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Ogawa L, Beaird OE, Schaenman JM. Risk factors for infection in patients with a failed kidney allograft on immunosuppressive medications. FRONTIERS IN NEPHROLOGY 2023; 3:1149116. [PMID: 37675348 PMCID: PMC10479655 DOI: 10.3389/fneph.2023.1149116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 07/17/2023] [Indexed: 09/08/2023]
Abstract
Patients with a failing kidney allograft are often continued on immunosuppression (IS) to preserve residual kidney function and prevent allosensitization. It has been previously accepted that maintaining patients on immunosuppressive therapy results in an increased risk of infection, hospitalization, and mortality. However, as the management of IS in patients with a failed kidney allograft continues to evolve, it is important to review the data regarding associations between infection and specific immunosuppression regimens. We present a review of the literature of failed kidney allograft management and infection risk, and discuss practices for infection prevention. Fifteen studies, published from 1995 to 2022, which investigated the experience of patients with failed allograft and infection, were identified. Infection was most commonly documented as a general event, but when specified, included infections caused by Candida, Mycobacterium tuberculosis, and Aspergillus. In addition, the definition of reduced "IS" varied from decreased doses of a triple drug regimen to monotherapy, whereas others did not specify which medications patients were receiving. Despite attempts at lowering net immunosuppression, patients with failed allografts remain at risk of acquiring opportunistic and non-opportunistic infections. Although opportunistic infections secondary to IS are expected, somewhat surprisingly, it appears that the greatest risk of infection may be related to complications of dialysis. Therefore, mitigating strategies, such as planning for an arteriovenous (AV) fistula over a hemodialysis catheter placement, may reduce infection risk. Additional studies are needed to provide more information regarding the types and timing of infection in the setting of a failed kidney allograft. In addition, more data are needed regarding specific medications, doses, and timing of taper of IS to guide future patient management and inform strategies for infection surveillance and prophylaxis.
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Affiliation(s)
| | | | - Joanna M. Schaenman
- Division of Infectious Diseases, David Geffen School of Medicine at University of California—Los Angeles, Los Angeles, CA, United States
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Tian N, Meng H, Fung WWS, Ng JKC, Chan GCK, Kwong VWK, Pang WF, Chow KM, Li PKT, Szeto CC. Peritoneal dialysis after failed kidney allograft: Comparing patients with and without pd before transplant. PLoS One 2023; 18:e0284152. [PMID: 37463181 DOI: 10.1371/journal.pone.0284152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/26/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND The result of published studies on the clinical outcome of peritoneal dialysis (PD) after kidney allograft failure is conflicting. There are also few published data on the outcome of patients who had PD before kidney transplant and then return to PD after allograft failure. METHODS We reviewed 100 patients who were started on PD after kidney allograft failure between 2001 and 2020 (failed transplant group); 50 of them received PD before transplant. We compared the clinical outcome to 200 new PD patients matched for age, sex, and diabetic status (control group). RESULTS The patients were followed for 45.8 ± 40.5 months. the 2-year patient survival rate was 83.3% and 87.8% for the failed transplant and control groups, respectively (log rank test, p = 0.2). The corresponding 2-year technique survival rate 66.5% and 71.7% (p = 0.5). The failed transplant and control groups also had similar hospitalization rate and peritonitis rate. In the failed transplant group, there was also no difference in patient survival, technique survival, hospitalization, or peritonitis rate between those with and without PD before transplant. In the failed transplant group, patients who had PD before transplant and then returned to PD after allograft failure had substantial increase in D/P4 (0.585 ± 0.130 to 0.659 ± 0.111, paired t-test, p = 0.032) and MTAC creatinine (7.74 ± 3.68 to 9.73 ± 3.00 ml/min/1.73m2, p = 0.047) from the time before the transplant to the time after PD was resumed after failed allograft. CONCLUSIONS The clinical outcome of PD patients with a failed kidney allograft is similar to other PD patients. However, patients who have a history of PD before kidney transplant and then return to PD after allograft failure have increased peritoneal transport parameters.
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Affiliation(s)
- Na Tian
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia
| | - Han Meng
- Department of Nephrology, General Hospital of Ningxia Medical University, Yinchuan, Ningxia
| | - Winston W S Fung
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Jack K C Ng
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Gordon C K Chan
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Vickie W K Kwong
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Wing-Fai Pang
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Kai-Ming Chow
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Philip K T Li
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Cheuk Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital, Hong Kong, China
- Li Ka Shing Institute of Health Sciences (LiHS), Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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Meng X, Wu W, Xu S, Cheng Z. Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies. Ren Fail 2021; 43:698-708. [PMID: 33896379 PMCID: PMC8079072 DOI: 10.1080/0886022x.2021.1914659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The influence of prior failed kidney transplants on outcomes of peritoneal dialysis (PD) is unclear. Thus, we conducted a systematic review and meta-analysis to compare the outcomes of patients initiating PD after a failed kidney transplant with those initiating PD without a prior history of kidney transplantation. METHODS We searched PubMed, Embase, CENTRAL, and Google Scholar databases from inception until 25 November 2020. Our meta-analysis considered the absolute number of events of mortality, technical failures, and patients with peritonitis, and we also pooled multi-variable adjusted hazard ratios (HR). RESULTS We included 12 retrospective studies. For absolute number of events, our analysis indicated no statistically significant difference in technique failure [RR, 1.14; 95% CI, 0.80-1.61; I2=52%; p = 0.48], number of patients with peritonitis [RR, 1.13; 95% CI, 0.97-1.32; I2=5%; p = 0.11] and mortality [RR, 1.00; 95% CI, 0.67-1.50; I2=63%; p = 0.99] between the study groups. The pooled analysis of adjusted HRs indicated no statistically significant difference in the risk of technique failure [HR, 1.25; 95% CI, 0.88-1.78; I2=79%; p = 0.22], peritonitis [HR, 1.04; 95% CI, 0.72-1.50; I2=76%; p = 0.85] and mortality [HR, 1.24; 95% CI, 0.77-2.00; I2=66%; p = 0.38] between the study groups. CONCLUSION Patients with kidney transplant failure initiating PD do not have an increased risk of mortality, technique failure, or peritonitis as compared to transplant-naïve patients initiating PD. Further studies are needed to evaluate the impact of prior and ongoing immunosuppression on PD outcomes.
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Affiliation(s)
- Xiaohua Meng
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Weifei Wu
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Shuang Xu
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
| | - Zhiqun Cheng
- Department of Nephrology, Huzhou Central Hospital, Affiliated Central Hospital of HuZhou University, Huzhou, Zhejiang Province, P.R. China
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La Porta E, Conversano E, Zugna D, Camilla R, Labbadia R, Paglialonga F, Parolin M, Vidal E, Verrina E. Returning to dialysis after kidney allograft failure: the experience of the Italian Registry of Paediatric Chronic Dialysis. Pediatr Nephrol 2021; 36:3961-3969. [PMID: 34128094 PMCID: PMC8599402 DOI: 10.1007/s00467-021-05140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/19/2021] [Accepted: 05/14/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The need for dialysis after kidney allograft failure (DAGF) is among the top five reasons for dialysis initiation, making this an important topic in clinical nephrology. However, data are scarce on dialysis choice after transplantation and clinical outcomes for DAGF in children. METHODS Patients receiving chronic dialysis < 18 years were recorded from January 1991 to January 2019 by the Italian Registry of Pediatric Chronic Dialysis (IRPCD). We investigated factors influencing choice of dialysis modality, patient outcome in terms of mortality, switching dialysis modality, and kidney transplantation. RESULTS Among 118 patients receiving DAGF, 41 (35%) were treated with peritoneal dialysis (PD), and 77 (65%) with haemodialysis (HD). Significant predictors for treatment with PD were younger age at dialysis start (OR 0.85 per year increase [95%CI 0.72-1.00]) and PD use before kidney transplantation (OR 8.20 [95%CI 1.82-37.01]). Patients entering DAGF in more recent eras (OR 0.87 per year increase [95%CI 0.80-0.94]) and with more than one dialysis modality before kidney transplantation (OR 0.56 for being treated with PD [0.12-2.59]) were more likely to be initiated on HD. As compared to patients on HD, those treated with PD exhibited increased but non-significant mortality risk (HR 2.15 [95%CI 0.54-8.6]; p = 0.28) and higher prevalence of dialysis-related complications during DAGF (p = 0.002) CONCLUSIONS: Patients entering DAGF in more recent years are more likely to be initiated on HD. In this specific population of children, use of PD seems associated with a more complicated course. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Edoardo La Porta
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
| | - Ester Conversano
- grid.418712.90000 0004 1760 7415Department of Pediatrics, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Daniela Zugna
- grid.7605.40000 0001 2336 6580Department of Medical Sciences, Cancer Epidemiology Unit, University of Torino and CPO-Piemonte, Turin, Italy
| | - Roberta Camilla
- grid.415778.80000 0004 5960 9283Paediatric Nephrology Unit, Regina Margherita Children’s Hospital, CDSS, Turin, Italy
| | - Raffaella Labbadia
- grid.414125.70000 0001 0727 6809Nephrology and Dialysis Unit, Department of Pediatrics, “Bambino Gesù” Children’s Hospital-IRCCS, Rome, Italy
| | - Fabio Paglialonga
- grid.414818.00000 0004 1757 8749Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mattia Parolin
- grid.411474.30000 0004 1760 2630Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman’s and Child’s Health, University Hospital, Padova, Padua, Italy
| | - Enrico Vidal
- Division of Pediatrics, Department of Medicine (DAME), University of Udine, P.le S.M della Misericordia, 15 33100, Udine, Italy.
| | - Enrico Verrina
- Dialysis Unit, Department of Pediatrics, IRCCS Giannina Gaslini, Genova, Italy
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Clinical outcomes of incident peritoneal dialysis patients coming from kidney transplantation program: A case-control study. PLoS One 2020; 15:e0227870. [PMID: 31978190 PMCID: PMC6980492 DOI: 10.1371/journal.pone.0227870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/01/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Brazil ranks second in the absolute number of transplantations in the world. Despite improvements in graft survival, many patients will progress to graft loss and return to dialysis. Concerns exist regarding adverse clinical outcomes in this population when undergone peritoneal dialysis (PD). Objective To compare the occurrence of mortality, technique failure, and peritonitis among incident patients in PD coming from either Tx or pre-dialysis treatment. Methodology A retrospective study in which 47 adult patients with Tx failure (Tx group) were matched for age, gender, diabetes mellitus (DM), modality and start year of PD, with 1:1 predialysis patient (nTx group). The Fine-Gray competing risk model was used to analyze mortality and technique failure. Results Compared to nTx, the Tx group had a lower body mass index, serum potassium, and albumin concentrations. A higher ferritin level, transferrin saturation and the number of patients with positive serology for viral hepatitis were also observed in the Tx group. In the multivariate analysis, patients of the Tx group had 4.4-times higher risk of death (p = 0.007), with infection as the main cause. Technique failure and peritonitis were similar in both groups. Conclusion Previous Tx is a risk factor for mortality but not for technique failure or peritonitis in incident patients on a PD program.
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Chaudhri S, Thomas AA, Samad N, Fan SL. Peritoneal dialysis in patients with failed kidney transplant: Single centre experience. Nephrology (Carlton) 2018; 23:162-168. [PMID: 27762063 DOI: 10.1111/nep.12951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/14/2016] [Accepted: 10/17/2016] [Indexed: 11/30/2022]
Abstract
AIM To determine if patients with failing kidney transplants who opt to have peritoneal dialysis (PD) have poor short-term PD technique survival and increased rates of peritonitis. METHODS We performed a retrospective analysis comparing 50 consecutive patients starting PD after a failed kidney transplant to 93 incident patients starting PD (matching for age, gender, diabetes causing renal failure, ethnicity and year of starting PD). RESULTS The mean follow-up period was 26 months. PD technique survival was lower for the post-transplant cohort. However, this did not appear to be related to PD peritonitis risk; infection rate was lower in the post-transplant group albeit not statistically significant (1 in 23.6 patient months vs 1 in 22.5 patient months). There were no differences in the proportion of Gram positive: Gran negative: Culture Negative infections. The only fungal peritonitis occurred in a Control patient. Results of baseline Peritoneal Equilibration Tests were not different; D/Pcr was 0.69 for post-TP versus 0.64 for Control (P = ns), and net UF was 250 mL for post-TP versus 310 mL for Control (P = ns). PET results after 12 months were also similar. CONCLUSION Our study found a small but significantly higher rate of PD technique failure in the post-transplant cohort, but this did not appear to be related to peritonitis rates or peritoneal membrane function. Further studies are required to explore reasons for PD technique failure in patients who have had kidney transplant, but our study supports the use of PD in selected patient from this cohort.
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Affiliation(s)
- Saurabh Chaudhri
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Alice A Thomas
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Nasreen Samad
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Stanley L Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
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Steroid Use and Infectious Complication in Peritoneal Dialysis After Kidney Transplant Failure. Transplantation 2015; 99:1514-20. [DOI: 10.1097/tp.0000000000000573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Santos C, Pérez-Fontán M, Rodríguez-Carmona A, Calvo-Rodríguez M, López-Muñiz A, López-Calviño B, García-Falcón T. Identification of Targets for Prevention of Peritoneal Catheter Tunnel and Exit-Site Infections in Low Incidence Settings. Perit Dial Int 2014; 36:43-51. [PMID: 25292406 DOI: 10.3747/pdi.2014.00131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/29/2014] [Indexed: 11/15/2022] Open
Abstract
UNLABELLED ♦ BACKGROUND Peritoneal catheter tunnel and exit-site infection (TESI) complicates the clinical course of peritoneal dialysis (PD) patients. Adherence to recommendations for catheter insertion, exit-site care, and management of Staphylococcus aureus (SAu) carriage reduces, but does not abrogate the risk of these infections. ♦ OBJECTIVE To reappraise the risk profile for TESI in an experienced center with a long-term focus on management of SAu carriage and a low incidence of these infections. ♦ METHOD Following a retrospective, observational design, we investigated 665 patients incident on PD. The main study variable was survival to the first episode of TESI. We considered selected demographic, clinical, and technical variables, applying multivariate strategies of analysis. ♦ MAIN RESULTS The overall incidence of TESI was 1 episode/68.5 patient-months. Staphylococcus aureus carriage disclosed at inception of PD (but not if observed sporadically during follow-up) (hazard ratio [HR] 1.53, p = 0.009), PD started shortly after catheter insertion (HR 0.98 per day, p = 0.011), PD after kidney transplant failure (HR 2.18, p = 0.017), lower hemoglobin levels (HR 0.88 per g/dL, p = 0.013) and fast peritoneal transport rates (HR 2.92, p = 0.03) portended an increased risk of TESI. Delaying PD ≥ 30 days after catheter insertion markedly improved the probability of TESI. Carriage of methicillin-resistant SAu since the start of PD was associated with a high incidence of TESI by these bacteria. On the contrary, resistance to mupirocin did not predict such a risk, probably due to the use of an alternative regime in affected patients. ♦ CONCLUSIONS Adherence to current recommendations results in a low incidence of TESI in PD patients. Interventions on specific risk subsets have a potential to bring incidence close to negligible levels. Despite systematic screening and management, SAu carriage is still a predictor of TESI. Antibiotic susceptibility patterns may help to refine stratification of the risk of TESI by these bacteria. Early insertion of the peritoneal catheter should be considered whenever possible, to reduce the risk of later TESI.
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Affiliation(s)
- Clara Santos
- Division of Nephrology, Vilanova da Gaia/Espinho Hospital Center, Portugal
| | - Miguel Pérez-Fontán
- Health Sciences Faculty, University of A Coruña, Spain Division of Nephrology, University Hospital of A Coruña, Spain
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