The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS): Unifying Efforts to Inform Practice and Improve Global Outcomes in Peritoneal Dialysis

Diagnostic Accuracy of MMP-8 and IL-6-Based Point-of-Care Testing to Detect Peritoneal Dialysis-Related Peritonitis: A Single-Center Experience

BACKGROUND

Peritoneal dialysis-related peritonitis (PDRP) is the most common complication of peritoneal dialysis (PD), which can lead to poor outcomes if not diagnosed and treated early. We aimed to investigate the diagnostic accuracy of MMP-8 and IL-6-based point-of-care tests (POCTs) in diagnosing PDRP in PD patients.

METHODS

This retrospective chart review study was conducted at a comprehensive kidney center in Qatar. It involved all adult PD patients who underwent PDRP from July 2018 to October 2019 and for whom MMP-8 and IL-6-based POCTs were used to diagnose presumptive peritonitis. Measures of diagnostic accuracy were computed. Peritoneal fluid effluent analysis was the reference standard.

RESULTS

We included 120 patients (68 [56.7%] females, ages 55.6 ± 15.6 years, treatment duration 39.5 ± 30.4 months [range: 5-142 months]). In this population, MMP-8 and IL-6-based POCTs yielded 100% in all dimensions of diagnostic accuracy (sensitivity, specificity, positive and negative predictive values).

CONCLUSIONS

MMP-8 and IL-6-based POCTs might be helpful in the early detection of PDRP. This monocentric observation requires further confirmation in a prospective multicentric setting.

Characteristics of patients and facility of peritoneal dialysis in Korea: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) Korea

BACKGROUND

Varying peritoneal dialysis (PD)-related clinical outcomes have been reported in different countries. As a participant of the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), this study investigated the characteristics of Korean PD patients, PD facilities and the incidence rates of clinical outcomes including mortality and PD-related outcomes.

METHODS

From July 2019 to December 2021, a total of 766 Korean PD patients were included for analysis. Poisson regression analysis was used to explore the incidence rates of various clinical events including mortality, modality transfer, exit site or catheter tunnel infection and peritonitis.

RESULTS

Among the 766 patients (median age 55.5 years, males 59.5%), 276 were incident and 490 were prevalent PD patients. The incidence rates of events were as follows: all-cause mortality (0.048), modality transfer (0.051), exit site or catheter tunnel infection (0.054) and peritonitis (0.136) events per person year. The most common causative organism for exit site or tunnel infection was staphylococcus species (47%) and that for peritonitis was streptococcus (28%) followed by staphylococcus (27%) species.

CONCLUSIONS

Up to now, PDOPPS Korea has recruited 766 Korean PD patients and started documentation of major PD-related outcomes which occurred during the follow-up period. The overall incidence rates of clinical outcomes in Korean PD patients were relatively favourable. There was no statistically significant difference in the incidence rates of clinical outcomes according to both facility and patient factors.

Peritoneal dialysis in the Arabian Gulf countries: Challenges and opportunities

The Gulf Cooperation Council (GCC) is a regional organisation, consisting of six Arab countries that share common objectives and cultural identities, with a total population of 57.3 million. The prevalence of patients requiring dialysis in GCC countries is increasing, with a current mean prevalence of 551 per million population. Despite the several patient-level and healthcare system benefits of peritoneal dialysis (PD) compared to in-centre haemodialysis, the growth in PD utilisation has been limited. This is related to several factors, including deficiencies in modality education for chronic kidney disease patients, nephrology training and governmental policies advocating for this dialysis modality. Establishing a detailed PD registry in GCC countries is an important step towards understanding our patients' characteristics, outcomes, current PD practices and challenges in order to increase the use of PD and to facilitate future initiatives aimed at optimising the management of PD patients in this part of the world. This article reviews common challenges around PD practices and utilisation in GCC countries and provides possible solutions to overcome these challenges. It should be noted that the literature on PD patients, outcomes and treatment practices in GCC countries is limited, and as a result, many of our recommendations and discussion are based on clinical observations, experience and data when available.

International variations in serum PTH and calcium levels and their mortality associations in peritoneal dialysis patients: Results from PDOPPS

BACKGROUND

Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients.

METHODS

We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calciumAlb) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase.

RESULTS

Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calciumAlb were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calciumAlb ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calciumAlb 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries.

CONCLUSIONS

A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes.

LAY SUMMARY

Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.

Gastric Acid Suppression Therapy and Its Association with Peritoneal Dialysis-Associated Peritonitis in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Key Points

In a large multinational cohort of PD patients, any GAS use was not associated with an increased risk of all-organism peritonitis. For peritonitis, risks were particularly high among certain classes of organisms particularly for Gram-negative, enteric, and streptococcal peritonitis episodes. The association with enteric peritonitis appeared to be stronger among H2RA users.

Background

Peritonitis is a major peritoneal dialysis–related complication. We determined whether gastric acid suppression (GAS) (proton pump inhibitor [PPI] or histamine-2 receptor antagonists [H2RAs]) use was associated with all-cause and organism-specific peritonitis in peritoneal dialysis patients.

Methods

In the Peritoneal Dialysis Outcomes and Practice Patterns Study (595 facilities, eight countries, years 2014–2022), associations between GAS use and time to first episode of all-cause peritonitis were examined using Cox proportional hazards models. The primary exposure of interest was GAS and secondarily PPI or H2RA use. Secondary outcomes were organism-specific peritonitis, peritonitis cure rates, and death.

Results

Among patients (N =23,797) at study baseline, 6020 (25.3%) used PPIs, and 1382 (5.8%) used H2RAs. Overall risks of GAS use and peritonitis risk (adjusted hazard ratio [AHR]=1.05, 95% confidence interval [CI], 0.98 to 1.13]) and use of PPI (AHR 1.06 [95% CI, 0.99 to 1.14]) or H2RA (AHR 1.02 [95% CI, 0.88 to 1.18]) did not reach statistical significance. In organism-specific analyses, GAS users displayed higher peritonitis risks for Gram-negative (AHR 1.29, 95% CI, 1.05 to 1.57), Gram-positive (AHR 1.15, 95% CI, 1.01 to 1.31), culture-negative (AHR 1.20, 95% CI, 1.01 to 1.42), enteric (AHR 1.23, 95% CI, 1.03 to 1.48), and particularly Streptococcal (AHR 1.47, 95% CI, 1.15 to 1.89) peritonitis episodes. GAS was also associated with higher overall mortality (AHR 1.13 [95% CI, 1.05 to 1.22]).

Conclusion

The association between GAS use and peritonitis risk was weaker (hazard ratio [HR] 1.05 [0.98 to 1.13]) than for streptococcal (HR 1.57 [1.15 to 1.89]) and Gram-negative (HR 1.29 [1.05 to 1.57]) peritonitis. A better understanding of mechanisms surrounding the differential effects of GAS subtype on peritonitis risks is needed. Clinicians should be cautious when prescribing GAS. The impact of GAS deprescribing on peritonitis risk requires further evaluation.

Catheter Event Rates in Medical Compared to Surgical Peritoneal Dialysis Catheter Insertion

Introduction

How patient, center, and insertion technique factors interact needs to be understood when designing peritoneal dialysis (PD) catheter insertion pathways.

Methods

We undertook a prospective cohort study in 44 UK centers enrolling participants planned for first catheter insertion. Sequences of regressions were used to describe the associations linking patient and dialysis unit-level characteristics with catheter insertion technique and their impact on the occurrence of catheter-related events in the first year (catheter-related infection, hospitalization, and removal). Factors associated with catheter events were incorporated into a multistate model comparing the rates of catheter events between medical and surgical insertion alongside treatment modality transitions and mortality.

Results

Of 784 first catheter insertions, 466 (59%) had a catheter event in the first year and 61.2% of transitions onto hemodialysis (HD) were immediately preceded by a catheter event. Catheter malfunction was less but infection was more common with surgical compared with medical insertions. Participants at centers with fewer late presenters and more new dialysis patients starting PD, had a lower probability of a catheter event. Adjusting for these factors, the hazard ratio for a catheter event following insertion (medical vs. surgical) was 0.70 (95% confidence interval [CI] 0.43 to 1.13), and once established on PD 0.77 (0.62 to 0.96).

Conclusion

Offering both medical and surgical techniques is associated with lower catheter event rates and keeps people on PD for longer.

Technique failure in peritoneal dialysis-related peritonitis: risk factors and patient survival

OBJECTIVE

This study aimed to investigate the association between patient clinical characteristics and technique failure in peritoneal dialysis-related peritonitis (PDRP). The effect of peritonitis-associated technique failure on patient survival was also assessed.

METHODS

Patients diagnosed with PDRP from January 1, 2010 to June 30, 2022 were retrospectively reviewed and analyzed. Relevant demographic, biochemical, and clinical data were collected. Univariate and multivariate logistic regression analyses were used to determine the predictors of peritonitis-associated technique failure in PD. Patients were divided into technique failure (F group) and nontechnique failure (NF group) groups. Patients were followed until death or until the date of Oct 1, 2022. Kaplan-Meier survival curves and landmark analysis were used to assess the survival of the PDRP cohort. Cox regression models were used to assess the association between potential risk factors and mortality.

RESULTS

A total of 376 patients with 648 cases of PDRP were included in this study. Multivariate logistic regression analysis demonstrated that peritoneal dialysis (PD) duration (OR = 1.12 [1.03, 1.21], p = 0.005), dialysate WBC count on Day 3 after antibiotic therapy (OR = 1.41 [1.22, 1.64], p = 0.001), blood neutrophil-to-lymphocyte ratio (NLR) (OR = 1.83 [1.25, 2.70], p = 0.002), and serum lactate dehydrogenase (LDH) (OR = 4.13 [1.69, 10.11], p = 0.002) were independent predictors for technique failure in PDRP. Furthermore, serum high-density lipoprotein (HDL) (OR = 0.28 [0.13, 0.64], p = 0.002) was a protective factor against technique failure. According to the Kaplan-Meier analysis, patients experiencing peritonitis-associated technique failure had lower postperitonitis survival (log-rank = 4.326, p = 0.038). According to the landmark analysis, patients with a history of peritonitis-associated technical failures had a higher 8-year mortality after peritoneal dialysis. A Cox model adjusted for plausible predetermined confounders showed that technique failure was independently associated with all-cause mortality.

CONCLUSIONS

Dialysate WBC count on Day 3, PD duration, NLR, and LDH were independent risk factors for technique failure, whereas HDL was a protective factor. Peritonitis-associated technique failure had a higher risk of mortality and adverse effects on postperitonitis survival.

Early outcomes of peritoneal dialysis in a middle-income country: A retrospective cohort study of a large dialysis network in Colombia

BACKGROUND

The first year of dialysis is critical given the significant risk for complications following dialysis initiation. We analysed complications during the first year among incident peritoneal dialysis (PD) patients.

METHODS

This retrospective cohort study comprised adult kidney failure patients starting PD in Baxter Renal Care Services in Colombia, receiving their first PD catheter between 1 January 2017 and 31 December 2020 and were followed up for up to 1 year. We analysed incidence, causes and factors associated with complications using logistic regression and transfer to haemodialysis (HD) using the Fine-Gray regression model.

RESULTS

Among 4743 patients receiving their first PD catheter: 4628 (97.6%) of catheter implantations were successful; 377 (7.9%) patients experienced early complications. The incidence rate of complications during the year was 0.51 events per patient-year (95% CI: 0.48-0.54). Age, obesity and urgent start were associated with higher probability of complications after catheter implantation. The cumulative incidence of transfer to HD within 1 year of PD initiation was 10.1% [95% CI: 9.2-11.1%]. The hazard function for transfer to HD showed an accelerating pattern during the first month followed by progressive decrease during the first year.

CONCLUSIONS

In this large population of incident PD patients, there is a high primary catheter placement success rate. Urgent start, age ≥65 years, obesity, centre size ≥150 PD patients and diabetes were risk factors associated with early complications. The follow-up of the cohort from day 1 of PD treatment showed that the risk for transfer to HD was higher during the first month.

Effects of Steady Glucose Concentration Peritoneal Dialysis on Ultrafiltration Volume and Sodium Removal: A Pilot Crossover Trial

BACKGROUND

Volume overload is common in patients treated with peritoneal dialysis (PD) and is associated with poor clinical outcome. Steady concentration PD is where a continuous glucose infusion maintains the intraperitoneal glucose concentration and as a result provides continuous ultrafiltration throughout the dwell. The primary objective of this study was to investigate the ultrafiltration rate and glucose ultrafiltration efficiency for steady concentration PD in comparison with a standard continuous ambulatory PD (CAPD) dwell, using the novel Carry Life UF device.

METHODS

Eight stable patients treated with PD (six fast and two fast average transporters) were investigated four times: a standard 4-hour CAPD dwell with 2 L of 2.5% dextrose solution as control and three 5-hour steady concentration PD treatments (glucose dose 11, 14, 20 g/h, initial fill 1.5 L of 1.5% dextrose solution). All investigations were preceded by an overnight 2 L 7.5% icodextrin dwell.

RESULTS

Intraperitoneal glucose concentration increased during the first 1-2 hours of the steady concentration PD treatments and remained stable thereafter. Ultrafiltration rates were significantly higher with steady concentration PD treatments (124±49, 146±63, and 168±78 mL/h with 11, 14, and 20 g/h, respectively, versus 40±60 mL/h with the control dwell). Sodium removal and glucose ultrafiltration efficiency (ultrafiltration volume/gram glucose uptake) were significantly higher with steady concentration PD treatments versus the control dwell, where the 11 g/h glucose dose was most efficient.

CONCLUSIONS

Steady concentration PD performed with the Carry Life UF device resulted in higher ultrafiltration rates, more efficient use of glucose (increased ultrafiltration volume/gram glucose absorbed), and greater sodium removal compared with a standard 2.5% dextrose CAPD dwell.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

A Performance Analysis of the Peritoneal Ultrafiltration (PUF) Achieved With the Carry Life ® UF, NCT03724682 .

Epidemiology and Outcomes of Children with Kidney Failure Receiving Kidney Replacement Therapy in Australia and New Zealand

Introduction

The incidence and outcomes of kidney replacement therapy (KRT) have been well-studied in adults, but much less so in children. This study aimed to investigate the epidemiology and outcomes of KRT in children in Australia and New Zealand from 2000 to 2020.

Methods

Children aged <18 years initiating KRT in Australia and New Zealand between January 1, 2000 and December 31, 2020 and reported to the Australia and New Zealand Dialysis and Transplant Registry were included. Patient survival, technique-survival, and graft survival were analyzed by Cox regression analyses.

Results

Overall, 1058 children (median [interquartile range (IQR)] age 11 [5-15] years, 41% female, 66% White) were followed-up with for a median period of 12.3 years. First KRT modalities were peritoneal dialysis (PD; 48%), hemodialysis (HD; 34%), and kidney transplantation (KT; 18%). Pre-emptive KT incidence was highest in Caucasian children (80.4%) and lowest in the Indigenous population (3.2%). There was no difference in 5-year patient survival rates between 2011 and 2020 (96.9%, 95% confidence interval [CI] 93.8-98.4) and the preceding decade, 2000-2010 (94.5%, 95% CI 90.4-96.8) (P = 0.79). There was no difference in 5-year death-censored technique survival between 2011 and 2020 (51.2%, 95% CI 39.1-62) and 2000-2010 (48.8%, 95% CI 40.5-56.6) (P = 0.27). However, 5-year derath-censored graft survival was significantly higher in 2011-2020 (88.4%, 95% CI 84.6-91.4) than in 2000-2010 (84.3%, 95% CI 80.4-87.5) (P < 0.001).

Conclusions

PD is the most commonly prescribed KRT modality for children in Australia and New Zealand. Patient-survival, technique-survival, and graft survival rates are excellent and graft survival has improved over the last 2 decades.

Enhancing healthcare quality and outcomes for peritoneal dialysis patients in Thailand: An evaluation of key performance indicators and PDOPPS cohort representativeness

AIM

To assess whether the peritoneal dialysis (PD) centres included in the Peritoneal Dialysis Outcomes and Practise Patterns Study (PDOPPS) in Thailand are representative of other PD centres in the country, based on 8 key performance indicators (KPIs 1-8).

METHODS

A retrospective analysis was conducted comparing PD-related clinical outcomes between PD centres included in the PDOPPS (the PDOPPS group) and those not included (the non-PDOPPS group) from January 2018 to December 2019. Logistic regression analysis was used to identify predictors associated with achieving the target KPIs.

RESULTS

Of 181 PD centres, 22 (12%) were included in the PDOPPS. PD centres in the PDOPPS group were larger and tended to serve more PD patients than those in the non-PDOPPS group. However, the process and outcome KPIs (KPIs 1-8) were comparable between the 2 groups. Large hospitals (≥120 beds), providing care to ≥100 PD cases and having experience for >10 years were independent predictors of achieving the peritonitis rate target of <0.5 episodes/year. Most PD centres in Thailand showed weaknesses in off-target haemoglobin levels and culture-negative peritonitis rate.

CONCLUSIONS

The PD centres included in Thai PDOPPS were found to be representative of other PD centres in Thailand in terms of clinical outcomes. Thus, Thai PDOPPS findings may apply to the broader PD population in Thailand.

Peritoneal dialysis after failed kidney allograft: Comparing patients with and without pd before transplant

BACKGROUND

The result of published studies on the clinical outcome of peritoneal dialysis (PD) after kidney allograft failure is conflicting. There are also few published data on the outcome of patients who had PD before kidney transplant and then return to PD after allograft failure.

METHODS

We reviewed 100 patients who were started on PD after kidney allograft failure between 2001 and 2020 (failed transplant group); 50 of them received PD before transplant. We compared the clinical outcome to 200 new PD patients matched for age, sex, and diabetic status (control group).

RESULTS

The patients were followed for 45.8 ± 40.5 months. the 2-year patient survival rate was 83.3% and 87.8% for the failed transplant and control groups, respectively (log rank test, p = 0.2). The corresponding 2-year technique survival rate 66.5% and 71.7% (p = 0.5). The failed transplant and control groups also had similar hospitalization rate and peritonitis rate. In the failed transplant group, there was also no difference in patient survival, technique survival, hospitalization, or peritonitis rate between those with and without PD before transplant. In the failed transplant group, patients who had PD before transplant and then returned to PD after allograft failure had substantial increase in D/P4 (0.585 ± 0.130 to 0.659 ± 0.111, paired t-test, p = 0.032) and MTAC creatinine (7.74 ± 3.68 to 9.73 ± 3.00 ml/min/1.73m2, p = 0.047) from the time before the transplant to the time after PD was resumed after failed allograft.

CONCLUSIONS

The clinical outcome of PD patients with a failed kidney allograft is similar to other PD patients. However, patients who have a history of PD before kidney transplant and then return to PD after allograft failure have increased peritoneal transport parameters.

Home hemodialysis technique survival: insights and challenges

Home hemodialysis (HHD) offers several clinical, quality of life and cost-saving benefits for patients with end-stage kidney disease. While uptake of this modality has increased in recent years, its prevalence remains low and high rates of discontinuation remain a challenge. This comprehensive narrative review aims to better understand what is currently known about technique survival in HHD patients, elucidate the clinical factors that contribute to attrition and expand on possible strategies to prevent discontinuation. With increasing efforts to encourage home modalities, it is imperative to better understand technique survival and find strategies to help maintain patients on the home therapy of their choosing. It is crucial to better target high-risk patients, examine ideal training practices and identify practices that are potentially modifiable to improve technique survival.

Continuous quality improvement in peritoneal dialysis: Your questions answered

Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.

Under-Recognized Pathogens in Peritoneal Dialysis Associated-Peritonitis: The Importance of Early Detection

Peritoneal dialysis-associated-peritonitis remains a major concern, increasing patient morbidity and mortality. Empirical antibiotics should be quickly started to allow a rapid resolution of symptoms and preservation of the peritoneal membrane. We report a case of peritoneal dialysis-associated-peritonitis due to Prevotella salivae and Corynebacterium jeikeium, in a 51-year-old male. Suspected peritonitis led to an immediate prescription of vancomycin and ceftazidime, with no clinical improvement. Prevotella is difficult to identify in culture since it's a gram-negative anaerobic bacterium, so metronidazole administration was delayed over days. New diagnostic techniques have been explored for the early diagnosis of peritonitis, including polymerase chain reaction (PCR) for bacterial DNA fragments. A multiplex PCR panel that includes Prevotella, already available for other applications, could be an advantage in cases like this.

Catheter insertion techniques for improving catheter function and clinical outcomes in peritoneal dialysis patients

BACKGROUND

Peritoneal dialysis (PD) relies on the optimal functionality of the flexible plastic PD catheter present within the peritoneal cavity to enable effective treatment. As a result of limited evidence, it is uncertain if the PD catheter's insertion method influences the rate of catheter dysfunction and, thus, the quality of dialysis therapy. Numerous variations of four basic techniques have been adopted in an attempt to improve and maintain PD catheter function. This review evaluates the association between PD catheter insertion technique and associated differences in  PD catheter function and post-PD catheter insertion complications OBJECTIVES: Our aims were to 1) evaluate if a specific technique used for PD catheter insertion has lower rates of PD catheter dysfunction (early and late) and technique failure; and 2) examine if any of the available techniques results in a reduction in post-procedure complication rates including postoperative haemorrhage, exit-site infection and peritonitis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 24 November 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) examining adults and children undergoing PD catheter insertion. The studies examined any two PD catheter insertion techniques, including laparoscopic, open-surgical, percutaneous and peritoneoscopic insertion. Primary outcomes of interest were PD catheter function and technique survival.  DATA COLLECTION AND ANALYSIS: Two authors independently performed data extraction and assessed the risk of bias for all included studies. Main outcomes in the Summary of Findings tables include primary outcomes - early PD catheter function, long-term PD catheter function, technique failure and postoperative complications. A random effects model was used to perform meta-analyses; risk ratios (RRs) were calculated for dichotomous outcomes, and mean differences (MD) were calculated for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. The certainty of the evidence was evaluated using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.  MAIN RESULTS: Seventeen studies were included in this review. Nine studies were suitable for inclusion in quantitative meta-analysis (670 randomised participants). Five studies compared laparoscopic with open PD catheter insertion, and four studies compared a 'medical' insertion technique with open surgical PD catheter insertion: percutaneous (2) and peritoneoscopic (2). Random sequence generation was judged to be at low risk of bias in eight studies. Allocation concealment was reported poorly, with only five studies judged to be at low risk of selection bias. Performance bias was judged to be high risk in 10 studies. Attrition bias and reporting bias were judged to be low in 14 and 12 studies, respectively. Six studies compared laparoscopic PD catheter insertion with open surgical insertion. Five studies could be meta-analysed (394 participants). For our primary outcomes, data were either not reported in a format that could be meta-analysed (early PD catheter function, long-term catheter function) or not reported at all (technique failure). One death was reported in the laparoscopic group and none in the open surgical group. In low certainty evidence, laparoscopic PD catheter insertion may make little or no difference to the risk of peritonitis (4 studies, 288 participants: RR 0.97, 95% CI 0.63 to 1.48; I² = 7%), PD catheter removal (4 studies, 257 participants: RR 1.15, 95% CI 0.80 to 1.64; I² = 0%), and dialysate leakage (4 studies, 330 participants: RR 1.40, 95% CI 0.49 to 4.02; I² = 0%), but may reduce the risk of haemorrhage (2 studies, 167 participants: RR 1.68, 95% CI 0.28 to 10.31; I² = 33%) and catheter tip migration (4 studies, 333 participants: RR 0.43, 95% CI 0.20 to 0.92; I² = 12%). Four studies compared a medical insertion technique with open surgical insertion (276 participants). Technique failure was not reported, and no deaths were reported (2 studies, 64 participants). In low certainty evidence, medical insertion may make little or no difference to early PD catheter function (3 studies, 212 participants: RR 0.73, 95% CI 0.29 to 1.83; I² = 0%), while one study reported long-term PD function may improve with peritoneoscopic insertion (116 participants: RR 0.59, 95% CI 0.38 to 0.92). Peritoneoscopic catheter insertion may reduce the episodes of early peritonitis (2 studies, 177 participants: RR 0.21, 95% CI 0.06 to 0.71; I² = 0%) and dialysate leakage (2 studies, 177 participants: RR 0.13, 95% CI 0.02 to 0.71; I² = 0%). Medical insertion had uncertain effects on catheter tip migration (2 studies, 90 participants: RR 0.74, 95% CI 0.15 to 3.73; I² = 0%). Most of the studies examined were small and of poor quality, increasing the risk of imprecision. There was also a significant risk of bias therefore cautious interpretation of results is advised.

AUTHORS' CONCLUSIONS

The available studies show that the evidence needed to guide clinicians in developing their PD catheter insertion service is lacking. No PD catheter insertion technique had lower rates of PD catheter dysfunction. High-quality, evidence-based data are urgently required, utilising multi-centre RCTs or large cohort studies, in order to provide definitive guidance relating to PD catheter insertion modality.

A different PET test: The relationship between pet ownership and peritonitis risk in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Pet ownership is common around the world, with pet ownership increasing in many countries. Current guidelines are not supportive of pet ownership for peritoneal dialysis (PD) patients. We examined the association between ownership of cats and dogs and the incidence of peritonitis among PD patients participating in the prospective, observational Peritoneal Dialysis Outcomes and Practice Patterns Study. A total of 3655 PD patients from eight different countries was included, with a median follow-up of 14 months and a total exposure time of 55,475 patient-months. There were 1347 peritonitis episodes with an overall peritonitis rate of 0.29 episodes per patient year. There was no significant increased risk of peritonitis with any type of pet ownership, adjusted hazard ratio (HR) of 1.09 (95% confidence interval (95% CI): 0.96-1.25). However, patients who owned both cats and dogs had an increased risk of peritonitis compared to patients without pets, HR = 1.45 (95% CI: 1.14-1.86). These results suggest that there is no increased risk of peritonitis with pet ownership except for those with both cats and dogs. This information should not prevent PD patients from owning pets but may be helpful for PD patients and their care team to direct training to minimise the risk of peritonitis.

Technique failure in peritoneal dialysis: Modifiable causes and patient-specific risk factors

BACKGROUND

Technique survival is a core outcome for peritoneal dialysis (PD), according to Standardized Outcomes in Nephrology-Peritoneal Dialysis. This study aimed to identify modifiable causes and risk factors of technique failure in a large Dutch cohort using standardised definitions.

METHODS

Patients who participated in the retrospective Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes cohort study and started PD between 2012 and 2016 were included and followed until 1 January 2017. The primary outcome was technique failure, defined as transfer to in-centre haemodialysis for ≥ 30 days or death. Death-censored technique failure was analysed as secondary outcome. Cox regression models and competing risk models were used to assess the association between potential risk factors and technique failure.

RESULTS

A total of 695 patients were included, of whom 318 experienced technique failure during follow-up. Technique failure rate in the first year was 29%, while the death-censored technique failure rate was 23%. Infections were the most common modifiable cause for technique failure, accounting for 20% of all causes during the entire follow-up. Leakage and catheter problems were important causes within the first 6 months of PD treatment (both accounting for 15%). APD use was associated with a lower risk of technique failure (hazard ratio 0.66, 95% confidence interval 0.53-0.83).

CONCLUSION

Infections, leakage and catheter problems were important modifiable causes for technique failure. As the first-year death-censored technique failure rate remains high, future studies should focus on infection prevention and catheter access to improve technique survival.

Gout Prevalence, Practice Patterns, and Associations with Outcomes in North American Dialysis Patients

INTRODUCTION

Gout occurs frequently in patients with kidney disease and can lead to a significant burden on quality of life. Gout prevalence, and its association with outcomes in hemodialysis (HD) and peritoneal dialysis (PD) populations located in North America, is unknown.

METHODS

We used data from North America cohorts of 70,297 HD patients (DOPPS, 2012-2020) and 5117 PD patients (PDOPPS, 2014-2020). We used three definitions of gout for this analysis: (1) having an active prescription for colchicine or febuxostat; (2) having an active prescription for colchicine, febuxostat, or allopurinol; or (3) having an active prescription for colchicine, febuxostat, or allopurinol, or prior diagnosis of gout. Propensity score matching was used to compare outcomes among patients with versus without gout. Outcomes included erythropoietin resistance index (ERI=erythropoiesis stimulating agent dose per week/(hemoglobin×weight)), all-cause mortality, hospitalization, and patient-reported outcomes (PROs).

RESULTS

The gout prevalence was 13% in HD and 21% in PD; it was highest among incident dialysis patients. Description of previous history of gout was rare, and identification of gout defined by colchicine (2%-3%) or febuxostat (1%) prescription was less frequent than by allopurinol (9%-12%). Both HD and PD patients with gout (versus no gout) were older, were more likely male, had higher body mass index, and had higher prevalence of cardiovascular comorbidities. About half of patients with a gout history were prescribed urate-lowering therapy. After propensity score matching, mean ERI was 3%-6% higher for gout versus non-gout patients while there was minimal evidence of association with clinical outcomes or PROs.

CONCLUSION

In a large cohort of PD and HD patients in North America, we found that gout occurs frequently and is likely under-reported. Gout was not associated with adverse clinical or PROs.

Assisted peritoneal dialysis performed by caregivers and its association with patient outcomes

BACKGROUND

Although caregivers allow peritoneal dialysis (PD) patients with disabilities the opportunity to perform PD, it is crucial to clarify the safety and effectiveness of assisted PD performed by caregivers compared to self-PD.

METHODS

PD patients from 22 PD centres in Thailand were prospectively followed in the Peritoneal Dialysis Outcomes and Practice Patterns Study during 2016-2017. Patients receiving assisted PD performed by caregivers were matched 1:1 with self-PD patients using propensity scores calculated by logistic regression. The associations between assisted PD and risk of mortality, peritonitis and permanent transfer to haemodialysis (HD) were assessed by multivariable competing risk regression.

RESULTS

Of 778 eligible patients, 447 (57%) required assisted PD performed by caregivers. Most of the caregivers were family members (98%), while the rest were non-family paid caregivers (2%). Patient factors associated with assisted PD were older age, female gender, lower educational level, cardiovascular comorbidities, diabetes, automated PD modality, poorer functional status and lower blood chemistries (albumin, creatinine, sodium, potassium and phosphate). After 1:1 matching, the baseline characteristics were adequately matched, and 269 patients in each group were analysed. Compared with self-PD, assisted PD was significantly associated with an increased risk of all-cause mortality (adjusted sub-hazard ratio: 2.15, 95% confidence interval: 1.24-3.74). There were no differences in the occurrences of peritonitis and permanent HD transfer between the groups.

CONCLUSIONS

Assisted PD was required by more than half of Thai PD patients and was independently associated with a higher mortality risk. This may reflect causal effect or confounding by indication.

Historical overview and current practice of peritoneal dialysis in Japan

In the early days of peritoneal dialysis (PD) therapy, its limited duration and peritoneal deterioration were argued to be its disadvantages. Biocompatible solutions and hybrid therapy have been used in Japan to overcome these issues, which resulted in a decrease in encapsulating peritoneal sclerosis (EPS) incidence and an extension of PD continuation; these results have been disseminated worldwide. Peritoneal dialysis outcomes and practice patterns study (PDOPPS), a prospective observational study, has begun to confirm the outcomes of PD therapy, and sufficient evidence has been published, which has influenced the preparation of PD guidelines. Current thinking about PD emphasizes the need to maintain quality of life and life goals as care goals for patients and to provide high-quality care. However, we must conduct basic research on the prevention of peritoneal deterioration.

Association of single and serial measures of serum phosphorus with adverse outcomes in patients on peritoneal dialysis: results from the international PDOPPS

BACKGROUND

While high serum phosphorus levels have been related to adverse outcomes in hemodialysis patients, further investigation is warranted in persons receiving peritoneal dialysis (PD).

METHODS

Longitudinal data (2014-17) from the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), a prospective cohort study, were used to examine associations of serum phosphorus with all-cause mortality and major adverse cardiovascular events via Cox regression adjusted for confounders. Serum phosphorus levels were parameterized by four methods: (i) baseline serum phosphorus; (ii) mean 6-month serum phosphorus; (iii) number of months with serum phosphorus >4.5 mg/dL; and (iv) mean area-under-the-curve of 6-month serum phosphorus control.

RESULTS

The study included 5847 PD patients from seven countries; 9% of patients had baseline serum phosphorus <3.5 mg/dL, 24% had serum phosphorus ≥3.5 to ≤4.5 mg/dL, 30% had serum phosphorus >4.5 to <5.5 mg/dL, 20% had serum phosphorus ≥5.5 to <6.5 mg/dL, and 17% had serum phosphorus ≥6.5 mg/dL. Compared with patients with baseline serum phosphorus ≥3.5 to ≤4.5 mg/dL, the adjusted all-cause mortality hazard ratio (HR) was 1.19 (0.92,1.53) for patients with baseline serum phosphorus ≥5.5 to <6.5 mg/dL and HR was 1.53 (1.14,2.05) for serum phosphorus ≥6.5 mg/dL. Associations between serum phosphorus measurements over 6 months and clinical outcomes were even stronger than for a single measurement.

CONCLUSIONS

Serum phosphorus >5.5 mg/dL was highly prevalent (37%) in PD patients, and higher serum phosphorus levels were a strong predictor of morbidity and death, particularly when considering serial phosphorus measurements. This highlights the need for improved treatment strategies in this population. Serial serum phosphorus measurements should be considered when assessing patients' risks of adverse outcomes.

Time on Therapy of Automated Peritoneal Dialysis with and without Remote Patient Monitoring: A Cohort Study

Background. Remote patient monitoring (RPM) of patients undergoing automated peritoneal dialysis (APD-RPM) may potentially enhance time on therapy due to possible improvements in technique and patient survival. Objective. To evaluate the effect of APD-RPM as compared to APD without RPM on time on therapy. Methods. Adult incident APD patients undergo APD for 90 days or more in the Baxter Renal Care Services (BRCS) Colombia network between January 1, 2017, and June 30, 2019, with the study follow-up ending June 30, 2021. The exposure variable was APD-RPM vs. APD-without RPM. The outcomes of time on therapy and mortality rate over two years of follow-up were estimated in the full sample and in a matched population according to the exposure variable. A propensity score matching (PSM) 1:1 without replacement utilizing the nearest neighbor within caliper (0.035) was used and created a pseudopopulation in which the baseline covariates were well balanced. Fine & Gray multivariate analysis was performed to assess the effect of demographic, clinical, and laboratory variables on the risk of death, adjusting for the competing risks of technique failure and kidney transplantation. Results. In the matched sample, the time on APD therapy was significantly longer in the RPM group than in the non-RPM group, 18.95 vs. 15.75 months, $p<0.001$ . The mortality rate did not differ between the two groups: 0.10 events per patient-year in the RPM group and 0.12 in the non-RPM group, $p=0.325$ . Conclusion. Over two years of follow-up, the use of RPM vs. no RPM in APD patients was associated with a significant increase in time on therapy, by 3.2 months. This result indicates that RPM-supported APD therapy may improve the clinical effectiveness and the overall quality of APD.

Peritoneal dialysis in the modern era

The practice and clinical outcomes of peritoneal dialysis (PD) have demonstrated significant improvement over the past 20 years. The aim of this review is to increase awareness and update healthcare professionals on current PD practice, especially with respect to patient and technique survival, patient modality selection, pathways onto PD, understanding patient experience of care and use prior to kidney transplantation. These improvements have been impacted, at least in part, by greater emphasis on shared decision-making in dialysis modality selection, the use of advanced laparoscopic techniques for PD catheter implantation, developments in PD connecting systems, glucose-sparing strategies, and modernising technology in managing automated PD patients remotely. Evidence-based clinical guidelines such as those prepared by national and international societies such as the International Society of PD have contributed to improved PD practice underpinned by a recognition of the place of continuous quality improvement processes.

Oral Health-Related Quality of Life, A Proxy of Poor Outcomes in Patients on Peritoneal Dialysis

Introduction

We sought to evaluate the associations of poor oral health hygiene with clinical outcomes in patients receiving peritoneal dialysis (PD).

Methods

As part of the multinational Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 participating PD centers throughout Thailand were enrolled from May 2016 to December 2019. The data were obtained from questionnaires that formed part of the PDOPPS. Oral health-related quality of life (HRQoL) used in this study was the short form of the oral health impact profile (oral health impact profile [OHIP]-14, including 7 facets and 14 items). Patient outcomes were assessed by Kaplan-Meier analysis. Cox proportional hazards model regression was used to estimate associations between oral HRQoL and clinical outcomes.

Results

Of 5090 PD participants, 675 were randomly selected, provided informed consent, and completely responded to the OHIP-14 questionnaire. The median follow-up time of the study was 3.5 (interquartile range = 2.7–5.1 months) years. Poor oral health was associated with lower educational levels, diabetes, older age, marriage, and worse nutritional indicators (including lower time-averaged serum albumin and phosphate concentrations). After adjusting for age, sex, comorbidities, serum albumin, shared frailty by study sites, and PD vintage, poor oral health was associated with increased risks of peritonitis (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI]: 1.06–2.00) and all-cause mortality (adjusted HR = 1.55, 95% CI: 1.04–2.32) but not hemodialysis (HD) transfer (adjusted HR = 1.89, 95% CI: 0.87–4.10) compared to participants with good oral health.

Conclusion

Poor oral health status was present in one-fourth of PD patients and was independently associated with a higher risk of peritonitis and death.

Variation in Peritoneal Dialysis Time on Therapy by Country: Results from the Peritoneal Dialysis Outcomes and Practice Patterns Study

BACKGROUND AND OBJECTIVES

Quantifying contemporary peritoneal dialysis time on therapy is important for patients and providers. We describe time on peritoneal dialysis in the context of outcomes of hemodialysis transfer, death, and kidney transplantation on the basis of the multinational, observational Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) from 2014 to 2017.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 218 randomly selected peritoneal dialysis facilities (7121 patients) in the PDOPPS from Australia/New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States, we calculated the cumulative incidence from peritoneal dialysis start to hemodialysis transfer, death, or kidney transplantation over 5 years and adjusted hazard ratios for patient and facility factors associated with death and hemodialysis transfer.

RESULTS

Median time on peritoneal dialysis ranged from 1.7 (interquartile range, 0.8-2.9; the United Kingdom) to 3.2 (interquartile range, 1.5-6.0; Japan) years and was longer with lower kidney transplantation rates (range: 32% [the United Kingdom] to 2% [Japan and Thailand] over 3 years). Adjusted hemodialysis transfer risk was lowest in Thailand, but death risk was higher in Thailand and the United States compared with most countries. Infection was the leading cause of hemodialysis transfer, with higher hemodialysis transfer risks seen in patients having psychiatric disorder history or elevated body mass index. The proportion of patients with total weekly Kt/V ≥1.7 at a facility was not associated with death or hemodialysis transfer.

CONCLUSIONS

Countries in the PDOPPS with higher rates of kidney transplantation tended to have shorter median times on peritoneal dialysis. Identification of infection as a leading cause of hemodialysis transfer and patient and facility factors associated with the risk of hemodialysis transfer can facilitate interventions to reduce these events.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_05_31_CJN16341221.mp3.

International Icodextrin Use and Association with Peritoneal Membrane Function, Fluid Removal, Patient and Technique Survival

BACKGROUND

Icodextrin has been shown in randomized controlled trials to benefit fluid management in peritoneal dialysis (PD). We describe international icodextrin prescription practices and their relationship to clinical outcomes.

METHODS

We analyzed data from the prospective, international PDOPPS, from Australia/New Zealand, Canada, Japan, the United Kingdom, and the United States. Membrane function and 24-hour ultrafiltration according to icodextrin and glucose prescription was determined at baseline. Using an instrumental variable approach, Cox regression, stratified by country, was used to determine any association of icodextrin use to death and permanent transfer to hemodialysis (HDT), adjusted for demographics, comorbidities, serum albumin, urine volume, transplant waitlist status, PD modality, center size, and study phase.

RESULTS

Icodextrin was prescribed in 1986 (35%) of 5617 patients, >43% of patients in all countries, except in the United States, where it was only used in 17% and associated with a far greater use of hypertonic glucose. Patients on icodextrin had more coronary artery disease and diabetes, longer dialysis vintage, lower residual kidney function, faster peritoneal solute transfer rates, and lower ultrafiltration capacity. Prescriptions with or without icodextrin achieved equivalent ultrafiltration (median 750 ml/d [interquartile range 300-1345 ml/d] versus 765 ml/d [251-1345 ml/d]). Icodextrin use was not associated with mortality (HR=1.03; 95% CI, 0.72 to 1.48) or HDT (HR 1.2; 95% CI, 0.92 to 1.57).

CONCLUSIONS

There are large national and center differences in icodextrin prescription, with the United States using significantly less. Icodextrin was associated with hypertonic glucose avoidance but equivalent ultrafiltration, which may affect any potential survival advantage or HDT.

Spiritual Well-Being and Its Relationship with Patient Characteristics and Other Patient-Reported Outcomes in Peritoneal Dialysis Patients: Findings from the PDOPPS

BACKGROUND

Spiritual well-being (SWB), an individual's understanding of the meaning and purpose of life, may help patients with chronic or terminal illnesses cope with their disease. This study aimed to assess SWB in patients on peritoneal dialysis (PD), as well as its relationship with patient characteristics and patient-reported outcomes (PRO).

METHODS

The data were obtained from questionnaires that formed part of the PD Outcomes and Practice Patterns Study (PDOPPS). Measures used in this study were SWB scores derived from the WHO Quality of Life, Spirituality, Religiousness, and Personal Beliefs (WHOQOL-SRPB) tool including 32 items from 8 facets; physical (PCS) and mental component summary (MCS) scores of the 12-Item Short-Form Health Survey (SF-12), Center of Epidemiologic Studies Depression Scale-10 (CES-D-10) scores, burden of kidney disease scores, and functional status scores.

RESULTS

Overall, 529 out of 848 participants (62%) completely responded to the questionnaires and were included in the analysis. Over two-thirds of PD patients (70%) had moderate or higher SWB scores. The SWB scores were significantly lower in patients with age > 65 years and unemployed status. SWB scores positively correlated with higher PCS, MCS, burden of kidney disease scores, and functional status scores, while negatively correlated with depression scores by CES-D-10 scale. Patients who reported significant depressive symptoms (CES-D-10 score ≥ 10) had significantly lower SWB scores.

CONCLUSION

Better SWB was significantly associated with better health-related QOL (HRQOL) and the absence of depressive symptoms. SWB may be an essential consideration in the delivery of high-quality PD.

Peritoneal dialysis care during the COVID-19 pandemic, Thailand

PROBLEM

The coronavirus disease 2019 (COVID-19) pandemic could affect health service provision of less urgent interventions, such as peritoneal dialysis for chronic kidney disease patients.

APPROACH

To assess how peritoneal dialysis centres in Thailand adapted their provision of care, we invited medical directors and peritoneal dialysis managers to respond to an online survey on 1 July 2021. We asked whether they had modified or deferred their training, catheter insertion or removal, intravenous supplements, follow-up and home visits, and workload.

LOCAL SETTING

Patients needing dialysis receive peritoneal dialysis free of charge in Thailand. As of 31 December 2020, 240 peritoneal dialysis centres in Thailand have provided care to 32 284 patients.

RELEVANT CHANGES

At 24.6% (29/118) of centres, educational sessions for patients were modified. Catheter insertion continued at 71.9% (82/114) of centres. Few facilities (19.7%; 23/117) continued to perform peritoneal equilibration tests as usual. On-site intravenous injections were mostly transferred to health centres close to the patients' homes. Most centres reduced their outpatient follow-up visits (51.7%; 61/118) and stopped visiting patients at home (66.9%; 79/118). Peritoneal dialysis nurses reported an increased workload at 62.7% (74/118) of centres, and in many instances (66.1%; 78/118) were providing nursing care to COVID-19 patients and administering COVID-19 vaccines.

LESSONS LEARNT

Health-care providers altered clinical care activities to protect their patients from COVID-19. However, further evidence is needed on the consequences of such alteration in care. To prepare for future pandemics, actors need to explore nonconventional peritoneal dialysis care as well as financial and nonfinancial incentive mechanisms for such care.

Practice variations in antibiotic administration for the management of peritonitis in patients on automated peritoneal dialysis in Australia and New Zealand

In the absence of guidelines on the management of peritoneal dialysis (PD)-associated peritonitis in patients on automated peritoneal dialysis (APD), variations in clinical practice potentially exist between PD units that could affect clinical outcomes. This study aimed to document the current practices of treating PD-associated peritonitis in patients on APD across Australia and New Zealand and the reasons for practice variations using a cross-sectional online survey. Of the 62 PD units, 34 medical leads (55%) responded to the survey. When treating APD-associated peritonitis, 21 units (62%) continued patients on APD and administered intraperitoneal (IP) antibiotics in manual daytime exchanges; of these, 17 (81%) considered allowing at least 6 h dwell time for adequate absorption of the IP antibiotics as an important reason for adding manual daytime exchange. Nine units (26%) temporarily switched patients from APD to continuous ambulatory peritoneal dialysis (CAPD); of these, five (55%) reported a lack of pharmacokinetic (PK) data for IP antibiotics in APD, four (44%) reported a shortage of APD-trained nursing staff to perform APD exchanges during hospitalisation and three (33%) reported inadequate time for absorption of IP antibiotics on APD as important reasons for their practice. Four units (12%) continued patients on APD and administered IP antibiotics during APD exchanges; of these, three (75%) believed that PK data available in CAPD could be extrapolated to APD. This study demonstrates wide variations in the management of APD-associated peritonitis in Australia and New Zealand; it points towards the lack of PK on antibiotics used to treat peritonitis as an important reason underpinning practice variations.

Representativeness of the PDOPPS cohort compared to the Australian PD population

BACKGROUND

The Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is an international, prospective study following persons treated by peritoneal dialysis (PD) to identify modifiable practices associated with improvements in PD technique and person survival. The aim of this study was to assess the representativeness of the Australian cohort included in PDOPPS compared to the complete Australian PD population, as reported to the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry.

METHODS

Adults with at least one PD treatment reported to ANZDATA Registry during the census period of PDOPPS Phase I (November 2014 to April 2018) were compared to the Australian PDOPPS cohort. The primary outcomes were the representativeness of centres and persons. Secondary outcomes explored the association of person characteristics with consent to study participation.

RESULTS

After data linkage, 511 PDOPPS participants were compared to 5616 Australians treated with PD. Within centres eligible for PDOPPS, selected centres were similar to other Australian centres. The PDOPPS participants' cohort tended to include older persons, more males, a higher proportion of Caucasians and more persons with higher socioeconomic advantage compared to the Australian PD population. Differences in distribution across sex and ethnicities between the PDOPPS cohort and the overall PD population were in part due to the selection and consent processes, during which females and non-Caucasians were more likely to not consent to PDOPPS participation.

CONCLUSION

Sampling methods used in PDOPPS allowed for good national representativeness of the included centres. However, representativeness of the unweighted PDOPPS sample was suboptimal in regard to some participant characteristics.

Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

International peritoneal dialysis training practices and the risk of peritonitis

BACKGROUND

The effects of training practices on outcomes of patients receiving peritoneal dialysis (PD) are poorly understood and there is a lack of evidence informing best training practices. This prospective cohort study aims to describe and compare international PD training practices and their association with peritonitis.

METHODS

Adult patients on PD < 3 months participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) were included. Training characteristics (including duration, location, nurse affiliation, modality, training of family members, use of individual/group training, and use of written/oral competency assessments) were reported at patient and facility levels. Hazard ratio for time to first peritonitis was estimated using Cox models, adjusted for selected patient and facility case-mix variables.

RESULTS

1376 PD patients from 120 facilities across 7 countries were included. Training was most commonly performed at the facility (81%), by facility-affiliated nurses (87%) in a 1:1 setting (79%). In the UK, being trained by both facility and third-party nurses was associated with reduced peritonitis risk (aHR 0.31, 95% CI 0.15-0.62, vs facility nurses only). However, this training practice was utilized in only 5 of 14 UK facilities. No other training characteristics were convincingly associated with peritonitis risk.

CONCLUSIONS

There was no evidence to support that peritonitis risk was associated with when, where, how, or how long PD patients are trained.

Evolving outcomes of peritoneal dialysis: secular trends at a single large center over three decades

Background

Peritoneal dialysis (PD) is improving as a renal replacement therapy for end-stage renal disease (ESRD) patients. We analyzed the main outcomes of PD over the last three decades at a single large-scale PD center with an established high-quality care system.

Methods

As a retrospective cohort study, we included participants (n = 1,203) who began PD between 1990 and 2019. Major PD-related outcomes were compared among the three 10-year cohorts.

Results

The 1,203 participants were 58.3% male with a mean age of 47.9 ± 13.8 years. The median PD treatment duration was 45 months (interquartile range, 19–77 months); 362 patients (30.1%) transferred to hemodialysis, 289 (24.0%) received kidney transplants, and 224 (18.6%) died. Overall, the 5- and 8-year adjust patient survival rates were 64% and 49%, respectively. Common causes of death included infection (n = 55), cardiac (n = 38), and cerebrovascular (n = 17) events. The 5- and 8-year technique survival rates were 77% and 62%, respectively, with common causes of technique failure being infection (42.3%) and solute/water clearance problems (22.7%). The 5-year patient survival significantly improved over time (64% for the 1990–1999 cohort vs. 93% for the 2010–2019 cohort). The peritonitis rate also substantially decreased over time, from 0.278 episodes/patient-year (2000–2004) to 0.162 episodes/patient-year (2015–2019).

Conclusion

PD is an effective treatment option for ESRD patients. There was a substantial improvement in the patient survival and peritonitis rates over time. Establishing adequate infrastructure and an effective system for high-quality PD therapy may be warranted to improve PD outcomes.

Variation in Peritoneal Dialysis-Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

RATIONALE & OBJECTIVE

Peritoneal dialysis (PD)-associated peritonitis is a significant PD-related complication. We describe the likelihood of cure after a peritonitis episode, exploring its association with various patient, peritonitis, and treatment characteristics.

STUDY DESIGN

Observational prospective cohort study.

SETTING & PARTICIPANTS

1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States.

EXPOSURE

Patient characteristics (demographics, patient history, laboratory values), peritonitis characteristics (organism category, concomitant exit-site infection), dialysis center characteristics (use of icodextrin and low glucose degradation product solutions, policies regarding antibiotic self-administration), and peritonitis treatment characteristics (antibiotic used).

OUTCOME

Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode.

ANALYTICAL APPROACH

Mixed-effects logistic models.

RESULTS

Overall, 65% of episodes resulted in a cure. Adjusted odds ratios (AOR) for cure were similar across countries (range, 54%-68%), by age, sex, dialysis vintage, and diabetes status. Compared with Gram-positive peritonitis, the odds of cure were lower for Gram-negative (AOR, 0.41 [95% CI, 0.30-0.57]), polymicrobial (AOR, 0.30 [95% CI, 0.20-0.47]), and fungal (AOR, 0.01 [95% CI, 0.00-0.07]) peritonitis. Odds of cure were higher with automated PD versus continuous ambulatory PD (AOR, 1.36 [95% CI, 1.02-1.82]), facility icodextrin use (AOR per 10% greater icodextrin use, 1.06 [95% CI, 1.01-1.12]), empirical aminoglycoside use (AOR, 3.95 [95% CI, 1.23-12.68]), and ciprofloxacin use versus ceftazidime use for Gram-negative peritonitis (AOR, 5.73 [95% CI, 1.07-30.61]). Prior peritonitis episodes (AOR, 0.85 [95% CI, 0.74-0.99]) and concomitant exit-site infection (AOR, 0.41 [95% CI, 0.26-0.64]) were associated with a lower odds of cure.

LIMITATIONS

Sample selection may be biased and generalizability may be limited. Residual confounding and confounding by indication limit inferences. Use of facility-level treatment variables may not capture patient-level treatments.

CONCLUSIONS

Outcomes after peritonitis vary by patient characteristics, peritonitis characteristics, and modifiable peritonitis treatment practices. Differences in the odds of cure across infecting organisms and antibiotic regimens suggest that organism-specific treatment considerations warrant further investigation.

Mortality, hospitalization and transfer to haemodialysis and hybrid therapy, in Japanese peritoneal dialysis patients

BACKGROUND AND OBJECTIVES

Survival of peritoneal dialysis (PD) patients in Japan is high, but few reports exist on cause-specific mortality, transfer to haemodialysis (HD) or hybrid dialysis and hospitalisation risks. We aimed to identify reasons for transfer to HD, hybrid dialysis and hospitalisation in the Japan Peritoneal Dialysis and Outcomes Practice Patterns Study.

METHODS

This observational study included 808 adult PD patients across 31 facilities in Japan in 2014-2017. Information on all-cause and cause-specific mortality and hospitalisation and permanent transfer to HD and PD/HD hybrid therapy were prospectively collected and rates calculated.

RESULTS

Median follow-up time was 1.66 years where 162 patients transferred to HD, 79 transferred to hybrid dialysis and 74 patients died. All-cause and cardiovascular disease (CVD)-related mortality rates were 5.1 and 1.7 deaths/100 patient-years, respectively. Rates of transfer to HD and hybrid therapy were 11.2 and 5.5 transfers/100 patient-years, respectively. Among HD transfers, 40% were due to infection (including peritonitis), while 20% were due to inadequate solute/water clearance. Eighty-one percent of hybrid dialysis transfers were due to inadequate solute/water clearance. All--cause, peritonitis-related and CVD-related hospitalisation rates were 120.4, 21.1 and 15.6/100 patient-years, respectively. Median hospital length of stay was 19 days.

CONCLUSIONS

Mortality, hospitalisation and transfer to HD/hybrid dialysis rates are relatively low in Japan compared to many other countries with hybrid transfers, accounting for one-third of dialysis transfers from PD. Further study is needed to explain the high inter-facility variation in hospitalisation rates and how to further reduce hospitalisation rates for Japanese PD patients.

Anemia Management in Peritoneal Dialysis: Perspectives From the Asia Pacific Region

Anemia is an important complication in patients with chronic kidney disease. Peritoneal dialysis (PD) is one of the most common modalities of kidney replacement therapy for patients with end-stage kidney disease. PD is particularly prevalent in the Asian Pacific region. Among the different countries and regions, including mainland China, Hong Kong, Japan, Malaysia, Singapore, South Korea, and Thailand, PD accounts for 2.8% to 74.6% of the dialysis population. In addition, 82% to 96% of the PD populations from these countries and regions are receiving erythropoiesis-stimulating agents (ESAs). Asian Pacific countries and regions follow the latest KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for the initiation of treatment of anemia in PD patients. The types of ESAs commonly used include shorter-acting (epoetin alfa and beta) and longer-acting agents, including darbepoetin alfa or methoxy polyethylene glycol-epoetin beta. The most commonly used ESAs in Mainland China, Malaysia, Singapore, and Thailand are the shorter-acting agents, whereas in Hong Kong, Japan, and South Korea, longer-acting ESAs are most common. Oral iron therapy is still the most commonly used iron supplement. The route and dosage of iron administration in PD patients requires more research studies. With the introduction of oral hypoxia-inducible factor prolyl hydroxylase inhibitors into clinical use, the landscape of treatment of anemia in the PD population in the Asia Pacific region may change in the coming years.

Outcome measures for technique survival reported in peritoneal dialysis: A systematic review

BACKGROUND

Peritoneal dialysis (PD) technique survival is an important outcome for patients, caregivers and health professionals, however, the definition and measures used for technique survival vary. We aimed to assess the scope and consistency of definitions and measures used for technique survival in studies of patients receiving PD.

METHOD

MEDLINE, EMBASE and CENTRAL databases were searched for randomised controlled studies (RCTs) conducted in patients receiving PD reporting technique survival as an outcome between database inception and December 2019. The definition and measures used were extracted and independently assessed by two reviewers.

RESULTS

We included 25 RCTs with a total of 3645 participants (41-371 per trial) and follow up ranging from 6 weeks to 4 years. Terminology used included 'technique survival' (10 studies), 'transfer to haemodialysis (HD)' (8 studies) and 'technique failure' (7 studies) with 17 different definitions. In seven studies, it was unclear whether the definition included transfer to HD, death or transplantation and eight studies reported 'transfer to HD' without further definition regarding duration or other events. Of those remaining, five studies included death in their definition of a technique event, whereas death was censored in the other five. The duration of HD necessary to qualify as an event was reported in only four (16%) studies. Of the 14 studies reporting causes of an event, all used a different list of causes.

CONCLUSION

There is substantial heterogeneity in how PD technique survival is defined and measured, likely contributing to considerable variability in reported rates. Standardised measures for reporting technique survival in PD studies are required to improve comparability.

Burden of Kidney Disease, Health-Related Quality of Life, and Employment Among Patients Receiving Peritoneal Dialysis and In-Center Hemodialysis: Findings From the DOPPS Program

RATIONALE & OBJECTIVE

Individuals faced with decisions regarding kidney replacement therapy options need information on how dialysis treatments might affect daily activities and quality of life, and what factors might influence the evolution over time of the impact of dialysis on daily activities and quality of life.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

7,771 hemodialysis (HD) and peritoneal dialysis (PD) participants from 6 countries participating in the Peritoneal and Dialysis Outcomes and Practice Patterns Studies (PDOPPS/DOPPS).

PREDICTORS

Patient-reported functional status (based on daily living activities), country, demographic and clinical characteristics, and comorbidities.

OUTCOME

Employment status and patient-reported outcomes (PROs) including Kidney Disease Quality of Life (KDQOL) instrument physical and mental component summary scores (PCS, MCS), kidney disease burden score, and depression symptoms (Center for Epidemiologic Studies Depression Scale [CES-D] score > 10).

ANALYTICAL APPROACH

Linear regression (PCS, MCS, kidney disease burden score), logistic regression (depression symptoms), adjusted for predictors plus 12 additional comorbidities.

RESULTS

In both dialysis modalities, patients in Japan had the highest PCS and employment (55% for HD and 68% for PD), whereas those in the United States had the highest MCS score, lowest kidney disease burden, and lowest employment (20% in HD and 42% in PD). After covariate adjustment, the association of age, sex, dialysis vintage, diabetes, and functional status with PROs was similar in both modalities, with women having lower PCS and kidney disease burden scores. Lower functional status (score <11) was strongly associated with lower PCS and MCS scores, a much greater burden of kidney disease, and greater likelihood of depression symptoms (CES-D, >10). The median change in KDQOL-based PROs was negligible over 1 year in participants who completed at least 2 annual questionnaires.

LIMITATIONS

Selection bias due to incomplete survey responses. Generalizability was limited to the dialysis populations of the included countries.

CONCLUSIONS

Variation exists in quality of life, burden of kidney disease, and depression across countries but did not appreciably change over time. Functional status remained one of the strongest predictors of all PROs. Routine assessment of functional status may provide valuable insights for patients and providers in anticipating outcomes and support needs for patients receiving either PD or HD.

Methods and rationale of the DISCOVER CKD global observational study

Background

Real-world data for patients with chronic kidney disease (CKD), specifically pertaining to clinical management, metabolic control, treatment patterns, quality of life (QoL) and dietary patterns, are limited. Understanding these gaps using real-world, routine care data will improve our understanding of the challenges and consequences faced by patients with CKD, and will facilitate the long-term goal of improving their management and prognosis.

Methods

DISCOVER CKD follows an enriched hybrid study design, with both retrospective and prospective patient cohorts, integrating primary and secondary data from patients with CKD from China, Italy, Japan, Sweden, the UK and the USA. Data will be prospectively captured over a 3-year period from >1000 patients with CKD who will be followed up for at least 1 year via electronic case report form entry during routine clinical visits and also via a mobile/tablet-based application, enabling the capture of patient-reported outcomes (PROs). In-depth interviews will be conducted in a subset of ∼100 patients. Separately, secondary data will be retrospectively captured from >2 000 000 patients with CKD, extracted from existing datasets and registries.

Results

The DISCOVER CKD program captures and will report on patient demographics, biomarker and laboratory measurements, medical histories, clinical outcomes, healthcare resource utilization, medications, dietary patterns, physical activity and PROs (including QoL and qualitative interviews).

Conclusions

The DISCOVER CKD program will provide contemporary real-world insight to inform clinical practice and improve our understanding of the epidemiology and clinical and economic burden of CKD, as well as determinants of clinical outcomes and PROs from a range of geographical regions in a real-world CKD setting.

Implementation of PDOPPS in a middle-income country: Early lessons from Thailand

BACKGROUND

Despite the implementation of a 'Peritoneal Dialysis (PD) First' policy in Thailand since 2008, nationwide PD practices and patients' outcomes have rarely been reported.

METHODS

As part of the multinational PD Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 PD centres from different geographic regions, sizes and affiliations, representing Thailand PD facilities, have been enrolled starting in May 2016. Demographic, clinical and laboratory data and patients' outcomes were prospectively collected and analysed.

RESULTS

The pilot and implementation phases demonstrated excellent concordance between study data and validation data collected at enrolment. In the implementation phase, 848 PD patients (including 262 (31%) incident PD patients) were randomly sampled from 5090 patients in participating centres. Almost all participants (95%) performed continuous ambulatory PD (CAPD), and a high proportion had hypoalbuminemia (67%, serum albumin < 3.5 g/dL), anaemia (42%, haemoglobin <10 g/dL) and hypokalaemia (37%, serum potassium < 3.5 mmol/L). The peritonitis rate was 0.40 episodes/year, but the culture-negative rate was high (0.13 episodes/year, 28% of total episodes). The patients from PD clinics located in Bangkok metropolitan region had higher socio-economic status, more optimal nutritional markers, blood chemistries, haemoglobin level and lower peritonitis rates compared to the provincial regions, emphasizing the centre effect on key success factors in PD.

CONCLUSIONS

Participation in the PDOPPS helps unveil the critical barriers to improving outcomes of PD patients in Thailand, including a high prevalence of hypokalaemia, anaemia, poor nutritional status and culture-negative peritonitis. These factors should be acted upon to formulate solutions and implement quality improvement on a national level.

Study of early complications associated with peritoneal dialysis catheters: an analysis of the New Zealand Peritoneal Dialysis Registry data

INTRODUCTION

Early peritoneal dialysis catheter (PDC)-related complications are frequent and make an important contribution to long-term PD survival. We aimed to analyse the incidence and specific causes of early PDC-related complications.

METHODS

This study was conducted from January 2001 to December 2012, utilising the New Zealand PD Registry (NZPDR) data. The objectives of this study were to analyse the incidence and causes of PDC-related complications within 4 weeks and 3 months of insertion. A logistic regression analysis was conducted to analyse any demographic or clinical risk factors of early PDC-related complications.

RESULTS

Of the 2573 PDC insertions during this period, majority 88% were surgically inserted. The number of complication within 4 weeks ranged from minimum of 20% to a maximum of 34% annually, with infections and flow dysfunctions leading the causes. There has been a minor drop in the infection rates from 19 to 16% (p = 0.21), and flow dysfunction from 12 to 9% (p = 0.16), from 2001 to 2012. A reduced odds of early complication was noted in elderly individuals above 60 years age, with odds ratio of (OR) of 0.73 (95% CI 0.53-0.99), while as higher odds of early complications were recorded in female gender, OR 1.41 (95% CI 1.06-1.88). Of the 10% of patients who failed to initiate PD within 90 days, flow dysfunction contributed to 32%, followed by infectious and surgical causes in 16% and 15%, respectively. The median time from insertion of PDC to initiation of PD was 17 days (interquartile range of 14-24 days) CONCLUSIONS: Improvements in PDC insertion techniques and reduction in infection rates may result in improvements in long-term PD technique 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.

Association between self-reported appetite and clinical outcomes of peritoneal dialysis patients: Findings from a low middle-income country

AIM

Patient-reported outcome measures (PROM) has gained international recognition as important predictors of clinical outcomes in peritoneal dialysis (PD). We sought to understand the associations between patient-reported appetite and clinical outcomes.

METHODS

In the Thailand Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), 690 of 848 randomly selected PD patients from 22 facilities reported their appetite by using the short form (three items) of the Appetite and Diet Assessment Tool (ADAT), between 2016 and 2018. In this questionnaire, the patients rated their appetite as well as a change in appetite over time. Cox proportional hazards model regression was used to estimating associations between self-reported appetite and clinical outcomes, including mortality, haemodialysis (HD) transfer and peritonitis.

RESULTS

Half of the PD patients reported a good appetite, whereas 34% and 16% reported fair and poor appetites, respectively. Poor appetite was more prevalent among female, diabetic, congestive heart failure, older age and patients who had worse nutritional indicators, including lower time-averaged serum albumin and serum creatinine concentrations, as well as a higher proportions of hypokalaemia and severe hypoalbuminemia (serum albumin <3 g/dl). After adjusting for age, sex, comorbidities, and PD vintage, poor appetite was associated with increased risks of peritonitis (adjusted hazard ratio [HR] 1.73, 95% confidence interval [CI] 1.14-2.62), HD transfer (adjusted HR 2.25, 95% CI 1.24-4.10) and all-cause mortality (adjusted HR 1.60, 95% CI 1.08-2.39) compared to patients with good appetite.

CONCLUSION

Patient-reported poor appetite was independently associated with higher risks of peritonitis, HD transfer and all-cause mortality. This warrants further investigation to identify effective interventions.

Association of Local Unit Sampling and Microbiology Laboratory Culture Practices With the Ability to Identify Causative Pathogens in Peritoneal Dialysis-Associated Peritonitis in Thailand

Introduction

This describes variations in facility peritoneal dialysis (PD) effluent (PDE) culture techniques and local microbiology laboratory practices, competencies, and quality assurance associated with peritonitis, with a specific emphasis on factors associated with culture-negative peritonitis (CNP).

Methods

Peritonitis data were prospectively collected from 22 Thai PD centers between May 2016 and October 2017 as part of the Peritoneal Dialysis Outcomes and Practice Patterns Study. The first cloudy PD bags from PD participants with suspected peritonitis were sent to local and central laboratories for comparison of pathogen identification. The associations between these characteristics and CNP were evaluated.

Results

CNP was significantly more frequent in local laboratories (38%) compared with paired PDE samples sent to the central laboratory (12%, P < 0.05). Marked variations were observed in PD center practices, particularly with respect to specimen collection and processing, which often deviated from International Society for Peritoneal Dialysis Guideline recommendations, and laboratory capacities, capabilities, and certification. Lower rates of CNP were associated with PD nurse specimen collection, centrifugation of PDE, immediate transfer of samples to the laboratory, larger hospital size, larger PD unit size, availability of an on-site nephrologist, higher laboratory capacity, and laboratory ability to perform aerobic cultures, undertake standard operating procedures in antimicrobial susceptibilities, and obtain local accreditation.

Conclusion

There were large variations in PD center and laboratory capacities, capabilities, and practices, which in turn were associated with the likelihood of culturing and correctly identifying organisms responsible for causing PD-associated peritonitis. Deviations in practice from International Society for Peritoneal Dialysis guideline recommendations were associated with higher CNP rates.

The Peritoneal Dialysis Telemedicine-assisted Platform Cohort (PDTAP) Study: Design and methods

OBJECTIVES

The primary objective of the Peritoneal Dialysis Telemedicine-assisted Platform Cohort (PDTAP) Study is to explore potential predictors and their effects on patient survival, technique survival, and the occurrence of infectious and noninfectious complications.

DESIGN

The PDTAP study is a national-level cohort study in China. A newly developed PD telemedicine application provided a unique and convenient way to collect multicenter, structured data across units.

SETTING

The PDTAP study was underway in 27 hospitals from 14 provinces located at 7 geographical regions (northwest, northeast, north, central, southwest, southeast, and south) in China.

PARTICIPANTS

Our study aims to enroll at least 7000 adult patients with end-stage renal disease receiving PD.

METHODS

Approval has been obtained through the ethics committees of all hospitals. All participants signed the informed consent form after the center had received ethics board approval in accordance with the Declaration of Helsinki.

MAIN OUTCOME MEASURES

Patient survival, technique survival, hospitalization, and the occurrence of infectious and noninfectious complications.

CONCLUSIONS

The PDTAP study aims to explore potential predictors and their effects on patient survival, technique survival, and infectious and noninfectious complications using a newly developed PD telemedicine system to collect multicenter, structured data in real-world practice. Substantial and transformable findings in relation to PD practices were expected. This study also developed a national-level infrastructure for further collaboration and ancillary investigation.

Low Serum Potassium Levels and Clinical Outcomes in Peritoneal Dialysis-International Results from PDOPPS

Introduction

Hypokalemia, including normal range values <4 mEq/l, has been associated with increased peritonitis and mortality in patients with peritoneal dialysis. This study sought to describe international variation in hypokalemia, potential modifiable hypokalemia risk factors, and the covariate-adjusted relationship of hypokalemia with peritonitis and mortality.

Methods

Baseline serum potassium was determined in 7421 patients from 7 countries in the Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2017). Association of baseline patient and treatment factors with subsequent serum potassium <4 mEq/l was evaluated by logistic regression, whereas baseline serum potassium levels (4-month average and fraction of 4 months having hypokalemia) on clinical outcomes was assessed by Cox regression.

Results

Hypokalemia was more prevalent in Thailand and among black patients in the United States. Characteristics/treatments associated with potassium <4 mEq/l included protein-energy wasting indicators, lower urine volume, lower blood pressure, higher dialysis dose, greater diuretic use, and not being prescribed a renin-angiotensin system inhibitor. Persistent hypokalemia (all 4 months vs. 0 months over the 4-month exposure period) was associated with 80% higher subsequent peritonitis rates (at K <3.5 mEq/l) and 40% higher mortality (at K <4.0 mEq/l) after extensive case mix/potential confounding adjustments. Furthermore, adjusted peritonitis rates were higher if having mean serum K over 4 months <3.5 mEq/l versus 4.0-4.4 mEq/l (hazard ratio, 1.15 [95% confidence interval, 0.96-1.37]), largely because of Gram-positive/culture-negative infections.

Conclusions

Persistent hypokalemia is associated with higher mortality and peritonitis even after extensive adjustment for patient factors. Further studies are needed to elucidate mechanisms of these poorer outcomes and modifiable risk factors for persistent hypokalemia.