Proton pump inhibitor use increases the risk of peritonitis in peritoneal dialysis patients

Abstract

Peritonitis is a major and the most significant complication of peritoneal dialysis (PD). Although some predictors of peritonitis in PD patients are known, the association between proton pump inhibitor (PPI) use and peritonitis has not been characterized. Here, we examined whether PPI use is a risk factor for the development of peritonitis, based on a single-center retrospective analysis of 230 consecutive Japanese PD patients at Narita Memorial Hospital. We assessed the association between PPI use and subsequent first episode of peritonitis using multivariate Cox proportional hazards models, following adjustment for clinically relevant factors. The median follow-up period was 36 months (interquartile range, 19–57 months). In total, 86 patients (37.4%) developed peritonitis. Analysis with multivariate Cox proportional hazards models revealed the following significant predictors of peritonitis: PPI use (adjusted hazard ratio [HR] = 1.72, 95% confidence interval [CI]: 1.11–2.66; P = 0.016) and low serum albumin level (per g/dl adjusted HR = 0.59, 95% CI: 0.39–0.90; P = 0.014). Thus, PPI use was independently associated with PD-related peritonitis. The results suggest that nephrology physicians should exercise caution when prescribing PPIs for PD patients.

Proton pump inhibitors long term use‐trends and patterns over 15 years of a large health maintenance organization

“…They are considered as a safe choice of treatment. 1 Over the years, a growing number of studies have tested the association between long-term use of PPIs and increased risk for various complications: infections, such as bacterial peritonitis in cirrhotic patients, 2 peritonitis in peritoneal dialysis patients, 3 Clostridium difficile infections, 4,5 community-acquired pneumonia 6 ; significant effects on the microbiome composition 7,8 ; mineral and vitamin malabsorption 9,10 ; cardiovascular morbidity [11][12][13][14] ; osteoporosis and impaired bone metabolism [15][16][17][18] ; dementia and recurrent falls in the elderly [19][20][21] ; kidney disease 22,23 ; gastric pre-malignantlesions 24 ; and multiple other conditions such as microscopic colitis, polymyositis and amyloid production. [25][26][27] The mechanisms related to PPIs potential adverse outcomes are not yet fully understood, but probably include achlorhydia, dysbiosis and vitamin and mineral malabsorption.…”

Proton‐pump inhibitor use and the risk of peritoneal dialysis associated peritonitis

“…A relationship between PPI use and PD peritonitis was demonstrated by Maeda et al . in a recent study, 16 where 56% of patients in the PPI group developed peritonitis compared with 29% in the non‐PPI group ( P < 0.001). The proportion of multiple peritonitis episodes in that study was 26% in the PPI group versus 15% in the non‐PPI group ( P = 0.041), which were trends noted in our own study.…”

“…[26][27][28] Coupled with intestinal bacterial overgrowth, which has been associated with PPI, there may be an increased risk of bacterial translocation from the gut into the peritoneal cavity, thereby increasing the risk of PD peritonitis secondary to PPI use. 6,7 A relationship between PPI use and PD peritonitis was demonstrated by Maeda et al in a recent study, 16 where 56% of patients in the PPI group developed peritonitis compared with 29% in the non-PPI group (P < 0.001). The proportion of multiple peritonitis episodes in that study was 26% in the PPI group versus 15% in the non-PPI group (P = 0.041), which were trends noted in our own study.…”

“…Kwon et al and Pérez-Fontan et al were not able to identify an elevated risk of PD peritonitis with PPI use, 14,15 while a more recent 2019 study by Maeda et al demonstrated a significantly increased risk of peritonitis with PPI use. 16 Given the low number of studies and conflicting results, our aim was to investigate whether PPI use during PD increased the risk of PD peritonitis in our patient cohort.…”

The concerns of proton pump inhibitors usage in cirrhotic patients with ascites

“…Acid suppression has been shown to cause increased bacterial colonization and risk of infection 1,4 . Similarly, PPI use also increases the risk of peritonitis in peritoneal dialysis patients 14 . Bowel dysmotility is also a risk factor for intestinal bacterial overgrowth.…”