Incidence of peritonitis in chronic peritoneal dialysis patients infused with intravenous iron dextran

Background: The Dialysis Outcomes Quality Initiative (DOQI) guidelines, pub lished in 1997, emphasize the need for careful monitoring of iron stores an d for provision of adequate iron replacement therapy to achieve target goal s of hemoglobin concentration in end-stage renal disease (ESRD) patients, e specially those treated with recombinant erythropoietin (rHuEPO). Intraveno us iron dextran (IVID) therapy, which has long been used in hemodialysis pa tients, is increasingly being used in chronic peritoneal dialysis (CPD) pat ients. In 1997, we began using this form of iron therapy for our CPD patien ts. However, because considerable data exists to show a relationship betwee n iron metabolism and acute infections, we questioned whether IVID infusion placed our patients at greater risk for peritonitis, the leading cause of death and patient dropout from CPD therapy. Objective: To evaluate the relationship between iron and infection, we stud ied episodes of peritonitis in CPD patients who were infused with IVID. Design: In a retrospective study of adult CPD patients who received IVID du ring 1998, we investigated the occurrence of peritonitis episodes and the s pectrum of causative organisms. Patients with a hemoglobin level of < 12.5 g/dL who also had a ferritin level < 100 ng/mL or a transferrin saturation level < 20% (or both) and who did not respond to oral iron therapy, were ad ministered between 0.5 g and 1.0 g of IVID in an outpatient hospital settin g. We calculated the expected and observed number of peritonitis episodes i n these patients within 30, 60, and 90 days after infusion of IVID. Results: During the study period, 56 patients received 77 doses of IVID, wi th 14 patients requiring 2 or more infusions. Of the 77 doses, 71 were give n as a 1-g bolus. The IVID was well tolerated by all patients. Within 90 da ys of IVID administration, 14 patients developed peritonitis: 6 episodes oc curred within 30 days, 7 episodes occurred between 31 and 60 days, and 1 ep isode occurred between 61 and 90 days after the IVID dosing. The peritoniti s rate for patients not receiving IVID was 1 episode per 13.7 patient-month s. Taking this rate as the "expected" rate, the expected number of episodes of peritonitis for the study population was 5.6 episodes within 30 days, 1 1.2 episodes within 60 days, and 16.8 episodes within 90 days following IVI D administration. The difference between the expected and observed rates of peritonitis in patients who were dosed with IVID was not statistically dif ferent. The spectrum of organisms seen in the peritonitis episodes in the s tudy population was not significantly different from that seen in the perit onitis episodes in our CPD unit population. Conclusions: There is evidence that IVID infusion therapy can improve anemi a and reduce rHuEPO requirements in CPD patients, usually without adverse r eaction and without exposing patients to an increased risk of peritonitis. More research is needed in the area of potential increased risk of infectio n in ESRD patients who are (1) infused with large doses of IVID, and (2) ir on-overloaded.