A Randomized, Multicenter, Open-Label Trial to Determine Peritonitis Rate, Product Defect, and Technique Survival Between ANDY-Disc® and UltraBag® in Patients on CAPD

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.

An early experience of Check List to Improve Patient Self-care and Product Defect Report in Continuous Ambulatory Peritoneal Dialysis (CLIP-SP) study

An increase in number of peritoneal dialysis patients and demand for peritoneal dialysis products following implementation of "PD First" policy in Thailand has led to logistics supply chain challenges and inherent product quality problems. Available evidences suggested that defective peritoneal dialysis products may predispose the patients to peritonitis. Thailand Clinical Practice Guideline for Peritoneal Dialysis 2017 recommends the patients to check peritoneal dialysis products themselves before use. In this report, we present our early experience from the Check List to Improve Patient Self-care and Product Defect Report in Continuous Ambulatory Peritoneal Dialysis study, a cluster randomized trial conducted in 22 peritoneal dialysis centers in Thailand. Patients from 11 randomly selected sites were asked to use the check list to report any product quality defects. The peritoneal dialysis product check list required patients to check the expiration date, glucose concentration, clarity, color, and integrity of bags of peritoneal dialysis fluid as well as the peritoneal dialysis connectors prior to each use. Among 338 patients who had received the check list from 5 centers, 28 returned the reports, detecting 8 defects out of 3960 products in total (0.2%). Although the obtained check list reports were not perfectly completed, they were comprehensible and provided important information on product defects which meant that the check list was simple enough for the patients and/or caregivers to follow. In conclusion, despite low response rate and incomplete report in this early phase analysis, the check list provides important information on product defects while an impact of these defects on peritoneal dialysis outcomes requires a further investigation.

Differences in peritoneal dialysis technique survival between patients treated with peritoneal dialysis systems from different companies

BACKGROUND

A number of peritoneal dialysis (PD) systems are available but there have been few studies comparing them. The aim of this study was to examine technique failure and patient survival between different PD company systems.

METHODS

The study included all patients who commenced PD between 1995 and 2014 in Australia and New Zealand. Groups were compared according to the initial PD company system that they received. The primary outcome was a composite of PD technique failure and death.

RESULTS

A total of 16 575 patients commenced PD using systems manufactured by Baxter [n = 13 438 (81%)], Fresenius Medical Care [n = 2848 (17%)] or Gambro [n = 289 (2%)]. Of these, 11 870 (72%) developed technique failure, including 5421 (33%) who died. The median time to technique failure or death for all patients was 625 [interquartile range (IQR) 318-1114] days: 629.5 (IQR 321-1121) days with Baxter, 620.5 (IQR 311-1069) days with Fresenius Medical Care and 538 (IQR 272-1001) days with Gambro systems (P = 0.023). There was a statistically significant increase in technique failure or mortality rates in patients on Gambro {adjusted incidence rate ratio [IRR] 1.46 [95% confidence interval (CI) 1.33-1.62]} and Fresenius [adjusted IRR 1.10 (95% CI 1.01-1.19)] systems compared with Baxter systems. No difference in patient survival was observed between the three PD systems.

CONCLUSIONS

PD systems manufactured by different companies may be associated with important differences in PD technique survival. This needs to be confirmed with adequately powered, prospective randomized controlled clinical trials.

Protocol for a randomised, open-label, parallel group, multicentre controlled study to evaluate the clinical performance and safety of Stay Safe Link compared with Stay Safe in patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis

INTRODUCTION

Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD), the risk of which is significantly influenced by the type of PD transfer system. Although the Y-disconnect and double-bag system is more efficient in preventing peritonitis compared with the spike system, little information is available to differentiate risks between different brands of the Y-disconnect double-bag system. A randomised controlled trial to evaluate the safety and efficacy of a newly introduced system is needed to provide the necessary clinical evidence to guide policy decision-making.

METHODS AND ANALYSIS

The study is an open-label randomised controlled trial. A total of 434 patients with end-stage renal disease undergoing CAPD will be enrolled and randomised to either the intervention group, Stay Safe Link, or the control group, Stay Safe. All study subjects will be followed up and monitored for 1 year. The primary safety outcome is the rate of peritonitis while the primary efficacy outcomes are the delivered dialysis dose and ultrafiltration volume.

ETHICS AND DISSEMINATION

The study was approved by the Medical Research Ethics Committee, National Institute of Health Malaysia. A written informed consent will be obtained from all participating subjects prior to any trial-related procedure and the study conduct will adhere strictly to Good Clinical Practice. The findings will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03177031; Pre-results.

Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage kidney disease

BACKGROUND

Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis.This is an update of a review first published in 2000.

OBJECTIVES

This systematic review sought to determine if modifications of the transfer set (Y-set or double bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register through contact with the Trials Search Co-ordinator. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE. Date of last search: 22 October 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing double bag, Y-set and standard peritoneal dialysis (PD) exchange systems in patients with end-stage kidney disease.

DATA COLLECTION AND ANALYSIS

Data were abstracted by a single investigator onto a standard form and analysed by Review Manager. Analysis was by a random effects model and results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI).

MAIN RESULTS

Twelve eligible trials with a total of 991 randomised patients were identified. Despite the large total number of patients, few trials covered the same interventions, small numbers of patients were enrolled in each trial and the methodological quality was suboptimal. Y-set and twin-bag systems were superior to conventional spike systems (7 trials, 485 patients, RR 0.64, 95% CI 0.53 to 0.77) in preventing peritonitis in PD.

AUTHORS' CONCLUSIONS

Disconnect systems should be the preferred exchange systems in CAPD.

Mycobacterium porcinum peritonitis in a patient on continuous ambulatory peritoneal dialysis

Mycobacterium porcinum has been reported to cause a variety of illnesses including wound infections, respiratory tract infections, osteomyelitis and catheter-related bacteremias. We report the first case of M. porcinum peritonitis in a patient on continuous ambulatory peritoneal dialysis (CAPD). A 67-year-old woman on CAPD presented with three weeks of constitutional symptoms and abdominal pain. Peritoneal fluid cultures on day three grew acid-fast rods. Nocardiosis was suspected and the patient was empirically treated with amikacin and trimethoprim-sulfamethoxazole. The dialysis catheter was removed. Two weeks later final culture results revealed M. porcinum. Ciprofloxacin and trimethoprim-sulfamethoxazole were initiated with good clinical response.

Impact of the bag exchange procedure on risk of peritonitis

OBJECTIVE

We studied whether improper bag exchange predicts the first peritonitis episode in continuous ambulatory peritoneal dialysis (CAPD) patients.

PATIENTS AND METHODS

Our single-center prospective observational study of 130 incident urban CAPD patients who started peritoneal dialysis (PD) between March 2005 and August 2008 aimed to determine the relationship between bag exchange procedures examined at the 6th month of PD and risk for a first peritonitis episode. All patients were followed until a first peritonitis episode, censoring, or the end of the study.

RESULTS

These 130 patients experienced 22 first peritonitis episodes during the 14-month follow-up. During bag exchange evaluation, 51.5% of patients washed their hands improperly, 46.2% failed to check expiration date or bag leakage, and 11.5% forgot to wear a face mask and cap. Patients experiencing peritonitis were more likely to forget to wear a face mask and cap. In multivariate Cox regression model, not wearing a face mask and cap [hazard ratio (HR): 7.26; 95% confidence interval (CI): 2.6 to 20.1; p < 0.001] and having anemia (HR: 0.96; 95% CI: 0.94 to 0.99; p = 0.005) were independent risk factors for a first episode of peritonitis.

CONCLUSIONS

Not wearing a face mask and cap and having anemia were independent risk factors for peritonitis. A further randomized control study needs to verify the correlation between improper bag exchange technique and peritonitis in PD patients.

Efficacy of the bovine antimicrobial peptide indolicidin combined with piperacillin/tazobactam in experimental rat models of polymicrobial peritonitis

OBJECTIVE

To investigate the efficacy of piperacillin/tazobactam combined with indolicidin in the prevention of lethality in two rat models of polymicrobial peritonitis.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

Research laboratory in a university hospital.

SUBJECTS

Adult male Wistar rats.

INTERVENTIONS

Adult male Wistar rats were given an intraperitoneal injection of 1 mg of Escherichia coli 0111:B4 lipopolysaccharide or had intraabdominal sepsis induced by cecal ligation and puncture. For each model, all animals were randomized to receive isotonic sodium chloride solution intraperitoneally, 1 mg/kg indolicidin, 120 mg/kg piperacillin/tazobactam, and 1 mg/kg indolicidin combined with 120 mg/kg piperacillin/tazobactam. Each group included 20 animals.

MEASUREMENTS AND MAIN RESULTS

Main outcome measures were: bacterial growth in blood, peritoneum, spleen, liver, and mesenteric lymph nodes; endotoxin, interleukin-6, and tumor necrosis factor-alpha concentrations in plasma; and lethality. All compounds reduced significantly bacterial growth and lethality compared with saline treatment. Treatment with indolicidin resulted in significant decrease in plasma endotoxin and cytokine levels, whereas piperacillin/tazobactam exerted the opposite effect. The combination between indolicidin and piperacillin/tazobactam proved to be the most effective treatment in reducing all variables measured.

CONCLUSION

Indolicidin may have potential therapeutic usefulness alone and when associated with piperacillin/tazobactam in polymicrobial peritonitis.

An Initial Experience of Continuous Peritoneal Dialysis in Children in the Armed Forces

BACKGROUND

Continuous peritoneal dialysis (CPD) is a modality of renal replacement therapy in children with renal failure. A retrospective study analysis of CPD data over four years at our center was carried out.

METHODS

Ten children with renal failure on CPD were included. Depending on the supply, peritoneal dialysis (PD) fluids of two different brands were used in the same patients over time. The patient months of CPD were divided into two groups based on the brand of PD fluid used. The rates of complications with the two different fluid brands were compared.

RESULTS

The mean age of our patients was 8.8 ± 2.51 years (range 4 - 13), with a total of 141 patient months of CPD. The mean follow up period was 13.6 months (range 1- 48). The commonest underlying renal pathology was focal segmental glomerulosclerosis in 30%, followed by cresentric glomerulonephritis in 20%. Peritonitis rate was 0.48 episodes per patient year. Patients in Group I had one episode of peritonitis per 53.5 patient months and Group II had one episode per 7.25 patient months (p= 0.021, relative risk of 7.3). Patients in Group I had one episode of hypertensive encephalopathy per 107 patient months and Group II had one episode per 4.8 patient months (p= 0.001, relative risk of 21.9). On analyzing the outcome, four patients were eventually transplanted, three continued on CPD awaiting a renal transplant, two died and one recovered spontaneously.

CONCLUSION

CPD is an effective bridge to renal transplant in children with end stage renal disease. The risk of developing peritonitis and hypertensive encephalopathy varied with the brand of fluid used over time in the same set of patients.

Key Success Factors for a Quality Peritoneal Dialysis Program

The success of a peritoneal dialysis (PD) program depends on a multitude of factors that are interlinked and inseparable from one another. Each program needs to identify its special circumstances, deficiencies, and strong points, and then to strategize accordingly. Ultimately, “teamwork” is the mantra for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.

Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal disease

BACKGROUND

Peritonitis is the most frequent serious complication of continuous ambulatory peritoneal dialysis (CAPD). It has a major influence on the number of patients switching from CAPD to haemodialysis and has probably restricted the wider acceptance and uptake of CAPD as an alternative mode of dialysis.

OBJECTIVES

This systematic review sought to determine if modifications of the transfer set (Y-set or double bag systems) used in CAPD exchanges are associated with a reduction in peritonitis and an improvement in other relevant outcomes.

SEARCH STRATEGY

A broad search strategy was employed which attempted to identify all RCTs or quasi-RCTs relevant to the management of end-stage renal disease (ESRD). Five electronic databases were searched (Medline 1966-1999, EMBASE 1984-1999, CINAHL 1982-1996, BIOSIS 1985-1996 and the Cochrane Library), authors of included studies and relevant biomedical companies were contacted, reference lists of identified RCTs and relevant narrative reviews were screened and Kidney International 1980-1997 was hand searched.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing double bag, Y-set and standard CAPD exchange systems in patients with ESRD.

DATA COLLECTION AND ANALYSIS

Data were abstracted by a single investigator onto a standard form and subsequently entered into Review Manager 4.0.4. Odds Ratio (OR) for dichotomous data and a (Weighted) Mean Difference (WMD) for continuous data were calculated with 95% confidence intervals (95% CI).

MAIN RESULTS

Twelve eligible trials with a total of 991 randomised patients were identified. In trials comparing either the Y-set or double bag systems with the standard systems significantly fewer patients (OR 0.33, 95% CI 0.24 to 0.46) experienced peritonitis and the number of patient-months on CAPD per episode of peritonitis were consistently greater. When the double bag systems were compared with the Y-set systems significantly fewer patients experienced peritonitis (OR 0.44, 95% CI 0.27 to 0.71) and the numbers of patient-months on CAPD/ episode of peritonitis were also greater.

REVIEWER'S CONCLUSIONS

Double bag systems should be the preferred exchange systems in CAPD.