Peritoneal dialysis patients who live remotely face high peritonitis risk

By Andrew Czyzewski

Patients with renal disease who live more than 100 km from their nearest peritoneal dialysis (PD) unit face a higher risk for peritonitis, particularly with Staphylococcus aureus, than their peers who live closer, results of a large Australian study show.

Furthermore, distant patients with a first peritonitis episode were less likely to be hospitalized and receive antifungal prophylaxsis.

Study co-author David Johnson (Princess Alexandra Hospital, Brisbane, Queensland) and colleagues explain that PD is usually considered a first-choice treatment for end-stage renal disease (ESRD) for patients living in remote areas, to avoid relocation.

"Given that PD peritonitis is a major cause of PD technique failure, addressing the impact of remote residence on PD outcomes, particularly PD peritonitis, is an imperative issue to be addressed," they comment in BMC Nephrology.

Of 6610 patients identified in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, 365 (6%) lived 100 km or more from their nearest PD unit (distant group), while 6183 (94%) lived within 100 km (local group).

After 10,470 patient-years of follow up (mean follow up of 1.58 years for each patient), there were 6213 episodes of peritonitis in 3128 (47%) patients (range one to 15 episodes per patient). The overall rate of peritonitis was 0.59 episodes per patient-year of treatment.

Median time to first peritonitis in distant patients was significantly shorter than in local patients (1.34 vs 1.68 years), while overall peritonitis rates were higher in distant patients (incidence rate ratio=1.32). Living 100 km or more away from a PD unit was independently associated with a higher risk for S. aureus peritonitis (adjusted odds ratio=1.64).

Distant patients with first peritonitis episodes were less likely to be hospitalized (64 vs 73%) and receive antifungal prophylaxis (4 vs 10%), but more likely to receive vancomycin-based antibiotic regimens (52 vs 42%).

Interestingly though, distant patients achieved higher cures rates with antimicrobial agents alone and lower rates of catheter removal or permanent haemodialysis transfer.

The authors say their study "highlights the need to focus on implementation of evidence-based infection control strategies (such as staphylococcal decolonisation) in this patient group."

Additionally they speculate that the findings "may reflect a stronger incentive to persist with antibiotics in remote living patients rather than removing the PD catheter and transferring to haemodialysis since such an action might have significant social implications for the patient, such as relocation closer to the dialysis service and dislocation from their family and community."

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