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Success with managing peritonitis linked to size, expertise of PD program
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The size and clinical expertise of a dialysis program contribute substantially to successful treatment of peritonitis and other medical issues associated with maintaining a patient on peritoneal dialysis, an Australian study shows.
Researchers led by Htay Htay, MBBS, MRCP, of the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), found centers with higher proportions of patients on dialysis using peritoneal dialysis (PD) had significantly greater odds of treating peritonitis successfully; lower odds of PD catheter removal and likely transfer to hemodialysis therapy because of PD technique failure; and less likelihood of peritonitis relapse/recurrence.
Also, “centers with higher proportions of peritonitis episodes receiving empirical antibiotics covering both gram-positive and gram-negative organisms had higher odds of cure with antibiotics,” the authors wrote.
The study was based on a review of all incident patients on PD in Australia who developed peritonitis from January 2004 through December 2014 and were included in the Australia and New Zealand Dialysis and Transplant Registry. When making comparisons of outcomes among centers, the researchers looked at several characteristics about the centers providing treatment, including whether it was a transplantation center; the size of the center, based on patient volume; the proportion of patients on PD; the percentage of patients who were on automated PD; and results from a peritoneal equilibration test. The researchers also identified patients with icodextrin exposure.
Of 9,100 peritonitis episodes, 69% were cured with antibiotic therapy alone – the outcome the researchers defined as the goal for the study and was “not complicated by relapse or recurrent peritonitis, catheter removal, transfer to HD therapy for 30 days or longer, or death,” they wrote. Peritonitis cure rates for individual centers varied between 38% and 86%, but the key center characteristics that were independently and significantly associated with achievement of cure were a greater proportion of patients on dialysis treated with PD (greater than 29%) and a greater proportion of peritonitis episodes receiving complete empirical antibiotic treatment.
When looking at other complications, researchers found the number of patients on PD at a center was also a key factor in successful patient care. There were 19% of patients who had peritonitis episodes that required PD catheter removal, with rates for individual centers varied between 12% and 50%.
“Centers with higher proportions of dialysis patients treated with PD (greater than 29% PD patients) were associated with lower odds of peritonitis-related catheter removal,” the researchers wrote. Similarly, patients had lower odds of transferring from PD to HD therapy for 30 days or longer because of peritonitis when treated at centers with a greater proportion of PD patients. Hospitalization for peritonitis was lower as well.
“This is one of few studies that has specifically examined the association between center characteristics and peritonitis outcomes in incident PD patients,” the authors wrote. “The study included a large population of peritonitis patients (4,428 patients with 9,100 episodes of peritonitis) across 51 centers in Australia. These strengths should be balanced against the study’s limitations, which include retrospective study design and limited depth of data collected by ANZDATA,” the authors concluded.
They added, “Future studies aimed at identifying specific aspects of education programs, quality initiatives and modifiable center attributes hold promise to improve PD peritonitis outcomes.”
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Martin J. Schreiber, MD
Center effects (center size, transplantation rate, percentage of automated PD, performance of peritoneal equilibration test, icodextrin use) were linked to peritonitis outcomes in this study by Htay and colleagues published in the American Journal of Kidney Diseases. Considering the variability in peritonitis outcomes across the United States, a closer look at PD program characteristics plays a critical role in optimizing patient outcomes and patient safety on PD going forward.
This retrospective review included more than 9,000 peritonitis events observed in 4,428 patients across 51 PD centers in Australia during a 10-year period (2004 to 2014). The authors highlighted how important center characteristics are on peritonitis outcomes. The analysis demonstrated that center-level characteristics were associated with a 42% decrease in catheter removal with peritonitis, higher odds of peritonitis cure, lower odds of transfer to HD, lower rates of peritonitis hospitalizations and lower risk of relapse, but no apparent impact on peritonitis-related mortality.
The added dimension brought out in this study positioned the actual percent of patients on PD at an individual center (practice) as an important determinant to patient outcomes, suggesting that a “practice culture” supporting the value of PD is important in overall PD success.
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