Abstract
Background
Delays in seeking medical attention cause delays in the initiation of antibiotic therapy, prolonging the duration of illness in patients with peritoneal dialysis-associated peritonitis (PDAP). However, there is limited information on the factors that cause delays in seeking initial medical attention after the onset of symptoms. This study aims to investigate the situation and factors influencing delayed consultation in PDAP patients.
Methods
Retrospective review of clinical and epidemiological data of all adult patients with peritoneal dialysis-associated peritonitis in three hospitals in Xiamen, China, who developed peritonitis between January 2022 and November 2024. Data were analysed with descriptive and inferential statistics (i.e. correlation and multiple logistic regression) using the Statistical Package for the Social Sciences version 27.
Results
A total of 134 patients were included in the current study, of whom 77 (57.5%) had symptom-to-contact time (SC time) ≦ 24 h. Cloudy effluent was the most common presenting symptom (73.9%), while 67.9% had abdominal pain and 53% had both. Univariate analysis showed that there was a statistically significant difference between groups in residence (χ2 = 10.059, P = 0.002), PD modality (χ2 = 7.151, P = 0.007), fever (χ2 = 10.631, P = 0.001), abdominal pain (χ2 = 13.206, P < 0.001), cloudy effluent (χ2 = 8.002, P = 0.005), and diarrhea (χ2 = 4.953, P = 0.026). Univariate logistic regression analysis demonstrated that Residence(OR = 2.54, 95% CI:1.09–5.94, p = 0.032)、PD modality(OR = 0.06, 95% CI:0.01–0.87, p = 0.039)、Abdominal pain(OR = 4.60, 95% CI:1.87–11.32, p = 0.001)、Fever(OR = 4.34, 95% CI:1.24–15.17, p = 0.022)、Diarrhea(OR = 0.26, 95% CI:0.07–0.94, p = 0.040)are factors affecting the SC time in patients with peritoneal dialysis-associated peritonitis.
Conclusion
A substantial proportion of PDAP patients experienced delayed consultation. Specifically, residence, PD modality, abdominal pain, fever, and diarrhea were the influencing factors for delayed consultation in PDAP patients. Targeted interventions in managing PDAP patients are therefore important to promote timely consultations, particularly in rural areas, by improving patient awareness and education. They should also enhance the accessibility of healthcare services and provide clear guidance on when to seek medical attention.
Trial registration
Not applicable.
Keywords: Influencing factors, Peritoneal dialysis-associated peritonitis, Symptom-to-contact time
Introduction
Peritoneal dialysis (PD) is one of the most effective renal replacement therapies for patients with end-stage kidney disease (ESKD) [1]. It is widely used worldwide, especially in developing countries, because of its simplicity, safety, effectiveness, and suitability for home treatment [2]. Peritoneal dialysis-associated peritonitis (PDAP) is the most common and serious complication in ESKD patients [3], increasing treatment costs, hospitalization rates, and mortality risk [4]. The study showed that PDAP accounted for 17.6% [5] of all causes of PD cessation, and the mortality rate attributable to PDAP in PD patients exceeded 15.0% [6]. According to the International Society for Peritoneal Dialysis (ISPD), if a patient develops PDAP, antibiotic therapy should begin immediately after a microbiological specimen has been properly obtained [7]. Preventing the occurrence of PDAP is crucial for patients’ continued PD treatment and survival.
Despite defined strategies to reduce the risk of PDAP [8], treatment of PDAP depends on the patient recognising symptoms and presenting to a health facility for antibiotics [9]. The three-step process of recognising symptoms, contacting a health facility, and receiving antibiotics presents several potential barriers to timely treatment [9]. Delays in seeking medical care refer to the behaviour and phenomenon of individuals who, for various reasons, do not seek medical care promptly after experiencing unusual symptoms or complaints. Studies show that delay in seeking medical attention leads to delay in initiating antibiotic therapy, which prolongs illness duration in PDAP patients and is an independent risk factor for catheter removal or death in PDAP patients [10]. Another Japanese study showed that differences in the Symptom to Contact (SC) time after the onset of PDAP affect the prognosis of patients and recommended strategies to encourage timely consultation at peritonitis onset to improve prognosis [11]. At present, most studies have examined the entire process of peritonitis patient consultation delay (including patient consultation delay and in-hospital delay) as a whole. In China, as in other countries, there is limited information on factors leading to delays in initial medical care after symptom onset.
Most existing studies have examined the whole process of peritonitis patients’ delays in seeking medical care, including both initial and in-hospital delays. However, fewer reports focus solely on the initial delay. Patient consultation delay reflects the outcome of healthcare-seeking behaviours, providing a more accurate reflection of patients’ actions. Therefore, it is necessary to clarify the current status and causes of delays in peritonitis patient visits to implement strategies aimed at accelerating antibiotic treatment. This study aimed to investigate delays in consulting with PDAP patients and the factors influencing these delays. It also aimed to analyse outcomes related to peritonitis in patients with delayed consultations, in order to inform the development of targeted interventions and promote timely consultations with patients.
Methods
Study design and setting
A retrospective review was conducted to select patients with PDAP from three grade III A hospitals in Xiamen, Fujian Province, China, to participate in the survey between January 2022 and October 2024. In China, hospitals are categorized into different levels based on their size, facilities, technical capabilities, and quality of medical services. A ‘grade III A hospital’ is the highest level in this classification system, indicating that the hospital possesses advanced medical equipment, specialized medical teams, and high-quality medical services. These hospitals are capable of providing comprehensive medical care, including complex surgeries and specialized treatments. In this study, all patients were treated in a grade III A hospital, ensuring access to the highest standard of care.
All three participating hospitals followed the same clinical protocol for managing peritonitis in patients undergoing peritoneal dialysis. This protocol was based on the latest recommendations from the International Society for Peritoneal Dialysis (ISPD) and included standardized procedures for diagnosis, treatment, and follow-up. The consistency of the clinical protocol across the hospitals ensured that patient management was uniform, minimizing potential center variation.
PDAP Diagnostic Criteria: According to the 2022 edition of the ISPD guidelines for the prevention and treatment of peritonitis [7], the criteria are as follows: the patient has abdominal pain and/or cloudy effluent, with or without fever; biochemical examination of the effluent shows a white blood cell count ≥ 100 µL or > 0. 1 × 10^9/L (with dwell/retention time of the effluent > 2 h) accompanied by a percentage of polymorphonuclear neutrophils (PMN) > 50%; the culture of the effluent is positive for pathogenic microorganisms (1 C). The presence of two or more of the above criteria permits the diagnosis of PDAP.
Participants
This multicentre study was conducted in three hospitals in Xiamen, China. The participating centres were the Zhongshan Hospital of Xiamen University, the Xiamen Traditional Chinese Medicine Hospital, and the Second Hospital of Xiamen Medical University. Inclusion criteria comprised the following: (1) patients aged 18 to 80 years; (2) patients meeting the diagnostic criteria for PDAP according to the ISPD. Exclusion criteria included: (1) patients without complete medical records or test results or those enrolled in other clinical studies; (2) patients undergoing haemodialysis treatment; (3) concurrent diagnosis of various benign or malignant tumours or tuberculosis; (4) patients with cerebrovascular accidents, cerebral infarction, bleeding, or similar conditions; (5) patients with severe infectious diseases.
Patients should promptly collect the first bag of turbid effluent and submit it for examination within six hours, avoiding antibiotics prior to specimen collection. Initial treatment should include a first-generation cephalosporin or vancomycin, combined with either a third-generation cephalosporin or an aminoglycoside antibiotic. This regimen should then be modified according to the antimicrobial susceptibility testing outcomes.
Data collection
This study collected data retrospectively from medical records. Data collected included patient demographics (age, sex, height, weight, BMI), comorbidities at the time of peritonitis (diabetes, vascular disease, coronary artery disease), primary cause of end-stage renal disease, PD modality (CAPD, APD), clinical data related to PDAP (date of diagnosis of peritonitis, symptom-to-contact time (SC): the time from recognition of the first patient-described symptom to the first time the healthcare provider was contacted, initial clinical manifestations of peritonitis, results of bacterial culture tests), and clinical biochemical indicators (haemoglobin, serum albumin, and serum potassium).
SC time is defined as the time from the recognition of the first symptom described by the patient to the first time the healthcare provider was contacted [9]. The symptom-to-contact time was calculated from the medical and nursing records, and to ensure the accuracy of the calculations, the symptom-to-contact time was determined by one nephrologist and one full-time PD nurse. If there was a discrepancy in the judgement of the time category between the two investigators, the case was excluded due to incomplete information.
Although no universal consensus defines “SC time” in peritoneal-dialysis-related peritonitis, converging evidence supports 24 h as a clinically relevant threshold. Population-based studies of acute infections (pulmonary embolism, myocardial infarction) consistently show that delays beyond 24 h are associated with significantly worse morbidity and mortality. Similar studies on PD peritonitis have demonstrated that patients who reach medical attention ≥ 24 h after symptom onset experience higher rates of refractory infection, catheter loss, and prolonged hospitalisation compared with those presenting earlier. Therefore, patients were classified into SC time ≤ 24 h and SC time > 24 h, aligning our definition with established epidemiological benchmarks while maintaining clinical relevance.
Statistical analyses
Descriptive statistics (means, standard deviations, frequencies, and percentages) were used to summarize the characteristics of peritoneal dialysis-associated peritonitis. Independent samples t-test and one-way ANOVA were employed for univariate analysis. Pearson’s correlation analysis was conducted to assess the relationship between symptom-to-contact time for PDAP in PD patients. A multivariate linear stepwise regression model was implemented to identify predictors of symptom-to-contact time ( ≦ 24 h, > 24 h) for PDAP in PD patients. Statistical analyses were conducted using SPSS (IBM Corp., Released 2020, IBM SPSS Statistics for Windows, version 27, Armonk, NY, USA). A p-value < 0.05 was considered statistically significant.
Ethical considerations
Our study was conducted based on the ethical guidelines of the Declaration of Helsinki (World Medical Association 2013). It was approved by The Second Hospital of Xiamen Medical University Research Ethics Committee (2024232).
Results
Patient characteristics
A total of 134 patients with peritoneal dialysis-associated peritonitis were included in this study, with 77 (57.5%) having an SC time of ≤ 24 h and 57 (42.5%) having an SC time > 24 h. Baseline characteristics at the time of peritonitis are summarized in Table 1. Cloudy effluent was the most frequent presenting symptom (73.9%), while 67.9% experienced abdominal pain and 53% presented with both symptoms. All patients with PDAP satisfied the ISPD guidelines for peritonitis diagnosis.
Table 1.
Comparisons of the SC time in PDAP patients
| Characteristics | n (%) | SC time ≦ 24 h | SCtime > 24 h | χ²/t/F | P-value |
|---|---|---|---|---|---|
| Age(years) | (55.43 ± 15.41) | 55.62 ± 15.91 | 55.16 ± 14.85 | 0.172a | 0.864 |
| BMI(kg/m 2 ) | (23.67 ± 3.95) | 23.30 ± 4.27 | 24.18 ± 3.46 | 1.277a | 0.204 |
| Gender | 0.012b | 0.913 | |||
| Male | 91(67.9%) | 52(67.5%) | 39(68.4%) | ||
| Female | 43(32.1%) | 25(32.5%) | 18(31.6%) | ||
| Residence | 10.059b | 0.002 | |||
| Urban | 66(49.2%) | 47(61.0%) | 19(33.3%) | ||
| Rural | 68(50.8%) | 30(39.0%) | 38(66.7%) | ||
| Cause of ESKD | 7.773c | 0.255 | |||
| Chronic glomerulonephritis | 33(24.6%) | 24(31.2%) | 9(15.8%) | ||
| Diabetic nephropathy | 30(22.4%) | 18(23.4%) | 12(21.1%) | ||
| Hypertensive nephropathy | 39(29.1%) | 17(22.1%) | 22(38.6%) | ||
| Polycystic kidney disease | 13(9.7%) | 8(10.4%) | 5(8.8%) | ||
| Lupus nepheritis | 7(5.2%) | 4(5.2%) | 3(5.3%) | ||
| Other | 1(0.8%) | 1(1.3%) | 0(0) | ||
| Unknown | 11(8.2%) | 5(6.5%) | 6(10.5%) | ||
| PD duration (months) | (21.97 ± 20.32) | 18.82 ± 19.49 | 26.22 ± 20.82 | 52.450a | 0.646 |
| PD modality | 7.151b | 0.007 | |||
| CAPD | 121(90.3%) | 65(84.4%) | 56(98.2%) | ||
| APD | 13(9.7%) | 12(15.6%) | 1(1.8%) | ||
| Fever | 10.631b | 0.001 | |||
| Yes | 27(20.1%) | 23(29.9%) | 4(7%) | ||
| No | 107(79.9%) | 54(70.1%) | 53(93.0%) | ||
| Abdominal pain | 13.206b | < 0.001 | |||
| Yes | 91(67.9%) | 62(80.5%) | 29(50.9%) | ||
| No | 43(32.1%) | 15(19.5%) | 28(49.1%) | ||
| Cloudy effluent | 8.002b | 0.005 | |||
| Yes | 99(73.9%) | 64(83.1%) | 35(62.4%) | ||
| No | 35(26.1%) | 13(16.9%) | 22(38.6%) | ||
| Diarrhea | 4.953b | 0.026 | |||
| Yes | 18(13.4%) | 6(7.8%) | 12(21.1%) | ||
| No | 116(86.6%) | 71(92.2%) | 45(78.9%) | ||
| the frst peritonitis episode | 0.462b | 0.497 | |||
| Yes | 97(72.4%) | 54(70.1%) | 43(75.4%) | ||
| No | 37(27.6%) | 23(29.9%) | 14(24.6%) |
Abbreviations: CAPD: continuous ambulatory peritoneal dialysis; APD: automated peritoneal dialysis
Note: P < 0.05 denotes statistical significance
Note: a t value; b χ2;c F value
Comparisons of the SC time in PDAP patients
Univariate analysis revealed significant differences between groups with SC time ≤ 24 h and > 24 h in Residence (49.2% vs. 50.8%, p = 0.002), PD modality (90.3% vs. 9.7%, p = 0.007), Fever (20.1% vs. 79.9%, p = 0.001), Abdominal pain (67.9% vs. 32.1%, p < 0.001), Cloudy effluent (73.9% vs. 26.1%, p = 0.005), and Diarrhea (13.4% vs. 86.6%, p = 0.026). Table 1 details these comparisons.
The treatment outcome in PD patients
The outcome of each PDRP episode was assessed at 30 days as (i) resolution of peritonitis (PD-cure), (ii) recurrent peritonitis, or (iii) Tenckhoff catheter removal. The composite primary outcome, PD failure (PD-fail), was defined as catheter removal or death within 30 days. Among 134 peritonitis episodes, clinical outcomes varied significantly by SC time (Table 2). PD cure occurred in 118 episodes (88% overall): 69 (58.5%) in patients evaluated within 24 h versus 49 (41.5%) in those evaluated after 24 h (χ² = 31.066, p < 0.001). Recurrent peritonitis happened in six episodes (4.5% overall); one (16.7%) was in the ≤ 24 h group, and five (83.3%) in the > 24 h group (χ² = 11.000, p < 0.001). Tenckhoff catheter removal was necessary in ten episodes (7.5% overall): seven (70%) in the ≤ 24 h group and three (30%) in the > 24 h group (χ² = 8.510, p < 0.001).
Table 2.
The treatment outcome in PD patients
| Outcome | n (%) | SC time ≦ 24 h | SCtime > 24 h | χ² test | P-value |
|---|---|---|---|---|---|
| PD-cure | 118(88%) | 69(58.5%) | 49(41.5%) | 31.066 | < 0.001 |
| Recurrent peritonitis | 6(4.5%) | 1(16.7%) | 5(83.3%) | 11.000 | < 0.001 |
| Tenckhoff catheter removal | 10(7.5%) | 7(70%) | 3(30%) | 8.510 | < 0.001 |
Regression analysis
Univariate logistic regression analyses were conducted with SC time (≤ 24 h, > 24 h) as the dependent variable and statistically significant variables from univariate analyses as independent variables. Results showed that Residence (OR = 2.54, 95% CI: 1.09–5.94, p = 0.032), PD modality (OR = 0.06, 95% CI: 0.01–0.87, p = 0.039), Abdominal pain (OR = 4.60, 95% CI: 1.87–11.32, p = 0.001), Fever (OR = 4.34, 95% CI: 1.24–15.17, p = 0.022), and Diarrhea (OR = 0.26, 95% CI: 0.07–0.94, p = 0.040) significantly influenced SC time in peritoneal dialysis-associated peritonitis patients, as shown in Table 3.
Table 3.
Univariate logistic regression analysis of PD patients’ SC time
| B | SD | Wald | df | p | Exp(B) | 95% CI | |
|---|---|---|---|---|---|---|---|
| Residence | 0.932 | 0.434 | 4.621 | 1 | 0.032 | 2.54 | 1.09–5.94 |
| PD modality | −2.803 | 1.358 | 4.257 | 1 | 0.039 | 0.06 | 0.01–0.87 |
| Fever | 1.467 | 0.639 | 5.264 | 1 | 0.022 | 4.34 | 1.24–15.17 |
| Abdominal pain | 1.527 | 0.459 | 11.043 | 1 | 0.001 | 4.60 | 1.87–11.32 |
| Cloudy Effluent | 0.783 | 0.469 | 2.783 | 1 | 0.095 | 2.19 | 0.87–5.49 |
| Diarrhea | −1.345 | 0.655 | 4.219 | 1 | 0.040 | 0.26 | 0.07–0.94 |
Abbreviations: CI confidence interval
Microbiologic causes of peritonitis
There were 134 identified episodes of peritonitis; all 134 episodes (100%) were cultured using the dialysate effluent, among which 80 were successfully isolated and identified, representing a positive rate of 59.7%. There was no significant difference in microbiologic causes of peritonitis between the two patient groups (P > 0.05). The microbiologic causes of these peritonitis episodes are summarized in Table 4.
Table 4.
Microbiologic causes of peritonitis
| Organisms identified | Case [n(%)] | SC time ≦ 24 h | SCtime > 24 h | χ2 test | p value |
|---|---|---|---|---|---|
| Gram-positive organisms | 6(4.5%) | 5(6.5%) | 1(1.8%) | 12.966 | 0.164 |
| Enterococcus | 3(2.2%) | 0(0) | 3(5.3%) | ||
| Streptococci | 15(11.2%) | 7(9.1%) | 8(14%) | ||
| Staphylococcus aureus | 9(6.7%) | 6(7.8%) | 3(5.3%) | ||
| Other Staphylococcus species staphylococcus | 13(9.7%) | 6(7.8%) | 7(12.3%) | ||
| Escherichia coli | 12(9%) | 7(9.1%) | 5(8.8%) | ||
| klebsiella pneumoniae | 7(5.2%) | 7(9.1%) | 0(0) | ||
| Gram-negative organisms | 3(2.2%) | 2(2.6%) | 1(1.8%) | ||
| culture negative | 54(40.3%) | 31(40.3%) | 23(40.4%) | ||
| Others | 12(9%) | 6(7.8%) | 6(10.5%) |
Discussion
Although the ISPD guidelines recommend initiating antibiotic therapy as early as possible in patients with peritonitis, they do not explicitly specify a precise time frame from symptom onset to antibiotic administration. Studies have shown that a delay of ≥ 24 h from symptom onset to treatment initiation is significantly associated with catheter removal in patients with peritonitis [11]. However, no such association was found when the time interval was divided into 12–18 h. One study showed that 71.1% of patients with PDAP were seen promptly within 24 h [12]. The results of the present study showed that 57.46% of PDAP patients were seen promptly within 24 h, and 42.54% were delayed, which is comparable to their research findings. Biofilm formation in PDAP patients may lead to refractory or recurrent peritonitis if initial therapeutic interventions are delayed, thereby increasing the risk of recurrent peritonitis within 1 month of catheter removal and initiation of therapy [9, 13]. Animal studies have shown that Staphylococcus aureus can rapidly form a mature biofilm on wounds within 24 h, and the bacteria can be present on the surface of a PD catheter during this period [14]. Therefore, it is necessary to initiate appropriate antibiotic therapy in patients with Peritoneal Dialysis-Associated Peritonitis (PDAP) no later than 24 h after the onset of symptoms. Strategies are recommended to address the current situation of delayed Symptom-to-Contact (SC) time and accelerate antibiotic treatment.
It has been reported that a symptom-to-contact (SC) time of > 24 h was independently associated with PD catheter removal or death due to peritonitis [7]. The longer the symptom-to-treatment time, the longer it takes for the patient’s peritonitis symptoms to resolve, with the mean number of days in remission being significantly lower in patients with a symptom-to-contact time of ≦ 24 h than in the delayed Symptom-to-Contact (SC) time group [12]. The results of this study showed that the percentage of patients with delayed access to care was higher among those living in rural areas. The reasons for this may be related to the distance between the patient’s home and the hospital and the availability of transport [15]. The distance between the patient and the PD centre indicates the accessibility of medical facilities and support for PD patients, which plays a crucial role in PD patients’ follow-up management and prognosis [16]. A study of delayed access to care for breast cancer in rural women showed that breast cancer patients living in rural townships were more likely to experience delayed access to care than those living in urban areas. Another study of four tertiary hospitals in two capital cities in central China revealed that place of residence was the main factor influencing pre-hospital delays [17]. It is difficult for patients who are far from peritoneal dialysis centres to adhere to regular follow-up due to factors such as lack of transportation, long distances, and inability to seek timely medical attention when peritonitis symptoms or complications occur; this can lead to the condition worsening. Due to the distance from home and the inconvenience of transport, patients may be unable to travel to the hospital if they have PDAP. It is recommended to speed up the construction of “medical association,” improve the level of primary medical services, and enhance the hierarchical diagnosis and treatment system so that when PDAP occurs, patients can receive medical help in a timely manner and close to the hospital.
This study found that abdominal pain was a factor influencing SC time in PDAP patients with peritonitis. The total incidence rate of abdominal pain in this study is 67.9%; of these, 80.5% occurred in the SC time < 24 h group, while 19.5% occurred in the SC time ≥ 24 h group. During the initial phase of peritonitis, the absence of abdominal pain can confuse some patients, who may fail to recognize the abdominal pain as a symptom of peritonitis or wait for pain relief. Jiang’s research revealed that patients who failed to recognize the symptoms of a stroke were more likely to experience prehospital delays of at least two hours compared to those who were aware of their symptoms [18]. Another review found that patients spent significantly less time seeking care when the first symptoms of acute stroke were epilepsy, impaired consciousness, or the presence of ≥ 3 symptoms [19]. Patients’ lack of concern about peritonitis symptoms, uncertainty about the symptoms, and failure to recognize them are potential barriers to timely seeking care, suggesting that retraining in peritonitis-related knowledge should be increased to improve patients’ ability to identify them.
The study also found that fever and diarrhea influenced SC time in PDAP patients with peritonitis. Fever is a common systemic response to infection and is often perceived as a severe and urgent symptom by both patients and healthcare providers. Its presence may prompt patients to seek medical attention more quickly, as it is widely recognized as an indication of an ongoing inflammatory process. Diarrhea is one of the most common symptoms of peritoneal dialysis-associated peritonitis, usually indicating an infection or inflammatory response in the abdominal cavity. The presence of diarrhea can make patients and families more alert, encouraging them to seek medical help earlier. Two qualitative studies involving patients undergoing peritoneal dialysis revealed that individuals may find it challenging to recognize the signs and symptoms of peritonitis [20, 21]. In order to reduce consultation delays and improve patient outcomes, it is recommended that education and follow-up for peritoneal dialysis patients be enhanced. This should increase their awareness of abnormal symptoms, such as fever and diarrhea, and emphasize the importance of seeking timely medical treatment. Furthermore, healthcare providers should implement an effective follow-up system to promptly detect and manage potential infections.
This study identified gram-negative bacteria (Klebsiella, Escherichia coli, Enterobacter, and other gram-negative) as the main causative organisms for peritonitis. Around 40.30% of the peritonitis cases were culture-negative, which is comparable to the results of a retrospective study on CAPD patients in Vietnam [22].
According to the ISPD guidelines, the proportion of culture-negative peritonitis cases should be less than 15% of all peritonitis incidents [7]. However, in this study, many of the peritonitis cases were culture-negative relative to the recommended guidelines. A high rate of culture-negative bacteria in the present study can be attributed to several reasons [23]. Firstly, there was a delay in collecting the samples, as antibiotics were often given beforehand. This affected the culture results. Secondly, the sample collection process was non-standard owing to a shortage of trained PD nurses and insufficient staffing, which led to inappropriate methods being used. Thirdly and most importantly, the microbiological laboratories in these centres were not adequately equipped to isolate and culture pathogens efficiently. The high prevalence of culture-negative peritonitis cases indicates gaps in diagnostic procedures or the presence of uncommon pathogens. These findings highlight the need for enhanced education, diagnostic practices, and interventions to reduce peritonitis risks and improve patient care in PD programs in China.
Strengths and limitations
The strength of our study is that we included differences in the timing of consultation after onset in PDAP patients and investigated the situation and factors affecting the symptom-to-contact time, as fewer data are available for this condition. However, some limitations of the present study should be noted. First, it relies on the accuracy and completeness of medical records, which may result in missing or biased data; variability in management protocols and record-keeping practices across the three hospitals may influence the consistency of findings. Second, the sample size of this study is limited; a larger sample size is necessary in the future to examine the relationship between additional demographic factors and symptom-to-contact time. Third, this study only examined the PDAP patients in Xiamen, China, which may cause regional bias. Future studies should include PDAP patients from more areas to avoid bias due to regional differences.
Although SC time was precisely measured, the present study design cannot determine the subsequent interval between first medical contact and initiation of definitive therapy (Contact-to-Treatment time, CT). The calculation Symptom-to-Treatment time minus SC time yields CT, yet this value remains unmeasured in our cohort. CT is likely to have been consistent across the three participating centres because all sites follow identical, protocol-driven triage and treatment algorithms; nevertheless, our data provide no means to quantify CT or to identify factors that might affect it.
Conclusion
In this study, we found that a significant proportion of PDAP patients experienced delayed consultation, which is concerning as it may lead to exacerbation of peritonitis and negatively affect the patient’s health outcomes. Residence, PD modality, abdominal pain, fever, and diarrhoea factors are major contributors to delayed consultation in PDAP patients. This suggests that in daily work, not only should we train and retrain PD patients on peritonitis to improve their ability to recognise the condition, but we should also make them aware of the importance of timely consultation after the onset of peritonitis, to support the improvement of the prognosis of PDAP. These programmes should enhance patients’ knowledge and understanding of peritonitis, including its symptoms, causes, and potential complications. By improving their ability to identify the early signs of peritonitis, patients can take timely action to seek medical attention.
Acknowledgements
We would like to express our gratitude to the patients who participated in this study and the Nephrology Ward staff for their tremendous cooperation.
Abbreviations
- PD
Peritoneal dialysis
- PDAP
Peritoneal dialysis-associated peritonitis
- ISPD
International Society for Peritoneal Dialysis
- CAPD
Continuous ambulatory peritoneal dialysis
- PMN
Polymorphonuclear neutrophils
- SC time
Symptom-to-contact time
- Hb
Haemoglobin
- Alb
Albumin
- ESKD
End stage kidney disease
Author contributions
Huimin Huang: conception, methodology, study design, drafting of the manuscript. Yan Luo: Conceptualisation, methodology, study design, critical revision of the manuscript for important intellectual content, study supervision. Meirong Lv: Critical revision of the manuscript for important intellectual content, study supervision. Qing Liao: Critical revision of the manuscript for important intellectual content, Study supervision. Juanjuan Ou: Data analysis and interpretation, critical revision of the manuscript for important intellectual content, statistical expertise. Cuirong Hu: Analysis and interpretation of data, critical revision of the manuscript for important intellectual content, statistical expertise.
Funding
The author(s) reported there is no funding associated with the work featured in this article.
Data availability
The corresponding author can provide the datasets used and/or analyzed during the current research upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by The Second Hospital of Xiamen Medical University Research Ethics Committee (2024232). Since this was a retrospective study, a waiver of consent was given by the ethics committee(The Second Hospital of Xiamen Medical University Research Ethics Committee). All methods were carried out in accordance with the Declaration of Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The corresponding author can provide the datasets used and/or analyzed during the current research upon reasonable request.