Nutritional risk and morbidity and mortality in intensive care unit patients with Coronavirus disease 2019

INTRODUCTION

The Coronavirus disease 2019 (COVID-19) spread rapidly, with 37 million cases and more than 699,000 deaths. Among intensive care unit (ICU) patients with COVID-19, a high incidence of acute kidney injury (AKI) has been observed, ranging from 50 to 80%; furthermore, 85.9% were calculated to have high nutritional risk, which doubled their odds of death. The aim of the present study was to evaluate possible associations between nutritional risk, acute kidney injury, and morbidity and mortality in patients with COVID-19 admitted to an ICU.

METHODS

Retrospective cohort study of adult and older-adult patients hospitalized for >24 h in an ICU. The exposure was diagnosis of COVID-19, while the outcomes were mortality, acute kidney injury, dialysis, mechanical ventilation, and vasopressor use. The association of nutritional risk with outcomes was evaluated. The sample consisted of two secondary datasets. Individuals aged <18 years, those with dialytic chronic kidney disease, pregnant women, and those diagnosed with brain death were excluded.

RESULTS

The sample consisted of 192 patients: 101 in the exposure group (positive for COVID-19) and 91 in the control group (no COVID-19 diagnosis). The COVID-19 and non-COVID-19 groups differed significantly in the variables weight, body mass index (BMI), nutritional risk, mNUTRIC-S score, and length of ICU stay. Our results suggest that the optimal mNUTRIC-S score cutoff to predict nutritional risk is <5 points.

CONCLUSION

COVID-19 has a significant impact on patients' kidney function, increasing the incidence of AKI and the likelihood of death. Nutritional risk is a major factor in the mortality of patients with COVID-19. Therefore, use of the mNUTRIC-S scale could contribute to assessment of prognosis in this patient population.

Assessment of the performance of vascular access for hemodialysis

BACKGROUND

Life and quality of life on hemodialysis depends on adequate vascular access. An autogenous arteriovenous fistula (AVF) has the best performance, while the use of a central venous catheter (CVC) may have a negative impact on fistula performance and may be associated with increased systemic inflammation. Our objective is to evaluate the performance of vascular accesses in patients undergoing a chronic hemodialysis program.

METHODS

This is an observational, cross-sectional, and descriptive study that included patients on chronic hemodialysis for more than 90 days. Patients with an acute systemic inflammatory disease and those with acute cardiovascular illness were excluded. Clinical data, dialysis session parameters, and serum levels of inflammatory markers were evaluated.

RESULTS

A total of 91 patients were evaluated, 59 (65%) had an AVF and 32 patients (35%) had a CVC. The adequacy rate was 67%; being 67.8% with AVF and 65.6% with CVC. Among the causes of AVF inadequacy, the ones that presented the highest prevalence ratio (PR) were non-mature AVF (PR: 4.055; 95% CI: 2.017-8.151), pseudoaneurysm (PR: 6.580; 95% CI: 3.723-11.629) and presence of hematoma (PR: 4.360; 95% CI: 2.125-8.946), p < 0.001. Among the catheter group, the causes of inadequacy with the highest PR were the presence of access thrombosis, indicating the use of thrombolytics (PR: 11.103; 95% CI: 4.746-25.977; p < 0.001) and infection (PR: 2.984; 95% CI: 1.293-6.889; p = 0.010). Median primary AVF patency was 72 months compared to 7 months of catheters (p < 0.001). There was no significant difference in serum inflammatory markers between the two groups.

CONCLUSIONS

Adequacy rates of vascular accesses did not differ between the groups, but the primary and functional patency of AVF is 10 times higher than that of catheters. Infection in dialysis catheters is associated with worse access performance. There was no association between systemic inflammation and vascular access.

An International Survey of Peritoneal Dialysis Exercise Practices and Perceptions

Introduction

Low activity levels and poor physical function are associated with technique failure and mortality in people receiving peritoneal dialysis (PD). Adequate levels of physical function are required to maintain independence for people choosing this predominantly home-based therapy. The objective of this study was to identify the exercise-related perceptions and practices of PD clinicians globally.

Methods

We conducted a cross-sectional survey of PD clinicians from English-, Thai-, Spanish-, and Portuguese-speaking PD-prevalent countries exploring clinicians' perceptions and practices of swimming, activity following PD catheter insertion, lifting, and falls prevention. This study was convened by the International Society of Peritoneal Dialysis and Global Renal Exercise Network between July and December 2021.

Results

Of 100 of the highest PD-prevalent countries, 85 responded and were represented in the findings. A total of 1125 PD clinicians (448 nephrologists, 558 nephrology nurses, 59 dietitians, and 56 others) responded from 61% high-income, 32% upper middle-income and 7% lower middle-income countries. The majority (n = 1054, 94%) agreed that structured exercise programs would be beneficial for people receiving PD. Most respondents believed people on PD could perform more exercise (n = 907, 81%) and that abdominal strengthening exercises could be safely performed (n = 661, 59%). Compared to clinicians in high-income countries, clinicians from lower middle-income status (odds ratio [OR], 5.57; 1.64 to 18.9) are more likely to promote participation in physical activity.

Conclusion

Clinicians know the importance of physical activity in people receiving PD. Exercise counseling and structured exercise plans could be included in the standard care of people receiving PD to maintain independence.

Assessment of the Impact of Fatigue on the Degree of Dependance in Hemodialysis Patients

Background: Patients undergoing hemodialysis (HD) go through a number of physical and emotional symptoms that can interfere with their comfort and quality of life, a common symptom is tiredness, a condition which is conventionally called post dialysis fatigue (PDF). Therefore, the objective is to evaluate the relationship between fatigue and the degree of dependence in performing basic and instrumental activities of daily living on patients undergoing hemodialysis. Method: Cross-sectional study, carried out at the hemodialysis unit of Hospital São Lucas da Pontificia Universidad Católica do Rio Grande do Sul.. The study reporting adheres to the STROBE checklist. Results: From the 101 patients interviewed, 63 (62.4%) had post dialysis fatigue, with a mean age of 59±7 years, where the majority were men with 66.3% (n=67).  The presence of PDF was related to vintage on HD (p<0,041), session recovery time (p<0,000) and shift of the session (p<0.001). There was no association of PDF with the degree of dependence on basic and instrumental activities of daily living. Conclusion: More than half of the patients on HD experience PDF, it is less frequent in patients dialyzing in the night shift and it is associated with dialysis vintage and with greater recovery time.

Development of an instrument to assess self-management capacity of patients receiving peritoneal dialysis: CAPABLE

BACKGROUND

Treatment of kidney failure with peritoneal dialysis (PD) at home implies that the patient and/or their caregiver develop a series of skills and basic knowledge about this therapy. There is not a specific inventory of the patient's abilities to safely perform the PD procedure at home. The objective of this study was to describe the development of an instrument that allows measuring the self-management capacity of patients receiving PD, locating the performance areas that justify the need for intervention by a caregiver.

METHODS

This is a qualitative study developed in three phases: The first phase was the identification of performance areas through bibliographic search and validation of the results with focus groups of experts in PD. The second phase was the design of a system to measure self-management capacities. The third phase was a pilot test of the preliminary version of the instrument applied in 20 incident PD patients.

RESULTS

Three domains were identified to evaluate the fundamental components of self-management capacity: cognitive and sensory, each one evaluated with four items and motor domain evaluated with eight items. After applying the instrument, we found that 15 patients (75%) did not require support from the caregiver in any of the items. PD patients and nurses found the tool valuable, easy to understand and applicable in the early evaluation of a PD patient.

CONCLUSIONS

We developed an easy-to-administer instrument to measure the self-management capacity of patients receiving PD. This inventory could locate areas that require specific support from a caregiver. Planning an individualised and focused education and training process could result in better health outcomes.

High prevalence of biochemical disturbances of chronic kidney disease - mineral and bone disorders (CKD-MBD) in a nation-wide peritoneal dialysis cohort: are guideline goals too hard to achieve?

INTRODUCTION

Chronic kidney disease - mineral and bone disorders (CKD-MBD) are common in dialysis patients. Definition of targets for calcium (Ca), phosphorus (P), parathormone (iPTH), and alkaline phosphatase (ALP) and their treatment recommendations, are provided by international guidelines. There are few studies analyzing CKD-MBD in peritoneal dialysis (PD) patients and the impact of guidelines on mineral metabolism control. The aim of our study was to describe the prevalence of biomarkers for CKD-MBD in a large cohort of PD patients in Brazil.

METHODS

Data from the nation-wide prospective observational cohort BRAZPD II was used. Incident patients were followed between December 2004 and January 2011. According to KDOQI recommendations, reference ranges for total Ca were 8.4 to 9.5 mg/dL, for P, 3.5 to 5.5 mg/dL, for iPTH, 150-300 pg/mL, and for ALP, 120 U/L.

RESULTS

Mean age was 59.8 ± 16 years, 48% were male, and 43% had diabetes. In the beginning, Ca was 8.9 ± 0.9 mg/dL, and 48.3% were on the KODQI target. After 1 year, Ca increased to 9.1 ± 0.9 mg/dL and 50.4% were in the KDOQI preferred range. P at baseline was 5.2 ± 1.6 mg/dL, with 52.8% on target, declining to 4.9 ± 1.5 mg/dL after one year, when 54.7% were on target. Median iPTH at baseline was 238 (P25% 110 - P75% 426 pg/mL) and it remained stable throughout the first year; patients within target ranged from 26 to 28.5%. At the end of the study, 80% was in 3.5 meq/L Ca dialysate concentration, 66.9% of patients was taking any phosphate binder, and 25% was taking activated vitamin D.

CONCLUSIONS

We observed a significant prevalence of biochemical disorders related to CKD-MBD in this dialysis population.

Efeitos da aplicação periódica da simulação in situ para educação permanente em ressuscitação cardiopulmonar no contexto da hemodiálise

Introdução: A parada cardiorrespiratória é um eventocrítico para o paciente dialítico, que necessita de umaequipe de enfermagem na hemodiálise apta a realizaro procedimento de ressuscitação cardiopulmonar.Justifica-se nesse contexto a educação permanenteem enfermagem, que por meio da simulação in situ,pode contribuir com a construção das competências emressuscitação cardiopulmonar.Objetivo: Verificar se diferentes periodicidades deformação utilizando a simulação in situ, influenciamna construção de competências para a ressuscitaçãocardiopulmonar no ambiente da hemodiálise.Material e Método: Trata-se de um estudo experimentalnão randomizado, realizado com profissionais deenfermagem de uma unidade de diálise situada em umHospital Universitário de grande porte da região sul doBrasil. Os participantes foram alocados em 3 grupos quereceberam periodicidades diferentes de intervenção (2,4, e 8 meses).Resultados: Os resultados apontaram diferençasestatisticamente significativa na análise doconhecimento, no grupo de periodicidade de 4 meses.Na avaliação das habilidades, observou-se resultado significativo (p=0,048) para o grupo de periodicidadede 4 meses, na técnica da compressão torácica.Conclusão: Com este estudo demonstramos que asimulação in situ promoveu a construção de competênciasno intervalo a cada 4 meses, corroborando com o fatode que a aprendizagem por meio da experimentaçãoe a reflexão, e dentro do contexto profissional, podemcontribuir com a educação permanente em saúde. Maisestudos no contexto da diálise são necessários paraconfirmar e generalizar os achados.

Good practices recommendations from the Brazilian Society of Nephrology to Peritoneal Dialysis Services related to the new coronavirus (Covid-19) epidemic

Considering the new coronavirus epidemic (Covid-19), the Brazilian Society of Nephrology, represented by the Peritoneal Steering Committee, in agreement with the and the Dialysis Department, developed a series of recommendations for good clinical practices for peritoneal dialysis (PD) clinics, to be considered during the period of the Covid-19 epidemic. We aim to minimize the disease spread, protecting patients and staff, and ensuring the quality of the treatment provided and adequate follow-up for PD patients. The recommendations suggested at this moment must be adapted to each clinic’s reality and the conditions of the structural and human resources, dependent on the adequate financial provision of the public health system for its full implementation.

Letramento em saúde: avaliação de pacientes em terapia renal substitutiva

Introdução: considerando a prevalência de pacientes em terapia renal substitutiva, torna-se extremamente revelevante a avaliação da capacidade de entendimento e aplicacação das orientações que esses indíviduos recebem nos serviços de saúde. Objetivo: estudar o impacto do nível de letramento em saúde de pacientes submetidos à hemodiálise, diálise peritoneal e transplante renal, associado aos aspectos cognitivos, adesão medicamentosa e qualidade de vida. Método: estudo transversal, realizado com indivíduos acima de 18 anos, submetidos a algum tipo de terapia renal substitutiva, há três meses consecutivos. Foram aplicadas as versões brasileiras dos instrumentos: Short Assessment of Health Literacy for Portuguese-speaking Adults-18, Mini Exame do Estado Mental, 36-Item Short Form e a escala de Morisky, além de um questionário sobre dados clínicos e sociodemográficos. Resultados: foram avaliados 138 pacientes, sendo 50 (36,2) submetidos à hemodiálise, 23 (16,7%) a diálise peritoneal e 65 (47,1%) ao transplante renal. A média de idade foi 52,0±15,5 anos e 58,0% do sexo masculino. Os pacientes com letramento inadequado (51,4%) tinham renda igual ou inferior a um salário mínimo (P=0,002) e ensino fundamental completo ou inferior (P<0,001). Os indivíduos com letramento adequado apresentavam ensino médio incompleto ou maior escolaridade, renda igual ou superior a cinco salários mínimos e maior escore no domínio dos aspectos emocionais referente a qualidade de vida (P=0,052). Conclusões: nossos resultados sugerem que o nível de letramento está associado com a renda e escolaridade nos pacientes que realizam a substituição da função renal.

Impact of Glucose Exposure on Outcomes of a Nation-Wide Peritoneal Dialysis Cohort - Results of the BRAZPD II Cohort

Background: Data investigating the association of glucose exposure with technique failure and patient survival are limited to retrospective cohorts and was never tested outside Asia and considering the presence of competing risks.

Methods: Prospective multicenter cohort study of incident peritoneal dialysis patients where the association of cumulative glucose exposure in 6, 12, and 24 months with patient survival and technique failure was tested using Cox regression analysis and competing risk analysis.

Results: We analyzed 4367 incident peritoneal dialysis patients with mean age 59.0 ± 15.8 years, 43.9% were diabetics, 46.7% males and 64.4% Caucasians. Glucose exposure was not associated with patient survival independent of the time of exposure and even after adjustments for confounders. In contrast, higher glucose exposure was associated with more technique failure in the Cox and competing risk models. The higher risk for technique failure was found in the subgroup exposed to the higher amount of glucose to a maximum of 86% in the model analyzing cumulative glucose exposure for 1 year.

Conclusion: Glucose exposure was associated with technique failure but not with patient survival.

Time to Positivity of Bacteria Cultures in Peritoneal Dialysis Fluid: Evaluation of Different Laboratory Techniques

Patients with chronic kidney disease on peritoneal dialysis (PD) are susceptible to infections, with peritonitis being the primary cause of dropout. Peritoneal fluid culture is one of the essential elements for proper diagnosis and peritonitis treatment. The aim of this study was to compare the time required to obtain a positive culture using different laboratory methods. An in vitro cross-sectional study was conducted comparing different techniques for preparation and culture of bacteria in peritoneal fluid. The research was carried out with 21 sterile dialysis bags and 21 PD bags containing peritoneal fluid drained from patients without peritonitis. Fluids from the 42 PD bags were contaminated by injecting a coagulase-negative Staphylococcus suspension and then prepared for culture using 4 distinct techniques: A - direct culture; B - post-centrifugation culture; C - direct culture after 4 h sedimentation; and D - culture after 4 h sedimentation and centrifugation. This was followed by seeding. In the 21 contaminated sterile bags, mean times to obtain a positive culture with techniques D (19.6 h ± 2.6) and C (19.1 h ± 2.3) were longer than with technique A (15.8 h ± 3.0; p < 0.01), but not statistically different from group B (19.0 h ± 3.2). The same occurred in the 21 bags drained from patients, with mean times for techniques D (14.0 h ± 1.9) and C (14.5 h ± 1.7) being longer than technique A (12.22 h ± 1.94; p < 0.05) but not statistically different from technique B (13.2 h ± 1.3). The sedimentation and centrifugation steps seem to be unnecessary and may delay antibiotic sensitivity test results by approximately 8 hours.

Impact of the Karnofsky Performance Status on Survival and its Dynamics during the Terminal Year of Peritoneal Dialysis Patients

Background

Simple and low-cost tools to monitor the risk profile of patients on peritoneal dialysis (PD) at high risk of complications and mortality are scarce. One of the tools available to monitor the variation in vitality and dependence levels is the Karnofsky performance status (KPS). This study analyzed the average trends and variation of KPS during the 12 months before death and its independent value in predicting patients’ survival.

Methods

The data were compiled from the BRAZPD II multi-center study, performed in Brazil between 2004 and 2011. For the analysis of KPS dynamics, we included patients with at least 12 months of follow-up on PD and who had a fatal event during the follow-up. The following covariables were evaluated: age, gender, ethnicity, educational level, and presence of diabetes. We used the linear regression model to present the results: the log (time) before death was represented by the regression variable and KPS was the response. We also analyzed the independent impact of baseline KPS on patients’ survival.

Results

From the population of 9,905 patients enrolled in the BRAZPD study, 4,133 survived 12 months on PD and were included in the analysis. There was a gradual decline in the KPS scores, which accelerated in the last 2 months before death. These changes were similar irrespective of age, race, family income, gender, diabetes, PD modality, and education level. We observed 989 fatal events in this population during the observation period, and the KPS score was identified as an independent predictor for mortality in this cohort.

Conclusions

This study demonstrates for the first time the dynamics of KPS before death in PD patients, indicating a progressive and accelerated decline of KPS in the 12 months before patients died. In addition, KPS was an independent predictor of mortality in this population.

Peritonitis in Children on Chronic Peritoneal Dialysis: The Experience of a Large National Pediatric Cohort

BACKGROUND

We performed this study to evaluate the incidence, risk factors, microbiology, treatment, and outcome of peritonitis in pediatric Peritoneal dialysis (PD) patients at a nationwide prospective study.

METHODOLOGY

Patients younger than 18 years recruited in the BRAZPD II study from 2004 to 2011, who presented their first peritonitis episode, were included in the study.

RESULTS

We found 125 first episodes of peritonitis in 491 children PD patients (0.43 episodes/patient-year). Patients free of peritonitis episode constituted 75.6% in 1 year. Culture-negative episodes were very high (59.2%) and gram-positive (GP) bacteria were the most commonly found organisms (58.8%). First-generation cephalosporin was the initial choice to cover GP (40.5%) and aminoglycosides was the most prescribed antibiotics used for gram-negative agents (27.5%). Treatment failure was 26.4%. Technique failure (TF) occurred in 12.1% and peritonitis was the main cause (65.1%). Pseudomonas (p = 0.04) and negative cultures (p < 0.001) were identified as predictors of TF.

CONCLUSION

Peritonitis remains a common complication of PD in children and negative cultures and pseudomonas had a negative impact on TF.

Impact of Renin-Angiotensin Aldosterone System Inhibition on Serum Potassium Levels among Peritoneal Dialysis Patients

BACKGROUND

The chronic use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blocker has been associated with hyperkalemia in patients with reduced renal function even after the initiation of hemodialysis. Whether such medications may cause a similar effect in peritoneal dialysis patients is not well established. So, the aim of our study was to analyze the impact of renin-angiotensin-aldosterone inhibitors on the serum levels of potassium in a national cohort of peritoneal dialysis patients.

METHOD

A prospective, observational, nationwide cohort study was conducted. We identified all incident patients on peritoneal dialysis that had angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) prescribed for at least 3 months and a similar period of time without these medications. Patients were divided into 4 groups: Groups I and III correspond to patients using, respectively, an ACEi or ARB and then got the drug suspended; Groups II and IV started peritoneal dialysis without the use of any renin-angiotensin aldosterone system inhibitor and then got, respectively, an ACEi or ARB introduced. Changes in potassium serum levels were compared using 2 statistical approaches: (1) the non-parametric Wilcoxon test for repeated measures and (2) a crossover analysis.

RESULTS

Mean potassium serum levels at the first phase of the study for Groups I, II, III, and IV were, respectively, 4.46 ± 0.79, 4.33 ± 0.78, 4.41 ± 0.63, and 4.44 ± 0.56. Changes in mean potassium serum levels for Groups I, II, III, and IV were -0.10 ± 0.60, 0.02 ± 0.56, -0.06 ± 0.46, and 0.03 ± 0.50, respectively.

CONCLUSION

The use of ACEi and ARB was not associated with a greater risk for hyperkalemia in stable peritoneal dialysis patients independently of residual renal function.

Racial and social disparities in the access to automated peritoneal dialysis - results of a national PD cohort

The prevalence of patients on automated peritoneal dialysis (APD) is increasing worldwide and may be guided by clinical characteristics, financial issues and patient option. Whether socioeconomic factors at the patient level may influence the decision for the initial peritoneal dialysis (PD) modality is unknown. This is a prospective cohort study. The primary outcome of interest was the probability to start PD on APD. The inclusion criteria were adult patients incident in PD. Exclusion criteria were missing data for either race or initial PD modality. We used a mixed-model analysis clustering patients according to their PD center and region of the country. We included 3,901 patients of which 1,819 (46.6%) had APD as their first modality. We found a significant disparity for race and educational level with African American patients less likely to start on APD (Odds ratio 0.74 CI95% 0.58-0.94) compared to Whites whilst those with greater educational levels were more likely to start on APD (Odds ratio 3.70, CI95% 2.25-6.09) compared to illiterate patients. Limiting the use of APD in disadvantaged population may be unethical. Demographics and socioeconomic status should not be necessarily part of the decision-making process of PD modality choice.

Determining Nurse Staffing for Peritoneal Dialysis Care

There is no consensus on the ideal staffing levels for peritoneal dialysis (PD) units. The objective of this two-phase study was to evaluate nurse staffing levels in a PD unit based on activities and time spent performing them. An instrument was created based on nursing activities identified by a focus group, and the time spent performing these activities was measured over a four-month period. Forty-seven activities were identified, including care assistance activities (29), management activities (12), educational activities (5), and research activities (1). Direct patient care predominated, consuming 55.3% of overall time worked. Based on time spent per activity, we estimate that 70.2 hours of nursing care is required to care for one patient for one year.

Automated Peritoneal Dialysis Is Associated with Better Survival Rates Compared to Continuous Ambulatory Peritoneal Dialysis: A Propensity Score Matching Analysis

Introduction

The impact of peritoneal dialysis modality on patient survival and peritonitis rates is not fully understood, and no large-scale randomized clinical trial (RCT) is available. In the absence of a RCT, the use of an advanced matching procedure to reduce selection bias in large cohort studies may be the best approach. The aim of this study is to compare automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) according to peritonitis risk, technique failure and patient survival in a large nation-wide PD cohort

Methods

This is a prospective cohort study that included all incident PD patients with at least 90 days of PD recruited in the BRAZPD study. All patients who were treated exclusively with either APD or CAPD were matched for 15 different covariates using a propensity score calculated with the nearest neighbor method. Clinical outcomes analyzed were overall mortality, technique failure and time to first peritonitis. For all analysis we also adjusted the curves for the presence of competing risks with the Fine and Gray analysis.

Results

After the matching procedure, 2,890 patients were included in the analysis (1,445 in each group). Baseline characteristics were similar for all covariates including: age, diabetes, BMI, Center-experience, coronary artery disease, cancer, literacy, hypertension, race, previous HD, gender, pre-dialysis care, family income, peripheral artery disease and year of starting PD. Mortality rate was higher in CAPD patients (SHR1.44 CI95%1.21-1.71) compared to APD, but no difference was observed for technique failure (SHR0.83 CI95%0.69-1.02) nor for time till the first peritonitis episode (SHR0.96 CI95%0.93-1.11).

Conclusion

In the first large PD cohort study with groups balanced for several covariates using propensity score matching, PD modality was not associated with differences in neither time to first peritonitis nor in technique failure. Nevertheless, patient survival was significantly better in APD patients.

Low Serum Potassium Levels Increase the Infectious-Caused Mortality in Peritoneal Dialysis Patients: A Propensity-Matched Score Study

BACKGROUND AND OBJECTIVES

Hypokalemia has been consistently associated with high mortality rate in peritoneal dialysis. However, studies investigating if hypokalemia is acting as a surrogate marker of comorbidities or has a direct effect in the risk for mortality have not been studied. Thus, the aim of this study was to analyze the effect of hypokalemia on overall and cause-specific mortality.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

This is an analysis of BRAZPD II, a nationwide prospective cohort study. All patients on PD for longer than 90 days with measured serum potassium levels were used to verify the association of hypokalemia with overall and cause-specific mortality using a propensity match score to reduce selection bias. In addition, competing risks were also taken into account for the analysis of cause-specific mortality.

RESULTS

There was a U-shaped relationship between time-averaged serum potassium and all-cause mortality of PD patients. Cardiovascular disease was the main cause of death in the normokalemic group with 133 events (41.8%) followed by PD-non related infections, n=105 (33.0%). Hypokalemia was associated with a 49% increased risk for CV mortality after adjustments for covariates and the presence of competing risks (SHR 1.49; CI95% 1.01-2.21). In contrast, in the group of patients with K <3.5 mEq/L, PD-non related infections were the main cause of death with 43 events (44.3%) followed by cardiovascular disease (n=36; 37.1%). For PD-non related infections the SHR was 2.19 (CI95% 1.52-3.14) while for peritonitis was SHR 1.09 (CI95% 0.47-2.49).

CONCLUSIONS

Hypokalemia had a significant impact on overall, cardiovascular and infectious mortality even after adjustments for competing risks. The causative nature of this association suggested by our study raises the need for intervention studies looking at the effect of potassium supplementation on clinical outcomes of PD patients.

Systemic lupus erythematous and clinical outcomes in peritoneal dialysis

Background: The prevalence of systemic lupus erythematous (SLE) patients requiring renal replacement therapy (RRT) is increasing but data on clinical outcomes are scarce. Interestingly, data on technique failure and peritoneal-dialysis (PD)-related infections are rarer, despite SLE patients being considered at high risk for infections. The aim of our study is to compare clinical outcomes of SLE patients on PD in a large PD cohort. Methods: We conducted a nationwide prospective observational study from the BRAZPD II cohort. For this study we identified all patients on PD for greater than 90 days. Within that subset, all those with SLE as primary renal disease were matched with PD patients without SLE for comparison of clinical outcomes, namely: patient mortality, technique survival and time to first peritonitis, then were analyzed taking into account the presence of competing risks. Results: Out of a total of 9907 patients, we identified 102 SLE patients incident in PD and with more than 90 days on PD. After matching the groups consisted of 92 patients with SLE and 340 matched controls. Mean age was 46.9 ± 16.8 years, 77.3% were females and 58.1% were Caucasians. After adjustments SLE sub-hazard distribution ratio for mortality was 1.06 (CI 95% 0.55–2.05), for technique failure was 1.01 (CI 95% 0.54–1.91) and for time to first peritonitis episode was 1.40 (CI 95% 0.92–2.11). The probability for occurrence of competing risks in all three outcomes was similar between groups. Conclusion: PD therapy was shown to be a safe and equally successful therapy for SLE patients compared to matched non-SLE patients.

Characterization of the BRAZPD II cohort and description of trends in peritoneal dialysis outcome across time periods

Observational studies from different regions of the world provide valuable information in patient selection, clinical practice, and their relationship to patient and technique outcome. The present study is the first large cohort providing patient characteristics, clinical practice, patterns and their relationship to outcomes in Latin America. The objective of the present study was to characterize the cohort and to describe the main determinants of patient and technique survival, including trends over time of peritoneal dialysis (PD) initiation and treatment. This was a nationwide cohort study in which all incident adult patients on PD from 122 centers were studied. Patient demographics, socioeconomic and laboratory values were followed from December 2004 to January 2011 and, for comparison purposes, divided into 3 groups according to the year of starting PD: 2005/06, 2007/08 and 2009/10. Patient survival and technique failure (TF) were analyzed using the competing risk model of Fine and Gray. All patients active at the end of follow-up were treated as censored. In contrast, all patients who dropped the study for any reason different from the primary event of interest were treated as competing risk. Significance was set to a p level of 0.05. A total of 9,905 patients comprised the adult database, 7,007 were incident and 5,707 remained at least 90 days in PD. The main cause of dropout was death (54%) and of TF was peritonitis (63%). Technique survival at 1, 2, 3, 4, and 5 years was 91%, 84%, 77%, 68%, and 58%, respectively. There was no change in TF during the study period but 3 independent risk factors were identified: lower center experience, lower age, and automated PD (APD) as initial therapy. Cardiovascular disease (36%) was the main cause of death and the overall patient survival was 85%, 74%, 64%, 54%, and 48% at 1, 2, 3, 4, and 5 years, respectively. Patient survival improved along all study periods: compared to 2005/2006, patients starting at 2007/2008 had a relative risk reduction (SHR) of 0.83 (95% confidence interval [CI] 0.72 - 0.95); and starting in 2009/2010 of 0.69 (95% CI 0.57 - 0.83). The independent risk factors for mortality were diabetes, age > 65 years, previous hemodialysis, starting PD modality, white race, low body mass index (BMI), low educational level, center experience, length of pre-dialysis care, and the year of starting PD. We observed an improvement in patient survival along the years. This finding was sustained even after correction for several confounders and using a competing risk approach. On the other hand, no changes in technique survival were found.

Hand hygiene in peritoneal dialysis patients: a comparison of two techniques

INTRODUCTION AND OBJECTIVES

Hand hygiene is essential for preventing peritoneal dialysis (PD)-related infections. The present study compared the effectiveness of two hygiene techniques in reducing the number of colony-forming units (CFUs) on the hands of patients undergoing PD.

METHODS

In this controlled clinical trial, 22 participants enrolled in the same PD program underwent a two-hand evaluation for microbiologic flora. Participants participated in two treatments: a) simple hand hygiene plus antiseptic hand hygiene, in which the patients washed their hands with water and glycerin soap for 1 minute and then rubbed and dried their hands with 70% ethyl alcohol gel; and b) antiseptic hand hygiene, in which the patients rubbed their hands with 70% ethyl alcohol gel until fully dry. To sample distal finger surfaces, we asked the participants to touch sheep blood agar plates directly.

RESULTS

The CFU count for both hands was significantly higher in the regular hygiene group than in the gel-only group [69.0 (16.0 - 101.0) CFU vs 9.0 (2.2 - 55.5) CFU, p < 0.010]. Growth of coagulase-negative Staphylococcus colonies was significantly higher in right-hand cultures from the regular hygiene group than in those from the gel-only group [69.5 (26.25 - 101.0) CFU vs 9.5 (1.0 - 41.7) CFU; p < 0.050].

CONCLUSIONS

Among patients undergoing PD, using 70% ethyl alcohol gel to cleanse the hands may be more effective than following the regular hygiene recommendations in reducing bacterial populations.

Peritonitis in patients on peritoneal dialysis: analysis of a single Brazilian center based on the International Society for Peritoneal Dialysis

INTRODUCTION

Peritonitis remains the major complication in patients on peritoneal dialysis (PD), peritonitis rates vary in the literature, reflecting differences between countries, study design and populations.

OBJECTIVE

This study aimed to determine the rates of peritonitis episodes per year at risk (ep./yr), ep./yr by causative microorganism and median of peritonitis in patients on peritoneal dialysis at Hospital São Lucas.

METHODS

Retrospective descriptive study, with a study sample composed of patients treated with peritoneal dialysis at the Renal Unit of São Lucas Hospital between the periods from 1984 to August 2012. Only patients with complete data were considered.

RESULTS

Of the 427 patients analyzed, 53.2% (227) were females, mean age was 48.0 ± 19.9 years, 13% (56) were diabetics and 71.5% (303) of the patients performed their own treatment. There were 503 episodes of peritonitis and 255 patients had at least one episode. Coagulase-negative Staphylococcus was the most prevalent organism. The main causes of dropout from treatment were death, renal transplantation and peritonitis with 34.4, 25.8 and 19.2%, respectively. The rate of peritonitis was 0.63 ep./yr, rates by microorganism were 0.18 ep./yr for coagulase-negative Staphylococcus, 0.12 ep./yr for Staphylococcus aureus and Gram negative. The median of peritonitis in the unit was 0.41 ep./yr.

CONCLUSION

The rate of peritonitis ep./yr and median of patients studied is within the recommended minimum, but below the suggested targets proposed by the position statement of ISPD.

[Comparison of two hand hygiene techniques in peritoneal dialysis patients]

INTRODUCTION

Hand hygiene is an important procedure in preventing peritoneal dialysis-related infections.

OBJECTIVE

To compare the effectiveness of two distinct techniques for hand hygiene in reducing the number of colony-forming units in patients on peritoneal dialysis.

MATERIALS AND METHOD

Controlled clinical trial. Thirty patients underwent three collections of microbiological flora from the hands in three different instances: before and after hand washing with glycerin soap and water, and after rubbing 70% glycerin gel-alcohol. Cultures were obtained by applying the fingers surface directly on agar-blood plates.

RESULTS

Cultures mean growth were 31, 30 e 12 colony-forming units prior to washing, after washing with glycerin soap and water, and following gel-alcohol, respectively (p < 0.001). Staphylococcus epidermidis was the predominant germ in culture, occurring in 93.7% of seeded plates.

CONCLUSION

Hand rubbing with gel-alcohol was more effective in reducing the number of colonies recovered than the other methods.

Calculation of Kt/V in haemodialysis: a comparison between the formulas

INTRODUCTION

The quality of delivered dialysis can be measured by the Kt/V ratio, which can be calculated in various ways.

OBJECTIVE

To compare the Kt/V ratio obtained with the formulas of Lowrie (L) and Daugirdas (D) with the results measured by an Online Clearance Monitor (OCM).

METHOD

Observational, cross-sectional study of 59 patients on hemodialysis (HD). Data were collected in the same dialysis session (predialysis and postdialysis urea) and Kt/V was calculated by the OCM of the Fresenius 4008S machine (Fresenius Medical Care AG, Bad Homburg, Germany).

RESULTS

A total of 95 sessions were assessed, with a predominance of males 56% (33), and a sample mean age of 57 + 14 years. Hypertension (42%; n = 25), diabetes (12%; n = 7) and glomerulonephritides (8%; n = 5) were the most frequent causes of chronic kidney disease (CKD). Mean Kt/V values obtained with the L and D formulas and the OCM were 1.31, 1.41 and 1.32, respectively. Comparison between the L and D formulas showed a statistically significant difference (p = 0.008), with a Pearson's correlation of 0.950. The difference between the D formula and the OCM was also significant (p = 0.011 and r = 0.346), probably due to convective loss, estimated by the D formula but not by the OCM and L formula. The difference between the L formula and the OCM was not significant (p = 0.999 and r = 0.577).

CONCLUSION

These data suggest that the OCM can be used as a guide to the real-time adjustment of the dialysis dose.

Invited manuscript poster on renal-related education American Society of Nephrology, Nov. 16-21, 2010. Improving access to kidney transplant information has increased preemptive living kidney donation

Transplantation provides the best outcomes and quality of life for people with end-stage renal disease and therefore offers the optimum treatment of choice. Preemptive living donor (LD) transplantation is an increasingly preferable alternative to dialysis as transplantation outcomes indicate lower morbidity and mortality rates and greater graft and patient survival rates compared to those who are transplanted after dialysis has commenced. Despite nursing and medical teams giving information to patients regarding transplantation and living donation, the number of people coming forward for preemptive transplant work-up remained limited. Changing the format, environment, and quality of information given to patients and families seemed necessary in order to increase the number of preemptive transplants. Our data show that we have improved the access to the information seminars with attendance rising from 5 to 15 attendees per seminar (3 per year) in 2005 to average 65 attendees per seminar (6 per year) in 2010. By expanding the access to information for patients, their families and friends, living donation has increased with a growth in the proportion of preemptive LD transplants from 28% (23/81) in 2006 to 44% in 2010 (29/66; p = 0.05). We can conclude that expanding the pool accessing information has increased the number of preemptive (LD) transplants in our center.

Bag exchange in continuous ambulatory peritoneal dialysis without use of a face mask: experience of five years

This article describes our five-year experience of continuous ambulatory peritoneal dialysis (CAPD) with bag exchanges performed without use of a face mask. The study took place in the renal unit at a university hospital. All patients admitted to the CAPD program from February 1995 to March 2000 were trained to perform bag exchanges without use of a face mask. Occurrence of peritonitis episodes was the outcome of interest. We evaluated 94 patients (52 women, 42 men) with a mean age of 48 +/- 21 years and a total follow-up of 50,502 patient-days. During that time, 79 episodes of peritonitis occurred in 46 patients, for a peritonitis rate of 0.57 episodes/year. The most frequently isolated micro-organisms were Staphylococcus epidermidis in 20 patients (25.3%) and S. aureus in 11 patients (13.9%). Renal transplantation was the major cause of drop-out [23 patients (43.4%)], followed by peritonitis [14 patients (26.4%)], death due to cardiovascular complications [9 patients (17.0%)], loss of ultrafiltration [2 patients (3.8%)], and other causes [5 patients (9.4%)]. The probability of being free of peritonitis at 12 months was 0.60, and at 60 months, 0.37. Peritonitis rates during the study period were not different from those reported by other centers, supporting the hypothesis that routine use of a face mask during CAPD bag exchange may be unnecessary.

Peritonitis prevention in CAPD: to mask or not?

OBJECTIVE

To assess the efficacy of wearing a face mask to prevent peritonitis during continuous ambulatory peritoneal dialysis (CAPD) bag exchange.

SETTING

Renal unit at a university hospital.

PATIENTS

Two groups of patients on CAPD were compared: those performing bag exchange with (n = 24) and those without a face mask (n = 40).

OUTCOMES

Occurrence of first episode of peritonitis and total number of episodes.

RESULTS

No difference was found between groups with respect to probability of developing the first episode of peritonitis (p = 0.757). Patients holding university degrees had evidence of protection, with borderline significance [relative risk (RR) 0.52; confidence interval (CI) 95%, 0.23 -1.18; p= 0.109]. Cox's proportional hazard regression analysis also demonstrated a significant protective factor for patients with university level education (RR 0.42; Cl 95%, 0.18 - 0.98; p = 0.04). Incidence of peritonitis was not significantly different between groups: with-mask group had 1.0 episode/year, and without-mask group had 0.94 episodes/year. Staphylococcus epidermidis was the most commonly identified agent. Staphylococcus aureus was found more frequently in the with-mask group (p = 0.003). Peritonitis due to Streptococcus viridans and Enterococci were detected only in the without-mask group.

CONCLUSION

The current study suggests that routine use of face masks during CAPD bag exchanges may be unnecessary and could be discontinued.