Back
Peritonitis is a relatively common and serious complication of peritoneal dialysis (PD). The reported incidence of peritonitis ranges widely between PD units in different countries and has been steadily decreasing from 0.60 to 0.30 episodes/patient-year in the most robust and recent systematic review (Marshall MR, Perit Dial Int 2022). As per the current International Society for Peritoneal Dialysis guidelines, the overall peritonitis rate should be no more than 0.40 episodes per year at risk (Li PK-T et al, Perit Dial Int 2022). Only a minority of patients treated with renal replacement therapy are concomitantly treated with immunosuppressive therapy. These include patients with systemic auto-immune disease that led to their renal failure, but also patients with autoimmune disease with no link to their renal disease and patients after solid organ transplantation. These patients are potentially at higher risk of infectious complications associated both with PD and haemodialysis (HD). The aim of our study was to determine whether PD patients treated with immunosuppressive therapy are at higher risk of developing peritonitis.
Retrospective analysis of medical reports from our dialysis center in the last 12 years was used for evaluation. The incidence of peritonitis was recorded for all patients. Patients treated concomitantly with immunosuppressive therapy while on PD were carefully reviewed with respect to immunosuppressive treatment length and regimen.
In the last 12 years, 168 patients were treated with PD at our center (males= 105, females= 63; median age 49.5 years). The overall incidence of peritonitis in our center was 0.22 episodes/ patient-year. We have identified 12 patients (males=6, females=6; median age 32 years) treated with immunosuppressive therapy while on PD. All of them had an autoimmune disease as a cause of their end stage kidney disease, with ANCA associated vasculitis being the most common cause (n=8), followed by systemic lupus erythematodes (n=3) and atypical hemolytical syndrome (n=1). Immunosuppressive treatment included either monotherapy with corticosteroids (n=2) or combined therapy (n=10) with another immunosuppressant or biologic drug (mycophenolate, cyclophosphamide, rituximab, azathioprine, eculizumab). The total duration of concomitant PD and immunosuppressive treatment in this cohort was 215 months. Two occurrences of peritonitis were recorded. Both occurred in the same patient and were caused by the same organism, 5 weeks apart, thus fulfilling the criteria for repeat peritonitis. The calculated peritonitis rate of these patients was therefore 0.11 episodes/ patient-year.
The scenario when patient with end stage kidney disease requires immunosuppressive treatment is relatively rare. Most commonly it is due to extrarenal manifestations of systemic autoimmune disease. Physicians often hesitate to choose PD in these patients due to concerns regarding the risk of infectious complications. Being usually of young age and having less comorbidities, these patients are often otherwise suitable to be treated with PD. In our study, we have shown that immunosuppressive treatment in PD patients was not associated with an increased frequency of peritonitis.
Supported by Czech Ministry of Health – RVO 00064165 and General Uni Hospital in Prague and Charles University Research program Cooperatio 207034