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Alrowiyti IM, Bargman J. A Review of Residual Kidney Function in Peritoneal Dialysis Patients. Indian J Nephrol 2023; 33:239-246. [PMID: 37781547 PMCID: PMC10503572 DOI: 10.4103/ijn.ijn_242_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/28/2023] [Accepted: 07/14/2023] [Indexed: 10/03/2023] Open
Abstract
Residual kidney function (RKF) has been associated with better survival, less morbidity, and improved quality of life in peritoneal dialysis (PD) patients. Since higher peritoneal clearance does not lead to better outcomes, more emphasis should be put on preserving kidney function. Many other benefits have been reported, including better volume and blood pressure control, better nutritional status, lower rates of PD peritonitis, preserved erythropoietin and vitamin D production, middle molecule clearance, lower Left Ventricular Hypertrophy, and better serum phosphate level. The most practical method of assessing RKF is the mean of 24-h urinary urea and creatinine clearance. Incremental PD prescription is an ideal option to supplement RKF in PD patients, which also offers more flexibility to the patient and, possibly, improved adherence. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be used when possible in PD patients to preserve RKF. Loop diuretics are underutilized in PD patients despite providing an additional means of maintaining fluid balance and reducing the need for higher glucose-containing PD solutions. In this paper, we outline the importance of RKF in PD patients and the different strategies for its preservation.
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Affiliation(s)
- Ibrahim Mohammed Alrowiyti
- Department of Nephrology, University Health Network, University of Toronto, Toronto, Canada
- Department of Nephrology, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Joanne Bargman
- Department of Nephrology, University Health Network, University of Toronto, Toronto, Canada
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Li PKT, Chow KM, Cho Y, Fan S, Figueiredo AE, Harris T, Kanjanabuch T, Kim YL, Madero M, Malyszko J, Mehrotra R, Okpechi IG, Perl J, Piraino B, Runnegar N, Teitelbaum I, Wong JKW, Yu X, Johnson DW. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int 2022; 42:110-153. [PMID: 35264029 DOI: 10.1177/08968608221080586] [Citation(s) in RCA: 184] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Kai Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yeoungjee Cho
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Stanley Fan
- Translational Medicine and Therapeutic, William Harvey Research Institute, Queen Mary University, London, UK
| | - Ana E Figueiredo
- Nursing School Escola de Ciências da Saúde e da Vida Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Tess Harris
- Polycystic Kidney Disease Charity, London, UK
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Magdalena Madero
- Division of Nephrology, Department of Medicine, National Heart Institute, Mexico City, Mexico
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Diseases, The Medical University of Warsaw, Poland
| | - Rajnish Mehrotra
- Division of Nephrology, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, DC, USA
| | - Ikechi G Okpechi
- Department of Medicine, Faculty of Health Sciences, University of Cape Town and Groote Schuur Hospital, South Africa
| | - Jeff Perl
- St Michael's Hospital, University of Toronto, ON, Canada
| | - Beth Piraino
- Department of Medicine, Renal Electrolyte Division, University of Pittsburgh, PA, USA
| | - Naomi Runnegar
- Infectious Management Services, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Isaac Teitelbaum
- Division of Nephrology, Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Xueqing Yu
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangzhou, China
- Guangdong Academy of Medical Sciences, Guangzhou, China
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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Population pharmacokinetics of intra-peritoneal gentamicin and the impact of varying dwell times on pharmacodynamic target attainment in patients with acute peritonitis undergoing peritoneal dialysis. Antimicrob Agents Chemother 2021; 66:e0167921. [PMID: 34902267 DOI: 10.1128/aac.01679-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
While the use of intraperitoneal (i.p.) gentamicin is common in the treatment of peritoneal dialysis (PD)-related infections, the ability of these regimens to attain pharmacodynamic target indices of interest in blood and dialysate has not been widely reported. Pharmacokinetic (PK) data was obtained and analyzed from a multiple-dose PK study of i.p. gentamicin with 24 patients who received the drug at 0.6 mg/kg dose of body weight. The probability of target attainment (PTA) for indices of treatment success (i.p. peak/MIC ratio >10) and toxicity (plasma AUC < 120 mg*h/L) was determined for 0.3 to 1.2 mg/kg i.p. regimens every 24 h for dwell times of 2 to 6 hours and for the duration of 2-week course. In the peritoneum, successful PTA was achieved by all of the simulated regimens up to an MIC of 1 mg/L, and by doses equal to or greater than 0.6 mg/kg up to the MIC of 2 mg/L. At the susceptibility break point of 4 mg/L only the highest dose of 1.2 mg/kg is likely to provide adequate PTA. Probability of achieving exposure below the threshold of 120 mg*h/L in the daily AUC in plasma seems acceptable for all regimens at or below 0.6 mg/kg. Based on the model we developed, a gentamicin dose of 0.6 mg/kg is sufficient to treat organisms with an MIC of ≤2 mg/L without the risk of significant systemic exposure. The 1.2 mg/kg dose necessary to reach the pharmacodynamic target for efficacy at the clinical break point of 4 mg/L is likely to produce early toxic levels of exposure that is expected to be detrimental to the renal system.
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Ito Y, Ryuzaki M, Sugiyama H, Tomo T, Yamashita AC, Ishikawa Y, Ueda A, Kanazawa Y, Kanno Y, Itami N, Ito M, Kawanishi H, Nakayama M, Tsuruya K, Yokoi H, Fukasawa M, Terawaki H, Nishiyama K, Hataya H, Miura K, Hamada R, Nakakura H, Hattori M, Yuasa H, Nakamoto H. Peritoneal Dialysis Guidelines 2019 Part 1 (Position paper of the Japanese Society for Dialysis Therapy). RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00348-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AbstractApproximately 10 years have passed since the Peritoneal Dialysis Guidelines were formulated in 2009. Much evidence has been reported during the succeeding years, which were not taken into consideration in the previous guidelines, e.g., the next peritoneal dialysis PD trial of encapsulating peritoneal sclerosis (EPS) in Japan, the significance of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), the effects of icodextrin solution, new developments in peritoneal pathology, and a new international recommendation on a proposal for exit-site management. It is essential to incorporate these new developments into the new clinical practice guidelines. Meanwhile, the process of creating such guidelines has changed dramatically worldwide and differs from the process of creating what were “clinical practice guides.” For this revision, we not only conducted systematic reviews using global standard methods but also decided to adopt a two-part structure to create a reference tool, which could be used widely by the society’s members attending a variety of patients. Through a working group consensus, it was decided that Part 1 would present conventional descriptions and Part 2 would pose clinical questions (CQs) in a systematic review format. Thus, Part 1 vastly covers PD that would satisfy the requirements of the members of the Japanese Society for Dialysis Therapy (JSDT). This article is the duplicated publication from the Japanese version of the guidelines and has been reproduced with permission from the JSDT.
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Al Sahlawi M, Zhao J, McCullough K, Fuller DS, Boudville N, Ito Y, Kanjanabuch T, Nessim SJ, Piraino BM, Pisoni RL, Teitelbaum I, Woodrow G, Kawanishi H, Johnson DW, Perl J. Variation in Peritoneal Dialysis-Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). Am J Kidney Dis 2021; 79:45-55.e1. [PMID: 34052357 DOI: 10.1053/j.ajkd.2021.03.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/09/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Peritoneal dialysis (PD)-associated peritonitis is a significant PD-related complication. We describe the likelihood of cure after a peritonitis episode, exploring its association with various patient, peritonitis, and treatment characteristics. STUDY DESIGN Observational prospective cohort study. SETTING & PARTICIPANTS 1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States. EXPOSURE Patient characteristics (demographics, patient history, laboratory values), peritonitis characteristics (organism category, concomitant exit-site infection), dialysis center characteristics (use of icodextrin and low glucose degradation product solutions, policies regarding antibiotic self-administration), and peritonitis treatment characteristics (antibiotic used). OUTCOME Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode. ANALYTICAL APPROACH Mixed-effects logistic models. RESULTS Overall, 65% of episodes resulted in a cure. Adjusted odds ratios (AOR) for cure were similar across countries (range, 54%-68%), by age, sex, dialysis vintage, and diabetes status. Compared with Gram-positive peritonitis, the odds of cure were lower for Gram-negative (AOR, 0.41 [95% CI, 0.30-0.57]), polymicrobial (AOR, 0.30 [95% CI, 0.20-0.47]), and fungal (AOR, 0.01 [95% CI, 0.00-0.07]) peritonitis. Odds of cure were higher with automated PD versus continuous ambulatory PD (AOR, 1.36 [95% CI, 1.02-1.82]), facility icodextrin use (AOR per 10% greater icodextrin use, 1.06 [95% CI, 1.01-1.12]), empirical aminoglycoside use (AOR, 3.95 [95% CI, 1.23-12.68]), and ciprofloxacin use versus ceftazidime use for Gram-negative peritonitis (AOR, 5.73 [95% CI, 1.07-30.61]). Prior peritonitis episodes (AOR, 0.85 [95% CI, 0.74-0.99]) and concomitant exit-site infection (AOR, 0.41 [95% CI, 0.26-0.64]) were associated with a lower odds of cure. LIMITATIONS Sample selection may be biased and generalizability may be limited. Residual confounding and confounding by indication limit inferences. Use of facility-level treatment variables may not capture patient-level treatments. CONCLUSIONS Outcomes after peritonitis vary by patient characteristics, peritonitis characteristics, and modifiable peritonitis treatment practices. Differences in the odds of cure across infecting organisms and antibiotic regimens suggest that organism-specific treatment considerations warrant further investigation.
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Affiliation(s)
- Muthana Al Sahlawi
- Division of Nephrology, St. Michael's Hospital and the Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Department of Internal Medicine, College of Medicine, King Faisal University, Al-Hasa, Saudi Arabia
| | - Junhui Zhao
- Arbor Research Collaborative for Health, Ann Arbor, MI
| | | | | | - Neil Boudville
- Medical School, University of Western Australia, Perth, Australia
| | | | - Talerngsak Kanjanabuch
- Center of Excellence in Kidney Metabolic Disorders and Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sharon J Nessim
- Division of Nephrology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | | | | | | | - Graham Woodrow
- Renal Unit, St. James's University Hospital, Leeds, United Kingdom
| | - Hideki Kawanishi
- Akane Foundation, Tsuchiya General Hospital, Nakaku, Hiroshima, Japan
| | - David W Johnson
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia; Translational Research Institute, Brisbane, Australia
| | - 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, University of Toronto, Toronto, ON, Canada.
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Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, Kuijper EJ, Li PKT, Lye WC, Mujais S, Paterson DL, Fontan MP, Ramos A, Schaefer F, Uttley L. Peritoneal Dialysis-Related Infections Recommendations: 2005 Update. Perit Dial Int 2020. [DOI: 10.1177/089686080502500203] [Citation(s) in RCA: 516] [Impact Index Per Article: 129.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Beth Piraino
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Judith Bernardini
- Renal Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Amit Gupta
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Clifford Holmes
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - Ed J. Kuijper
- Department of Medical Microbiology, University Medical Center, Leiden, The Netherlands
| | - Philip Kam-Tao Li
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Wai-Choong Lye
- Centre for Kidney Diseases, Mount Elizabeth Medical Centre, Singapore
| | - Salim Mujais
- Renal Division, Baxter Healthcare Corporation, McGaw Park, Illinois, USA
| | - David L. Paterson
- Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Alfonso Ramos
- Division of Nephrology, Hospital General de Zona #2, Instituto Mexicano del Seguro Social, Hermosillo, Mexico
| | - Franz Schaefer
- Pediatric Nephrology Division, University Children's Hospital, Heidelberg, Germany
| | - Linda Uttley
- Renal Dialysis Treatment, Manchester Royal Infirmary, Manchester, United Kingdom
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Yeung SM, Walker SE, Tailor SA, Awdishu L, Tobe S, Yassa T. Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686080402400509] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BackgroundIn order to avoid aminoglycosides, the International Society for Peritoneal Dialysis recommends cefazolin and ceftazidime for empirical treatment of peritonitis. Ciprofloxacin covers relevant gram-negative pathogens without the resistance associated with ceftazidime. However, ciprofloxacin pharmacokinetic data in patients on continuous cycling peritoneal dialysis (CCPD) are lacking.Objectives( 1 ) To determine the pharmacokinetics of oral ciprofloxacin in CCPD patients, ( 2 ) to compare serum and dialysate ciprofloxacin concentrations with minimum inhibitory concentrations (MIC) of the gram-negative bacteria associated with peritonitis, and ( 3 ) to establish oral ciprofloxacin dosing guidelines for the empirical treatment of peritonitis in patients receiving CCPD.MethodsEligible CCPD patients received 2 doses of ciprofloxacin: 750 mg orally every 12 hours. Serial blood and end-of-dwell dialysate samples were collected during the first 12-hour interval; an end-of-dwell dialysate sample from the overnight dwell and a final blood sample were collected at the end of the second 12-hour interval. Ciprofloxacin concentrations were determined using a liquid chromatographic (HPLC)-fluorescence method. Pharmacokinetic calculations were completed assuming a one-compartment model.ResultsEight patients completed the study. The pharmacokinetic parameters determined for ciprofloxacin were (mean ± SEM) serum half-life 10.1 ± 1.2 hours, maximum serum concentration 2.7 ± 0.5 mg/L, time to maximum serum concentration 1.6 ± 0.1 hours after the first dose, and peritoneal clearance 1.2% ± 0.1% of the mean calculated total body clearance. While all patients achieved serum area under the concentration-time curve: MIC > 125 for Escherichia coli and Klebsiella species after the first dose, only 2 patients achieved this goal for Pseudomonas aeruginosa. End-of-dwell dialysate concentrations were above the MIC for E. coli, Klebsiella spp, and P. aeruginosa after the second dose.ConclusionCiprofloxacin 750 mg orally every 12 hours in CCPD patients may be useful for empirical gram-negative coverage of CCPD peritonitis and for treatment of documented peritonitis caused by sensitive E. coli or Klebsiella species. While ceftazidime may be required for documented pseudomonal peritonitis, the oral ciprofloxacin regimen achieved adequate serum concentrations to treat systemic gram-negative infections caused by sensitive E. coli or Klebsiella species.
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Affiliation(s)
- Sharon M. Yeung
- Department of Pharmacy, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Scott E. Walker
- Department of Pharmacy, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Sandra A.N. Tailor
- Department of Pharmacy, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
- Divisions of Infectious Diseases, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda Awdishu
- Department of Pharmacy, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
- Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Sheldon Tobe
- Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
| | - Teraiza Yassa
- Nephrology, Sunnybrook & Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Affiliation(s)
| | - Kai-Ming Chow
- Department of Medicine & Therapeutics Prince of Wales Hospital The Chinese University of Hong Kong Shatin, Hong Kong, China
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Affiliation(s)
- Wai-Choong Lye
- Centre for Kidney Diseases Mount Elizabeth Medical Centre Singapore
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Chen CH, Perl J, Teitelbaum I. Prescribing high-quality peritoneal dialysis: The role of preserving residual kidney function. Perit Dial Int 2020; 40:274-281. [DOI: 10.1177/0896860819893821] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Maintenance of residual kidney function (RKF) is independently associated with increased survival in patients with end-stage renal disease. Presence of RKF is also associated with improved volume status, better nutritional status, reduced erythropoietin requirement, and decreased rate of peritonitis in patients on peritoneal dialysis (PD). Thus, the preservation of RKF is an important therapeutic end point in the management of patients on PD. Measurement of RKF in PD patients should be based on the mean of 24-h urinary creatinine and urea clearances, and ideally, this should be done quarterly. Compared to those started on hemodialysis, patients initiated on PD appear to have slower decline in RKF. The choice of PD modality should be based on patient preference, as there is no clear evidence to date showing one modality is superior than the other in preserving RKF. Peritoneal dialysates with neutral pH and low glucose degradation products seem to have a favorable effect on RKF. An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should be used whenever possible to preserve RKF and reduce cardiac mortality. Both loop diuretics and icodextrin can be utilized to maintain fluid balance in PD patients. However, caution should be taken to avoid volume depletion which could accelerate RKF decline. Short-term use of aminoglycosides does not have a detrimental impact on RKF, but prolonged use (>3 weeks) should be avoided to minimize the risk of ototoxicity. Lastly, potential nephrotoxic agents such as intravenous contrast should be used judiciously.
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Affiliation(s)
- Chang Huei Chen
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeff Perl
- Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Isaac Teitelbaum
- Department of Medicine, University of Colorado Health Sciences Center, Aurora, CO, USA
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Van Biesen W, Brown EA. Diagnostic and therapeutic approach to peritonitis. Nephrol Dial Transplant 2017; 32:1283-1284. [DOI: 10.1093/ndt/gfx226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/23/2017] [Indexed: 11/14/2022] Open
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Yan H, Fang W, Lin A, Cao L, Ni Z, Qian J. Three Versus 4 Daily Exchanges and Residual Kidney Function Decline in Incident CAPD Patients: A Randomized Controlled Trial. Am J Kidney Dis 2017; 69:506-513. [DOI: 10.1053/j.ajkd.2016.08.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 08/04/2016] [Indexed: 11/11/2022]
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Liu X, Dai C. Advances in Understanding and Management of Residual Renal Function in Patients with Chronic Kidney Disease. KIDNEY DISEASES 2016; 2:187-196. [PMID: 28232935 DOI: 10.1159/000449029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 08/10/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Residual renal function (RRF), defined as the ability of native kidneys to eliminate water and uremic toxins, is closely correlated with mortality and morbidity rates among patients receiving either peritoneal dialysis (PD) or hemodialysis (HD) via continuous clearance of middle-sized molecules and protein-bound solutes. Therefore, preserving RRF is considered to be one of the primary goals in managing patients with end-stage renal disease (ESRD). SUMMARY AND KEY MESSAGES In this article, we provide a review on the understanding and management of RRF in patients on dialysis. RRF may be estimated and measured by calculating the mean 24-hour urine creatinine level and urea clearance. Currently, several middle-sized molecules are reported but rarely used in practice. Many risk factors such as original renal diseases, dietary intake, and nephrotoxic agents impair RRF. Targeting such factors may halt the decline in RRF and offer better outcomes for patients on PD or HD. Except for in PD patients, RRF is a powerful predictor of survival in HD patients. RRF requires more clinical and research attention in the care of patients with ESRD on dialysis.
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Affiliation(s)
- Xin Liu
- Center for Kidney Diseases, 2nd Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
| | - Chunsun Dai
- Center for Kidney Diseases, 2nd Affiliated Hospital, Nanjing Medical University, Nanjing, PR China
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Li PKT, Szeto CC, Piraino B, de Arteaga J, Fan S, Figueiredo AE, Fish DN, Goffin E, Kim YL, Salzer W, Struijk DG, Teitelbaum I, Johnson DW. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int 2016; 36:481-508. [PMID: 27282851 PMCID: PMC5033625 DOI: 10.3747/pdi.2016.00078] [Citation(s) in RCA: 612] [Impact Index Per Article: 76.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/04/2016] [Indexed: 12/19/2022] Open
Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Beth Piraino
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Javier de Arteaga
- Department of Nephrology, Hospital Privado and Catholic University, Cordoba, Argentina
| | - Stanley Fan
- Department of Renal Medicine and Transplantation, Barts Health NHS Trust, London, UK
| | - Ana E Figueiredo
- Nursing School-FAENFI, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Douglas N Fish
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - Eric Goffin
- Department of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Belgium
| | - Yong-Lim Kim
- Department of Internal Medicine, Kyungpook National University School of Medicine, Clinical Research Center for End Stage Renal Disease, Daegu, Korea
| | - William Salzer
- University of Missouri-Columbia School of Medicine, Department of Internal Medicine, Section of Infectious Disease, MI, USA
| | - Dirk G Struijk
- Department of Nephrology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - David W Johnson
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
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15
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Nongnuch A, Assanatham M, Panorchan K, Davenport A. Strategies for preserving residual renal function in peritoneal dialysis patients. Clin Kidney J 2015; 8:202-11. [PMID: 25815178 PMCID: PMC4370298 DOI: 10.1093/ckj/sfu140] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 12/11/2014] [Indexed: 12/19/2022] Open
Abstract
Although there have been many advancements in the treatment of patients with chronic kidney disease (CKD) over the last 50 years, in terms of reducing cardiovascular risk, mortality remains unacceptably high, particularly for those patients who progress to stage 5 CKD and initiate dialysis (CKD5d). As mortality risk increases exponentially with progressive CKD stage, the question arises as to whether preservation of residual renal function once dialysis has been initiated can reduce mortality risk. Observational studies to date have reported an association between even small amounts of residual renal function and improved patient survival and quality of life. Dialysis therapies predominantly provide clearance for small water-soluble solutes, volume and acid-base control, but cannot reproduce the metabolic functions of the kidney. As such, protein-bound solutes, advanced glycosylation end-products, middle molecules and other azotaemic toxins accumulate over time in the anuric CKD5d patient. Apart from avoiding potential nephrotoxic insults, observational and interventional trials have suggested that a number of interventions and treatments may potentially reduce the progression of earlier stages of CKD, including targeted blood pressure control, reducing proteinuria and dietary intervention using combinations of protein restriction with keto acid supplementation. However, many interventions which have been proven to be effective in the general population have not been equally effective in the CKD5d patient, and so the question arises as to whether these treatment options are equally applicable to CKD5d patients. As strategies to help preserve residual renal function in CKD5d patients are not well established, we have reviewed the evidence for preserving or losing residual renal function in peritoneal dialysis patients, as urine collections are routinely collected, whereas few centres regularly collect urine from haemodialysis patients, and haemodialysis dialysis patients are at risk of sudden intravascular volume shifts associated with dialysis treatments. On the other hand, peritoneal dialysis patients are exposed to a variety of hypertonic dialysates and episodes of peritonitis. Whereas blood pressure control, using an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB), and low-protein diets along with keto acid supplementation have been shown to reduce the rate of progression in patients with earlier stages of CKD, the strategies to preserve residual renal function (RRF) in dialysis patients are not well established. For peritoneal dialysis patients, there are additional technical factors that might aggravate the rate of loss of residual renal function including peritoneal dialysis prescriptions and modality, bio-incompatible dialysis fluid and over ultrafiltration of fluid causing dehydration. In this review, we aim to evaluate the evidence of interventions and treatments, which may sustain residual renal function in peritoneal dialysis patients.
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Affiliation(s)
- Arkom Nongnuch
- Renal Unit, Department of Medicine, Faculty of Medicine , Ramathibodi Hospital , Mahidol University , Bangkok , Thailand ; UCL Centre for Nephrology, Royal Free Hospital , University College London Medical School , London , UK
| | - Montira Assanatham
- Renal Unit, Department of Medicine, Faculty of Medicine , Ramathibodi Hospital , Mahidol University , Bangkok , Thailand
| | - Kwanpeemai Panorchan
- UCL Centre for Nephrology, Royal Free Hospital , University College London Medical School , London , UK ; Bumrungrad International Hospital , Bangkok , Thailand
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free Hospital , University College London Medical School , London , UK
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Strategies for the preservation of residual renal function in pediatric dialysis patients. Pediatr Nephrol 2014; 29:825-36; quiz 832. [PMID: 23868107 DOI: 10.1007/s00467-013-2554-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 06/05/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
Abstract
In adults with end-stage renal disease (ESRD), the preservation of residual renal function (RRF) has been shown to be associated with decreased mortality and improved control of complications of chronic kidney disease. However, less is known on the benefits of RRF in the pediatric dialysis population. The purpose of this article is to review the clinical significance of RRF and to discuss strategies for the preservation of RRF in children with ESRD.
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Ballinger AE, Palmer SC, Wiggins KJ, Craig JC, Johnson DW, Cross NB, Strippoli GFM. Treatment for peritoneal dialysis-associated peritonitis. Cochrane Database Syst Rev 2014; 2014:CD005284. [PMID: 24771351 PMCID: PMC11231986 DOI: 10.1002/14651858.cd005284.pub3] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Peritonitis is a common complication of peritoneal dialysis (PD) that is associated with significant morbidity including death, hospitalisation, and need to change from PD to haemodialysis. Treatment is aimed to reduce morbidity and recurrence. This is an update of a review first published in 2008. OBJECTIVES To evaluate the benefits and harms of treatments for PD-associated peritonitis. SEARCH METHODS For this review update we searched the Cochrane Renal Group's Specialised Register to March 2014 through contact with the Trials Search Co-ordinator using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE and EMBASE, and handsearching conference proceedings. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in PD patients (adults and children). We included any study that evaluated: administration of an antibiotic by different routes (e.g. oral, intraperitoneal (IP), intravenous (IV)); dose of an antibiotic agent; different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal. DATA COLLECTION AND ANALYSIS Multiple authors independently extracted data on study risk of bias and outcomes. Statistical analyses were performed using the random effects model. We expressed summarised treatment estimates as a risk ratio (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) with 95% CI for continuous outcomes. MAIN RESULTS We identified 42 eligible studies in 2433 participants: antimicrobial agents (36 studies); urokinase (4 studies), peritoneal lavage (1 study), and IP immunoglobulin (1 study). We did not identify any optimal antibiotic agent or combination of agents. IP glycopeptides (vancomycin or teicoplanin) had uncertain effects on primary treatment response, relapse rates, and need for catheter removal compared to first generation cephalosporins, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 2.72). For relapsing or persistent peritonitis, simultaneous catheter removal and replacement was better than urokinase at reducing treatment failure rates (RR 2.35, 95% CI 1.13 to 4.91) although evidence was limited to a single small study. Continuous and intermittent IP antibiotic dosing schedules had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure in one small study (RR 3.52, 95% CI 1.26 to 9.81). Longer duration treatment (21 days of IV vancomycin and IP gentamicin) had uncertain effects on risk of treatment relapse compared with 10 days treatment (1 study, 49 patients: RR 1.56, 95% CI 0.60 to 3.95) although may have increased ototoxicity.In general, review conclusions were based on a small number of studies with few events in which risk of bias was generally high; interventions were heterogeneous, and outcome definitions were often inconsistent. There were no RCTs evaluating optimal timing of catheter removal and data for automated PD were absent. AUTHORS' CONCLUSIONS Many of the studies evaluating treatment of PD-related peritonitis are small, out-dated, of poor quality, and had inconsistent definitions and dosing regimens. IP administration of antibiotics was superior to IV administration for treating PD-associated peritonitis and glycopeptides appear optimal for complete cure of peritonitis, although evidence for this finding was assessed as low quality. PD catheter removal may be the best treatment for relapsing or persistent peritonitis.Evidence was insufficient to identify the optimal agent, route or duration of antibiotics to treat peritonitis. No specific antibiotic appears to have superior efficacy for preventing treatment failure or relapse of peritonitis, but evidence is limited to few trials. The role of routine peritoneal lavage or urokinase is uncertain.
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Affiliation(s)
- Angela E Ballinger
- Department of Medicine, University of Otago Christchurch, 2 Riccarton Ave, Christchurch, New Zealand, 8041
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Préservation de la fonction rénale résiduelle en dialyse. Nephrol Ther 2013; 9:403-7. [DOI: 10.1016/j.nephro.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 05/02/2013] [Indexed: 11/20/2022]
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Oliveira LG, Luengo J, Caramori JCT, Montelli AC, Cunha MDLRS, Barretti P. Peritonitis in recent years: clinical findings and predictors of treatment response of 170 episodes at a single Brazilian center. Int Urol Nephrol 2013; 44:1529-37. [PMID: 22302733 DOI: 10.1007/s11255-011-0107-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 12/16/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE Peritonitis continues to be a major cause of dropout in peritoneal dialysis (PD) patients. Changes in the prevalence of peritonitis etiologies and an increase in the frequency of methicillin-resistant coagulase-negative staphylococci (CoNS) and Gram-negative species resistant to commonly used antibiotics have been reported. As a consequence, the current clinical presentation and patient outcome may differ from classical descriptions. The objectives of this study were to describe the clinical and microbiological characteristics of PD-related peritonitis episodes that occurred over a period of 6 years at a single Brazilian dialysis center and to identify predictors of outcome. METHODS A total of 170 peritonitis episodes that occurred in 92 PD patients between January 2004 and December 2009 were reviewed. Multivariate analysis was used to identify demographic, clinical, and microbiological factors predicting endpoints (resolution and peritonitis-related death). Patients' characteristics and peritonitis incidence, etiology and outcomes were compared with a series of 232 episodes that occurred in the first 6 years (1995-2000) of the PD program at the same center. RESULTS The overall peritonitis rate was 0.65 episodes/patient-year. Gram-positive cocci were identified in 79 (46.5%) episodes, whereas Gram-negative bacilli were isolated from 48 (28.2%). CoNS were the main Gram-positive species identified in 48 episodes. Of these, 56.3% were resistant to methicillin. Among Gram-negative species, amikacin resistance was observed in 60% of non-fermentative Gram-negative bacilli (NFGNB) and in only 3.6% of Enterobacteriaceae. The overall resolution rate was 44.1%. Oxacillin resistance and NFGNB etiology were strong predictors of non-resolution, whereas older age was the only predictor of death. Antibiotic protocols did not influence outcome. Comparison with the results obtained for the 1990-1995 period showed a lower peritonitis rate, a strong decline in the proportion of Staphylococcus aureus episodes, a significant increase in the frequency of oxacillin-resistant CoNS and amikacin-resistant NFGNB, and a significantly lower resolution and higher death rate. CONCLUSIONS The current clinical characteristics and outcome suggest a greater severity of peritonitis episodes and higher risk of death, possibly due to bacterial resistance. Older age is a risk factor for death.
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Affiliation(s)
- Luiz Gustavo Oliveira
- Department of Internal Medicine, Botucatu Medical School, Sao Paulo State University-UNESP, Botucatu, Sao Paulo 18618-970, Brazil
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Kang SH, Cho KH, Park JW, Yoon KW, Do JY. Impact of heavy proteinuria on clinical outcomes in patients on incident peritoneal dialysis. BMC Nephrol 2012; 13:171. [PMID: 23245677 PMCID: PMC3538719 DOI: 10.1186/1471-2369-13-171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 11/27/2012] [Indexed: 11/18/2022] Open
Abstract
Background There are few reports on the nutritional status changes and residual renal function (RRF) according to proteinuria levels in patients on peritoneal dialysis (PD). Methods A total of 388 patients on PD were enrolled. The patients were divided into 3 groups with respect to initial proteinuria: the A (n = 119; <500 mg/day), B (n = 218; 500–3,500 mg/day), and C groups (n = 51; >3,500 mg/day). Results The patients with higher proteinuria levels had a higher incidence of male sex, diabetes mellitus, and icodextrin use than those with lower proteinuria levels. Although initial peritoneal albumin loss in C group was lower than that detected in the other groups, no significant difference was observed in peritoneal albumin loss among the 3 groups at the end of follow-up period. At the time of PD initiation, the Geriatric nutritional risk index (GNRI) was lower in the C group than in the other 2 groups. However, at the end of the follow-up period, there was no significant difference in GNRI between the 3 groups. The GNRI increased, and the proteinuria level or RRF decreased more in the C group than in the other 2 groups. There were no significant differences in lean mass index or fat mass index change from the time of PD initiation to the end of the follow-up period. However, fat mass index and nPNA showed greater increases in the C group. The multivariate analysis revealed that proteinuria was negatively correlated with GNRI at the time of PD initiation and at the end of the follow-up period. The initial RRF and proteinuria were negatively correlated with the RRF decline during the follow-up. Conclusion The attenuation of the nephrotic proteinuria, along with the RRF decline, was associated with the improvement of the malnutrition.
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Affiliation(s)
- Seok Hui Kang
- Department of Internal Medicine, Division of Nephrology, Yeungnam University Hospital, 317-1 Daemyung-Dong, Nam-Ku 705-717, Daegu, Korea
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Li PKT, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, Johnson DW, Kuijper EJ, Lye WC, Salzer W, Schaefer F, Struijk DG. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2012; 30:393-423. [PMID: 20628102 DOI: 10.3747/pdi.2010.00049] [Citation(s) in RCA: 585] [Impact Index Per Article: 48.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong.
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Herget-Rosenthal S, von Ostrowski M, Kribben A. Definition and risk factors of rapidly declining residual renal function in peritoneal dialysis: an observational study. Kidney Blood Press Res 2012; 35:233-41. [PMID: 22223267 DOI: 10.1159/000332887] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 09/05/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is critical to preserve residual renal function (RRF) in peritoneal dialysis (PD), as RRF is associated with lower morbidity and mortality. There is no uniform definition of RRF, and rapidly declining RRF has rarely been studied and predominately limited to single factor analysis and not corrected for lead-time bias. METHODS An observational study in 71 incident PD patients. RRF was defined as urine output (UO) ≥500 ml/day and renal glomerular filtration rate (rGFR) ≥2 ml/min/1.73 m(2), rapid declining RRF as UO <500 ml/day and rGFR <2 ml/min/1.73 m(2) occurring within 6 months which were separately evaluated. Independent risk factors associated with rapid RRF decline were identified while correcting for lead-time bias. RESULTS RRF declined rapidly by both definitions in 65% patients 2.5 years after PD start. Both definitions of RRF decline were consistent in 96%. Nephrotoxic drugs, renal transplant failure and absent angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) were independent risk factors associated with rapidly declining RRF defined both by definitions, intravascular radiocontrast additionally for UO decline. CONCLUSIONS Most PD patients demonstrated rapid RRF decline, independent of its definition. Both definitions are highly consistent and interchangeable. Nephrotoxic drugs and radiocontrast were identified as risk factors of acute, absent ACEI or ARB, and renal transplant failure of chronic renal injury.
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Blake PG, Bargman JM, Brimble KS, Davison SN, Hirsch D, McCormick BB, Suri RS, Taylor P, Zalunardo N, Tonelli M. Clinical Practice Guidelines and Recommendations on Peritoneal Dialysis Adequacy 2011. Perit Dial Int 2012; 31:218-39. [PMID: 21427259 DOI: 10.3747/pdi.2011.00026] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Peter G Blake
- Division of Nephrology,1 University of Western Ontario, London, Ontario, Canada.
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Girard LP, Ceri H, Gibb AP, Olson M, Sepandj F. MIC versus MBEC to determine the antibiotic sensitivity of Staphylococcus aureus in peritoneal dialysis peritonitis. Perit Dial Int 2011; 30:652-6. [PMID: 21148059 DOI: 10.3747/pdi.2010.00010] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Peritoneal dialysis (PD)-related peritonitis is a common and morbid complication of PD. Bacteria are able to create a biofilm on the PD catheter, which can be a source of recurrent infection. Biofilms undergo a phenotypic change resulting in increased antibiotic resistance. ♢ METHODS 21 clinical isolates of different patients with PD peritonitis secondary to Staphylococcus aureus were collected. They were analyzed for their antibiotic susceptibility in the planktonic form using the standard minimum inhibitory concentration (MIC) and in a biofilm using minimum biofilm eradication concentration (MBEC). Chi-square was used to compare the sensitivity results. ♢ RESULTS The isolates were susceptible to all the antibiotics tested using MIC. Every antibiotic except gentamicin lost its efficacy when the bacteria were grown in a biofilm (p > 0.05). The change in susceptibility was statistically significant to a level of p < 0.001 for all antibiotics tested. ♢ DISCUSSION In PD peritonitis that is long standing, recurrent, or not responsive to therapy, MBEC testing should be considered as a biofilm may be present. Gentamicin should be strongly considered over other agents for empiric gram-negative coverage as it may be providing synergy in the setting of Staphylococcus aureus. Also, the newer anti-staphylococcal drugs should be tested for their performance in a biofilm using the MBEC method.
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Affiliation(s)
- Louis P Girard
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
Aminoglycosides are the mainstay in the treatment of serious gram negative infections including catheter-associated infections. They are not metabolized and are rapidly excreted as such by glomerular filtration resulting in a plasma t½ of approximately two hours in those with normal renal function. The t½, however, can extend to 30-60 hours in patients who are functionally anephric; therefore, dosage reduction or modification is necessary in renal failure patients. In patients on hemodialysis the clearance of aminoglycosides is significant and variable. The concept of conventional postdialysis dosing in patients on hemodialysis needs to be revised in favor of higher predialysis doses to maintain effective bactericidal activity. This article is a brief review of the use of aminoglycosides in renal failure patients.
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Affiliation(s)
- S Nayak-Rao
- Department of Nephrology, Bahrain Specialist Hospital, PO Box 10588, Manama, Bahrain
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Badve SV, Hawley CM, McDonald SP, Brown FG, Boudville NC, Wiggins KJ, Bannister KM, Johnson DW. Use of aminoglycosides for peritoneal dialysis-associated peritonitis does not affect residual renal function. Nephrol Dial Transplant 2011; 27:381-7. [PMID: 21633101 DOI: 10.1093/ndt/gfr274] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aminoglycosides offer several potential benefits in their treatment of peritoneal dialysis (PD)-associated peritonitis, including low cost, activity against Gram-negative organisms (including Pseudomonas aeruginosa), synergistic bactericidal activity against some Gram-positive organisms (such as Staphylococci) and relatively low propensity to promote antimicrobial resistance. However, there is limited conflicting evidence that aminoglycosides may accelerate loss of residual renal function (RRF) in PD patients. The aim of this study was to study the effect of aminoglycoside use on slope of decline in RRF. METHODS The study included 2715 Australian patients receiving PD between October 2003 and December 2007 in whom at least two measurements of renal creatinine clearance were available. Patients were divided according to tertiles of slope of RRF decline (rapid, intermediate and slow). The primary outcome was the slope of RRF over time in patients who received aminoglycosides for PD peritonitis versus those who did not. RESULTS A total of 1412 patients (52%) experienced at least one episode of PD peritonitis. An aminoglycoside was used as the initial empiric antibiotic in 1075 patients. The slopes of RRF decline were similar in patients treated and not treated with at least one course of aminoglycoside (median [interquartile range] -0.26 [-1.17 to 0.04] mL/min/1.73 m(2)/month versus -0.22 [-1.11 to 0.01] mL/min/1.73 m(2)/month, P = 0.9). The slopes of RRF decline were also similar in patients receiving repeated courses of aminoglycoside. CONCLUSIONS Empiric treatment with aminoglycoside for peritonitis was not associated with an adverse effect on RRF in PD patients.
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Affiliation(s)
- Sunil V Badve
- Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
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Rüger W, van Ittersum FJ, Comazzetto LF, Hoeks SE, ter Wee PM. Similar peritonitis outcome in CAPD and APD patients with dialysis modality continuation during peritonitis. Perit Dial Int 2010; 31:39-47. [PMID: 20558813 DOI: 10.3747/pdi.2009.00235] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND As few data exist on treatment of peritonitis in patients on automated peritoneal dialysis (APD), and as pharmacokinetics of several antibiotics are reported to be unfavorable in APD, some favor switching to continuous ambulant PD (CAPD) while treating APD-related peritonitis. We explored whether treating peritonitis with patients continuing their usual PD modality had an effect on outcome. METHODS We performed a retrospective analysis of the 508 episodes of PD-associated peritonitis seen in 205 patients in our center from January 1993 to January 2007. During this period, the standard initial therapy for PD-related peritonitis was a combination of intraperitoneal gentamicin and rifampicin. RESULTS There was no difference in cure rate between CAPD and APD groups. Likewise, initial and maximal leukocyte counts in the PD fluid (PDF), relapse rates, catheter removal rates, and death during treatment of peritonitis were similar in the CAPD and APD groups. Median (interquartile range) duration of elevated leukocyte count in PDF was longer in APD: 5.0 (3.0 - 9.0) days versus 4.0 (2.5 - 7.0) days in CAPD (p <0.001). APD patients were treated with antibiotics longer than CAPD patients: 16.0 (12.5 - 21.0) versus 15.0 (12.0 - 18.0) days (p = 0.036). Also, after correction for possible confounders, odds ratios for death and for the combined end point death or catheter removal showed no difference when patients treated for peritonitis stayed on their own modality. CONCLUSION Regarding rate of relapse, mortality, or the combined end point mortality plus catheter removal, we found no difference between CAPD and APD patients continuing their own PD modality during treatment of PD-related peritonitis. Intermediate end points such as duration of elevated PDF leukocyte count and duration of antibiotic treatment were longer in APD patients.
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Affiliation(s)
- Wim Rüger
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands.
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Clinical benefit of preserving residual renal function in dialysis patients: an update for clinicians. Am J Med Sci 2010; 339:453-6. [PMID: 20375877 DOI: 10.1097/maj.0b013e3181cf7d5b] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Residual renal function (RRF) remains important even after beginning of dialysis. RRF contributes significantly to the overall health and well-being of patients on dialysis. It plays an important role in maintaining fluid balance, phosphorus control, nutrition, and removal of middle molecular uremic toxins and shows inverse relationships with valvular calcification and cardiac hypertrophy in patients on dialysis. RRF may allow for a reduction in the duration of hemodialysis sessions and the need for dietary and fluid restrictions in both patients on peritoneal dialysis and hemodialysis. More importantly, the loss of RRF is a powerful predictor of mortality. This article will review the evidence supporting the importance of RRF on outcome and outline potential strategies that may better preserve RRF in patients on dialysis.
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Kendrick J, Teitelbaum I. Strategies for improving long-term survival in peritoneal dialysis patients. Clin J Am Soc Nephrol 2010; 5:1123-31. [PMID: 20430945 DOI: 10.2215/cjn.04300709] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The incidence and prevalence of ESRD in the United States continues to increase. Currently there are over 26,000 patients maintained on peritoneal dialysis. Mortality rates have fallen over the past several years, but long-term survival remains poor, with only 11% of peritoneal dialysis patients surviving past 10 years. Cardiovascular disease accounts for most deaths, and dialysis patients have many traditional and nontraditional cardiovascular risk factors. Lowering of these risk factors has not resulted in reduced cardiovascular morbidity and mortality in dialysis patients. Maneuvers to improve long-term peritoneal dialysis patient survival must therefore focus on modifiable risk factors including residual renal function, peritoneal membrane integrity, rate of infections, and peritoneal dialysis center size. This article reviews strategies for preserving residual renal function and peritoneal membrane integrity as well as strategies for reducing the rate of infections to enhance long-term survival in peritoneal dialysis patients.
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Affiliation(s)
- Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, Aurora, CO, USA
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Chadha V, Schaefer FS, Warady BA. Dialysis-associated peritonitis in children. Pediatr Nephrol 2010; 25:425-40. [PMID: 19190935 PMCID: PMC2810362 DOI: 10.1007/s00467-008-1113-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 11/18/2008] [Accepted: 12/09/2008] [Indexed: 01/06/2023]
Abstract
Peritonitis remains a frequent complication of peritoneal dialysis in children and is the most common reason for technique failure. The microbiology is characterized by a predominance of Gram-positive organisms, with fungi responsible for less than 5% of episodes. Data collected by the International Pediatric Peritonitis Registry have revealed a worldwide variation in the bacterial etiology of peritonitis, as well as in the rate of culture-negative peritonitis. Risk factors for infection include young age, the absence of prophylactic antibiotics at catheter placement, spiking of dialysis bags, and the presence of a catheter exit-site or tunnel infection. Clinical symptoms at presentation are somewhat organism specific and can be objectively assessed with a Disease Severity Score. Whereas recommendations for empiric antibiotic therapy in children have been published by the International Society of Peritoneal Dialysis, epidemiologic data and antibiotic susceptibility data suggest that it may be desirable to take the patient- and center-specific history of microorganisms and their sensitivity patterns into account when prescribing initial therapy. The vast majority of patients are treated successfully and continue peritoneal dialysis, with the poorest outcome noted in patients with peritonitis secondary to Gram-negative organisms or fungi and in those with a relapsing infection.
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Affiliation(s)
- Vimal Chadha
- Department of Pediatrics, Section of Nephrology, Virginia Commonwealth University Medical Center, Richmond, VA USA
| | - Franz S. Schaefer
- Center for Pediatric and Adolescent Medicine, Section of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Bradley A. Warady
- Department of Pediatrics, Section of Nephrology, The Children’s Mercy Hospital, Kansas City, MO USA
- University of Missouri–Kansas City School of Medicine, The Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108 USA
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Ranganathan D, Varghese JM, Fassett RG, Lipman J, D'Intini V, Healy H, Roberts JA. Optimising intraperitoneal gentamicin dosing in peritoneal dialysis patients with peritonitis (GIPD) study. BMC Nephrol 2009; 10:42. [PMID: 20003546 PMCID: PMC2800106 DOI: 10.1186/1471-2369-10-42] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 12/16/2009] [Indexed: 02/09/2023] Open
Abstract
Background Antibiotics are preferentially delivered via the peritoneal route to treat peritonitis, a major complication of peritoneal dialysis (PD), so that maximal concentrations are delivered at the site of infection. However, drugs administered intraperitoneally can be absorbed into the systemic circulation. Drugs excreted by the kidneys accumulate in PD patients, increasing the risk of toxicity. The aim of this study is to examine a model of gentamicin pharmacokinetics and to develop an intraperitoneal drug dosing regime that maximises bacterial killing and minimises toxicity. Methods/Design This is an observational pharmacokinetic study of consecutive PD patients presenting to the Royal Brisbane and Women's Hospital with PD peritonitis and who meet the inclusion criteria. Participants will be allocated to either group 1, if anuric as defined by urine output less than 100 ml/day, or group 2: if non-anuric, as defined by urine output more than 100 ml/day. Recruitment will be limited to 15 participants in each group. Gentamicin dosing will be based on the present Royal Brisbane & Women's Hospital guidelines, which reflect the current International Society for Peritoneal Dialysis Peritonitis Treatment Recommendations. The primary endpoint is to describe the pharmacokinetics of gentamicin administered intraperitoneally in PD patients with peritonitis based on serial blood and dialysate drug levels. Discussion The study will develop improved dosing recommendations for intraperitoneally administered gentamicin in PD patients with peritonitis. This will guide clinicians and pharmacists in selecting the most appropriate dosing regime of intraperitoneal gentamicin to treat peritonitis. Trial Registration ACTRN12609000446268
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Perl J, Bargman JM. The Importance of Residual Kidney Function for Patients on Dialysis: A Critical Review. Am J Kidney Dis 2009; 53:1068-81. [PMID: 19394737 DOI: 10.1053/j.ajkd.2009.02.012] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Accepted: 02/06/2009] [Indexed: 11/11/2022]
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Barretti P, Pereira D, Brasil MA, de Lourdes Cunha M, Caramori J, Montelli A. Evolution of Gram-Negative Bacilli Susceptibility in Peritoneal Dialysis-Related Peritonitis in Brazil: A Single Center's Experience over Nine Years. Perit Dial Int 2009. [DOI: 10.1177/089686080902900219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
BACKGROUND Peritonitis is a common complication of peritoneal dialysis (PD) and is associated with significant morbidity. Adequate treatment is essential to reduce morbidity and recurrence. OBJECTIVES To evaluate the benefits and harms of treatments for PD-associated peritonitis. SEARCH STRATEGY We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE, EMBASE and reference lists without language restriction. Date of search: February 2005 SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs assessing the treatment of peritonitis in peritoneal dialysis patients (adults and children) evaluating: administration of an antibiotic(s) by different routes (e.g. oral, intraperitoneal, intravenous); dose of an antibiotic agent(s); different schedules of administration of antimicrobial agents; comparisons of different regimens of antimicrobial agents; any other intervention including fibrinolytic agents, peritoneal lavage and early catheter removal were included. DATA COLLECTION AND ANALYSIS Two authors extracted data on study quality and outcomes. Statistical analyses were performed using the random effects model and the dichotomous results were expressed as relative risk (RR) with 95% confidence intervals (CI) and continuous outcomes as mean difference (WMD) with 95% CI. MAIN RESULTS We identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). For relapsing or persistent peritonitis, simultaneous catheter removal/replacement was superior to urokinase at reducing treatment failure rates (1 study, 37 patients: RR 2.35, 95% CI 1.13 to 4.91). Continuous IP and intermittent IP antibiotic dosing had similar treatment failure and relapse rates. IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). The methodological quality of most included studies was suboptimal and outcome definitions were often inconsistent. There were no RCTs regarding duration of antibiotics or timing of catheter removal. AUTHORS' CONCLUSIONS Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious. There is no role shown for routine peritoneal lavage or use of urokinase. No interventions were found to be associated with significant harm.
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Affiliation(s)
- K J Wiggins
- St Vincent's Hospital, Nephrology, Level 4, Clinical Sciences Building, Fitzroy, VIC, Australia, 3065.
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Warady BA, Feneberg R, Verrina E, Flynn JT, Müller-Wiefel DE, Besbas N, Zurowska A, Aksu N, Fischbach M, Sojo E, Donmez O, Sever L, Sirin A, Alexander SR, Schaefer F. Peritonitis in children who receive long-term peritoneal dialysis: a prospective evaluation of therapeutic guidelines. J Am Soc Nephrol 2007; 18:2172-9. [PMID: 17582162 DOI: 10.1681/asn.2006101158] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In children who are on chronic peritoneal dialysis, peritonitis is the primary complication compromising technique survival, and the optimal therapy of peritonitis remains uncertain. An Internet-based International Pediatric Peritonitis Registry was established in 47 pediatric centers from 14 countries to evaluate the efficacy and safety of largely opinion-based peritonitis treatment guidelines in which empiric antibiotic therapy was stratified by disease severity. Among a total of 491 episodes of nonfungal peritonitis entered into the registry, Gram-positive organisms were cultured in 44%, Gram-negative organisms were cultured in 25%, and cultures remained negative in 31% of the episodes. In vitro evaluation revealed 69% sensitivity of Gram-positive organisms to a first-generation cephalosporin and 80% sensitivity of Gram-negative organisms to a third-generation cephalosporin. Neither the risk factors assumed by the guidelines nor the choice of empiric therapy was predictive of either the early treatment response or the final functional outcome of the peritonitis episodes. Overall, 89% of cases achieved full functional recovery, a portion after relapsing peritonitis (9%). These data serve as the basis for new evidence-based guidelines. Modification of empiric therapy to include aminoglycosides should be considered.
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Affiliation(s)
- Bradley A Warady
- Pediatric Nephrology, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Wong SS, Ho PL, Yuen KY. Evolution of Antibiotic Resistance Mechanisms and their Relevance to Dialysis-Related Infections. Perit Dial Int 2007. [DOI: 10.1177/089686080702702s47] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As the survival of patients with end-stage renal failure has improved, their exposure to antibiotics has also increased. Infections, especially peritoneal dialysis–related peritonitis, are unavoidable because of lapses in technique and the slow worsening of systemic and peritoneal defense associated with aging and dialysis. The selective pressure inherent in the use of antibiotics shapes the pattern of antibiotic resistance in the bacteria causing peritonitis and extraperitoneal infections, and vice versa. Renal function–preserving and non-ototoxic regimens that incorporate double β-lactams (first- and third-generation cephalosporins) for peritonitis have increased the selective pressure in favor of methicillin-resistant staphylococci (MRS) and extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae. Attempts to use the fluoroquinolones as alternatives to β-lactams was met with rocketing quinolone resistance. The high incidence of MRS led many nephrologists to use empiric vancomycin—until the début of vancomycin-resistant enterococci. The recent emergence of heterogeneous and high-level vancomycin resistance in staphylococci (which are especially prevalent in patients on dialysis) calls for further prudence in the use of vancomycin. The coming challenges are ESBL-producing Enterobacteriaceae with carbapenemase, multi-resistant Pseudomonas, and highly virulent community-acquired methicillin-resistant Staphylococcus aureus with Panton–Valentine leukocidin. Antibiotic auditing programs and meticulous patient training by nurses are the only available defense at the moment. Novel approaches such as antibiotic-impregnated Tenckhoff catheters, biocompatible dialysis fluid, and peritoneal immuno-augmentation strategies are eagerly awaited.
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Affiliation(s)
- Samson S.Y. Wong
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Hong Kong SAR, PR China
| | - Pak-Leung Ho
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Hong Kong SAR, PR China
| | - Kwok-Yung Yuen
- Department of Microbiology, Research Centre of Infection and Immunology, The University of Hong Kong, Hong Kong SAR, PR China
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Abstract
The success of a peritoneal dialysis (PD) program depends on a multitude of factors that are interlinked and inseparable from one another. Each program needs to identify its special circumstances, deficiencies, and strong points, and then to strategize accordingly. Ultimately, “teamwork” is the mantra for a successful outcome, the patient being central to all endeavors. A belief and a passion for PD are the fountainhead and cornerstone on which to build a quality PD program.
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Affiliation(s)
- K.S. Nayak
- PD Center, Department of Nephrology, Global Hospitals, Hyderabad, Andhra Pradesh, India
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Weisbord SD, Bernardini J, Mor MK, Hartwig KC, Nicoletta PJ, Palevsky PM, Piraino B. The effect of coronary angiography on residual renal function in patients on peritoneal dialysis. Clin Cardiol 2007; 29:494-7. [PMID: 17133846 PMCID: PMC6654194 DOI: 10.1002/clc.4960291105] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The risk of intravascular radiocontrast to residual renal function (RRF) in patients on peritoneal dialysis (PD) remains largely unknown. HYPOTHESIS This study sought to estimate the effect of coronary angiography on RRF in patients on PD. METHODS All patients at the VA Pittsburgh Healthcare System and University of Pittsburgh who underwent coronary angiography between 1993 and 2005 while on PD and who had RRF measured prior to angiography were identified retrospectively. For patients without a postprocedure RRF recorded, medical records were reviewed to determine whether anuria had developed. The longer-term rate of loss of RRF among cases was compared with a composite rate of decline in RRF among cases before angiography and matched controls. RESULTS Twenty-nine patients with a mean preprocedure RRF of 4.4+/-3.2 ml/min/1.73m(2) were evaluated. Of these patients, 23 (79%) had postangiography RRF assessments (mean clearance 3.4+/-3.0 ml/min/1.73m(2)). One of the remaining six patients definitely became permanently anuric following angiography, one was lost to follow-up, and there was no postprocedure RRF assessment in four others. The rate of decline in RRF in the cases was similar to the composite rate (0.07 ml/min/1.73m(2)/month vs. 0.09 ml/min/1.73m(2)/month, p=0.53) CONCLUSION The risk for permanent anuria in patients on PD undergoing coronary angiography appears to be quite small. Patients who do not develop anuria following coronary angiography have the same gradual rate of loss of RRF as other patients on PD. Providers should be vigilant in protecting RRF in patients on PD undergoing coronary angiography.
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Affiliation(s)
- Steven D Weisbord
- Renal Section, Medical Specialty Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA.
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Lui SL. Article Commentary: Empirical Antibiotic Treatment for Peritoneal Dialysis-Related Peritonitis: Can “One Size” Fit All? Perit Dial Int 2007. [DOI: 10.1177/089686080702700111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sing Leung Lui
- Department of Medicine The University of Hong Kong
Tung Wah Hospital Hong Kong SAR, People's Republic of China
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Leppänen H, Metsärinne KP, Nikoskelainen J, Tertti R. Three-year analysis of microbial aetiology and antimicrobial susceptibilities of PD peritonitis. ACTA ACUST UNITED AC 2006; 38:645-9. [PMID: 16857609 DOI: 10.1080/00365540600606390] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The first-line antibiotic treatment of peritoneal dialysis (PD) peritonitis has to cover the most common causative microorganisms. Our aim was to analyse antimicrobial sensitivities of different empirical protocols for initial therapy of PD peritonitis. We analysed the aetiological microorganisms of PD peritonitis and their antimicrobial sensitivities during a 36-month period. Clinical characteristics of the cases were recorded. Altogether 86 PD peritonitides were diagnosed during the study period. In 58 cases, microbial cultures were positive with 72 different causative agents. 28 cases (33%) were culture-negative. Over-representation of icodextrin users was noted among the culture-negative cases. Staphylococcus aureus was the most frequent causative agent, often leading to severe course of illness. Of antimicrobial protocols for initial treatment of peritonitis tested in vitro, the combination of a first-generation cephalosporin and an aminoglycoside was superior to the combination of a first-generation cephalosporin and ceftazidime as well as to fluoroquinolone monotherapy but similar to the combination of vancomycin and ceftazidime. Based on antimicrobial sensitivities we continue using an aminoglycoside in the empirical treatment of PD peritonitis. In the present material, users of icodextrin PD fluid were over-represented among patients with culture-negative peritonitis.
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Affiliation(s)
- Heidi Leppänen
- Department of Internal Medicine, Turku University Central Hospital, Turku, Finland
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Abstract
Preserving residual renal function has always been the primary clinical goal for every nephrologist managing patients with chronic kidney disease. There is no reason why this important goal should not extend to patients with stage 5 chronic kidney disease receiving dialysis. Indeed, there is now clear evidence that preserving residual renal function remains important after the commencement of dialysis. Residual renal function contributes significantly to the overall health and well-being of dialysis patients. It not only provides small solute clearance but also plays an important role in maintaining fluid balance, phosphorus control, and removal of middle molecular uremic toxins, and shows strong inverse relationships with valvular calcification and cardiac hypertrophy in dialysis patients. Decline of residual renal function also contributes significantly to anemia, inflammation, and malnutrition in patients on dialysis. More importantly, the loss of residual renal function, especially in patients on peritoneal dialysis, is a powerful predictor of mortality. In addition, there is increasing evidence that residual renal and peritoneal dialysis clearance cannot be assumed to be equivalent qualitatively, thus indicating the need to preserve residual renal function in patients on dialysis. In this article, we will review evidence that residual renal function is important in dialysis patients (especially peritoneal dialysis) and outline potential strategies that may better preserve residual renal function in dialysis patients.
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Affiliation(s)
- A Y-M Wang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, China.
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Lui SL, Cheng SW, Ng F, Ng SY, Wan KM, Yip T, Tse KC, Lam MF, Lai KN, Lo WK. Cefazolin plus netilmicin versus cefazolin plus ceftazidime for treating CAPD peritonitis: effect on residual renal function. Kidney Int 2006; 68:2375-80. [PMID: 16221243 DOI: 10.1111/j.1523-1755.2005.00700.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED BACKGROUND. The International Society for Peritoneal Dialysis (ISPD) treatment guidelines for continuous ambulatory peritoneal dialysis (CAPD) peritonitis 2000 recommended the use of cefazolin plus ceftazidime as the initial empirical therapy in patients with residual renal function (RRF). However, this treatment regimen has not been compared with the conventional regimen of cefazolin plus netilmicin in prospective, randomized controlled trials. METHODS Stable CAPD patients who developed clinical evidence of peritonitis were randomized to receive intraperitoneal (i.p.) cefazolin plus netilmicin or cefazolin plus ceftazidime once daily in the long dwell for 14 days. For patients with RRF (>1 mL/minute) before entry into the study (N= 50), RRF and 24-hour urine volume were measured at days 1, 14, and 42 after commencement of i.p. antibiotic treatment. RESULTS One hundred and two patients were recruited into the study. The primary cure rates of i.p. cefazolin plus netilmicin and cefazolin plus ceftazidime were 66.7% and 64.7%, respectively. The overall cure rate for the 2 treatment regimens was 82.3% for both. Seven patients (14%) from each treatment group required removal of the dialysis catheters due to treatment failure. Relapse of peritonitis occurred in 2 patients (4%) in both treatment groups. Thirty-six patients with RRF at baseline achieved primary cure of their peritonitis by the assigned antibiotics. In this subgroup of patients, their RRF and daily urine volume showed significant reduction at day 14 and returned to near baseline values at day 42. The degree of reduction in RRF and urine volume did not differ significantly between the patients treated with cefazolin plus netilmicin and cefazolin plus ceftazidime. CONCLUSION Intraperitoneal cefazolin plus netilmicin and cefazolin plus ceftazidime have similar efficacy as empirical treatment for CAPD peritonitis. In CAPD patients with RRF, significant but reversible reduction in RRF and 24-hour urine volume could occur after an episode of peritonitis, despite successful treatment by i.p. antibiotics. The effect of i.p. cefazolin plus netilmicin, or i.p. cefazolin plus ceftazidime on RRF in CAPD patients with peritonitis does not appear to be different. Our findings do not support the routine use of cefazolin and ceftazidime as the empirical treatment for CAPD peritonitis.
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Affiliation(s)
- Sing Leung Lui
- Division of Nephrology, University Department of Medicine, Tung Wah Hospital, Hong Kong SAR, People's Republic of China.
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Elwell RJ, Manley HJ, Frye RF, Bailie GR. Pharmacokinetics of intraperitoneal cefazolin and ceftazidime coadministered to CAPD patients. Int J Artif Organs 2006; 28:808-16. [PMID: 16211531 DOI: 10.1177/039139880502800807] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Guidelines for empiric treatment of PD-related peritonitis published in 2000 recommend concurrent intraperitoneal (IP) cefazolin and ceftazidime. The pharmacokinetics (PK) of these agents combined have not been studied. This study was designed to determine the PK of combined IP cefazolin and ceftazidime in CAPD patients. DESIGN Prospective PK study in seven non-infected CAPD patients. PROCEDURES Patients had a peritoneal equilibration test (PET), then received one IP dose of cefazolin and ceftazidime (15 mg/kg each) co-administered over a 4-hour dwell, then performed three CAPD exchanges over the next 16 hours. Serum and dialysate samples collected over the 20-hour study period were assayed for drug concentrations by HPLC. OUTCOME MEASURES PK parameters. STATISTICAL METHODS Correlations were tested between PET and PK parameters using the Pearson-product correlation coefficient. MAIN FINDINGS Serum cefazolin and ceftazidime levels exceeded the minimum inhibitory concentrations for susceptible organisms (8 mg/L) throughout the 20 hour study period. Mean cefazolin and ceftazidime PK parameters included: bioavailability, 71% and 63%; elimination rate constant, 0.031 and 0.045 h -1 ; total clearance, 5.8 and 16.0 ml/min; peritoneal clearance, 1.6 and 3.9 ml/min; renal clearance, 2.3 and 3.9 ml/min, respectively. Predictive equations suggest that 1000 mg IP of cefazolin and of ceftazidime every 24 hours would produce average steady-state trough serum cefazolin and ceftazidime concentrations of 70 +/- 52 mg/L and 17 +/- 7 mg/L, respectively. There was no correlation between PET and PK parameters. CONCLUSIONS Co-administration did not adversely affect the PK of either agent. IP cefazolin and ceftazidime (15 mg/kg) produced adequate serum and dialysate concentrations in CAPD patients for 20 hours. PK predictions suggest that most patients would achieve adequate cefazolin and ceftazidime concentrations with 1000 mg IP once-daily. Anuric patients and those with significant residual renal function may require a more individualized approach.
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Affiliation(s)
- R J Elwell
- Department of Pharmacy Practice, Albany College of Pharmacy, 106 New Scotland Avenue, Albany, NY 12208, USA
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Bargman JM, Golper TA. The importance of residual renal function for patients on dialysis. Nephrol Dial Transplant 2005; 20:671-3. [PMID: 15755759 DOI: 10.1093/ndt/gfh723] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Joanne M Bargman
- University Health Network, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Affiliation(s)
- George R. Bailie
- Albany Nephrology Pharmacy (ANephRx) Group Albany College of Pharmacy Albany, New York and Nephrology Pharmacy Associates, Inc. Ann Arbor, Michigan, USA
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McCormick BB, Bargman JM. The implications of the ADEMEX study for the peritoneal dialysis prescription: the role of small solute clearance versus salt and water removal. Curr Opin Nephrol Hypertens 2003; 12:581-5. [PMID: 14564193 DOI: 10.1097/00041552-200311000-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review examines the results of the ADEMEX (Adequacy of Peritoneal Dialysis in Mexico) study in the context of other recent advances in peritoneal dialysis, and assesses the implication of this new knowledge for the optimal peritoneal dialysis prescription. RECENT FINDINGS The prospective randomized controlled ADEMEX study demonstrated no survival advantage of an increased dose of peritoneal small molecule clearance delivered by chronic ambulatory peritoneal dialysis. Coincident with this finding, there has been increasing awareness that many peritoneal dialysis patients are volume expanded, and that there are adverse cardiovascular consequences to this chronic overhydration. As a result there has been a shift away from interest in peritoneal small solute clearance with renewed interest in peritoneal removal of salt and water. There is also increasing evidence of the importance of residual renal function in maintaining euvolemia and as a prognostic indicator for survival. SUMMARY The ADEMEX study and subsequent investigations have changed the way we perceive the optimal peritoneal dialysis prescription. This has resulted in de-emphasis of peritoneal small molecule clearance and increased emphasis on clinical assessment of dialysis adequacy, preservation of residual renal function, and optimization of salt and water removal.
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Sherman RA. Briefly Noted. Semin Dial 2002. [DOI: 10.1111/j.1467-9590.2006.00345.x-i1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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