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

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

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

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

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

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

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

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

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

infections in transplanted patients should be treated using the ISPD guidelines 6.

transplantation, and the graft from an older donor [28].

thrombosis and a matched control group of 88 patients [29].

length of hospital stay did not differ between the two groups[25].

non-function, and urinary leakage [26].

196 Current Issues and Future Direction in Kidney Transplantation

peritonitis rate was 7% [27].

peritonitis [24].

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 transplantation.

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

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

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 found [33].

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 transplantation [35].

A recent retrospective single center analysis in 38 PD and 268 HD patients describes a higher incidence of DGF and primary allograft failure for HD patients, but was no difference in acute rejection episodes, long-term survivals, or renal function [36].

The PD-group consisted out of 28 male and 22 female patients with a mean age of 48.7 +/- 11.5 years (HD: 31 m, 19 w, 49,8 +/-13, p=n.s.) quite reflecting the German dialysis population. With respect to time on renal replacement therapy, cytomegalo-virus-status, HLA-mismatch, proportion of living donors, age, sex and initial immunosuppression there were no differences

Comparison of Renal Transplantation Outcomes in Patients After Peritoneal Dialysis and Hemodialysis…

http://dx.doi.org/10.5772/55711

199

Although, during follow up more less PD-patients (n=3) than HD-patients (n=8) died, this difference did not reach statistical significance. With respect to graft failure, transplant loss (n=18) occurred significantly more in HD patients (n=13) than in PD patients (n=5). Neverthe‐ less, mean serum-creatinine after 1, 2 and 5 years was not significant different between the groups. Also, delayed graft function was reported in only 4 PD patients compared to 10 HD

To summarize, in our retrospective match-pair analysis patients on PD before renal trans‐ plantation developed less delayed graft function and had less graft loss during follow-up than

Peritoneal dialysis (PD) is an established method of renal replacement therapy. PD and hemodialysis (HD) seem to be equivalent for long-term survival of the patients. Nevertheless, there is a beneficial effect of PD on patient survival after initiation of dialysis therapy. Probably, better preservation of residual renal function in PD patients compared to HD patients may be

Renal transplantation is the best treatment option for patients with endstage renal disease. The potential risk of infectious complications in PD patients after renal transplantation is attributed to the remaining PD catheter. However, this risk seems to be low and without effect on graft survival. For patients on HD a higher percentage of delayed graft function after renal trans‐ plantation is constantly reported in the literature. Nevertheless, long time patient and graft

Our own long-time clinical experience is congruent with the published literature and proves that peritoneal dialysis is a valuable treatment option for patients with end stage renal disease

Department of Nephrology and Transplantation Medicine, Westpfalz-Klinikum GmbH, Kai‐

survival are not different between both treatment modalities.

\*Address all correspondence to: trath@westpfalz-klinikum.de

between the groups.

patients (p<0.05).

**8. Conclusion**

responsible for this effect.

waiting for renal transplantation.

and Stephan Ziefle

**Author details**

serslautern, Germany

Thomas Rath\*

patients on HD before transplantation.

A case control study the incidence of DGF, defined as necessity to perform dialysis after transplantation, was analyzed in 117 PD and HD patients with a follow-up of 6 months. When matching the patients for age, sex, HLA compatibility PD-patients developed less DGF (23.1%) than HD patients (50.4%). In addition the decline of creatinine levels after transplantation was faster in PD patients. However, PD patients developed more acute rejection episodes, than HD patients, but creatinine levels after 6 weeks and 6 months were not different between the groups [37].

Besides a bundle of published single center experiences with renal transplantation in PD patients we do have at least two registry studies reporting on the effect of pre-transplant dialysis modality on renal transplant results.

Data from the United Network of Organ Sharing on all cadaveric graft recipients who were dialysis-dependent at the time of transplantation were analyzed with respect to different outcomes in the immediate post-transplant period for HD or PD patients. In total more than 9000 patients were evaluated, showing that PD patients were on dialysis for a shorter period of time, were more likely to be white, had a better HLA match, and had a lower PRA. After adjusting for comorbidities, the odds of oliguria were 1.60 times higher in black HD patients compared with PD patients and 1.29 times higher in white HD patients. Also, the odds of requiring dialysis in the first week were 1.56 times higher in black HD patients versus PD patients and 1.40 times higher in white HD patients. The rate of acute rejection was similar during the first hospitalization. Therefore, the authors suggest that there may be an association between hemodialysis and delayed graft function assuming that differences in biocompati‐ bility between the two modalities could potentially be responsible [38].

A large retrospective analysis compared transplantation rates in PD and HD and outcomes after transplantation in more than 22000 patients from the years 1995 to 1998 in a US cohort. PD patients were more likely to be transplanted and their death censored graft failure was higher. However, mortality and overall graft failure were not different. Interestingly, the risk for early graft failure was higher for PD patients despite DGF was less common [39].
