Treatment and outcomes of peritonitis in peritoneal dialysis caused by mycobacterium tuberculosis: a systematic literature review

Abstract

INTRODUCTION: Peritoneal dialysis (PD)-associated peritonitis remains a severe complication of PD. Although the incidence of tuberculous peritonitis has progressively declined in the developed world, the optimal treatment of tuberculous peritonitis in patients on PD remains unclear. Our study aims to review the literature on peritonitis caused by Mycobacterium tuberculosis (M. tuberculosis) spp. METHODS: A literature search of Medline, Scopus, Embase, ClinicalTrials.gov, Cochrane CENTRAL Register of Controlled Trials and Google Scholar for articles published between 1948 and 2022 was conducted using the search terms "Mycobacterium tubercul* OR tubercul* OR tuberculous, "peritonitis", and "peritoneal dialysis". To be eligible, articles had to describe patient characteristics, initial antitubercular therapy and treatment outcomes in all PD patients with peritonitis caused by M. tuberculosis. Articles describing M. tuberculosis not causing PD-associated peritonitis, tuberculous peritonitis in patients not on PD and articles that only described adverse effects from antitubercular therapy were excluded. This protocol was registered in PROSPERO (registration number CRD42022348318). RESULTS: From the 67 articles identified from the literature search, 90 patients on PD with peritonitis caused by M. tuberculosis were included. The countries reporting the commonest cases of tuberculous peritonitis in PD patients originated from Turkey (17.8%), followed by the USA (14.4%) and Taiwan (11.1%). Of these, 48 (55.2%) were males; and 77 (91.7%) were on continuous ambulatory peritoneal dialysis (CAPD) at the time of infection. The mean (+/- SD) age of the patients was 50 (+/- 15.62 ) years; the median (IQR) time from the PD commencement date to peritonitis caused by M. tuberculosis was 12 (5-24) months. Eighty-six episodes (95.5%) were treated with a combination antitubercular regimen. Of these, the two commonest antitubercular regimens used were isoniazid + rifampicin + ethambutol + pyrazinamide (26.7%) and isoniazid + rifampicin + ethambutol (21.1%). The median (IQR) duration of antitubercular therapy was 12 (6.75-12) months. Overall, 35 (38.9%) were alive but had PD-catheter removal. Of these, 21 (23.3%) permanently transferred to haemodialysis (HD), 5 (5.6%) were switched to interim HD, 3 (3.3%) had PD-catheter removal and reinsertion concurrently. In 6 (6.7%) patients, the types of dialysis were not specified. Twenty-nine (32.2 %) died while receiving antitubercular treatment or PD fluid culture for M. tuberculosis returned positive after they died, 24 (26.7%) were alive and had cure/clinical improvement without PD-catheter removal, 1 (1.1%) had recurrence of peritonitis, 1 (1.1%) patient was alive, but the status of the PD catheter was unknown. CONCLUSIONS: PD-associated peritonitis due to M. tuberculosis is associated with high rates of PD-catheter removal. Conflict of interest Potential conflict of interest: Kamal Sud has received speaker's honoraria from Baxter Healthcare and is on the medical advisory board of Fresenius Medical Care for Australia and New Zealand. Other authors declared no conflict of interest regarding the research, authorship, and publication of this article.