The first peritonitis episode alters the natural course of peritoneal membrane characteristics in peritoneal dialysis patients.
OBJECTIVE
Little or no evidence is available on the impact of the first peritonitis episode on peritoneal transport characteristics. The objective of this study was to investigate the importance of the very first peritonitis episode and distinguish its effect from the natural course by comparison of peritoneal transport before and after infection.


METHODS
We analyzed prospectively collected data from 541 incident peritoneal dialysis (PD) patients, aged > 18 years, between 1990 and 2010. Standard Peritoneal Permeability Analyses (SPA) within the year before and within the year after (but not within 30 days) the first peritonitis were compared. In a control group without peritonitis, SPAs within the first and second year of PD were compared.


METHODS
SPA data included the mass transfer area coefficient of creatinine, glucose absorption and peritoneal clearances of β-2-microglobulin (b2m), albumin, IgG and α-2-macroglobulin (a2m). From these clearances, the restriction coefficient to macromolecules (RC) was calculated. Also, parameters of fluid transport were determined: transcapillary ultrafiltration rate (TCUFR), lymphatic absorption (ELAR), and free water transport. Crude and adjusted linear mixed models were used to compare the slopes of peritoneal transport parameters in the peritonitis group to the control group. Adjustments were made for age, sex and diabetes.


RESULTS
Of 541 patients, 367 experienced a first peritonitis episode within a median time of 12 months after the start of PD. Of these, 92 peritonitis episodes were preceded and followed by a SPA within one year. Forty-five patients without peritonitis were included in the control group. Logistic reasons (peritonitis group: 48% vs control group: 83%) and switch to hemodialysis (peritonitis group: 22% vs control group: 3%) were the main causes of missing SPA data post-peritonitis and post-control. When comparing the slopes of peritoneal transport parameters in the peritonitis group and the control group, a first peritonitis episode was associated with faster small solute transport (glucose absorption, p = 0.03) and a concomitant lower TCUFR (p = 0.03). In addition, a discreet decrease in macromolecular transport was seen in the peritonitis group: mean difference in post- and pre-peritonitis values: IgG: -8 μL/min (p = 0.01), a2m: -4 μL/min (p = 0.02), albumin: -10 μL/min (p = 0.04). Accordingly, the RC to macromolecules increased after peritonitis: 0.09, p = 0.04.


CONCLUSIONS
The very first peritonitis episode alters the natural course of peritoneal membrane characteristics. The most likely explanation might be that cured peritoneal infection later causes long-lasting alterations in peritoneal transport state.
Division of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
Anouk T N
AT
van Diepen
Division of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Nephrology Department and Internal Medicine, St Elisabeth Hospital, Tilburg, The Netherlands.
Sadie
S
van Esch
Division of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Dianet, Amsterdam-Utrecht, The Netherlands.
Dirk G
DG
Struijk
Division of Nephrology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
Raymond T
RT
Krediet
D000328:Adult; D000368:Aged; D015314:Dialysis Solutions / Q000493:pharmacokinetics*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008567:Membranes, Artificial; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010530:Peritoneal Dialysis / Q000009:adverse effects*; D010537:Peritoneum / Q000378:metabolism*; D010538:Peritonitis / Q000453:epidemiology / Q000209:etiology*; D010539:Permeability; D011446:Prospective Studies; D017211:Treatment Failure; D055815:Young Adult
D015314:Dialysis Solutions; D008567:Membranes, Artificial
Infection; peritoneal dialysis; peritoneal transport; peritoneum; peritonitis; standard peritoneal permeability analysis