 Abstract | | | Peritoneal dialysis (PD) is one of the modes of renal replacement therapy being utilized for the management of end-stage renal failure in King Khalid University Hospital, King Saud University, Riyadh, for more than two decades. The aim of this study was to evaluate the complications related to PD as well as its outcome in patients on this mode of therapy during the period between January 2004 and December 2008. There were 72 patients included in the study, of whom 43 were females. The average age was 50.7 ± 30.1 years (14-88 years). Diabetes was the leading cause of endstage renal disease (ESRD) seen in 40.2% of the study patients. Twenty-eight patients (38.9%) were on continuous ambulatory peritoneal dialysis (CAPD) and 44 (61.1%) were on automated PD (nocturnal intermittent peritoneal dialysis, NIPD or continuous cycler peritoneal dialysis, CCPD). The mean duration on PD of the study patients was 25.5 ± 16.58 months (1-60 months). The peritonitis rate was one episode per 24.51 patient-months or one episode per 2.04 patient-years. The incidence of peritonitis per person-year was calculated as 0.42. The leading causative agent for peritonitis was Staphylococcus (32%). Exit-site infection (ESI) rate was one episode per 56.21 patient-months. The incidence of ESI was 0.214 per person-years. The most common infective organism for ESI was Pseudomonas aeruginosa (58.8%). At the end of 5 years, 35 patients were continuing on PD, 13 patients were shifted to hemodialysis (HD), nine patients underwent renal transplantation, and six patients were transferred to other centers. Among the 13 patients who were shifted to HD, four patients had refractory peritonitis, four others had catheter malfunction, three patients had inadequate clearance on PD and two patients had lack of compliance. A total of 11 patients died during the study period, giving an overall mortality rate of 15.27% for the five-year period. Our study suggests that there has been considerable improvement in overall outcome and mortality in patients on PD. Additionally, a marked reduction in the infectious and non-infectious complications was noted with the peritonitis and ESI rates in our center being comparable to other studies and international guidelines. How to cite this article:
Alwakeel JS, Alsuwaida A, Askar A, Memon N, Usama S, Alghonaim M, Feraz NA, Shah IH, Wilson H. Outcome and complications in peritoneal dialysis patients: A five-year single center experience. Saudi J Kidney Dis Transpl 2011;22:245-51 |
How to cite this URL:
Alwakeel JS, Alsuwaida A, Askar A, Memon N, Usama S, Alghonaim M, Feraz NA, Shah IH, Wilson H. Outcome and complications in peritoneal dialysis patients: A five-year single center experience. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2014 Mar 3];22:245-51. Available from: http://www.sjkdt.org/text.asp?2011/22/2/245/77598 |
| Introduction | |  |
Peritoneal dialysis (PD) was primarily initiated in the 1960s as an alternative and viable treatment to hemodialysis (HD). [1],[2] The King Khalid University Hospital (KKUH), Riyadh, implemented the use of PD in 1984 and since then, there has been a gradual increase of renal patients.
Accumulation and collection of data is constantly done by designated analyzers in various centers in order to be continually updated on the demographics of renal patients using PD. These data are constantly documented and analyzed to assess the outcome and complications of PD as well as the advances made and current trends of this mode of dialysis. [3],[4],[5]
This study was aimed at evaluating the outcome in patients on PD during a five-year period, and to assess the incidence of peritonitis and other PD-related complications.
| Methods | | |
This was a longitudinal retrospective study involving all patients registered in the Peritoneal Dialysis Unit at the KKUH over a period of five years from January 2004 to December 2008. The demographic data, investigations performed and complications encountered were recorded for all patients included in the study.
Peritonitis was defined as a white blood cell (WBC) count >100 cells/mm3 in the affluent sample taken, preferably after a minimum dwell time of four hours. Exit-site infection (ESI) was defined as purulent drainage from the exit site, with or without erythema. [6] Technique failure was defined as transfer to long-term HD with removal of PD catheter due to any reason.
| Statistical Analysis | | |
The data of the study patients were analyzed by SPSS version 12 for statistical analysis. The data were described as mean and standard deviation.
| Results | | |
There were 72 patients, of whom 43 (59.7%) were females. The age distribution was as follows: 10 patients were less than 20 years old (13.8%), 29 patients (40.2%) were between 20 and 40 years of age, 23 patients (31.9%) between 40 and 60 years of age and 10 patients were above 60 years of age.
Twenty-eight (38.9%) patients were on continuous ambulatory peritoneal dialysis (CAPD) and 44 (61.1%) were on automated PD (NIPD or CCPD). Thirty-eight of the patients were using Icodextrin as a long dwell in CAPD as well as APD. The mean duration on PD at the time of study was 25.53 ± 16.58 months (1-60 months). The average age was 50.7 ± 30.06 years (14-88 years). The mean body mass index (BMI) was 27.1 ± 6.9 (12.49-39.86) kg/m 2 and the mean body surface area (BSA) was 1.72 ± 0.21 (1-2.2) m 2 .
Primary renal disease
Diabetes was the leading cause of end-stage renal disease (ESRD) seen in 40.2% of the patients, followed by glomerulonephritis (27.8%) and hypertension (15.3%). Other causes included nephrolithiasis, pyelonephritis, systemic lupus erythematosus (SLE), reflux nephropathy, multiple myeloma and adult polycystic kidney disease [Table 1].  | Table 1: Frequency of causes of end-stage renal disease in the study patients.
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Co-morbidities
Thirty-five (48.6%) of the 72 study patients had associated hypertension; however, it was not believed to be the primary cause of chronic kidney disease (CKD). Ten patients were hypertensive before they developed chronic renal failure, while 25 patients developed hypertension after reaching ESRD.
Initiation of PD
PD was started as primary therapy in 65% of the patients and as secondary therapy following HD failure in 31%. Four percent of the patients were started on PD after renal transplant rejection.
Membrane characteristics
Based on standardized peritoneal equilibration test results, 41% patients were low average, 40% were high average, 12% were high (rapid) transporters and 7% belonged to the low (slow) transporter group.
Biochemical markers
The mean blood urea nitrogen (BUN) was 17.03 mmol/L (5.5-30.7 mmol/L), the mean serum creatinine was 695.24 μmol/L (89-1322 μmol/L), the mean corrected calcium (Ca) level was 2.29 mmol/L (1.4-2.8 mmol/L), the mean phosphorous was 1.6 mmol/L (0.71-2.89 mmol/L), the mean parathyroid hormone (PTH) level was 56.84 (0.34-295)pmol/L and the mean serum albumin level was 28.25g/L (17.42 ± 4.24 g/L).
Sixty-six of the total 72 patients were using calcium carbonate, and 69 were using sevelamer as phosphate binder. Seventy patients were using calcitriol and five patients were recently started on cinalcet for raised parathyroid hormone levels.
The mean hemoglobin (Hb) was 11.06 g/dL (7.2-15.8 g/dL); 68 of the patients were on erythropoietin (EPO) injections with the mean EPO dose being 7000 units/week (2000-30,000 units/week).
| Complications of PD | | |
Peritonitis
There were 78 cases of peritonitis in the five study-years; the average peritonitis free period was 24.51 patient-months. The peritonitis rate was one episode per 2.04 patient-years. The incidence of peritonitis per person-year was calculated as 0.42. (6) Empirical therapy was started with a first-generation cephalosporin, plus a third-generation cephalosporin or an aminoglycoside depending upon the patient's residual renal function. The therapy was altered if needed, according to the culture results.
The leading causative agent of peritonitis was Staphylococcus, seen in 31% of the cases, with Staphylococcus aureus responsible for eight (11%) and Staphylococcus epidermidis responsible for 16 cases (20%). There were no episodes of infection with methicillin-resistant S. aureus (MRSA). Pseudomonas aeruginosa was isolated in 15 cases (19%), Escherichia More Details coli was grown in four cases (5%) and other gramnegative organisms (including Klebsiella, Serratia and Enterobacter species) were grown in 11 cases (14%). In 21 cases (26%), there was no growth on culture while there was one case each caused by fungal and mycobacterial species (1%). There were five episodes of peritonitis (6%) with growth of multiple organisms. Overall, 38% of the cases of peritonitis were due to gram-negative organisms, 34% due to gram-positive organisms and 26% were culture negative. The incidence of culture negative peritonitis decreased from 58% in 2004 to 11% in 2008 due to improved specimen collection and processing techniques in accordance with the ISPD guidelines (6).
Exit-site infection
There were 34 cases of ESI in a total 1,911 patient-months; thus, the ESI rate was one episode per 56.21 patient-months or one episode per 4.68 patient-years. The incidence of ESI was 0.214 per person-years.
The most common infective organism was P. aeruginosa which was responsible for 58.8% of cases. S. aureus was isolated in 29.4% of the cases, and of these, two cases (5.8%) had MRSA. ESI was caused by gram-negative bacteria including Klebsiella, E. coli and Serratia species in 12% of the cases (one case each). Both cases of MRSA occurred in the same patient. The various causative organisms for ESI are shown in [Table 2]. The management of ESI included daily dressing with local application of gentamycin cream and oral antibiotics, as indicated by the culture results.
Technique failure
Thirteen patients were shifted to HD over the five-year period; four of these patients had refractory peritonitis and four others had catheter malfunction. Three patients were shifted to HD due to inadequate clearance on PD, while in two others, PD was discontinued due to lack of compliance by the patient.
Catheter-related complications
The PD catheter was surgically removed and re-inserted in three patients. In one case, it was due to refractory multi-organism peritonitis, and the catheter was re-inserted after an interval of two months following resolution of peritonitis. In one other patient, the catheter was removed due to leakage of fluid from the exit-site, following catheter insertion by laparoscopy. It was treated by surgical repositioning. In the third patient, there was outflow obstruction not relieved by non-invasive means and the catheter was replaced.
During the study period, two patients presented with decreased fluid removal and abdominal discomfort. Abdominal X-ray showed catheter tip migration above the pelvis. The predisposing factor in both cases was constipation and the problem was relieved by use of laxatives and patient education about diet, bowel habits and ambulation.
Patient morbidity
Two patients, both known to have longstanding type-2 diabetes, developed gangrene secondary to diabetic foot. They underwent amputation and continued on PD following the surgery. Overall, there were 55 admissions to the hospital in the study period, of which 29 (52.7%) were due to peritonitis.
Non-peritoneal infections were the second most common cause responsible for 11 hospital admissions. The non-peritoneal infections included skin infections in five patients, pneumonia in three patients, urinary tract infection in two and post-CABG wound infection in one patient. Four patients were admitted due to fluid overload and three were admitted for management of hypotension. There were two admissions for congestive cardiac failure in patients with pre-existing cardiac disease. There were two episodes of diabetic foot and two patients were admitted due to epileptic fits. One patient was admitted with myocardial infarction and underwent coronary artery bypass grafting.
Patient mortality
A total of 11 patients died during the study period, yielding an overall mortality rate of 15.27% for the five-year period. The cause of death was systemic infection and cardiovascular causes in five patients each (45.45%) and mycobacterial peritonitis in one patient (9.09%).
PD outcome
At the end of five years, 35 (47%) patients were continuing on PD, nine patients (15%) underwent renal transplantation, 13 (18%) were shifted to HD, 11 patients (15%) died and six (8%) were transferred to other centers.
| Discussion | | |
In recent years, various studies from around the world have shown the efficacy of PD [7] and a favorable outcome, in patients treated with PD for a long term. [7],[8],[9],[10],[11] Similar results have been obtained in studies conducted in the Middle East and Arab populations. [12],[13] Nevertheless, compared to HD and renal transplant, PD is utilized in only a minority of patients worldwide. [14],[15],[16] This can be attributed to a number of factors, including lack of awareness about PD among patients and physicians as well as a fear of complications. [17],[18]
Patient education before initiating dialysis and specialized centers for PD training have proved to be effective in this regard. [18],[19] The results of the present study were compared to the previous data from the same center, reported in 1995 and 2002. [2],[3],[4] The major difference was that in the earlier reports, all the patients included were using CAPD, as automated PD was not widely available for our patients at that time. In the 1995 report, all patients were using straight tube system; however, by 2002, all CAPD patients were on Y-tube twin bag system with flush-before-fill technique. The salient features of the previous publications and the current study are compared in [Table 3]. These results are comparable to data collected by other centers both worldwide and in the Middle East.  | Table 3: The frequency of occurrence of peritonitis in the years 1995, 2002 and 2008.
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| Comparison with International Data | | |
ANZ Registry Data
We compared our results with the data from Australia and New Zealand Renal Registry (ANZDATA). [20] According to the data available, the mean peritonitis-free period or the interval between episodes of peritonitis in patients on PD was 20.4 patient-months in Australia and 13.4 patient-months in New Zealand. The most common primary cause of technique failure was social (generally patient preference), rather than a technical cause. This accounted for 45% of all transfers in the year 2008. Infections (primarily peritonitis) were the second most common cause, followed by inadequate dialysis and mechanical complications. In New Zealand, the most common primary cause of technique failure was social cause. This accounted for 31% of all transfers in 2007 and inadequate dialysis in 29%. The mortality rate was 14.3% in Australia and 16% in New Zealand. A total of 16.51 and 15.5% of the patients were transplanted among the patients in Australia and New Zealand, respectively. About 48.2% were transferred to HD among the patients in Australia and 50% in New Zealand.
In the Registre de Dialyse Peritoneale de Langue Française (RDPLF Registry), 11,744 patients (56% males and 44% females) on PD from all over France, were included from 1995 to 2005. [21] The median age of these patients was 71 years and 21.5% were over 80 years of age; 29% of the patients were diabetic. During the study period, 31.4% of patients were on automated PD.
The overall average rate of peritonitis was one episode every 29 months. There was a considerable change in the distribution of organism causing peritonitis during the ten-year period. For the period from 1995 to 2000, gram-negative-associated peritonitis comprised 20% of all peritonitis episodes. However, in the period from 2000 to 2005, gram-negative bacteria were responsible for more than 33% of the episodes of peritonitis [Figure 1]. The major reasons for discontinuing PD and transfer to HD were peritonitis (22.2% of transfers) and inadequate dialysis (23.8%). Ultrafiltration failure was seen in 5.1% of the cases. PD was discontinued in 10,138 patients during the study period. Out of these, 31% were transferred to HD, 51.8% of the patients died, 15.6% underwent kidney transplantation, and 1.7% recovered residual renal function.
The complications and outcome of PD among patients in our center are comparable to the data obtained from other populations [Figure 2]. The mortality rate is higher in the data from the RDPLF registry. This can be attributed to the higher mean age of the patients (71 years) with 21.5% of patients being above 80 years of age. A higher number of patients were switched to HD in the ANZ data, which can be attributed to easier availability of home HD as well as social reasons. The transplant rates were almost equal across all populations.  | Figure 2: Complications of peritoneal dialysis in the study patients in the various reports.
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| Conclusion | | |
The patient characteristics and demographic parameters seen in this population are comparable to those seen in other studies in the Middle East and worldwide. [8],[9],[10] Our results demonstrate that there are differences in the bacterio-logical organisms causing peritonitis, related to both region and time; additionally, our results showed that lower the peritonitis rate, higher the proportion of gram-negative organisms. There has been continued improvement in the outcome of PD and incidence of peritonitis in our center over the last two decades.
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Correspondence Address:
Jamal S Alwakeel
Department of Medicine (38), King Saud University, P.O. Box 2925, Riyadh 11461
Kingdom of Saudi Arabia
PMID: 21422621
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3] |
