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

Analysis of risk factors for refractory peritonitis in patients undergoing peritoneal dialysis

OBJECTIVE

To explore the risk factors for refractory peritonitis in patients undergoing peritoneal dialysis.

METHODS

We retrospectively collected data from 130 patients who underwent peritoneal dialysis (PD) and received peritonitis treatment at the Renal Disease Center of Beijing Luhe Hospital affiliated with Capital Medical University from January 1, 2016 to January 30, 2023. According to clinical treatment results, patients with refractory peritonitis were classified as the refractory group (n=52 cases), and those with non-refractory peritonitis were classified as the non-refractory group (n=78 cases). Baseline information and laboratory indicators of patients in each group were collected, and Logistic regression model was used to identify the risk factors for the poor prognosis of peritonitis patients.

RESULTS

There were statistically significant differences in dialysis time, dialysate sugar concentration and inducement type between the refractory group and the non-refractory group (P<0.05). The values of peripheral white blood cells (pWBC), T helper 2 cell (Th2), T regulatory cell (Treg), Treg/Th17 and C-reactive protein (CRP) in the refractory group were significantly higher than those in the non-refractory group, while the values of T helper 17 cell (Th17) and albumin (ALB) were significantly lower (all P<0.05). There were no significant differences in serum creatinine, blood urea, Th1, hemoglobin (Hb) and blood calcium levels between the two groups (all P>0.05). Gram-positive bacteria were the main pathogenic bacteria of peritonitis in all groups. The proportion of enterococcus/streptococcal peritonitis in the refractory group was higher than that in the non-refractory group (P<0.05). Logistic regression identified elevated pWBC, higher dialysate sugar concentration, exit-site infection and gram-negative bacteria infection as independent risk factors for refractory peritonitis in patients undergoing PD (all P<0.05).

CONCLUSION

Elevated pWBC, high glucose dialysate concentration, exit-site infection, and gram-negative bacteria infection are risk factors for refractory peritonitis in patients undergoing PD.

Risk factors of peritoneal dialysis-related peritonitis in the Japan Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Background

Peritoneal dialysis (PD)-related peritonitis is a major complication of PD. Wide variations in peritonitis prevention, treatment strategies and consequences are seen between countries. These between-country differences may result from modifiable risk factors and clinical practices.

Methods

A total of 1225 Japanese PD patients were included and prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study phase 1 (2014-2018) and phase 2 (2018-2022). Associations between PD-related peritonitis and various risk factors were assessed by Cox proportional hazards survival models.

Results

During follow-up (median 1.52 years), 539 peritonitis episodes were experienced by 364 patients. The country crude peritonitis rate was 0.27 episodes/patient-year. In the fully adjusted model, noticeable patient-level factors associated with experiencing any peritonitis included age {hazard ratio [HR] 1.07 per 5-year increase [95% confidence interval (CI) 1.01-1.14]}, serum albumin level [HR 0.63 per 1 g/dl higher (95% CI 0.48-0.82)] and continuous ambulatory peritoneal dialysis (PD) [HR 1.31 versus automated PD (95% CI 1.05-1.63)]. The adoption of antibiotic prophylaxis practice at the time of PD catheter insertion [HR 0.63 (95% CI 0.51-0.78)] or when having complicated dental procedures [HR 0.74 (95% CI 0.57-0.95)] or lower endoscopy [HR 0.69 (95% CI 0.54-0.89)] were associated with lower hazards of any peritonitis, while a routine facility practice of having more frequent regular medical visits was associated with a higher hazard.

Conclusion

Identification of risk factors in Japan may be useful for developing future versions of guidelines and improving clinical practices in Japan. Investigation of country-level risk factors for PD-related peritonitis is useful for developing and implementing local peritonitis prevention and treatment strategies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical profile and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis-associated peritonitis at a tertiary care center

Background

We present risk factors, clinical profile, and microbiological spectrum of patients with continuous ambulatory peritoneal dialysis (CAPD)-associated peritonitis who were managed at our center.

Methods

All consecutive patients with CAPD-associated peritonitis who presented to our center between July 2018 and December 2019 were included in the study. Risk factors, microbiological spectrum, clinical profile, and outcome of patients were studied.

Results

Eighty-five patients with CAPD-associated peritonitis and 50 patients who never had peritonitis during the study period were included. Diabetes Mellitus (OR 0.058, 95% CI0.007-0.493, p < 0.05), residence in rural area (OR 3.376, 95% CI 1.084-10.516, p < 0.05), duration of peritoneal dialysis (OR 0.935, 95% CI 0.886-0.987, p < 0.05), mean serum hemoglobin (OR 1.674, 95% CI 1.119-2.502, p < 0.05) and serum albumin (OR 0.148, 95% CI 0.066-0.333, p < 0.05) were associated with higher risk of peritonitis in CAPD patients. Eight-three patients (98.8%) had turbid CAPD fluid and 52 (61.2%) had fever at the time of presentation to the hospital. The mean CAPD fluid TLC on day 1, 3, and 5 were 2034.3 ± 3330.1 cells/cumm, 1049.0 ± 1210.9 cells/cumm, and 605.2 ± 950.5 cells/cumm, respectively. The organisms isolated were two Escherichia coli (2.4%), one Staphylococcus aureus (1.2%), one Klebsiella (1.2%), two Acinetobacter (2.4%), 10 Fungal organisms (11.7%), and in two (2.4%) cases, Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction (PCR) of CAPD fluid. Thirty-seven (43.5%) patients had a complete cure and 48 (56.5%) patients were refractory to treatment; hence catheter was removed in them (catheter loss). Six (7.0%) patients died during the study period.

Conclusion

CAPD-associated peritonitis is an important risk factor for technique failure. The majority of episodes are culture-negative, and PCR can help in detecting fungal and tubercular peritonitis early in the course.

Association between dialysis effluent leukocyte count after initial antibiotic treatment and outcomes of patients with peritoneal dialysis-associated peritonitis: a retrospective study

BACKGROUND

Among patients with peritoneal dialysis-associated peritonitis (PDAP), It has been regarded as an indicator of deterioration of clinical condition that peritoneal dialysis effluent leukocyte count (PDELC) cannot be restored to normal after initial antibiotic therapy. However, the precise relationship between PDELC on day 5 and the clinical outcomes of PDAP episodes remains uncertain.

AIMS

To explore the association between PDELC on day 5 and clinical outcomes of PDAP episodes.

METHODS

This retrospective study was based on the medical chart database of the Affiliated Hospital of Guangdong Medical University. Multivariable regressions were used to evaluate the association between PDELC on day 5 and 60-day mortality, half-year mortality, treatment failure, and the length of stay in hospital with adjustment for confounding factors.

RESULTS

A total of 549 PDAP episodes in 309 patients were enrolled. The total 60-day mortality, half-year mortality, and rate of treatment failure was 6.0%, 9.8%, and 14.2%, respectively. Compared with patients with normal PDELC, those with PDELC ≥2000 × 106/L on day 5 had significantly higher 60-day mortality (31.1% vs 2.7%), half-year mortality (35.6% vs 5.6%), and treatment failure (46.7% vs 5.7%). In multivariate adjusted regression, the ORs (95%CI) were 6.99 (2.33, 20.92; p = 0.001), 4.97(1.93, 12.77; p = 0.001), and 5.77 (2.07, 16.11; p = 0.001), respectively. Patients with PDELC were 100-2000 × 106/L on day 5 had a higher rate of treatment failure than those with normal PDELC (26.9% vs 5.7%) (OR = 3.03, 95%CI 1.42, 6.46; p = 0.004). After sensitivity analysis, the results remained robust.

CONCLUSIONS

Among patients with PDAP, increased PDELC on day 5 was associated with a greater risk of 60-day mortality, half-year mortality, and treatment failure.

Development of a clinical risk score system for peritoneal dialysis-associated peritonitis treatment failure

OBJECTIVE

This study aimed to construct a clinical risk score system for peritoneal dialysis-associated peritonitis (PDAP) treatment failure to provide a theoretical basis for clinical workers.

METHODS

A total of 161 PDAP individuals admitted to our hospital were included, among whom 70 cases were in the treatment-improved group and 87 cases were in the treatment failure group. We compared the general condition, clinical manifestations, and laboratory examination indicators of the two groups of individuals, used multivariate logistic regression analysis to identify the factors influencing PDAP treatment failure, and developed a clinical risk score system. The diagnostic performance of the risk score system was evaluated utilizing the receiver operating characteristic (ROC) curve.

RESULTS

Significant differences (P < 0.05) were observed between the two groups in terms of contamination, peritoneal fluid culture results, blood urea nitrogen (BUN) level, C-reactive protein (CRP) level, B-type natriuretic peptide (BNP) level, average residual urine (RU) volume, and urea clearance rate (UCR). Multivariate logistic regression analysis showed that BUN level, CRP level, BNP level, average RU volume, and UCR were independent risk factors affecting PDAP patient treatment outcomes (P < 0.05). The ROC curve analysis of the risk score system for predicting treatment failure in PDAP individuals showed an area under the curve of 0.895 [95% confidence interval (0.847-0.943)]. The optimal cut-off point was 2.5 points, with corresponding sensitivity and specificity of 88.5% and 74.3%, separately.

CONCLUSION

BUN level, CRP level, BNP level, average RU volume, and UCR are independent risk factors for PDAP treatment failure. The clinical risk score system based on these five independent risk factors can accurately predict the risk of treatment failure in PDAP individuals.

Multidrug-resistant organism-peritoneal dialysis associated peritonitis: clinical and microbiological features and risk factors of treatment failure

Background

Multidrug-resistant (MDR) bacterial infection causes difficulty in the therapy of peritoneal dialysis-associated peritonitis (PDAP); however, there are few studies on multidrug-resistant organism (MDRO)-PDAP. In view of growing concerns about MDRO-PDAP, the aim of this study was to investigate the clinical features, risk factors of treatment failure, and causative pathogens of MDRO-PDAP.

Methods

In total, 318 patients who underwent PD between 2013 and 2019 were included in this multicenter retrospective study. Clinical features, patient outcomes, factors related to treatment failure, and microbiological profiles associated with MDRO-PDAP were analyzed and risk factors for treatment failure associated with MDR-Escherichia coli (E. coli) were further discussed.

Results

Of 1,155 peritonitis episodes, 146 eligible episodes of MDRO-PDAP, which occurred in 87 patients, were screened. There was no significant difference in the composition ratio of MDRO-PDAP between 2013-2016 and 2017-2019 (p > 0.05). E. coli was the most prevalent MDRO-PDAP isolate, with high sensitivity to meropenem (96.0%) and piperacillin/tazobactam (89.1%). Staphylococcus aureus was the second most common isolate and was susceptible to vancomycin (100%) and linezolid (100%). Compared to non-multidrug-resistant organism-PDAP, MDRO-PDAP was associated with a lower cure rate (66.4% vs. 85.5%), higher relapse rate (16.4% vs. 8.0%), and higher treatment failure rate (17.1% vs.6.5%). Dialysis age [odds ratio (OR): 1.034, 95% confidence interval (CI): 1.016-1.052, p < 0.001] and >2 previous peritonitis episodes (OR: 3.400, 95% CI: 1.014-11.400, p = 0.047) were independently associated with treatment failure. Furthermore, longer dialysis age (OR: 1.033, 95% CI: 1.003-1.064, p = 0.031) and lower blood albumin level (OR: 0.834, 95% CI: 0.700-0.993, p = 0.041) increased the risk of therapeutic failure for MDR-E. coli infection.

Conclusion

The proportion of MDRO-PDAP has remained high in recent years. MDRO infection is more likely to result in worse outcomes. Dialysis age and previous multiple peritonitis infections were significantly associated with treatment failure. Treatment should be promptly individualized based on local empirical antibiotic and drug sensitivity analyses.

Seasonal variations of enteric peritonitis in Belgium and France : RDPLF data

Summary Little information is available on the seasonal ecology of germs responsible for peritoneal dialysis peritonitis. We performed a retrospective study based on RDPLF data covering the last 20 years and 20411 episodes of peritonitis. We show that the percentage of enteric peritonitis is highest in summer, lowest in winter and identical in spring and autumn. This higher proportion of organisms of enteric origin in summer has itself tended to increase in recent years. We postulate that a food contamination by enteric germs associated with an increased bacterial translocation at the level of the digestive tract itself favoured by constipation, as well as changes of the food nature could be responsible for this phenomenon. These seasonal variations may suggest that probabilistic initial antibiotic therapy should be adapted in cases of suspected peritonitis before the results of bacteriological analysis.  

Microbiology and outcomes of polymicrobial peritonitis associated with peritoneal dialysis: a register-based cohort study from the French Language Peritoneal Dialysis Registry (RDPLF)

BACKGROUND

Previous studies have reported that polymicrobial peritonitis in peritoneal dialysis (PD) is associated with poor outcomes, but recent data from European cohorts are scarce.

METHODS

We included from the French Language Peritoneal Dialysis Registryall patients ≥ 18 years who started PD between January 2014 and November 2020. We compared microbiology and patient characteristics associated with mono- and polymicrobial peritonitis. We assessed patient outcomes after a first polymicrobial peritonitis using survival analysis with competing events. We differentiated microorganisms isolated from dialysis effluent as enteric or non-enteric pathogens.

RESULTS

8848 patients contributed 13 023 patient-years of follow-up and 3348 culture-positive peritonitis, including 251 polymicrobial ones. This corresponded to rates of 0.32 and 0.02 episodes/patient-year, respectively. For most patients (72%) who experienced polymicrobial peritonitis, this was their first peritonitis episode. Enteric pathogens were more frequently isolated in poly- than in monomicrobial peritonitis (57 vs 44%, P < 0.001). In both cases of peritonitis with or without enteric pathogens, the poly- versus monomicrobial character of the peritonitis was not associated with mortality in patients who did not switch to hemodialysis (adjusted cause-specific hazard ratio, a.cs-HR, 1.2 [95% CI, 0.3-5.0], P = 0.78 and 1.1 [0.7-1.8], P = 0.73, respectively). However, the risks of death and switch to hemodialysis were higher for monomicrobial peritonitis with enteric pathogens, compared to those without (a.cs-HR, 1.3 [1.1-1.7], P = 0.02 and 1.9 [1.5-2.4], P < 0.0001, respectively).

CONCLUSION

Isolation of enteric pathogens, rather than the polymicrobial character of the peritonitis, is associated with poorer outcomes.

Investigation of risk factors for tunneled hemodialysis catheters dysfunction: competing risk analysis of a tertiary center data

BACKGROUND

Hemodialysis tunneled catheters are prone to failure due to infection or thrombosis. Prediction of catheter dysfunction chance and finding the predisposing risk factors might help clinicians to prolong proper catheter function. The multidimensional mechanism of failures following infection or thrombosis needs a multivariable and comprehensive analytic approach.

METHODS

A longitudinal cross-sectional study was implemented on 1048 patients admitted for the first hemodialysis tunneled catheterization attempt between 2013 and 2019 in Shahid Hasheminejdad hospital, Tehran, Iran. Patients' information was extracted from digital and also paper records. Based on their criteria, single and multiple variable analyses were done separately in patients with catheter dysfunction due to thrombosis and infection. T-test and Chi-square test were performed in quantitative and categorical variables, respectively. Competing risk regression was performed under the assumption of proportionality for infection and thrombosis, and the sub-distributional hazard ratios (SHR) were calculated. All statistical inferences were made with a significance level of 0.05.

RESULTS

Four hundred sixty-six patients were enrolled in the analysis based on study criteria. Samples' mean (SD) age was 54(15.54), and 322 (69.1%) patients were female. Three hundred sixty-five catheter dysfunction cases were observed due to thrombosis 123(26.4%) and infection 242(52%). The Median (range) time to catheter dysfunction event was 243(36-1131) days. Single variable analysis showed a statistically significant higher proportion of thrombosis in females (OR = 2.66, 95% CI: 1.77-4.00) and younger patients, respectively. Multivariate competing risk regression showed a statistically significant higher risk of thrombosis in females (Sub-distributional hazard (SHR) = 1.81), hypertensive (SHR = 1.82), and more obese patients (BMI SHR = 1.037). A higher risk of infection was calculated in younger (Age SHR = 0.98) and diabetic (SHR = 1.63) patients using the same method.

CONCLUSION

Female and hypertensive patients are considerably at higher risk of catheter thrombosis, whereas diabetes is the most critical risk factor for infectious catheter dysfunction. Competing risk regression analysis showed a comprehensive result in the assessment of risk factors of catheter dysfunction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of multidisciplinary pre-dialysis care on the outcomes of incident peritoneal dialysis patients

Background

This study aims to evaluate the impact of multidisciplinary pre-dialysis care (MDPC) on the risks of peritonitis, technique failure and mortality in peritoneal dialysis (PD) patients.

Methods

Incident end-stage kidney disease patients who received peritoneal dialysis (PD) for more than 90 days were recruited in this study from 1 January 1, 2007 to December 31, 2018. Patients were classified into two groups, the MDPC group and the control group, that received the usual care by nephrologists. Risks of the first episode of peritonitis, technique failure and mortality were compared between the two groups.

Results

There were 126 patients under the usual care and 546 patients under the MDPC. Patients in the MDPC group initiated dialysis earlier than those in the non-MDPC group. There was no significant difference between these two groups in time to the first episode of peritonitis. Compared to the non-MDPC group, the MDPC group was at similar risks of technique failure (adjusted HR = 0.85, 95% CI = 0.64–1.15) and mortality (adjusted HR = 0.66, 95% CI = 0.42–1.02). Among patients with diabetes, the risk of mortality was significantly reduced in the MDPC group with an adjusted HR of 0.45 (95% CI = 0.25–0.80).

Conclusions

There was no significant difference in time to develop the first episode of peritonitis, and risks of technique failure and mortality between these two groups. Diabetic PD patients under MDPC had a lower risk of mortality than those under the usual care.

Low Serum Albumin Is Associated with Poor Prognosis in Patients Receiving Peritoneal Dialysis Treatment

Background

The number of patients receiving dialysis treatment is sustainably increasing, especially peritoneal dialysis.

Objectives

It is necessary to find out potential factors that may indicate the prognosis of patients receiving peritoneal dialysis treatment.

Methods

This study retrospectively involved 325 patients who received peritoneal dialysis treatment.

Results

Low serum albumin (HR = 2.254; 95% CI: 1.534-3.311; P < 0.001) and high FBG (Fasting blood glucose) (HR = 1.474; 95% CI: 1.025-2.120; P=0.037) were risk factors for death in patients receiving peritoneal dialysis treatment. Serum albumin (AUC = 0.683; P < 0.001) and creatinine (AUC = 0.625; P < 0.001) exhibited value of prognosis prediction. Both high FBG (P=0.005) and low albumin (P < 0.001) were associated with poor prognosis, and low albumin predicted poorer survival.

Conclusions

Low serum albumin and high fasting blood glucose were risk factors and associated with poor prognosis. Low albumin has a potential in predicting the prognosis of patients receiving peritoneal dialysis treatment.

Kt/V reach rate is associated with clinical outcome in incident peritoneal dialysis patients

Background

The urea clearance index (Kt/V) is an important index for predicting the clinical outcome of peritoneal dialysis (PD) patients, but it changes with time depending on the clinical condition. This study aimed to investigate the association between the Kt/V reach rate (defined as the percentage of Kt/V measurements that reached ≥ 1.70) and clinical outcome in incident PD patients.

Methods

In this retrospective cohort study, 210 patients were enrolled from the First Affiliated Hospital of Zhengzhou University from 1 January 2013 to 31 October 2019. The target Kt/V reach rate in the first year was applied as the predictor variable. Kaplan-Meier survival curves were drawn to evaluate differences in prognosis. The association between Kt/V reach rate and the composite clinical outcome (death or transfer to hemodialysis) was tested by Cox regression analysis.

Results

The dialysis adequacy group (Kt/V reach rate 3/3 times) and the dialysis intermittent adequacy group (1/3 or 2/3 times) had significantly better clinical outcomes than the dialysis inadequacy group (0/3 times). There was no difference in clinical outcome between the lower-rate group (reach rate 1/3 times) and the higher-rate group (2/3 times). Compared with the dialysis inadequacy group, the dialysis intermittent adequacy group and dialysis adequacy group had significantly lower risks of the composite outcome (HR 0.487, 95% CI 0.244–0.971, p = 0.041; HR 0.150, 95% CI 0.043–0.520, p = 0.003) in the fully adjusted analysis.

Conclusion

Higher Kt/V reach rates are associated with a better prognosis in incident PD patients.

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.

Platelet-to-albumin ratio: a risk factor associated with technique failure and mortality in peritoneal dialysis patients

Background

Peritoneal dialysis (PD) patients have a high incidence of poor clinical outcomes, which is related to the inflammatory and nutritional status of this population. Platelet-to-albumin ratio (PAR), recently identified as a useful biomarker to monitor inflammation and nutrition, can predict a poor prognosis in various diseases. The aim of this study was to investigate the association between PAR and technique failure and mortality in PD patients.

Methods

This single-center retrospective study enrolled 405 PD patients from 1 January 2011 to 31 December 2019 and collected complete demographic characteristics, clinical laboratory baseline data. The outcomes were technique failure and mortality. The associations between PAR and technique failure, death were analyzed by Cox proportional hazard models and competing risk regression models with kidney transplantation as a competing event. The areas under the curve (AUC) of receiver-operating characteristic analysis were used to determine the predictive values of PAR for technique failure and mortality.

Results

During a median follow-up period of 24.0 (range, 4.0–91.0) months, 139 (34.3%) PD patients experienced technique failure, 61 (15.1%) PD patients died. The patients with higher PAR levels had increased risk of technique failure and mortality. After adjustment for confounding factors, we found that high PAR levels were risk factor for both technique failure (subdistribution hazard ratio [SHR] 1.775; 95%CI, 1.157–2.720; p = 0.033] and mortality [SHR 3.710; 95%CI, 1.870–7.360; p < 0.001]. The predictive ability of PAR was superior to platelet and albumin based on AUC calculations for technique failure and mortality.

Conclusions

PAR was a risk factor associated with technique failure and mortality in PD patients.

Impact of peritoneal dialysis-related peritonitis on PD discontinuation and mortality: A population-based national cohort study

BACKGROUND

The impact of peritoneal dialysis-associated peritonitis (PD peritonitis) on long-term outcomes is uncertain. This nationwide retrospective study was conducted in Taiwan to understand the incidence, risk factors and long-term outcomes of PD peritonitis.

METHODS

A total of 11,202 incident adult peritoneal dialysis (PD) patients from 2000 to 2010 were collected from a Longitudinal Health Insurance Database and followed up until the end of 2011. Definition of peritonitis, the primary outcome, simultaneously met the diagnosis of peritonitis (International Classification of Diseases, Ninth Revision, Clinical Modification 567) and antibiotic use. Secondary outcomes included the impact of peritonitis on PD discontinuation and survival. Cox proportional hazards models with and without time-dependent variables were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

There were 7634 peritonitis episodes in 4245 patients during the follow-up period. The overall incidence of peritonitis was 0.18 episodes per patient-year. Peritonitis-associated risk factors included older age, female gender, chronic heart failure, cerebrovascular disease, liver cirrhosis and lower monthly income. In an adjusted Cox hazard proportional regression with the time-dependent model, peritonitis patients had a higher risk of PD discontinuation (HR 2.71, 95% CI 2.52-2.92) and mortality (HR 1.68, 95% CI 1.57-1.81) compared to patients without peritonitis. The adjusted HRs for mortality increased with each prior episode: one episode, two episodes and more than two episodes (all p < 0.05). The adjusted HRs for PD discontinuation also increased with the frequency of peritonitis. These negative effects were greatest during the first year and persisted significantly after 5 years. In a sensitivity analysis in which peritonitis within 30 days of death or PD discontinuation was excluded, peritonitis patients still had significantly increased risk of PD discontinuation and mortality compared to patients without peritonitis.

CONCLUSIONS

Although peritonitis incidence was low, our findings reveal that peritonitis carried acute and long-term sequelae of higher PD discontinuation and lower patient survival.

Peritoneal Dialysis Modality Failure in a Middle-Income Country: A Retrospective Cohort Study

Rationale & Objective

Technique failure in peritoneal dialysis (PD) remains one of the most critical challenges of this therapy and is associated with a significant increase in costs and morbidity. Our objective was to estimate the frequency of PD technique failure and identify factors associated with technique failure.

Study Design

A retrospective multicenter observational cohort study.

Setting & Participants

All adult patients initiating PD between January 1, 2010, and December 31, 2015, with follow-up until December 31, 2018, at the Renal Therapy Services network in Colombia.

Exposure & Predictors

PD modality (continuous ambulatory PD and automated PD) and demographic and clinical characteristics.

Outcomes

Technique failure, defined as a switch to hemodialysis lasting at least 30 days.

Analytical Approach

Sociodemographic and clinical characteristics of all patients were summarized descriptively according to modality. We estimated the cumulative incidence of technique failure, and a flexible parametric survival model with competing risks was used to evaluate factors associated with this outcome.

Results

Among 6,452 patients meeting inclusion criteria, 67% were treated with continuous ambulatory PD. The cumulative incidence of technique failure within 1 year of PD initiation adjusting for competing risks was 6.9% (95% CI, 6.3%-7.6%); within 2 years, technique failure was 13.5% (95% CI, 12.6%-14.4%); and within 3 years, 19.6% (95% CI, 18.5%-20.7%). Female sex, larger center size, and higher Kt/V were associated with lower risk for modality change, whereas diabetes, history of major abdominal surgery, catheter implant technique (laparotomy and percutaneous techniques), obesity, and peritonitis were associated with a higher likelihood of technique failure.

Limitations

Variables of distance to the center, use of icodextrin, and measures of outcomes reported by patients were not included.

Conclusions

Technique failure is relatively uncommon in Colombia; catheter-related problems are the most frequent cause of technique failure. Best practices in catheter insertion could minimize the risk for this outcome.

Successful treatment of Serratia Marcescens peritonitis in a patient receiving peritoneal dialysis

An old man receiving peritoneal dialysis was diagnosed with Serratia marcescens peritonitis, a rare case with poor prognosis. Powerful antibiotics based on culture results and enough duration cured the case successfully despite its high virulence.

Comparison of clinical features and outcomes in peritoneal dialysis-associated peritonitis patients with and without diabetes: A multicenter retrospective cohort study

BACKGROUND

The number of end-stage renal disease patients with diabetes mellitus (DM) who are undergoing peritoneal dialysis is increasing. Peritoneal dialysis-associated peritonitis (PDAP) is a serious complication of peritoneal dialysis leading to technical failure and increased mortality in patients undergoing peritoneal dialysis. The profile of clinical symptoms, distribution of pathogenic organisms, and response of PDAP to medical management in the subset of end-stage renal disease patients with DM have not been reported previously. Discrepant results have been found in long-term prognostic outcomes of PDAP in patients with DM. We inferred that DM is associated with bad outcomes in PDAP patients.

AIM

To compare the clinical features and outcomes of PDAP between patients with DM and those without.

METHODS

In this multicenter retrospective cohort study, we enrolled patients who had at least one episode of PDAP during the study period. The patients were followed for a median of 31.1 mo. They were divided into a DM group and a non-DM group. Clinical features, therapeutic outcomes, and long-term prognostic outcomes were compared between the two groups. Risk factors associated with therapeutic outcomes of PDAP were analyzed using multivariable logistic regression. A Cox proportional hazards model was constructed to examine the influence of DM on patient survival and incidence of technical failure.

RESULTS

Overall, 373 episodes occurred in the DM group (n = 214) and 692 episodes occurred in the non-DM group (n = 395). The rates of abdominal pain and fever were similar in the two groups (P > 0.05). The DM group had more infections with coagulase-negative Staphylococcus and less infections with Escherichia coli (E. coli) as compared to the non-DM group (P < 0.05). Multivariate logistic regression analysis revealed no association between the presence of diabetes and rates of complete cure, catheter removal, PDAP-related death, or relapse of PDAP (P > 0.05). Patients in the DM group were older and had a higher burden of cardiovascular disease, with lower level of serum albumin, but a higher estimated glomerular filtration rate (P < 0.05). Cox proportional hazards model confirmed that the presence of diabetes was a significant predictor of all-cause mortality (hazard ratio = 1.531, 95% confidence interval: 1.091-2.148, P < 0.05), but did not predict the occurrence of technical failure (P > 0.05).

CONCLUSION

PDAP patients with diabetes have similar symptomology and are predisposed to coagulase-negative Staphylococcus but not E. coli infection compared those without. Diabetes is associated with higher all-cause mortality but not therapeutic outcomes of PDAP.

Comparison of peritoneal function within the first 1 year of peritoneal dialysis between diabetic and non-diabetic patients

The aim of this study was to compare the changes in peritoneal function and residual renal function in the first year between diabetic and non-diabetic patients receiving peritoneal dialysis (PD). We extracted 73 incident PD patients (male, 73%; age, 59 ± 15 years) from a previous cohort, and investigated the changes in PD-related parameters, including the dialysate to plasma ratio of creatinine (D/P Cr) and Kt/V. D/P Cr increased in non-diabetics, whereas it did not change significantly in diabetic patients. These differences were more pronounced among icodextrin users. On multivariate analysis, the presence of diabetes was independently associated with the changes in D/P Cr. On the contrary, there was no significant difference in the changes of renal Kt/V between the two groups. A higher peritoneal solute transport rate at the start of PD in diabetics was attenuated within 1 year. Icodextrin is thought to have an important role through improving body fluid status.

Early technique failure in peritoneal dialysis patients in a multi-ethnic Asian country

PURPOSE

Early technique failure is a serious complication for peritoneal dialysis (PD) patients. The study aimed to examine the incidence, causes, and risk factors associated with early technique failure.   METHODS: This retrospective study included all incident PD patients in a hospital in Singapore from 2013 to 2017. The primary outcome was early technique failure, which was defined as transfer to hemodialysis for ≥ 30 days or death, within the first year of PD initiation. Secondary outcomes were death, technique failure due to PD infection, and death-censored technique failure.

RESULTS

Overall, 517 patients were included in the study. Of these, 98 patients (19.0%) developed early technique failure. The common causes of early technique failure were death (41.8%) and infection (40.8%). Peripheral vascular disease was significantly associated with a higher hazard of early technique failure [hazard ratio (HR) 1.95, 95% confidence interval (CI) 1.04-3.63] and death (HR 3.75, 95% CI 1.71-8.21), whilst glomerulonephritis as a cause of end-stage kidney disease (compared with hypertension) was associated with a lower hazard of early technique failure (HR 0.38, 95% CI 0.18-0.77) and death (HR 0.08, 95% CI 0.02-0.37). Male gender was associated with early technique failure due to PD infection (HR 2.55, 95% CI 1.32-4.95). No specific factor was associated with death-censored early technique failure.

CONCLUSION

Technique failure in the first year of PD initiation occurs in one-fifth of PD patients and is associated with peripheral vascular disease and cause of end-stage kidney disease.

The prevalence and bacterial distribution of peritonitis amongst adults undergoing continuous ambulatory peritoneal dialysis at Universitas hospital

Background

Peritonitis is the leading cause of morbidity and technique failure in peritoneal dialysis (PD) patients. The International Society for Peritoneal Dialysis (ISPD) recommends each centre to monitor the peritonitis rates and the causative organisms in order to guide local empiric antibiotic protocols. The aim of this study was to report on the peritonitis rates and describe the causative microorganisms and the antibiotic susceptibility in continuous ambulatory peritoneal dialysis (CAPD) adult patients at the Universitas Academic Hospital.

Methods

A single-centre, retrospective descriptive survey was conducted to determine the peritonitis rates in PD patients (January–December 2016). All CAPD patients aged ≥18 years, who presented with clinical features of PD-associated peritonitis, were included. The peritonitis episodes were studied per patient, and the causative microorganisms and the antibiotic susceptibility of the organisms were described.

Results

One hundred and twenty-eight patients underwent CAPD. The peritonitis rate was 1.45 episodes per year at risk. The prevalence of CAPD patients affected by at least one episode of CAPD-associated peritonitis during 2016 was 56.3%. The majority of episodes (76.7%) (n = 122) were mono-microbial. Gram-positive organisms accounted for 73.0% (n = 116) of the peritonitis episodes, coagulase-negative Staphylococcus being the most common. Gram-negative organisms accounted for 15.7% (n = 25) of the peritonitis episodes, and the common pathogens was Enterobacteriaceae.

Conclusion

The peritonitis rate was alarmingly high, with 1.45 episodes per year at risk; this is three times more than the recommended 0.5 episodes per year according to the ISPD guidelines. The culture-negative rate of 8.8% is within ISPD-acceptable limits. There is a need to strengthen preventive measures with regard to peritonitis.