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

Abstract

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.