Myths in Peritoneal Dialysis

Martin B. Lee; Joanne M. Bargman

Curr Opin Nephrol Hypertens. 2016;25(6):602-608.

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.^[15] 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.

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Table 1. Published reports of hernia repair in peritoneal dialysis patients
Reference and publication year	Number of hernioplasties (h), mesh repairs (m) and patients (p)	Type of hernia. Umbilical (U), inguinal (I), femoral (F), epigastric (E), ventral (V), incisional (Inc), others (Ot)	Surgical method. Preperitoneal mesh (PP) or Intraperitoneal mesh (IP) placement	Peritoneal dialysis converted to haemodialysis. Temporary (T), Permanent (P)	Duration of peritoneal dialysis suspension, in days (d), weeks (wks) or months (mth)	Mesh infection	Follow-up duration, days or months (mth)	Nonmesh infection. Peritonitis (perit), tunnel tract, exit site (es), surgical wound infection (wi) or other	Leak (L) or hernia recurrence (R)
Haggerty and Jorge (2013) [22]	3h, 3m, 3p	I	EP	3T	2–4 weeks	NR	NR	None	None
Peppelenbosch et al. (2015) [23]	9h, 9m, 9p	NS	NR			NR		NR	NR
Schoenmaeckers et al. (2011) [24]	1h, 1m, 1p	Inc	IP	T	6 mth	None	>13 mth	2 perit	No
Martinez-Mier et al. (2008) [25]	58h, 29m, 50p	I and NS	PP	Some T	0–3d Preop peritoneal dialysis regimen reinstated by 14^th postop day except for 1 patient	None	2–45 mth	4 wi 2 perit	No
Imvrios et al. (1994) [26]	46h, 5m, 35p	E, I, Inc, Ot	NS	1T	0–1d	None	12–21 mth	2es	1L
Wakasugi et al. (2011) [27]	11h, 11m, 9p	I	PP	6T pre-2007. None since 2007	2.3–7.6d Since 2007, all patients resumed peritoneal dialysis within 3 post op days	None	Mean 56.2 mth (10–134 mth)	None	No
Garcia-Urena et al. (2006) [28]	26h, 26m, 21p	U, I, F, E, V	PP	19T	0–10d	None	6–39 mth	NR	No
Shah et al. (2006) [29]	50h, 20m, 50p	U, I, Inc, Epig	NR	None	2d then low volume IPD for 4 weeks	NR	Mean 33.4 mths	NR	No leaks 13R
Sodo et al. (2015) [30]	26h, 26m, 21p	I, U, Inc	PP	All incident ESRD initiating RRT with peritoneal dialysis	Peritoneal dialysis initiated 3 wks postop	None	342–1274 days	NR	No

ESRD, end-stage renal disease; h, Hernioplasties; IPD, intermittent peritoneal dialysis; NA, not assessed; NR, not reported; NS, not specified; RRT, renal replacement therapy.