Myth 4: Peritoneal Dialysis Increases the Risk of Mediastinitis After Coronary Artery Bypass Surgery
There is a concern amongst some cardiothoracic surgeons that peri- and postoperative peritoneal dialysis may increase the risk of mediastinitis after coronary artery bypass grafting (CABG) as a result of translocation of bacteria from the dialysate into the mediastinum. This could occur through native transdiaphragmatic channels or a breach of the peritoneum during surgery. However, there are no reports of mediastinitis after CABG in peritoneal dialysis patients. A PubMed search using the terms 'mediastinitis' AND ['bypass' or 'CABG'] AND ['peritoneal dialysis' OR 'peritoneal'] yielded no hits. An analysis of mediastinitis episodes after CABG revealed diabetes mellitus to be a risk factor. Extrapolating from this observation, we postulate that in any future studies that try to ascertain the incidence of mediastinitis in peritoneal dialysis patients, the high incidence of coronary artery disease in diabetic end-stage renal disease (ESRD) and attendant CABG may give rise to a covariate association of post-CABG mediastinitis with peritoneal dialysis that may spuriously implicate peritoneal dialysis as a cause of mediastinitis.
In contrast, mediastinitis has been reported in haemodialysis patients post-CABG,[16,17] although it is not known if bacteraemia from repeated haemodialysis vascular access was responsible. There is no evidence at this time that peritoneal dialysis is a greater risk factor for mediastinitis than haemodialysis via a tunnelled catheter, or that converting peritoneal dialysis patients to haemodialysis reduces the risk. Given the high morbidity and mortality of mediastinitis, if peritoneal dialysis is performed in the perioperative or early postoperative period, we suggest that scrupulous peritoneal dialysis technique, infection control measures and heightened vigilance for and early aggressive treatment of peritonitis would be prudent. The benefit or risk of prophylactic intraperitoneal antibiotics in preventing mediastinitis is unknown.
Curr Opin Nephrol Hypertens. 2016;25(6):602-608. © 2016 Lippincott Williams & Wilkins