| Abstract|| |
Peritoneal dialysis (PD) program was established in Farwaniya Hospital Kidney Center, Kuwait, in February 2011. Patient recruitment for this modality of treatment was growing steadily. One of the major complications of PD is peritonitis. There is a belief that PD therapy is inferior and carries more complications than hemodialysis, we aimed to show that PD is a good and a non-inferior option for dialysis therapy with comparable outcome in both patient and technique survival. This was a retrospective analysis of all patients who were on PD from February 2011 to December 2014. Peritonitis rate, exit site infection rate, and all-cause mortality rate were all assessed for this period. Peritonitis rate during the 1 st year, 2011, was 0.92 incidents/year. This number had progressively declined in the following years; in 2012, it was 0.65 incidents/year; in 2013, it was 0.58 incidents/year; and in 2014, it was 0.38 incidents/year. This improvement in the rate of peritonitis incidence could be explained by better education of patients and meticulous supervision of the nursing staff. Farwaniya Hospital Kidney Center had an all-cause mortality rate of 9.3% among patients on renal replacement therapy in 2011. In 2012, all-cause mortality rate increased to 17.1%. The following year, 2013, it decreased to 14.3%, and in 2014, all-cause mortality rate dropped further to 7.6%. All-cause mortality rate among PD patients was zero in 2011. In 2012, the all-cause mortality rate in PD was 11.54%, and in 2013, it decreased to 10.52%. Then, again in 2014, the all-cause mortality rate among PD patients was zero. This improvement in all-cause mortality rate could be explained by the better medical care offered to the end-stage renal disease patients, in particular PD patients, in Farwaniya Hospital Kidney Center.
|How to cite this article:|
Alyousef AM, Abdou SM, Mansour YS, Radi AD. Peritoneal dialysis and peritonitis rate: Kuwait, four years' experience. Saudi J Kidney Dis Transpl 2016;27:762-8
|How to cite this URL:|
Alyousef AM, Abdou SM, Mansour YS, Radi AD. Peritoneal dialysis and peritonitis rate: Kuwait, four years' experience. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2021 Oct 19];27:762-8. Available from: https://www.sjkdt.org/text.asp?2016/27/4/762/185240
| Introduction|| |
End-stage renal disease (ESRD) is a growing disease entity worldwide. There is progressive rise in incident cases yearly and this number varies in between countries. It is expected that by 2030, the number of patients who require dialysis will double from 2.62 to 5.4 million, the majority of which will be in Asia and the Middle East.  Between the two available modalities of dialysis, patients tend to choose hemodialysis (HD) in favor to peritoneal dialysis (PD) for a number of factors that leave PD an underutilized modality. About 10% of ESRD patients in the USA and some developed countries are on PD. Yet, in other areas of the world, as in Hong Kong and Mexico, for example, 80% of ESRD patients are on PD.  There is no doubt that PD is equivalent and equal in efficacy, if not better in certain factors to HD as a first line of renal replacement therapy (RRT).  Several studies have shown an early survival advantage for PD over HD in the first two years of therapy, with equivalent outcomes to five years of therapy. ,
Peritonitis is a serious complication of PD. It is associated with significant morbidity, catheter loss, possible permanent membrane damage, and occasionally death. ,,, Among PD patients, peritonitis may be PD-related or secondary. PD-related peritonitis, which is the common cause, is due to touch contamination with pathogenic skin bacteria or due to catheter-related infection. Secondary peritonitis is caused by an underlying pathology of the gastrointestinal tract; however, it is less common than PD-related peritonitis. 
With the advancement of PD therapy and enforcement of proper technique in terms of connectology, exit site care, and bacterial prophylaxis, this have led to a reduced incidence of both peritonitis and exit-site infections.  However, exit site infections are still a source of morbidity in these patients that could result in a significant number of patients transfer from PD to HD. Although <4% of peritonitis episodes result in death, peritonitis is a contributing factor in about 16% of deaths in patients on PD. 
| Materials and Methods|| |
Data were analyzed retrospectively for all patients who were on PD from February 2011 to December 2014. We included all patients who were on continuous ambulatory PD and automated PD. Patients who spent <1 year on PD or were temporary receiving dialysis therapy were excluded from the study. Peritonitis was defined as a turbid color dialysate from a fresh sample and leukocyte cell count higher than 100/mm 3 mainly polymorphonuclear cells. Peritonitis rates were calculated by Patient OnLine 5.0 electronic program, which is a program developed by Fresenius Medical Care that helped in assessing patients' dialysis prescription and general care (R5, total number of incidents divided by total PD time in years, and R6, total time in months divided by total number of incidents). An exit site infection is considered to be present if there is purulent discharge from the exit site. An optimal culture technique was used that is by sending two samples of peritoneal fluid for culture and sensitivity that include a 50 mL effluent peritoneal fluid and bedside inoculation of 5-10 mL effluent in two blood culture bottles. The specimens were sent to the laboratory within 6 h. Peritoneal effluent is centrifuged at 3000 g for 15 min, followed by re-suspension of the sediment in 3-5 mL of sterile saline, and inoculation of this material both on solid culture media and into a standard blood culture medium. The solid media should be incubated in aerobic, microaerophilic, and anaerobic environments. With this method, <5% of samples will be culture negative.
| Results|| |
This retrospective study was done in Farwaniya Dialysis Center, Kuwait, from patients' records between February 2011 and December 2014. Since the beginning of the program in February 2011, we had 11 PD patients who had successful renal transplantations (one in 2012, four in 2013, and six in 2014). Four of them had cadaveric non-related renal transplantation, six patients had live non-related renal transplantation, and one patient had live-related renal and liver transplantation. There were a total of seven patients who were shifted to HD for different reasons all of them were during 2014 [Figure 1].
During 2011, 12 patients were enrolled in our PD program (8 males and 4 females). Nine patients were new starters on PD and three patients were transferred from other PD centers in Kuwait. In the same period, there were 95 patients on regular HD (45 males and 50 females). The percentage of PD patients was 11.21% of the total number of dialysis patients, 88.79% on HD. There were ten deaths among all dialysis patients (6 males and 4 females). All mortalities were in HD patients, none among PD patients. All-cause mortality rate was 9.3% in all ESRD patients maintained on dialysis and 10.5% in HD patients.
During 2012, we had a significant increase in the number of patients maintained on PD with a total of 26 patients (15 males and 11 females) compared to 97 patients managed by regular intermittent HD (49 males and 48 females). PD patients were 21.1% compared to 78.9% maintained on HD. Mortality rate was slightly higher as expected by the growing number of dialysis patients. There were a total of 21 deaths divided as three PD patients (one male and two females) and 18 HD patients (eight males and ten females). All-cause mortality rate was 17.1% among patients maintained on RRT (all-cause mortality rate of 11.5% among PD patients and all-cause mortality rate of 18.6% among HD patients).
During 2013, again we had a rise in regular patients maintained on PD reaching 38 patients, 22 males and 16 females, compared to 123 managed by regular HD (57 males and 66 females). The percentage of PD patients to the total number of dialysis patients was 23.6% compared to 76.3% maintained on HD. Total of 23 patients expired (4 PD patients and 19 HD patients) with an all-cause mortality rate of 14.3% among patients maintained on RRT (an all-cause mortality rate of 10.5% among PD patients and an all-cause mortality rate of 15.5% among HD patients).
During 2014, the number of regular patients maintained on PD reached 42, 24 males and 18 female, compared to 169 managed by regular HD (74 males and 95 females). The percentage of PD patients to RRT patients was 19.9% compared to 80.1% maintained on HD. There were 16 deaths among dialysis patients; all of them were HD patients. All-cause mortality rate among ESRD patients was 7.6%. Among the HD patients, the all-cause mortality rate was 9.5% and as for the PD patients, all-cause mortality rate was 0%.
During 2011, we had a peritonitis rate of 1:1 year and one month (0.92 incidents/year), [Table 1]. This rate is also expressed as 1:13 (13 months between incidents) [Figure 2]. We had only one exit site infection [Table 2].
During 2012, Peritonitis rate was 1:1 year and seven months (0.65 incidents/year). This rate is also expressed as 1:19 (19 months between incidents). Seven Isolated organisms were grown.
There was total of eight exit site infections during 2012 giving a rate of 1:12 years and four months (0.08 incidents/year). Half of these infections were Pseudomonas species [Table 2].
During 2013, our center had a peritonitis rate of 1:1 year and nine months (0.58 incidents/year). This rate is also expressed as 1:21 (21 months between incidents). Multiple organisms were grown on cultures as shown in [Table 1].
There were ten exit site infections with a rate of 0.19 incidents/year, mostly of Gram-negative Bacilli as seen in [Table 2].
During 2014, Farwaniya Dialysis Center achieved its best rate of peritonitis that was 1:2 years and eight months (0.38 incidents/year). This rate is also expressed as 1:32 (32 months between incidents).
There were seven cases of exit site infection with a rate of 0.13 incidents/year.
| Discussion|| |
The percentage of patients undergoing HD far surpasses that of PD. Based on the 2009 United States Renal Data System (USRDS) report, 94% and 6% began HD and PD in the USA, respectively, as a first dialysis modality.  Approximately, 11% of dialysis patients worldwide are treated with PD, with the relative proportion increasing in developing, but not developed countries. HD is generally more expensive than PD. In 2006, Medicare expenditures for HD were USD $71,889 per patient per year, compared with USD $53,327 for those on PD.  PD as an initial modality of RRT provides significant benefits principally via its ability to preserve residual renal function. Other benefits include preservation of veins for vascular access and better survival during the first few years of dialysis. ,
As per the International Society for PD (ISPD) Guidelines, peritonitis rate of a PD center should not exceed one episode every 18 months (0.67 episodes/year).  However, rates as low as one episode every 41-52 months (0.29-0.23/year) have been reported. 
The variation in peritonitis rates in recently published studies is astonishing; from as low as 0.06 episodes/year in one program to as high as 1.66 episodes/year in another program.  Those rates mean that an individual patient, on average, may expect to have peritonitis as rarely as once every 17 years in one center, or as frequently as once every seven months in another. Even at centers within a single country, there is often a marked variation in the peritonitis rate. 
ISPD has recommended targeted rates for Staphylococcus aureus-related catheter infections of <0.05 episodes/patients-years at risk (240 months or 20 years between episodes) with an overall catheter infection rate of 0.2 episodes/patients-years at risk or less. 
Mortality rates in ESRD population are declining but remain much higher than in the general population, according to the 2013 Annual Data Report from the USRDS.  The adjusted mortality rate among ESRD patients (per 1000 patients-years at risk) decreased from 351 in 1996 to 241 in 2011, a decline of 31.3%.  During that same period, the adjusted mortality rate in the dialysis population dropped from 362 to 266, a decrease of 26.5%. 
Our study revealed that there has been a steady rise in the number of patients in need for the RRT in our hospital every year (From 107 in the year 2011 to 211 patients maintained on RRT in our Dialysis Center by the end of 2014). The number of patients who have started PD therapy parallels this rise (from 12 patients in the year 2011 to 42 patients maintained on PD by the end of 2014). This represents an increase in incident dialysis patients from 11.2% in 2011 to 19.9% in 2014.
Our center's annual mortality rate is comparable, if not lower, to international records in this group of patients. The reported 1 st -year mortality rate for PD patients in the USA in 2009 is 6-12.5%. , However, we had no single mortality among our PD patients in our 1 st year of the program.
With regard to peritonitis rate, it is of paramount importance for a PD program to be successful; to take all precautions necessary to prevent PD-related infectious complications, that is, exit-site infections, tunnel infections, and peritonitis. As we mentioned earlier, there is huge variation in infectious complications in PD patients between centers worldwide that was also noticed even at centers within a single country.  According to the International Society of PD, most programs can reach a peritonitis rate of 0.36 episodes per patient per year although the rate achieved will depend to some extent on the patient population. Peritonitis rates as low as 0.06-0.24 episodes per year at risk (1 episode every 50-200 months) have been reported, and so those are the goals that dialysis programs should strive to achieve. 
The relatively high rate of peritonitis during 2011 in our center that was 0.92 incidents/year could be explained by the small number of patients and limited experience of the medical and nursing team at the start of the program. The peritonitis rate has improved during 2012 reaching 0.65 incidents/year, and improved further during 2013 to 0.58 incidents/year to achieve the recommended 2010 ISPD guidelines target of PD-related infection rates of 0.67 incidents/year. During 2014, our peritonitis rate again has improved to 0.38 incidents/year, [Figure 3]. This could be explained by the growing experience in the PD program of our center, in particular the cumulative experience of the nursing staff and dedication to ensure proper and professional compliance with international infection control guidelines.
|Figure 3: Peritonitis (incidents/year), compared with International Society for Peritoneal Dialysis Guidelines.|
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| Conclusion|| |
Incidence of ESRD is rising globally, which carries a significant burden on health systems. In comparison to HD, peritoneal dialysis is relatively a cheap, safe, efficient, and noninferior modality of RRT that needs to be explored more worldwide. It is a home-based therapy, so it is of great importance to spend much time in teaching patients, the proper technique of doing the procedure itself in a clean environment to prevent infection-related complications. Our data show excellent outcomes of both morbidity and mortality in PD population, and we have reached and moved beyond the international standards of PD-related infection rates. This study also highlights the importance of meticulous sterile technique and enhanced patient education to minimize infection-related complications in PD patients. We believe that PD therapy should be made more available in different parts of the world as it is an effective and significantly cheaper therapy compared with HD.
| Acknowledgments|| |
The authors would like to thank both Sister Liberty and Sister Sherly for their help in preparing this manuscript.
Conflict of interest: None declared.
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Anas M Alyousef
Department of Medicine, Nephrology Unit, Farwaniya Hospital, Kuwait City
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]