Peritonitis rate: traditional versus low calcium dialysate

Outcome measures for technique survival reported in peritoneal dialysis: A systematic review

BACKGROUND

Peritoneal dialysis (PD) technique survival is an important outcome for patients, caregivers and health professionals, however, the definition and measures used for technique survival vary. We aimed to assess the scope and consistency of definitions and measures used for technique survival in studies of patients receiving PD.

METHOD

MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled studies (RCTs) conducted in patients receiving PD reporting technique survival as an outcome between database inception and December 2019. The definition and measures used were extracted and independently assessed by two reviewers.

RESULTS

We included 25 RCTs with a total of 3645 participants (41-371 per trial) and follow up ranging from 6 weeks to 4 years. Terminology used included 'technique survival' (10 studies), 'transfer to haemodialysis (HD)' (8 studies) and 'technique failure' (7 studies) with 17 different definitions. In seven studies, it was unclear whether the definition included transfer to HD, death or transplantation and eight studies reported 'transfer to HD' without further definition regarding duration or other events. Of those remaining, five studies included death in their definition of a technique event, whereas death was censored in the other five. The duration of HD necessary to qualify as an event was reported in only four (16%) studies. Of the 14 studies reporting causes of an event, all used a different list of causes.

CONCLUSION

There is substantial heterogeneity in how PD technique survival is defined and measured, likely contributing to considerable variability in reported rates. Standardised measures for reporting technique survival in PD studies are required to improve comparability.

Long-term effects on PTH and mineral metabolism of 1.25 versus 1.75 mmol/L dialysate calcium in peritoneal dialysis patients: a meta-analysis

Background

This study aimed to compare 1.25 and 1.75 mmol/L dialysate calcium for their effects on parathyroid hormone (PTH) and mineral metabolism in peritoneal dialysis (PD).

Methods

The PubMed, Cochrane Library, and EmBase databases were searched from inception to October 2016. Methodological quality assessment of the included studies was performed using the risk of bias tool of the Review Manager software. The meta-analysis was carried out with the Stata12.0 software. Subgroup analysis was performed by study design [randomized controlled trial (RCT) and non-RCT]. Odds ratios or standardized mean differences were used to assess the outcome measures, including intact parathyroid hormone (i-PTH) levels, serum total calcium amounts, ionized calcium levels, phosphate concentrations, and peritonitis episodes.

Results

Seven studies were enrolled in the synthesized analysis, including 4 RCTs and 3 non-RCTs. All studies compared 1.25 mmol/L and 1.75 mmol/L dialysate calcium for PD. Pooled analysis revealed that 1.75 mmol/L dialysate calcium significantly reduced i-PTH levels compared with the 1.25 mmol/L dose in PD patients. However, 1.25 mmol/L dialysate calcium was superior to the 1.75 mmol/L dose in decreasing the levels of serum total calcium and ionized calcium in PD patients. No significant differences in phosphate amounts and peritonitis episodes were observed between the two groups.

Conclusion

These findings indicated that 1.75 mmol/L dialysate calcium is more appropriate for PD patients with secondary hyperparathyroidism. Meanwhile, 1.25 mmol/L dialysate calcium is more favorable to PD patients with secondary hypercalcemia. However, further well-designed and high-quality studies are required to validate these findings.

Treatment for peritoneal dialysis-associated peritonitis

BACKGROUND

Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008.

OBJECTIVES

To evaluate the benefits and harms of treatments for PD-associated peritonitis.

SEARCH METHODS

For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal.

DATA COLLECTION AND ANALYSIS

Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes.

MAIN RESULTS

We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent.

AUTHORS' CONCLUSIONS

Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.

Intermittent versus continuous intraperitoneal glycopeptide/ceftazidime treatment in children with peritoneal dialysis-associated peritonitis. The Mid-European Pediatric Peritoneal Dialysis Study Group (MEPPS)

Intermittent intraperitoneal antibiotic administration appears as a practical and economical therapeutic concept in continuous peritoneal dialysis (CPD)-related peritonitis, but the equivalence of this principle with standard continuous treatment awaits confirmation by prospective, randomized clinical trials. This study evaluates the efficacy, safety, and clinical acceptance of an initial combination treatment including a glycopeptide (vancomycin or teicoplanin) and ceftazidime, each applied either intermittently or continuously, in a cohort of pediatric patients with CPD-related peritonitis. Patients randomized for continuous treatment received an intraperitoneal loading dose of glycopeptide and ceftazidime followed by maintenance doses added to each dialysate bag. In the intermittent treatment groups, the glycopeptide was administered in two loading doses 7 d apart, and ceftazidime during one dialysis cycle per day. Initial treatment response was evaluated after 60 h by the change in a Disease Severity Score and by the clinical decision to continue initial treatment. Of 152 patients observed for a total of 234 patient years, 90 patients developed 195 episodes of peritonitis (including 27 relapses within 4 wk after end of treatment). Dialysate cultures were positive in 83% of the episodes. In gram-positive peritonitis (79% of culture-positive cases), the primary success (overall 95%) and relapse rates (21%) were not different between continuous and intermittent, or between vancomycin and teicoplanin treatment. Oversensitivity reactions occurred in three and ototoxicity in one vancomycin-treated patient, whereas no such side effects were observed with teicoplanin. Residual renal function declined during peritonitis episodes regardless of treatment modality. In gram-negative peritonitis (18% of cases), intermittent ceftazidime treatment was less successful than continuous treatment according to clinical judgment (3 of 11 versus 10 of 14, P < 0.05), but not when rated by Disease Severity Score (8 of 11 versus 12 of 14). In conclusion, intermittent and continuous intraperitoneal treatment of CPD-related peritonitis with glycopeptides and ceftazidime is equally efficacious and safe when measured by objective clinical criteria. This contrasts with a strong tendency of clinicians to move from intermittent to continuous treatment in severe peritonitis.

Calcium Metabolism in Blood and Peritoneal L Ymphocytes from Continuous Ambulatory Peritoneal Dialysis Patients

Objective

Cellular immune function in peritoneal dialysis patients has been shown to be depressed, but the mechanism of this immunosuppression has not been ascertained. Because calcium is an important mediator of lymphocyte activation, this study was designed to investigate if there was an alteration of calcium metabolism in the lymphocytes of continuous ambulatory peritoneal dialysis (CAPD) patients.

Design

Sixteen CAPD patients were studied at the initiation of CAPD and after two months of treatment. Twenty-three normal controls were also enrolled in the study. Cytoplasmic calcium changes were investigated in response to the mitogen phytohemagglutinin (PHA) in peripheral blood and peritoneal lymphocytes, using the intracellular calcium probe indo-1 and flow cytometry. Baseline cytoplasmic calcium levels and changes in cytoplasmic calcium in response to PHA were assessed at the initiation of CAPD and after two months of therapy.

Results

Peripheral lymphocytes of patients and controls had similar calcium baseline levels, but the peritoneal lymphocytes had baseline cytoplasmic calcium levels averaging 81% higher than the corresponding calcium levels of the patients’ peripheral blood lymphocytes. As compared to peripheral lymphocytes, the response to PHA stimulation was significantly less in the peritoneal lymphocytes, increasing an average of only 46.8% above baseline. Peripheral blood lymphocytes of the patients responded by an average increase of 78.9% over baseline. Control cells increased an average of 66.3% over baseline. Follow-up studies done two months after the initiation of CAPD indicated there were no significant changes (as compared to month 0) that occurred in baseline or stimulated intracellular calcium concentrations.

Conclusions

While the peripheral lymphocytes of CAPD patients respond adequately to PHA, the high baseline calcium levels of the peritoneal lymphocytes suggest that these cells may be in a state of chronic activation and may respond minimally to an antigenic challenge.