Long-term cardiovascular outcomes in peritoneal dialysis patients: a systematic review

Peritoneal dialysis (PD) is a therapy for end-stage kidney disease that is increasingly used worldwide, especially in developing countries. Despite its benefits, PD patients remain at high risk for cardiovascular disease and related mortality due to unique metabolic and inflammatory risk factors. We performed a systematic review of cohort studies reporting cardiovascular and all-cause events in adult patients receiving PD. A search of PubMed, Embase, Scopus, and the Cochrane Library identified 716 studies; following after the screening and full-text review, 20 studies (7 prospective, 13 retrospective) were included. Data were extracted on study and participant characteristics, PD modality, outcomes, risk factors and methodological quality. All-cause mortality varied between 19.4 and 42.4% with CVD-related mortality representing 40–55% of all deaths. Vascular calcification (HR 8.01 for AAC >39%), hypoalbuminemia (HR 2.84), hypomagnesemia (HR 1.58), and inflammation (elevated neutrophil-to-lymphocyte ratio, HR 2.60; platelet-to-albumin ratio, HR 1.50) were significant modifiable risk factors for events. The incidence of peritonitis predicted cardiovascular death in a dose-response relationship. Cardiopathy (LV diastolic dysfunction, HR 2.25) and metabolism (remission of low triiodothyronine, HR 0.86 for each 10 ng/dl) were also independent predictors. Confounding and missing data yielded risk of bias as moderate or serious in most studies. Long-term cardiovascular outcomes in PD patients are driven by a complex interplay of vascular, inflammatory, metabolic, and cardiac factors. Addressing these modifiable risks should be prioritized in clinical management and research to improve survival in this high-risk population.