Risk of Peritoneal Dialysis-Related Peritonitis in a Multi-Racial Asian Population.

♦ BACKGROUND: Peritonitis is one of the most common complications of peritoneal dialysis (PD). Understanding the risk factors of peritonitis in a multi-racial Asian population may help to improve outcomes on PD. ♦ METHODS: We conducted a prospective observational study to identify risk factors for PD-related peritonitis over a 1-year period in 15 adult PD centers. All peritonitis episodes were independently adjudicated. ♦ RESULTS: A total of 1,603 participants with a mean age of 51.6 years comprising 52.7% females, 62.6% ethnic Malays, 27.0% Chinese, and 8.1% Indians were recruited. The overall peritonitis rate was 1 episode per 44.0 patient-months with 354 episodes recorded in 282 (17.6%) patients over 15,588 patient-months. Significant risk factors of peritonitis were severe obesity (incidence-rate ratio [IRR] 3.32, 95% confidence interval [CI]: 1.30, 8.45), hypoalbuminemia (IRR 1.61, 95% CI: 1.06, 2.46), Staphylococcus aureus nasal carriage (IRR 2.26, 95% CI: 1.46, 3.50), and use of Fresenius system (Fresenius Medical Care North America, Waltham, MA, USA) (IRR 2.49, 95% CI: 1.27, 4.89). The risk of peritonitis was lower in those on automated PD compared with standard PD (IRR 0.43, 95% CI: 0.25, 0.74), and in centers with a patient-staff ratio of 15 to 29.9 (IRR 0.67, 95% CI: 0.49, 0.90) and ≥ 30 (IRR 0.52, 95% CI: 0.34, 0.80). Prevalent patients and exit-site care with topical antibiotics were also protective against peritonitis. Peritonitis rates varied between racial groups. The IRRs of overall peritonitis and gram-positive peritonitis in Chinese versus other racial groups were 0.65 (95% CI: 0.46, 0.90) and 0.47 (95% CI: 0.24, 0.91), respectively. ♦ CONCLUSIONS: Multiple patient, center, and PD-system factors influence the risk of peritonitis. In the Asian population, there are racial differences in the risk of peritonitis.

Non-candidal fungal peritonitis in Far North Queensland: a case series.

BACKGROUND: Fungal peritonitis is a recognized complication in patients with end-stage renal failure treated with peritoneal dialysis (PD). Most infections are attributable to Candida species. In approximately one third of cases, the causative fungus is a non-Candida species. Recent reports in the literature show a rising incidence of non-candidal fungal peritonitis (NCFP). We report a case series of NCFP, together with two hitherto unreported species of fungi causing peritonitis, from a tropical geographic area (Far North Queensland). METHODS: This series of 10 cases of NCFP was identified from the PD peritonitis database in Far North Queensland between 1998 and 2010. All 10 patients were from the Aboriginal and Torres Strait Islander ethnic group, 8 of whom lived in remote locations. All but 1 patient had type 2 diabetes mellitus. Of the 10 cases, 7 occurred while the patients received continuous ambulatory PD. Only 1 patient avoided catheter removal, and 5 patients were permanently transferred to hemodialysis. No patient died as a result of the fungal infection. All 10 fungi represented different species. Most (6 of 10) were saprophytic; only 2 were normal skin flora. Two of the causative species (Chaetomium and Beauveria) have rarely been associated with any form of human infection. In 7 patients, the infection occurred during the wet season (November - April). All cases met clinical criteria for peritonitis. DISCUSSION AND CONCLUSIONS: The NCFP cases described in this series involved a variety of previously known fungal species and also two new species that have not been reported to cause disease in humans. Indigenous patients from Far North Queensland are particularly predisposed to infection with these exotic fungi as a result of environmental and social factors. Further understanding is desirable to help devise preventive strategies to avoid the consequences of catheter failure.

Familial Mediterranean fever in Germany: clinical presentation and amyloidosis risk.

OBJECTIVE: To characterize patients with familial Mediterranean fever (FMF) with and without AA amyloidosis living in Germany. METHOD: Clinical and genetic data from 64 FMF patients were analysed for amyloidosis risk factors. RESULTS: Fifty-five patients (85%) were of Turkish or Armenian origin. Thirty-one patients (48%) developed FMF symptoms before the age of 16 years. Sixteen patients (26%) became symptomatic after age 20. Symptoms reported were peritonitis (95%), fever (78%), pleuritis (59%), arthralgia (60%), arthritis (32%), erysipelas-like erythema (23%), and vasculitis (8%). FMF diagnosis was delayed for a median of 8.0 years. Genetic analysis confirmed M694V as the most prevalent Mediterranean fever (MEFV) gene mutation in 46 out of 59 patients (78%). M694V homozygosity was associated with an earlier FMF onset (median age 5.5 years, p = 0.0001) and a higher prevalence of peritonitis (p = 0.007) and pleuritis (p = 0.0007) compared to patients without an M694V mutation. AA amyloidosis was detected in 16 patients (25%) at a median age of 36.5 years and tended to be associated with a higher age at disease onset (p = 0.062) and a higher FMF activity score (p = 0.093). AA amyloidosis was significantly associated with a higher age at FMF diagnosis (p = 0.0022). CONCLUSIONS: Clinical symptoms of FMF-affected migrants living in Germany resemble those observed in their home country. In particular, patients with an onset of FMF symptoms after age 20 and a later FMF diagnosis have a high risk of AA amyloidosis. Symptomatic patients who originate from countries with a higher FMF prevalence should be screened for FMF and proteinuria.

Does allograft failure impact infection risk on peritoneal dialysis: a North American Pediatric Renal Trials and Collaborative Studies Study.

BACKGROUND AND OBJECTIVES: Several adult studies report that patients returning to peritoneal dialysis after allograft failure have increased infection-related morbidity. The impact of allograft failure on infection risk in children is uncertain. We compared peritonitis-free survival between pediatric peritoneal dialysis patients with prior allograft failure and those who were transplant naive. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We studied patients, 2-21 years of age, who initiated peritoneal dialysis from January 1, 1992, to December 31, 2007, in the North American Pediatric Renal Trials and Collaborative Studies registry. Demographic characteristics were compared between transplant naive and allograft failure patients using a chi-squared statistic. Peritonitis-free survival was compared between the two groups using Kaplan-Meier estimates. A Cox regression analysis was performed to adjust for covariates, which impact risk of peritonitis. RESULTS: Of 2829 patients on peritoneal dialysis, 445 had a prior history of allograft failure and 2384 did not (transplant naive). Demographic characteristics including age at dialysis initiation, race, primary renal disease, and era of dialysis initiation were significantly different between the two groups. Peritonitis-free survival was poorer for the allograft failure group. After covariate adjustment, allograft failure showed borderline significance as a factor predictive of peritonitis. CONCLUSIONS: Children initiating peritoneal dialysis after allograft failure may experience a slightly higher infection risk.

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.

Peritonitis and exit site infections in First Nations patients on peritoneal dialysis.

BACKGROUND AND OBJECTIVES: First Nations (FN) patients on peritoneal dialysis experience poor outcomes. Whether discrepancies exist regarding the microbiology, rate of infections, and outcomes between FN and non-FN peoples remains unknown. Design, setting, participants, & measures: All adult peritoneal dialysis patients (n = 727) from 1997 to 2007 residing in Manitoba, Canada, were included. Parametric and nonparametric tests were used as necessary. Negative binomial regression was used to determine the relationship of rates of exit site infections (ESIs) and peritonitis between FN and non-FN peoples. RESULTS: A total of 161 FN and 566 non-FN subjects were included in the analyses. The unadjusted relative rates of peritonitis and ESIs in FN subjects were 132.7 and 86.0/100 patient-years compared with 87.8 and 78.2/100 patient-years in non-FN populations, respectively. FN subjects were more likely to have culture-negative peritonitis (36.5 versus 20.8%, P < 0.0001) and Staphylococcus ESIs (54.1 versus 32.9%, P < 0.0001). The crude and adjusted rates of peritonitis were higher in FN subjects for total episodes and culture-negative and gram-negative peritonitis. Catheter removal because of peritonitis was similar in both groups (42.9 versus 38.1% for FN and non-FN subjects, respectively; P = 0.261). CONCLUSIONS: FN patients experience higher rates of peritonitis and similar rates of ESIs compared with non-FN patients. Interventions to improve outcomes and prevent infections should specifically be targeted to the FN population.

Pseudomonas peritonitis in Australia: predictors, treatment, and outcomes in 191 cases.

BACKGROUND AND OBJECTIVES: Pseudomonas peritonitis is a serious complication of peritoneal dialysis. To date, there as been no comprehensive, multicenter study of this condition. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The predictors, treatment, and clinical outcomes of Pseudomonas peritonitis were examined by binary logistic regression and multilevel, multivariate Poisson regression in all Australian PD patients in 66 centers between 2003 and 2006. RESULTS: A total of 191 episodes of Pseudomonas peritonitis (5.3% of all peritonitis episodes) occurred in 171 individuals. Its occurrence was independently predicted by Maori/Pacific Islander race, Aboriginal/Torres Strait Islander race, and absence of baseline peritoneal equilibration test data. Compared with other organisms, Pseudomonas peritonitis was associated with greater frequencies of hospitalization (96 versus 79%; P = 0.006), catheter removal (44 versus 20%; P < 0.001), and permanent hemodialysis transfer (35 versus 17%; P < 0.001) but comparable death rates (3 versus 2%; P = 0.4). Initial empiric antibiotic choice did not influence outcomes, but subsequent use of dual anti-pseudomonal therapy was associated with a lower risk for permanent hemodialysis transfer (10 versus 38%, respectively; P = 0.03). Catheter removal was associated with a lower risk for death than treatment with antibiotics alone (0 versus 6%; P < 0.05). CONCLUSIONS: Pseudomonas peritonitis is associated with high rates of catheter removal and permanent hemodialysis transfer. Prompt catheter removal and use of two anti-pseudomonal antibiotics are associated with better outcomes.

Higher rate and earlier peritonitis in Aboriginal patients compared to non-Aboriginal patients with end-stage renal failure maintained on peritoneal dialysis in Australia: analysis of ANZDATA.

BACKGROUND: Aboriginal patients maintained on peritoneal dialysis (PD) have a higher rate of technique failure than any other racial group in Australia. Peritonitis accounts for the bulk of these technique failures, but it is uncertain whether the increased risk of peritonitis in Aboriginal patients was independent of associated comorbid conditions, such as diabetes mellitus. METHODS: Using data collected by the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), peritonitis rates and time to first peritonitis were compared between Aboriginal (n = 238) and non-Aboriginal patients (n = 2924) commencing PD in Australia between 1 April 1999 and 31 March 2003. RESULTS: Aboriginal PD patients were younger, and had a higher incidence of diabetes than their non-Aboriginal counterparts. Mean peritonitis rates were significantly higher among Aboriginal (1.15 episodes/year; 95% confidence interval (CI): 1.03-1.28) than non-Aboriginal patients (0.60 episodes/year; 95% CI: 0.57-0.62, P < 0.05). Using multivariate negative binomial regression, independent predictors of higher peritonitis rates include Aboriginal racial origin (adjusted odds ratio 1.78; 95% CI: 1.45-2.19), obesity, age and absence of a recorded dialysate : plasma creatinine ratio (D/P creatinine) measurement. Aboriginal racial origin was also associated with a shorter median time to first peritonitis (9.9 vs 19.3 months, P < 0.05), which remained statistically significant in a multivariate Cox proportional hazards model (adjusted hazard ratio 1.76; 95% CI: 1.47-2.11, P < 0.05). CONCLUSION: Aboriginal and obese PD patients have a higher rate of peritonitis and a shorter time to first peritonitis, independent of demographic and comorbid factors. Further investigation of the causes of increased peritonitis risk in Aboriginal patients is needed.

Is there a role for peritoneal dialysis in remote aboriginal patients with end-stage renal disease in Australia?

Peritoneal dialysis (PD) is often the preferred treatment modality of many Aboriginal patients with end-stage renal disease (ESRD) due to their remote locations and the scarcity of remote satellite haemodialysis units. Infectious complications remain an important cause of morbidity in Aboriginal patients maintained on PD in Australia. Analysis of the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) has revealed that Aboriginal PD patients are more likely to have earlier and a higher rate of peritonitis, higher risk of PD technique failure, and higher mortality compared to non-Aboriginal PD patients independent of other factors. However, the finding of Aboriginality as a risk factor for PD-related complications is at least partly attributable to socioeconomic factors, such as poor housing and hygiene. As PD will remain a necessary first-line therapy in this group of isolated and disadvantaged patients, implementing aggressive preventive strategies and targeting modifiable socioeconomic risk factors may reduce morbidity and preserve their independence and way of life.

Racial differences and peritonitis in an urban peritoneal dialysis center.

Racial differences have been reported among various groups with end-stage renal disease maintained on dialysis. In particular, patient survival on dialysis has been reported to be better in African-American patients than in Caucasian patients. Peritonitis rates and dropout from chronic peritoneal dialysis (CPD) have been reported to be higher in African-American patients. We decided to review our experience with peritonitis rates in African-American and Caucasian patients. From 1994 to 2000, 403 patients were maintained on CPD in the New Haven continuous ambulatory peritoneal dialysis (CAPD) unit. Peritonitis rates were 1 episode in 14 patient-months in Caucasian patients and 1 episode in 13.6 patient-months in African-American patients. Mean ages at the start of dialysis were 52.4 +/- 16.2 years in the Caucasian patients and 62.6 +/- 14.9 years in the African-American patients. African-American patients were older. African-American and Caucasian patients had similar peritonitis rates. Time of first episode of peritonitis was not different in the two groups.

Polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.

We retrospectively evaluated 232 continuous ambulatory peritoneal dialysis (CAPD) patients entering our program from January 1, 1987, to December 31, 1997, for polymicrobial peritonitis. Polymicrobial peritonitis occurred in 16% of the patients (polymicrobial-peritonitis group), whereas 52% of the patients had peritonitis episodes with only a single organism (single-organism group), and 32% of the patients had no episode of peritonitis. Polymicrobial peritonitis accounted for 8% of the 554 peritonitis episodes, occurred after 23 +/- 20 months on peritoneal dialysis (PD), and was preceded by greater than three episodes of peritonitis in 73% of the patients. Peritonitis rates were greater in the polymicrobial-peritonitis group compared with patients in the single-organism group (1.8 versus 1.2 episodes/patient-year; P: < 0.001). The majority of polymicrobial infections involved gram-negative and/or fungal pathogens, but in 21% of the episodes, only gram-positive organisms were identified. An intra-abdominal process was identified in only 7% of the patients. Catheter loss overall was greatest in the polymicrobial-peritonitis group (65% versus single-organism group, 30% versus patients without peritonitis, 5%; P < 0.001), but only 33% of the polymicrobial infections resulted in catheter loss. At last follow-up, 70% of the patients in the polymicrobial-peritonitis group had permanently transferred to hemodialysis compared with 25% from the single-organism group and 15% from the no-peritonitis group (P < 0.001). In conclusion, polymicrobial peritonitis is an infrequent but serious complication of CAPD that occurs late in the course of PD and is often preceded by recurrent episodes of peritonitis. Polymicrobial peritonitis is rarely the result of a catastrophic intra-abdominal process, and although the majority of patients can be successfully treated without catheter removal, the long-term prognosis is poor, with a high rate of transfer to hemodialysis.

Peritonitis in an urban peritoneal dialysis program: an analysis of infecting pathogens.

We have previously found that race, level of education, and peritoneal dialysis system are factors that significantly and independently influence peritonitis rates in our patient population. We now extend these observations by assessing the pathogens responsible for peritonitis in these subgroups. Between January 1, 1981, and May 15, 1993, 248 peritoneal dialysis patients underwent dialysis at our facility. The rate of peritonitis by pathogen was determined in these patients using the fixed effects Poisson model. Total peritonitis rates in black patients (1.89 episodes/patient-year) were significantly greater compared with white patients (1.11 episodes/patient-year; P < 0.0001). Increased infection rates in black patients were significant for Staphylococcus epidermidis, Staphylococcus aureus, and gram-negative pathogens. The level of education had a negative correlation with peritonitis rates (< or = 8 years, 2.00 episodes/patient-year; 9 to 12 years, 1.64 episodes/patient-year; and > or = 13 years, 1.24 episodes/patient-year) with patients having > or = 13 years of education at the start of dialysis demonstrating a significantly lower total peritonitis rate compared with patients with 9 to 12 years (P = 0.001) or < or = 8 years (P < 0.001) of education. This was accounted for by a significant decrease in infection rates for S epidermidis, polymicrobial, and gram-negative organisms. Finally, patients on automated peritoneal dialysis had significantly lower total peritonitis rates (0.59 episodes/patient-year) compared with patients on either a connect (2.11 episodes/patient-year) or disconnect (1.46 episodes/patient-year) system.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic peritoneal dialysis: seven-year experience in a large Hispanic program.

OBJECTIVE: To analyze the clinical results of our patient population on continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) in relation to treatment modality systems, compliance, rehabilitation characteristics, complications, and survivals. DESIGN: The medical records of all patients trained on CAPD or CCPD between 1985 and 1992 were reviewed for the above-mentioned outcome objectives. SETTING: Outpatient CAPD facility affiliated to a tertiary care community hospital. PATIENTS: The total of 305 patients trained during the study period were studied. MAIN OUTCOME MEASURES: The patients were studied for age, sex, primary renal disease, peritoneal dialysis modality, need of assistance from a partner during the dialysis procedure, causes of transfer and hospitalization, peritonitis, rehabilitation, patient compliance, and outcome including mortality. PATIENT POPULATION: 179 (58.7%) males and 126 (41.3%) females, aged 1-80 years (mean 47.2 +/- 15.09) with a total observation time of 15,753 patient-months. The most common diagnosis of the renal disease was diabetic nephropathy (41%). Peritonitis was the main cause of hospitalizations (36.7%) and of transfers (69.5%). Patient survival at one, two, and three years was 87.9%, 76.6%, and 67.0%, respectively. Likewise, technique survival was 65.5%, 45.5%, and 30.6%. Peritonitis rate for CAPD has improved from 1.9 episodes per patient-year to 1.2 episodes per patient-year and an overall rate of 1.5 episodes per patient-year. CONCLUSIONS: The experience in a large Hispanic program shows a good patient survival rate. Although there is a trend to a lower peritonitis rate, this continues to be the main cause of transfer, hospitalization, and one of the main causes of death.

Race and the risk of peritonitis: an analysis of factors associated with the initial episode.

To study how clinical characteristics influence the risk of peritonitis in African American patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis (CAPD), we examined the risk of developing a first episode of peritonitis among 1,595 new dialysis patients initially treated by CAPD over a two year period in North Carolina, South Carolina, and Georgia (Network 6). Characteristics examined were demographic and socioeconomic factors, functional status, serum albumin and comorbid conditions. There were 538 initial episodes of peritonitis during an average of 8.8 patient months of follow-up; the time to peritonitis for the entire cohort was 26 months. Factors found to be independently associated with a risk for peritonitis were student status (Odds Ratio and 95% Confidence Interval = 2.4; 1.4 to 4.3), rental housing (1.2; 1.0 to 1.5), and substance abuse (1.9; 1.1 to 3.2). African Americans were 60% more likely to have an initial episode of peritonitis during follow-up than whites (1.6; 1.3 to 1.8). The time to the initial episode was 21 months for African Americans versus 32 months for whites (P < 0.001). Even after adjusting for other factors, African Americans were significantly more likely to develop peritonitis (1.5; 1.2 to 1.8). Thus, the increased risk of peritonitis of African American patients treated by CAPD is independent of other demographic, socioeconomic and comorbid characteristics.

Higher incidence of peritonitis in native Canadians on continuous ambulatory peritoneal dialysis.

OBJECTIVE: To determine if the rate of peritoneal dialysis (PD)-related infections in our large Native population was higher than in non-Natives. DESIGN: Prospective study of PD-related infections, 1987 to 1993. PATIENTS: Forty-eight Natives and 136 non-Natives were studied. Comparisons of infection rates were made as well as determinations of the effect of diabetes and of dialysis techniques on infection rate. RESULTS: The chance of remaining free of peritonitis was far lower at 6 and 12 months in Natives versus non-Natives, 40% versus 76% at 6 months, and 24% versus 54% at 12 months (p < 0.01). Having diabetes or adding intraperitoneal insulin did not confer additional risk of peritonitis. The Y-line reduced the risk of peritonitis in non-Natives only. Exit-site infection (ESI) was significantly higher in Natives versus non-Natives, 0.42 versus 0.19 episodes per patient year (p < 0.01) mainly due to Staph. aureus. However, less than 30% of episodes of peritonitis were due to that organism. Staph. epidermidis peritonitis episodes were not more common in Native patients, whereas infections due to most other organisms were. CONCLUSION: The susceptibility to both peritonitis and exit-site infection is increased in Native Canadians compared to non-Natives. The nonprotective effect of the Y-line combined with increased peritonitis due to most organisms except Staph. epidermidis in Natives suggests that host factors could be important in these patients.