Association between reduced left ventricular ejection fraction and peritoneal dialysis related peritonitis: A single center retrospective cohort study in Japan

Q: What is the association between reduced left ventricular ejection fraction (LVEF) and the development of peritonitis in patients undergoing peritoneal dialysis (PD)?

This study showed that reduced LVEF was significantly associated with the development of peritonitis, particularly enteric peritonitis. Patients with reduced LVEF may be at risk of developing enteric peritonitis caused by intestinal conditions triggered by cardiac dysfunction. This suggests that physicians should monitor peritonitis caused by enteric microorganisms in patients with cardiac dysfunction. Previous studies have reported gastrointestinal conditions, such as constipation and hypokalemia, as risk factors for peritonitis. The pathogenesis of peritonitis in PD patients may involve gastrointestinal dysmotility and intestinal bacterial overgrowth, leading to bacterial translocation from the intestine to the peritoneal cavity. Cardiac dysfunction may increase vulnerability to peritonitis due to alterations in the morphology, function, and bacterial flora of the intestine. Physicians should consider the development of peritonitis from bowel sources in patients with cardiac dysfunction undergoing PD. However, the study had limitations, including its retrospective nature, small cohort size, and lack of assessment of volume status and urine volume. Further studies are required to validate these findings and understand the pathomechanism of peritonitis development in patients with reduced LVEF.

Question

1. How does left ventricular dysfunction affect peritonitis risk in PD patients?

2. What factors were considered in the present study's design?

3. What method is used to measure LVEF in echocardiography?

4. What are the primary and secondary outcomes of interest in the Exposure and outcomes section?

Accepted Answer

Left ventricular (LV) dysfunction can directly lead to cardiac failure and is strongly associated with poor survival in patients undergoing dialysis with constant hypervolemia. However, no previous studies have assessed the relationship between heart failure and peritoneal dialysis (PD)-related peritonitis. The present study aims to assess whether patients with PD and reduced left ventricular ejection fraction (LVEF) are vulnerable to developing PD-related peritonitis. The results of the study may provide useful clinical information for identifying patients with PD who are at high risk of developing peritonitis by examining their LV function. This research can help in developing strategies to reduce the risk of peritonitis in PD patients with LV dysfunction.

Accepted Answer

The present study's design considered various factors such as urine volume, peritoneal transport characteristics, daily peritoneal ultra ltration rate, domestic pets, smoking, constipation, usage of PPI or H2RA, cardiothoracic ratio on chest X-ray, and ultrasonic echocardiography findings. Additionally, follow-up data on BMI and urine volume were collected every 12 months. PD-related peritonitis was diagnosed based on specific clinical and laboratory criteria. The anonymized data set is available in Table S1.

Accepted Answer

LVEF is measured using the modified Simpson method, as recommended by the American Society of Echocardiography. This method involves dividing patients into two groups based on their LVEF values, with one group having an LVEF of less than 50% and the other group having an LVEF of 50% or higher. The LV mass is then calculated using a formula recommended by the American Society of Echocardiography and indexed based on body surface area. Additionally, the diameters of the inferior vena cava (IVC) are measured at end expiration and inspiration, and the collapsibility of the IVC (IVCC) is calculated by subtracting the IVC min from the IVC max and dividing the result by the IVC max. These measurements and calculations provide valuable information about the heart's function and structure, aiding in the diagnosis and treatment of various cardiac conditions.

Accepted Answer

The primary exposure of interest in the Exposure and outcomes section is left ventricular ejection fraction (LVEF) at baseline and the first episode of peritonitis from any cause. The primary outcome of interest is the first episode of peritonitis. Secondary outcomes include incident enteric and non-enteric peritonitis. Additionally, outcomes such as PD withdrawal and its causes (PD-related peritonitis, inadequate solute clearance, impairment of activities of daily living, fluid overload, and kidney transplantation) were obtained.

Accepted Answer

The Wilcoxon rank-sum test and Fisher's exact test were used to compare differences in clinical characteristics and outcomes according to the LVEF groups (reduced LVEF and preserved LVEF).

Accepted Answer

The study included 228 PD patients, with 30 in the reduced LVEF group (LVEF < 50%) and 198 in the preserved LVEF group (LVEF >= 50%). The reduced LVEF group had a higher proportion of patients with a previous history of coronary heart disease and heart failure, higher BNP, cardiothoracic ratio on chest X-ray, LV mass index, LV end-diastolic dimension, LV end-systolic dimension, and IVC (max and min) on echocardiography. Conversely, the IVCC in patients with reduced LVEF was lower than that in patients with preserved LVEF. Other baseline factors did not differ significantly between the two groups.

Accepted Answer

The reduced LVEF group had a higher risk of developing peritonitis than the preserved LVEF group. In the unadjusted models, diabetes mellitus, lower serum albumin levels, PPI use, and reduced LVEF (LVEF < 50%) were significantly associated with the first episode of peritonitis. Time-dependent multivariable-adjusted CPH models showed that PPI use and reduced LVEF were associated with peritonitis. A multivariable-adjusted restricted cubic spline model confirmed the nonlinear association between LVEF and incidence of peritonitis, suggesting that reduced LVEF was associated with a higher risk of peritonitis. The pattern of association between LVEF groups and the incidence of enteric peritonitis was similar to that with peritonitis from any cause, with the reduced LVEF group having a higher cumulative probability of developing enteric peritonitis. However, no significant association was observed between LVEF and non-enteric peritonitis.

Accepted Answer

This study showed that reduced LVEF was significantly associated with the development of peritonitis, particularly enteric peritonitis. Patients with reduced LVEF may be at risk of developing enteric peritonitis caused by intestinal conditions triggered by cardiac dysfunction. This suggests that physicians should monitor peritonitis caused by enteric microorganisms in patients with cardiac dysfunction. Previous studies have reported gastrointestinal conditions, such as constipation and hypokalemia, as risk factors for peritonitis. The pathogenesis of peritonitis in PD patients may involve gastrointestinal dysmotility and intestinal bacterial overgrowth, leading to bacterial translocation from the intestine to the peritoneal cavity. Cardiac dysfunction may increase vulnerability to peritonitis due to alterations in the morphology, function, and bacterial flora of the intestine. Physicians should consider the development of peritonitis from bowel sources in patients with cardiac dysfunction undergoing PD. However, the study had limitations, including its retrospective nature, small cohort size, and lack of assessment of volume status and urine volume. Further studies are required to validate these findings and understand the pathomechanism of peritonitis development in patients with reduced LVEF.

Association between reduced left ventricular ejection fraction and peritoneal dialysis related peritonitis: A single center retrospective cohort study in Japan

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Most frequently asked questions

1. How does left ventricular dysfunction affect peritonitis risk in PD patients?

2. What factors were considered in the present study's design?

3. What method is used to measure LVEF in echocardiography?

4. What are the primary and secondary outcomes of interest in the Exposure and outcomes section?

5. What statistical tests were used to compare LVEF groups?

6. What are the baseline characteristics of reduced LVEF and preserved LVEF groups?

7. What is the association between reduced LVEF and the risk of peritonitis?

8. What is the association between reduced left ventricular ejection fraction (LVEF) and the development of peritonitis in patients undergoing peritoneal dialysis (PD)?

References

Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

Revised equations for estimated GFR from serum creatinine in Japan.

Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

Heart Failure with Preserved and Reduced Ejection Fraction in Hemodialysis Patients: Prevalence, Disease Prediction and Prognosis

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