Peritonitis Remains the Major Clinical Complication of Peritoneal Dialysis: The London, Uk, Peritonitis Audit 2002–2003

Background

Over the past two decades, the rate of peritonitis in patients treated by peritoneal dialysis (PD) has been significantly reduced. However, peritonitis remains a major complication of PD, accounting for considerable mortality and hospitalization among PD patients.

Objective

To compare the outcome of peritonitis in a large unselected group of PD patients with that from singlecenter and selected groups.

Method

We audited the outcome of peritonitis in PD patients attending the 12 PD units in the Thames area in 2002 and 2003. There were 538 patients on continuous ambulatory PD (CAPD) and 325 patients on automated PD (APD) and/or continuous cycling PD (CCPD) at the end of 2002, and 635 CAPD and 445 APD/CCPD patients at the end of 2003.

Results

There were 1467 episodes of PD peritonitis during the 2-year period, including 129 recurrent episodes, with the average number of months between peritonitis episodes being 14.7 for CAPD and 18.1 for APD/CCPD, p < 0.05. However there was considerable variation between units. Coagulase-negative staphylococcus (CoNS) was the most common cause, accounting for around 30% of all peritonitis episodes, including recurrences, followed by non-pseudomonas gram negatives and Staphylococcus aureus. Cure rates were 77.2% for CoNS, 46.6% for S. aureus, and 7.7% for methicillin-resistant S. aureus. The cure rate for pseudomonas was 21.4%, and other gram negatives 56.7%. In total, there were 351 episodes of culture-negative peritonitis, with an average cure rate of 76.9%. Cure rates were higher for those centers that used a combination of intraperitoneal gentamicin and cephalosporins than those centers that used oral-based regimes. A total of 296 PD catheters were removed as a direct consequence of PD peritonitis: 121 due to gram-positive and 123 due to gram-negative organisms. Only 49 catheters were reinserted and the patients returned to PD. 52 patients died during or subsequent to their episode of PD peritonitis, with an overall mortality rate of 3.5%.

Conclusion

This audit showed that, in a large unselected population of PD patients, the incidence of peritonitis was significantly greater than that reported in single-center short-term studies, and varied from unit to unit. Similarly, the success of treating PD peritonitis varied not only with the cause of the infection but also from unit to unit. PD peritonitis remains a major cause of patients discontinuing PD and switching to hemodialysis.

Editorials: Will Peritoneal Dialysis be Left Behind?

Peritoneal dialysis (PD) enjoyed huge growth in the 1980s, followed by a rapid decline in the late 1990s, and a now persistently low utilization rate in many countries, including the United States. Recent clinical data indicate a survival advantage for patients started on PD. Residual renal function is better preserved with PD. Adequacy targets are being revised and will likely allow PD prescriptions to be simplified. The physiology of the peritoneum is better understood and treatment strategies reflect that understanding. New solutions have been developed in response to studies that have assessed the impact of conventional PD dialysate on the structure and function of the peritoneum. A remaining challenge is to ensure that nephrology trainees and nephrologists in practice are fully informed of the advantages of PD for many patients and of the advances in the therapy. If this can be achieved, PD should start to grow again.