Peritonitis still represents the main acute complication of peritoneal dialysis (PD) and is a leading cause of hospitalization [
To further reduce the risk of morbidity, mortality, and technique failure patient-specific risk factors, which one can divide into modifiable and nonmodifiable, gain more attention in PD patient care. The aim of this paper was to perform a comprehensive collection of published studies on modifiable and nonmodifiable risk factors for PD-associated peritonitis between 1990 and 2012, to assess the methodological quality of the identified studies and to offer an overview of evidence-based patient factors which are associated with an increased risk for peritonitis in PD patients.
Relevant studies were identified by searches of Pubmed in April 2012, with key words that included “peritonitis,” “peritoneal dialysis,” and “risk factor”. The search was limited to studies with at least 40 patients in human adults in English language, published between 1990 and 2012. In order to provide an unbiased comparison, only studies reporting on peritonitis of any cause, that is, studies which reported data on all peritonitis episodes regardless of underlying germ were included. Hence, studies only reporting on risk factors for fungal or enteric peritonitis were excluded. The term “patient factor” was defined as a modifiable or nonmodifiable factor which is related to the individual. Data extraction was carried out by J. Kerschbaum and reviewed by M. Rudnicki. Studies were assessed for methodological quality using a modified checklist of the STROBE statement [
Assessment of methodological quality. Each statement scored with one point for the quality scoring.
(1) | Provide in the abstract an informative and balanced summary of what was done and what was found. |
(2) | State specific objectives, including any prespecified hypotheses. |
(3) | Describe the setting, location, type of data collection and relevant dates, including periods of recruitment. |
(4) | Describe relevant data of follow-up time, including end of study period. |
(5) | Give the eligibility criteria of participants, and the sources and methods of selection. |
(6) | Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria for episodes of peritonitis. |
(7) | Explain how the study size was arrived at. |
(8) | Describe all statistical methods, including those used to control for confounding. |
(9) | Describe any methods used to examine subgroups and interactions. |
(10) | Give demographic characteristics of study participants, at least gender and age. |
(11) | Summarize follow-up time (average per patient and total amount). |
(12) | Report numbers of peritonitis episodes or peritonitis rate over time. |
(13) | Give unadjusted and confounder-adjusted estimates and their precision. |
(14) | Discuss limitations of the study, taking into account sources of potential bias or imprecision. |
(15) | Give a cautious overall interpretation of results considering objectives, multiplicity of analyses, results from similar studies, and other relevant evidence. |
The search identified 415 potentially relevant studies. First, 112 articles had to be excluded because they were no study on peritonitis of any cause. Then, 303 abstracts were screened and 3 articles were additionally identified through the references of the former identified articles. In a next step, 93 full-text articles were selected for detailed analysis, 49 articles had to be excluded due to the predefined exclusion criteria. Finally, 44 studies were assessed for methodological quality. Nine articles were excluded because of having low methodological scoring and finally, thirty-five studies were scored as having “acceptable” methodological quality. Selection process is depicted in Figure
Characteristics of identified studies on patient-based risk factors for PD-associated peritonitis.
Study | Number of patients | Age (years) | Female (%) | FU-time (months) | Ethnicity | Peritonitis rate | CAPD/APD |
---|---|---|---|---|---|---|---|
[ |
102 |
|
38.2 | 10.7a | Asian | 0.36/patient year | Both |
[ |
149 |
|
41 |
|
N.R. | N.R. | Both |
[ |
204 |
|
42.6 |
|
Asian | 0.30/patient year | CAPD |
[ |
246 |
|
46 | N.R. | Asian | 0.48/patient year | APD |
[ |
322 |
|
45 | 23.9 | Asian | 4.63/100 patient years | CAPD |
[ |
506 |
|
49 | N.R. | Mixed | N.R. for whole cohort | Both |
[ |
10709 | N.R. | 49 | N.R. | Mixed | 0.86/patient year | Both |
[ |
11975 |
|
46 | 24 | Mixed | N.R. | Both |
[ |
8237 |
|
45.9 | N.R. | Mixed | N.R. | Both |
[ |
727 |
|
44.7 | N.R. | Mixed | N.R. | Both |
[ |
330 |
|
49.1 | N.R. | N.R. | N.R. | Both |
[ |
55 |
|
43.6 |
|
Caucasian | N.R. | Both |
[ |
48 |
|
41.7 |
|
Caucasian | N.R. | Both |
[ |
393 |
|
39.7 | 13.4a | Mixed | N.R. | Both |
[ |
56 |
|
28.6 | 20.8 | N.R. | N.R. | Both |
[ |
51 |
|
53 | N.R. | N.R. | N. R. | Both |
[ |
54 |
|
63 | N.R. | Asian | N.R. | Both |
[ |
69 |
|
87 | N.R. | Asian | N.R. for whole cohort | Both |
[ |
71 |
|
56 | N.R. | Mixed | N.R. | Both |
[ |
103 |
|
45 | 12 | N.R. | N.R. | Both |
[ |
120 |
|
33 | N.R. | Mixed | N.R. | Both |
[ |
132 |
|
56 | N.R. | Mixed | 2.7/patient year | Both |
[ |
140 | 56.4 | 33 | 10.4 | N.R. | N.R. | Both |
[ |
146 |
|
46 | N.R. | Mixed | N.R. | Both |
[ |
147 | 43.6 | 41 | N.R. | N.R. | N.R. | Both |
[ |
162 |
|
46 | N.R. | Mixed | N.R. | Both |
[ |
179 |
|
54 | N.R. | Asian | N.R. | Both |
[ |
184 | N.R. | N.R. | N.R. | Mixed | N.R. | Both |
[ |
185 | N.R. | 48 | N.R. | Mixed | 0.8/patient year | Both |
[ |
328 |
|
47 |
|
N.R. | N.R. | Both |
[ |
1595 |
|
46 | N.R. | Mixed | N.R. | Both |
[ |
1990 |
|
44 |
|
N.R. | 0.68/patient year | Both |
[ |
3162 | N.R. | 46 | N.R. | Mixed | N.R. for whole cohort | Both |
[ |
4247 | N.R. | 45 | N.R. | Mixed | N.R. | Both |
[ |
4247 |
|
45 | N.R. | Mixed | N.R. | Both |
aMedian. N.R.: not reported.
Process of identification of eligible studies. *16 studies: not on all-cause peritonitis; 21 studies: no patient risk factors, 6 studies: cohorts including children; 5 studies: cohorts < 40 patients; 1 study: single event report.
Identified patient risk factors. Factors are divided by nonmodifiable and modifiable risk factors.
Identified non-modifiable risk factors.
Ref | Risk factor | Statistics | Result | Meth. quality |
---|---|---|---|---|
Ethnicity | ||||
| ||||
[ |
Aboriginal ethnicity (versus non-indigenous ethnicity) | IRR (adj.) | 1.93 (1.63–2.28) | Good |
[ |
Aboriginal ethnicity (versus white) | HR (adj.) | 1.78 (1.45–2.19) | Average |
[ |
Indigenous and remote living (versus other) | HR (adj.) | 1.92 (1.69–2.18) | Good |
[ |
First Nations people (versus other) | Comp. of PET (not adj.) |
|
Good |
[ |
Black ethnicity (versus other) | IRR (adj.) | 2.2 ( |
Average |
[ |
Black ethnicity (versus white) | HR (adj.) | 1.255 (1.178–1.338) | Good |
[ |
Black ethnicity (versus white) | HR (adj.) | 1.5 (1.2–1.8) | Average |
[ |
Black ethnicity (versus white) | IRR (adj.) | 1.629 ( |
Average |
[ |
African American (versus white) | IRR (adj.) | 1.36 (1.04–1.77) | Average |
[ |
Maori/Pacific Islander (versus non-indigenous ethnicity) | IRR (adj.) | 1.64 (1.43–1.87) | Good |
[ |
Native Canadian (versus Caucasian) | Time to first PE (not adj.) |
|
Average |
[ |
Black ethnicity (versus other) | IRR (adj.) | 1.37 (1.00–1.88) | Average |
[ |
White ethnicity (versus other) | HR (adj.) | 0.90 (0.39–2.35) | Average |
[ |
Asian (versus other) | IRR (adj.) | 0.89 (0.74–1.08) | Average |
| ||||
Age | ||||
| ||||
[ |
Age per 10 years | OR (adj.) | 1.26 (1.07–1.48) | Good |
[ |
Age per 10 years | IRR (adj.) | 1.06 (1.01–1.10) | Average |
[ |
Age per 10 years | IRR (adj.) | 1.04 (1.01–1.08) | Average |
[ |
Age per year | HR (adj.) | 1.02 (1.01–1.03) | Average |
[ |
Age from 45–64 (versus 65–74) | HR (adj.) | 1.094 (1.007–1.188) | Good |
[ |
Age from 65–74 (versus 45–54) | HR (adj.) | 1.14 (1.06–1.22) | Good |
[ |
Age from 75-84 (versus 45–54) | HR (adj.) | 1.28 (1.15–1.43) | Good |
[ |
Age ≥ 65 years (versus <65 years) | OR (adj.) | 2.15 (1.09–4.24) | Good |
[ |
Age > 70 years (versus <70) | Comp. of PET (not adj.) |
|
Good |
[ |
Age > 85 years (versus 45–54) | HR (adj.) | 1.94 (1.20–3.13) | Good |
[ |
Age < 45 years (versus 65–74) | HR (adj.) | 1.094 (1.007–1.188) | Good |
[ |
Younger age (NFI) | IRR (adj.) | N.R. ( |
Average |
[ |
Age ≥ 65 years (versus <65) | HR (adj.) | 0.80 (0.29–1.48) | Average |
[ |
Age ≥ 75 years (versus <75) | HR (adj.) | 1.071 (0.988–1.162) | Good |
[ |
Age 0–24.9 years (versus ≥65) | HR (adj.) | 0.90 (0.66–1.22) | Average |
[ |
Age 25–44.9 years (versus ≥65) | HR (adj.) | 0.83 (0.70–1.00) | Average |
[ |
Age 45–64.9 years (versus ≥65) | HR (adj.) | 0.88 (0.77–1.01) | Average |
[ |
Age per year | HR (adj.) | 0.99 (0.91–1.01) | Good |
[ |
Age < 40 years | HR (adj.) | 2.87 (0.80–10.30) | Good |
[ |
Age ≥ 60 years (versus <60 years) | Time to first PE (not adj.) |
|
Average |
[ |
Age ≥ 65 years (versus <65 years) | Time to first PE (not adj.) |
|
Average |
| ||||
Gender | ||||
| ||||
[ |
Females (versus males) | OR (adj.) | 1.91 (1.20–3.01) | Good |
[ |
Females (versus males) | HR (adj.) | 0.968 (0.918–1.020) | Good |
[ |
Males (versus females) | OR (adj.) | 0.73 (0.44–1.21) | Good |
[ |
Males (versus females) | HR (adj.) | 0.95 (0.89–1.02) | Good |
[ |
Females (versus males) | Time to first PE (not adj.) |
|
Average |
[ |
Females (versus males) | IRR (adj.) | 1.25 (0.63–1.01) | Average |
| ||||
Comorbidities | ||||
| ||||
[ |
Chronic lung disease (versus no chronic lung disease) | HR (adj.) | 1.10 (1.03–1.18) | Good |
[ |
Congestive heart failure (versus no congestive heart failure) | HR (adj.) | 1.101 (1.034–1.172) | Good |
[ |
Coronary artery disease (versus no coronary artery disease) | IRR (adj.) | 1.06 (1.01–1.12) | Good |
[ |
Cardiovascular disease (versus no CVD) | HR (adj.) | 1.09 (1.04–1.17) | Good |
[ |
No hypertension (versus hypertension) | HR (adj.) | 0.76 (0.61–0.94) | Average |
[ |
Catheter exit site infection (versus none) | OR (adj.) | 2.63 (1.57–4.41) | Good |
[ |
Coronary artery disease (versus no coronary artery disease) | HR (adj.) | 0.60 (0.39–1.79) | Average |
[ |
History of cerebrovascular disease (versus no history) | HR (adj.) | 1.39 (0.82–2.35) | Good |
[ |
Cerebrovascular disease (versus no cerebrovascular disease) | HR (adj.) | 1.04 (0.95–1.14) | Good |
[ |
Cardiovascular disease (versus no cardiovascular disease) | Time to first PE (not adj.) |
|
Average |
| ||||
Diabetes mellitus | ||||
| ||||
[ |
Diabetes versus no diabetes | HR (adj.) | 1.131 (1.069–1.195) | Good |
[ |
Diabetes versus no diabetes | HR (adj.) | 1.5 (1.05–2.40) | Good |
[ |
Diabetes versus no diabetes | HR (adj.) | 1.64 (1.08–2.50) | Good |
[ |
Diabetes versus no diabetes | IRR (adj.) | 1.81 ( |
Average |
[ |
Diabetes in females (versus no diabetes) | IRR (adj.) | 1.27 (1.10–1.47) | Average |
[ |
Type 1 diabetes (versus no diabetes) | HR (adj.) | 1.24 (1.08–1.42) | Good |
[ |
Type 2 diabetes (versus no diabetes) | HR (adj.) | 1.1 (1.03–1.17) | Good |
[ |
Diabetes versus no diabetes | Comp. of PET (not adj.) |
|
Average |
[ |
Diabetes versus no diabetes | HR (adj.) | 1.00 (0.46–2.17) | Average |
[ |
Diabetes versus no diabetes | HR (adj.) | 1.06 (0.94–1.18) | Good |
[ |
Diabetes versus no diabetes | HR (adj.) | 2.08 (0.88–4.95) | Good |
[ |
Diabetes versus no diabetes | Time to first PE (not adj.) |
|
Average |
[ |
Diabetes versus no diabetes | Time to first PE (not adj.) |
|
Average |
[ |
Diabetes versus no diabetes | Time to first PE (not adj.) |
|
Average |
[ |
Diabetes in males (versus no diabetes) | IRR (adj.) | 0.99 (0.87–1.13) | Average |
| ||||
Underlying renal disease | ||||
| ||||
[ |
Lupus nephritis (versus other) | HR (adj.) | HR N.R. ( |
Average |
[ |
Glomerulonephritis (versus other) | IRR (adj.) | 0.87 (0.75–1.00) | Average |
| ||||
Residual renal function | ||||
| ||||
[ |
GFR per mL/min/1.73 m2 increase | HR (adj.) | 0.81 (0.74–0.88) | Good |
Comp. of PET: comparison of peritonitis episodes per time period. HR: hazard ratio. NFI: no further information. IRR: incidence rate ratio. OR: odds ratio. PE: peritonitis episode.
Eleven studies found differences between ethnicities such as a higher risk in aboriginal ethnicity (IRR 1.93; 1.63–2.28) [
Although these studies adjusted for some psychosocial factors and/or socioeconomic status in multivariable analyses, residual confounding might also account for these findings. Furthermore, it is possible that this association reflects a lower ability of receiving social support or health care service in these patient groups. Whether social assistance might decrease the risk for peritonitis in certain ethnicities remains unknown.
Results on age as a risk factor were inconsistent. Four studies found an increased risk for peritonitis in older patients defined as >65 or >70 years [
Kotsanas et al. [
Only a few studies evaluated the impact of mainly cardiovascular comorbidities on the risk for peritonitis. McDonald et al. [
Six studies [
As diabetes mellitus is regarded as a risk factor for infections in general [
Huang et al. [
Han et al. [
Identified modifiable risk factors.
Ref | Risk factor | Statistics | Result | Meth. quality |
---|---|---|---|---|
Malnutrition | ||||
| ||||
[ |
Albumin per g/dL increase | HR (adj.) | 0.73 (0.59–0.91) | Good |
[ |
Albumin per 10 g/L decrease | HR (adj.) | 1.67 (1.08–2.60) | Good |
[ |
Albumin < 3 g/dL (versus ≥3 g/dL) | Comp. of PET (not adj.) |
|
Average |
[ |
Albumin < 3 g/dL (versus ≥3 g/dL) | OR (adj.) | 2.03 (1.21–3.43) | Good |
[ |
Declining Albumin | Comp. of PET (not adj.) |
|
Average |
[ |
No malnutrition (versus malnutritiona) | HR (adj.) | 0.08 (0.018–0.365) | Average |
[ |
Albumin < 2.9 g/dL (versus ≥2.9) | IRR (adj.) | 0.74 (0.61–0.89) | Average |
[ |
Albumin per 1 g/dL increase | HR (adj.) | 0.61 (0.37–1.13) | Good |
[ |
Albumin per 10 g/L decrease | HR (adj.) | 1.80 (0.68–4.80) | Good |
[ |
Level of serum albumin | Comp. of RF (not adj.) |
|
Average |
| ||||
Weight | ||||
| ||||
[ |
BMI per 5 kg/m2 | HR (adj.) | 1.08 (1.04–1.12) | Good |
[ |
BMI > 30 kg/m2 (versus 20–24.9) | HR (adj.) | 1.25 (1.04–1.50) | Average |
[ |
BMI > 30 kg/m2 (versus 0–18.5) | HR (adj.) | 1.21 (1.01–1.43) | Good |
[ |
BMI < 20 kg/m2 (versus 20–24.9) | HR (adj.) | 0.98 (0.81–1.20) | Average |
[ |
BMI 25–29.9 kg/m2 (versus 20–24.9) | HR (adj.) | 1.08 (0.94–1.24) | Average |
[ |
BMI per kg/m2 | HR (adj.) | 0.98 (0.91–1.05) | Good |
| ||||
Smoking | ||||
| ||||
[ |
Current smoking (versus never) | OR (adj.) | 1.71 (1.04–2.82) | Good |
[ |
Current smoking (versus never) | OR (adj.) | 1.15 (1.07–1.23) | Good |
[ |
Smoker (versus non-smoker) | HR (adj.) | 1.04 (0.97–1.11) | Good |
| ||||
|
||||
| ||||
[ |
|
Comp. of PET (not adj.) |
|
Average |
| ||||
Comedication | ||||
| ||||
[ |
Use of oral active vitamin D (versus none) | HR (adj.) | 0.20 (0.06–0.64) | Good |
[ |
Immunosuppression (versus none) | Comp. of PET (not adj.) |
|
Average |
[ |
Use of Sevelamer (versus none) | HR (adj.) | 0.55 (0.21–1.42) | Good |
| ||||
Psychosocial factors | ||||
| ||||
[ |
Depression (versus no depression) | HR (adj.) | 2.70 (1.23–6.03) | Average |
[ |
Depression (versus no depression) | Comp. of PET (not adj.) |
|
Average |
[ |
Passive dependent personality (NFI). | IRR (adj.) | N.R | Average |
[ |
Substance abuse (versus no substance abuse) | HR (adj.) | 1.9 (1.1–3.2) | Average |
| ||||
Socioeconomic status | ||||
| ||||
[ |
Education per year | IRR (adj.) | 0.945 ( |
Average |
[ |
Educational level < 4 years of schooling (versus ≥4 years) | OR (adj.) | 2.15 (1.09–4.24) | Good |
[ |
Student (versus no student) | HR (adj.) | 2.4 (1.4–4.3) | Average |
[ |
Illiteracy (versus literacy) | HR (adj.) | 2.73 (1.04–7.20) | Good |
[ |
Receiving social security assistance (versus no assistance) | HR (adj.) | 2.69 (1.10–6.54) | Good |
[ |
Living in a rented house (versus own house) | HR (adj.) | 1.2 (1.0–1.5) | Average |
| ||||
Patient’s choice | ||||
| ||||
[ |
PD as second choice (versus first choice) | Time to first PE (not adj.) |
|
Average |
[ |
PD against patient’s or first physician’s choice | HR (adj.) | 1.6 (1.1–2.2) | Average |
| ||||
Former modality | ||||
| ||||
[ |
Transfer from HD | IRR (adj.) | 1.24 (1.11–1.38) | Average |
[ |
Failed transplant (versus no failed transplant) | IRR (adj.) | 1.27 (0.95–1.69) | Average |
In three studies [
In a large evaluation by McDonald et al. [
Kotsanas et al. [
In a study by Luzar et al. [
Andrews et al. [
Two studies [
Farias et al. [
Three studies found an influence of patient’s choice on the risk of peritonitis. In a study by Viglino et al. [
Nessim et al. [
They hypothesize that this increased risk may be attributable to two high-risk groups: those who were “crash starts” on HD with little predialysis care who subsequently chose to transfer to PD, and those who had been on HD for years and were out of vessel.
In 2007, Chow and Li [
In summary plenty of risk factors for peritoneal dialysis-associated peritonitis have been identified in studies of acceptable methodological quality. However, the evidence for many of these risk factors is based on single studies or studies including a relatively small patient number. Diabetes mellitus, ethnicity, and malnutrition might be considered as relatively well-established risk factors for peritonitis. Data on the impact of comorbidities are scarce. Whether the presence of multiple identified risk factors in an individual should lead to the definition of a “high risk patient” has not been evaluated yet. However, it seems reasonable to hypothesize that patients presenting with a number of these identified patient risk factors, might be at higher risk for peritonitis. Furthermore, it remains elusive if modification of one or more of these risk factors would result in a reduction of the peritonitis rate and probably in a higher rate of technique survival in PD patients. Nevertheless, the decision whether a patient with certain risk factors should perform PD remains the choice of the individual patient and the treating nephrologist. However, data from this and from other reviews might serve as a basis to score patients as low and high risk, and thus facilitate the short- and longterm management of these patients.
Data on modifiable and nonmodifiable risk factors for peritonitis are limited. Nevertheless, available evidence might be used as a basis for patient selection for peritoneal dialysis, and also for the grade of monitoring of high-risk patients. Especially diabetes mellitus, ethnicity and malnutrition might be considered as relatively well established risk factors for peritonitis. Nevertheless, due to the somewhat limited quality of the available evidence the decision whether a patient with certain risk factors should perform PD remains the choice of the individual patient and the treating nephrologist.
The authors declare no conflict of interests.