Outcomes of elderly peritoneal dialysis patients: 65-74 years old versus ≥ 75 years old

OBJECTIVE

To analyze the clinical data of elderly patients with peritoneal dialysis (PD) and compare patient and technique survival rates between Group 1 (65-74 years old) and Group 2 (≥75 years old).

METHODS

This retrospective study enrolled 296 elderly patients (≥65 years old) on maintenance PD who were admitted to the Peritoneal Dialysis Center of the Second Hospital of Soochow University. The patients were categorized by outcome into ongoing PD, changed to hemodialysis, renal recovery dialysis stopped, or death groups. The patients were divided into Group 1 (65-74 years old) and Group 2 (≥75 years old). Patient survival and technique survival rates were calculated by the Kaplan-Meier method. Factors associated with patient survival were analyzed using the Cox regression model.

RESULTS

There were 176 (59.5%) subjects in Group 1 and 120 (40.5%) subjects in Group 2. The primary causes of death were cardiovascular events, peritonitis, and other infections. The patient survival rates at 1, 3, and 5 years were 91.2%, 68.0%, and 51.3% in Group 1 and 76.8%, 37.5%, and 17.6% in Group 2 (p < 0.001, HR 0.387, 95% CI 0.282-0.530). There was no statistically significant difference in the technique survival rate between the two groups (p = 0.54).

CONCLUSION

The elderly PD patients in this cohort mostly died from cardiovascular events, with a higher patient survival rate in Group 1 and similar technique survival in both groups. Older age, lower prealbumin, higher creatinine, not being on activated vitamin D, and high Charlson's comorbidity index (CCI) score were independent risk factors for death.

Management of Type 2 Diabetes Mellitus and Kidney Failure in People with HIV-Infection in Africa: Current Status and a Call to Action

There is an increasing global burden of diabetes mellitus (DM) and chronic kidney disease (CKD), coupled with a high burden of people with HIV (PWH). Due to an increased lifespan on ART, PWH are now at risk of developing non-communicable diseases, including DM. Africa has the greatest burden of HIV infection and will experience the greatest increase in prevalence of DM over the next two decades. In addition, there is a rising number of people with CKD and progression to kidney failure. Therefore, there is an urgent need for the early identification and management of all 3 diseases to prevent disease progression and complications. This is particularly important in Africa for people with CKD where there is restricted or no access to dialysis and/or transplantation. This review focuses on the epidemiology and pathophysiology of the interaction between HIV infection and DM and the impact that these diseases have on the development and progression of CKD. Finally, it also aims to review the data on the management, which stems from the growing burden of all three diseases.

Survival Rates in Elderly Patients on Continuous Ambulatory Peritoneal Dialysis

Purpose

The present study aimed at evaluating the survival rate, its associated factors, and the causes of death in elderly patients undergoing continuous ambulatory peritoneal dialysis (CAPD) in Vietnam.

Patients and Methods

This is a retrospective, observational study conducted among patients aged ≥65 years who underwent CAPD at Thong Nhat Hospital, Ho Chi Minh City, Vietnam, from April 2012 to December 2020. The Kaplan-Meier method was used to calculate the cumulative survival rate, and the Log rank test was used to analyze the factors associated with the survival rate of patients.

Results

This study enrolled a total of 68 patients with a mean age of 71.93 ± 7.44 years at the initiation of CAPD. The most common complication among kidney failure patients was diabetic nephropathy (39.71%). The rate of concomitant cardiovascular diseases was 58.82%. The average survival rate was 45.59 ± 4.01 months. Peritonitis was the most common factor causing death (31.25%), followed by cardiovascular diseases (28.12%) and malnutrition (25%). The factors that impacted the survival rate included concomitant cardiovascular diseases, low serum albumin (<35 g/dL), and an indication of CAPD due to exhausted vascular access for hemodialysis at baseline. The main factor associated with a shorter survival time was concomitant cardiovascular diseases.

Conclusion

It is necessary to improve the survival time beyond 5 years for elderly patients undergoing CAPD, especially for those with concomitant cardiovascular diseases. Besides the prevention of peritonitis, adequate measures to protect from cardiovascular diseases and malnutrition will reduce the mortality rate in patients on CAPD.

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment

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.

Peritoneal Dialysis-Related Peritonitis: Rate, Clinical Outcomes and Patient Survival

Peritoneal dialysis-related peritonitis remains the major complication and primary challenge to the long-term success of peritoneal dialysis (PD). The study aimed to analyze the peritonitis rate, the cause, the outcomes, and the association of peritonitis with the survival of patients on peritoneal dialysis. Patient data were collected retrospectively from medical charts. A total of 96 patients received peritoneal dialysis in the PD center from 1 January 1999 to 31 December 2018. Episodes of peritonitis (n=159) were registered in 54 (56.3%) patients. The study population was divided into two groups, a group of patients (n=54) who experienced peritonitis and a group of patients free of peritonitis (n=42). The peritonitis rate was 0.47 episodes per patient year. The majority of causative microorganisms were gram-positive bacteria (53.5%). Outcomes of the episodes of peritonitis were resolved infection in 84.9% of episodes, catheter removal in 11.3% of episodes, and death in 3.8% of the episodes of peritonitis. A Kaplan-Meier analysis and log-rank test revealed that the group with peritonitis tended to survive significantly longer than the peritonitis-free group. A 67% reduction rate in the risk of patient mortality was observed for the peritonitis group compared with the peritonitis-free group (hazard ratio: 0.33, 95% CI 0.19-0.57, P=0.000). The prevention and management of PD-related infections, resulted in their worldwide reduction, supporting the use of PD as a first-line dialysis modality.

Are sex differences in the outcome of peritoneal dialysis explained by nurse-assistance? A cohort study with data from the RDPLF

BACKGROUND

We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes.

METHODS

This was a retrospective study using data from the French Language Peritoneal Dialysis Registry of incident PD patients between 2005 and 2016. Cox proportional hazard modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori.

RESULTS

Of the 14659 patients included, they were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men ((2926/5970 (49.1%) vs. 3357/8689 (38.7%)). In the multivariable analysis, women had a lower risk of transfer to HD (cause-specific hazard ratio(cs-HR): 0.82[95% confidence interval(CI): 0.77-0.88]), death (cs-HR: 0.90[95%CI: 0.85-0.95]), peritonitis (cs-HR: 0.82[95%CI: 0.78-0.87]), PD failure (cs-HR: 0.86[95%CI: 0.83-0.90]) and a lower chance of undergoing transplant (cs-HR: 0.83[95%CI: 0.77-0.90]) than men. There was a direct effect of sex on the risk of transfer to HD (cs-HR: 0.82[95%CI: 0.82-0.83]) with an indirect effect of nurse-assisted PD (cs-HR: 0.97[95%CI: 0.96-0.99]). Nurse-assisted PD had no indirect effect on the risk of peritonitis.

CONCLUSIONS

Our results suggest that compared with men, women have both a lower risk of transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Incremental peritoneal dialysis in incident end-stage kidney disease patients

BACKGROUND

This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre.

METHODS

ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed.

RESULTS

One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m². The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year.

CONCLUSIONS

Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Assisted peritoneal dialysis: a feasible KRT modality for frail older patients with end-stage kidney disease (ESKD)

Assisted PD is used as an alternative option for the growing group of frail, older ESKD patients unable to perform their own PD. This study was undertaken to investigate the outcomes of assisted PD in older patients by comparing assisted PD patients with self-care PD patients. This study included all patients aged 70 and above who started on PD in our hospital from 2009 to 2018. Patients were followed up until death, PD cessation or to the end of the study (December 31, 2019). Risk factors associated with mortality, peritonitis and technique failure were evaluated using both cause-specific hazards and subdistribution hazards models. 180 patients were enrolled, including 106 (58.9%) males with a median age of 77.5 (77.2-81.2) years. Among the 180 patients, 62 patients (34.4%) were assisted. Patients on assisted PD group were older, more likely to be female, more prevalent in DM and CVD, with a higher Charlson score than patients undergoing self-care PD (P all < 0.05). In the multivariable analysis, assisted patients had a comparable patient survival and peritonitis-free survival compared to self-care PD patients either in the Cox or in the FG models. According to a Cox model, the use of assisted PD was associated with a lower risk of technique failure (cs-HR 0.20, 95% CI 0.04-0.76), but the association lost its statistical significance in the Fine and Gray model. Our results suggest that assisted PD could be a safe and effective KRT modality for older ESKD patients who need assistance.

Two decades of analysis of peritonitis in peritoneal dialysis in Andalusia: Epidemiological, clinical, microbiological and progression aspects

BACKGROUND

This study focuses on the main complication associated with peritoneal dialysis, peritonitis. Its relevance derives from its high morbidity, the negative effect it has on the peritoneum as a dialysis membrane and its financial cost.

METHODS

Analytical, non-interventional, observational cohort study, whose main objective is the analysis of peritonitis in patients on peritoneal dialysis in Andalusia from 1 January 1999 to 31 December 2017, with a total of 2904 peritonitis cases. The database used is the Andalusian Autonomous Transplant Coordination Information System (SICATA).

OBJECTIVES

To ascertain how the rate of peritonitis is evolving in our community, analyse descriptive data pertaining to patients and peritonitis, ascertain the course of these infectious complications and analyse the factors that influence these cases of peritonitis and their outcomes: germ, hospitalisation and date.

RESULTS

The rate of peritonitis decreased progressively during the study period, from 0.7 peritonitis per patient in 1999 to 0.33 at the end of the period. Most infections were treated on an outpatient basis (72.5%). The most common germs were Gram-positive (55.9%), including coagulase-negative staphylococci (28.1%). Most cases of peritonitis progressed to healing (77.8%). The factors that significantly influence the need for hospitalisation and peritonitis progression were the causative germ and associated exit site infection.

CONCLUSIONS

In our population, the rate of peritonitis decreased progressively during the study period, meeting guideline recommendations.

Comparison of long-term outcomes between Chinese peritoneal dialysis patients with and without diabetes: A 10-year cohort study

AIMS

This study aimed to evaluate the long-term outcomes of peritoneal dialysis (PD) patients with and without diabetes in southern China.

METHODS

This retrospective and observational cohort study included all adult patients with end-stage renal disease (ESRD) who received PD in our center from January 2009 to December 2017 and were followed until December 2019. Clinical outcomes were compared by Kaplan-Meier survival analysis and cumulative incidence function, and risk factors were estimated using Cox regression analyses and competing risk models.

RESULTS

Of 401 patients receiving PD, 120 (29.9%) had type 2 diabetes mellitus (DM), and 281 (70.1%) did not have diabetes mellitus (NDM). Patients with DM were older and had more cardiovascular disease (CVD) morbidities than patients without DM. Kaplan-Meier analysis showed that patients with DM had shorter survival (Log-rank 3.215, P < 0.0001) compared with patients without DM. Patients with DM had a lower death-censored technique survival (Log-rank 2.029, P = 0.0180), however, there was no significant difference in peritonitis-free period (Log rank 1.375, P = 0.1133). These results were reproduced after taking competing events into account. Both on multivariate Cox analysis and on multivariate competing risk regression, diabetes was an independent predictor for increased mortality and technique failure, but not for peritonitis-free survival.

CONCLUSIONS

Patients undergoing PD with DM had increased risk of mortality and technique failure, and closer monitoring and additional focus in patients with DM treated by PD are, therefore, warranted.

Two decades of analysis of peritonitis in peritoneal dialysis in Andalusia: Epidemiological, clinical, microbiological and progression aspects

BACKGROUND

This study focuses on the main complication associated with peritoneal dialysis, peritonitis. Its relevance derives from its high morbidity, the negative effect it has on the peritoneum as a dialysis membrane and its financial cost.

METHODS

Analytical, non-interventional, observational cohort study, whose main objective is the analysis of peritonitis in patients on peritoneal dialysis in Andalusia from 1 January 1999 to 31 December 2017, with a total of 2,904 peritonitis cases. The database used is the Andalusian Autonomous Transplant Coordination Information System (SICATA).

OBJECTIVES

To ascertain how the rate of peritonitis is evolving in our community, analyse descriptive data pertaining to patients and peritonitis, ascertain the course of these infectious complications and analyse the factors that influence these cases of peritonitis and their outcomes: germ, hospitalisation and date.

RESULTS

The rate of peritonitis decreased progressively during the study period, from 0.7 peritonitis per patient in 1999 to 0.33 at the end of the period. Most infections were treated on an outpatient basis (72.5%). The most common germs were Gram-positive (55.9%), including coagulase-negative staphylococci (28.1%). Most cases of peritonitis progressed to healing (77.8%). The factors that significantly influence the need for hospitalisation and peritonitis progression were the causative germ and associated exit site infection.

CONCLUSIONS

In our population, the rate of peritonitis decreased progressively during the study period, meeting guideline recommendations.

Risk of Peritoneal Dialysis-Related Peritonitis in a Multi-Racial Asian Population

Background

Peritonitis is one of the most common complications of peritoneal dialysis (PD). Understanding the risk factors of peritonitis in a multi-racial Asian population may help to improve outcomes on PD.

Methods

We conducted a prospective observational study to identify risk factors for PD-related peritonitis over a 1-year period in 15 adult PD centers. All peritonitis episodes were independently adjudicated.

Results

A total of 1,603 participants with a mean age of 51.6 years comprising 52.7% females, 62.6% ethnic Malays, 27.0% Chinese, and 8.1% Indians were recruited. The overall peritonitis rate was 1 episode per 44.0 patient-months with 354 episodes recorded in 282 (17.6%) patients over 15,588 patient-months. Significant risk factors of peritonitis were severe obesity (incidence-rate ratio [IRR] 3.32, 95% confidence interval [CI]: 1.30, 8.45), hypoalbuminemia (IRR 1.61, 95% CI: 1.06, 2.46), Staphylococcus aureus nasal carriage (IRR 2.26, 95% CI: 1.46, 3.50), and use of Fresenius system (Fresenius Medical Care North America, Waltham, MA, USA) (IRR 2.49, 95% CI: 1.27, 4.89). The risk of peritonitis was lower in those on automated PD compared with standard PD (IRR 0.43, 95% CI: 0.25, 0.74), and in centers with a patient-staff ratio of 15 to 29.9 (IRR 0.67, 95% CI: 0.49, 0.90) and ≥ 30 (IRR 0.52, 95% CI: 0.34, 0.80). Prevalent patients and exit-site care with topical antibiotics were also protective against peritonitis. Peritonitis rates varied between racial groups. The IRRs of overall peritonitis and gram-positive peritonitis in Chinese versus other racial groups were 0.65 (95% CI: 0.46, 0.90) and 0.47 (95% CI: 0.24, 0.91), respectively.

Conclusions

Multiple patient, center, and PD-system factors influence the risk of peritonitis. In the Asian population, there are racial differences in the risk of peritonitis.

Comparison of peritoneal dialysis with hemodialysis on survival of diabetic patients with end-stage kidney disease: a meta-analysis of cohort studies

Aim: Renal replacement therapy was primary treatment for end stage kidney (ESRD) patients. Numbers of studies comparing peritoneal dialysis (PD) and hemodialysis (HD) yielded inconsistent results. The aim of this study was to assess the mortality risk between diabetic PD patients and those in HD.

Methods: We included cohort studies comparing the risk of death among diabetic ESRD patients who receiving peritoneal dialysis or hemodialysis by searching Medline and Embase. Overall estimates were calculated using the random-effects model.

Results: Seventeen studies were included in the meta-analyses. Mortality comparison between PD and HD in the diabetic ESRD patients showed PD significantly increased mortality rate (hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.10–1.30; I² = 89.1%). The overall HR using an intention-to-treat analysis was 1.23 with 95% CI (1.13 to 1.34). Meta-regression demonstrated PD patients from Asian country were associated with increase in mortality risk (coefficient = 0.270, SE = 0.112, p = .033).

Limitation: The high heterogeneity in our meta-analyses undermined the robustness of the findings.

Conclusion: ESRD patients with diabetes may benefit more from HD than PD.

Risk factors associated with outcomes of peritoneal dialysis in Taiwan: An analysis using a competing risk model

Peritoneal dialysis (PD) is one option for renal replacement therapy in patients with end-stage renal disease (ESRD). Maintenance of the PD catheter is an important issue for patient outcomes and quality of life. The aim of this retrospective cohort study is to clarify the risk factors of technique failure and outcomes at a single institute in Taiwan.The study enrolled ESRD patients who had received PD catheters in a tertiary hospital in northern Taiwan. Using a competing risks regression model, we reviewed clinical data and analyzed them in terms of the time to technical failure and clinical outcomes, including PD-related peritonitis and mortality.A total of 514 patients receiving PD between 2001 and 2013 were enrolled in the study. According to the multivariate analysis model, we found that diabetes mellitus was a risk factor for PD-related peritonitis (subdistribution hazard ratio [SHR] 1.47, 95% confidence interval [CI] 1.06-2.04, P = .021). Female gender and higher serum albumin levels were associated with lower risks of technique failure (SHR 0.67, 95% CI 0.48-0.94, P = .02; SHR 0.75, 95% CI 0.58-0.96, P = .023, respectively), but Gram-negative and polymicrobial infection increased the technique failure rate (SHR 1.68, 95% CI 1.08-2.61, P = .021; SHR 1.93, 95% CI 1.11-3.36, P = .02, respectively). Female gender was a risk factor associated with overall mortality (SHR 6.4, 95% CI 1.42-28.81, P = .016). Higher weekly urea clearance (Kt/V) and weekly creatinine clearance (WCCr) were associated with a lower risk of mortality (SHR 0.1, 95% CI 0.01-0.89, P = .04; SHR 0.97, 95% CI 0.96-0.99, P = .004, respectively).Diabetes mellitus is a risk factor contributing to PD-related peritonitis. Male patients and lower serum albumin levels were associated with higher rates of technique failure. Female gender, lower Kt/V, and WCCr are risk factors for overall mortality in PD patients.

Number of Daily Peritoneal Dialysis Exchanges and Mortality Risk in a Chinese Population

Background

We report outcomes on ≥ 4 compared with < 4 exchanges/day in a Chinese cohort on continuous ambulatory peritoneal dialysis (CAPD).

Methods

Data were sourced from the Baxter (China) Investment Co. Ltd Patient Support Program database, comprising an inception cohort commencing CAPD between 1 January 2005 and 13 August 2015. We used cause-specific Cox proportional hazards and Fine-Gray competing risks (kidney transplantation, change to hemodialysis) models to estimate mortality risk on ≥ 4 compared with < 4 exchanges/day. We matched or adjusted for age, gender, employment, insurance, primary renal disease, size of CAPD program, year of dialysis inception, and treatment center.

Results

We modeled 100,022 subjects from 1,177 centers over 239,876 patient-years. Of these subjects, 43,185 received < 4 exchanges/day and 56,837 ≥ 4 exchanges/day. The proportion of patients on < 4 exchanges/day varied widely between centers. Those on < 4 exchanges/day were significantly older, more often female, of unknown employment, and from rural China. In the various models, ≥ 4 exchanges/day was associated with a significantly lower risk of death by 30% – 35% compared with < 4 exchanges/day. This beneficial effect was greatest in younger and rural patients.

Conclusions

In this Chinese CAPD cohort, ≥ 4 exchanges/day was associated with significantly lower mortality risk than < 4 exchanges/day. Analyses are limited by residual confounding from unavailability of important prognostic covariates (e.g., comorbidity, socioeconomic factors) and data on residual renal function, peritoneal clearance, and transport status with which to judge the clinical appropriateness of CAPD prescription. Nonetheless, our study indicates this area as a high priority for further detailed study.

What PD Research in China Tells Us

Peritoneal dialysis (PD) was introduced in China later than in most Western countries, and PD research activity was quite limited until the 1990s. However, in the 2000s, and even more so during the last decade, there has been an unsurpassed increase in the number of PD patients, paralleled by a substantial increase in PD research activity reflected by an increasing number of PD papers from China. In this brief review, we describe some of the factors that may explain the dramatic developments in PD research in mainland China, such as the focus on basic research using scientific approaches that subsequently could be applied also in clinical studies. Another important factor was the growing interactions with international PD research centers in Hong Kong and in Western countries. Thanks to strong support from Chinese national and regional funding sources, a growing number of young Chinese researchers went to key international PD centers to learn about novel advanced research techniques. This paved the way for long-lasting, productive collaborations with benefits also for the foreign host institutions. Finally, we present some current research projects, including basic research that may contribute to the understanding of mechanisms behind complications such as peritonitis, and clinical projects aiming at improving PD management guidelines and better understanding of the potential of PD in China. Because of the size of the PD population, now the largest in the world, and the increasing number, and quality, of researchers in the PD field, PD research in China is destined to be a major contributor to advancements in PD in the near future.

Benefit of an operating vehicle preventing peritonitis in peritoneal dialysis patients: a retrospective, case-controlled study

BACKGROUND

Peritonitis, which is one of the leading complications of peritoneal dialysis (PD) worldwide, severely affected morbidity and mortality of the PD patients. Although many efforts have been made to prevent PD-related peritonitis, it seems impossible to prevent it completely. Many causes have been reported to lead to peritonitis, and contamination during bag exchange is one of the important risk factors for peritonitis.

METHODS

Here, we introduce an operating vehicle, which we invented to provide a sterile and safe space for bag exchange. A single-center, retrospective, case-control study was undertaken to determine whether this operating vehicle has a protective role in preventing peritonitis. In total, 462 continuous ambulatory peritoneal dialysis patients were included in this study from October 2014 to March 2017. According to their personal will, these patients chose to use operating vehicle or traditional method during their bag exchange. The demographic, clinical and laboratory data of these patients in the two groups were collected, analyzed and compared.

RESULTS

Of 462 patients with home dialysis, operating vehicle group consisted of 61 patients, and control group consisted of 401 patients. In the control group, over 677 patient-years, peritonitis occurred in 69 of 401 patients (17.2%), while in the operating vehicle group, over 60 patient-years, only 4 of 61 patients (6.6%) had episodes of peritonitis. The number of patients suffered from peritonitis was significantly decreased in the operating vehicle group (P = 0.034). Besides, there were a total of 99 episodes of peritonitis, and the rate was 1 episode every 7.2 patient-years in control group and 1 episode every 12 patient-years in the operating vehicle group. There was significant difference between the two groups (0.013). Positive dialysate cultures were obtained in majority of the peritonitis episodes (60.6%).

CONCLUSION

Operating vehicle might help to reduce PD-related peritonitis by preventing contamination during bag exchange. Further studies are still needed to demonstrate the protective role of the operating vehicle in preventing peritonitis.

Six-minute walk test predicts all-cause mortality and technique failure in ambulatory peritoneal dialysis patients

AIM

This study investigated the associated factors of 6-min walk test (6MWT) and its predictive value of outcome in patients undergoing peritoneal dialysis (PD).

METHODS

This is a single centre prospective observational cohort study. Stable ambulatory PD patients in our centre between 1 May 2010 and 30 April 2011 were enrolled in this study. All included subjects performed 6MWT, and 6-min walk distances (6MWDs) were recorded. Patients were divided into two groups according to 6MWD and prospectively followed up until death, cessation of PD or to the end of the study (30 September 2012).

RESULTS

A total of 145 patients were enrolled, including 63 (43%) males. Multiple stepwise regression showed that age (β = -0.295, P = 0.001), diastolic blood pressure (DBP) (β = 0.292, P = 0.001), left ventricular ejection fraction (LVEF) (β = 0.198, P = 0.019) were independently associated with lower 6MWD. By the end of the study, six (8%) patients died in long 6MWD group while 15 (20%) died in the short 6MWD group, a significantly lower patient survival was observed in short 6MWD group (Log-rank = 4.983, P = 0.026). Patients with short 6MWD also showed inferior technique survival (Log-rank = 4.838, P = 0.028). There was no significant difference in peritonitis-free survival between the two groups (Log-rank = 0.801, P = 0.371). However, more patients in short 6MWD group had been transferred to hemodialysis due to peritonitis (25% vs 4.2%, P = 0.013).

CONCLUSION

Age, diastolic blood pressure, LVEF are independent associated factors of 6MWD in patients undergoing PD. Having the advantages of easy applicability and safety, 6MWT may be proposed as an important predictor of outcome in ambulatory PD patients.

Single Daily Icodextrin Exchange as Initial and Solitary Therapy

Background

Incremental dialysis utilizes gradually increasing dialysis doses in response to declines in residual kidney function, and it is the preferred renal replacement therapy for patients who have just transitioned to end-stage renal disease (ESRD). Incremental peritoneal dialysis (PD) may impose fewer restrictions on patients’ lifestyle, help attenuate lifetime peritoneal and systemic exposure to glucose and its degradation products, and minimize connections that could compromise the sterile fluid path. In this study, we utilized a 3-pore kinetic model to assess fluid and solute removal during single daily icodextrin treatments for patients with varying glomerular filtration rates (GFR).

Methods

Single icodextrin exchanges of 8 to 16 hours using 2- and 2.5-L bag volumes were simulated for different patient transport types (i.e., high to low) to predict daily peritoneal ultrafiltration (UF), daily peritoneal sodium removal, and weekly total (peritoneal + residual kidney) Kt/V (Kt/VTotal) for patients with residual renal GFRs ranging from 0 to 15 mL/min/1.73 m2.

Results

Daily peritoneal UF varied from 359 to 607 mL, and daily peritoneal Na removal varied from 52 to 87 mEq depending on length of icodextrin exchange and bag volume. Both were effectively independent of patient transport type. All but very large patients (total body water [TBW] > 60 L) were predicted to achieve adequate dialysis (Kt/VTot al ≥ 1.7) with a GFR of 10 mL/min/1.73 m2, and small patients (TBW: 30 L) were predicted to achieve adequate dialysis with a GFR of 6 mL/min/1.73 m2.

Conclusions

A single daily icodextrin exchange can be tailored to augment urea, UF, and Na removal in patients with sufficient residual kidney function (RKF). A solitary icodextrin exchange may therefore be reasonable initial therapy for some incident ESRD patients.

Impact of early-onset peritonitis on mortality and technique survival in peritoneal dialysis patients

Background

Early onset peritonitis (EOP) is not uncommon in peritoneal dialysis patients. We aimed to compare the prognosis of EOP and non-EOP peritoneal dialysis patients.

Methods

This study included subjects that underwent PD from January 1, 2004 to July 31, 2013. Patient characteristics were collected. EOP was defined as peritonitis occurring within 6 months after initiation of PD. Patient and technique survival were compared between EOP and non-EOP patients using Cox regression analyses.

Results

In total, 189 subjects were included in this study. Patients were divided into EOP (n = 55) and non-EOP groups (n = 134). There was no significant difference in the causative organisms of peritonitis between the two groups. After adjusting for age, diabetes status, serum albumin level and residual renal function, the multivariable Cox regression model revealed that EOP was an independent risk factor for patient mortality (HR 2.03, RI 1.09–3.80, p = 0.026), technique failure (HR 1.69, RI 1.12–2.87, p = 0.015) and total survival (HR 1.73, RI 1.12–2.68, p = 0.013).

Conclusions

EOP was identified as an independent risk factor for mortality and technique failure in peritoneal dialysis patients.

Technique failure in Korean incident peritoneal dialysis patients: a national population-based study

Background

Technique failure is an important issue for peritoneal dialysis (PD) patients. In this study, we aimed to analyze technique failure rate in detail and to determine the predictors for technique failure in Korea.

Methods

We identified all patients who had started dialysis between January 1, 2005, and December 31, 2008, in Korea, using the Korean Health Insurance Review and Assessment Service database. A total of 7,614 PD patients were included, and the median follow-up was 24.9 months.

Results

The crude incidence rates of technique failure in PD patients were 54.1 per 1,000 patient-years. The cumulative 1-, 2-, and 3-year technique failure rates of PD patients were 4.9%, 10.3%, and 15.6%, respectively. However, those technique failure rates by Kaplan–Meier analysis were overestimated compared with the values by competing risks analysis, and the differences increased with the follow-up period. In multivariate analyses, diabetes mellitus and Medical Aid as a crude reflection of low socioeconomic status were independent risk factors in both the Cox proportional hazard model and Fine and Gray subdistribution model. In addition, cancer was independently associated with a lower risk of technique failure in the Fine and Gray model.

Conclusion

Technique failure was a major concern in patients initiating PD in Korea, especially in diabetic patients and Medical Aid beneficiaries. The results of our study offer a basis for risk stratification for technique failure.

Impact of dialysis modality on technique survival in end-stage renal disease patients

BACKGROUND/AIMS

This study analyzed the risk factors for technique survival in dialysis patients and compared technique survival rates between hemodialysis (HD) and peritoneal dialysis (PD) in a prospective cohort of Korean patients.

METHODS

A total of 1,042 patients undergoing dialysis from September 2008 to June 2011 were analyzed. The dialysis modality was defined as that used 90 days after commencing dialysis. Technique survival was compared between the two dialysis modalities, and the predictive risk factors were evaluated.

RESULTS

The dialysis modality was an independent risk factor predictive of technique survival. PD had a higher risk for technique failure than HD (hazard ratio [HR], 10.8; 95% confidence interval [CI], 1.9 to 62.0; p = 0.008) during a median follow-up of 11.0 months. In the PD group, a high body mass index (BMI) was an independent risk factor for technique failure (HR, 1.3; 95% CI, 1.0 to 1.8; p = 0.036). Peritonitis was the most common cause of PD technique failure. The difference in technique survival between PD and HD was more prominent in diabetic patients with a good nutritional status and in non-diabetic patients with a poor nutritional status.

CONCLUSIONS

In a prospective cohort of Korean patients with end-stage renal disease, PD was associated with a higher risk of technique failure than HD. Diabetic patients with a good nutritional status and non-diabetic patients with a poor nutritional status, as well as patients with a higher BMI, had an inferior technique survival rate with PD compared to HD.

Safety and effectiveness evaluation of a domestic peritoneal dialysis fluid packed in non-PVC bags: study protocol for a randomized controlled trial

BACKGROUND

Peritoneal dialysis is an important type of renal replacement therapy for uremic patients. In peritoneal dialysis, fluids fill in and flow out of the abdominal cavity three to five times per day. Usually, the fluid is packed in a polyvinyl chloride (PVC) bag. Safety concerns have arisen over di-(2-ethylhexyl) phthalate, which is essential in the formation of PVC materials. In 2011, the National Development and Reform Commission of China released a catalog of industrial structural adjustments, mandating the elimination of PVC bags for intravenous infusion and food containers. Although bags for peritoneal dialysis fluid were not included in the elimination list, several manufacturers began to develop new materials for fluid bags. HUAREN peritoneal dialysis fluid consists of the same electrolytes and buffer agent as in Baxter fluid, but is packed in bags that do not contain PVC. This multicenter randomized controlled trial was designed to compare peritoneal dialysis fluid packed in non-PVC-containing and PVC-containing bags. Further, the study sought to determine the proper dose of peritoneal dialysis fluid and the actual survival rates of Chinese patients undergoing peritoneal dialysis.

METHODS/DESIGN

The study participants are adults undergoing continuous ambulatory peritoneal dialysis for 30 days to 6 months. All eligible patients are randomized (1:1) to peritoneal dialysis with Baxter and HUAREN dialysis fluids (initial dose, 6 l/day), with dosages adjusted according to a unified protocol. The primary outcomes are the 1-, 2-, 3-, 4-, and 5-year overall survival rates. Secondary outcome measures include technique survival rates, reductions in estimated glomerular filtration rate, nutritional status, quality of life, cardiovascular events, medical costs and drop-out rates. Safety outcome measures include adverse events, changes in vital signs and laboratory parameters, peritonitis, allergies, and quality of products.

DISCUSSION

This study is the first to evaluate the long-term safety and effectiveness of a non-PVC packed peritoneal dialysis fluid. The effects of plasticizer on patient long-term survival will be determined. The characteristics of Chinese patients undergoing peritoneal dialysis will be determined, including proper dose, technique survival rates, patient survival rates, and medical costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01779557 .

A Global Overview of the Impact of Peritoneal Dialysis First or Favored Policies: An Opinion

Given the ever-increasing burden of end-stage renal disease (ESRD) in a global milieu of limited financial and health resources, interested parties continue to search for ways to optimize dialysis access. Government and payer initiatives to increase access to renal replacement therapies (RRTs), particularly peritoneal dialysis (PD) and hemodialysis (HD), may have meaningful impacts from clinical and health-economic perspectives; and despite similar clinical and humanistic outcomes between the two dialysis modalities, PD may be the more convenient and resource-conscious option. This review assessed country-specific PD-First/Favored policies and their associated background, implementation, and outcomes. It was found that barriers to policy-implementation are broadly associated with government policy, economics, provider or healthcare professional education, modality-related factors, and patient-related factors. Notably, the success of a given country's PD-Favored policy was inversely associated with the extent of HD infrastructure. It is hoped that this review will provide a foundation across countries to share lessons learned during the development and implementation of PD-First/Favored policies.

Continuous ambulatory peritoneal dialysis in Limpopo province, South Africa: predictors of patient and technique survival

♦

INTRODUCTION AND AIM

Continuous ambulatory peritoneal dialysis (CAPD) is not a frequently used modality of dialysis in many parts of Africa due to several socio-economic factors. Available studies from Africa have shown a strong association between outcome and socio-demographic variables. We sought to assess the outcome of patients treated with CAPD in Limpopo, South Africa. ♦

METHODS

This was a retrospective study of 152 patients treated with CAPD at the Polokwane Kidney and Dialysis Centre (PKDC) from 2007 to 2012. We collected relevant demographic and biochemical data for all patients included in the study. A composite outcome of death while still on peritoneal dialysis (PD) or CAPD technique failure from any cause requiring a change of modality to hemodialysis (HD) was selected. The peritonitis rate and causes of peritonitis were assessed from 2008 when all related data could be obtained. ♦

RESULTS

There were 52% males in the study and the average age of the patients was 36.8 ± 11.4 years. Unemployment rate was high (71.1%), 41.1% had tap water at home, the average distance travelled to the dialysis center was 122.9 ± 78.2 kilometres and half the patients had a total income less than USD ($)180 per month. Level of education, having electricity at home, having tap water at home, body mass index (BMI), serum albumin and hemoglobin were significantly different between those reaching the composite outcome and those not reaching it (p < 0.05). The overall peritonitis rate was 0.82/year with 1-year, 2-year and 5-year survival found to be 86.7%, 78.7% and 65.3% (patient survival) and 83.3%, 71.7% and 62.1% (technique survival). Predictors of the composite outcome were BMI (p = 0.011), serum albumin (p = 0.030), hemoglobin (p = 0.002) and more than 1 episode of peritonitis (p = 0.038). ♦

CONCLUSION

Treatment of anemia and malnutrition as well as training and re-training of CAPD patients and staff to prevent recurrence of peritonitis can have positive impacts on CAPD outcomes in this population.

Impact of continuous quality improvement initiatives on clinical outcomes in peritoneal dialysis

OBJECTIVE

We evaluated the role of a quality improvement initiative in improving clinical outcomes in peritoneal dialysis (PD).

METHODS

In a retrospective analysis of 6 years of data from a hospital registry, the period between 1 July 2005 and 30 June 2008 (control group) provided baseline data from before implementation of systemic outcomes monitoring, and the period between 1 July 2008 and 30 June 2011 [continuous quality improvement (CQI) group] represented the time when a CQI program was in place. Peritonitis incidence, patient and technique survival, cardiovascular status, causes of death, and drop-out were compared between the groups.

RESULTS

In the 370 patients of the CQI group and the 249 patients of the control group, the predominant underlying kidney diseases were chronic glomerulonephritis and diabetic nephropathy. After implementation of the CQI initiative, the peritonitis rate declined to 1 episode in 77.25 patient-months from 1 episode in 22.86 patient-months. Ultrasound parameters of cardiac structure were generally unchanged in the CQI group, but significant increases in cardiothoracic ratio and interventricular septal thickness were observed in the control group (both p < 0.05). Patient survival at 1, 2, and 3 years was significantly higher in the CQI group (97.3%, 96.3%, and 96.3% respectively) than in the control group (92.6%, 82.4%, and 67.3% respectively, p < 0.001). Implementation of the CQI initiative also appeared to significantly improve technique survival rates: 95.6%, 92.6%, and 92.6% in the CQI group compared with 89.6%, 79.2%, and 76.8% in the control group (p < 0.001) after 1, 2, and 3 years respectively.

CONCLUSION

Integration of a CQI process into a PD program can significantly improve the quality of therapy and its outcomes.

Key factors for a high-quality peritoneal dialysis program--the role of the PD team and continuous quality improvement

The proportion of end-stage renal disease (ESRD) patients on peritoneal dialysis (PD) has increased very fast in China over the last decade. Renji Hospital, affiliated with Shanghai Jiaotong University School of Medicine, is a recognized high-quality PD unit with a high PD utilization rate, excellent patient and technique survival (1-year and 5-year patient survival rate of 93% and 71%, and 1-year and 5-year technique survival of 96% and 82%, respectively), low peritonitis rate and a well-documented good quality of life of the treated patients. We believe that a dedicated and experienced PD team, a structured patient training program, continuous patient support, establishing and utilizing standardized protocols, starting PD with low dialysis dose, monitoring key performance indicators (KPIs), and continuous quality improvement (CQI) are the key factors underlying this successful PD program.

Role of a center of excellence program in improving the quality of peritoneal dialysis--a Chinese experience

Improving the quality of peritoneal dialysis (PD) in areas with a rapid increase in PD patient numbers constitutes the most significant PD challenge in China. Here, we share our experience of implementing a quality improvement program in 8 PD centers, with guidance from matched experienced centers.

Impact of break-in period on the short-term outcomes of patients started on peritoneal dialysis

OBJECTIVES

Peritoneal dialysis (PD) is one of the first-line modalities of renal replacement therapy in patients with end-stage renal disease. Guidelines recommended a break-in period of at least 2 weeks before full PD start. However, the optimal duration of the break-in period is still unclear. In the present study, we investigated the effect of various break-in periods on short-term outcomes in patients on PD. ♢

METHODS

All patients who underwent Tenckhoff catheter implantation and initiated PD in Renji Hospital, Shanghai Jiao Tong University School of Medicine, between 1 January 2001 and 31 December 2010 were included. Patients were grouped according to the duration of their break-in period: 7 days or less (BI ≤ 7), 8 - 14 days (BI8-14), and more than 14 days (BI>14). Kaplan-Meier curves and log-rank tests were used to compare short-term outcomes in the various groups. ♢

RESULTS

Our study enrolled 657 patients (44.5% men), of whom 344, 137, and 176 patients were in the respective break-in groups. Compared with BI>14 patients, BI ≤ 7 patients had a lower estimated glomerular filtration rate (5.34 ± 1.86 mL/min/1.73 m(2) vs 6.55 ± 1.71 mL/min/1.73 m(2), p < 0.001) and lower serum albumin (33.29 ± 5.36 g/L vs 36.64 ± 5.40 g/L, p < 0.001). The incidence of mechanical complications during the first 6 months was significantly higher in BI ≤ 7 patients than in BI>14 patients (8.4% vs 1.7%, p = 0.004). However, we observed no significant differences between the three groups with respect to the prevalence of catheter dysfunction requiring surgical intervention (p > 0.05). Logistic regression analysis showed that BI ≤ 7 [relative risk: 4.322; 95% confidence interval (CI): 1.278 to 14.608; p = 0.019] was an independent predictor of catheter dysfunction, but not of catheter dysfunction requiring surgical intervention (p > 0.05). Catheter dysfunction [hazard ratio (HR): 20.087; 95% CI: 7.326 to 55.074; p < 0.001] and peritonitis (HR: 4.533; 95% CI: 1.748 to 11.751; p = 0.002) were risk factors for technique failure during the first 6 months, but BI ≤ 7 was not correlated with technique failure. ♢

CONCLUSIONS

Patients starting PD with a break-in period of less than 1 week might experience a minor increased risk of mechanical complications, but no major effect on technique survival.

Peritoneal dialysis in China: meeting the challenge of chronic kidney failure

Due to limited medical and economic resources, particularly in the countryside and remote areas, the proportion of individuals with end-stage kidney disease who are treated with dialysis in China is only about 20%. For the rest, renal replacement therapy currently is not available. Peritoneal dialysis (PD) has been developed and used for more than 30 years in China to treat patients with end-stage kidney disease. Several national PD centers of first-rate scale and quality have sprung up, but the development of PD varies widely among geographic regions across China. The Chinese government has dedicated itself to continually increasing the coverage and level of medical service for patients with end-stage kidney disease. Under the guidance of the government and because of promotion by kidney care professionals, presently there are more than 40,000 prevalent PD patients in China, representing approximately 20% of the total dialysis population. Recently, a National Dialysis Unit Training Program for countywide hospitals has been initiated. Through the efforts of programs like this, we believe that awareness of PD and advances in the underlying technology will benefit more patients with end-stage kidney disease in China.

Implementation of a continuous quality improvement program reduces the occurrence of peritonitis in PD

OBJECTIVE

To investigate the causes of peritonitis in patients with peritoneal dialysis (PD) using continuous quality improvement (CQI) to develop effective interventions and reduce the occurrence of peritonitis.

METHODS

A quality control team consisting of 10 members, including the department head, four nephrologists and four nurses, all specialized in PD care, and the head nurse, was established at the Peritoneal Dialysis Center of the Third Xiangya Hospital of Central South University. All patients with peritonitis occurring between 1 July 2010 and 31 December 2011 (pre-CQI period) were analyzed and compared with data obtained between January 2012 (implementation of CQI) and March 2013 to investigate possible causes of peritonitis and to develop corresponding interventions. Fishbone analysis, including laboratory parameters, was carried out monthly.

RESULTS

Gastrointestinal tract dysfunction, nonstandard procedures and malnutrition were found to be the top three risk factors for peritonitis. Gastrointestinal tract dysfunction was the likely cause of peritonitis in 42.8% of the subjects before CQI and 36.0% after CQI (p<0.05). Nonstandard procedures were the cause of peritonitis in 33.3% of the subjects before CQI and 24.0% after CQI (p<0.05). The overall incidence of peritonitis reduced from once every 40.1 patient months before the CQI to once every 70.8 patient months after CQI (p<0.05). The incidence of Gram-positive bacteria peritonitis reduced from once every 96.9 patients per month before CQI to once every 209.1 patient months after CQI (p<0.05), whereas the incidence of Gram-negative bacteria peritonitis reduced from once every 234.2 patient months before CQI to once every 292.8 patient months after CQI.

CONCLUSION

CQI can effectively reduce the occurrence of PD-related peritonitis.

Outcomes of peritoneal dialysis patients and switching to hemodialysis: a competing risks analysis

BACKGROUND

We performed a review of a large incident peritoneal dialysis cohort to establish the impact of current practice and that of switching to hemodialysis.

METHODS

Patients starting peritoneal dialysis between 2004 and 2010 were included and clinical data at start of dialysis recorded. Competing risk analysis and Cox proportional hazards model with time-varying covariate (technique failure) were used.

RESULTS

Of 286 patients (median age 57 years) followed for a median of 24.2 months, 76 were transplanted and 102 died. Outcome probabilities at 3 and 5 years respectively were 0.69 and 0.53 for patient survival (or transplantation) and 0.33 and 0.42 for technique failure. Peritonitis caused technique failure in 42%, but ultrafiltration failure accounted only for 6.3%. Davies comorbidity grade, creatinine and obesity (but not residual renal function or age) predicted technique failure. Due to peritonitis deaths, technique failure was an independent predictor of death hazard. When successful switch to hemodialysis (surviving more than 60 days after technique failure) and its timing were analyzed, no adverse impact on survival in adjusted analysis was found. However, hemodialysis via central venous line was associated with an elevated death hazard as compared to staying on peritoneal dialysis, or hemodialysis through a fistula (adjusted analysis hazard ratio 1.97 (1.02 - 3.80)).

CONCLUSIONS

Once the patients survive the first 60 days after technique failure, the switch to hemodialysis does not adversely affect patient outcomes. The nature of vascular access has a significant impact on outcome after peritoneal dialysis failure.

Predictors of peritonitis and the impact of peritonitis on clinical outcomes of continuous ambulatory peritoneal dialysis patients in Taiwan--10 years' experience in a single center

OBJECTIVE

Peritoneal dialysis (PD) has become more prevalent as a treatment modality for end-stage renal disease, and peritonitis remains one of its most devastating complications. The aim of the present investigation was to examine the frequency and predictors of peritonitis and the impact of peritonitis on clinical outcomes. ♢

METHODS

Our retrospective observational cohort study enrolled 391 patients who had been treated with continuous ambulatory PD (CAPD) for at least 90 days. Relevant demographic, biochemical, and clinical data were collected for an analysis of CAPD-associated peritonitis, technique failure, drop-out from PD, and patient mortality. ♢

RESULTS

The peritonitis rate was 0.196 episodes per patient-year. Older age (>65 years) was the only identified risk factor associated with peritonitis. A multivariate Cox regression model demonstrated that technique failure occurred more often in patients experiencing peritonitis than in those free of peritonitis (p < 0.001). Kaplan-Meier analysis revealed that the group experiencing peritonitis tended to survive longer than the group that was peritonitis-free (p = 0.11). After multivariate adjustment, the survival advantage reached significance (hazard ratio: 0.64; 95% confidence interval: 0.46 to 0.89; p = 0.006). Compared with the peritonitis-free group, the group experiencing peritonitis also had more drop-out from PD (p = 0.03). ♢

CONCLUSIONS

The peritonitis rate was relatively low in the present investigation. Elderly patients were at higher risk of peritonitis episodes. Peritonitis independently predicted technique failure, in agreement with other reports. However, contrary to previous studies, all-cause mortality was better in patients experiencing peritonitis than in those free of peritonitis. The underlying mechanisms of this presumptive "peritonitis paradox" remain to be clarified.

Prognostic factors of all-cause mortalities in continuous ambulatory peritoneal dialysis: a cohort study

Background

The role of small solute clearance on mortalities in patients with CAPD has been controversial. We therefore conducted a study with 3 years' follow up in adult patients who participated in the CAPD-first policy.

Methods

There were 11,523 patients with end-stage renal disease who participated in the CAPD-first policy between 2008 and 2011. Among them, 1,177 patients were included in the retrospective cohort study. A receiver operating characteristic curve was applied to calibrate the cutoffs of tKt/V, rKt/V and tCrcl. Kaplan-Meier and Cox-regression models with time varying covariates were applied to estimate overall death rate, probability of death and prognosis, respectively.

Results

The cutoffs of rKt/V and tKt/V were 0.25 and 1.75, respectively. The Cox regression suggested that the higher these clearance parameters, the lower the risks of death after adjusting for covariables. The risks of death for those above these cutoffs were 57% (HR = 0.43, 95% CI: 0.31, 0.60) and 29% (HR = 0.71, 95% CI: 0.52, 0.98) lower for rKt/V and tKt/V, respectively. Age, serum albumin, hemoglobin, systolic blood pressure, and ultra-filtration volume significantly affected the mortality outcome.

Conclusions

Our study suggested that the cutoffs of 0.25 and 1.75 for rKt/V and tKt/V might be associated with mortality in CAPD patients. A minimum tKt/V of 1.75 should be targeted, but increased dialysis dosage to achieve tKt/V > 2.19 adds no further benefit. Serum albumin, hemoglobin, SBP, and UF volume are also associated with mortality. However, our study may face with selection and other unobserved confounders, so further randomized controlled trials are required to confirm these cutoffs.

Recent peritonitis associates with mortality among patients treated with peritoneal dialysis

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.

Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients

We analyzed data from the Australia and New Zealand Dialysis and Transplant Registry for 1 October 2003 to 31 December 2008 with the aim of describing the nature of peritonitis, therapies, and outcomes in patients on peritoneal dialysis (PD) in Australia. At least 1 episode of PD was observed in 6639 patients. The overall peritonitis rate was 0.60 episodes per patient-year (95% confidence interval: 0.59 to 0.62 episodes), with 6229 peritonitis episodes occurring in 3136 patients. Of those episodes, 13% were culture-negative, and 11% were polymicrobial. Gram-positive organisms were isolated in 53.4% of single-organism peritonitis episodes, and gram-negative organisms, in 23.6%. Mycobacterial and fungal peritonitis episodes were rare. Initial antibiotic therapy for most peritonitis episodes used 2 agents (most commonly vancomycin and an aminoglycoside); in 77.2% of episodes, therapy was subsequently changed to a single agent. Tenckhoff catheter removal was required in 20.4% of cases at a median of 6 days, and catheter removal was more common in fungal, mycobacterial, and anaerobic infections, with a median time to removal of 4 - 5 days. Peritonitis was the cause of death in 2.6% of patients. Transfer to hemodialysis and hospitalization were frequent outcomes of peritonitis. There was no relationship between center size and peritonitis rate. The peritonitis rate in Australia between 2003 and 2008 was higher than that reported in many other countries, with a particularly higher rate of gram-negative peritonitis.

Impact of dialysis modality on survival after kidney transplant failure

BACKGROUND AND OBJECTIVES

An increasing number of patients are returning to dialysis after allograft loss (DAGL). These patients are at a higher mortality risk compared with incident ESRD patients. Among transplant-naïve patients, those treated with peritoneal dialysis (PD) enjoy an early survival advantage compared with those treated with hemodialysis (HD), but this advantage is not sustained over time. Whether a similar time-dependent survival advantage exists for PD-treated patients after allograft loss is unclear and may impact dialysis modality selection in these patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We identified 2110 adult patients who initiated dialysis after renal transplant failure between January 1991 and December 2005 from The Canadian Organ Replacement Register. Multivariable regression analysis was used to evaluate the impact of initial dialysis modality on early (2 years), late (after 2 years), and overall mortality using an intention-to-treat approach.

RESULTS

After adjustment, there was no difference in overall survival between HD- and PD-treated patients (hazard ratio((HD:PD)), 1.05; 95% confidence interval, 0.85 to 1.31), with similar results seen for both early and late survival. Superior survival was seen in more contemporary cohorts of patients returning to DAGL.

CONCLUSIONS

The use of PD compared with HD is associated with similar early and overall survival among patients initiating DAGL. Differences in both patient characteristics and predialysis management between patients returning to DAGL and transplant-naive incident dialysis patients may be responsible for the absence of an early survival advantage with the use of PD in DAGL patients.

Randomized controlled trial of icodextrin versus glucose containing peritoneal dialysis fluid

BACKGROUND AND OBJECTIVES

While peritoneal dialysis with icodextrin is commonly used in patients with poor peritoneal membrane characteristics, the data on the usefulness of this solution in patients with lower transport characteristics are limited. The study was designed to compare icodextrin to glucose in Chinese prevalent peritoneal dialysis patients of different peritoneal transport characteristics (PET) categories.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a randomized, double-blind, perspective control study. Stable prevalent continuous ambulatory peritoneal dialysis (CAPD) patients were randomized to either 7.5% icodextrin (ICO) or 2.5% glucose (GLU) solution for 4 wk. Peritoneal membrane function was measured to define PET category in baseline. Creatinine clearance (Ccr), urea nitrogen clearance (C(BUN)), ultrafiltration (UF) during the long night dwell, dialysate, and metabolic biomarkers were measured at baseline, 2, and 4 wk. UF, Ccr, and C(BUN) were compared among different PET categories.

RESULTS

A total of 201 CAPD patients were enrolled in the study. There were no baseline differences between the groups. Following 2 and 4 wk of therapy, Ccr, C(BUN,) and UF were all significantly higher in the ICO versus the GLU group. Additionally, switching to ICO resulted in a significant increase in UF in high, high-average, and low-average transporters as compared with baseline. The extent of increased UF was more obvious in higher transporters. Blood cholesterol level in the ICO group decreased significantly than that in the GLU group.

CONCLUSION

Compared with glucose-based solution, 7.5% icodextrin significantly improved UF and small solute clearance, even in patients with low-average peritoneal transport.