Dialysis Related Infections: Peritoneal Dialysis Poses more Dangers

By Peter Laird, MD

Every patient with ESRD by law is required to have education at the start of treatment on all of the differing options of renal replacement therapy including in-center conventional hemodialysis, in-center nocturnal hemodialysis, home hemodialysis either short daily, nocturnal and standard, peritoneal dialysis and renal transplantation options.  Each modality carries with it a unique set of risks and benefits that fit the lifestyle choices of individual patients.  One of the major risks of renal replacement therapy no matter the choice are serious infections often requiring hospitalization to treat. The second leading cause of death in dialysis patients is infection causing approximately 15% of all deaths, second only to cardiovascular related deaths. 

Vascular Access-Related Infections: Definitions, Incidence Rates and and Risk Factors

Hemodialysis is associated with a high risk of morbidity and mortality, often caused by infections. Infections account for approximately 15% of all deaths in this patient population (the second leading cause after cardiovascular events) and for about one-fifth of admissions. Approximately one-fourth of infection-related admissions are caused by dialysis-associated peritonitis or vascular access infection that may lead to such significant complications as endocarditis or death.

A recent study by Jean-Philippe Lafrance, MD, of the University of Montreal revealed a surprising finding that peritoneal dialysis patients are at much higher risk of a serious infection requiring hospitalization than hemodialysis patients with access related infections. As recently reported in Renal Urology News, peritoneal dialysis patients had a 51% increased risk of hospitalization from infections compared to a similar hemodialysis control group:

Hospitalization Risk for Infections Higher with PD

Twenty-one percent of the PD patients had been hospitalized once in the previous year (not counting the hospitalization during which dialysis was initiated) compared with 16% of the matched HD patients. PD patients were also more likely than HD patients to have two or more and three or more hospitalizations (8% vs. 5% and 8% vs. 3%, respectively).

PD was associated with a nearly 2.9-fold higher risk compared to HD of hospitalization due to dialysis-related infections, a twofold increased risk of other hospitalizations due to other infections, including a 1.6-fold higher risk of hospitalization due to abdominal infections. However, PD also was associated with 70% and 40% lower probabilities of being hospitalized for septicemia or pneumonia, respectively.

In a previous retrospective cohort study of 168 patients initiating outpatient dialysis (71 on PD and 97 on HD), researchers at Sunnybrook Health Sciences Centre in Toronto found that patients who initiate outpatient PD do not have a significantly increased risk of infection-related hospitalization compared with patients who initiate outpatient HD, according to a report published in Peritoneal Dialysis International (2011;31:440-449). The study, however, showed that patients starting outpatient treatment on PD were significantly more likely than those starting on HD to be hospitalized for peritonitis.

The risks of peritoneal dialysis vs. hemodialysis must be assessed and weighed against the intended benefits  of PD which includes ease of use, independence, greater mobility, fewer dietary restrictions, preservation of residual renal function and no need for vascular access. Researchers need to evaluate and develop further strategies to prevent PD related infections to maximize the benefits of this treatment option that many patients prefer over hemodialysis. The quest for the perfect renal replacement treatment options continues unabated but remains still in the future. 

For patients initiating dialysis, adherence to proper technique can further diminish infection risks but cannot eliminate them completely no matter how diligent and careful the practitioner is. Infection is a reality that all that have ESRD must consider and design their technique with that sobering thought in mind. Many patients have successfully avoided any infection for years, but with the nature of chronic kidney disease and poor immune function, we shall always be at higher risk that the general population. Certainly it is true however that we can do much better than we do today most often by failing to promote and practice safe and proper infection control techniques. Sadly, one of the greatest failures found during state and CMS inspections is improper hand hygiene and infection control. We can and must do better. Proper technique does lend optimism to infection avoidance as many patients doing self care can testify.

Choosing which modality is best for any given patient comes down to personal preference in many instances. The goals of therapy should not only be ease of use but consider all aspects especially in reguard to survival and avoiding hospitalizations. Despite the many benefits of PD, the infection risk is and has been one of the most difficult issues to resolve.

Comments

[Roberta Mikles BA RN]

Peter, thank you, once again, for providing information that is most-important for patients, in order for them to self-protect,

Although patients are suppose to obtain information on renal replacement therapy options, I continue to speak with patients who have not been fully educated in this respect. I believe, from my experience, this happens more pre-dialysis, but once a patient enters incenter, often this aspect of education is not as complete as it should be e.g. patients continue to state they do not know about home dialysis.

For many years, I participated in the CMS Open-Door Forums where mostly providers were present -- I focused on preventable acquired infections (incenter) and continued deficiencies cited in this area. To date, in center, nothing has changed with respect to the types of cited deficiencies in infection control - (California).

Over the last many years, I have communicated with patients who were on PD and acquired an infection, hospitalized and then received incenter HD treatments. Some, then, acquired access-related infections -

Often, I have also found, patients are not given enough information in order to make a fully informed decision -- regarding the best option for them, to meet their lifestyle. But, the one thing that I do stress, when talking with patients, is to ask questions and question anything that one does not understand. Many patients would benefit more from longer dialysis treatments, more frequently incenter, while others might do better at home -- each patient is unique with their own individual needs.

opinion of - Roberta Mikles
www.qualitysafepatientcare.com

[roberta mikles]

Peter, over the years I have read survey findings (inspection reports) in twenty eight states, however, more recently, since 2009, have mostly focused on California. I continue to not only be shocked, but appalled that those at the top still do NOT GET IT -- The survey findings continue to show failures in infection prevention -- One must ask, "what is wrong when staff can NOT implement the most basic of basic practices of correct hand hygiene practices?" For years, I have stated that 'patients should be given a written document listing what staff will do to prevent an acquired infection' - this means that the patients, and their loved ones, would be able to KNOW and be EDUCATED in the facility's policy/procedure for infection prevention --- hence, if a patient then observes a staff, for instance, not conducting hand hygiene prior to putting on gloves, or touching the machine, etc, after putting on gloves, prior to cannulating, etc, the patient then can remind staff. Unless the patient is made aware of correct infection control practices, they have NO idea what is correct, or incorrect --- unless they educate themself. The only educational material, or similar that I know of that states educate the patient as to the correct practices that staff will implement is the APIC Guidelines for IP in HD facilities. Of course, we continue to hear from patients, in California, of the retaliation that is experienced when they speak up to ensure safe care -- and, that is how my father's retaliation started -- he told a staff that he did not want him to use gloves that were kept in the staff's pockets of his pants -- this started the ball rolling -- Staff are NOT adequately trained in understanding the REAL role of the patient -- the patient IS the CENTER OF CARE and should be aware of policies/procedures (transparency) --
As I review and reread the surveys from California, where we both live, I see, as stated many times before, NO difference in the deficiencies cited related to infection prevention --some facilities continue to have Conditions not met, while others have many Standards NOT met... This continues to send a message and a loud one, at that --- who is supervising these staff and who is educating these staff? When RNs are not aware of policies and not supervising other staff, what can one expect? When we still see that staff are providing care for immune and non immune Hep patients, without being aware that this is a NO NO - what can one expect? Where are those big dogs who are working with CDC and HHS on infection reduction? Are they sending the message to the units? there is a definite disconnect as we can see from the survey findings. The only reason my father never acquired an access-related infection was because he was observing constantly --and reminding staff -- interesting, that when we brought forth our concerns about lack of correct implementation of infection control practices, we were told by the nephrologist and staff, no problems with infections -- come to find out, thanks to ProPublica data released, that during this time, the unit had HIGH infection rates. So, we were right on in bringing our concerns forth -- but we were seen as a problem, etc.. to the point of my being almost banned from the unit..of course, when I speak with some who remain in the unit, nothing has changed.
The surveys speak for themselves and if you read through the California surveys, most of them have deficiencies in infection prevention. HELLO PROVIDERS<<< LET"S GET WITH THE PROGRAM AND RE-EDUCATE YOUR STAFF ---
opinions of Roberta Mikles
Dialysis Patient Safety Advocate

[Brian Riddle]

I was on PD for nearly 13 years. I had peritonitis 3 times. Two of the three required more than one day in hospital. The third time around I became very ill to the point of nearly dying with the rare complication of Encapsulating Peritoneal Sclerosis (EPS). I had never heard of this prior to my experience with it. I was fortunate in that my physician recognized it quickly and my life was saved but it has not been easy since. I have had several small bowel obstructions and a gall bladder that the surgeon was unable to remove because of the horrific condition of my abdomianl cavity because of the extensive adhesions. My gall bladder ruptured and surgery was not an option A drain was placed through my liver for several months to resolve that issue. I am known as "Miracle Man" to the doctor that treated me. EPS is the sole debilitating reason that keeps me from re-entering the work force. I live with some level of pain every day. I wish doctors would inform patients of ALL negative possibilities when addressing dialysis options. I still believe PD should be a first option then transplant (if possible) and finally HD. But, this is my opinion.

[Dawn]

Good article. I've had both an infection in my fistula. That was in the 1970's though when HD was newer & some centers reused artificial kidney filters. Yes and tubing too. But it not only caused me to be hospitalized it almost cost my arm. I've also had peritonitis a few times. However, I've been on PD 26 years as of August 2012 and have only had 3 episodes of peritonitis that caused hospitalizations. One of those occurred because I was fighting pneumonia at the time, too. With proper training and quick identification of an infection in PD most patients can be treated at home. I was required to learn to medicate my own dialysate at 17 years old when I started training for PD. I did very well when I had to use the training 5 years later. My latest unit has you come in for a nurse to medicate if it's before midnight but I can still medicate myself in an emergency & they supply us with meds in case. But then you return home. With this system I have been able to not only survive but live a very full life. Every patient of course is different & every treatment has patients that do better on it than the others, but with good aseptic procedure & training to identify & treat PD infections early hospital stays for PD infections would come down.

[Peter Laird, MD]

No matter what your renal replacement option, infection control is a central survival tactic for all ESRD patients. I truly believe we have much data to support that technique can significantly reduce the risk of infection. This is not a time to become complacent. Diligent adherence to proper technique is not optional if you wish to avoid serious infections that can lead to poor outcomes.