Introduction:
Patients from rural and Indigenous communities often choose peritoneal dialysis (PD) due to a lack of access and options for hemodialysis. They also have unique and specific needs around professional relationships to build trust and safety with healthcare teams. Studies show higher rates of PD-related complications, including bacterial peritonitis and associated mortality in this population. This retrospective study aimed to investigate factors underlying higher rates of PD peritonitis during the COVID-19 pandemic between 2021 and 2023 in a regional program with a high prevalence of PD patients from remote and Indigenous communities of the northern region of British Columbia, Canada.
Methods:
A retrospective descriptive analysis was conducted after a detailed chart review of patients with PD peritonitis (as per ISPD criteria) from 2021-2023. Data collection included demographic details, chart entries from interdisciplinary team members, encounters during PD clinic visits, hospitalizations, medication, co-morbidities, frequency of PD peritonitis episodes (first, repeat and relapse), pertinent laboratory and microbiology results, and outcome after episode. The presence of the previously known risk factor/s for peritonitis was recorded, and correlation was established by reviewing the sequence of events leading up to the episode in addition to prevalent risk factors. The analysis was carried out using IBM SPSS Version 28. The factors contributing to peritonitis were categorized into 4 main categories: 1) Technique-related factors (such as known breaks in PD technique; 2) Medical factors, including patients experiencing a new medical issue or progression of existing comorbidities; 3) Psycho-social barriers which included patients with active or worsening mental health issues, those who resumed substance use post-training, individuals facing housing challenges (e.g., eviction); 4) Marginal PD candidates included patients who were known to be at risk but offered a trial to live in own community.
Results:
A total of 78 episodes of PD peritonitis were diagnosed in 45 patients between 2021 and 2023, with a mean age of 63.5 ± 12.11 years. 15 patients (33.3%) identified as Indigenous and living in First Nation communities and accounted for 55 (70%) cases. The common comorbid conditions among these patients were hypertension (n = 39, 21.1%), diabetes (n = 30, 16.2%), coronary artery disease (n = 20, 11.0%), and depression (n = 13, 7.0%). Additionally, there were 18 cases (40.0%) that were relapses. The mean time to the onset of the first episode of peritonitis was 16.11 ± 13.8 months. Among patients with peritonitis, 26 (57.8%) had only one episode, 11 (24.4%) had 2 episodes, 6 (11.1%) had 3 episodes, 1 (2.2%) had four episodes. Technique-related lapses were the predominant driver (n = 30, 63.8%), followed by medical issues (n = 9, 19.1%) (e.g. cardiac event, cancer, abdominal infections like C. colitis), and Psychosocial challenges (n = 8, 17.0%). The logistic regression model revealed a significant positive relationship between the number of peritonitis episodes and technique-related issues during peritoneal dialysis, OR= 3.12 (95% CI [1.42, 6.84], p = 0.005). Additional analysis revealed co-relation to remote geographic location, reduced self-reporting of symptoms and ableism, and virtual visits (85%), which meant that PD technique was not reviewed after each episode, loss of primary care provider or support, and concurrent hospitalization at remote sites (untrained staff in rural hospitals). 4 episodes of lapses in technique occurred but were not reported to the provider team to manage contaminations, possibly leading to PD peritonitis.
Conclusions:
Virtual assessments of PD patients during the pandemic were inadequate for reviewing PD techniques and ineffective for follow-up after PD peritonitis. Additionally, the lack of in-person connection with patients that offered safety led to mistrust of the healthcare system at large which contributed to worsening co-morbidities, including frailty and disability. Our study concludes that maintaining trust and relationships between patients and providers is vital in sustaining clinical outcomes for PD peritonitis rates in 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.