What is the safety of peritoneal dialysis (PD)?

Safety of Peritoneal Dialysis

Peritoneal dialysis is a safe and effective renal replacement therapy when properly implemented, with centers achieving 75% 2-year technique survival rates, though infectious complications—particularly peritonitis—remain the primary safety concern affecting morbidity, mortality, and technique failure. 1

Key Safety Outcomes

Technique Survival and Overall Safety

• Centers should strive to achieve a 75% 2-year technique survival rate, which represents the benchmark established in major clinical studies. 1
• PD technique survival depends on multiple factors including infections, patient motivation, ultrafiltration capacity, and adequate solute clearance. 1
• Approximately 16% of patients experience technique failure due to peritonitis, requiring transfer to hemodialysis. 2

Hospitalization Rates

• PD patients average 1.8 hospitalizations per year, which serves as an important safety and effectiveness indicator. 1
• Hospitalizations can be ESRD-related (peritonitis, catheter infections, hernias, leaks) or ESRD-unrelated (cardiovascular, other infections). 1
• Low creatinine clearance is associated with increased hospitalization rates and prolonged hospital stays. 1

Primary Safety Concerns

Infectious Complications

Peritonitis remains the most serious safety threat in PD, with reported rates of 0.24-1.66 episodes per patient-year, though quality standards demand rates below 0.67 episodes per patient-year. 3

Impact on Mortality and Morbidity

• For every 0.5-per-year increase in peritonitis rate, mortality risk increases by 4%. 3
• 18% of peritonitis episodes result in catheter removal. 3
• 3.5% of peritonitis episodes result in death. 3
• Frequent peritonitis causes severe malnutrition through excessive protein losses, further increasing mortality and morbidity. 2

Common Causative Organisms

• Gram-positive cocci (Staphylococcus epidermidis, coagulase-negative staphylococci, S. aureus) are the most frequent causes worldwide. 3
• Candida species are the most common fungal cause. 2
• Aspergillus species also cause peritonitis, though less frequently. 2

Management of Fungal Peritonitis

• Catheter removal is mandatory for fungal peritonitis, along with antifungal treatment for minimum 3 weeks and transfer to hemodialysis. 3

Exit-Site and Tunnel Infections

• These infections increase risk of peritonitis and technique failure. 3, 4
• Mupirocin prophylaxis can reduce exit-site infection risk by 46%, though it does not decrease overall peritonitis risk. 3

Mechanical Complications

Mechanical complications, while less life-threatening than infections, can lead to technique failure if not properly managed. 5

• Hernias and peritoneal leaks occur more frequently with larger instilled dialysate volumes. 1
• Inadequate ultrafiltration can result from high peritoneal transport characteristics or catheter mechanical defects. 2
• Abdominal wall defects are significantly associated with previous abdominal surgery history. 5

Encapsulating Peritoneal Sclerosis (EPS)

• EPS is a rare but serious complication with high morbidity and 20% mortality rate. 5
• Risk increases with duration of PD treatment. 5
• Diagnosis requires high index of suspicion based on clinical symptoms; no reliable early screening tests exist. 5
• Surgical enterolysis is the only established treatment; conservative management should not delay definitive intervention. 5

Contraindications to PD

Absolute Contraindications

• Documented loss of peritoneal function or extensive abdominal adhesions limiting dialysate flow. 6
• Physical or mental inability to perform PD without suitable assistant. 6
• Uncorrectable mechanical defects (irreparable hernias, omphalocele, gastroschisis, diaphragmatic hernia, bladder exstrophy). 6

Relative Contraindications

• Recently implanted intra-abdominal foreign bodies (require 4-month waiting period). 6
• Inflammatory or ischemic bowel disease (increases transmural contamination risk). 6
• Frequent diverticulitis episodes. 6
• Morbid obesity (complicates catheter placement and adequate dialysis delivery). 6
• Severe malnutrition (compromises wound healing). 6

Safety Optimization Strategies

Infection Prevention

• Prophylactic antibiotics before catheter placement reduce infection risk. 3
• S. aureus nasal carriage treatment with mupirocin. 3
• Proper exit-site care protocols. 3, 4
• Adequate initial patient training with periodic retraining. 3, 4
• Antifungal prophylaxis during antibiotic treatment courses. 7

Quality Monitoring

• Continuous monitoring of infection rates (exit-site and peritonitis) is essential. 4
• Root cause analysis of every infection episode should be routine. 4
• Monthly patient evaluations reviewing ultrafiltration, clearance requirements, quality of life, and adherence. 1

Critical Safety Pitfalls

• Delayed surgical intervention for peritonitis unresponsive to medical treatment can result in peritoneal membrane loss or death—surgical observation is mandatory in every peritonitis case. 5
• Underestimating clinical symptoms of EPS leads to delayed diagnosis and worse outcomes. 5
• Inadequate dialysis dosing increases uremic symptoms (nausea, vomiting, GI bleeding) and may increase infection risk. 1
• Failure to monitor and address declining residual kidney function compromises overall clearance. 1