In their article “Peritoneal Dialysis–Related Peritonitis: Towards Improving Evidence, Practices, and Outcomes,” Cho and Johnson discuss the epidemiology, risk factors, diagnosis, and treatment of peritonitis. Peritoneal dialysis (PD) currently makes up approximately 11% of the global ESRD population, and peritonitis directly contributes to approximately 20% of PD technique failures and 2-6% of deaths. As PD gains popularity and utility in the population, practitioners will be expected to learn to diagnosis and treat this serious complication of PD.
Cho and Johnson classifies the risk factors for peritonitis as modifiable and non-modifiable. The modifiable factors include obesity, smoking, remoteness from the PD unit, depression, hypoalbuminemia, hypokalemia, invasive medical procedures, absence of vitamin D supplementation, biocompatible fluids, nasal S. aureus carrier status, previous exit site infection, PD against the patient’s choice, prior hemodialysis, pets in the home, and patient training. The non-modifiable factors include older age, female sex, indigenous racial origin, black ethnicity, lower socioeconomic status, diabetes mellitus, coronary artery disease, chronic lung disease, hypertension, and poor residual kidney function.
Clinician should be aware of these factors in order to risk stratify their patients. A review of these factors is essential in every evaluation for PD as well as monthly encounters with existing PD patients.
The authors then discuss the diagnosis of peritonitis based on the International Society of Peritoneal Dialysis (ISPD) guidelines. Once the diagnosis is made, empiric therapy with antibiotics that cover both gram-negative and gram-positive organisms should be initiated. An important aspect of the diagnosis involves the classification of the episode as a relapse, recurrence, or repeats.
Once the diagnosis and classification is made, choosing the appropriate antibiotic regimen is the next step. The authors once again mention the ISPD treatment guidelines in order to plot the appropriate steps in management. One of the key steps in the treatment algorithm involves determining when catheter removal and modality change is necessary.
The final discussion focuses on preventing and improving outcomes in PD peritonitis. Clinicians should always seek to improve the outcomes in their PD units as peritonitis can have devastating effects on a patient’s life. While the measures discussed in the prevention and improvement sections may seem obvious, the overall effects can be lifesaving.
Dr. Sean Kalloo