Peritonitis in elderly peritoneal dialysis patients: risk factors, outcomes, and implications for long-term care

Peritoneal dialysis (PD) is widely used in end-stage renal disease (ESRD), especially in the elderly due to its home-based nature. However, peritonitis remains a major complication, often causing treatment failure and transfer to hemodialysis (HD). Elderly patients are particularly vulnerable because of immunosuppression, comorbidities, and technical challenges. This study aimed to examine the clinical features and outcomes of peritonitis-related transfer in PD patients aged ≥65 years to inform infection prevention and long-term care.

We retrospectively reviewed records of patients aged ≥65 years who received PD for over three months at our institution between January 2018 and December 2024. A total of 357 patients were included. Data collected covered demographics, peritonitis episodes, microbiology, reasons for stopping PD, and subsequent renal replacement. The main outcomes were peritonitis incidence, its characteristics, and treatment switch.

Among the 357 patients, 246 (68.9%) discontinued PD during the study period, whereas 111 (31.1%) remained on PD. HD was the most common subsequent modality (n = 115, 46.7%), followed by death (n = 103, 41.9%) (Figure 1). Peritonitis was the leading cause of transfer to HD (n = 49, 42.6%), followed by abdominal surgery–related complications (n = 36, 31.3%) and non-infectious complications such as hydrothorax (n = 11, 9.6%). During follow-up, 126 patients (35.3%) developed peritonitis. Of these, 112 (88.9%) eventually discontinued PD, while only 14 (11.1%) remained on PD. The mean age at infection was 74.1 years, with a slight female predominance (50.8%). The first episode accounted for the majority (77%), and Gram-positive organisms were the most common pathogens (38%). The mean time to the first peritonitis episode was 3.5 years after PD initiation, corresponding to an incidence of 73.8 episodes per 100 patient-months. Clinical outcomes of peritonitis showed that 64 patients (50.8%, mean age 76.0 years) achieved resolution, 52 (41.2%, mean age 73.6 years) transferred to HD, 6 (4.8%, mean age 77.5 years) died, and 4 (3.2%, mean age 75.9 years) withdraw from dialysis in favor of palliative care (Figure 2). Although more than half of patients achieved resolution, most eventually discontinued PD due to subsequent complications, highlighting the limited durability of PD in the elderly. Hypertension was the most prevalent comorbidity among peritonitis patients (70.6%), followed by diabetes mellitus (43.7%) and cardiovascular disease (17.5%). Notably, 37.3% had two or more concurrent comorbidities (Table 1).

Peritonitis is the main cause of PD discontinuation in elderly patients, closely linked to advanced age, recurrent infections, comorbidities, and technique-related contamination. Most affected patients eventually transition to HD, with risk rising notably after three years on PD, indicating a critical period for stronger preventive measures. These results highlight the importance of strategies such as improved hand hygiene, regular retraining in aseptic technique, and structured education for patients and caregivers. High-risk groups—including those with impaired immunity, recurrent infections, or poor nutrition—require closer monitoring and targeted interventions. A comprehensive approach may reduce peritonitis-related transfer, prolong PD use, and improve outcomes in elderly patients