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Jayanti S, Rangan GK. Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis. Int J Nephrol Renovasc Dis 2024; 17:91-104. [PMID: 38525412 PMCID: PMC10961023 DOI: 10.2147/ijnrd.s387598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.
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Affiliation(s)
- Sumedh Jayanti
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
- Michael Stern Laboratory for Polycystic Kidney Disease, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Gopala K Rangan
- Department of Renal Medicine, Westmead Hospital, Sydney, NSW, Australia
- Michael Stern Laboratory for Polycystic Kidney Disease, Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, NSW, Australia
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Albert A, Richter S, Kalk P, Stieger P, Woitas RP, Braun-Dullaeus RC, Albert C. Analysis of a nurse-provided on-call peritoneal dialysis support in an outpatient reference care centre. BMC Nurs 2024; 23:144. [PMID: 38429782 PMCID: PMC10905825 DOI: 10.1186/s12912-024-01812-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND To analyse the nature of medical or technical emergency issues of ambulatory peritoneal dialysis (PD) patients calling a nurse-provided emergency PD support service of a reference centre that is provided all year in the after-hours. METHODS We retrospectively analysed patients' chief complaint, urgency, resolution of and association to current PD treatment and modality directed to an on-call nurse-provided PD support service from 2015-2021 based on routinely collected health data. Calls were systematically categorized being technical/procedural-, medical-, material-related or type of correspondence. Call urgency was categorized to have "immediate consequence", inquiry was eligible for "processing next working day" or whether there was "no need for further action". Call outcomes were classified according to whether patients were able to initiate, resume or finalize their treatments or whether additional interventions were required. Unexpected adverse events such as patients' acute hospitalization or need for nurses' home visits were evaluated and quantified. RESULTS In total 753 calls were documented. Most calls were made around 7:30 a.m. (5:00-9:00; median, 25-75th CI) and 6:30 p.m. (5:00-8:15). 645 calls were assigned to continuous ambulatory- (CAPD) or automated PD (APD). Of those, 430 calls (66.7%) had an "immediate consequence". Of those 77% (N = 331) were technical/procedural-, 12.8% (N = 55) medical- and 6.3% (N = 27) material related issues. 4% (N = 17) were categorized as other correspondence. Issues disrupting the course of PD were identified in 413 cases. In 77.5% (N = 320) patients were able to initiate, resume or finalize their treatment after phone consultation. Last-bag exchange was used in 6.1% enabling continued therapy in 83.6%. In 35 cases a nurse visit at patients' home or patients' visit to the practice at the earliest possible date were required, while hospitalization was required in seven medical category cases (5.4% and 1.09% of total assessed calls, respectively). CONCLUSION The on-call PD-nurse provides patient support for acute and imminent issues enabling them to successfully initiate, resume or finalize their prescribed treatment. Nurses triage of acute conditions facilitated rapid diagnostics and therapy. Maintaining quality PD homecare, the provision of trained personnel is indispensable. The information gathered in this study may therefore be used as a foundation to tailor educational programs for nephrology nurses and doctors to further develop their competencies in PD.
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Affiliation(s)
- Annemarie Albert
- Diaverum Renal Services, Am Neuen Garten 11, Potsdam, 14469, Germany
- Department of Nephrology and Endocrinology, Ernst von Bergmann Hospital, Charlottenstraße 72, Potsdam, 14467, Germany
| | - Stefan Richter
- Diaverum Renal Services, Am Neuen Garten 11, Potsdam, 14469, Germany
| | - Philipp Kalk
- Diaverum Renal Services, Am Neuen Garten 11, Potsdam, 14469, Germany
| | - Philipp Stieger
- University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | | | - Rüdiger C Braun-Dullaeus
- University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany
| | - Christian Albert
- Diaverum Renal Services, Am Neuen Garten 11, Potsdam, 14469, Germany.
- University Clinic for Cardiology and Angiology, Otto-von-Guericke University Magdeburg, Leipziger Str. 44, Magdeburg, 39120, Germany.
- Department of Nephrology, Central Clinic Bad Berka, Robert-Koch-Allee 9, Bad Berka, 99438, Germany.
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3
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Li P, Cao X, Liu W, Zhao D, Pan S, Sun X, Cai G, Zhou J, Chen X. Evolving peritoneal dialysis care in Chinese mainland from 2010 to 2020: Comparison data from two surveys. Semin Dial 2022; 36:214-220. [PMID: 36450343 DOI: 10.1111/sdi.13129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/28/2022] [Accepted: 08/13/2022] [Indexed: 12/05/2022]
Abstract
INTRODUCTION Along with the peritoneal dialysis (PD)-favored policy in China and the implementation of more comprehensive PD management, PD has evolved in Chinese mainland over the last decade. Despite the existence of national registries and several provincial epidemiological descriptive studies, there was almost no national research on the changing trajectory in PD population. A comparison study, based on two national surveys that were 10 years apart, was conducted to reveal the evolvement of PD care in Chinese mainland. METHODS Two national surveys have been done respectively in 2010 and 2020 to capture the epidemiological status, application of different modalities, management of perioperative infection, and long-term complications among PD patients. RESULTS In the study with 730 participating hospitals (n = 14,912 PD patients) in 2010 and 746 hospitals (n = 101,537) in 2020, prevalent PD patients have increased in the past 10 years with increased numbers of PD patients in both secondary (average 5 ± 16 vs. 43 ± 41, p < 0.01) and tertiary hospitals (32 ± 53 vs. 153 ± 215, p < 0.01). Automated PD has been accessible in 0.4% of all hospitals, only in tertiary centers in 2010 and its application increased to 51% in 2020. PD centers have become more engaged in PD catheter placement, treated properly for the PD-related infection, and carried out the follow-up in compliance with the national protocols. CONCLUSIONS Our study indicates that over the past decade, the prevalent PD population has quickly expanded with increased APD availability in Chinese mainland. The management of PD patients has become better conforming to the guidelines and long-term follow-up of patients have remained stable. Further studies are warranted to evaluate whether the rapidly changing paradigm of PD could translate into the socio-economic benefits in the society.
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Affiliation(s)
- Ping Li
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Xueying Cao
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Weicen Liu
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Delong Zhao
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Sai Pan
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Xuefeng Sun
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Guangyan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Jianhui Zhou
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
| | - Xiangmei Chen
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Nephrology Institute of the Chinese People's Liberation Army, State Key Laboratory of Kidney Diseases National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research Beijing P.R. China
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4
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Guía clínica de la Sociedad Española de Nefrología para la prevención y tratamiento de la infección peritoneal en diálisis peritoneal. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Chen ST, Yao Y, Tseng YS, Sun FK. Developing a theory to help guide End-Stage Renal Disease Patients to adapt to Peritoneal Dialysis: A grounded theory study. J Clin Nurs 2021; 31:134-144. [PMID: 34056778 DOI: 10.1111/jocn.15890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Abstract
AIM AND OBJECTIVES The aim of this study was to develop a theory to help guide patients with end-stage renal disease to adapt to peritoneal dialysis. BACKGROUND Taiwan ranks first worldwide in end-stage renal disease incidence and dialysis prevalence. Many patients cannot accept long-term dialysis treatment and thus face several physical and psychological suffering. No theory has yet been developed to help guide patients with end-stage renal disease to adapt to peritoneal dialysis. DESIGN A grounded theory approach was used in this study. METHODS A theoretical sampling was performed after interviewing 25 patients who had adapted to peritoneal dialysis at a medical centre in Taiwan from January 2018 to September 2018; data saturation was achieved. Data were analysed using open, axial and selective coding and while using the constant comparison technique. COREQ reporting guidelines were utilised. RESULTS A substantive theory was developed to help guide patients with end-stage renal disease to adapt to peritoneal dialysis. The core category that emerged from the data collected was 'Confronting peritoneal dialysis to live and co-exist with peritoneal dialysis'. Other key categories linked to and embraced in this core category were as follows: positive self-regulation, regulation of daily life and the process of adaptation to dialysis method. CONCLUSION The results could help healthcare professionals to better understand the process of end-stage renal disease patients' adaptation to peritoneal dialysis, thereby facilitating patients' adaptation to dialysis in their daily life, enhancing their quality of life and improving the quality of medical care. RELEVANCE TO CLINICAL PRACTICE Healthcare professionals could use this theory as reference when providing care for peritoneal dialysis patients to assist them in adapting to life with peritoneal dialysis as soon as possible through positive self-regulation, daily life adjustments and the process of adapting to the dialysis method.
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Affiliation(s)
- Shui-Tao Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital/I-Shou University, Kaohsiung City, Taiwan, ROC
| | - YuChun Yao
- Department of Nursing, I-Shou University, Spalding University, Kaohsiung City, Taiwan, ROC
| | - Yun Shan Tseng
- Department of Nursing, I-Shou University/University of Texas Health Science Center at Houston, Kaohsiung City, Taiwan, ROC
| | - Fan-Ko Sun
- Department of Nursing, I-Shou University, University of Ulster, Kaohsiung City, Taiwan, ROC
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6
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Marshall MR. A systematic review of peritoneal dialysis-related peritonitis rates over time from national or regional population-based registries and databases. Perit Dial Int 2021; 42:39-47. [PMID: 33827339 DOI: 10.1177/0896860821996096] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Peritoneal dialysis (PD)-related peritonitis is one of the top priorities for care and research among PD stakeholders. This study summarizes PD peritonitis rates from available population-based national or regional registries around the world, examining trends over time. This is a systematic review of PD peritonitis rates in patients treated with PD for kidney failure, from census-based national or provincial/statewide/provider registries or databases. MEDLINE (via PubMed) was searched from inception to August 2020, and inquiries made to national registry personnel using the International Comparisons section of the 2018 United States Renal Data System Annual Data Report as a contact list. Quantitative synthesis was done using weighted random-effects Poisson regression. Of 81 countries that reported utilization of PD, 19 did not have a traditional dialysis registry (governed by either professional societies or government entities), and only 33 monitored PD peritonitis rates correctly and accessibly. There is wide variation in PD peritonitis rates between countries, although the global average has been decreasing over time, from 0.600 episodes/patient-year in 1992 to 0.303 in 2019. Other sources of variability include the continent in which the country is nested and the size of its PD population. PD peritonitis, despite its importance for PD stakeholders, is under-monitored. While the global rate is decreasing over time, the presence and extent of this improvement varies from country to country. There is an opportunity for better monitoring, research into underachieving and overachieving nations and development of international clinical support networks.
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Affiliation(s)
- Mark R Marshall
- School of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, New Zealand.,Department of Renal Medicine, Middlemore Hospital, Counties Manukau Health, Auckland, New Zealand
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Perl J, Fuller DS, Boudville N, Kliger AS, Schaubel DE, Teitelbaum I, Warady BA, Neu AM, Patel PR, Piraino B, Schreiber M, Pisoni RL. Optimizing Peritoneal Dialysis-Associated Peritonitis Prevention in the United States: From Standardized Peritoneal Dialysis-Associated Peritonitis Reporting and Beyond. Clin J Am Soc Nephrol 2021; 16:154-161. [PMID: 32764025 PMCID: PMC7792655 DOI: 10.2215/cjn.11280919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Peritoneal dialysis (PD)-associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology, St. Michael’s Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
| | - Alan S. Kliger
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Isaac Teitelbaum
- Division of Kidney Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
| | - Bradley A. Warady
- Division of Nephrology, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Alicia M. Neu
- Division of Pediatric Nephrology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Priti R. Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Beth Piraino
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
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8
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Bonnal H, Bechade C, Boyer A, Lobbedez T, Guillouët S, Verger C, Ficheux M, Lanot A. Effects of educational practices on the peritonitis risk in peritoneal dialysis: a retrospective cohort study with data from the French peritoneal Dialysis registry (RDPLF). BMC Nephrol 2020; 21:205. [PMID: 32471380 PMCID: PMC7260816 DOI: 10.1186/s12882-020-01867-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/25/2020] [Indexed: 12/02/2022] Open
Abstract
Background Peritoneal dialysis (PD) is a home-based therapy performed by patients or their relatives in numerous cases, and the role of patients’ educational practices in the risk of peritonitis is not well assessed. Our aim was to evaluate the effect of PD learning methods on the risk of peritonitis. Methods This was a retrospective multicentric study based on data from a French registry. All incident adults assisted by family or autonomous for PD exchanges in France between 2012 and 2015 were included. The event of interest was the occurrence of peritonitis. Cox and hurdle regression models were used for statistical analysis to asses for the survival free of peritonitis, and the risk of first and subsequent peritonitis. Results 1035 patients were included. 967 (93%) received education from a specialized nurse. Written support was used for the PD learning in 907 (87%) patients, audio support in 221 (21%) patients, and an evaluation grid was used to assess the comprehension in 625 (60%) patients. In the “zero” part of the hurdle model, the use of a written support and starting PD learning with hands-on training alone were associated with a lower survival free of peritonitis (respectively HR 1.59, 95%CI 1.01–2.5 and HR 1.94, 95%CI 1.08–3.49), whereas in the “count” part, the use of an audio support and starting of PD learning with hands-on training in combination with theory were associated with a lower risk of presenting further episodes of peritonitis after a first episode (respectively HR 0.55, 95%CI 0.31–0.98 and HR 0.57, 95%CI 0.33–0.96). Conclusions The various PD education modalities were associated with differences in the risk of peritonitis. Prospective randomized trials are necessary to confirm causal effect. Caregivers should assess the patient’s preferred learning style and their literacy level and adjust the PD learning method to each individual.
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Affiliation(s)
- Hélène Bonnal
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France.,U1086 INSERM - ANTICIPE - Centre Régional de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Clémence Bechade
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France.,U1086 INSERM - ANTICIPE - Centre Régional de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Annabel Boyer
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France.,U1086 INSERM - ANTICIPE - Centre Régional de Lutte Contre le Cancer François Baclesse, Caen, France
| | - Thierry Lobbedez
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France.,RDPLF, 30 Rue Sere Depoin, 95 300, Pontoise, France
| | - Sonia Guillouët
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France
| | | | - Maxence Ficheux
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France
| | - Antoine Lanot
- Normandie Univ, UNICAEN, CUMR, CHU de Caen Normandie, Néphrologie, Avenue de la cote de nacre, 14033, Caen-Cedex, France. .,U1086 INSERM - ANTICIPE - Centre Régional de Lutte Contre le Cancer François Baclesse, Caen, France.
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Boudville N, Johnson DW, Zhao J, Bieber BA, Pisoni RL, Piraino B, Bernardini J, Nessim SJ, Ito Y, Woodrow G, Brown F, Collins J, Kanjanabuch T, Szeto CC, Perl J. Regional variation in the treatment and prevention of peritoneal dialysis-related infections in the Peritoneal Dialysis Outcomes and Practice Patterns Study. Nephrol Dial Transplant 2020; 34:2118-2126. [PMID: 30053214 DOI: 10.1093/ndt/gfy204] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 05/29/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Peritoneal dialysis (PD)-related infections lead to significant morbidity. The International Society for Peritoneal Dialysis (ISPD) guidelines for the prevention and treatment of PD-related infections are based on variable evidence. We describe practice patterns across facilities participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). METHODS PDOPPS, a prospective cohort study, enrolled nationally representative samples of PD patients in Australia/New Zealand (ANZ), Canada, Thailand, Japan, the UK and the USA. Data on PD-related infection prevention and treatment practices across facilities were obtained from a survey of medical directors'. RESULTS A total of 170 centers, caring for >11 000 patients, were included. The proportion of facilities reporting antibiotic administration at the time of PD catheter insertion was lowest in the USA (63%) and highest in Canada and the UK (100%). Exit-site antimicrobial prophylaxis was variably used across countries, with Japan (4%) and Thailand (28%) having the lowest proportions. Exit-site mupirocin was the predominant exit-site prophylactic strategy in ANZ (56%), Canada (50%) and the UK (47%), while exit-site aminoglycosides were more common in the USA (72%). Empiric Gram-positive peritonitis treatment with vancomycin was most common in the UK (88%) and USA (83%) compared with 10-45% elsewhere. Empiric Gram-negative peritonitis treatment with aminoglycoside therapy was highest in ANZ (72%) and the UK (77%) compared with 10-45% elsewhere. CONCLUSIONS Variation in PD-related infection prevention and treatment strategies exist across countries with limited uptake of ISPD guideline recommendations. Further work will aim to understand the impact these differences have on the wide variation in infection risk between facilities and other clinically relevant PD outcomes.
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Affiliation(s)
- Neil Boudville
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | - Brian A Bieber
- Arbor Research Collaborative for Health, Ann Arbor, MI, USA
| | | | - Beth Piraino
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Judith Bernardini
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sharon J Nessim
- Department of Nephrology, Division of Nephrology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Nagakute, Japan
| | - Graham Woodrow
- Department of Nephrology, St James's University Hospital, Leeds, UK
| | - Fiona Brown
- Department of Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
| | - John Collins
- Department of Renal Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Internal Medicine, and Kidney & Metabolic Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Cheuk-Chun Szeto
- Carol & Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Jeffrey Perl
- Department of Medicine, Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Harmanjeet H, Jani H, Zaidi STR, Wanandy T, Castelino RL, Sud K, Peterson GM, Patel RP. Stability of ceftolozane and tazobactam in different peritoneal dialysis solutions. Perit Dial Int 2020; 40:470-476. [PMID: 32052692 DOI: 10.1177/0896860820902590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Peritonitis is a common and serious complication of peritoneal dialysis (PD). PD-associated peritonitis (PDAP) caused by Pseudomonas is usually resistant to most antibiotics, resulting in high failure rates. Ceftolozane/tazobactam (C/T) has been shown to be effective in treating urinary tract and intra-abdominal infections caused by beta-lactam resistant Pseudomonas and other gram-negative bacteria. Given its favourable adverse effects profile, it has a potential role in the treatment of PDAP caused by Pseudomonas species resistant to other antibiotics. Intraperitoneal administration of antibiotics admixed with PD solutions for the treatment of PDAP is associated with superior outcomes. However, there is a lack of published data on the stability of C/T in PD solutions. Therefore, this study investigated the physical and chemical stability of C/T in commonly used PD solutions at different temperatures. METHODS A total of 27 PD bags (3 PD bags for each type of PD solution including Dianeal®, Extraneal®, Balance® and Physioneal® PD bags) containing C/T were prepared and stored at 25°C for 6 h, followed by 4°C for 168 h and then 37°C for 12 h. An aliquot from each PD bag was withdrawn, and the concentration of C/T before (0 h) and after predefined time points was determined using a stability-indicating high-performance liquid chromatography assay. Samples were also assessed for pH, colour change and particulate matter immediately after preparation and on each day of analysis. RESULTS C/T retained more than 97% of their initial concentration when stored at 25°C for 6 h followed by storage at 4°C for 168 h and then at 37°C for 12 h. Particle formation was not detected at any time under the tested storage conditions. The pH and colour remained essentially unchanged throughout the study. CONCLUSIONS These results provide a platform for clinical studies to determine the safety and therapeutic efficacy of intraperitoneal C/T for the treatment of PDAP caused by resistant Pseudomonas species.
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Affiliation(s)
| | - Het Jani
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia
| | - Syed Tabish R Zaidi
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia.,School of Healthcare, University of Leeds, UK
| | - Troy Wanandy
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia.,Department of Pharmacy, 497744Royal Hobart Hospital, Australia
| | - Ronald L Castelino
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia.,School of Nursing, 4334University of Sydney, Australia.,Peritoneal Dialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Australia
| | - Kamal Sud
- Peritoneal Dialysis Unit, Regional Dialysis Centre, Blacktown Hospital, Australia.,Department of Renal Medicine, Nepean Hospital and Nepean Clinical School, 4334The University of Sydney, Australia
| | - Gregory M Peterson
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia
| | - Rahul P Patel
- Division of Pharmacy, School of Medicine, 3925University of Tasmania, Australia
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11
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Campbell DJ, Mudge DW, Gallagher MP, Lim WH, Ranganathan D, Saweirs W, Craig JC. Infection Prophylaxis in Peritoneal Dialysis Patients: Results from an Australia/New Zealand Survey. Perit Dial Int 2020; 37:191-197. [DOI: 10.3747/pdi.2016.00037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/03/2016] [Indexed: 11/15/2022] Open
Abstract
BackgroundClinical practice guidelines aim to reduce the rates of peritoneal dialysis (PD)-related infections, a common complication of PD in end-stage kidney disease patients. We describe the clinical practices used by Australian and New Zealand nephrologists to prevent PD-related infections in PD patients.MethodsA survey of PD practices in relation to the use of antibiotic and antifungal prophylaxis in PD patients was conducted of practicing nephrologists identified via the Australia and New Zealand Society of Nephrology (ANZSN) membership in 2013.ResultsOf 333 nephrologists approached, 133 (39.9%) participated. Overall, 127 (95.5%) nephrologists prescribed antibiotics at the time of Tenckhoff catheter insertion, 85 (63.9%) routinely screened for nasal S. aureus carriage, with 76 (88.4%) reporting they treated S. aureus carriers with mupirocin ointment. Following Tenckhoff catheter insertion, 79 (59.4%) prescribed mupirocin ointment at the exit site or intranasally, and 93 (69.9%) nephrologists routinely prescribed a course of oral antifungal agent whenever their PD patients were given a course of antibiotics.ConclusionsAlthough the majority of nephrologists prescribe antibiotics at the time of Tenckhoff catheter insertion, less than 70% routinely prescribe mupirocin ointment and/or prophylactic antifungal therapy. This variation in practice in Australia and New Zealand may contribute to the disparity in PD-related infection rates that is seen between units.
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Affiliation(s)
- Denise J. Campbell
- Centre for Kidney Research, Auckland, New Zealand
- Sydney Children's Hospital Network (Westmead), Westmead, NSW, Australia; School of Public Health, Auckland, New Zealand
| | - David W. Mudge
- University of Sydney, Sydney, NSW, Australia; University of Queensland at Princess Alexandra Hospital, Auckland, New Zealand
| | - Martin P. Gallagher
- Brisbane, QLD, Australia; University of Sydney and George Institute for Global Health, Auckland, New Zealand
| | - Wai Hon Lim
- Sydney, NSW, Australia; Sir Charles Gairdner Hospital, Auckland, New Zealand
| | - Dwaraka Ranganathan
- Perth, WA, Australia; Royal Brisbane and Women's Hospital, Auckland, New Zealand
| | - Walaa Saweirs
- Herston, QLD, Australia; Whangarei Hospital, Auckland, New Zealand
- Northland District Health Board, Whangarei, New Zealand; and University of Auckland, Auckland, New Zealand
| | - Jonathan C. Craig
- Centre for Kidney Research, Auckland, New Zealand
- Sydney Children's Hospital Network (Westmead), Westmead, NSW, Australia; School of Public Health, Auckland, New Zealand
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12
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Mancini A, Piraino B. Review of Antibiotic Dosing with Peritonitis in APD. Perit Dial Int 2020; 39:299-305. [DOI: 10.3747/pdi.2018.00209] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 01/14/2019] [Indexed: 01/19/2023] Open
Abstract
Peritonitis is the leading cause of transfer from peritoneal dialysis (PD) to hemodialysis (HD). It is also the leading cause of hospitalization of PD patients. The usual treatment of peritonitis for automated PD (APD) patients consists of antibiotics given once daily in the long dwell. However, the once-daily antibiotic dosing recommendations are based primarily on studies with continuous ambulatory PD (CAPD) regimens. Published studies on antibiotic dosing in APD are very limited. We will review the scant literature on this topic. It is possible that extrapolating once-daily dosing from CAPD to APD may lead to underdosing. There is a need for further pharmacokinetic studies of antibiotic dosing in APD.
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Affiliation(s)
- Ann Mancini
- Baxter Healthcare Corporation, Renal Division, Deerfield, IL, USA
| | - Beth Piraino
- Renal Electrolyte Division at The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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13
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Lee A. Swimming on Peritoneal Dialysis: Recommendations from Australian PD Units. Perit Dial Int 2019; 39:527-531. [PMID: 31582469 DOI: 10.3747/pdi.2018.00254] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/01/2019] [Indexed: 11/15/2022] Open
Abstract
Background:There is no evidence to support the need for protection of the peritoneal dialysis (PD) catheter and exit site for people on PD who want to swim. Swimming with a PD catheter is perceived to potentially put that person at increased risk of infection. Objectives of this study were to determine the proportion of Australian PD units supporting swimming for people on PD, recommendations made to protect the PD catheter, and exit site and any subsequent infective complications.Method:Phone surveys were conducted with PD nurses from a cross section of 39 Australian PD units.Results:Almost all units reported that patients on PD do swim despite only 77% of units advocating swimming. Swimming in sea water (85%) or a private swimming pool (90%) is mostly recommended. Covering the exit site and PD catheter is recommended with a waterproof film dressing or colostomy bag. Performing routine exit-site care after swimming is recommended (100%). There were 7 reported exit-site infections and 2 episodes of peritonitis perceived to be associated with swimming with a PD catheter.Conclusion:Most PD units in Australia report that patients on PD swim. Swimming is recommended in either sea water or private swimming pools. The PD catheter and exit site should be covered with either a clear waterproof dressing or colostomy bag. Routine exit-site care should be performed after swimming. Infections were rarely reported in those who swim. Until further research is available, best practice recommendations are warranted for the safety of those on PD who want to swim.
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Affiliation(s)
- Anna Lee
- Renal Nurse Practitioner Renal Services, Illawarra Shoalhaven Local Health District (ISLHD), New South Wales, Australia
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14
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Vernier I, Fabre E, Dratwa M, Verger C. Peritoneal catheter infections : data from the French language peritoneal dialysis registry (RDPLF), risk factors. BULLETIN DE LA DIALYSE À DOMICILE 2019. [DOI: 10.25796/bdd.v2i3.21383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Peritoneal catheter infections : data from the French language peritoneal dialysis registry (RDPLF), risk factors
The French Language Peritoneal Dialysis Registry (RDPLF) record since 1997 all data dealing with peritoneal catheter insertion and follow up.
The aim of this study is to analyze catheter infections on 10801 catheters in 144 centres from January 1, 1997 and December 31, 2018.
Infections are more common in the first month and 50% occur before the tenth month. The risk of infection increases in case of wall hematoma, initial fluid leakage, and obesity. It decreases with the use of prophylactic antibiotics at the time of catheter insertion, with experienced operator, if the first dressing is delayed for 7 days, and with mupirocin as exit-site prophylaxis.
During last two decades the percentage of Staphylococcus aureus infections has decreased, whereas the proportion of Pseudomonas, Corynebacterium and other Gram + cocci increased.
The incidence of catheter infections is low compared to literature data: it decreased to 0.16 episodes per year for the 2013-2017 period.
Adherence to ISPD guidelines: preoperative antibioprophylaxis is the most followed guideline (70.7% of catheter implantations in 2018). Local antibioprophylaxis concerns only 15.6% of catheters, and remains concentrated in a few centres ; mupirocin is the most frequently used agent. Screening for nasal carriage of S. aureus is performed in only 42% of cases.
The catheter section of the RDPLF has allowed the follow-up of clinical practices incidence of infections and ecology for 21 years, both at the national and center level Our study confirms a wide variability in clinical practices, compared to ISPD guidelines.
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15
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Lanot A, Bechade C, Verger C, Fabre E, Vernier I, Lobbedez T. Patterns of peritoneal dialysis catheter practices and technique failure in peritoneal dialysis: A nationwide cohort study. PLoS One 2019; 14:e0218677. [PMID: 31220171 PMCID: PMC6586404 DOI: 10.1371/journal.pone.0218677] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/06/2019] [Indexed: 11/27/2022] Open
Abstract
Introduction Our objective was to assess whether clusters of centers with similar peritoneal dialysis (PD) catheter related practices were associated with differences in the risk of technique failure. Methods Patients on incident PD in French centers contributing to the French Language PD Registry from 2012 to 2016 were included in a retrospective analysis of prospectively collected data. Centers with similar catheter cares practices were gathered in clusters in a hierarchical analysis. Clusters of centers associated with technique failure were evaluated using Cox and Fine and Gray models. A mixed effect Cox model was used to assess the influence of a center effect, as explained by the clusters. Results Data from 2727 catheters placed in 64 centers in France were analyzed. Five clusters of centers were identified. After adjustment for patient-level characteristics, the fourth cluster was associated with a lower risk of technique failure (cause specific-HR 0.70, 95%CI 0.54–0.90. The variance of the center effect decreased by 5% after adjusting for patient characteristics and by 26% after adjusting for patient characteristics and clusters of centers in the mixed effect Cox model. Favorable outcomes were observed in clusters with a greater proportion of community hospitals, where catheters were placed via open surgery, first dressing done 6 to 15 days after catheter placement, and local prophylactic antibiotics was applied on exit-site. Conclusion Several patterns of PD catheter related practices have been identified in France, associated with differences in the risk of technique failure. Combinations of favorable practices are suggested in this study.
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Affiliation(s)
- Antoine Lanot
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Néphrologie, CAEN, France
- Normandie université, Unicaen, UFR de médecine, Caen, France
- * E-mail:
| | - Clemence Bechade
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Néphrologie, CAEN, France
| | | | | | - Isabelle Vernier
- RDPLF, Pontoise, France
- Néphrologie, polyclinique le Languedoc, Narbonne, France
| | - Thierry Lobbedez
- Normandie Univ, UNICAEN, CHU de Caen Normandie, Néphrologie, CAEN, France
- Normandie université, Unicaen, UFR de médecine, Caen, France
- RDPLF, Pontoise, France
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16
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Chow JSF, Cho Y, Equinox KL, Figueiredo A, Frasca S, Hawley C, Howard K, Johnson DW, Jose M, Lee A, Maley M, Moodie JA, Brent PA, Pascoe E, Reidinger D, Steiner GZ, Tomlins M, Voss D, Woodward P, Boudville N. An Intervention Design: Supporting Skills Development for Peritoneal Dialysis Trainers. Perit Dial Int 2019; 39:134-141. [PMID: 30661004 DOI: 10.3747/pdi.2018.00159] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 09/11/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD) is a home-based therapy where nurses train patients in its use. There has been no published randomized controlled trial (RCT) evaluating any specific protocol for nurses delivering PD training. A standardized education package based upon the best available evidence and utilizing modern educational practices may lead to improved patient outcomes. The aim is to develop a standardized, evidence-based curriculum for PD trainers and patients aligned with guidelines from the International Society for Peritoneal Dialysis (ISPD), using best practice pedagogy. METHODS A literature search and clinical audit were conducted to identify current practice patterns and best practice. Results were reviewed by a focus group of practitioners comprising PD nurses, nephrologists, consumers, a medical education expert, and an eLearning expert. From this, a training curriculum and modules were developed. RESULTS A comprehensive PD training curriculum has been developed, which includes modules for training PD nurses (trainers) and patient training manuals. The package comprises 2 introductory modules and 2 clinical case modules. The curriculum is designed for both interactive digital media (trainers) and traditional paper-based teaching with practical demonstrations (patients). Assessment is also addressed. CONCLUSION The need for the development of a comprehensive and standardized curriculum for PD nurse trainers and their patients was confirmed. This paper outlines the process of the development of this curriculum. Pilot testing of the modules was launched in late 2017 to examine feasibility, and planning has commenced for a RCT in 2019 to investigate the effect of the modules on clinical outcomes, and their wider application across Australia and New Zealand.
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Affiliation(s)
- Josephine S F Chow
- Clinical Innovation & Business Unit, South Western Sydney Local Health District, Sydney, Australia .,Faculty of Nursing, University of Sydney, Sydney, Australia.,School of Health Science, University of Tasmania, Tasmania, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Instittue, Brisbane, Australia
| | - Keri-Lu Equinox
- Department of Renal Medicine, Cairns Hospital, Sydney, Australia
| | - Ana Figueiredo
- School of Health Sciences, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Serena Frasca
- Central Northern Adelaide Renal and Transplantation Service, Adelaide, Australia
| | - Carmel Hawley
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Instittue, Brisbane, Australia
| | - Kirsten Howard
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia.,Translational Research Instittue, Brisbane, Australia
| | - Matthew Jose
- School of Medicine, University of Tasmania, Tasmania, Australia
| | - Anna Lee
- Department of Renal Medicine, Illawarra Shoalhaven Local Health District, NSW, Australia
| | - Moira Maley
- Medical School, University of Western Australia, Perth, Australia
| | - Jo-Anne Moodie
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Peta-Anne Brent
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Elaine Pascoe
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Donna Reidinger
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Genevieve Z Steiner
- NICM Health Research Institute and Translational Health Research Institute (THRI), Western Sydney University, Penrith, Australia
| | - Melinda Tomlins
- Department of Renal Medicine, Hunter New England Local Health District, New Lambton, Australia
| | - David Voss
- Renal Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Paula Woodward
- The Med Collective (Medical Education and Communications), Sydney, Australia
| | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
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17
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Cho Y, Htay H, Johnson DW. Centre effects and peritoneal dialysis-related peritonitis. Nephrol Dial Transplant 2018; 32:913-915. [PMID: 28505351 DOI: 10.1093/ndt/gfx054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia.,Australasian Kidney Trial Network, Centre for Health Services Research, University of Queensland, Brisbane, Australia
| | - Htay Htay
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia.,Australasian Kidney Trial Network, Centre for Health Services Research, University of Queensland, Brisbane, Australia.,Department of Nephrology, Singapore General Hospital, Singapore
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia.,Australasian Kidney Trial Network, Centre for Health Services Research, University of Queensland, Brisbane, Australia
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18
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Peritoneal dialysis-related peritonitis caused by Pseudomonas species: Insight from a post-millennial case series. PLoS One 2018; 13:e0196499. [PMID: 29746497 PMCID: PMC5944923 DOI: 10.1371/journal.pone.0196499] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/11/2018] [Indexed: 11/19/2022] Open
Abstract
Background Pseudomonas peritonitis is a serious complication of peritoneal dialysis (PD). However, the clinical course of Pseudomonas peritonitis following the adoption of international guidelines remains unclear. Methods We reviewed the clinical course and treatment response of 153 consecutive episodes of PD peritonitis caused by Pseudomonas species from 2001 to 2015. Results Pseudomonas peritonitis accounted for 8.3% of all peritonitis episodes. The bacteria isolated were resistant to ceftazidime in 32 cases (20.9%), and to gentamycin in 18 cases (11.8%). In 20 episodes (13.1%), there was a concomitant exit site infection (ESI); in another 24 episodes (15.7%), there was a history of Pseudomonas ESI in the past. The overall primary response rate was 53.6%, and complete cure rate 42.4%. There was no significant difference in the complete cure rate between patients who treated with regimens of 3 and 2 antibiotics. Amongst 76 episodes (46.4%) that failed to respond to antibiotics by day 4, 37 had immediate catheter removal; the other 24 received salvage antibiotics, but only 6 achieved complete cure. Conclusions Antibiotic resistance is common amongst Pseudomonas species causing peritonitis. Adoption of the treatment guideline leads to a reasonable complete cure rate of Pseudomonas peritonitis. Treatment with three antibiotics is not superior than the conventional two antibiotics regimen. When there is no clinical response after 4 days of antibiotic treatment, early catheter removal should be preferred over an attempt of salvage antibiotic therapy.
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19
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Htay H, Cho Y, Pascoe EM, Darssan D, Nadeau-Fredette AC, Hawley C, Clayton PA, Borlace M, Badve SV, Sud K, Boudville N, McDonald SP, Johnson DW. Center Effects and Peritoneal Dialysis Peritonitis Outcomes: Analysis of a National Registry. Am J Kidney Dis 2017; 71:814-821. [PMID: 29289475 DOI: 10.1053/j.ajkd.2017.10.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 10/11/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Peritonitis is a common cause of technique failure in peritoneal dialysis (PD). Dialysis center-level characteristics may influence PD peritonitis outcomes independent of patient-level characteristics. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data, all incident Australian PD patients who had peritonitis from 2004 through 2014 were included. PREDICTORS Patient- (including demographic data, causal organisms, and comorbid conditions) and center- (including center size, proportion of patients treated with PD, and summary measures related to type, cause, and outcome of peritonitis episodes) level predictors. OUTCOMES & MEASUREMENT The primary outcome was cure of peritonitis with antibiotics. Secondary outcomes were peritonitis-related catheter removal, hemodialysis therapy transfer, peritonitis relapse/recurrence, hospitalization, and mortality. Outcomes were analyzed using multilevel mixed logistic regression. RESULTS The study included 9,100 episodes of peritonitis among 4,428 patients across 51 centers. Cure with antibiotics was achieved in 6,285 (69%) peritonitis episodes and varied between 38% and 86% across centers. Centers with higher proportions of dialysis patients treated with PD (>29%) had significantly higher odds of peritonitis cure (adjusted OR, 1.21; 95% CI, 1.04-1.40) and lower odds of catheter removal (OR, 0.78; 95% CI, 0.62-0.97), hemodialysis therapy transfer (OR, 0.78; 95% CI, 0.62-0.97), and peritonitis relapse/recurrence (OR, 0.68; 95% CI, 0.48-0.98). Centers with higher proportions of peritonitis episodes receiving empirical antibiotics covering both Gram-positive and Gram-negative organisms had higher odds of cure with antibiotics (OR, 1.22; 95% CI, 1.06-1.42). Patient-level characteristics associated with higher odds of cure were younger age and less virulent causative organisms (coagulase-negative staphylococci, streptococci, and culture negative). The variation in odds of cure across centers was 9% higher after adjustment for patient-level characteristics, but 66% lower after adjustment for center-level characteristics. LIMITATIONS Retrospective study design using registry data. CONCLUSIONS These results suggest that center effects contribute substantially to the appreciable variation in PD peritonitis outcomes that exist across PD centers within Australia.
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Affiliation(s)
- Htay Htay
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia; Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Yeoungjee Cho
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia
| | - Elaine M Pascoe
- Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia
| | - Darsy Darssan
- Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia
| | | | - Carmel Hawley
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - Monique Borlace
- Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital, Adelaide, Australia
| | - Sunil V Badve
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Nephrology, St George Hospital, Sydney, Australia
| | - Kamal Sud
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Renal Medicine, Nepean Hospital, Sydney, Australia; Department of Renal Medicine, Westmead Hospital, Sydney, Australia; University of Sydney Medical School, Sydney, Australia
| | - Neil Boudville
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Central Northern Adelaide Renal and Transplantation Service; Royal Adelaide Hospital, Adelaide, Australia; School of Medicine, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia
| | - David W Johnson
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trial Network, Diamantina Institute, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia.
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20
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Nataatmadja M, Cho Y, Johnson DW. Continuous Quality Improvement Initiatives to Sustainably Reduce Peritoneal Dialysis-Related Infections in Australia and New Zealand. Perit Dial Int 2017; 36:472-7. [PMID: 27659926 DOI: 10.3747/pdi.2016.00114] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia Translational Research Institute, Brisbane, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia Translational Research Institute, Brisbane, Australia Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
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21
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Htay H, Cho Y, Pascoe EM, Darssan D, Nadeau-Fredette AC, Hawley C, Clayton PA, Borlace M, Badve SV, Sud K, Boudville N, McDonald SP, Johnson DW. Multicenter Registry Analysis of Center Characteristics Associated with Technique Failure in Patients on Incident Peritoneal Dialysis. Clin J Am Soc Nephrol 2017; 12:1090-1099. [PMID: 28637862 PMCID: PMC5498362 DOI: 10.2215/cjn.12321216] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 04/04/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Technique failure is a major limitation of peritoneal dialysis. Our study aimed to identify center- and patient-level predictors of peritoneal dialysis technique failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS All patients on incident peritoneal dialysis in Australia from 2004 to 2014 were included in the study using data from the Australia and New Zealand Dialysis and Transplant Registry. Center- and patient-level characteristics associated with technique failure were evaluated using Cox shared frailty models. Death-censored technique failure and cause-specific technique failure were analyzed as secondary outcomes. RESULTS The study included 9362 patients from 51 centers in Australia. The technique failure rate was 0.35 (95% confidence interval, 0.34 to 0.36) episodes per patient-year, with a sevenfold variation across centers that was mainly associated with center-level characteristics. Technique failure was significantly less likely in centers with larger proportions of patients treated with peritoneal dialysis (>29%; adjusted hazard ratio, 0.83; 95% confidence interval, 0.73 to 0.94) and more likely in smaller centers (<16 new patients per year; adjusted hazard ratio, 1.10; 95% confidence interval, 1.00 to 1.21) and centers with lower proportions of patients achieving target baseline serum phosphate levels (<40%; adjusted hazard ratio, 1.15; 95% confidence interval, 1.03 to 1.29). Similar results were observed for death-censored technique failure, except that center target phosphate achievement was not significantly associated. Technique failure due to infection, social reasons, mechanical causes, or death was variably associated with center size, proportion of patients on peritoneal dialysis, and/or target phosphate achievement, automated peritoneal dialysis exposure, icodextrin use, and antifungal use. The variation of hazards of technique failure across centers was reduced by 28% after adjusting for patient-specific factors and an additional 53% after adding center-specific factors. CONCLUSIONS Technique failure varies widely across centers in Australia. A significant proportion of this variation is related to potentially modifiable center characteristics, including peritoneal dialysis center size, proportion of patients on peritoneal dialysis, and proportion of patients on peritoneal dialysis achieving target phosphate level.
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Affiliation(s)
- Htay Htay
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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22
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Chan S, Cho Y, Koh YH, Boudville NC, Clayton PA, McDonald SP, Pascoe EM, Francis RS, Mudge DW, Borlace M, Badve SV, Sud K, Hawley CM, Johnson DW. Association of Socio-Economic Position with Technique Failure and Mortality in Australian Non-Indigenous Peritoneal Dialysis Patients. Perit Dial Int 2017; 37:397-406. [PMID: 28183859 DOI: 10.3747/pdi.2016.00209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/03/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Few studies have examined the relationship between socio-economic position (SEP) and peritoneal dialysis (PD) outcomes, particularly at a country level. The aim of this study was to investigate the relationships between SEP, technique failure, and mortality in PD patients undertaking treatment in Australia. METHODS The study included all Australian non-indigenous incident PD patients between January 1, 1997, and December 31, 2014, using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. The SEP was assessed by quartiles of postcode-based Australian Socio-Economic Indexes for Areas (SEIFA), including Index of Relative Socio-economic Advantage and Disadvantage (IRSAD - primary index), Index of Relative Socio-economic Disadvantage (IRSD), Index of Economic Resources (IER), and Index of Education and Occupation (IEO). Technique and patient survival were evaluated by multivariable Cox proportional hazards survival analyses. RESULTS The study included 9,766 patients (mean age 60.6 ± 15 years, 57% male, 38% diabetic). Using multivariable Cox regression, no significant association was observed between quartiles of IRSAD and technique failure (30-day definition p = 0.65, 180-day definition p = 0.68). Similar results were obtained using competing risks regression. However, higher SEP, defined by quartiles of IRSAD, was associated with better patient survival (Quartile 1 reference; Quartile 2 adjusted hazards ratio [HR] 0.96, 95% confidence interval [CI] 0.86 - 1.06; Quartile 3 HR 0.87, 95% CI 0.77 - 0.99; Quartile 4 HR 0.86, 95% CI 0.76 - 0.97). Similar results were found when IRSD was analyzed, but results were no longer statistically significant for IER and IEO. CONCLUSIONS In Australia, where there is universal free healthcare, SEP was not associated with PD technique failure in non-indigenous PD patients. Higher SEP was generally associated with improved patient survival.
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Affiliation(s)
- Samuel Chan
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Yeoungjee Cho
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Yung H Koh
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Neil C Boudville
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Sir Charles Gairdner Hospital Unit, The University of Western Australia, Perth, Australia
| | - Philip A Clayton
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen P McDonald
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Elaine M Pascoe
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ross S Francis
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David W Mudge
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Monique Borlace
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Sunil V Badve
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Nephrology, St. George Hospital, Sydney, Australia
| | - Kamal Sud
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Departments of Renal Medicine, Nepean and Westmead Hospitals, Sydney, Australia.,School of Medicine, Faculty of Health Sciences, University of Adelaide
| | - Carmel M Hawley
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - David W Johnson
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, South Australia, Australia .,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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23
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Li PKT, Chow KM, Van de Luijtgaarden MWM, Johnson DW, Jager KJ, Mehrotra R, Naicker S, Pecoits-Filho R, Yu XQ, Lameire N. Changes in the worldwide epidemiology of peritoneal dialysis. Nat Rev Nephrol 2016; 13:90-103. [PMID: 28029154 DOI: 10.1038/nrneph.2016.181] [Citation(s) in RCA: 323] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
As the global burden of chronic kidney disease continues to increase, so does the need for a cost-effective renal replacement therapy. In many countries, patient outcomes with peritoneal dialysis are comparable to or better than those with haemodialysis, and peritoneal dialysis is also more cost-effective. These benefits have not, however, always led to increased utilization of peritoneal dialysis. Use of this therapy is increasing in some countries, including China, the USA and Thailand, but has proportionally decreased in parts of Europe and in Japan. The variable trends in peritoneal dialysis use reflect the multiple challenges in prescribing this therapy to patients. Key strategies for facilitating peritoneal dialysis utilization include implementation of policies and incentives that favour this modality, enabling the appropriate production and supply of peritoneal dialysis fluid at a low cost, and appropriate training for nephrologists to enable increased utilization of the therapy and to ensure that rates of technique failure continue to decline. Further growth in peritoneal dialysis use is required to enable this modality to become an integral part of renal replacement therapy programmes worldwide.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Carol &Richard Yu PD Research Centre, Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Kai Ming Chow
- Department of Medicine and Therapeutics, Carol &Richard Yu PD Research Centre, Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong
| | - Moniek W M Van de Luijtgaarden
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Centre, University of Amsterdam, PO Box 22700, Amsterdam 1100 DE, Netherlands
| | - David W Johnson
- Department of Nephrology, Division of Medicine, ARTS Building, University of Queensland at Princess Alexandra Hospital, Woolloongabba, Queensland 4102, Australia
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Centre, University of Amsterdam, PO Box 22700, Amsterdam 1100 DE, Netherlands
| | - Rajnish Mehrotra
- Kidney Research Institute and Harborview Medical Center, Division of Nephrology, University of Washington, 325 9th Avenue, BOX 359606, Seattle, Washington 98104, USA
| | - Sarala Naicker
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg, 2193, South Africa
| | | | - Xue Qing Yu
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - Norbert Lameire
- University Hospital Gent, 185, De Pintelaan, BE-9000 Gent, Belgium
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24
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Jha V. Setting up a national dialysis service in India: Change, choice and principles. Nephrology (Carlton) 2016; 21:913-915. [DOI: 10.1111/nep.12803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 04/17/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Vivekanand Jha
- George Institute for Global Health India and Professor of Nephrology; University of Oxford
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25
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Toussaint ND, McMahon LP, Dowling G, Holt SG, Smith G, Safe M, Knight R, Fair K, Linehan L, Walker RG, Power DA. Introduction of Renal Key Performance Indicators Associated with Increased Uptake of Peritoneal Dialysis in a Publicly Funded Health Service. Perit Dial Int 2016; 37:198-204. [PMID: 27680765 DOI: 10.3747/pdi.2016.00149] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 08/17/2016] [Indexed: 11/15/2022] Open
Abstract
♦ BACKGROUND: Increased demand for treatment of end-stage kidney disease has largely been accommodated by a costly increase in satellite hemodialysis (SHD) in most jurisdictions. In the Australian State of Victoria, a marked regional variation in the uptake of home-based dialysis suggests that use of home therapies could be increased as an alternative to SHD. An earlier strategy based solely on increased remuneration had failed to increase uptake of home therapies. Therefore, the public dialysis funder adopted the incidence and prevalence of home-based dialysis therapies as a key performance indicator (KPI) for its health services to encourage greater uptake of home therapies. ♦ METHODS: A KPI data collection and bench-marking program was established in 2012 by the Victorian Department of Health and Human Services, with data provided monthly by all renal units in Victoria using a purpose-designed website portal. A KPI Working Group was responsible for analyzing data each quarter and ensuring indicators remained accurate and relevant and each KPI had clear definitions and targets. We present a prospective, observational study of all dialysis patients in Victoria over a 4-year period following the introduction of the renal KPI program, with descriptive analyses to evaluate the proportion of patients using home therapies as well as home dialysis modality survival. ♦ RESULTS: Following the introduction of the KPI program, the net growth of dialysis patient numbers in Victoria remained stable over 4 years, at 75 - 80 per year (approximately 4%). However, unlike the previous decade, about 40% of this growth was through an increase in home dialysis, which was almost exclusively peritoneal dialysis (PD). The increase was identified particularly in the young (20 - 49) and the elderly (> 80). Disappointingly, however, 67% of these incident patients ceased PD within 2 years of commencement, 46% of whom transferred to SHD. ♦ CONCLUSIONS: Introduction of a KPI program was associated with an increased uptake of PD but not home HD. This change in clinical practice restricted growth of SHD and reduced pressure on satellite services. The effect was offset by a modest PD technique survival. Many patients in whom PD was unsuccessful were subsequently transferred to SHD rather than home HD.
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Affiliation(s)
- Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, VIC, Australia .,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Lawrence P McMahon
- Department of Renal Medicine, Eastern Health, Box Hill, VIC, Australia.,Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Gregory Dowling
- Department of Health and Human Services, Melbourne, VIC, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Gillian Smith
- Department of Health and Human Services, Melbourne, VIC, Australia
| | - Maria Safe
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Richard Knight
- Department of Renal Medicine, Barwon Health, Geelong, VIC, Australia
| | - Kathleen Fair
- Department of Nephrology, Bendigo Health, Bendigo, VIC, Australia
| | - Leanne Linehan
- Department of Nephrology, Monash Health, Clayton, VIC, Australia
| | - Rowan G Walker
- Department of Nephrology, Alfred Hospital, Prahran, VIC, Australia
| | - David A Power
- Department of Medicine, The University of Melbourne, Parkville, VIC, Australia.,Department of Nephrology, Austin Health, Heidelberg, VIC, Australia
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