Peritoneal dialysis in patients with failed kidney transplant: Single centre experience

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The uptake of peritoneal dialysis (PD) as a proportion to haemodialysis (HD) for patients starting dialysis is falling world‐wide. This is particularly true for patients with failing kidney transplants who need to restart dialysis.1 There may be many medical reasons why PD may not be suitable for this particular group of patients (e.g. prior use of PD and prior abdominal surgery), but there is a general perception that this group of patients have poor short‐term technique survival. This negative bias was reinforced by case reports of PD patients developing ‘unusual’ infections when concomitantly treated with immunosuppressive drugs.2 Moreover, the studies by Andrews et al.3 and Sasal4 both suggested a trend towards higher peritonitis rates in the PD patients receiving immunosuppression. However, these studies were in an era when Y‐disconnect PD systems were being introduced (between 1989 and 1996) and peritonitis rates were considerably higher (up to 1 in 9.7 patients months) than current infection rates.
A recent registry study from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) that extended to 2004 suggests that with current connectology and management, the infection risk of patients starting on PD after a failed transplant is not higher than transplant naïve patients.5 However, this was somewhat contradicted by the North American Pediatric Renal Trials and Collaborative Studies registry showing that prior transplantation was a predictor of infections albeit this was a study of children.6
Issues other than infection may also be relevant for the transplant patients starting PD. There are theoretical reasons to believe that immunosuppression and ESRF vintage have an adverse effect on the peritoneal membrane. Peritoneal thickness was greater in uraemic (pre‐PD) patients compared to control.7 Patients with failing transplants by definition have at least two periods of failing kidney function and often an additional period of ESRF prior to transplantation. Thus, this group of patients may have significantly compromised peritoneal membranes that make them unsuitable for PD. Calciuneurin inhibitors are now the mainstay of immunosuppression, but they have a pro‐fibrotic effect most notably on the kidney.8 They are now recognised to also have an effect on the peritoneal membrane9 and may be another reason why starting PD after a failed transplant is relatively contra‐indicated. Peritoneal membrane transporter status is routinely monitored in patients, often by the Peritoneal Equilibration Test (PET) that determines the Dialysate/Plasma ratio of creatinine (D/Pcr) concentrations after a 4 h dwell utilising a 2.27% glucose PD bag. The ultrafiltration (UF) during this dwell also provides an indication about the osmotic conductance of the membrane. However, we are not aware of studies that have compared the results of PET of post‐transplant versus transplant naïve patients.
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