Peritoneal Dialysis-Related Infection in the Older Population

Total knee arthroplasty in dialysis patients: a national in-patient sample-based study of perioperative complications

BACKGROUND

Chronic kidney disease (CKD) is a growing disease that affects millions of people in the USA every year. Many CKD patients progress to end-stage renal disease (ESRD), necessitating the use of hemodialysis to alleviate symptoms and manage kidney function. Furthermore, many of these patients have lower bone quality and experience more postoperative complications. However, there is currently limited information on hospitalization information and perioperative complications in this population following procedures such as total knee arthroplasty (TKA). The purpose of this study was to assess the patient characteristics, demographics, and prevalence of postoperative problems among dialysis patients who received TKA.

METHODS

In this retrospective study, we used the Nationwide Inpatient Sample (NIS) data from 2016 to 2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as dialysis patients, compared with those who were not. Propensity matching was conducted to consider associated factors that may influence perioperative complications.

RESULTS

From 2016 to 2019, 558,371 patients underwent TKAs, according to the National In-Sample (NIS) database. Of those, 418 patients (0.1%) were in the dialysis group, while the remaining 557,953 patients were included in the control group. The mean age of the dialysis group was 65.4 ± 9.8 years, and the mean age in the control group was 66.7 ± 9.5 years (p = 0.006). After propensity matching, dialysis group patients had a higher risk of receiving blood transfusions [odds ratio (OR): 2; 95% confidence interval (CI): 1.2, 3.4] and a significantly larger COC in comparison to those in the control group (91,434.3 USD versus 71,943.6 USD, p < 0.001). In addition, dialysis patients had significantly higher discharges to another facility, as compared with the control group patients.

CONCLUSIONS

The dialysis group had a significantly higher cost of care, higher rates of requiring blood transfusion, and more cases of being discharged to another facility than non-dialysis patients. This data will help providers make informed decisions about patient care and resource allocation for dialysis patients undergoing TKA.

Home dialysis in older adults: challenges and solutions

There is a rising demand for dialysis in the older population given the increased numbers of older adults living with chronic kidney disease (CKD) progressing to kidney failure. Home dialysis, i.e. peritoneal dialysis (PD) and home hemodialysis (HHD), has been available for decades, but more recently there has been a rapid increase in home dialysis utilization as patients and clinicians consider its practical and clinical advantages. For older adults, incident home dialysis utilization more than doubled and prevalent home dialysis growth nearly doubled over the past decade. Whilst its advantages and recent rise in popularity are evident, there are numerous barriers and challenges that are important to consider prior to initiating older adults on home dialysis. Some nephrology healthcare professionals do not view home dialysis as an option for older adults. Successful delivery of home dialysis for older adults may be made even more difficult by physical or cognitive limitations, concerns around dialysis adequacy, and treatment-related complications, as well as challenges relating to caregiver burnout and patient frailty that are unique to home dialysis and older adults. Ultimately, it would be important for clinicians, patients and their caregivers to define what constitutes a 'successful therapy' to ensure treatment goals are aligned towards each individual's priorities of care, considering the complex challenges that surround an older adult receiving home dialysis. In this review, we evaluate some of the key challenges surrounding the delivery of home dialysis to older adults and propose potential solutions based on updated evidence to overcome these challenges.

Poorer clinical outcomes of early-onset peritonitis in elderly peritoneal dialysis patients: A longitudinal and multicenter study

INTRODUCTION

Early-onset peritonitis (EOP) is a risk factor for mortality in peritoneal dialysis (PD) patients. This study investigates the clinical features and outcomes of EOP in elderly patients.

METHODS

This multicenter retrospective study evaluated 433 elderly PD patients with end-stage renal disease. The cohort was divided into nonperitonitis group (n = 239), EOP group (≤12 months, n = 109) and late-onset peritonitis (LOP) group (>12 months, n = 85). Clinical data, treatment results, and outcomes were compared between the groups.

RESULTS

Compared with LOP group, there were no significant intergroup differences in the rate of primary recovery, complete cure, relapse, catheter removal, or death from PDAP (p >0.05) in the most recent PDAP episode. However, Kaplan-Meier analysis showed that patients in the EOP group were likely to have multiple episodes of PD-associated peritonitis (PDAP), technique failure, all-cause death, and composite endpoint in the long-term prognostic outcomes (p <0.001).

CONCLUSIONS

EOP is significantly associated with poorer clinical outcomes in older PD patients.

Comparison of mortality and complications between urgent-start peritoneal dialysis and urgent-start hemodialysis: A systematic review and meta-analysis

The advantages of urgent-start peritoneal dialysis (PD) vis-à-vis urgent-start hemodialysis (HD) are not clear. We performed a systematic review and meta-analysis of studies comparing the two modalities. Databases of PubMed, Embase, Ovoid, and Google Scholar were searched up to November 1, 2020. The primary outcome was mortality, and secondary outcomes were dialysis-related infectious complications and mechanical complications. Risk ratios (RRs) were calculated for all outcomes. Seven studies were included. The pooled analysis revealed a statistically significant reduced risk of all-cause mortality in patients undergoing urgent-start PD as compared to urgent-start HD (RR: 0.61, 95% confidence interval [CI] [0.40, 0.94], I²  = 56.34%). A meta-analysis of dialysis-related infectious complications indicated no statistically significant difference between the two modalities (RR: 0.66, 95% CI [0.29, 1.50], I²  = 69.62%). Our analysis revealed a statistically significant reduced risk of mechanical complications in patients undergoing urgent-start PD (RR: 0.54, 95% CI [0.40, 0.73], I²  = 0%). To conclude, unadjusted data from observational studies are indicative of lower mortality and lower risk of mechanical complications with urgent-start PD versus urgent-start HD. The risk of infectious complications was not different between the two groups. Further studies with a larger sample size using propensity-matched cohorts are needed to strengthen current evidence.

Análisis del tiempo de entrenamiento y su relación con los episodios de peritonitis

Introducción: El entrenamiento es fundamental para garantizar el éxito de la Diálisis Peritoneal. Objetivo: Valorar la relación entre el tiempo de apren-dizaje y la aparición del primer episodio de peritonitis, comparando entre pacientes jóvenes y ancianos.Material y Método: Estudio observacional, retrospec-tivo. Se incluyó a los pacientes entrenados entre el 1 enero 2014 a 31 diciembre 2018, en el Complejo Asis-tencial Universitario de León. Se estudiaron variables demográficas, nivel de autonomía, tiempo de entrena-miento, primera peritonitis y germen causante. El punto de corte para diferenciar entre jóvenes y ancianos fue 70 años. Los datos se obtuvieron de la base de datos existente en nuestra unidad. Resultados: Se estudiaron 112 pacientes, 68% hombres, edad media 62,68 ±15,69 años, 40% ma-yores de 70 años, el 82% eran autónomos para rea-lizar la diálisis. La media de horas de entrenamiento fue 14,82±6,55; ancianos 18,13±7,93 horas, jóvenes 12,73±4,27, (p=0,004). El 25% tuvieron peritonitis, 64% por gérmenes Gram+. La media al primer episo-dio fue 266±283 días. Los ancianos tardan 84 días me-nos de media en tener peritonitis. Análisis del tiempo de entrenamiento y su relación con los episodios de peritonitisAna Isabel Aguilera-Flórez, Aránzazu Sastre-López, Blanca Linares-Fano, Juan Ramón Guerra-Ordoñez, Ana Cristina Alonso-Rojo, Mario Prieto-Velasco Servicio de Nefrología. Complejo Asistencial Universitario de León. León. EspañaComo citar este artículo:Aguilera-Flórez AI, Sastre-López A, Linares-Fano B, Guerra-Ordoñez JR, Alonso-Rojo AC, Prieto-Velasco M. Análisis del tiempo de entrenamiento y su relación con los episodios de peritonitis. Enferm Nefrol. 2020 Ene-Mar;23(1):54-59Conclusiones: Aunque aparecieron más peritonitis en los pacientes que necesitaron más horas de entre-namiento, no se pudo establecer relación estadística alguna entre ambas variables; si bien los ancianos ne-cesitan más tiempo para completar el entrenamiento y el primer episodio de peritonitis aparece más pre-cozmente.

Infections in the Elderly Critically-Ill Patients

Infections are leading causes of morbidity and mortality in the advanced aged. Various factors including immunosenescens, comorbid chronic diseases, and alterations in normal physiological organ functions may modify the frequency and severity of infections in elderly patients. Normal body reactions to ensuing infection, such as increased body temperature, may be blunted in those patients causing difficulties in differential diagnosis between infection and other diseases. In severe infections the respiratory and urinary tracts are the most frequently involved systems which may be accompanied by severe sepsis. Bacteremia and sepsis are also associated with indwelling vascular catheters in the elderly who are admitted to the intensive care unit (ICU). Older patients are more vulnerable to the Clostridioides difficile infection, as well. Although the general management of infections in severely ill elderly patients is not different than in younger patients, meticulous care in fluid management and careful individualized optimization in antibiotic therapy, along with the other principals of antimicrobial stewardship are warranted in order to prevent increased mortality caused by infection. Organized team management when treating critically ill elderly patients in the ICU is essential and will reduce the morbidity and mortality due to infection in such patients.

Risk Factors And Prevention of Peritoneal Dialysis-Related Peritonitis

BACKGROUND

Peritonitis is a major complication and the main cause of peritoneal dialysis (PD) failure. The aim of the present study was to evaluate peritonitis risk factors and its prevention with a new peritoneal educational program (NPEP).

METHODS

We performed a retrospective analysis of a cohort of chronic PD patients, older than 16 years, who began PD in the period 1 January 1999 to 31 December 2015 at a Uruguayan PD center, with follow-up until 31 December 2016.

RESULTS

The population included 222 cases (219 patients, 128 men), median age 59 (interquartile range [IQR] 47.0 - 72.0) years, median time on PD 17.5 (IQR 6.0 - 36.2) months. Ninety-five patients suffered 1 or more episodes of peritonitis, and they had been on PD for a longer period and had nasal-positive culture more frequently. A NPEP started in September 2008; patients who trained with it, as well as younger patients, had longer peritonitis-free survival. After the NPEP, global peritonitis rates decreased significantly (from 0.48 to 0.29 episodes/patient-year, respectively), particularly gram-positive bacteria and Staphylococcus aureus / coagulase-negative (CoNS) (from 0.26 to 0.12 and 0.21 to 0.07 episodes/patient-year, respectively). In the multivariate Cox analysis of peritonitis risk factors, survival to first peritonitis was significantly associated only with age (hazard ratio [HR] 1.024, 95% confidence interval [CI] 1.007 - 1.397, p = 0.007) and the NPEP (HR 0.600, 95% CI 0.394 - 0.913, p = 0.017).

CONCLUSION

A multidisciplinary peritoneal educational program may improve peritonitis rates, independently of other risk factors.

Fungal peritonitis in peritoneal dialysis: 5-year review from a North China center

PURPOSE

Fungal peritonitis (FP) is a rare but devastating complication in peritoneal dialysis (PD), accounting for high rates of technique failure, morbidity and mortality. This study was conducted to investigate FPs with regard to peritonitis rate, microbiology testing, patient characteristics, clinical features, antifungal treatments, and clinical outcomes in patients on PD.

METHODS

This single-center study retrospectively reviewed all FP episodes diagnosed from June 1, 2012 to June, 2017. All FPs were matched in a 1:5 ratio with PD patients diagnosed with bacterial peritonitis. Clinical, biochemical characteristics and detailed data on peritonitis episodes were recorded.

RESULTS

Eleven fungal peritonitis episodes (rate of 0.0067 episodes per patient-year on dialysis) were identified. All FPs were caused by Candida species (identification and antifungal susceptibility testing were performed with VITEK 2^® compact system), including C. albicans (6/11), C. parapsilosis (4/11) and C. krusei (1/11). Except C. krusei, no Candida resistance to fluconazole was detected. Compared to bacterial peritonitis (matched cases, n = 55), FP group showed higher rate of previous antibiotic use (p = 0.002), higher total effluent cell count (p = 0.007), and lower serum albumin (p = 0.01), higher rate of infection-related surgery (p < 0.001), HD transfer (p = 0.001), and all-cause death (p = 0.006). High prevalence (≥ 50%) of female gender, anuria, CCI ≥ 4, hypoalbuminemia, anemia, and hypokalemia were also observed in FP patients. More than half of the FP patients presented gastrointestinal symptoms (7/11) and extraperitoneal infection (6/11). Eight (72.7%) patients had catheter surgically removed with a median 5.5 lag days, four (36.4%) patients died within 3 months and six (54.5%) cases led to technique failure.

CONCLUSIONS

FP results in high rates of catheter loss and all-cause mortality in 3 months of follow-up, candida species were the commonest pathogens in our center. Variations of clinical features and susceptibility patterns were observed. Gastrointestinal disorders maybe a potential risk factor for FP.