Diverticular Disease and Treatment with Gastric Acid Inhibitors do not Predispose to Peritonitis of Enteric Origin in Peritoneal Dialysis Patients

Abstract

Objective Enteric peritonitis (EP) is an infrequent complication of peritoneal dialysis (PD), with severe consequences for peritoneal membrane viability and patient outcome. Factors such as diverticular disease and gastric acid inhibitors have been implicated in its appearance. We investigated several risk factors, including those mentioned below, that can influence the development of EP. Design Retrospective cross-sectional study. Setting Tertiary-care public university hospital. Patients Fifty-seven PD patients treated in our PD unit during August 1998. Main Outcome Measures A barium enema was performed on 50 of the 57 patients (the remaining 7 patients refused it) in order to exclude the presence of diverticulosis. All episodes of peritonitis occurring in those patients, including EP, were registered. Enteric peritonitis was defined as that caused by gram-positive, gram-negative, or fungus micro-organisms that colonized the intestinal tract, excluding episodes secondary to genitourinary tract or peritoneal catheter exit-site infections. Results Twenty-four patients showed diverticular disease in the barium enema, but only 5 of them (21%) had any EP episode. Five of the 26 patients with no diverticula (19%) had EP. Fifty-five episodes of peritonitis were reported in 21 patients; 15 episodes of EP (27.3% of all) developed in 11 patients. Seven of the 11 patients (64%) required peritoneal catheter removal and 3 of them (27%) finally were transferred to hemodialysis due to consequences of the EP episode. Logistic regression analysis did not find any of the independent variables analyzed (age, sex, time on PD, type of PD, peritoneal transport parameters, presence of polycystic kidney disease, constipation or diverticulosis, or treatment with gastric acid inhibitors, or phosphate-binding agents) to be risk factors for developing EP. Conclusions Neither diverticulosis nor treatment with gastric acid inhibitors seem to be risk factors for developing peritonitis of enteric origin in PD patients. This type of peritonitis has to be promptly identified and treated in order to diminish the high frequency of peritoneal catheter removal and PD dropout due to such episodes.

Use of gastric-acid suppressants may be a risk factor for enteric peritonitis in patients undergoing peritoneal dialysis: A meta-analysis

“…A total of 829 people were included in our meta-analysis. Two-thirds (n = 4) of studies found that GAS use did not relate to an increased risk of enteric peritonitis, 19,[23][24][25] whereas the other two studies showed that GAS use increased that risk. 17,18 Obvious heterogeneity was not observed, so a fixed-effects model was used.…”

“…Thus, heterogeneity might have derived from these low-quality studies. 17,19,23 Due to these limitations, our results should be interpreted with caution. Randomized, prospective studies with a large number of cases and an updated, high-quality meta-analysis are needed to confirm our findings.…”

“…After our search and assessment of 332 potential articles (Figure 1), six articles met the inclusion criteria of this meta-analysis. Therefore, this meta-analysis contained four case-control, 17,23-25 one cross-sectional 19 and one retrospective cohort study. 18 Three of them were conducted in Europe, two in North America and one in Asia.…”

“…17,18 Compared with non-enteric peritonitis (which is usually caused by Staphylococcus epidermidis), enteric peritonitis occupies >25% of all PD-associated peritonitis and originates from micro-organisms known to colonize the gastrointestinal tract, usually Enterobacteriaceae, Enterococcus species and/or enteric anaerobes. [18][19][20] Enteric peritonitis may be caused by a change in the composition and function of gut microbiota due to small intestinal bacterial overgrowth (SIBO) and a reduction in the number of butyrate-producing bacteria, which can reduce microbial translocation, upon GAS use. 21,22 However, other studies have suggested that GAS intake is not associated with an increased risk of enteric peritonitis.…”

“…21,22 However, other studies have suggested that GAS intake is not associated with an increased risk of enteric peritonitis. 19,[23][24][25] GASs are used commonly in ESRD patients, and the outcome of PD-related enteric peritonitis is poor, leading to a high prevalence of catheter removal, transfer to permanent haemodialysis and death. 26 Hence, it is imperative to ascertain whether GAS intake can increase the risk of enteric peritonitis in these patients.…”