Factors Associated With Urgent-Start Peritoneal Dialysis Catheter Complications in ESRD

Minimizing early catheter failure using a risk stratification model for peritoneal dialysis

BACKGROUND

Early catheter failure is the main reason for peritoneal dialysis (PD) failure, which often causes patients to withdraw from PD. Reducing the early catheter failure is critical to increase the acceptance of PD. The purpose of our study was to establish a risk stratification model to minimize early catheter failure.

METHODS

A retrospective study with patients underwent PD catheter placement from January 2013 to March 2022 was conducted. The primary outcome event was early catheter failure. Univariate and multivariable logistic regression were performed to select potential risk predictors. A risk stratification model and a clinical procedure were established. The effectiveness of the model was evaluated by external validation.

RESULTS

A total of 432 patients were finally enrolled in the study. The risk for early catheter failure was associated with younger age (odds ratio [OR], 0.930; 95% confidence interval [95% CI], 0.884 to 0.972; p = 0.002), lower body mass index (BMI) (OR, 0.797; 95% CI, 0.629 to 0.964; p = 0.036), and lower albumin (ALB) levels (OR, 0.881; 95% CI, 0.782 to 0.985; p = 0.036). The risk stratification model was established and performed great discrimination capability with AUC of 0.832 (cut-off value: 0.061, sensitivity: 0.853, specificity: 0.812). The model proved to be effective in external validation; the rate of early catheter failure was dropped off from 4.1% to 0%.

CONCLUSIONS

We established an effective risk stratification model, by which patients with high risk of early catheter failure could be precisely identified. The clinical procedure based on the model was proved to be helpful to minimize early catheter failure.

The prognostic values of estimating intraperitoneal pressure in the occurrence of abdominal wall complications in peritoneal dialysis patients

BACKGROUND

Increased intraperitoneal pressure is associated with abdominal wall complications and technical failure of peritoneal dialysis (PD). Several equations have been developed to estimate intraperitoneal pressure. We aimed to assess the prognostic yield of the intraperitoneal pressure as estimated by current equations on the occurrence of abdominal wall complications in peritoneal dialysis patients.

METHODS

This is a retrospective analysis of data from a prospective cohort which recruited 1207 incident PD patients. Estimated intraperitoneal pressure was calculated using four available equations (according to Sigogne, Castellanos, Scanziani and de Jesus Ventura). Abdominal wall complications were recorded during follow-up. Univariate analysis and multivariate analysis with competing risk regression were used to assess the predictive power of the estimates of intraperitoneal pressure in the occurrence of abdominal wall complications.

RESULTS

During a median follow-up of 30 months, 66 (5.5%) patients (1.6/100 patient-years) developed abdominal wall complications. The median time to the occurrence of abdominal wall complications was 5.7 months. Only the estimated intraperitoneal pressure by the de Jesus Ventura equation significantly predicted abdominal wall complications by using univariate analyses. Associations between estimated intraperitoneal pressure by the de Jesus Ventura equation and the occurrence of abdominal wall complications disappeared after adjusting for significant clinical factors.

CONCLUSIONS

We verified the prognostic value of estimation of intraperitoneal pressure by four available equations in predicting abdominal wall complications in our single-center PD cohort. Due to a low diagnostic yield, a novel equation for estimating the intraperitoneal pressure is urgently needed.

Cardiac Surgery Outcomes in Patients Receiving Hemodialysis Versus Peritoneal Dialysis

Rationale & Objective

We sought to compare outcomes of patients receiving dialysis after cardiothoracic surgery on the basis of dialysis modality (intermittent hemodialysis [HD] vs peritoneal dialysis [PD]).

Study Design

This was a retrospective analysis.

Setting & Participants

In total, 590 patients with kidney failure receiving intermittent HD or PD undergoing coronary artery bypass graft and/or valvular cardiac surgery at Cleveland Clinic were included.

Exposure

The patients received PD versus HD (intermittent or continuous).

Outcomes

Our primary outcomes were in-hospital and 30-day mortality. Secondary outcomes were length of stay, days in the intensive care unit, the number of intraoperative blood transfusions, postsurgical pericardial effusion, and sternal wound infection, and a composite of the following 4 in-hospital events: death, cardiac arrest, effusion, and sternal wound infection.

Analytical Approach

We used χ2, Fisher exact, Wilcoxon rank sum, and t tests, Kaplan-Meier survival, and plots for analysis.

Results

Among the 590 patients undergoing cardiac surgery, 62 (11%) were receiving PD, and 528 (89%) were receiving intermittent HD. Notably, 30-day Kaplan-Meier survival was 95.7% (95% CI: 93.9-97.5) for HD and 98.2% (95% CI: 94.7-100) for PD (P = 0.30). In total, 75 patients receiving HD (14.2%) and 1 patient receiving PD (1.6%) had a composite of 4 in-hospital events (death, cardiac arrest, effusion, and sternal wound infection) (P = 0.005). Out of 62 patients receiving PD, 16 (26%) were converted to HD.

Limitations

Retrospective analyses are prone to residual confounding. We lacked details about nutritional data. Intensive care unit length of stay was used as a surrogate for volume status control. Patients have been followed in a single health care system. The HD cohort outnumbered the PD cohort significantly.

Conclusions

When compared with PD, HD does not appear to improve outcomes of patients with kidney failure undergoing cardiothoracic surgery. Patients receiving PD had a lower incidence of a composite outcome of 4 in-hospital events (death, cardiac arrest, pericardial effusion, and sternal wound infections).

Novel equations for estimating intraperitoneal pressure among peritoneal dialysis patients

Background

Increased intraperitoneal pressure (IPP) is associated with abdominal wall complications and technical failure in peritoneal dialysis (PD). Since the standard measurement of IPP is limited due to its cumbersome procedures, we aimed to develop and validate equations for estimating IPP.

Methods

We performed a cross-sectional study with a total of 200 prevalent PD patients who were divided into development and validation datasets after random sampling matched by body mass index. The IPPs were measured using the Durand method, with whole-body and abdominal anthropometry indices collected. Equations with 2.0-L and 1.5-L fill volumes were generated by stepwise linear regression modelling. The bias, accuracy and precision of the estimated IPP (eIPP) with 2-L and 1.5-L fill volumes were compared with actual IPPs by the Durand method. The eIPP for the 2-L fill volume was also compared with other existing equations.

Results

Two new equations incorporating waist circumference and height from the decubitus plane to mid-axillary line were generated. The eIPPs exhibited small biases in relation to the Durand method , with median differences of -0.24 cmH2O and -0.10 cmH2O for 2 L and 1.5 L, respectively. The precisions evaluated by the standard deviation of the absolute value of the differences were 2.59 cmH2O and 2.50 cmH2O, respectively. The accuracies evaluated by the value of the percentage of estimates that differed by >20% for the eIPP were 26% for 2.0 L and 27% for 1.5 L. Better bias, precision and accuracy were observed for the eIPP equation compared with other existing equations for the 2.0-L fill volume.

Conclusions

We provided two new equations developed from abdominal anthropometry indices to accurately estimate the IPP in the PD population.

Break-in Period ≤24 Hours as an Option for Urgent-start Peritoneal Dialysis in Patients With Diabetes

BACKGROUND

The optimal break-in period (BI) of urgent-start peritoneal dialysis (USPD) initiation for patients with end-stage renal disease (ESRD) and diabetes is unclear. We aimed to explore the safety and applicability of a BI ≤24 h in patients with ESRD and diabetes.

METHODS

We used a retrospective cohort design wherein we recruited patients with ESRD and diabetes who underwent USPD at five institutions in China between January 2013 and August 2020. The enrolled patients were grouped according to BI. The primary outcomes were mechanical and infectious complication occurrences, whereas the secondary outcome was technique survival.

RESULTS

We enrolled 310 patients with diabetes, of whom 155 and 155 patients were in the BI ≤24 h and BI >24 h groups, respectively. The two groups showed a comparable incidence of infectious and mechanical complications within 6 months after catheter insertion (p>0.05). Logistic regression analysis revealed that a BI ≤24 h was not an independent risk factor for mechanical or infectious complications. Kaplan-Meier estimates showed no statistically significant between-group differences in technique survival rates (p>0.05). Cox multivariate regression analysis revealed that a BI ≤24 h was not an independent risk factor for technique failure.

CONCLUSION

USPD initiation with a BI ≤24 h may be safe and feasible for patients with ESRD and diabetes.

Urgent vs. planned peritoneal dialysis initiation: complications and outcomes in the first year of therapy

INTRODUCTION

Urgent-start peritoneal dialysis (US-PD) has been proposed as a safe modality of renal replacement therapy (RRT) for end-stage renal disease (ESRD) patients with an indication for emergency dialysis initiation. We aimed to compare the characteristics, 30-day complications, and clinical outcomes of US-PD and planned peritoneal dialysis (Plan-PD) patients over the first year of therapy.

METHODS

This was a single-center retrospective study that included incident adult patients followed for up to one year. US-PD was considered when incident patients started therapy within 7 days after Tenckhoff catheter implantation. Plan-PD group consisted of patients who started therapy after the breaking period (15 days). Mechanical and infectious complications were compared 30 days from PD initiation. Hospitalization and technique failure during the first 12 months on PD were assessed by Kaplan-Meier curves and the determinants were calculated by Cox regression models.

RESULTS

All patients starting PD between October/2016 and November/2019 who fulfilled the inclusion criteria were analyzed. We evaluated 137 patients (70 in the US-PD x 67 Plan-PD). The main complications in the first 30 days were catheter tip migration (7.5% Plan-PD x 4.3% US-PD - p= 0.49) and leakage (4.5% Plan-PD x 5.7% US-PD - p=0.74). Most catheters were placed using the Seldinger technique. The main cause of dropout was death in US-PD patients (15.7%) and transfer to HD in Plan-PD patients (13.4%). The occurrence of complications in the first 30 days was the only risk factor for dropout (OR = 2.9; 95% CI 1.1-7.5, p = 0.03). Hospitalization rates and technique survival were similar in both groups.

CONCLUSION

The lack of significant differences in patients' outcomes between groups reinforces that PD is a safe and applicable dialysis method in patients who need immediate dialysis.

Risk factors for early death in urgent-start peritoneal dialysis patients: A multicenter retrospective cohort study

BACKGROUND

Assess risk factors for early death in patients who underwent urgent-start peritoneal dialysis (USPD).

METHODS

Patients who initiated USPD in five peritoneal dialysis centers from 2013 to 2019 were screened in this multicenter retrospective cohort study. Risk factors for all-cause mortality within 3 months were explored.

RESULTS

A total of 1265 USPD patients with 43 early deaths were included. Cox regression analyses showed that age older than 60 years (hazard ratio [HR], 3.054; 95% CI [1.597, 5.842]; p = 0.001), albumin less than 30 g/L (HR, 2.234; 95%CI [1.207, 4.136]; p = 0.011), blood glucose greater than 7 mmol/L (HR, 2.766; 95%CI [1.477, 5.180]; p = 0.001), higher estimated glomerular filtration rate (eGFR; HR, 1.121; 95%CI [1.071, 1.172]; p = 0.000), and poor stages of heart failure (class IV compared with class 0-I; HR, 5.165; 95%CI [2.544, 10.486]; p = 0.000) were independent predicting factors for early death.

CONCLUSIONS

Risk factors for early death were older age, hypoproteinemia, hyperglycemia, higher eGFR, and severe heart failure.

Risk Factors and Management of Catheter Malfunction During Urgent-Start Peritoneal Dialysis

Background: Catheter malfunction is a common complication of peritoneal dialysis (PD). This study aimed to retrospectively analyze the risk factors and management of catheter malfunction in urgent-start PD.

Methods: Patients who underwent urgent-start PD were divided into catheter-malfunction and control groups. Baseline demographic and laboratory data of the two groups were compared, and the risk factors for catheter malfunction were analyzed. Primary outcome measure was catheter survival, and the secondary outcomes were surgical complications and malfunction treatment.

Results: Total of 700 patients was analyzed, among whom 143 (20.4%) experienced catheter malfunctions, specifically catheter migration (96, 67.1%), omental wrapping (36, 25.2%), and migration plus omental wrapping (11, 7.7%). Catheter survival time in the malfunction group (202.5 ± 479.4 days) was significantly shorter than that in the control group (1295.3 ± 637.0 days) (P < 0.001). Multivariate analysis revealed higher body mass index [hazard ratio (HR), 1.061; 95% confidence intervals (CI), 1.010–1.115; P = 0.018], lower surgeon count (HR, 1.083; 95% CI, 1.032–1.136; P = 0.001), and higher serum potassium (HR, 1.231; 95% CI, 1.041–1.494; P = 0.036) as independent risk factors for catheter malfunction, while older age (HR, 0.976, 95% CI, 0.962–0.991; P = 0.002) and colonic dialysis (HR, 0.384; 95% CI, 0.254–0.581; P < 0.001) as protective factors. Further subgroup analysis revealed a shorter catheter survival time in patients with younger age ( ≤ 40 years), higher serum potassium levels (≥5 mmol/L), while a longer catheter survival time in patients with colonic dialysis. PD tube and subcutaneous tunnel preservation was successful in 41 out of 44 patients with omental wrapping. All patients had good post-incision prognoses.

Conclusions: Urgent-start PD is safe and effective for unplanned PD patients. Adequate pre-operative colonic dialysis and serum potassium level control are conducive in preventing catheter malfunction. Conservative treatment is effective in managing catheter migration alone, while preservation of the PD tube and the subcutaneous tunnel is effective for omental wrapping.