Fungal peritonitis in the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative

Clinical practice guideline for the prevention and management of peritoneal dialysis associated infections in children: 2024 update

Infection-related complications remain the most significant cause for morbidity and technique failure in infants, children and adolescents who receive maintenance peritoneal dialysis (PD). The 2024 update of the Clinical Practice Guideline for the Prevention and Management of Peritoneal Dialysis Associated Infection in Children builds upon previous such guidelines published in 2000 and 2012 and provides comprehensive treatment guidance as recommended by an international group of pediatric PD experts based upon a review of published literature and pediatric PD registry data. The workgroup prioritized updating key clinical issues contained in the 2012 guidelines, in addition to addressing additional questions developed using the PICO format. A variety of new guideline statements, highlighted by those pertaining to antibiotic therapy of peritonitis as a result of the evolution of antibiotic susceptibilities, antibiotic stewardship and clinical registry data, as well as new clinical benchmarks, are included. Recommendations for future research designed to fill important knowledge gaps are also provided.

Frequency and prognosis of peritoneal dialysis-associated peritonitis in children

BACKGROUND

Peritonitis is the leading cause of peritoneal dialysis (PD) discontinuation. However, few data concern risk factors of peritonitis development and catheter removal caused by treatment failure in pediatric patients.

METHODS

This single-center, retrospective study analyzed data from pediatric patients who underwent chronic PD between March 2002 and June 2022. The incidence rates of peritonitis by the person-year method were calculated, and they were stratified by patient age groups. Risk factors for peritonitis development and catheter removal were also analyzed by multivariate analysis using logistic regression model.

RESULTS

Ninety patients were enrolled, and 62 peritonitis episodes were observed in 41 (46%) patients. The incidence rate of peritonitis was 0.21 episodes per patient-year, which was the highest in children aged under 2 years old (0.26 episodes per patient-year). Moreover, 44 (71%) cases were successfully cured by antibiotics alone, although 17 (27%) cases required catheter removal, and 4 (6%) cases transitioned to chronic hemodialysis because of peritoneal dysfunction. One patient died. The risk factor for peritonitis development and catheter removal caused by treatment failure was PD insertion at under 2 years old (odds ratio = 2.5; P = 0.04) and Pseudomonas aeruginosa (odds ratio = 11.0; P = 0.04) in the multivariate analysis. P. aeruginosa was also a risk factor for difficulty in re-initiating PD (P = 0.004).

CONCLUSIONS

The incidence rate of peritonitis was the highest in children under 2 years old. P. aeruginosa peritonitis is a risk factor for catheter removal and peritoneal dysfunction.

SAGES peritoneal dialysis access guideline update 2023

BACKGROUND

Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children.

METHODS

A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed.

RESULTS

After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction.

CONCLUSIONS

In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

The learning health system for pediatric nephrology: building better systems to improve health

Learning health systems (LHS) align science, informatics, incentives, and culture for continuous improvement and innovation. In this organizational system, best practices are seamlessly embedded in the delivery process, and new knowledge is captured as an integral byproduct of the care delivery experience aimed to transform clinical practice and improve patient outcomes. The objective of this review is to describe how building better health systems that integrate clinical care, improvement, and research as part of an LHS can improve care within pediatric nephrology. This review will provide real-world examples of how this system can be established in a single center and across multiple centers as learning health networks.

Reduction in peritonitis rates: 18-year results from the most active pediatric peritoneal dialysis center in China

BACKGROUND

Most of the available epidemiological data on peritonitis have been derived from developed countries. Limited data from China have been reported.

METHODS

An 18-year (2001-2018) peritoneal dialysis (PD) program at the Children's Hospital of Fudan University was described, and data on peritonitis were retrospectively analyzed.

RESULTS

Since 2001, a program with a comprehensive PD care bundle has been developed, and 283 patients (53.7% male, median age 9.3 years) were enrolled between 2001 and 2018. Among these patients, 117 peritonitis episodes occurred in 68 (24.0%) patients over 4896 patient-months. The peritonitis rate decreased 20-fold from 2.2 episodes per patient-year in 2003 to 0.11 episodes in 2018. The culture-negative rate decreased from 68.7% during 2001-2006 to 18.5% during 2013-2018, and the proportion of gram-negative and fungal infections increased significantly from 6.6 to 33.8% and 0 to 9.2%, respectively (p < 0.001). Short stature as height ≤  - 2 SD (OR 2.35, 95% CI 1.30-4.24, p = 0.005) and PD duration ≥ 1 year (OR 3.38, 95% CI 1.76-6.49, p < 0.001) were independently associated with a higher risk of developing peritonitis. Of the 117 peritonitis episodes, 9.4% required permanent removal of the catheter, among which half were fungal infections. Patients with peritonitis had a higher risk for PD technique failure (p = 0.006), but there was no difference in estimated patient survival rates and no patient death due to peritonitis.

CONCLUSIONS

With the successful development of the PD program and care bundles per the International Society of Pediatric Dialysis (ISPD) guidelines, peritonitis rates have been tremendously reduced in the most active pediatric PD center in China. Growth deficits and a long PD duration were risk factors for developing peritonitis, requiring further close monitoring for a better outcome. A higher resolution version of the Graphical abstract is available as Supplementary information.

Variability in Culture-Negative Peritonitis Rates in Pediatric Peritoneal Dialysis Programs in the United States

BACKGROUND AND OBJECTIVES

International guidelines suggest a target culture-negative peritonitis rate of <15% among patients receiving long-term peritoneal dialysis. Through a pediatric multicenter dialysis collaborative, we identified variable rates of culture-negative peritonitis among participating centers. We sought to evaluate whether specific practices are associated with the variability in culture-negative rates between low- and high-culture-negative rate centers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Thirty-two pediatric dialysis centers within the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative contributed prospective peritonitis data between October 1, 2011 and March 30, 2017. Clinical practice and patient characteristics were compared between centers with a ≤20% rate of culture-negative peritonitis (low-rate centers) and centers with a rate >20% (high-rate centers). In addition, centers completed a survey focused on center-specific peritoneal dialysis effluent culture techniques.

RESULTS

During the 5.5 years of observation, 1113 patients had 1301 catheters placed, totaling 19,025 patient months. There were 620 episodes of peritonitis in 378 patients with 411 catheters; cultures were negative in 165 (27%) peritonitis episodes from 125 (33%) patients and 128 (31%) catheters. Low-rate centers more frequently placed catheters with a downward-facing exit site and two cuffs (P<0.001), whereas high-rate centers had more patients perform dialysis themselves without the assistance of an adult care provider (P<0.001). The survey demonstrated that peritoneal dialysis effluent culture techniques were highly variable across centers. No consistent practice or technique helped to differentiate low- and high-rate centers.

CONCLUSIONS

Culture-negative peritonitis is a frequent complication of maintenance peritoneal dialysis in children. Despite published recommendations for dialysis effluent collection and culture methods, great variability in culture techniques and procedures exists among individual dialysis programs and respective laboratory processes.

Clinical Features and Risk Factors of Fungal Peritonitis in Children on Peritoneal Dialysis

Objective: To analyse the clinical manifestations, aetiology, prognosis, and risk factors of fungal peritonitis (FP) in children on peritoneal dialysis (PD). Methods: Among 322 children undergoing PD at Children's Hospital of Fudan University, between January 2001 and December 2019, FP cases were retrospectively analysed and compared with those of bacterial peritonitis (BP) to analyse the risk factors of FP. Results: A total of 124 cases of peritonitis were treated, including 11 FP cases in 11 children (0.0019 episodes/patient^*month) and 113 BP cases in 64 children (0.02 episodes/patient^*month). Among the 11 FP cases, 7 cases (63.64%) were caused by Candida and Candida parapsilosis (5/7) was the most common pathogen of Candida. All FP patients were converted to haemodialysis (HD) and did not resume PD during follow-up. Two patients (18.2%) died after 6 months of HD due to heart failure, 2 patients underwent kidney transplant after 2 years of infection, and the other 7 patients were still on HD. The univariate analysis showed the usage rate of antibiotics in the month before the onset of peritonitis was higher (45.45 vs. 15.93%) and the mean serum albumin was lower (31.4 vs. 34.4 g/L) in the FP group when compared with BP group (P < 0.05), while multivariate analysis showed that serum albumin ≤ 30 g/L was an independent risk factor for FP (odds ratio 4.896, 95% confidence interval 1.335-17.961). Conclusion: FP is a rare complication of PD in children, but it is associated with high technique failure. Attention should be paid to hypoproteinaemia and antibiotic use in children on PD.

Fungal peritonitis in children on peritoneal dialysis at a tertiary care Centre

BACKGROUND

Fungal peritonitis (FP) is an infrequent but serious complication in children undergoing peritoneal dialysis (PD). This study aimed to explore the risk factors, clinical manifestations, causative organisms, fungal susceptibility findings, and outcomes of FP in children from Saudi Arabia.

METHODS

In this case-control study, the medical records and laboratory results of paediatric patients aged 0-14 years who underwent PD were reviewed for FP episodes. All FP episodes were matched with PD-related bacterial peritonitis episodes (1:4 ratio).

RESULTS

A total of 194 episodes of PD-related peritonitis occurred between 2007 and 2017, among which 11 were FP episodes (5.6%), representing a rate of 0.03 episodes per patient-year. Of these 11 episodes, 9 were caused by Candida species (82%). Compared with the bacterial peritonitis group, the FP group had a higher proportion of patients with congenital/infantile nephrotic syndrome (p = 0.005) and those younger than 5 years of age (p = 0.001). We observed a higher rate of catheter removal in the FP group than in the bacterial peritonitis group (p <  0.001); however, 1 patient died despite catheter removal. Moreover, 75% of Candida species isolates were susceptible to fluconazole.

CONCLUSIONS

This study revealed that FP is associated with a significant risk of peritoneal membrane failure among children undergoing PD. Therefore, early diagnosis and prompt management are essential. We also found that congenital/infantile nephrotic syndrome and young age (5 years old or younger) were risk factors for FP in children undergoing PD.

Chronic peritoneal dialysis in children: a single-centre experience in Jordan

The aim of the present study is to share the experience of chronic peritoneal dialysis (PD) at King Hussein Medical Center, Amman, Jordan, and to highlight the complications of this procedure. This is a retrospective chart review study for all the children from day 1 of life to 14 years, who underwent chronic PD for end-stage renal disease (ESRD) during the period of 10 years extending from 2009 to 2019. The following data were collected: mode of dialysis, type of peritoneal dialysis, age of starting peritoneal dialysis, gender, aetiology of ESRD, duration on PD, complications and outcome. A total number of 269 children were included: 229 patients received haemodialysis and 40 children (22 boys and 18 girls) received PD. Of those, two children were on automated PD and 38 children were on continuous ambulatory peritoneal dialysis. The mean age at the start of PD was 62 ± 38 months. The mean duration of PD was 43 months. The mean catheter duration was 34 months. Six patients were shifted to haemodialysis permanently and four patients received a kidney transplant. Eleven patients died. The most common complications were peritonitis (52.5%), exit-site infection (30%) and malfunctioning catheter (12.5%). The rate of peritonitis was one episode per 22 patient-months. Peritoneal dialysis is a promising mode of dialysis for children in Jordan. Peritonitis is the most common complication associated with PD. Kidney transplantation is the best modality of renal replacement therapy in terms of long-term survival and quality of life and should be encouraged on national level.