Beyond the Five-Year survival threshold in Peritoneal Dialysis: Public Health insights from the Moroccan experience in a Low- and Middle-Income country context: Five-Year outcomes in Moroccan peritoneal dialysis

Nabil Hmaidouch; Nada El Kadiri; Naima Ouzeddoun; Loubna Benamar

doi:10.56101/rimj.v5i1.185

Authors

Nabil Hmaidouch Ibn Sina University Hospital Center
Nada El Kadiri Ibn Sina University Hospital Center
Naima Ouzeddoun Ibn Sina University Hospital Center
Loubna Benamar Ibn Sina University Hospital Center

DOI:

https://doi.org/10.56101/rimj.v5i1.185

Keywords:

Five years survival, peritonitis, mortality, nutrition

Abstract

Background: Long-term survival on peritoneal dialysis (PD) remains uncommon globally and is even more challenging in low- and middle-income countries (LMICs), where resource constraints and health system factors influence dialysis outcomes. This study compared clinical, biological, and outcome differences between Moroccan patients who achieved ≥5 years of PD survival and those who did not.

Methods: We conducted a retrospective descriptive and analytical study from June 2006 to January 2024 including 175 PD patients. Participants were categorized into long-term survivors (≥5 years, n=61) and non-survivors (<5 years, n=114). Demographic characteristics, comorbidities, laboratory parameters, and technique-related complications were assessed. Survival and mortality determinants were analyzed using linear and logistic regression models.

Results: Female sex was significantly associated with longer PD survival (p=0.019). Non-survivors presented higher baseline urea, creatinine, and vitamin D levels, and lower bicarbonate, albumin, residual kidney function (RKF), and weekly creatinine clearance (WCC). Infectious complications—including peritonitis and catheter infections—were more frequent among non-survivors. Among long-term survivors, RKF, Kt/V, and albumin decreased over time, while hemoglobin and vitamin D improved. Cardiovascular events were the leading cause of death across both groups. Low ultrafiltration, hypoalbuminemia, and recurrent peritonitis were major predictors of mortality.

Conclusion: Although uncommon, long-term PD survival is achievable in Morocco. Better preservation of RKF, higher serum albumin, and fewer infectious complications contribute to prolonged survival. Strengthening early identification and management of these modifiable factors may improve outcomes in PD programs. Enhancing PD management strategies, infection control practices, and nutritional support could significantly reduce mortality and ease the burden on health systems in LMICs where access to renal replacement therapies remains limited.

Author Biographies

Nabil Hmaidouch, Ibn Sina University Hospital Center

Department of Nephrology Dialysis Kidney Transplantation, Ibn Sina University Hospital Center, Rabat, Morocco

Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

Nada El Kadiri, Ibn Sina University Hospital Center

Department of Nephrology Dialysis Kidney Transplantation, Ibn Sina University Hospital Center, Rabat, Morocco

Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

Naima Ouzeddoun, Ibn Sina University Hospital Center

Department of Nephrology Dialysis Kidney Transplantation, Ibn Sina University Hospital Center, Rabat, Morocco

Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

Loubna Benamar, Ibn Sina University Hospital Center

Department of Nephrology Dialysis Kidney Transplantation, Ibn Sina University Hospital Center, Rabat, Morocco

Faculty of Medicine and Pharmacy of Rabat, Mohammed V University of Rabat, Rabat, Morocco

References

Ounissi M, Abdallah TB, Abderrahim E, Hamida FB, Goucha R, Maiz HB, et al. LA DIALYSE PERITONEALE CHEZ LE SUJET AGE. Tunis Med. 2009;87.

Brown EA, Bargman J, van Biesen W, Chang MY, Finkelstein FO, Hurst H, et al. Length of Time on Peritoneal Dialysis and Encapsulating Peritoneal Sclerosis - Position Paper for ISPD: 2017 Update. Perit Dial Int J Int Soc Perit Dial. 2017;37(4):362–74.

Davies SJ, Phillips L, Naish PF, Russell GI. Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc. 2002 Jun;17(6):1085–92.

Churchill DN, Thorpe KE, Nolph KD, Keshaviah PR, Oreopoulos DG, Pagé D. Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol JASN. 1998 Jul;9(7):1285–92.

Flayou K, En Niya F, Dione J, Jmahri H, Snaiki A, Ouzeddoun N, et al. Evolution de la dialyse péritonéale au Maroc : expérience de 7 ans. Néphrologie Thérapeutique. 2014 Sep 1;10(5):301.

Li PKT, Chow KM, Cho Y, Fan S, Figueiredo AE, Harris T, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int J Int Soc Perit Dial. 2022 Mar;42(2):110–53.

Ayed A, Ben Salem M, Haouala F, Letaief A, Jaafar I, Hammouda M, et al. Survie de la technique et du patient : un fardeau en dialyse péritonéale. Néphrologie Thérapeutique. 2019 Sep 1;15(5):324–5.

Kendrick J, Teitelbaum I. Strategies for Improving Long-Term Survival in Peritoneal Dialysis Patients. Clin J Am Soc Nephrol. 2010 Jun;5(6):1123.

Sanchez JE, Ulloa C, Bueno CM, Astudillo E, Rodríguez-Suárez C. Impact of peritoneal dialysis strategy on technique and patient survival. Clin Kidney J. 2023 Dec 1;16(12):2523–9.

TEKKARIŞMAZ N, TORUN D. Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single centre in Turkey. Turk J Med Sci. 2020 Apr 9;50(2):386–97.

Venegas-Ramírez J, Barrios-Mora KE, Ríos-Bracamontes EF, Guzmán-Esquivel J, Cárdenas-Rojas MI, Murillo-Zamora E. Ten-Year Single-Center Study Examining Patient Survival after Commencing Long-Term Peritoneal Dialysis. J Clin Med. 2023 Jan;12(23):7283.

De Sousa-Amorim E, Bajo-Rubio MA, Bajo-Rubio MA, del Peso-Gilsanz G, Castro MJ, Castro MJ, et al. Thirty years in a peritoneal dialysis unit: long-term survival. Nefrol Engl Ed. 2013 Jul 1;33(4):546–51.

Rottembourg J, Rostoker G. La réalité de la dialyse péritonéale en France : 40 ans après. Néphrologie Thérapeutique. 2018 Dec 1;14(7):507–17.

Salem MB, Ayed A, Taieb SK, Handous I, Saleh MB, Hamouda M, et al. Peritoneal dialysis in Tunisia: complications, technique and patient’s survival (twenty-seven years of experience in a single center). Pan Afr Med J. 2021 Jul 7;39:179.

Benbella M, Guennoun A, Belrhiti M, Bouattar T, Bayahia R, Ouzeddoun N, et al. Peritoneal Dialysis at Ibn Sina Hospital in Rabat: 10 years’ experience. Bull Dial À Domic. 2020 Apr 9;3(1):27–35.

Elzorkany KMA. Current state of continuous ambulatory peritoneal dialysis in Egypt. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant Saudi Arab. 2017;28(6):1369–74.

Elhassan EAM, Kaballo B, Fedail H, Abdelraheem MB, Ali T, Medani S, et al. Peritoneal Dialysis in the Sudan. Perit Dial Int. 2007 Sep 1;27(5):503–10.

Karkar A, Wilkie M. Peritoneal dialysis in the modern era. Perit Dial Int. 2023 Jul 1;43(4):301–14.

Choi JY, Jang HM, Park J, Kim YS, Kang SW, Yang CW, et al. Survival Advantage of Peritoneal Dialysis Relative to Hemodialysis in the Early Period of Incident Dialysis Patients: A Nationwide Prospective Propensity-Matched Study in Korea. PLOS ONE. 2013 Dec 30;8(12):e84257.

Mehrotra R, Devuyst O, Davies SJ, Johnson DW. The Current State of Peritoneal Dialysis. J Am Soc Nephrol JASN. 2016 Nov;27(11):3238–52.

Camargo JA, Quiroz G, Méndez P, Castañeda M, Vargas JG, Achiardi RD, et al. Factores de riesgo de mortalidad en pacientes que presentaron peritonitis en diálisis peritoneal crónica en el Hospital Militar Central de Bogotá. Rev Colomb Nefrol. 2014;1(2):92–7.

Cupisti A, D’Alessandro C, Finato V, Del Corso C, Catania B, Caselli GM, et al. Assessment of physical activity, capacity and nutritional status in elderly peritoneal dialysis patients. BMC Nephrol. 2017 May 30;18:180.

Crabtree J, Shrestha B, Chow K, Figueiredo A, Povlsen J, Wilkie M, et al. Creating and Maintaining Optimal Peritoneal Dialysis Access in the Adult Patient: 2019 Update. Perit Dial Int J Int Soc Perit Dial. 2019 Oct 26;39:pdi.2018.00232.

Kim H, An JN, Kim DK, Kim MH, Kim H, Kim YL, et al. Elderly Peritoneal Dialysis Compared with Elderly Hemodialysis Patients and Younger Peritoneal Dialysis Patients: Competing Risk Analysis of a Korean Prospective Cohort Study. PloS One. 2015;10(6):e0131393.

Lam JYW, Wu AKL, Leung WS, Cheung I, Tsang CC, Chen JHK, et al. Gordonia Species as Emerging Causes of Continuous-Ambulatory-Peritoneal-Dialysis-Related Peritonitis Identified by 16S rRNA and secA1 Gene Sequencing and Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS). J Clin Microbiol. 2015 Feb;53(2):671–6.

Ali I, Haddad D, Soliman MA, Al-Sabi A, Jebreen K, Abuzahra D, et al. Quality of life and nutritional status in peritoneal dialysis patients: a cross-sectional study from Palestine. BMC Nephrol. 2024 Jan 12;25(1):20.

Li PKT, Ng JKC, Mcintyre CW. Inflammation and Peritoneal Dialysis. Semin Nephrol. 2017 Jan 1;37(1):54–65.

Fried LF, Bernardini J. Peritonitis influences mortality in peritoneal dialysis patients. J Am Soc Nephrol JASN. 1996 Oct;7(10):2176–82.

Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, et al. Seven-year follow-up of peritoneal dialysis patients in Taiwan. Perit Dial Int. 2009;29(4):450–7.

Tam P. Peritoneal dialysis and preservation of residual renal function. Perit Dial Int J Int Soc Perit Dial. 2009 Feb;29 Suppl 2:S108-110.

Horinek A, Misra M. Does residual renal function decline more rapidly in hemodialysis than in peritoneal dialysis? How good is the evidence? Adv Perit Dial Conf Perit Dial. 2004;20:137–40.

Unsal A, Basturk T, Koc Y, Sinangil A, Ahbap E, Sakaci T, et al. Factors Associated with Above and Under 5-Year Survival in Peritoneal Dialysis Patients. Ren Fail. 2012 Oct;34(9):1129–34.

Fontán MP, Rodríguez-Carmona A, García-Naveiro R, Rosales M, Villaverde P, Valdés F. Peritonitis-Related Mortality in Patients Undergoing Chronic Peritoneal Dialysis. Perit Dial Int. 2005 May 1;25(3):274–84.

Kim DK, Yoo TH, Ryu DR, Xu ZG, Kim HJ, Choi KH, et al. Changes in causative organisms and their antimicrobial susceptibilities in CAPD peritonitis: a single center’s experience over one decade. Perit Dial Int J Int Soc Perit Dial. 2004;24(5):424–32.

Sipahioglu MH, Aybal A, Unal A, Tokgoz B, Oymak O, Utas C. Patient and technique survival and factors affecting mortality on peritoneal dialysis in Turkey: 12 years’ experience in a single center. Perit Dial Int J Int Soc Perit Dial. 2008;28(3):238–45.

Ku E, Mitsnefes MM. Cardiovascular disease in young adults with incident ESRD. Nat Rev Nephrol. 2019 Jul;15(7):390–1.

Lee YC, Lin CW, Ho LC, Hung SY, Wang HK, Chang MY, et al. All-Cause Standardized Mortality Ratio in Hemodialysis and Peritoneal Dialysis Patients: A Nationwide Population-Based Cohort Study. Int J Environ Res Public Health. 2023 Jan 28;20(3):2347.

Bekhechi W, Benmansour M. Peritoneal Dialysis Following the Loss of Vascular Access: only Therapeutic Option, how to Improve the Results! 3(1).

Bello AK, Okpechi IG, Osman MA, Cho Y, Cullis B, Htay H, et al. Epidemiology of peritoneal dialysis outcomes. Nat Rev Nephrol. 2022 Dec;18(12):779–93.