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Park PG, Ahn YH, Kang HG, Ha IS. Decreased incidence of peritoneal dialysis-associated peritonitis in young children. J Paediatr Child Health 2024. [PMID: 39091153 DOI: 10.1111/jpc.16630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 07/05/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024]
Abstract
AIM Peritonitis is the most common complication of peritoneal dialysis (PD). This study aimed to investigate changes in the incidence, risk factors, microbiology, and clinical outcomes of PD-associated peritonitis in the past decades. METHODS This was a retrospective study that included children who initiated chronic PD at our institution between 2000 and 2017. The patients were divided into two groups according to the year of initiation: those who initiated PD between 2000 and 2008 and those who initiated PD between 2009 and 2017. The incidence and characteristics of peritonitis were compared between the groups. RESULTS A total of 184 patients with a median age of 10.2 years were included in this study. Of the patients, 92 experienced 210 episodes of peritonitis. The incidence rate of peritonitis decreased from 0.35 to 0.21 episodes/patient year during the study period (P = 0.001). During the 2000-2008 period, the 2-year peritonitis-free survival rate was significantly lower for patients under 2 years of age than for the other age groups (P = 0.004), whereas this was not observed during the 2009-2017 period. The multivariable Cox proportional hazard model showed that the <2 years age group had a significantly higher risk of developing peritonitis in the 2000-2008 period. However, this was not evident in the 2009-2017 period. CONCLUSIONS The incidence of PD-associated peritonitis decreased, particularly in children under 2 years of age. Thus, younger age may not be a risk factor for PD-associated peritonitis.
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Affiliation(s)
- Peong Gang Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
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Kamath N, Lobo S, Joseph S, Iyengar A. Structured training initiative (STI) for caregivers of children on peritoneal dialysis: a prospective study of the impact on the rate of peritonitis. Pediatr Nephrol 2024:10.1007/s00467-024-06455-w. [PMID: 39023537 DOI: 10.1007/s00467-024-06455-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Training caregivers performing PD is an important measure to prevent peritonitis. A low literacy rate hinders training in low-resource settings. We designed a structured training initiative (STI) and objective structured assessment (OSA) using visual and kinesthetic resources with minimal use of written resources. We studied the impact of STIs on caregivers' knowledge and practical skills and the rate of peritonitis. METHODS This prospective study conducted initial STI (iSTI) for caregivers of children initiating PD and retraining STI (rSTI) for those already on PD. OSA was administered after completion of training, and those scoring < 95% were retrained. Re-assessment was done at 3, 6, and 12 months, and those who scored < 95% underwent re-training. The rate of PD peritonitis and the time to first peritonitis were compared between the STI group and the cohort on PD in our center who received standard training before STI (controls). RESULTS Caregivers of 40 children were included. The median duration of iSTI and rSTI was 19.5 (18, 20) and 9 (9, 9.5) hrs, and the OSA scores were 97% (97%, 98%) and 96% (96%, 98%), respectively. Only 5% required retraining. There was a significant reduction in the rate of PD peritonitis (0.29 vs. 0.69 episodes/patient-year; p < 0.001) and longer time to peritonitis (189 vs. 69 days; p < 0.001) in the STI group when compared to the controls (n = 32). CONCLUSIONS STI was effective in training caregivers for peritoneal dialysis. There was a reduction in the rate of peritonitis and a longer time to first peritonitis in the STI cohort.
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Affiliation(s)
- Nivedita Kamath
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bangalore, India.
| | - Shaila Lobo
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bangalore, India
| | - Smitha Joseph
- Department of Biostatistics, St John's Medical College, Bangalore, India
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College Hospital, Bangalore, India
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Bakkaloğlu SA, Özdemir Atikel Y, Schmitt CP, Lévai E, Adalat S, Goodman N, Dursun İ, Pınarbaşı AS, Yazıcıoğlu B, Paglialonga F, Vondrak K, Guzzo I, Printza N, Zurowska A, Zagożdżon I, Karabay Bayazıt A, Atmış B, Tkaczyk M, Faria MDS, Zaloszyc A, Jankauskienė A, Ekim M, Edefonti A, Shroff R. Comparative analysis of hospitalizations among patients treated with hemodialysis and peritoneal dialysis in European pediatric nephrology centers: results from a prospective EPDWG/ESPN Dialysis Working Group study. Clin Kidney J 2024; 17:sfad291. [PMID: 38223336 PMCID: PMC10784969 DOI: 10.1093/ckj/sfad291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Indexed: 01/16/2024] Open
Abstract
Background and hypothesis Hospital admissions in pediatric dialysis patients need to be better studied, and most existing studies are retrospective and based on registry data. This study aimed to analyse and compare hospital admission rates, causes, length of stay (LOS), and outcomes in children treated with peritoneal dialysis (PD) and hemodialysis (HD). Methods Data from 236 maintenance PD and 138 HD patients across 16 European dialysis centers were collected between 1 July 2017 and 30 June 2018. A total of 178 hospitalized patients (103 PD, 75 HD) were included for further analyses. Results There were 465 hospitalization events (268 PD, 197 HD) with a rate of 0.39 admissions per 100 patient-days at risk (PDAR) and 2.4 hospital days per 100 PDAR. The admission rates were not significantly different between HD and PD patients. The most common causes of hospitalization were access-related infections (ARI) (17%), non-infectious complications of access (NIAC) (14%), and infections unrelated to access (12%). ARI was the leading cause in PD patients (24%), while NIAC was more common in HD patients (19%). PD patients had more ARIs, diagnostic procedures, and treatment adjustments (P < .05), while HD patients had more NIACs, infections unrelated to access, access placement procedures, and interventional/surgical procedures (P < .001). LOS was longer with acute admissions than non-acute admissions (P < .001). Overall LOS and LOS in the intensive care unit were similar between HD and PD patients. High serum uric acid and low albumin levels were significant predictors of longer LOS (P = .022 and P = .045, respectively). Young age, more significant height deficit, and older age at the start of dialysis were predictors of longer cumulative hospital days (P = .002, P = .001, and P = .031, respectively). Conclusion Access-related complications are the main drivers of hospitalization in pediatric dialysis patients, and growth and nutrition parameters are significant predictors of more extended hospital stays.
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Affiliation(s)
- Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Yeşim Özdemir Atikel
- Department of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
- Department of Pediatric Nephrology, Eskişehir City Hospital, Eskişehir, Turkey
| | - Claus Peter Schmitt
- Department of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Eszter Lévai
- Department of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Shazia Adalat
- Department of Pediatric Nephrology, Evelina London Children's Hospital, London, United Kingdom
| | - Nadine Goodman
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - İsmail Dursun
- Department of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ayşe Seda Pınarbaşı
- Department of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Burcu Yazıcıoğlu
- Department of Pediatric Nephrology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Fabio Paglialonga
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Karel Vondrak
- Department of Pediatric Nephrology, University Hospital Motol, Prague, Czech Republic
| | - Isabella Guzzo
- UO di Nefrologia e Dialisi, Ospedale Pediatrico Bambino Gesu-IRCCS, Rome, Italy
| | - Nikoleta Printza
- Department of Pediatric Nephrology, Medical School of Aristotle University, Thessaloniki, Greece
| | - Aleksandra Zurowska
- Department of Pediatrics Nephrology & Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Ilona Zagożdżon
- Department of Pediatrics Nephrology & Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Aysun Karabay Bayazıt
- Department of Pediatric Nephrology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Bahriye Atmış
- Department of Pediatric Nephrology, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Marcin Tkaczyk
- Department of Pediatric Nephrology, Instytut Centrum Zdrowia, Matki, Poland
| | - Maria do Sameiro Faria
- Department of Pediatric Nephrology, Centro Materno-Infantil do Norte, CHP, Porto, Portugal
| | - Ariane Zaloszyc
- Department of Pediatric Nephrology, Country Hautepierre CHU, Strasbourg, France
| | - Augustina Jankauskienė
- Institute of Clinical Medicine, Vilnius University, Pediatric Center, Vilnius, Lithuania
| | - Mesiha Ekim
- Department of Pediatric Nephrology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Alberto Edefonti
- Department of Pediatric Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rukshana Shroff
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children, London, United Kingdom
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Kamath N, Borzych-Dużałka D, Kaur A, Neto G, Arbeiter K, Yap YC, Lahoche A, Eid L, Hooman N, Richardson T, Schaefer F, Warady BA. Pediatric peritoneal dialysis training program and its relationship to peritonitis: a study of the International Pediatric Peritoneal Dialysis Network. Pediatr Nephrol 2023; 38:4111-4118. [PMID: 37405492 DOI: 10.1007/s00467-023-05995-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND The guidelines for training of patients and caregivers to perform home peritoneal dialysis (PD) uniformly include recommendations pertaining to the prevention of peritonitis. The objective of this study conducted by the International Pediatric Peritoneal Dialysis Network (IPPN) was to investigate the training practices for pediatric PD and to evaluate the impact of these practices on the peritonitis and exit-site infection (ESI) rate. METHODS A questionnaire regarding details of the PD program and training practices was distributed to IPPN member centers, while peritonitis and ESI rates were either derived from the IPPN registry or obtained directly from the centers. Poisson univariate and multivariate regression was used to determine the training-related peritonitis and ESI risk factors. RESULTS Sixty-two of 137 centers responded. Information on peritonitis and ESI rates were available from fifty centers. Training was conducted by a PD nurse in 93.5% of centers, most commonly (50%) as an in-hospital program. The median total training time was 24 hours, with a formal assessment conducted in 88.7% and skills demonstration in 71% of centers. Home visits were performed by 58% of centers. Shorter (< 20 hours) training duration and lower number of training tools (both p < 0.02) were associated with higher peritonitis rate, after adjustment for proportion of treated infants and income of country of residence. CONCLUSIONS An association between training duration and the number of training tools represent potentially modifiable risk factors to reduce peritonitis rates within the pediatric PD population. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
| | - Dagmara Borzych-Dużałka
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Gdańsk, Poland
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Amrit Kaur
- Royal Manchester Children's Hospital, Manchester, UK
| | - Gisela Neto
- Pediatric Nephrology Unit, Dona Estefania Hospital, Lisbon, Portugal
| | | | - Yok Chin Yap
- Women and Children Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | | | - Loai Eid
- Dubai Hospital, Dubai, United Arab Emirates
| | - Nakysa Hooman
- Ali Asghar Clinical Research Development Center, Department of Pediatrics, Iran University of Medical Science, Tehran, Iran
| | | | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, USA
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Wasik HL, Keswani M, Munshi R, Neu A, Richardson T, Warady B. Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis. Pediatr Nephrol 2023; 38:4119-4125. [PMID: 37421469 DOI: 10.1007/s00467-023-06076-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/18/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD. METHODS We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis. RESULTS There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59). CONCLUSIONS PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Heather L Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Physicians' Office Building 805, 725 Irving Avenue, Syracuse, NY, 13210, USA.
| | - Mahima Keswani
- Division of Pediatric Nephrology, Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Raj Munshi
- Division of Pediatric Nephrology, Seattle Children's Hospital, Seattle, WA, USA
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
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Begin B, Richardson T, Ehrlich J, Warady BA, Neu AM. Training practices and peritonitis rates in children on maintenance peritoneal dialysis: results from the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) collaborative. Pediatr Nephrol 2023; 38:3401-3406. [PMID: 37097515 DOI: 10.1007/s00467-023-05975-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Comprehensive training of children on peritoneal dialysis (PD) and their caregivers is crucial to minimize peritonitis risk. Few studies have evaluated the impact of training on infection, so many published recommendations rely on expert opinion. This study uses data from the SCOPE collaborative to examine the impact of compliance with 4 components of PD training on the risk for peritonitis. METHODS A retrospective cohort study of children enrolled in the SCOPE collaborative between 2011 and 2021 who received training prior to initiating PD. Compliance with 4 training components were assessed: performance of a home visit, 1:1 training, delaying training ≥ 10 days after PD catheter insertion and average individual training session length ≤ 3 h. Univariate and multivariable generalized linear mixed modeling were used to assess relationships between peritonitis ≤ 90 days after PD training and median days to peritonitis and compliance with each component as well as all-or-none compliance. RESULTS Among 1450 trainings, 51.7% had median session length ≤ 3 h, 67.1% delayed training ≥ 10 days after catheter insertion, 74.3% had a home visit and 94.6% had 1:1 training. Only 333 trainings (23%) were compliant with all 4 training components. There was no statistically significant association between compliance with individual components, or all-or-none compliance and either the percentage of catheters with peritonitis ≤ 90 days after training end or median days to peritonitis. CONCLUSION No associations between 4 PD training components and risk for peritonitis were found. SCOPE requires monthly review of PD catheter practices which may have decreased the impact of training non-compliance. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Brandy Begin
- Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR, USA
| | | | | | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Alicia M Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, 200 N Wolfe Street, Room 3055, Baltimore, MD, 21287, USA.
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The effects of hospital and dialysis unit characteristics on hospitalizations for access-related complications among children on maintenance dialysis: a European, multicenter, observational, cross-sectional study. Pediatr Nephrol 2023:10.1007/s00467-022-05842-5. [PMID: 36595069 DOI: 10.1007/s00467-022-05842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Previous studies investigating hospitalizations in dialysis patients have focused primarily on patient-centered factors. We analyzed the impact of hospital and dialysis unit characteristics on pediatric dialysis patients' hospitalizations for access-related complications (ARCs). METHODS This cross-sectional study involved 102 hemodialysis (HD) and 163 peritoneal dialysis (PD) patients. Data between July 2017 and July 2018 were analyzed. RESULTS Children's hospitals (CHs) had more pediatric nephrologists and longer PD experience (years) than general hospitals (GHs) (p = 0.026 and p = 0.023, respectively). A total of 53% of automated PD (APD) and 6% of continuous ambulatory PD (CAPD) patients were in CHs (p < 0.001). Ninety-three percent of APD and 69% of CAPD patients were treated in pediatric-specific PD units (p = 0.001). CHs had a higher prevalence in providing hemodiafiltration (HDF) than GHs (83% vs. 30%). Ninety-seven percent of HDF vs. 66% for conventional HD (cHD) patients, and 94% of patients with arteriovenous fistula (AVF) vs. 70% of those with central venous catheters (CVC), were dialyzed in pediatric-specific HD units (p = 0.001 and p = 0.016, respectively). Eighty patients (51 PD and 29 HD) had 135 (84 PD, 51 HD) hospitalizations. CAPD was an independent risk factor for hospitalizations for infectious ARCs (I-ARCs) (p = 0.009), and a health center's PD experience negatively correlated with CAPD patient hospitalizations for I-ARCs (p = 0.041). cHD and dialyzing in combined HD units significantly increased hospitalization risk for non-infectious (NI-)ARCs (p = 0.044 and p = 0.017, respectively). CONCLUSIONS CHs and pediatric-specific dialysis units have higher prevalence of APD and HDF use. Hospitalizations for I-ARCs in CAPD are lower in centers with longer PD experience, and pediatric HD units are associated with fewer hospitalizations due to NI-ARCs. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Varnell CD, Margolis P, Goebel J, Hooper DK. The learning health system for pediatric nephrology: building better systems to improve health. Pediatr Nephrol 2023; 38:35-46. [PMID: 35445971 PMCID: PMC9021363 DOI: 10.1007/s00467-022-05526-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 02/28/2022] [Accepted: 02/28/2022] [Indexed: 01/10/2023]
Abstract
Learning health systems (LHS) align science, informatics, incentives, and culture for continuous improvement and innovation. In this organizational system, best practices are seamlessly embedded in the delivery process, and new knowledge is captured as an integral byproduct of the care delivery experience aimed to transform clinical practice and improve patient outcomes. The objective of this review is to describe how building better health systems that integrate clinical care, improvement, and research as part of an LHS can improve care within pediatric nephrology. This review will provide real-world examples of how this system can be established in a single center and across multiple centers as learning health networks.
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Affiliation(s)
- Charles D Varnell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Peter Margolis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Goebel
- Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI, USA
- Pediatric Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - David K Hooper
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Nephrology & Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Chua AN, Kumar R, Warady BA. Care of the pediatric patient on chronic peritoneal dialysis. Pediatr Nephrol 2022; 37:3043-3055. [PMID: 35589990 DOI: 10.1007/s00467-022-05605-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/29/2022] [Accepted: 04/30/2022] [Indexed: 01/10/2023]
Abstract
Peritoneal dialysis is the most commonly prescribed dialysis modality for infants and young children with kidney failure worldwide. Provision of high-quality care for the pediatric patient on chronic peritoneal dialysis requires a multidisciplinary approach and a strong collaboration with the patient and their caregiver. This article not only reviews current recommendations and advances in the care of pediatric patients on peritoneal dialysis with a focus on the provision of high-quality care and improvement in outcomes, but it also draws attention to health care disparities that exist locally and globally.
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Affiliation(s)
- Annabelle N Chua
- Division of Pediatric Nephrology, Department of Pediatrics, Duke Children's Hospital, Duke University School of Medicine, Box 3959, Durham, NC, 27710, USA.
| | - Reeti Kumar
- Division of Pediatric Nephrology, Department of Pediatrics, Duke Children's Hospital, Duke University School of Medicine, Box 3959, Durham, NC, 27710, USA
| | - Bradley A Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy Kansas City, Kansas City, MO, USA
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Reduction in peritonitis rates: 18-year results from the most active pediatric peritoneal dialysis center in China. Pediatr Nephrol 2022; 37:2437-2448. [PMID: 35166916 DOI: 10.1007/s00467-022-05450-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Most of the available epidemiological data on peritonitis have been derived from developed countries. Limited data from China have been reported. METHODS An 18-year (2001-2018) peritoneal dialysis (PD) program at the Children's Hospital of Fudan University was described, and data on peritonitis were retrospectively analyzed. RESULTS Since 2001, a program with a comprehensive PD care bundle has been developed, and 283 patients (53.7% male, median age 9.3 years) were enrolled between 2001 and 2018. Among these patients, 117 peritonitis episodes occurred in 68 (24.0%) patients over 4896 patient-months. The peritonitis rate decreased 20-fold from 2.2 episodes per patient-year in 2003 to 0.11 episodes in 2018. The culture-negative rate decreased from 68.7% during 2001-2006 to 18.5% during 2013-2018, and the proportion of gram-negative and fungal infections increased significantly from 6.6 to 33.8% and 0 to 9.2%, respectively (p < 0.001). Short stature as height ≤ - 2 SD (OR 2.35, 95% CI 1.30-4.24, p = 0.005) and PD duration ≥ 1 year (OR 3.38, 95% CI 1.76-6.49, p < 0.001) were independently associated with a higher risk of developing peritonitis. Of the 117 peritonitis episodes, 9.4% required permanent removal of the catheter, among which half were fungal infections. Patients with peritonitis had a higher risk for PD technique failure (p = 0.006), but there was no difference in estimated patient survival rates and no patient death due to peritonitis. CONCLUSIONS With the successful development of the PD program and care bundles per the International Society of Pediatric Dialysis (ISPD) guidelines, peritonitis rates have been tremendously reduced in the most active pediatric PD center in China. Growth deficits and a long PD duration were risk factors for developing peritonitis, requiring further close monitoring for a better outcome. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Ruebner RL, De Souza HG, Richardson T, Bedri B, Marsenic O, Iorember F, Warejko JK, Warady BA, Neu AM. Epidemiology and Risk Factors for Hemodialysis Access-Associated Infections in Children: A Prospective Cohort Study From the SCOPE Collaborative. Am J Kidney Dis 2022; 80:186-195.e1. [PMID: 34979159 DOI: 10.1053/j.ajkd.2021.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/04/2021] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Infections cause significant morbidity and mortality for children receiving maintenance hemodialysis (HD). The Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a quality-improvement initiative aimed at reducing dialysis-associated infections by implementing standardized care practices. This study describes patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) and examines the association between dialysis center-level compliance with standardized practices and risk of CA-BSI. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS Children enrolled in SCOPE between June 2013 and July 2019. EXPOSURES Data were collected on patient characteristics and center-level compliance with HD catheter care practices across the study period. Centers were categorized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with HD care practices over time. OUTCOME CA-BSIs. ANALYTICAL APPROACH Generalized linear mixed models were used to evaluate (1) patient-level risk factors for CA-BSI and (2) associations between change in center-level compliance and CA-BSIs. RESULTS The cohort included 1,277 children from 35 pediatric dialysis centers; 1,018 (79.7%) had a catheter and 259 (20.3%) had an arteriovenous fistula or graft. Among children with a catheter, mupirocin use at the catheter exit site was associated with an increased rate of CA-BSIs (rate ratio [RR], 4.45; P = 0.004); the use of no antibiotic agent at the catheter exit site was a risk factor of borderline statistical significance (RR, 1.79; P = 0.05). Overall median compliance with HD catheter care practices was 87.5% (IQR, 77.3%-94.0%). Dynamic performing centers showed a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 patient-months; RR, 0.98; P < 0.001), whereas no significant change in CA-BSI rates was detected among consistent or inconsistent performers. LIMITATIONS Lack of data on adherence to HD care practices on the individual patient level. CONCLUSIONS Improvement in compliance with standardized HD care practices over time may lead to a reduction in dialysis-associated infections.
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Affiliation(s)
- Rebecca L Ruebner
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | | | - Badreldin Bedri
- Division of Pediatric Nephrology, Cook Children's Hospital, Fort Worth, Texas
| | - Olivera Marsenic
- Division of Pediatric Nephrology, Stanford University School of Medicine, Stanford, California
| | - Franca Iorember
- Division of Pediatric Nephrology, Baylor College of Medicine San Antonio, San Antonio, Texas
| | - Jillian K Warejko
- Section of Pediatric Nephrology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Alicia M Neu
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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A comparison of the buttonhole and rope-ladder AVF cannulation techniques and infection rates within the SCOPE collaborative. Pediatr Nephrol 2021; 36:3915-3921. [PMID: 34115208 DOI: 10.1007/s00467-021-05137-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Studies regarding hemodialysis (HD) arteriovenous fistula (AVF) cannulation in adults indicate a higher risk of infection with the buttonhole (BH) technique compared to the rope-ladder (RL) technique. Pediatric data on this issue is sparse. METHODS We compared infection rates within the Standardizing Care to Improve Outcomes in Pediatric End stage kidney disease (SCOPE) centers performing BH cannulation versus RL cannulation of AVF. Generalized linear mixed modeling was used to assess differences in access-related blood stream infection (BSI) and access site infection (ASI) rates between the centers. RESULTS Data was available from 211 AVF enrollments among 210 children. There were 61 AVF enrollments at 6 BH centers and 150 enrollments at 13 RL centers. Demographics were similar between the two groups. There were 12 total infections in 3383 patient months. BH centers had 3 infections (0 BSI, 3 ASI) and RL centers had 9 infections (5 BSI, 3 ASI). Mean [95% confidence interval] infection rates per 1000 patient months were not different between BH and RL centers (BH: 3.1 [0.6,15.6], RL: 3.2 [1.3,9.4], p = 0.947). A survey was also completed by the BH centers to describe their BH practices. The BH procedure at the majority of sites was characterized by a small patient/nurse ratio and strict antiseptic protocols. CONCLUSIONS This data provides evidence of a low BSI rate associated with BH cannulation in pediatric HD patients. Further studies are needed to better delineate the differences in the pediatric and adult experience with the BH cannulation technique.
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13
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Teo S, Yuen TW, Cheong CWS, Rahman MA, Bhandari N, Hussain NH, Mistam H, Geng J, Goh CYP, Than M, Chan YH, Yap HK, Ng KH. Structured re-training to reduce peritonitis in a pediatric peritoneal dialysis program: a quality improvement intervention. Pediatr Nephrol 2021; 36:3191-3200. [PMID: 33797581 DOI: 10.1007/s00467-021-05039-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Decline in skills and knowledge among patients and/or caregivers contributes to peritoneal-dialysis (PD)-related peritonitis. Re-training is important, but no guidelines exist. We describe the implementation of a structured re-training program to decrease peritonitis rates. METHODS This is a prospective quality improvement study involving pediatric patients on long-term home automated PD at National University Hospital, Singapore, between 2012 and 2018. With increasing peritonitis rates, systematic root cause analysis was performed, and based on the contributory factors identified, a structured re-training program was implemented from 2015. This was conducted in 5 cycles, each consisting of 4 modules (hand hygiene, exit site care, peritonitis, and PD troubleshooting). RESULTS Peritonitis rates were analyzed in 2 phases: Phase 1 (2012-2014) when no re-training was performed and Phase 2 (2016-2018) after re-training was instituted. Fifty-nine patients were included. Of these, 45 patients were in Phase 1, 32 in Phase 2, and 18 in both phases. Peritonitis rates decreased from 0.37 ± 0.67 episodes per patient-year in Phase 1 to 0.13 ± 0.32 episodes per patient-year in Phase 2. After adjusting for age at kidney failure onset, PD vintage, years of nursing experience, and the average patient-to-nurse ratio over the study period for each patient, the adjusted peritonitis rates decreased by 0.38 episodes per patient-year (95% CI, 0.09 to 0.67, p = 0.011) from Phase 1 to Phase 2. CONCLUSION Despite an improvement in staffing ratio, peritonitis rates only improved significantly after intensive structured re-training was instituted.
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Affiliation(s)
- Sharon Teo
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Tin Wei Yuen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Md Azizur Rahman
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Neha Bhandari
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Noor-Haziah Hussain
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Hamidah Mistam
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jing Geng
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Charmaine Yan-Pin Goh
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Mya Than
- Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yiong-Huak Chan
- Biostatistics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hui-Kim Yap
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore.,Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kar-Hui Ng
- Shaw-NKF-NUH Children's Kidney Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, NUHS Tower Block Level 12, 1E Kent Ridge Road, Singapore, 119228, Singapore. .,Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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Continued reduction in peritonitis rates in pediatric dialysis centers: results of the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative. Pediatr Nephrol 2021; 36:2383-2391. [PMID: 33649895 DOI: 10.1007/s00467-021-04924-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In its first 3 years, the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative demonstrated a statistically significant increase in the likelihood of compliance with a standardized follow-up care bundle and a significant reduction in peritonitis. We sought to determine if compliance with care bundles and low peritonitis rates could be sustained in centers continuously participating for 84 months. METHODS Centers that participated from collaborative launch through the 84-month study period and provided pre-launch peritonitis rates were included. Children on maintenance peritoneal dialysis were eligible for enrollment. Changes in bundle compliance were assessed using a logistic regression model or a generalized linear mixed model (GLMM). Changes in average annualized peritonitis rates over time were modeled using GLMMs. RESULTS Nineteen centers contributed 1055 patients with 1268 catheters and 17,247 follow-up encounters. The likelihood of follow-up compliance increased significantly over the study period (OR 1.05 95% confidence interval (CI) 1.03, 1.07; p < 0.001). Centers achieved ≥ 80% follow-up bundle compliance by 28 months and maintained a mean compliance of 84% between 28 and 84 months post-launch. Average monthly peritonitis rates decreased from 0.53 (95% CI 0.37, 0.70) infections per patient-year pre-launch to 0.30 (95% CI 0.23, 0.43) at 84 months post-launch, p < 0.001. CONCLUSIONS Centers participating in the SCOPE Collaborative for 84 months achieved and maintained a high level of compliance with a standardized follow-up care bundle and demonstrated a significant and continued reduction in average monthly peritonitis rates.
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15
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Shroff R. Peritoneal dialysis in children: Reaching milestones but room for growth. Perit Dial Int 2021; 41:137-138. [DOI: 10.1177/0896860821995385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Rukshana Shroff
- University College London Great Ormond Street Institute of Child Health, London, UK
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16
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Opportunities for Improvement in Quality of Care of PD-Related Peritonitis in Children. Clin J Am Soc Nephrol 2021; 16:191-193. [PMID: 33462086 PMCID: PMC7863660 DOI: 10.2215/cjn.19461220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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17
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Perl J, Fuller DS, Boudville N, Kliger AS, Schaubel DE, Teitelbaum I, Warady BA, Neu AM, Patel PR, Piraino B, Schreiber M, Pisoni RL. Optimizing Peritoneal Dialysis-Associated Peritonitis Prevention in the United States: From Standardized Peritoneal Dialysis-Associated Peritonitis Reporting and Beyond. Clin J Am Soc Nephrol 2021; 16:154-161. [PMID: 32764025 PMCID: PMC7792655 DOI: 10.2215/cjn.11280919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Peritoneal dialysis (PD)-associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.
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Affiliation(s)
- Jeffrey Perl
- Division of Nephrology, St. Michael’s Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
| | - Alan S. Kliger
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine and Yale New Haven Health System, New Haven, Connecticut
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Isaac Teitelbaum
- Division of Kidney Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado
| | - Bradley A. Warady
- Division of Nephrology, Children’s Mercy Kansas City, Kansas City, Missouri
| | - Alicia M. Neu
- Division of Pediatric Nephrology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Priti R. Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Beth Piraino
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
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18
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Effects of an Omaha system-based continuing nursing program on nutritional status in patients undergoing peritoneal dialysis: a randomized controlled trial. Int Urol Nephrol 2020; 52:981-989. [DOI: 10.1007/s11255-020-02449-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/16/2020] [Indexed: 12/24/2022]
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19
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Marsenic O, Rodean J, Richardson T, Swartz S, Claes D, Day JC, Warady B, Neu A. Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative. Pediatr Nephrol 2020; 35:135-143. [PMID: 31654224 DOI: 10.1007/s00467-019-04384-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE. METHODS Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques. RESULTS Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001). CONCLUSIONS Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.
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MESH Headings
- Adolescent
- Catheter-Related Infections/epidemiology
- Catheter-Related Infections/etiology
- Catheterization, Central Venous/adverse effects
- Catheterization, Central Venous/instrumentation
- Catheterization, Central Venous/standards
- Catheterization, Central Venous/statistics & numerical data
- Central Venous Catheters/adverse effects
- Central Venous Catheters/standards
- Central Venous Catheters/statistics & numerical data
- Child
- Child, Preschool
- Female
- Guideline Adherence/statistics & numerical data
- Humans
- Infant
- Infant, Newborn
- Intersectoral Collaboration
- Kidney Failure, Chronic/therapy
- Male
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Program Evaluation
- Prospective Studies
- Quality Improvement/organization & administration
- Renal Dialysis/adverse effects
- Renal Dialysis/instrumentation
- Renal Dialysis/standards
- Renal Dialysis/statistics & numerical data
- Sepsis/epidemiology
- Sepsis/etiology
- Standard of Care/organization & administration
- Standard of Care/statistics & numerical data
- Young Adult
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Affiliation(s)
- Olivera Marsenic
- Pediatric Nephrology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.
| | | | | | | | - Donna Claes
- Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | | | - Alicia Neu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Colostomy in children on chronic peritoneal dialysis. Pediatr Nephrol 2020; 35:119-126. [PMID: 31673828 DOI: 10.1007/s00467-019-04372-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND This study aimed to evaluate outcome of children on chronic peritoneal dialysis (PD) with a concurrent colostomy. METHODS Patients were identified through the International Pediatric Peritoneal Dialysis Network (IPPN) registry. Matched controls were randomly selected from the registry. Data were collected through the IPPN database and a survey disseminated to all participating sites. RESULTS Fifteen centers reported 20 children who received chronic PD with a co-existing colostomy. The most common cause of end stage kidney disease was congenital anomalies of the kidney and urinary tract (n = 16, 80%). The main reason for colostomy placement was anorectal malformation (n = 13, 65%). The median age at colostomy creation and PD catheter (PDC) insertion were 0.1 (IQR, 0-2.2) and 2.8 (IQR 0.2-18.8) months, respectively. The colostomies and PDCs were present together for a median 18 (IQR, 4.9-35.8) months. The median age at PDC placement in 46 controls was 3.4 (IQR, 0.2-7.4) months of age. Fourteen patients (70%) developed 39 episodes of peritonitis. The annualized peritonitis rate was significantly higher in the colostomy group (1.13 vs. 0.70 episodes per patient year; p = 0.02). Predominant causative microorganisms were Staphylococcus aureus (15%) and Pseudomonas aeruginosa (13%). There were 12 exit site infection (ESI) episodes reported exclusively in colostomy patients. Seven colostomy children (35%) died during their course of PD, in two cases due to peritonitis. CONCLUSION Although feasible in children with a colostomy, chronic PD is associated with an increased risk of peritonitis and mortality. Continued efforts to reduce infection risk for this complex patient population are essential.
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21
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Factors associated with high-cost hospitalization for peritonitis in children receiving chronic peritoneal dialysis in the United States. Pediatr Nephrol 2019; 34:1049-1055. [PMID: 30603809 DOI: 10.1007/s00467-018-4183-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 12/03/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although peritonitis causes significant morbidity and mortality in children receiving chronic peritoneal dialysis (CPD), little is known about costs associated with treatment. METHODS We analyzed 246 peritonitis-related hospitalizations in the USA, linked by the Standardized Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) and Pediatric Health Information Systems (PHIS) databases. Multivariable logistic regression was used to assess the relationship between high-cost hospitalizations (at or above the 75th percentile) and patient characteristics. Multivariable modeling was used to assess differences in the service-line specific geometric mean between (1) high- and low-cost (below the 75th percentile) hospitalizations and (2) fungal versus other types of peritonitis. Wage-adjusted hospitalization charges were converted to estimated costs using reported cost-to-charge ratios to estimate the cost of hospitalization. RESULTS High-cost hospitalizations were associated with the following: age 3-12 years, Hispanic ethnicity, intensive care unit (ICU) stay, length of stay (LOS), and fungal peritonitis. Whereas absolute standardized cost by service line was significantly different when comparing high- and low-cost hospitalizations, the percentage of total cost by service line was similar in the two groups. Cost per case for fungal peritonitis was higher (p < 0.001) in every service line except pharmacy when compared to other peritonitis cases. The median (IQR) cost of hospitalization for the treatment of peritonitis was $13,655 ($7871, $28434) USD. CONCLUSIONS Hospitalization-related costs for peritonitis treatment are substantial and arise from a variety of service lines. Fungal peritonitis is associated with high-cost hospitalization.
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Terao M, Hoffman JM, Brilli RJ, Finch A, Walsh KE, Coffey M. Accelerating Improvement in Children's Healthcare Through Quality Improvement Collaboratives: A Synthesis of Recent Efforts. ACTA ACUST UNITED AC 2019; 5:111-130. [PMID: 32789105 DOI: 10.1007/s40746-019-00155-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Purpose of review Quality improvement collaboratives can accelerate quality improvement and patient safety efforts. We reviewed major pediatric quality improvement collaboratives that have published results in the past five years and discussed common success factors and barriers encountered by these collaboratives. Recent Findings Many pediatric quality improvement collaboratives are active in neonatal, cystic fibrosis, congenital heart disease, hematology/oncoogy, chronic kidney disease, rheumatology, critical care, and general pediatric care. Summary Factors important to the success of these pediatric quality improvement collaboratives include data sharing and communication, trust among institutions, financial support, support from national organizations, use of a theoretical framework to guide collaboration, patient and family involvement, and incentives for participation at both the individual and institutional levels. Common barriers encountered by these collaboratives include insufficient funding or resources, legal concerns, difficulty coming to consensus on best practices and outcome measures, and overcoming cultural barriers to change. Learning from the successes and challenges encountered by these collaboratives will enable the pediatric healthcare quality improvement community to continue to evolve this approach to maximize benefits to children.
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Affiliation(s)
- Michael Terao
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - James M Hoffman
- Office of Quality and Patient Care and Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Richard J Brilli
- Nationwide Children's Hospital; Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Amanda Finch
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
| | - Kathleen E Walsh
- MD, MS, James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital, Cincinnati, OH
| | - Maitreya Coffey
- Children's Hospitals' Solutions for Patient Safety and Cincinnati Children's, Cincinnati, OH
- The Hospital for Sick Children, Toronto, Ontario, Canada
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23
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Bieber S, Mehrotra R. Peritoneal Dialysis Access Associated Infections. Adv Chronic Kidney Dis 2019; 26:23-29. [PMID: 30876613 DOI: 10.1053/j.ackd.2018.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 11/11/2022]
Abstract
Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and peritonitis.
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Sanderson KR, Yu Y, Dai H, Willig LK, Warady BA. Outcomes of infants receiving chronic peritoneal dialysis: an analysis of the USRDS registry. Pediatr Nephrol 2019; 34:155-162. [PMID: 30141177 PMCID: PMC6289046 DOI: 10.1007/s00467-018-4056-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Outcome data for infants on chronic peritoneal dialysis (CPD) is limited and has been based primarily on the analyses of voluntary entry registry data. In contrast, the United States Renal Data Systems (USRDS) collects data on all infants with end-stage kidney disease (ESKD) on chronic dialysis in the USA. We aimed to describe the clinical characteristics of this population and to determine the associated patient mortality. METHODS The USRDS database was reviewed retrospectively for data on infants who initiated CPD at ≤ 12 months of age from 1990 to 2014. Infants were categorized into four groups, CPD initiation age (≤ 1 month of age or neonates and > 1-12 months of age or older infants) and initiation era (1990-1999 and 2000-2014). RESULTS A total of 1723 infants (574 neonates and 1149 older infants) were identified. Overall, 20.9% of infants (147 neonates and 213 older infants) died on dialysis during the follow-up. The most commonly identified causes of death on dialysis were cardiorespiratory disease (25.8%) and infection (22.8%). There was an increased risk for mortality in all infants who initiated CPD in the earlier initiation era (1990-1999) vs the later era (2000-2014) (aHR of 1.95), for females vs males (aHR 1.43), and for those with a primary diagnosis of cystic kidney diseases vs congenital anomalies of the kidney and urinary tract (CAKUT) (aHR 1.84). In 2000-2014, patient survival at 1 and 5 years was 86.8% and 74.6% for those who initiated CPD as neonates and 89.6% and 79.3% for those who did so as older infants. CONCLUSIONS In this large cohort of infants who received chronic peritoneal dialysis over more than two decades, the probability of survival after initiating CPD in the first year of life has significantly improved. There is no difference in the probability of death for neonates compared to older infants. However, the mortality rate remains substantial in association with multiple risk factors.
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Affiliation(s)
- Keia R. Sanderson
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Yichun Yu
- University of North Carolina Department of Medicine-Nephrology, 7024 Burnett-Womack, CB 7155, Chapel Hill, NC 27599, USA
| | - Hongying Dai
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Laurel K. Willig
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
| | - Bradley A. Warady
- Children’s Mercy Hospitals and Clinics, Kansas City, Kansas City, MO, USA
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Exit site and tunnel infections in children on chronic peritoneal dialysis: findings from the Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative. Pediatr Nephrol 2018; 33:1029-1035. [PMID: 29480421 DOI: 10.1007/s00467-018-3889-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/06/2018] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative is a quality improvement initiative to reduce dialysis-associated infections. The frequency of peritoneal dialysis (PD) catheter exit site infection (ESI) and variables influencing its development and end result are unclear. We sought to determine ESI rates, to elucidate the epidemiology, risk factors, and outcomes for ESI, and to assess for association between provider compliance with care bundles and ESI risk. METHODS We reviewed demographic, dialysis and ESI data, and care bundle adherence and outcomes for SCOPE enrollees from October 2011 to September 2014. ESI involved only the exit site, only the subcutaneous catheter tunnel, or both. RESULTS A total of 857 catheter insertions occurred in 734 children over 10,110 cumulative months of PD provided to these children. During this period 207 ESIs arose in 124 children or 0.25 ESIs per dialysis year. Median time to ESI was 392 days, with 69% of ESIs involving exit site only, 23% involving the tunnel only, and 8% involving both sites. Peritonitis developed in 6%. ESI incidence was associated with age (p = 0.003), being the lowest in children aged < 2 years and highest in those aged 6-12 years, and with no documented review of site care or an exit site score of > 0 at prior month's visit (p < 0.001). Gender, race, end stage renal disease etiology, exit site orientation, catheter cuff number or mobilization, and presence of G-tube, stoma, or vesicostomy were unassociated with ESI incidence. Of the ESIs reported, 71% resolved with treatment, 24% required hospitalization, and 9% required catheter removal, generally secondary to tunnel infection. CONCLUSIONS Exit site infections occur at an annualized rate of 0.25, typically well into the dialysis course. Younger patient age and documented review of site care are associated with lower ESI rates. Although most ESIs resolve, hospitalization is frequent, and tunnel involvement/catheter loss complicate outcomes.
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Newland JG, Gerber JS, Kronman MP, Meredith G, Lee BR, Thurm C, Hersh AL, Berman DM, Handy L, Chan S, Tribble AC, Klein K, Maples H, Stahl D, Flett KB, Shapiro C, Fernandez AJ, Child J, Hurst AL, Parker SK, Pearce K, Mongkolrattanothai K, Metjian T, Grapentine S, Pomputius W, Goldman J, Yu D, Patel K, Yarbrough A, Cassady KA, Courter J, Haslam D, Thurman R, Mazade M, Varman M, Green A, Zwiener J, Simonsen K, Stec R, Bennett N, Girotto JE, Nolt D, Thomas J, Olivero R, Van Dyke C, Smith MJ, Lee K, Arnold SR, Schwenk H, Lee B, Patel SJ, Patel R, Calderon R, Dixon TC, Jaggi P, Tansmore J, Olson J, Thorell EM, Pong A, Nichols K, Cox E, Weissman S, Brothers A, Pak D, Bridger K, Poole N, Nelson M, Hymes S, Taylor R, Palazzi D, Wattier R, Faldasz J, Naeem F, Kuzmic B, Islam S. Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative. J Pediatric Infect Dis Soc 2018; 7:124-128. [PMID: 28379408 DOI: 10.1093/jpids/pix020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 02/22/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Although many children's hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children. METHODS A national antimicrobial stewardship collaborative among children's hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings. RESULTS Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions. CONCLUSION A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.
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Affiliation(s)
- Jason G Newland
- Division of Pediatric Infectious Diseases, Washington University in St. Louis School of Medicine, Missouri
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle.,Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Georgann Meredith
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Brian R Lee
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, Kansas City, Missouri.,Health Services and Outcomes Research, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Cary Thurm
- Children's Hospital Association, Statistical Analysis Services, Washington, DC
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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Teufel RJ, Shuler AB, Ebeling MD, Morella K, Andrews AL. Enhancing Postdischarge Asthma Care by Using Pharmacy Claims and Telephone Follow-up. Hosp Pediatr 2018; 8:251-259. [PMID: 29610252 DOI: 10.1542/hpeds.2017-0094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Asthma is a common reason for hospital readmission. The majority of children are not receiving adequate preventive care after discharge. Our objective is to decrease return visits to the emergency department (ED) or hospital for asthma through a series of interventions (eg, access to real-time claims data and structured follow-up phone calls) designed to increase preventive care. METHODS We performed a single-site quality improvement project for children 2 to 17 years old discharged with asthma from January 2010 to March 2014. We compared a baseline period and a stepwise intervention period including the following: brief follow-up phone calls to families, access to medication claims data, and structured phone calls. The primary outcome of return visits to the ED or hospital and preventive care outcomes (controller refills and ambulatory visits) up to 90 days were assessed using state all-payer and Medicaid data sets. Interrupted time series analysis was used to investigate secular trends. RESULTS Six hundred and seventy-seven asthma discharges were analyzed. The majority of children were 2 to 7 years old, African American, and insured by Medicaid. Successful phone contact occurred in 57% of encounters. Ninety-day revisits to the ED or hospital demonstrated a significant decline (15% to 8%; P < .05), but preventive care measures did not improve. CONCLUSIONS A process to improve transitions for children who are hospitalized with an asthma exacerbation that includes follow-up phone calls was associated with a decrease in ED or hospital revisits. The lack of a detectable increase in preventive care warrants further exploration.
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Affiliation(s)
| | | | - Myla D Ebeling
- Department of Pediatrics, College of Medicine, The Medical University of South Carolina, Charleston, South Carolina
| | - Kristen Morella
- Department of Public Health, The Medical University of South Carolina, Charleston, South Carolina; and
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Epidemiology of peritonitis following maintenance peritoneal dialysis catheter placement during infancy: a report of the SCOPE collaborative. Pediatr Nephrol 2018; 33:713-722. [PMID: 29150711 DOI: 10.1007/s00467-017-3839-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/16/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Maintenance peritoneal dialysis (PD) is the dialysis modality of choice for infants and young children. However, there are limited outcome data for those who undergo PD catheter insertion and initiate maintenance PD within the first year of life. METHODS Using data from the Children's Hospital Association's Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (ESRD) Collaborative (SCOPE), we examined peritonitis rates and patient survival in 156 infants from 29 North American pediatric dialysis centers who had a chronic PD catheter placed prior to their first birthday. RESULTS In-hospital and overall annualized rates of peritonitis were 1.73 and 0.76 episodes per patient-year, respectively. Polycystic kidney disease was the most frequent renal diagnosis and pulmonary hypoplasia the most common co-morbidity in infants with peritonitis. Multivariable regression models demonstrated that nephrectomy at or prior to PD catheter placement and G-tube insertion after catheter placement were associated with a nearly sixfold and nearly threefold increased risk of peritonitis, respectively. Infants with peritonitis had longer initial hospital stays and lower overall survival (86.3 vs. 95.6%, respectively; P < 0.02) than those without an episode of peritonitis. CONCLUSIONS In this large cohort of infants with ESRD, the frequency of peritonitis was high and several risk factors associated with the development of peritonitis were identified. Given that peritonitis was associated with a longer duration of initial hospitalization and increased mortality, increased attention to the potentially modifiable risk factors for infection is needed.
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29
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Vidal E. Peritoneal dialysis and infants: further insights into a complicated relationship. Pediatr Nephrol 2018; 33:547-551. [PMID: 29218436 DOI: 10.1007/s00467-017-3857-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 11/24/2017] [Accepted: 11/24/2017] [Indexed: 01/23/2023]
Abstract
Peritoneal dialysis (PD) in infants represents one of the greatest challenges for pediatric nephrologists. Over recent years, positive outcome data described by several multicenter experiences and registry studies have increased the amount of information available to help determine whether to initiate a dialysis program in this high-risk patient population. There is no doubt that the rigorous implementation of strategies aimed at preventing infectious complications may have contributed to reducing the morbidity rate of these patients. However, the complex nature of infants with end-stage renal disease and the presence of multiple comorbidities still represent hallmarks that significantly impact on outcome. Although the rigorous application of improved scientific techniques can still contribute to enhancing PD results in infants, we have to acknowledge that the severity of illness in infants, especially at dialysis initiation, represents an undeniable and nonmodifiable factor.
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Affiliation(s)
- Enrico Vidal
- Pediatric Nephrology, Dialysis and Transplantation Unit, Department of Woman's and Child's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy.
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Patel PR, Brinsley-Rainisch K. The Making Dialysis Safer for Patients Coalition: A New Partnership to Prevent Hemodialysis-Related Infections. Clin J Am Soc Nephrol 2018; 13:175-181. [PMID: 28794000 PMCID: PMC5753304 DOI: 10.2215/cjn.02730317] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The Making Dialysis Safer for Patients Coalition is a partnership of organizations and individual stakeholders that share the common goal to prevent bloodstream infections among patients receiving hemodialysis. Led by the Centers for Disease Control and Prevention (CDC), in collaboration with the CDC Foundation, this public-private partnership strives to improve adherence to evidence-based recommendations, share information and experiences, and engage patients in infection prevention efforts.
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Affiliation(s)
- Priti R Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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31
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Abstract
Optimal care of the pediatric end-stage renal disease (ESRD) patient on chronic dialysis is complex and requires multidisciplinary care as well as patient/caregiver involvement. The dialysis team, along with the family and patient, should all play a role in choosing the dialysis modality which best meets the patient's needs, taking into account special considerations and management issues that may be particularly pertinent to children who receive peritoneal dialysis or hemodialysis. Meticulous attention to dialysis adequacy in terms of solute and fluid removal, as well as to a variety of clinical manifestations of ESRD, including anemia, growth and nutrition, chronic kidney disease-mineral bone disorder, cardiovascular health, and neurocognitive development, is essential. This review highlights current recommendations and advances in the care of children on dialysis with a particular focus on preventive measures to minimize ESRD-associated morbidity and mortality. Advances in dialysis care and prevention of complications related to ESRD and dialysis have led to better survival for pediatric patients on dialysis.
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32
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Redpath Mahon A, Neu AM. A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science. Pediatr Nephrol 2017; 32:1331-1341. [PMID: 27757588 DOI: 10.1007/s00467-016-3531-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/24/2016] [Accepted: 09/27/2016] [Indexed: 01/22/2023]
Abstract
Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.
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Affiliation(s)
- Allison Redpath Mahon
- Pediatric Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Alicia M Neu
- Pediatric Nephrology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Werner E. It is time to address ambulatory central venous line infections in pediatric hematology/oncology patients. Pediatr Blood Cancer 2017; 64:221-222. [PMID: 27616180 DOI: 10.1002/pbc.26245] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Eric Werner
- Division of Pediatric Hematology/Oncology, Children's Specialty Group, Eastern Virginia Medical School, Norfolk, Virginia
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Borzych-Duzalka D, Aki TF, Azocar M, White C, Harvey E, Mir S, Adragna M, Serdaroglu E, Sinha R, Samaille C, Vanegas JJ, Kari J, Barbosa L, Bagga A, Galanti M, Yavascan O, Leozappa G, Szczepanska M, Vondrak K, Tse KC, Schaefer F, Warady BA. Peritoneal Dialysis Access Revision in Children: Causes, Interventions, and Outcomes. Clin J Am Soc Nephrol 2017; 12:105-112. [PMID: 27899416 PMCID: PMC5220659 DOI: 10.2215/cjn.05270516] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 09/30/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015. RESULTS In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03). CONCLUSIONS Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged.
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Affiliation(s)
- Dagmara Borzych-Duzalka
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Twichell SA, Fiascone J, Gupta M, Prendergast M, Rodig N, Hansen A. A Regional Evaluation of Survival of Infants with End-Stage Renal Disease. Neonatology 2017; 112:73-79. [PMID: 28359062 PMCID: PMC5931204 DOI: 10.1159/000456647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/16/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Information regarding morbidity and mortality of infants born with end-stage renal disease (ESRD) requiring dialysis early in life is critical to optimize patient care and better counsel families. OBJECTIVE We evaluated outcomes of infants born regionally with ESRD, and those within our broader catchment area referred for dialysis. STUDY DESIGN We screened deaths at 5 regional referral hospitals, identifying infants with ESRD who did not survive to transfer for dialysis. We also screened all infants <8 weeks old seen at our institution over a 7-year period with ESRD referred for dialysis. We evaluated factors associated with survival to dialysis and transplant. RESULTS We identified 14 infants from regional hospitals who died prior to transfer and 12 infants at our institution who were dialyzed. Because of the large burden of lethal comorbidities in our regional referral centers, overall survival was low, with 73% dying at birth hospitals. Amongst dialyzed infants, 42% survived to transplant. CONCLUSION This study is unusual in reporting survival of infants with ESRD including those not referred for dialysis, which yields an expectedly lower survival rate than reported by dialysis registries.
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Affiliation(s)
- Sarah A Twichell
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Sethna CB, Bryant K, Munshi R, Warady BA, Richardson T, Lawlor J, Newland JG, Neu A. Risk Factors for and Outcomes of Catheter-Associated Peritonitis in Children: The SCOPE Collaborative. Clin J Am Soc Nephrol 2016; 11:1590-1596. [PMID: 27340282 PMCID: PMC5012476 DOI: 10.2215/cjn.02540316] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/21/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative is a quality improvement initiative that aims to reduce peritoneal dialysis-associated infections in pediatric patients on chronic peritoneal dialysis. Our objectives were to determine whether provider compliance with peritoneal dialysis catheter care bundles was associated with lower risk for infection at the individual patient level and describe the epidemiology, risk factors, and outcomes for peritonitis in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We collected peritoneal dialysis characteristics, causative organisms, compliance with care bundles, and outcomes in children with peritonitis between October of 2011 and September of 2014. Chi-squared tests, t tests, and generalized linear mixed models were used to assess risk factors for peritonitis. RESULTS Of 734 children enrolled (54% boys; median age =9 years old; interquartile range, 1-15) from 29 centers, 391 peritonitis episodes occurred among 245 individuals over 10,130 catheter-months. The aggregate annualized peritonitis rate was 0.46 episodes per patient-year. Rates were highest among children ≤2 years old (0.62 episodes per patient-year). Gram-positive peritonitis predominated (37.8%) followed by culture-negative (24.7%), gram-negative (19.5%), and polymicrobial (10.3%) infections; fungal only peritonitis accounted for 7.7% of episodes. Compliance with the follow-up bundle was associated with a lower rate of peritonitis (rate ratio, 0.49; 95% confidence interval, 0.30 to 0.80) in the multivariable model. Upward orientation of the catheter exit site (rate ratio, 4.2; 95% confidence interval, 1.49 to 11.89) and touch contamination (rate ratio, 2.22; 95% confidence interval, 1.44 to 3.34) were also associated with a higher risk of peritonitis. Infection outcomes included resolution with antimicrobial treatment alone in 76.6%, permanent catheter removal in 12.2%, and catheter removal with return to peritoneal dialysis in 6% of episodes. CONCLUSIONS Lower compliance with standardized practices for follow-up peritoneal dialysis catheter care in the Standardizing Care to Improve Outcomes in Pediatric ESRD Collaborative was associated with higher risk of peritonitis. Quality improvement and prevention strategies have the potential to reduce peritoneal dialysis-associated peritonitis.
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Affiliation(s)
- Christine B. Sethna
- Division of Pediatric Nephrology, Cohen Children’s Medical Center of New York, New Hyde Park, New York
| | - Kristina Bryant
- Division of Pediatric Infectious Diseases, Kosair Children’s Hospital, Louisville, Kentucky
| | - Raj Munshi
- Division of Pediatric Nephrology, Seattle Children’s Hospital, Seattle, Washington
| | - Bradley A. Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - John Lawlor
- Children’s Hospital Association, Alexandria, Virginia
| | - Jason G. Newland
- Division of Infectious Diseases, Washington University, St. Louis, Missouri; and
| | - Alicia Neu
- Division of Pediatric Nephrology, Johns Hopkins Children’s Center, Baltimore, Maryland
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