Impact of hypokalemia on peritonitis in peritoneal dialysis patients: a systematic review
© The Author(s) 2017
Received: 12 April 2017
Accepted: 22 August 2017
Published: 23 November 2017
Hypokalemia is a common electrolyte disorder in peritoneal dialysis patients. Some studies showed the association of serum potassium levels with all-cause and cardiovascular mortality and infection. This review aims to clarify the relationship of hypokalemia and peritonitis in peritoneal dialysis.
The MEDLINE and Cochrane Library databases were searched for articles published from 1990 to May 2016. The following search terms were used: hypokal(a)emia, potassium, peritoneal dialysis, peritonitis, and infection. Additional studies were identified by hand searching through references and using the MEDLINE-related articles option. Two investigators independently selected studies using predefined criteria and assessed each study’s quality using the Newcastle-Ottawa Quality Assessment Scale.
A total of 159 abstracts were identified and 6 trials were included in the systematic review (n = 3613). One national prospective study and two retrospective single-center studies indicated that hypokalemia increases the risk of peritonitis, whether two single-center studies indicated otherwise. One case-control study indicated that lower potassium level was associated with a poor therapeutic outcome in peritonitis.
Convincing clinical trial data are unavailable to show the association of hypokalemia with peritonitis in peritoneal dialysis patients, and we need to clarify whether the therapeutic intervention to normalize serum potassium levels decreases the risk of peritonitis and infection-related mortality in peritoneal dialysis patients.
Peritonitis is one of the specific and major complications in peritoneal dialysis, which does not occur in hemodialysis. It is well known that peritonitis is the major reason for withdrawal of peritoneal dialysis [1, 2]. Candidates for renal replacement therapy often hesitate to select peritoneal dialysis due to fear of the possibility of peritonitis.
For reducing the risk of peritonitis, various strategies are indicated in position statement of the international society for peritoneal dialysis, such as prophylactic antibiotics at catheter insertion and before invasive gastrointestinal procedures, patient training program, and avoidance of constipation . In spite of those efforts of prevention of peritonitis, peritoneal dialysis-associated peritonitis rates have not been reduced sufficiently [1, 4]. Even the introduction of disconnect systems has not been dramatically improved the risk of peritonitis [5, 6].
How can we reduce the risk of peritonitis more? Although strong evidence does not exist yet, hypoalbuminemia, vitamin D insufficiency, depression, and hypokalemia are reported as the residual modifiable risk factors for peritonitis [3, 7]. Hypokalemia is common, but insufficiently studied, electrolyte disorder that occurs in patients undergoing peritoneal dialysis. This review aims to clarify the relationship between hypokalemia and peritonitis in peritoneal dialysis.
The review protocol has been registered in PROSPERO International Prospective Register of Systematic Reviews (CRD42016039950).
Search strategy and selection criteria
The MEDLINE and Cochrane Library databases were searched for articles published from 1990 to May 2016. The following search terms were used: hypokal(a)emia, potassium, peritoneal dialysis, peritonitis, and infection. Additional studies were identified by manually searching through references and using the “related articles” option in MEDLINE. Eligible studies or studies in which eligibility criteria were unclear after the title and abstract screening underwent full-text review. A study that met the following criteria was included: (1) the study compared the clinical outcomes of peritoneal dialysis patients with or without hypokalemia and (2) the study reported the incidence of peritonitis. Two reviewers (K.N. and K.S.) assessed the criteria for all studies identified for full-text review.
Data extraction and quality assessment
We extracted characteristics of the study populations (sample size, age, sex, prevalence of diabetes mellitus, and other clinical information), characteristics of the studies (study design, source of cohort, and follow-up periods), and outcome characteristics. According to the Newcastle-Ottawa scale [8, 9], the quality of the included studies was scored independently by two investigators (K.N. and K.S.), with disagreements resolved by consensus. The systematic review of the literature was performed according to PRISMA guidelines .
Details of cohort studies included in this analysis
Study and year (reference)
Peritonitis rate (patient-month per episode)
Ribeiro, 2015 
Fan, 2014 
Liawnoraset, 2011 
Su, 2012 
Chuang, 2009 
Risk-of-bias and quality assessment
Risk of bias in included cohort studies
Study and year (reference)
Selection of controls
Not present at outset
Duration of follow-up
Adequacy of follow-up
Ribeiro, 2015 
Fan, 2014 
Liawnoraset, 2011 
Su, 2012 
Chuang, 2009 
Trial characteristics and outcome
Several mechanisms can be speculated for hypokalemia to promote peritonitis in peritoneal dialysis (Fig. 3). At first, hypokalemia may induce gastrointestinal dysmotility  and intestinal bacterial overgrowth . As a result, the translocation of bacteria from the intestine to peritoneal cavity may cause peritonitis. Moreover, potassium chloride supplementation decreased pain intensity and erythrocyte sediment rate in patients with rheumatoid arthritis  and may have the protective effect on inflammatory response .
Our review could not find a consistent correlation between hypokalemia and peritonitis in patients with peritoneal dialysis. We did not identify sufficient data and studies with low-risk bias to clarify the association. To confirm the causal connection, further well-designed studies are needed whether the adjustment of potassium levels can improve the risk of peritonitis in peritoneal dialysis patients with hypokalemia.
The authors wish to acknowledge contributions to this work from Daisuke Kanai and Atsushi Shirai for secure data collection and helpful discussion. This work was partly presented at the ASN Kidney Week 2016 Annual Meeting, November 15-20 in Chicago, IL.
Availability of data and materials
Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.
KN contributed to the research idea and study design. KN and KS contributed to the data acquisition and data analysis/interpretation. HF and SN contributed to the supervision or mentorship. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. All authors approved the final version of the submitted manuscript.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
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