**5. PD and complications after renal transplantation**

There is some concern with respect for the risk of infections, especially peritonitis caused by the peritoneal catheter in PD patients. In a retrospective single center analysis the experience with 18 renal transplantations in 16 PD patients was reported. In two cases cultures of the peritoneal catheter removed a few days after successful transplantation were positive. Nevertheless, with adequate antibiotic treatment none of the patients ever developed clinical peritonitis [24].

peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis

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For patients returning to PD after graft failure, there may be a survival advantage in main‐ taining them on long-term immunosuppressive therapy. At least, a decision analytic model comparing the use of immunosuppression after transplant failure and return to peritoneal dialysis with immunosuppressive withdrawal, lead the authors to conclude, that there may be a survival advantage in maintaining patients on long-term immunosuppression [31].

It is well known, that delayed graft function (DGF) and acute renal failure (ARF) after renal transplantation negatively influence short- and long-term graft outcome, therefore it is of interest to know if peritoneal dialysis affects occurrence or severity of DGF after renal

A study in 250 patients (70 PD, 180 HD) evaluated the influence of dialysis modality on transplant outcomes. Among HD patients, 16% displayed DGF, versus 12% of PD patients. Multivariate analysis showed that factors affecting DGF were mode of dialysis, serum concentrations of parathyroid hormone and C-Reactive-Protein, and hemoglobin levels. Also after 3 and 5 years follow-up, PD patients showed fewer graft failures than HD patients (14%

In an analysis of 92 PD patients and 587 HD patients there was higher immediate graft function, less delayed graft function and less patients with never functioning grafts in the PD group. The groups were comparable except for a higher prevalence of diabetes (p < 0.05) and a shorter

A retrospective study in 40 PD and 79 HD patients receiving their first renal transplant analyzed the occurrence and frequency of DGF and acute renal failure. Both, DGF and ARF were observed less in the PD group than in the HD group. In a multivariate model, the authors could show that PD as pre-transplantation modality favorably modified the relative risk of developing DGF and ARF after renal transplantation[34]. A single center analysis in more than 650 patients (92 PD, 587 HD) reports a higher rate of DGF in HD patients (39.5% vs. 22.5%) and a higher rate of never functioning grafts in HD patients compared to PD patients (14% vs. 9%). When potential risk factors for DGF were compared, no relevant differences could be

Also for PD patients on automated peritoneal dialysis (APD), a retrospective matched-pairs study with 67 APD-patients showed favorable effects for PD on initial graft function (patients with a creatinine clearance below 10 ml/min 6 days after surgery) after post-mortem renal

occurred at a much faster rate in patients with a failed transplant [30].

**6. PD and the occurrence of delayed graft function after renal**

**transplantation**

transplantation.

found [33].

transplantation [35].

vs. 20%; and 17% vs. 28%[32].

time on dialysis (p < 0.01) in PD patients [33].

A cohort analysis of 500 first renal transplant recipients (241 on CAPD, 259 on HD) showed identical graft and patient survival after five years. However, 10 PD patients developed peritonitis [21]. Also, in a series of 100 patients undergoing simultaneous pancreas-kidney (SPK) transplantation (25 PD patients, 75 HD patients) frequency of abdominal infections, one year pancreas-graft survival rates, acute rejection episodes, kidney graft survival rates, or length of hospital stay did not differ between the two groups[25].

The question of peritonitis in peritoneal dialysis patients after renal transplantation was also addressed by a retrospective, single center study of 232 PD patients. In total, 30 peritonitis episodes with predominantly Staphylococcus aureus (10/30) or gram-negative bacteria (12/30) were observed. Risk factors associated with post-transplant peritonitis were the total number of peritonitis episodes, previous peritonitis with S. aureus bacteria, male sex, technical surgical problems at the time of transplantation, more than two rejection episodes, permanent graft non-function, and urinary leakage [26].

Comparable results are reported in a two-center study on post-transplant PD-related complications in 137 PD patients. There, only in a minority of the patients (n=19) PDcatheters were removed on the time of transplantation. In the remaining 118 patients the peritonitis rate was 7% [27].

In the European Best Practice Guidelines for Peritoneal Dialysis it is recommended to remove the catheter early after transplantation, nevertheless the catheter could be left in situ for 3–4 months despite a functioning graft. The guidelines also state, that peritonitis and exit site infections in transplanted patients should be treated using the ISPD guidelines 6.

In the last years the problem of post-transplant diabetes mellitus (PTDM) has gained more attention. A single center study reports on the occurrence of PTDM in 72 renal transplant recipients. In univariate analysis, the factors associated with the elevated risk of PTDM appearance were treatment by PD, older recipient age, positive family history of diabetes, hypertensive nephropathy as end-stage renal disease cause, higher body mass index at transplantation, and the graft from an older donor [28].

PD may be associated with an increased risk for graft thrombosis. At least, a single center experience revealed that in 915 consecutive renal transplantations CAPD was associated with a growing frequency of renal allograft thrombosis (7.3% vs. 3.6 %, p<0.02). No differences in transplant characteristics, including hemodynamics, hematological parameters, immunosup‐ pressive therapy, graft anatomy and preservation, were observed between the cases with graft thrombosis and a matched control group of 88 patients [29].

After renal allograft failure, patients may chose PD as their primary treatment option again. For this situation, it was shown, that after a failed renal transplantation PD-patients are prone to greater risk of death compared to PD-patients never transplanted. In addition, time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in patients with a failed transplant [30].

For patients returning to PD after graft failure, there may be a survival advantage in main‐ taining them on long-term immunosuppressive therapy. At least, a decision analytic model comparing the use of immunosuppression after transplant failure and return to peritoneal dialysis with immunosuppressive withdrawal, lead the authors to conclude, that there may be a survival advantage in maintaining patients on long-term immunosuppression [31].
