Introduction:
Patients from rural and Indigenous communities often choose peritoneal dialysis (PD) due to a lack of hemodialysis access. Indigenous patients have specific needs around relationships to build trust and safety with healthcare teams. Studies show higher rates of PD-related complications and associated mortality in this population. This study investigated the factors that contribute to increased rates of PD peritonitis during the COVID-19 pandemic in a regional program that serves several rural and Indigenous communities in British Columbia, Canada.
Methods:
A retrospective chart review was conducted of patients with PD peritonitis from a single centre between 2021-2023. Data was collected on demographics, hospitalizations, medications, co-morbidities, PD peritonitis episodes, culture results, and outcomes from patient chart reviews. Known risk factors and sequence of events leading up to each episode were recorded. The analysis was carried out using IBM SPSS Version 28. The factors contributing to peritonitis were divided into 4 categories: 1) PD technique-related 2) Medical, including ‘new medical issue’ or progression of existing comorbidities; 3) Psycho-social barriers (active or worsening mental health issues, substance use, housing challenges, and non-adherence) 4) Marginal PD candidates included patients who were offered a trial to live in own community.
Results:
A total of 78 episodes of PD peritonitis were diagnosed in 45 patients over 3 years with a mean age of 63.5 ± 12.11 years. 15 patients (33.3%) identified as Indigenous and living in Indigenous communities and accounted for 55 (70%) cases. Prevalent co-morbidities included hypertension (n = 39, 21.1%), diabetes (n = 30, 16.2%), coronary artery disease (n = 20, 11.0%), and depression (n = 13, 7.0%). The mean time to the onset of the first episode of peritonitis was 16.11 ± 13.8 months. 26 patients (57.8%) had only one episode, 11 (24.4%) had 2 episodes, 6 (11.1%) had 3 episodes, 1 (2.2%) had 4 episodes of PD peritonitis. Additionally, there were 18 cases (40.0%) of relapses. Technique-related factors were the main contributor (n = 30, 63.8%), followed by medical factors (n = 9, 19.1%) (e.g. cardiac event, ischemic bowel, cancer, abdominal infections like C. difficile or colitis), and psychosocial factors (n = 8, 17.0%). The logistic regression model revealed a significant positive relationship with technique-related factors, OR= 3.12 (95% CI [1.42, 6.84], p = 0.005), living in an Indigenous community, reduced self-reporting of symptoms and virtual visits (85%). Results also showed an association with a lack of review of the aseptic technique after peritonitis and hospitalization at remote sites with untrained staff. Four episodes of contamination were not intentionally reported. Virtual assessments of PD patients during the pandemic were inadequate for reviewing the aseptic PD technique.
Conclusions:
Heavy reliance on virtual care delivery during the COVID-19 pandemic was a barrier to optimal clinical assessments of PD patients. Loss of in-person connection with the healthcare team led to distrust and reduced self-reporting of challenges with the PD technique, which contributed to recurrent infections. Our study concludes that sustaining trusting relationships between patients and providers is vital for optimal clinical outcomes for PD patients living in rural and Indigenous communities.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.