Introduction:
Peritonitis, a severe complication in peritoneal dialysis (PD), is associated with morbidity, mortality, and a leading cause of hemodialysis (HD) transfer. This study evaluated the association between self-reported hygiene and key clinical outcomes in a large cohort of patients on PD.Peritonitis, a severe complication in peritoneal dialysis (PD), is associated with morbidity, mortality, and a leading cause of hemodialysis (HD) transfer. This study evaluated the association between self-reported hygiene and key clinical outcomes in a large cohort of patients on PD.
Methods:
This prospective cohort study utilized data from the Thailand PD Outcomes and Practice Patterns Study (PDOPPS). Hygiene was assessed using an 8-item structured self-reported questionnaire, which evaluated key aspects of personal hygiene, including hand hygiene, bathing frequency, oral care, nail grooming, clothing cleanliness, hair management, skin care, and the use of hand sanitizer. Receiver operating characteristic (ROC) curve analysis identified a cutoff ≥3, categorizing patients as having "poorer hygiene," while scores <3 indicated "better hygiene.". Primary outcomes included peritonitis incidence, HD transfer, and mortality. Time-to-event analyses were conducted using the Kaplan-Meier method, and hazard ratios (HRs) were estimated through multivariable Cox proportional hazards regression. Incidence rate ratios (IRRs) for the association between hygiene behavior and clinical outcomes were estimated using Poisson regression models.
Results:
Of 5,090 patients, 845 were randomly selected from 22 facilities, and 669 (70%) completed the hygiene behavior questionnaire and were included in the analysis. Patients with poorer hygiene (scores ≥3) exhibited a significantly higher incidence of peritonitis (adjusted IRR 1.57, 95% CI 1.05–2.33) and an increased risk of HD transfer (adjusted HR 2.45, 95% CI 1.07–5.61) compared to those with better hygiene (scores <3). Although the mortality rate was higher in the poorer hygiene group (36%) compared to the better hygiene group (29%), the difference was not statistically significant after adjusting for key covariates, including age, gender, PD vintage, comorbidities (e.g., diabetes, coronary artery disease, cardiovascular diseases), shared frailty by study sites, and serum albumin levels (adjusted HR 1.33, 95% CI 0.78–2.28). Subgroup analyses revealed that poorer hand hygiene and lack of nail grooming were particularly associated with adverse outcomes (Table 1). Kaplan-Meier curves for peritonitis-free survival in PD patients showed a trend toward lower survival in the poorer hygiene group (adjusted HR 1.35, 95% CI 0.99–1.82, p = 0.06). Similarly, Kaplan-Meier curves illustrated a significantly higher risk of HD transfer in patients with poorer hygiene (adjusted HR 2.45, 95% CI 1.07–5.61, p = 0.04).
Table 1: Incidence Rates of Peritonitis, HD Transfer, and Mortality by Hygiene Behavior Score.
aCox proportional hazard regression; bPoisson regression incidence rate ratio; c Adjusted for age, sex, PD vintage, comorbidities (diabetes, congestive heart failure, coronary artery disease, and cerebrovascular disease), shared frailty by study sites, serum albumin, and after multiple imputations and accounting for facility clustering.
* Relapsing episode was counted at once
Conclusions:
This study demonstrates that poorer personal hygiene behavior is strongly associated with higher rates of peritonitis and HD transfer, but not mortality in patients treated with PD. Incorporating the hygiene behavior questionnaire into routine clinical visits could enable early identification of high-risk patients, facilitating targeted interventions that may improve outcomes and support the long-term sustainability of PD as a treatment option.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.