Roxadustat and incidence of peritoneal dialysis-associated peritonitis: a propensity score-matched cohort study

Roxadustat, a hypoxia-inducible factor prolyl hydroxylase inhibitor (HIF-PHI), exerts pleiotropic effects beyond erythropoiesis, including modulation of inflammation and immune responses. Preliminary studies suggest Roxadustat may modulate inflammation to reduce peritoneal dialysis-associated peritonitis (PDAP) risk, but this requires further proof.

Patients treated with Roxadustat or recombinant human erythropoietin (rhuEPO) at least three months from September 2014 and September 2024 were respectively enrolled. 1:1 propensity score matching (PSM) was performed based on age, sex, albumin, hemoglobin, lipid profiles, and initial urine volume. The primary outcome was PDAP incidence rate, expressed as episodes per person-year. Incidence rate ratios (IRRs) were estimated using Poisson regression models.

Among 296 eligible patients, PSM yielded 136 well-balanced individuals (68 per group). Over 225.85 patient-years of follow-up, 41 peritonitis episodes were recorded. The Roxadustat group exhibited a significantly lower PDAP incidence rate than the rhuEPO group (0.131 vs. 0.212 episodes per patient-year). Multivariable Poisson regression, adjusted for age, potassium, and albumin, confirmed that Roxadustat was associated with lower PDAP risk (adjusted IRR 0.494, 95% CI 0.252-0.970; p = 0.041). The trend persisted after multivariate adjustment.

Roxadustat was associated with a reduced incidence of PDAP compared to rhuEPO, suggesting that HIF stabilization may offer protective benefits beyond anemia correction. Prospective validation is warranted.