From the Guidelines
The most common cause of peritoneal dialysis failure is peritonitis, which is an infection of the peritoneal membrane, as indicated by the need for recurrent antibiotic treatments and potential long-term damage to the peritoneal membrane 1.
Causes of Peritoneal Dialysis Failure
Peritonitis typically occurs when bacteria enter the peritoneal cavity through the catheter or due to contamination during dialysis exchanges. Patients usually present with cloudy dialysate fluid, abdominal pain, and fever.
- Treatment requires prompt administration of antibiotics, typically starting with empiric therapy that covers both gram-positive and gram-negative organisms.
- Common regimens include vancomycin plus a third-generation cephalosporin or an aminoglycoside, with antibiotics often administered directly into the peritoneal cavity.
- Recurrent episodes of peritonitis can lead to peritoneal membrane damage, fibrosis, and ultimately failure of the dialysis technique, necessitating a switch to hemodialysis.
Prevention Strategies
Prevention strategies include:
- Meticulous exit site care
- Proper hand hygiene before exchanges
- Using connection systems that minimize contamination risk
Other Significant Causes
Other significant causes of peritoneal dialysis failure include:
- Ultrafiltration failure due to membrane changes over time
- Mechanical complications with the catheter
- Inadequate clearance of uremic toxins, as discussed in the context of peritoneal dialysis adequacy and the importance of regular assessment of peritoneal membrane transport characteristics 1.
From the Research
Causes of Peritoneal Dialysis Failure
- Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis, with peritoneal dialysis (PD)-related peritonitis being the most frequent treatment-related infection 2
- PD-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality 3
- The most common cause of peritoneal dialysis failure is peritonitis, which is estimated to occur at a rate of 0.24-1.66 episodes/patient/year 4
Risk Factors for Peritonitis
- Gram-positive cocci such as Staphylococcus epidermidis, other coagulase negative staphylococcoci, and Staphylococcus aureus (S. aureus) are the most frequent aetiological agents of PD-associated peritonitis worldwide 4
- Modifiable peritonitis risk factors include domestic pets, hypokalaemia, and histamine-2 receptor antagonists 3
- Exit-site infection is a significant risk factor for peritonitis, and prophylactic antibiotic administration before catheter placement, adequate patient training, exit-site care, and treatment for S. aureus nasal carriage can help prevent PD associated infections 4
Treatment and Prevention of Peritonitis
- Empiric antibiotic therapy must cover both gram-positive and gram-negative organisms, and the use of systemic vancomycin and ciprofloxacin administration is a simple and efficient first-line protocol antibiotic therapy for PD peritonitis 4
- Intraperitoneal cefepime monotherapy may be a reasonable alternative first-line treatment for CAPD-associated peritonitis, with a noninferior primary response rate compared to combination therapy of cefazolin and ceftazidime 5
- The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation, and provide new targets for overall peritonitis rate and percentage of patients free of peritonitis per unit time 3