Peritoneal Dialysis-Related Infection in the Older Population

Abstract

With appropriate training and adequate support, it is possible to keep the peritonitis rate of elderly peritoneal dialysis (PD) patients at a highly respectable level. In general, the latest recommendations for the treatment and prevention of PD-related infections by the International Society for Peritoneal Dialysis (ISPD) are applicable to older patients. However, there are minor differences in the spectrum of causative organisms amongst elderly patients, with coagulase-negative staphylococcal species (CNSS) and Enterobacteriaceae species being more common in elderly patients. Elderly PD patients who develop peritonitis have an excessive short-term mortality, and, amongst elderly patients, a high burden of comorbid load increases the risk of relapsing episodes. In addition, technical problems, social difficulties, and concomitant comorbid diseases often have profound effects on the risk of peritonitis as well as its management. KEY WORDS: Chronic kidney disease; infection; survival T he proportion of elderly people in the general population is increasing, and a similar trend can be observed in patients treated with long-term dialysis. Data from the United States Renal Data System (USRDS) show that over 60% of the endstage renal disease patients in the US are over the age of 60 (1). Similarly, over half of the new dialysis patients in Hong Kong are now over 60 years of age (2). Peritoneal dialysis (PD) offers many potential advantages, such as a stable internal milieu and less hemodynamic disturbance than hemodialysis (3,4). Worldwide experience also suggests satisfactory tolerance to PD as long-term renal replacement therapy for older patients (5-8). THE EFFECT OF AGE ON PD-RELATED INFECTIONSIt remains controversial whether older PD patients have a substantially increased risk of peritonitis than their younger counterparts. A number of observational studies published in the 1990s reported that age is not a major risk factor of PD-related peritonitis (9-11), and the peritonitis-free survival is similar between PD patients above and below 65 years of age (12). On the other hand, 3 retrospective studies noted that patients above 65 or 70 years old have a significantly higher peritonitis rate than younger patients (8,13,14), although there is no difference in peritonitis-free survival or the rate of exit-site infection between older and younger patients (8).More recently, a retrospective study of 391 PD patients found that older age (above 65 years) was the only identified risk factor associated with peritonitis (15). Nonetheless, we believe the important clinical question is not whether older PD patients have a higher peritonitis rate than young patients, but whether their absolute peritonitis rate is acceptable. In this regard, a retrospective dialysis registry study of 1,613 patients older than 75 years reported that the median peritonitis-free survival was 32.1 months, and neither the modality of assistance nor the center size was associated with peritonitis risk (16). Similar peritonitis rates amongst older PD...

Peritonitis: Episode Sequence, Microbiological Variation, Risk Factors and Clinical Outcomes in a North China Peritoneal Dialysis Center

“…The effect of educational attainment on peritonitis risk has been discussed in several studies; lower educational level and lower socioeconomic status [3,6,17,14] are associated with higher peritonitis rates. One of our findings was at odds with previous studies in which advanced age is associated with peritonitis [30,31]. As a home-based dialysis modality, PD provides more self-managed time and space.…”

Fungal peritonitis in peritoneal dialysis: 5-year review from a North China center

“…Higher burden of comorbidities, loss of residual kidney function, longer PD duration were identified factors associated with FP in previous studies [5,22]. The association between aging and peritonitis remains controversial [27,28], a 10-year cohort study from Taiwan revealed that aged over 65 was the only independent risk factor associated with the incidence of peritonitis [29]. On the other hand, factors such as diabetes, malnutrition, comorbidities, hypoproteinemia and anemia are well-established risk factors associated with mortality.…”

Depression and Physical Frailty Have Additive Effect on the Nutritional Status and Clinical Outcome of Chinese Peritoneal Dialysis

“…In the non-dialysis elderly general population, depression and frailty are additive risk factors for mortality and other adverse health outcomes [18][19][20]. In previous studies on dialysis patients, physical frailty [6,7] and depression [12,13] have each been shown to be associated with adverse clinical outcomes. Our results show that their effects in PD patients are also additive.…”

“…Cognitive impairment is present in over 20% of dialysis patients [9,10], and is associated with increased risks of mortality and adverse clinical outcome [9,11]. Similarly, depressive symptoms are present in over 50% of PD patients [10] and is associated with excessive morality and represents a risk factor of peritonitis [12,13].…”