Timing, causes, predictors and prognosis of switching from peritoneal dialysis to hemodialysis: a prospective study

Retroperitoneal leakage as an important cause of acquired ultrafiltration decline in peritoneal dialysis: clinical characteristics and related risk factors

BACKGROUND

Peritoneal dialysis (PD) is a widely-used renal replacement therapy while low ultrafiltration volume usually results in technique failure. Retroperitoneal leakage has been reported to be one of the causes of acquired decline in ultrafiltration. The present study investigated retroperitoneal leakage in PD patients and explored related risk factors.

METHODS

This study was designed as a prospective, observational study. A total of 420 PD patients regularly followed up at our center were enrolled from May 2011 to July 2021 and followed until December 2021. Retroperitoneal leakage was determined by magnetic resonance peritoneography and was used as the endpoint. Patients with retroperitoneal leakage were given intermittent PD or temporary hemodialysis (HD) as therapy. Cox regression models were used to identify risk factors for retroperitoneal leakage.

RESULTS

The cohort was followed up for up to 125.0 months (median: 46.4 months; interquartile range: 16.6 months). During the follow-up, 68 patients developed retroperitoneal leakage, with 31 (45.6%) cases occurring within the first year after PD initiation. A total of 62 (91.2%) patients recovered from retroperitoneal leakage and resumed their original PD regimen. Multivariate Cox regression analysis revealed that age and gender were independent predictors for retroperitoneal leakage. Younger males were more likely to develop retroperitoneal leakage. In females, waistline and body mass index (BMI) were found to be risk factors for retroperitoneal leakage.

CONCLUSIONS

Retroperitoneal leakage was common in PD patients with ultrafiltration insufficiency and was usually reversible after appropriate treatment. Age and gender were independent risk factors for retroperitoneal leakage.

Discontinuation of maintenance peritoneal dialysis in children-A 10-year review from a single center in a low resource setting

INTRODUCTION

In South Africa, only children considered eligible for transplantation are offered dialysis as bridge to kidney transplantation. Maintenance peritoneal dialysis (PD) is preferred and has several advantages over hemodialysis (HD). While awaiting transplantation, PD may be discontinued due to permanent transfer to HD or death while on PD, of which the occurrence and burden is not known in our setting. We investigated the rate of discontinuation of maintenance PD, and associated factors among children awaiting a kidney transplant under challenging socio-economic circumstances in a low resource setting.

METHODS

Single center retrospective analysis of children receiving maintenance PD. Outcomes included the proportion of children who discontinued PD before transplantation, associated factors and timing of discontinuation, and the proportion transplanted. Time to discontinuation or transplantation was displayed using a Kaplan-Meier curve.

RESULTS

Sixty-seven children who received maintenance automated PD as initial dialysis modality were identified from the kidney transplant waiting list between January 2009 and December 2018. Complete data was available for 52 of the 67 children. Four children had prior failed kidney transplants. The median age was 11 years (interquartile range 6.0, 13.1). Overall, 17/52 (32.7%) children discontinued PD, with 13 (25%) transfers to HD and 4 deaths (7.7%), whereas 29/52 (55.8%) received a kidney transplant. Three of the deaths were PD related. Six children remained on maintenance PD at the end of the study period. Over a half of our patients discontinued PD by 12 months, and 80% by 30 months. Most PD discontinuations were associated with peritonitis.

CONCLUSIONS

The proportion discontinuing PD was high, highlighting the need to optimize measures to improve retention rates, especially through prevention of peritonitis.

Diagnostic Accuracy of MMP-8 and IL-6-Based Point-of-Care Testing to Detect Peritoneal Dialysis-Related Peritonitis: A Single-Center Experience

BACKGROUND

Peritoneal dialysis-related peritonitis (PDRP) is the most common complication of peritoneal dialysis (PD), which can lead to poor outcomes if not diagnosed and treated early. We aimed to investigate the diagnostic accuracy of MMP-8 and IL-6-based point-of-care tests (POCTs) in diagnosing PDRP in PD patients.

METHODS

This retrospective chart review study was conducted at a comprehensive kidney center in Qatar. It involved all adult PD patients who underwent PDRP from July 2018 to October 2019 and for whom MMP-8 and IL-6-based POCTs were used to diagnose presumptive peritonitis. Measures of diagnostic accuracy were computed. Peritoneal fluid effluent analysis was the reference standard.

RESULTS

We included 120 patients (68 [56.7%] females, ages 55.6 ± 15.6 years, treatment duration 39.5 ± 30.4 months [range: 5-142 months]). In this population, MMP-8 and IL-6-based POCTs yielded 100% in all dimensions of diagnostic accuracy (sensitivity, specificity, positive and negative predictive values).

CONCLUSIONS

MMP-8 and IL-6-based POCTs might be helpful in the early detection of PDRP. This monocentric observation requires further confirmation in a prospective multicentric setting.

Efficacy of sucrose and povidone-iodine mixtures in peritoneal dialysis catheter exit-site care

BACKGROUND

Exit-site infection (ESI) is a common recurring complication in patients undergoing peritoneal dialysis (PD). Sucrose and povidone-iodine (SPI) mixtures, antimicrobial ointments that promote wound healing, have been used for the treatment of ulcers and burns, but their efficacy in exit-site care is still unclear.

METHODS

This single-center retrospective observational study included patients who underwent PD between May 2010 and June 2022 and presented with episodes of ESI. Patients were divided into SPI and non-SPI groups and followed up from initial ESI onset until PD cessation, death, transfer to another facility, or June 2023.

RESULTS

Among the 82 patients (mean age 62, [54-72] years), 23 were treated with SPI. The median follow-up duration was 39 months (range, 14-64), with an overall ESI incidence of 0.70 episodes per patient-year. Additionally, 43.1% of second and 25.6% of third ESI were caused by the same pathogen as the first. The log-rank test demonstrated significantly better second and third ESI-free survival in the SPI group than that in the non-SPI group (p < 0.01 and p < 0.01, respectively). In a Cox regression analysis, adjusting for potential confounders, SPI use was a significant predictor of decreased second and third ESI episodes (hazard ratio [HR], 0.22; 95% confidence interval [CI], 0.10-0.52 and HR, 0.22; 95%CI, 0.07-0.73, respectively).

CONCLUSIONS

Our results showed that the use of SPI may be a promising option for preventing the incidence of ESI in patients with PD.

TRIAL REGISTRATION

This study was approved by the Keio University School of Medicine Ethics Committee (approval number 20231078) on August 28, 2023. Retrospectively registered.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Nephrologists' perspectives on communication and decision-making regarding technique survival in peritoneal dialysis: an international qualitative interview study

OBJECTIVES

Peritoneal dialysis (PD) allows patients increased autonomy and flexibility; however, both infectious and non-infectious complications may lead to technique failure, which shortens treatment longevity. Maintaining patients on PD remains a major challenge for nephrologists. This study aims to describe nephrologists' perspectives on technique survival in PD.

DESIGN

Qualitative semistructured interview study. Transcripts were thematically analysed.

SETTING AND PARTICIPANTS

30 nephrologists across 11 countries including Australia, the USA, the UK, Hong Kong, Canada, Singapore, Japan, New Zealand, Thailand, Colombia and Uruguay were interviewed from April 2017 to November 2019.

RESULTS

We identified four themes: defining patient suitability (confidence in capacity for self-management, ensuring clinical stability and expected resilience), building endurance (facilitating access to practical support, improving mental well-being, optimising quality of care and training to reduce risk of complications), establishing rapport through effective communications (managing expectations to enhance trust, individualising care and harnessing a multidisciplinary approach) and confronting fear and acknowledging barriers to haemodialysis (preventing crash landing to haemodialysis, facing concerns of losing independence and positive framing of haemodialysis).

CONCLUSION

Nephrologists reported that technique survival in PD is influenced by patients' medical circumstances, psychological motivation and positively influenced by the education and support provided by treating clinicians and families. Strategies to enhance patients' knowledge on PD and communication with patients about technique survival in PD are needed to build trust, set patient expectations of treatment and improve the process of transition off PD.

Assessing knowledge of end-stage kidney disease and treatment options in hospitalized African American patients undergoing hemodialysis

OBJECTIVE

African Americans are more likely to develop end-stage kidney disease (ESKD) than whites and face multiple inequities regarding ESKD treatment, renal replacement therapy (RRT), and overall care. This study focused on determining gaps in participants' knowledge of their chronic kidney disease and barriers to RRT selection in an effort to identify how we can improve health care interventions and health outcomes among this population.

METHODS

African American participants undergoing hemodialysis were recruited from an ongoing research study of hospitalized patients at an urban Midwest academic medical center. Thirty-three patients were interviewed, and the transcribed interviews were entered into a software program. The qualitative data were coded using template analysis to analyze text and determine key themes. Medical records were used to obtain demographic and additional medical information.

RESULTS

Three major themes emerged from the analysis: patients have limited information on ESKD causes and treatments, patients did not feel they played an active role in selecting their initial dialysis unit, and interpersonal interactions with the dialysis staff play a large role in overall unit satisfaction.

DISCUSSION

Although more research is needed, this study provides information and suggestions to improve future interventions and care quality, specifically for this population.

Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register

RATIONALE & OBJECTIVE

The integrated home dialysis model proposes the initiation of kidney replacement therapy (KRT) with peritoneal dialysis (PD) and a timely transition to home hemodialysis (HHD) after PD ends. We compared the outcomes of patients transitioning from PD to HHD with those initiating KRT with HHD.

STUDY DESIGN

Observational analysis of the Canadian Organ Replacement Register (CORR).

SETTINGS & PARTICIPANTS

All patients who initiated PD or HHD within the first 90 days of KRT between 2005 and 2018.

EXPOSURE

Patients transitioning from PD to HHD (PD+HHD group) versus patients initiating KRT with HHD (HHD group).

OUTCOME

(1) A composite of all-cause mortality and modality transfer (to in-center hemodialysis or PD for 90 days) and (2) all hospitalizations (considered as recurrent events).

ANALYTICAL APPROACH

A propensity score analysis for which PD+HHD patients were matched 1:1 to (1) incident HHD patients ("incident-match" analysis) or (2) HHD patients with a KRT vintage at least equivalent to the vintage of PD+HHD patients at the transition time ("vintage-matched" analysis). Cause-specific hazards models (composite outcome) and shared frailty models (hospitalization) were used to compare groups.

RESULTS

Among 63,327 individuals in the CORR, 163 PD+HHD patients (median of 1.9 years in PD) and 711 HHD patients were identified. In the incident-match analysis, compared to the HHD patients, the PD+HHD group had a similar risk of the composite outcome (HR, 0.88 [95% CI, 0.58-1.32]) and hospitalizations (HR, 1.04 [95% CI, 0.76-1.41]). In the vintage-match analysis, PD+HHD patients had a lower hazard for the composite outcome (HR, 0.61 [95% CI, 0.40-0.94]) but a similar hospitalization risk (HR, 0.85 [95% CI, 0.59-1.24]).

LIMITATIONS

Risk of survivor bias in the PD+HHD cohort and residual confounding.

CONCLUSIONS

Controlling for KRT vintage, the patients transitioning from PD to HHD had better clinical outcomes than the incident HHD patients. These data support the use of integrated home dialysis for patients initiating home-based KRT.

PLAIN-LANGUAGE SUMMARY

The integrated home dialysis model proposes the initiation of dialysis with peritoneal dialysis (PD) and subsequent transition to home hemodialysis (HHD) once PD is no longer feasible. It allows patients to benefit from initial lifestyle advantages of PD and to continue home-based treatments after its termination. However, some patients may prefer to initiate dialysis with HHD from the outset. In this study, we compared the long-term clinical outcomes of both approaches using a large Canadian dialysis register. We found that both options led to a similar risk of hospitalization. In contrast, the PD-to-HHD model led to improved survival when controlling for the duration of kidney failure.

Clinical impact of catheter insertion for peritoneal dialysis on patient survival and catheter-related complications

OBJECTIVES

The stepwise initiation of peritoneal dialysis (PD) using Moncrief and Popovich's technique (SMAP) for catheter insertion is recommended for the systemic introduction of PD and prevention of catheter-related infections. In this study, we investigated patient outcomes in patients who underwent insertion of a PD catheter with a direct method versus the SMAP method.

METHODS

We enrolled 295 consecutive patients who underwent PD as a primary renal replacement therapy and underwent insertion of a PD catheter at our institute between 2006 and 2021. We retrospectively reviewed their data and investigated patient outcomes, including mortality and PD catheter-related complications.

RESULTS

Median age at PD induction was 65 years in the direct insertion group and 65 years in the SMAP group (P = 0.80). The rate of PD introduction after emergency hemodialysis was significantly higher in the direct insertion group than in the SMAP group (P < 0.001). There was no significant difference in survival between the direct insertion and SMAP groups during the median follow-up period of 54 months (P = 0.12). Additionally, patients who transitioned to hemodialysis or kidney transplantation after PD showed significantly longer survival (P < 0.001). The incidence of PD catheter-related complications was not significantly different between the two groups. A body mass index ≥ 23 kg/m2 was an independent risk factor for peritonitis and exit-site infection (P = 0.006 and P = 0.011, respectively).

CONCLUSIONS

Planned sequential renal replacement therapy including hybrid hemodialysis, complete hemodialysis, and kidney transplantation after PD is important for improving patient outcomes. PD catheter insertion by SMAP may not be mandatory in our clinical practice.

The use of mini-invasive surgical techniques to treat refractory exit-site and tunnel infections in peritoneal dialysis patients: a clinical approach

Peritoneal dialysis-(PD) related infections continue to be a major cause of morbidity and mortality in patients on PD. Although great advances have been made in the prevention and treatment of infectious complications over the past two decades, catheter-related infections represent a significant cause of technical failure in PD. Recent studies support the role of exit-site/tunnel infections in causing peritonitis. Peritonitis secondary to tunnel infection led to catheter loss in most cases. Thus, removing the catheter when exit-site/tunnel infection is refractory to medical therapy has been recommended. This approach requires interrupting PD and, after the placement of a central venous catheter, and transferring the patient to haemodialysis. In order to continue PD, simultaneous catheter removal and replacement of the PD catheter has been suggested. Although simultaneous catheter removal and replacement avoids temporary haemodialysis, it implies the removal/reinsertion of the catheter and the immediate initiation of PD with the risk of mechanical complications, such as leakage and malfunction. Hence, several mini-invasive surgical techniques, such as curettage, cuff-shaving, removal of the superficial cuff, and partial reimplantation of the catheter, have been proposed as rescue treatments. These procedures may allow the rescue of the catheter with a success rate of 70-100%. Therefore, in case of refractory exit-site/tunnel infection, a mini-invasive surgical revision should be considered before removing the catheter.

Comparative outcomes of bariatric surgery in patients with ESRD on dialysis in the modern era of renal transplantation: analysis using the 2015-2020 MBSAQIP database

BACKGROUND

Severe obesity is a relative contraindication for renal transplantation, therefore bariatric surgery is an important option as a pre-kidney transplant weight loss strategy. However, comparative data regarding postoperative outcomes of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with or without ESRD on dialysis are scarce.

METHODS

Patients between 18- and 80-year-old who underwent LSG and RYGB were included. To determine the outcomes of patient who underwent bariatric surgery with ESRD on dialysis, a 1:4 PSM was performed between the patients with ESRD on dialysis and those without renal disease. The PSM analyses in both groups were performed using 20 preoperative characteristics. Then 30-day postoperative outcomes were assessed.

RESULTS

The operative time and postoperative-LOS were significantly longer in ESRD patients on dialysis compared to those with no renal disease either for LSG (82.37 ± 40.42 vs. 73.62 ± 38.65; P < 0.001, 2.22 ± 3.01 vs. 1.67 ± 1.90; P < 0.001) or for LRYGB (129.13 ± 63.20 vs. 118.72 ± 54.16; P = 0.002, 2.53 ± 1.74 vs. 2.00 ± 1.68; P < 0.001). In the LSG cohort (2137 vs. 8495 matched cases), patients with ESRD on dialysis showed significant increase in mortality (0.7% vs 0.3%; P = 0.019), unplanned ICU admission (3.1% vs 1.3%; P < 0.001), blood transfusions (2.3% vs 0.8%; P 0.001), readmissions (9.1% vs. 4.0%; P < 0.001), reoperations (3.4% vs. 1.2%; P < 0.001), interventions (2.3% vs. 1.0%; P = 0.006). In the LRYGB group (443 vs. 1769 matched cases), patients with ESRD on dialysis showed a significantly higher need for unplanned ICU admission (3.8% vs. 1.4%; P = 0.027), readmissions (12.4% vs. 6.6%; P = 0.011), and interventions (5.2% vs. 2.0%; P = 0.050).

CONCLUSION

Bariatric surgery is a safe procedure for patients with ESRD on dialysis to help them get a kidney transplant. Even though this group experienced a higher incidence of postoperative complications compared to those without kidney disease, the absolute complication rates are low and not associated with bariatric-specific complications. Therefore, ESRD should not be perceived as contraindications to bariatric surgery.

Home hemodialysis technique survival: insights and challenges

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Value of an Integrated Home Dialysis Model in the United Kingdom: A Cost-Effectiveness Analysis

OBJECTIVES

This study aimed to determine the lifetime cost-effectiveness of increasing home hemodialysis as a treatment option for patients experiencing peritoneal dialysis technique failure compared with the current standard of care.

METHODS

A Markov model was developed to assess the lifetime costs, quality-adjusted life-years, and cost-effectiveness of increasing the usage an integrated home dialysis model compared with the current patient pathways in the United Kingdom. A secondary analysis was conducted including only the cost difference in treatments, minimizing the impact of the high cost of dialysis during life-years gained. Sensitivity and scenario analyses were performed, including analyses from a societal rather than a National Health Service perspective.

RESULTS

The base-case probabilistic analysis was associated with incremental costs of £3413 and a quality-adjusted life-year of 0.09, resulting in an incremental cost-effectiveness ratio of £36 341. The secondary analysis found the integrated home dialysis model to be dominant. Conclusions on cost-effectiveness did not change under the societal perspective in either analysis.

CONCLUSIONS

The base-case analysis found that an integrated home dialysis model compared with current patient pathways is likely not cost-effective. These results were primarily driven by the high baseline costs of dialysis during life-years gained by patients receiving home hemodialysis. When excluding baseline dialysis-related treatment costs, the integrated home dialysis model was dominant. New strategies in kidney care patient pathway management should be explored because, under the assumption that dialysis should be funded, the results provide cost-effectiveness evidence for an integrated home dialysis model.

The Controversies of Coronary Artery Disease in End-Stage Kidney Disease Patients: A Narrative Review

Cardiovascular disease (CVD) accounts for more than 50% of deaths among patients with end-stage kidney disease (ESKD). Approximately 40-50% of ESKD patients have clinically significant coronary artery disease (CAD) due to atherosclerosis which accounts for a significant proportion of CVD risk. However, other CVD pathologies including myocardial fibrosis, vascular calcification and arterial stiffening play important contributory roles. The pathophysiology of CAD in ESKD is distinct from the general population. ESKD patients is typically have diffuse multi-vessel involvement with increased calcification that involves both intimal and medial layers of the arterial wall. There is a complex interplay between an increased burden of traditional Framingham risk factors and exposure to non-traditional risk factors including chronic inflammation and dialysis per se. Established treatments for CAD risk factors including cholesterol lowering with statin therapy have attenuated effects and ESKD patients also have worse outcomes after revascularisation. Recent trials such as the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) have established that direct modulation of inflammation improves CVD outcomes in the general population, which may prove to be a potential attractive therapeutic target in ESKD patients. Multiple retrospective observational studies comparing mortality outcomes between haemodialysis (HD) and peritoneal dialysis (PD) patients have been inconclusive. Randomised trials on this issue of clinical equipoise are clearly warranted but are unlikely to be feasible. Screening for stable CAD in asymptomatic ESKD patients remains a clinical dilemma which is unique to chronic dialysis patients being assessed for kidney transplantation. This has become particularly relevant in light of the recent ISCHEMIA-CKD trial which demonstrated no difference between optimal medical therapy and revascularisation upon CVD outcomes or mortality. The optimal strategy for screening is currently being investigated in the ongoing large international multi-centre CARSK trial. Here we discuss the pathophysiology, risk modification, treatment, screening and future directions of CAD in ESKD.

Under-Recognized Pathogens in Peritoneal Dialysis Associated-Peritonitis: The Importance of Early Detection

Peritoneal dialysis-associated-peritonitis remains a major concern, increasing patient morbidity and mortality. Empirical antibiotics should be quickly started to allow a rapid resolution of symptoms and preservation of the peritoneal membrane. We report a case of peritoneal dialysis-associated-peritonitis due to Prevotella salivae and Corynebacterium jeikeium, in a 51-year-old male. Suspected peritonitis led to an immediate prescription of vancomycin and ceftazidime, with no clinical improvement. Prevotella is difficult to identify in culture since it's a gram-negative anaerobic bacterium, so metronidazole administration was delayed over days. New diagnostic techniques have been explored for the early diagnosis of peritonitis, including polymerase chain reaction (PCR) for bacterial DNA fragments. A multiplex PCR panel that includes Prevotella, already available for other applications, could be an advantage in cases like this.

Technique failure in peritoneal dialysis: Modifiable causes and patient-specific risk factors

BACKGROUND

Technique survival is a core outcome for peritoneal dialysis (PD), according to Standardized Outcomes in Nephrology-Peritoneal Dialysis. This study aimed to identify modifiable causes and risk factors of technique failure in a large Dutch cohort using standardised definitions.

METHODS

Patients who participated in the retrospective Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes cohort study and started PD between 2012 and 2016 were included and followed until 1 January 2017. The primary outcome was technique failure, defined as transfer to in-centre haemodialysis for ≥ 30 days or death. Death-censored technique failure was analysed as secondary outcome. Cox regression models and competing risk models were used to assess the association between potential risk factors and technique failure.

RESULTS

A total of 695 patients were included, of whom 318 experienced technique failure during follow-up. Technique failure rate in the first year was 29%, while the death-censored technique failure rate was 23%. Infections were the most common modifiable cause for technique failure, accounting for 20% of all causes during the entire follow-up. Leakage and catheter problems were important causes within the first 6 months of PD treatment (both accounting for 15%). APD use was associated with a lower risk of technique failure (hazard ratio 0.66, 95% confidence interval 0.53-0.83).

CONCLUSION

Infections, leakage and catheter problems were important modifiable causes for technique failure. As the first-year death-censored technique failure rate remains high, future studies should focus on infection prevention and catheter access to improve technique survival.

Long-term impact of early non-infectious complications at the initiation of peritoneal dialysis

BACKGROUND

Early non-infectious complications at initiation of peritoneal dialysis (PD) are a major burden with unknown long-term impacts on individuals.

METHODS

Prospective multicentre cohort study using univariable and multivariable Cox regression to identity mortality risk and PD discontinuation risk in those with and without non-infectious complications. All individuals commencing PD between 1 January 2014 and 31 December 2018, registered in the New Zealand Peritoneal Dialysis Registry (NZPDR) were followed up to 31 December 2020. Early non-infectious complications defined as functional, catheter-related, exit-site dialysate leak or anatomical leak complications occurring within 30 days of initiation of PD. Primary outcomes were patient survival and time on PD therapy. Secondary outcomes were peritonitis free survival, first PD catheter survival and catheter tunnel infection free survival.

RESULTS

Of 1596 individuals included in the study, 102 experienced an early non-infectious complication. Multivariable analysis demonstrated these complications were associated with higher risk of overall mortality (hazard ratio (HR) 1.71; 95% confidence interval (CI) 1.21-2.44), PD discontinuation (HR 1.84; 95% CI 1.41-2.41) and first catheter failure (HR 2.89; 95% CI 2.28-3.66). No difference was found for risk of development of first peritonitis episode or catheter tunnel infection. Mortality risk was associated with functional and exit-site dialysate leak complications and continued beyond 180 days. Risk of PD discontinuation and first catheter loss were associated with catheter and functional complications in the first 180 days.

CONCLUSION

Early non-infectious complications are associated with long-term mortality risk. Further research in risk factors and causes of early non-infectious complications are required.

Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Summary Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

Comparison of risk of peritoneal dialysis-associated peritonitis between roxadustat and recombinant human erythropoietin in peritoneal dialysis patients: a retrospective comparative cohort study

Background

Roxadustat and recombinant human erythropoietin (rhuEPO) have been approved for the treatment of renal anemia in patients undergoing dialysis. The comparison of risk of peritoneal dialysis (PD)-associated peritonitis between roxadustat and rhuEPO in PD patients remains uncertain. We aimed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO and examine possible modifiers for the comparison in PD patients.

Methods

A total of 437 PD patients with renal anemia (defined as hemoglobin ≤10.0 g/dL) from 4 centers were selected. Participants were scheduled for follow-up every 1-3 months at each center. We compared differences in baseline characteristics by medication group and 1:1 matching group based on propensity scores. PD-associated peritonitis was defined according to the International Society for Peritoneal Dialysis guidelines. Univariable and multivariable Cox proportional hazard analyses were performed to compare the risk of PD-associated peritonitis between roxadustat and rhuEPO in PD patients. Propensity score matching method was used to examine the robustness of results.

Results

A total of 437 participants, including 291 in roxadustat group and 146 in rhuEPO group, were included in the current study, respectively. During a median follow-up of 13.0 (25th-75th, 10.0-15.0) months, PD-associated peritonitis occurred in 68 patients, including 26 of 291 (0.10 episodes per patient-year) patients in the roxadustat group and 42 of 146 (0.27 episodes per patient-year) patients in the rhuEPO group. Overall, compared to patients in the rhuEPO group, the roxadustat group (hazard ratio, 0.345; 95% confidence interval: 0.202-0.589) was associated with a lower risk of PD-associated peritonitis with adjustment of use of roxadustat medication, age, sex, hypertension status, diabetes status, dialysis vintage, serum potassium, hemoglobin, and albumin. Furthermore, the results were consistent with the propensity score analysis. None of the variables, including age, sex, body mass index, PD vintage, presence of residual renal function, hemoglobin, albumin, serum potassium, and C-reactive protein levels, significantly modified the associations.

Conclusions

Our study demonstrated that compared with rhuEPO, roxadustat may reduce the risk of PD-associated peritonitis in PD patients, highlighting the importance of roxadustat for the prevention of PD-associated peritonitis in PD patients.

A Comparison of US Medicare Expenditures for Hemodialysis and Peritoneal Dialysis

BACKGROUND

Observations that peritoneal dialysis (PD) may be an effective, lower-cost alternative to hemodialysis for the treatment of ESKD have led to policies encouraging PD and subsequent increases in its use in the United States.

METHODS

In a retrospective cohort analysis of Medicare beneficiaries who started dialysis between 2008 and 2015, we ascertained average annual expenditures (for up to 3 years after initiation of dialysis) for patients ≥67 years receiving in-center hemodialysis or PD. We also determined whether differences in Medicare expenditures across dialysis modalities persisted as more patients were placed on PD. We used propensity scores to match 8305 patients initiating PD with 8305 similar patients initiating hemodialysis.

RESULTS

Overall average expenditures were US$108,656 (2017) for hemodialysis and US$91,716 for PD (proportionate difference, 1.11; 95% confidence interval [CI], 1.09 to 1.13). This difference did not change over time (P for time interaction term=0.14). Hemodialysis had higher estimated intravenous (iv) dialysis drug costs (1.69; 95% CI, 1.64 to 1.73), rehabilitation expenditures (1.35; 95% CI, 1.26 to 1.45), and other nondialysis expenditures (1.34; 95% CI, 1.30 to 1.37). Over time, initial differences in total dialysis expenditures disappeared and differences in iv dialysis drug utilization narrowed as nondialysis expenditures diverged. Estimated iv drug costs declined by US$2900 per patient-year in hemodialysis between 2008 and 2014 versus US$900 per patient-year in PD.

CONCLUSIONS

From the perspective of the Medicare program, savings associated with PD in patients ≥67 years have remained unchanged, despite rapid growth in the use of this dialysis modality. Total dialysis expenditures for the two modalities converged over time, whereas nondialysis expenditures diverged.

High body mass index is a risk factor for transition to hemodialysis or hybrid therapy and peritoneal dialysis-related infection in Japanese patients undergoing peritoneal dialysis

PURPOSE

Obesity may negatively impact the clinical outcomes of patients undergoing peritoneal dialysis (PD). However, the impact of obesity on PD-related outcomes remains unclear. We herein examined the association of high body mass index (BMI) with complete hemodialysis (HD) transfer, transition to HD and PD/HD hybrid therapy, peritonitis, catheter exit-site and tunnel infection (ESI/TI), and heart failure-related hospitalization.

METHODS

This retrospective cohort study included 120 patients who underwent PD-catheter insertion between January 2008 and June 2018. BMI ≥ 25 kg/m² at the time of PD-catheter insertion was defined as high BMI, and its association with outcomes was analyzed using the log-rank test and Cox proportional hazards models.

RESULTS

The follow-up duration was 46.2 (23.3-75.3) months. The time until transfer to HD and hybrid therapy was significantly shorter in the high BMI group than that in the low BMI group, whereas the time until HD transfer was not significantly different between the two groups (P < 0.001 and 0.18, respectively). Peritonitis-free and ESI/TI-free survivals were significantly shorter in the high BMI group than those in the low BMI group (P = 0.006 and 0.03, respectively). After adjusting for age, sex, diabetes mellitus, and estimated glomerular filtration rate, high BMI remained a significant risk factor for transferring to HD and hybrid therapy, peritonitis, and ESI/TI (hazard ratio [HR] 2.60, P < 0.001; HR 2.08, P = 0.01; HR 2.64, P = 0.02, respectively).

CONCLUSION

BMI ≥ 25 kg/m² is a risk factor for transition to HD and hybrid therapy, peritonitis, and ESI/TI, but not for complete HD transfer in Japanese patients with PD.

Outcome Analysis of Transition From Peritoneal Dialysis to Hemodialysis: A Population-Based Study

If a technical failure occurs during peritoneal dialysis (PD), the patients undergoing PD may be transitioned to hemodialysis (HD). However, the clinical outcomes of patients who have undergone such a transition are under studied. This study assessed whether patients undergoing HD who have transitioned from PD have the same clinical outcomes as HD-only patients. This research was a retrospective cohort study by searching a National Health Insurance research database for data on patients in Taiwan who had undergone HD between January 2006 and December 2013. The patients were divided into two groups, namely a case group in which the patients were transitioned from PD to HD and a HD-only control group, through propensity score matching at a ratio of 1:4 (n = 1,100 vs. 4,400, respectively). We used the Cox regression model to estimate the hazard ratios (HRs) for all-cause death, all-cause hospitalization, infection-related admission, and major adverse cardiac events (MACE). Those selected patients will be followed until death or the end of the study period (December, 2017), whichever occurs first. Over a mean follow-up of 3.2 years, 1,695 patients (30.8%) died, 3,825 (69.5%) required hospitalization, and 1,142 (20.8%) experienced MACE. Patients transitioning from PD had a higher risk of all-cause death (HR: 1.36; 95% CI: 1.21–1.53) than HD-only patients. However, no significant difference was noted in terms of MACE (HR: 0.91; 95% CI: 0.73–1.12), all-cause hospitalization (HR: 1.07; 95% CI: 0.96–1.18), or infection-related admission (HR: 0.97, 95% CI: 0.80–1.18) between groups. Because of the violation of the proportional hazard assumption, the piecewise-HRs showed that the risk of mortality in the case group was significant within 5 months of the transition (HR: 2.61; 95% CI: 2.04–3.35) not in other partitions of the time axis. In conclusion, patients undergoing HD who transitioned from PD had a higher risk of death than the HD-only patients, especially in the first 5 months after transition (a 161% higher risk). Therefore, more caution and monitoring may be required for patients undergoing HD who transitioned from PD.

Incidence and Risk Factors Associated with Technique Failure in the First Year of Peritoneal Dialysis: A Single Center Retrospective Cohort Study in Southern China

Background

Technique failure is more likely to occur during the first 12 months after peritoneal dialysis (PD) initiation, which is a great challenge encountered in PD patients. The aim of this study was to investigate the incidence and risk factors associated with technique failure within the first year of PD patients in Southern China.

Methods

Incident PD patients who were followed up for at least one year at The First Affiliated Hospital of Sun Yat-sen University from January 1, 2006 to December 31, 2015 were included. Technique failure was defined as transferring to hemodialysis (HD) for more than 30 days or death within the first year after start of PD. A competitive risk regression analysis was used to explore the incidence and risk factors of the technique failure.

Results

Overall, 2,290 incident PD patients were included in this study, with a mean age of 48.2 ± 15.7 years, 40.9% female and 25.2% with diabetes. A total of 173 patients (7.5%) had technique failure during the first year of PD. Among them, the patient death account for 62.4% (n = 108) and transferring to HD account for 37.6% (n = 65). The main reasons for death were cardiovascular diseases (n = 32, 29.6%), infection (n = 15, 13.8%) and for conversion to HD were mechanical cause (n = 28, 43.1%), infection cause (n = 22, 33.8%). The risk factors for the technique failure included advanced age (HR 2.78, 95%CI 1.82–4.30), low body mass index (BMI < 18.5 kg/m²: HR 1.77, 95%CI 1.17–2.67), history of congestive heart failure (HR 2.81, 95%CI 1.58–4.98), or time on HD before PD ≤ 3 months (HR 1.49, 95%CI 1.05–2.10), peritonitis (HR 2.02, 95%CI 1.36–3.01);while higher serum albumin (HR 0.93, 95%CI 0.89–0.96) and using employee medical insurance to pay expenses (HR 0.47, 95%CI 0.32–0.69) were associated with reduced risk.

Conclusions

Advanced age, poor nutritional status, history of HD or congestive heart failure, and peritonitis are related factors that increase the risk of technique failure in the first year of PD, while patients' type of medical insurance may also have an influence on early technique failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02833-4.

Influence of climatic factors on singlecenter peritoneal dialysisassociated peritonitis

OBJECTIVES

Peritoneal dialysis associated peritonitis (PDAP), one of the most common complications of peritoneal dialysis, is generally believed as an important factor causing technique failure and increasing hospital admission and fatality rate in peritoneal dialysis patients. Moreover, the prevention and treatment for PDAP have always been considered as an important link in clinical peritoneal dialysis. Thus, the study is performed to investigate the impact of climate factors on the incidence and prognosis of single-center PDAP in Hunan Province, China, which can provide a clinical basis for the prevention and treatment strategy for PDAP.

METHODS

A total of 885 patients on peritoneal dialysis, who were admitted to Department of Nephrology, Third Xiangya Hospital, Central South University (hereinafter referred to as our hospital) from January 1, 2009 to December 31, 2017, were enrolled as the subjects, and the demographic and clinical data for patients with PDAP from 2009 to 2017 as well as climate data of Hunan Province were collected.The patients were divided into different season groups, and the general information and clinical biochemical indicators in different season groups were compared. The incidence, the proportion of pathogenic bacteria and the clinical outcome of PDAP in the different season groups were compared. The risk factors of PDAP in different season groups were analyzed by using a multivariate logistic regression. Pearson's correlation analysis was used to analyze the correlations of the overall incidence of PDAP with the monthly mean temperature and the monthly mean humidity.

RESULTS

There were 448 cases of PDAP that occurred in the peritoneal dialysis center of our hospital from 2009 to 2017 (9 years), the incidence was 0.17 time/patient-years. The incidence of overall PDAP (0.246 time/patient-years) and the incidence of Gram-negative (G-) bacterial PDAP (0.048 time/patient-years) in the summer group were the highest compared with the other season groups, with significant difference (all P<0.05). Compared with the spring group (OR=0.321, 95% CI 0.144-0.713; P<0.01), the autumn group (OR=0.419, 95% CI 0.187, 0.937; P<0.05) and the winter group (OR=0.326; 95% CI 0.139, 0.763; P<0.05), the probability suffered from PDAP in the summer group were higher. The patients with low body mass index (BMI) in the spring group were more likely to suffer from PDAP in the summer group. The overall incidences of PDAP (r=0.258, P<0.05) and G- bacterial PDAP (r=0.278, P<0.05) were significantly positively correlated with the monthly mean temperature in Hunan Province, which was not correlated with the monthly average humidity. The overall cure rate of PDAP was 83%, and there was no difference in the treatment outcomes among the different season groups (all P>0.05).

CONCLUSIONS

The climate factors in Hunan, China have a significant impact on the incidence of PDAP in peritoneal dialysis patients in our hospital. Summer is the peak of PDAP, especially G- bacterial PDAP. Intestinal dysfunction and low BMI are risk factors for the onset of PDAP in summer. High temperature rather than high humidity is correlated with increased incidence of overall PDAP, especially for G- bacterial PDAP.

International Icodextrin Use and Association with Peritoneal Membrane Function, Fluid Removal, Patient and Technique Survival

BACKGROUND

Icodextrin has been shown in randomized controlled trials to benefit fluid management in peritoneal dialysis (PD). We describe international icodextrin prescription practices and their relationship to clinical outcomes.

METHODS

We analyzed data from the prospective, international PDOPPS, from Australia/New Zealand, Canada, Japan, the United Kingdom, and the United States. Membrane function and 24-hour ultrafiltration according to icodextrin and glucose prescription was determined at baseline. Using an instrumental variable approach, Cox regression, stratified by country, was used to determine any association of icodextrin use to death and permanent transfer to hemodialysis (HDT), adjusted for demographics, comorbidities, serum albumin, urine volume, transplant waitlist status, PD modality, center size, and study phase.

RESULTS

Icodextrin was prescribed in 1986 (35%) of 5617 patients, >43% of patients in all countries, except in the United States, where it was only used in 17% and associated with a far greater use of hypertonic glucose. Patients on icodextrin had more coronary artery disease and diabetes, longer dialysis vintage, lower residual kidney function, faster peritoneal solute transfer rates, and lower ultrafiltration capacity. Prescriptions with or without icodextrin achieved equivalent ultrafiltration (median 750 ml/d [interquartile range 300-1345 ml/d] versus 765 ml/d [251-1345 ml/d]). Icodextrin use was not associated with mortality (HR=1.03; 95% CI, 0.72 to 1.48) or HDT (HR 1.2; 95% CI, 0.92 to 1.57).

CONCLUSIONS

There are large national and center differences in icodextrin prescription, with the United States using significantly less. Icodextrin was associated with hypertonic glucose avoidance but equivalent ultrafiltration, which may affect any potential survival advantage or HDT.

The rationale for the need to study sodium-glucose co-transport 2 inhibitor usage in peritoneal dialysis patients

The wave of kidney and heart outcome trials, showing multiple potential benefits for sodium-glucose co-transport 2 (SGLT2) inhibitors, have excluded patients with an estimated glomerular filtration rate below 25 ml/min/1.73 m2. However, dialysis patients are at the highest risk of cardiovascular disease and would benefit most from effective cardioprotective therapies. There is emerging evidence from experimental studies and post hoc analyses of randomised clinical trials that SGLT2 inhibitors are well tolerated and may also be effective in preventing cardiovascular and mortality outcomes in patients with severe chronic kidney disease, including patients receiving dialysis. As such, extending the usage of SGLT2 inhibitors to dialysis patients could provide a major advancement in their care. Peritoneal dialysis (PD) patients have an additional unmet need for effective pharmacotherapy to preserve their residual kidney function (RKF), with its associated mortality benefits, and for treatment options that help reduce the risk of transfer to haemodialysis. Experimental data suggest that SGLT2 inhibitors, via various mechanisms, may preserve RKF and protect the peritoneal membrane. There is sound physiological rationale and an urgent clinical need to execute robust randomised control trials to study the use of SGLT2 inhibitors in PD patients to answer important questions of relevance to patients and healthcare systems.

Artificial intelligence in peritoneal dialysis: general overview

OBJECTIVE

This article is a general overview about artificial intelligence/machine learning (AI/ML) algorithms in the domain of peritoneal dialysis (PD).

METHODS

We searched studies that used AI/ML in PD, which were classified according to the type of algorithm and PD issue.

RESULTS

Studies were divided into (a) predialytic stratification, (b) peritoneal technique issues, (c) infections, and (d) complications prediction. Most of the studies were observational and majority of them were reported after 2010.

CONCLUSIONS

There is a number of studies proved that AI/ML algorithms can predict better than conventional statistical method and even nephrologists. However, the soundness of AI/ML algorithms in PD still requires large databases and interpretation by clinical experts. In the future, we hope that AI will facilitate the management of PD patients, thus increasing the quality of life and survival.

[Development and validation of a prediction model for treatment failure in peritoneal dialysis-associated peritonitis patients: a multicenter study]

OBJECTIVE

To develop and validate a risk prediction model of treatment failure in patients with peritoneal dialysis-associated peritonitis (PDAP).

METHODS

We retrospectively analyzed the data of patients undergoing peritoneal dialysis (PD) in 3 dialysis centers in Jilin Province who developed PDAP between January 1, 2013 and December 31, 2019. The data collected from the Second Hospital of Jilin University and Second Division of First Hospital of Jilin University) were used as the training dataset and those from Jilin Central Hospital as the validation dataset. We developed a nomogram for predicting treatment failure using a logistic regression model with backward elimination. The performance of the nomogram was assessed by analyzing the C-statistic and the calibration plots. We also plotted decision curves to evaluate the clinical efficacy of the nomogram.

RESULTS

A total of 977 episodes of PDAP were included in the analysis (625 episodes in the training dataset and 352 episodes in the validation dataset). During follow-up, 78 treatment failures occurred in the training dataset and 35 in the validation dataset. A multivariable logistic regression prediction model was established, and the predictors in the final nomogram model included serum albumin, peritoneal dialysate white cell count on day 5, PD duration, and type of causative organisms. The nomogram showed a good performance in predicting treatment failure, with a C-statistic of 0.827 (95% CI: 0.784-0.871) in the training dataset and of 0.825 (95% CI: 0.743-0.908) in the validation dataset. The nomogram also performed well in calibration in both the training and validation datasets.

CONCLUSION

The established nomogram has a good accuracy in estimating the risk of treatment failure in PDAP patients.

Mortality Trends after Transfer from Peritoneal Dialysis to Hemodialysis

Introduction

Transition to hemodialysis (HD) is a common outcome in peritoneal dialysis (PD), but the associated mortality risk is poorly understood. This study sought to identify rates of and risk factors for mortality after transitioning from PD to HD.

Methods

Patients with incident PD (between 2000 and 2014) who transferred to HD for ≥1 day were identified, using data from Australia and New Zealand Dialysis and Transplantation registry (ANZDATA), Canadian Organ Replacement Register (CORR), Europe Renal Association (ERA) Registry, and the United States Renal Dialysis System (USRDS). Crude mortality rates were calculated for the first 180 days after transfer. Separate multivariable Cox models were built for early (<90 days), medium (90–180 days), and late (>180 days) periods after transfer.

Results

Overall, 6683, 5847, 21,574, and 80,459 patients were included from ANZDATA, CORR, ERA Registry, and USRDS, respectively. In all registries, crude mortality rate was highest during the first 30 days after a transfer to HD declining thereafter to nadir at 4 to 6 months. Crude mortality rates were lower for patients transferring in the most recent years (than earlier). Older age, PD initiation in earlier cohorts, and longer PD vintage were associated with increased risk of death, with the strongest associations during the first 90 days after transfer and attenuating thereafter. Mortality risk was lower for men than women <90 days after transfer, but higher after 180 days.

Conclusion

In this multinational study, mortality was highest in the first month after a transfer from PD to HD and risk factors varied by time period after transfer. This study highlights the vulnerability of patients at the time of modality transfer and the need to improve transitions.

Association of Prescription With Body Composition and Patient Outcomes in Incident Peritoneal Dialysis Patients

Objective: The nutritional status of patients on peritoneal dialysis (PD) is influenced by patient- and disease-related factors and lifestyle. This analysis evaluated the association of PD prescription with body composition and patient outcomes in the prospective incident Initiative for Patient Outcomes in Dialysis–Peritoneal Dialysis (IPOD-PD) patient cohort.

Design and Methods: In this observational, international cohort study with longitudinal follow-up of 1,054 incident PD patients, the association of PD prescription with body composition was analyzed by using the linear mixed models, and the association of body composition with death and change to hemodialysis (HD) by means of a competing risk analysis combined with a spline analysis. Body composition was regularly assessed with the body composition monitor, a device applying bioimpedance spectroscopy.

Results: Age, time on PD, and the use of hypertonic and polyglucose solutions were significantly associated with a decrease in lean tissue index (LTI) and an increase in fat tissue index (FTI) over time. Competing risk analysis revealed a U-shaped association of body mass index (BMI) with the subdistributional hazard ratio (HR) for risk of death. High LTI was associated with a lower subdistributional HR, whereas low LTI was associated with an increased subdistributional HR when compared with the median LTI as a reference. High FTI was associated with a higher subdistributional HR when compared with the median as a reference. Subdistributional HR for risk of change to HD was not associated with any of the body composition parameters. The use of polyglucose or hypertonic PD solutions was predictive of an increased probability of change to HD, and the use of biocompatible solutions was predictive of a decreased probability of change to HD.

Conclusion: Body composition is associated with non-modifiable patient-specific and modifiable treatment-related factors. The association between lean tissue and fat tissue mass and death and change to HD in patients on PD suggests developing interventions and patient counseling to improve nutritional markers and, ultimately, patient outcomes.

Study Registration: The study has been registered at Clinicaltrials.gov (NCT01285726).

Regression of Left Ventricular Hypertrophy in Patients Combined with Peritoneal Dialysis and Hemodialysis

METHODS

This retrospective study enrolled 58 patients at The Second Affiliated Hospital of Soochow University who switched from PD to PHD. Clinical data and echocardiographic examination results were collected. Data from the two groups with a normal distribution were compared with the paired t-test. A pvalue <0.05 (two-tailed) was considered statistically significant.

RESULTS

A total of 58 subjects were enrolled, including 46 males and 12 females, with a median age of 50.2 ± 11.1 (47-68) years. The mean duration of peritoneal dialysis was 67.2 ± 33.6 months. Before and after PHD, the ultrafiltration volume (p = 0.021) and hemoglobin (p = 0.001) were increased, while SBP (p = 0.002), DBP (p = 0.002), phosphorus (p < 0.001), and ESA dosage (p < 0.001) were decreased. Before and after combined dialysis (PHD), the incidence of LVH was 76.4% and 61.8%, respectively (p = 0.013), and LVMI decreased from 173.8 ± 86.2 g/m² to 160.6 ± 78.5 g/m² (p < 0.001).

CONCLUSION

Compared with PD alone, the combination of PD and HD resulted in regression of LVH and reduced LVMI.

The scientific principles and technological determinants of haemodialysis membranes

In most biological or industrial (including medical) separation processes, a membrane is a semipermeable barrier that allows or achieves selective transport between given compartments. In haemodialysis (HD), the semipermeable membrane is in a tubular geometry in the form of miniscule pipes (hollow fibres) and separation processes between compartments involve a complex array of scientific principles and factors that influence the quality of therapy a patient receives. Several conditions need to be met to accomplish the selective and desired removal of substances from blood in the inner cavity (lumen) of the hollow fibres and across the membrane wall into the larger open space surrounding each fibre. Current HD membranes have evolved and improved beyond measure from the experimental membranes available in the early developmental periods of dialysis. Today, the key functional determinants of dialysis membranes have been identified both in terms of their potential to remove uraemic retention solutes (termed ‘uraemic toxins’) as well subsidiary criteria they must additionally fulfill to avoid undesirable patient reactions or to ensure safety. The production of hundreds of millions of kilometres of hollow fibre membranes is truly a technological achievement to marvel, particularly in ensuring that the fibre dimensions of wall thickness and inner lumen diameter and controlled porosity—all so vital to core solute removal and detoxification functions of dialysis—are maintained for every centimetre length of the fragile fibres. Production of membranes will increase in parallel with the increase in the number of chronic kidney disease (CKD) patients expected to require HD therapies in the future. The provision of high-quality care entails detailed consideration of all aspects of dialysis membranes, as quality cannot in any way be compromised for the life-sustaining—like the natural membranes within all living organisms—function artificial dialysis membranes serve.

Association between conscientiousness and peritoneal dialysis-related peritonitis

AIM

Peritonitis is a critical complication in patients undergoing peritoneal dialysis. Patient characteristics, especially conscientiousness, potentially influence self-care activity. This study aimed to examine the relationship between the peritonitis risk and the patient conscientiousness.

METHODS

This retrospective observational study was conducted at three Japanese medical centres in 2018. Adult patients undergoing peritoneal dialysis were evaluated for conscientiousness with the Japanese version of the Ten-Item Personality Inventory. We followed the patients from peritoneal dialysis induction retrospectively on chart review. The primary outcome was time to first episode of peritonitis after initiation of peritoneal dialysis in the entire observation period. Hazard ratios were estimated using a Cox model adjusted for potential confounders.

RESULTS

Among 111 patients enrolled, 32 experienced peritonitis. The patients were divided into the more conscientious group (n = 64) and less conscientious group (n = 47) based on a mean conscientiousness score of 3.991. Additionally, less conscientious patients tended to be at higher risk for peritonitis during the entire study period (hazard ratio adjusted for age and sex, 1.99; 95% confidence interval, 0.98-4.03; p = .057). The increased risk in the less conscientious group was statistically significant in the first year (adjusted hazard ratio, 6.98; 95% confidence interval, 1.42-34.40; p = .017).

CONCLUSION

Less conscientious patients significantly have shorter peritonitis-free survival in the early phase after peritoneal dialysis induction although not significantly during the entire study period. Personality trait assessment using the Ten-Item Personality Inventory could be helpful in educating and following up patients undergoing peritoneal dialysis.

Risk Factors for Early Peritoneal Dialysis Discontinuation: Importance of Heart Failure

BACKGROUND

The number of patients on peritoneal dialysis (PD) in our hospital has increased during the past 5 years, but the number discontinuing PD has also increased. The purpose of this study was to identify the risk factors for PD discontinuation by analyzing the association between technical survival period (defined as the duration of PD) and various clinical factors.

METHODS

We retrospectively investigated 87 patients who were started on PD at our hospital and attended regularly from April 2015 to March 2020, and we analyzed the association between technical survival period and various clinical factors. We also looked for associations between technical survival period and hospitalizations for heart failure, peritonitis, and exit-site infections among patients undergoing PD.

RESULTS

The patients using renin-angiotensin-aldosterone system inhibitors (RASi) (P = 0.0218), those with left ventricular ejection fraction (LVEF) > 50% (P = 0.0194) when they started PD, and those with estimated glomerular filtration rate (eGFR) ≥ 6 (mL/ min/1.73m²) (P = 0.0013) at the initiation of PD showed significantly longer technical survival period, and those who were hospitalized for heart failure had significantly shorter period (P = 0.0008).

CONCLUSION

Treatment of RASi, LVEF > 50% and eGFR ≥ 6 mL/ min/1.73m² when the initiation of PD and better volume control to prevent ultrafiltration failure and heart failure may improve technical survival period in patients undergoing PD.

Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?

In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

Simultaneous catheter removal and reinsertion, is it acceptable in M. abscessus exit site infection?

In recent times, increasing reports of exit site infections (ESI) in peritoneal dialysis (PD) patients related to environmentally acquired atypical organisms, such as nontuberculous mycobacterium (NTM), have been reported in the literature. Among these NTM, Mycobacterium abscessus (M. abscessus) is unique and is associated with high morbidity and treatment failure rates. The international society of PD guidelines suggests individualizing therapeutic options for NTM-related ESI. Moreover, the guidelines encourage simultaneous catheter removal and reinsertion (SCRR) in isolated ESI, not responding to antimicrobial therapy to avoid PD interruptions. Physicians should be aware of the limitations of such approaches as delay in appropriate PD catheter intervention can be fraught with complications in patients with M. abscessus ESI. We report an M. abscessus ESI in a PD patient who underwent SCRR in conjunction with targeted antimicrobial therapy, and developed M. abscessus peritonitis requiring PD catheter removal and conversion to hemodialysis. The patient also developed ESI at the new exit site long after the PD catheter was removed, requiring prolonged antimicrobial therapy. Our case, taken together with available published case reports, highlights the futility of the SCRR approach towards the M. abscessus ESI and makes the cases for early PD catheter removal in these patients.

The Effect of Nutritional Interventions on Long-Term Patient Survival in Advanced Chronic Kidney Disease

Patients with end-stage kidney disease (ESKD) are at high risk of malnutrition and subsequent related mortality when starting dialysis. However, there have been few clinical studies on the effect of nutritional interventions on long-term patient survival. A 2-year longitudinal study was conducted from January 2012 to December 2016. A total of 186 patients with non-dialysis ESKD started the nutritional education program (NEP), and 169 completed it. A total of 128 patients participated in a NEP over 6 months (personalized diet, education and oral supplementation, if needed). The control group (n = 45) underwent no specific nutritional intervention. The hospitalization rate was significantly lower for the patients with NEP (13.7%) compared with the control patients (26.7%) (p = 0.004). The mortality odds ratio for the patients who did not receive NEP was 2.883 (95% CI 0.993-8.3365, p = 0.051). The multivariate analysis showed an independent association between mortality and age (OR, 1.103; 95% CI 1.041-1.169; p = 0.001) and between mortality and the female sex (OR, 3.332; 95% CI 1.054-10.535; p = 0.040) but not between mortality and those with NEP (p = 0.051). Individualized nutrition education has long-term positive effects on nutritional status, reduces hospital admissions and increases survival among patients with advanced CKD who are starting dialysis programs.

Persistent colonization of exit site is associated with modality failure in peritoneal dialysis

Exit-site infections (ESIs) increase the risk of developing peritoneal dialysis (PD) peritonitis and PD technique failure. There are no clear guidelines on how to monitor exit site (ES) after ESI with Staphylococcus aureus or Pseudomonas. We report on a 1-year observational study of 23 patients who developed an ESI with one of these serious pathogens. After completing initial antibiotic treatment, swabs were taken every month for 3 months. Primary treatment cure occurred in 19/23 (83%). Colonization of ES after primary cure occurred in 8/19 (42%) patients. In the eight colonized patients, five had subsequent PD technique failure due to infections. By contrast, during an average follow-up period of 7.2 months, none of the 11 patients who were proven noncolonized developed PD technique failure from infections; HR (colonized vs. noncolonized) = 10.89, 95% CI 2.6-45.43, p < 0.05. In conclusion, colonization significantly increased the risk of catheter loss. Increased surveillance and aggressive treatment may ameliorate this risk.

Exit site infection and peritonitis due to Serratia species in patients receiving peritoneal dialysis: Epidemiology and clinical outcomes

AIM

To study the epidemiology and clinical outcomes of catheter-related infections of Serratia species in peritoneal dialysis (PD) patients.

METHODS

We retrospectively reviewed the patient characteristics, antibiotics susceptibility/resistance patterns and treatment outcomes of exit site infection (ESI) and peritonitis due to Serratia in PD patients during the period of 2004 to 2017.

RESULTS

One hundred and sixty-one patients had Serratia ESI, of which 10 (6.2%) progressed to tunnel tract involvement and 11 (6.8%) developed PD peritonitis. Nineteen (11.8%) patients with Serratia ESI failed to respond to medical treatment and required catheter removal. Fifty-six (34.8%) patients had repeat Serratia ESI, which occurred at 12.9 ± 13.6 months after the previous episode. Twenty-two patients had Serratia peritonitis, which accounted for 1% of peritonitis during the study period. Ten (45.5%) patients responded to medical treatment while 12 (54.5%) patients required catheter removal. Nine patients (36.4%) failed to resume PD and were converted to long-term haemodialysis. Two patients had repeat peritonitis at 2 months and 3 years, respectively, after the initial episode. Serratia species in PD patients showed high rates of resistance to ampicillin, and first- and second-generation cephalosporins, but were generally susceptible to aminoglycosides, carboxy-/ureido-penicillins and carbapenems.

CONCLUSION

Our results suggest that Serratia ESI show low risk of progression to peritonitis and favourable response to medical therapy, while Serratia peritonitis was associated with high rates of catheter removal and peritoneal failure.

Peritoneal Dialysis and Mortality, Kidney Transplant, and Transition to Hemodialysis: Trends From 1996-2015 in the United States

Rationale & Objective

Transitions between dialysis modalities can be disruptive to care. Our goals were to evaluate rates of transition from peritoneal dialysis (PD) to in-center hemodialysis (HD), mortality, and transplantation among incident PD patients in the US Renal Data System from 1996 to 2015 and identify factors associated with these outcomes.

Study Design

Observational registry-based retrospective cohort study.

Setting & Participants

Medicare patients incident to end-stage renal disease (ESRD) from January 1, 1996, through December 31, 2011 (for adjusted analyses; through December 31, 2014, for unadjusted analyses), and treated with PD 1 or more days within 180 days of ESRD incidence (n = 173,533 for adjusted analyses; n = 219,787 for unadjusted analyses).

Exposure & Predictors

Exposure: 1 or more days of PD. Predictors: patient- and facility-level characteristics obtained from Centers for Medicare & Medicaid Services Form 2728 and other data sources.

Outcomes

Patients were followed up for 3 years until transition to in-center HD, death, or transplantation.

Analytical Approach

Multivariable Cox regression was used to estimate hazards over time and associations with predictors.

Results

Compared with earlier cohorts, recent incident PD patient cohorts had lower rates of death (48% decline) and transition to in-center HD (13% decline). Among many other findings, we found that: (1) rates of transition to in-center HD and death were lowest in the 2008 to 2011 cohort, (2) longer time receiving PD was associated with higher mortality risk but lower risk for transition to in-center HD, and (3) larger PD programs (≥25 vs ≤6 patients) displayed lower risks for death and transition to in-center HD.

Limitations

Data collected on Form 2728 are only at the time of ESRD incidence and do not provide information at the time of transition to in-center HD, death, or transplantation.

Conclusions

Rates of transition from PD to in-center HD and death rates for PD patients decreased over time and were lowest in PD programs with 25 or more patients. Implications of the observed improved technique survival warrant further investigation, focusing on modifiable factors of center-level performance to create opportunities for improved patient outcomes.

Technique Failure in Peritoneal Dialysis: Etiologies and Risk Assessment

Technique failure (TF) is a well-recognized challenge encountered in patients undergoing peritoneal dialysis (PD). Identification of patients at risk for this complication is of utmost importance. Early detection of patients at risk and development of preventative strategies can improve technique survival that may lead to an increased utilization of PD. It will also promote a safe and planned transfer to hemodialysis once a patient identified with TF. The aim of this review is to summarize risk factors and scenarios associated with TF focusing on prevention of remediable factors at their earliest stage. Furthermore, integration of this knowledge into quality improvement initiatives should be entertained in an effort to improve outcomes.

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BACKGROUND

The low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.

METHODS

This retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).

RESULTS

Eighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.

CONCLUSIONS

Our study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.

Setting Up and Expanding a Home Dialysis Program: Is There a Recipe for Success?

Home dialysis modalities remain significantly underused in the United States despite similar overall survival in the modalities, and recent incentives to expand these modalities. Although the absolute number of patients using home modalities has grown, the proportion compared to in-center hemodialysis (ICHD) continues to remain quite low. Well known barriers to home dialysis utilization exist, and an organized and team-based approach is required to overcome these barriers. Herein, we describe our efforts at growing our home dialysis program at a large academic medical center, with the proportion of home dialysis patients growing from 12% to 21% over the past 9 years. We prioritized individualized education for patients and better training for physicians, with the help of existing resources, aimed at better utilization of home modalities; an example includes dedicated dialysis education classes taught twice monthly by an experienced nurse practitioner, as well as the utilization of the dialysis educator from a dialysis provider for inpatient education of patients with CKD. The nephrology fellowship curriculum was restructured with emphasis on home modalities, and participation in annual home dialysis conferences has been encouraged. For timely placement and troubleshooting of access for dialysis, we followed a complementary team approach using surgeons and interventional radiologists and nephrologists, driven by a standardized protocol developed at UAB, and comanaged by our access coordinators. A team-based approach, with emphasis on staff engagement and leadership opportunities for dialysis nurses as well as collaborative efforts from a team of clinical nephrologists and the dialysis provider helped maintain efficiency, kindle growth, and provide consistently high-quality clinical care in the home program. Lastly, efforts at reducing burden of disease such as decreased number of monthly visits as well as using innovative strategies, such as telenephrology and assisted PD and HHD, were instrumental in reducing attrition.

Going Home: Access for Home Modalities

The cost and health burden of ESRD continues to increase globally. Total Medicare expenditure on dialysis has increased from 229 million USD in 1973 to 35.4 billion USD in 2016. Dialysis access can represent almost a tenth of these costs. Central venous catheters have been recognized as a significant factor driving costs and mortality in this population. Home dialysis, which includes peritoneal dialysis and home hemodialysis, is an effective way of reducing costs related to renal replacement therapy, reducing central venous catheter usage and in many cases improving the clinical and psychosocial aspects of patients' health. Addressing access-related issues for peritoneal dialysis, urgent-start peritoneal dialysis and home hemodialysis can have impact on the success of home dialysis. This article reviews issues related to dialysis access for home therapies.

Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single centre in Turkey

Background/aim

The aim of this study was to evaluate the clinical outcomes and identify the predictors of mortality in peritoneal dialysis patients.

Materials and methods

Medical records of all incident peritoneal dialysis (PD) patients followed up between January 2011 and May 2019 were reviewed retrospectively. All patients were followed up until death, renal transplantation, transfer to haemodialysis or the end of the study.

Results

A total of 242 patients were included in the study. The incidence of peritonitis was 0.18 (ranging from 0 to 14.9) episodes per patient year. Death occurred in 28% (n: 68) of cases. Age, diabetes mellitus, malignancy and refractory heart failure were independent risk factors for all-cause mortality according to multivariate analysis. The presence of comorbid disease and diabetes mellitus and patients aged > 65 years were associated with increased risk of mortality and decreased patient survival. Peritonitis history was associated with increased risk of mortality. Between peritonitis and peritonitis-free group, there was no significant difference in Kaplan-Meier curves in terms of patient survival.

Conclusion

This is the first study to define 9-year mortality predictors in PD patients in our centre. Although peritonitis is the most feared complication of PD, our study showed that peritonitis did not reduce patient survival.

Changes in serum albumin concentrations during transition to dialysis and subsequent risk of peritonitis after peritoneal dialysis initiation: a retrospective cohort study

BACKGROUND

Evidence shows that lower serum albumin concentrations are associated with the risk of peritoneal dialysis (PD)-related peritonitis. However, little is known regarding its relationship and magnitude of change before PD initiation and peritonitis risk.

METHODS

We performed a multicenter retrospective cohort study on 1169 adult cases of PD in Thailand. The associations of serum albumin at concentration (< 2.5, 2.5-3.5, > 3.5 [reference] g/dL) and changes (unchanged + 0.1 to - 0.1 [reference], decrease or increase > 0.1 g/dL) over 3- and 6-month before PD initiation with PD-related peritonitis were examined. Time-to-first and longitudinal rates of peritonitis were examined using the multivariable Cox proportional hazards model and Poisson regression analyses, respectively.

RESULTS

At baseline PD initiation, patients with serum albumin concentration < 2.5 and 2.5-3.5 g/dL had an adjusted hazard ratio (HR) of 1.69 and 2.0 times higher peritonitis (vs. > 3.5 g/dL), respectively. Compared to the unchanged group, patients with a decrease and increase in serum albumin concentrations during transitioning to dialysis were significantly associated with higher and lower risk of peritonitis, adjusted HR of 2.25 (95% confidence interval [CI] 1.85-2.75) and 0.53 (95% CI 0.42-0.68) over three-month, and 1.43 (95% CI 1.15-1.79) and 0.64 (95% CI 0.52-0.79) over six-month, respectively. Similar trends of longitudinal rates of serum albumin concentrations and peritonitis risk were observed.

CONCLUSIONS

Serum albumin concentrations at PD initiation and its magnitude of change during the transition to dialysis are strongly associated with subsequent risk of peritonitis. Further studies are required on strategies modifying serum albumin concentration during the transition to PD.

Early Peritoneal Dialysis Technique Failure: Review

There is a growing, global burden of patients with end-stage kidney disease (ESKD) requiring renal replacement therapy. Although peritoneal dialysis (PD) is considered to be the most cost-effective dialysis modality, its utilization has been declining in some regions. The first year after starting PD is thought to be a vulnerable period for technique failure, which in turn contributes to poor patient retention. Improved understanding of the risk factors for technique failure during this period may help the development of targeted strategies to lower its incidence and improve both the utilization and utility of PD. This up-to-date review will summarize current evidence regarding the definition, incidence, causes, and predictors of early PD technique failure. Promising avenues for directing future research efforts will also be discussed.

The impact of volume overload on technique failure in incident peritoneal dialysis patients

Background

Technique failure in peritoneal dialysis (PD) can be due to patient- and procedure-related factors. With this analysis, we investigated the association of volume overload at the start and during the early phase of PD and technique failure.

Methods

In this observational, international cohort study with longitudinal follow-up of incident PD patients, technique failure was defined as either transfer to haemodialysis or death, and transplantation was considered as a competing risk. We explored parameters at baseline or within the first 6 months and the association with technique failure between 6 and 18 months, using a competing risk model.

Results

Out of 1092 patients of the complete cohort, 719 met specific inclusion and exclusion criteria for this analysis. Being volume overloaded, either at baseline or Month 6, or at both time points, was associated with an increased risk of technique failure compared with the patient group that was euvolaemic at both time points. Undergoing treatment at a centre with a high proportion of PD patients was associated with a lower risk of technique failure.

Conclusions

Volume overload at start of PD and/or at 6 months was associated with a higher risk of technique failure in the subsequent year. The risk was modified by centre characteristics, which varied among regions.

Optimization of Dialysis Modality Transitions for Improved Patient Care

Purpose of review:

Initial and subsequent modality decisions are important, impacting both clinical outcomes and quality of life. Transition from chronic kidney disease to dialysis and between dialysis modalities are periods were patients may be especially vulnerable. Reviewing our current knowledge surrounding these critical periods and identifying areas for future research may allow us to develop dialysis strategies beneficial to patients.

Sources of information:

We searched the electronic database PubMed and queried Google Scholar for English peer-reviewed articles using appropriate keywords (non-exhaustive list): dialysis transitions, peritoneal dialysis, home hemodialysis, integrated care pathway, and health-related quality of life. Primary sources were accessed whenever possible.

Methods:

In this narrative review, we aim to expose the controversies surrounding home-dialysis first strategies and examine the evidence underpinning home-dialysis first strategies as well as home-to-home and home-to-in-center transitions.

Key findings:

Diverse factors must be taken into consideration when choosing initial and subsequent dialysis modalities. Given the limitations of available data (and lack of convincing benefit or detriment of one modality over the other), patient-centered considerations may prime over suspected mortality benefits of one modality or another.

Limitations:

Available data stem almost exclusively from retrospective and observational studies, often using large national and international databases, susceptible to bias. Furthermore, this is a narrative review which takes into account the views and opinions of the authors, especially as it pertains to optimal dialysis pathways.

Implications:

Emphasis must be placed on individual patient goals and preferences during modality selection while planning ahead to achieve timely and appropriate transitions limiting discomfort and anxiety for patients. Further research is required to ascertain specific interventions which may be beneficial to patients.