247] vs 133 [IQR, 41-197] days, P = 0.03). Compared with conventional treatment, the protocol-based group had a significantly lower hazard of peritonitis (HR, 0.47 [95% CI, 0.24-0.93]) but did not differ significantly with respect to any of the secondary outcomes. Asymptomatic hyperkalemia (>6 mEq/L) without characteristic electrocardiographic changes occurred in 3 patients (4%) in the protocol-based treatment group.

LIMITATIONS

Not double-masked.

CONCLUSIONS

Compared with reactive potassium supplementation when the serum potassium level falls below 3.5 mEq/L, protocol-based oral potassium treatment to maintain a serum potassium concentration in the range of 4-5 mEq/L may reduce the risk of peritonitis in patients receiving PD who have hypokalemia.

TRIAL REGISTRATION

Registered at the Thai Clinical Trials Registry with study number TCTR20190725004.