Comparison of Unplanned/Urgent-Start Versus Conventional-Start Peritoneal Dialysis: A Systematic Review and Meta-Analysis

The timing of peritoneal dialysis (PD) initiation, whether conventional-start (planned) or urgent-start (unplanned), may impact the outcomes of PD and the rate of associated complications in individuals with chronic kidney disease (CKD). The goal of this study was to evaluate the effects of unplanned/urgent-start PD versus conventional-start PD in this cohort of patients. Electronic search of MEDLINE (via PubMed), EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases was done from inception until July 2023 for studies reporting outcomes of unplanned/urgent-start and conventional-start PD in CKD patients. Outcomes of interest included mechanical complications, post-procedure infections, mortality, and transfer to hemodialysis. Heterogeneity, publication bias, and the influence of individual studies on the pooled odds ratio (OR) with 95% confidence interval (CI) were evaluated. Twenty-seven studies were finally included in the review. The overall risk of post-procedure infectious was comparable for both PD initiation methods (OR: 1.05; 95% CI: 0.83-1.34). Similarly, the risks for peritonitis and exit site infections did not differ significantly. However, urgent-start PD correlated with a significantly higher risk of overall mechanical complications (OR: 1.70; 95% CI: 1.23-2.34). Specifically, the risk for leaks was notably higher (OR: 2.47; 95% CI: 1.67-3.65) in the urgent-start group compared to the conventional-start PD group. Urgent-start PD correlated with significantly increased mortality rates (OR: 1.83; 95% CI: 1.39-2.41). There was no difference in the likelihood of technique survival and transfer to hemodialysis. Both urgent-start and conventional-start PD correlated with similar risks of overall infectious complications. Urgent-start PD resulted in significantly increased risks of mechanical complications and mortality. Our findings emphasize the need for meticulous planning and consideration when opting for PD initiation.

Pathogenic spectrum and risk factors of peritoneal dialysis-associated peritonitis: a single-center retrospective study

The present study aimed to explore the pathogenic spectrum and risk factors of peritoneal dialysis-associated peritonitis (Peritoneal dialysis associated peritonitis, PDAP) in Yongzhou, Hunan, China. The clinical and epidemiological data on regular peritoneal dialysis (Peritoneal dialysis, PD) between January 2016 and December 2020 in Yongzhou were collected for retrospective analysis. The related factors of peritonitis were evaluated by single-factor analysis, while risk factors of refractory PDAP were evaluated by multivariate logistic regression analysis.172/331 172 (51.9%) patients developed peritonitis. The risk factors of PDAP in PD patients included high C-reactive protein (C-reactive protein, CRP), low albumin(Albumin, ALB), low hemoglobin (Hemoglobin, Hb), low educational level (junior high school or lower), preference of spicy food, irregular diet, low annual household income, unfavorable fluid exchange conditions, unstable employment (including working as a farmer), and unfavorable humidity conditions (P < 0.05). 63/172 (36.6%) PDAP patients were intractable cases with a pathogenic bacteria positive rate of 74.60% in the peritoneal dialysate cultures, and 109/172 patients were non-intractable cases with a pathogenic bacteria positive rate of 53.21%. Gram-positive bacteria (G+) were detected in most of the dialysate cultures, with Staphylococcus epidermidis (S. epidermidis) as the most common type, while Escherichia coli (E. coli) was the most common Gram-negative bacteria (G-). Gram-positive bacteria were sensitive to vancomycin and linezolid, while G- bacteria were sensitive to imipenem and amikacin. Lifestyle, educational level, and environmental factors are the major contributors to PDAP in PD patients. Fungal and multi-bacterial infections are the major causes of death; PD is stopped for such patients.

The effect of hand fine motor skills on peritoneal dialysis-related peritonitis

INTRODUCTION

We aimed to evaluate the relationship between the hand fine motor skills of peritoneal dialysis (PD) practitioners and PD-related peritonitis.

METHODS

This multicenter prospective observational study was conducted with 120 incident PD patients. Patients were divided into two groups who had PD-related peritonitis within the first year as Group 1, and those who did not as Group 2. Hand fine motor skills were evaluated by Nine-Hole Peg Test (NHPT) and Nut Screwing Test (NST).

RESULTS

Initial NHPT (28.5 ± 6.0 s vs. 25.8 ± 5.0 s, p = 0.011) and NST (82.3 (61.5-102.8) s versus 65.3 (52.3-88.5) s p = 0.023) scores were significantly higher in Group 1 than Group 2. In multivariate logistic regression analysis, NHPT, Body Mass Index, Mini-Mental Test, self PD practitioner, and catheter complications were found to be independent variables in predicting PD-related peritonitis.

CONCLUSION

Decreased hand fine motor skills of PD patients is a risk factor for peritonitis.

Effect of two different peritoneal dialysis modalities on wound infection in peritoneal dialysis patients: A meta-analysis

Peritoneal dialysis(PD) is one of the most efficient methods in end-stage kidney disease, and it is very important for PD to perform well. No research has been conducted to evaluate the effect of various types of PD catheters on the prognosis of post-operative wound complications. While recent meta-analyses are in favour of straight tubing, there is still uncertainty as to whether direct or coiled PD is beneficial. The purpose of this meta-analysis was to compare the efficacy of direct and coiled PD catheters on the incidence of post-operative wound infection, bleeding and peritonitis. A comprehensive search was carried out on three databases, including PubMed and Embase, and a manual search was carried out on the links in the paper. The results showed that the incidence rate of bleeding after operation and the degree of infection among the straight and coiled pipes were compared. The results showed that there were no statistically significant differences in the incidence of post-operative wound infection among straight PD patients with coiled PD (OR, 0.79; 95% CI, 0.58-1.08 p = 0.13). No statistical significance was found in the case of PD with coiled tubing compared with that of straight PD group in wound leakage (OR, 1.17; 95% CI, 0.71-1.93 p = 0.55). No statistically significantly different rates of post-operative peritonitis were observed for coiled tubing compared with straight ones in PD patients (OR, 1.06; 95% CI, 0.78-1.45 p = 0.7). There is no statistical significance on the rate of wound infection, wound leakage and peritonitis among coiled and straight tube in PD.

The association between new inflammation markers and frequent peritoneal dialysis-associated peritonitis

OBJECTIVE

To validate an association between new inflammation and frequent peritoneal dialysis-associated peritonitis (PDAP).

MATERIALS AND METHODS

In China, retrospective clinical data were collected on 208 patients who received continuous ambulatory peritoneal dialysis (CAPD) between 2010 and 2021. The patients were divided into two groups: non-frequent PDAP (the interval between two peritonitis episodes of more than one year) and frequent PDAP (the interval between two peritonitis episodes of less than one year). Patients with their first episode of peritonitis had their age, gender, history of hypertension, diabetic disease, underlying renal disease, bacterial infection, and laboratory data collected. The outcomes of bacterial dispersion, systemic immune-inflammation index (SII), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), and risk variables associated with frequent PDAP were analyzed.

RESULTS

There are differences between the two groups in dialysis time (p = 0.006), hypertensive nephropathy (p = 0.038), staphylococcus (p = 0.035), white blood cells (p = 0.001), neutrophil (p < 0.01), lymphocyte (p < 0.01), platelet(p = 0.01), SII(p < 0.01), CRP/HDL-C (p = 0.002), CRP (p < 0.001), serum creatinine (p = 0.007), blood urea nitrogen (p = 0.05), serum magnesium (0.03), serum potassium (p = 0.007), and dialysate polymorphonuclear cells (p = 0.004). Multifactorial logistic regression analysis found that SII (p < 0.001), CRP/HDL-C (p = 0.041), and Diabetes mellitus (p = 0.027) were independent risk factors for frequent PDAP. The ROC curve analysis revealed that combining SII with CRP/HDL-C resulted in the largest AUC area (AUC = 0.814).

CONCLUSIONS

Our findings offer clinical proof of the combination of SII and CRP/HDL-C in patients with frequent PDAP.

A population-based study on the incidence and aetiology of infectious complications in peritoneal dialysis in South Sweden

BACKGROUND

Peritonitis is a major cause of morbidity in peritoneal dialysis (PD) and an independent risk factor for elevated all-cause mortality. The aims of this study were to report the incidence, trend, aetiology, and antimicrobial susceptibility of PD-associated peritonitis and catheter-related infections in South Sweden between 2011-2020.

METHODS

This population-based observational cohort study included all patients with PD between the years 2011-2020 in the county of Skåne. Data was accessed through the Swedish Renal Registry and the Department of Clinical Microbiology in Lund. Definitions issued by the International Society for Peritoneal Dialysis were implemented to assess PD-associated infections.

RESULTS

Medical records of 675 paediatric and adult PD patients were eligible for inclusion. Of those, 208 (31%) were female and the median age was 67 years (range 0-91). The overall rate of PD-peritonitis was 0.38 episodes per year at risk. Out of 484 episodes of peritonitis, 61% (n = 295) were caused by Gram-positive bacteria. There were 289 occurrences of exit site infections, of which most (n = 152, 53%) were Gram-positive. Tunnel infections occurred in 16 episodes and were caused by S. aureus or P. aeruginosa. Among all isolates, 37 were of MRSE, four of ESBL-producing E. coli, and one of MRSA.

CONCLUSION

The crude rate of PD-peritonitis was stable during the study period. Gram-positive bacteria dominated the microbial aetiology, and antibiotic resistance was limited. It is important to monitor the aetiology, incidence, and resistance rates in PD-associated infections, to base empirical antibiotic regimens and facilitate prevention.

Comparison of young and old patients on peritoneal dialysis: A retrospective observational study

BACKGROUND

With a global increase in life expectancy around the world, the burden of chronic kidney disease in the elderly is increasing. The number of elderly patients undergoing peritoneal dialysis (PD) is also increasing. There is still a perception that PD may be associated with an increased risk of complications in these elderly patients.

METHODS

A total of 311 patients, of which 103 PD patients aged 65 and over and 208 PD patients under 65 years of age, were followed in a single center and evaluated, retrospectively. Demographic data of these patients, albumin values at first PD and during PD time, residual urine amount, number of peritonitis, time to the first peritonitis attack, PD endpoints, and mortality were compared.

RESULTS

Peritonitis and technique failure rates were lower in patients aged 65 and over who applied PD (0.61-0.75, 6.8%-23.1%, respectively). There was no difference in peritonitis-free survival (p = 0.931). Need for help HR 2.569 [95%CI 1.564-4.219] (p < 0.05), time to first peritonitis attack HR 0.983 [95%CI 0.974-0.992] (p < 0.05), mean albumin value HR 0.191 [95%CI 0.088-0.413] (p < 0.05), urine output level HR 1.154 [95%CI 1.010-1.318] (p < 0.05) were factors affecting mortality.

CONCLUSION

Peritonitis and technical survival evaluations of elderly PD patients, other than mortality, were lower than younger PD patients. However, the need for help is one of the biggest obstacles to this method for the elderly. We believe that incentives in this regard will increase the number of elderly PD patients.

Persistent peritonitis in peritoneal dialysis: a comphrenesive review of recurrent, relapsing, refractory, and repeat peritonitis

Peritonitis is a major cause of morbidity and technique failure in patients receiving peritoneal dialysis. Complicated peritonitis that manifests as multiple or unresolving episodes is classified as refractory, recurrent, relapsing, or repeat peritonitis, and often possesses higher risk of technique failure and mortality as well as lower complete cure rates than primary or uncomplicated episodes. While these peritonitis subtypes affect a considerable portion of PD patients, details regarding their epidemiology, pathogenesis, diagnosis, clinical sequelae, and management have not yet been fully elucidated. Improved clinical awareness and understanding of complicated peritonitis subtypes is crucial to ensure optimal management for these patients; thus, we consolidate and report the pertinent findings of recent literature on these four entities.

Epidemiological, clinical and prognosis aspects of acute generalized peritonitis in South-Kivu Province: descriptive observational study of 278 cases

Introduction

the aim was to determine epidemiological, clinical, therapeutic, and prognostic aspects of acute generalized peritonitis (AGP).

Methods

we conducted an observational, cross-sectional and multicentre study over 2 years of 278 cases of acute generalized peritonitis operated in semi-urban and urban hospitals in South-Kivu Province, Democratic Republic of Congo.

Results

the population of this study was young with a mean age was 28.9 ± 16.1 years with extremes of 1.3 years to 80 years with a sex ratio M: F of 0.8. Peritonitis aetiology was dominated by intestinal perforation 132 cases (47.4%), the admission time in 65, 5% was more than 72 hours. Acute abdominal pain was the most reason for consultation in 93.2% of cases, 11.9% of patients were in hypovolemic shock. In 40.6%, the treatment of patients consisted in intestinal resection with terminal anastomosis, or ileostomy in 32.7%. About the outcomes, 32.4% of the patients had a surgical reoperation and 15.8% of the digestive fistulas were reported. The average duration of the hospitalization was 23.4 ± 20.3 days. Morbidity rate was 14.7%.

Conclusion

the AGP remains one of the abdominal emergencies observed in different semi-urban and urban hospitals of the province of South-Kivu, causing some problems of medical and surgical management, starting from the delay of admission, the severity of the symptoms related to the etiology of the intestinal perforation. In all cases, AGP requires a well-executed resuscitation procedure and surgical technique to improve the prognosis and reduce mortality, which seems to be high in this study.

The influence of different peritoneal dialysis techniques on wound infection in patients with peritoneal dialysis tube

More and more research has started to investigate the effect of peritoneal dialysis treatment on the incidence of pericatheter wound complications in chronic kidney disease (CKD). This meta-study evaluated the effect of emergency peritoneal dialysis (EPD) with conventional peritoneal dialysis (CPD) in patients with catheter-related complications. We looked up 4 databases: PubMed, EMBASE, Cochrane, and Web of Science, and analysed the data with RevMan 5. There were a total of 15 studies with 3034 participants. While the quality of the research included was fairly good, the evidence was mediocre. In the meta-analyses, the risk of leak in the conduit with PD was very high (OR, 2.48; 95% CI, 1.72, 3.59, p < 0.00001). However, for those treated with urgent medical method prior to initiation of PD, the risk for peritonitis, catheter dysfunction and bleeding was similar compared with CPD. Based on limited information, immediate initiation of PDs is advised in order to increase the quality of life for people in urgent need, except if there is no consideration for loss of fluid. The low quality of the evidence is holding up the evidence. This research, however, is also informative because of the large number of available data. Consequently, additional high quality, large, randomized controlled studies are required to establish.

Association between reduced left ventricular ejection fraction and peritoneal dialysis related peritonitis: a single center retrospective cohort study in Japan

We present a single-center retrospective analysis of 228 Japanese patients with peritoneal dialysis, in which we examined whether reduced left ventricular ejection fraction (LVEF) is a risk factor for peritonitis development. Time-dependent multivariable-adjusted Cox proportional hazards models revealed that reduced LVEF (LVEF < 50% vs. preserved LVEF ≥ 50%, hazard ratio (HR) 2.10; 95% confidence interval (CI) 1.16-3.82) was associated with peritonitis. Qualitatively, similar associations with reduced LVEF (< 50%) were observed for enteric peritonitis (adjusted HR 7.68; 95% CI 2.51-23.5) but not for non-enteric peritonitis (adjusted HR 1.15; 95% CI 0.54-2.44). Reduced LVEF is associated with a significantly higher risk of subsequent peritonitis, particularly enteric peritonitis. These results indicate that patients with reduced LVEF may be at risk of enteric peritonitis from bowel sources caused by intestinal involvement due to cardiac dysfunction.

Pediatric peritoneal dialysis training program and its relationship to peritonitis: a study of the International Pediatric Peritoneal Dialysis Network

BACKGROUND

The guidelines for training of patients and caregivers to perform home peritoneal dialysis (PD) uniformly include recommendations pertaining to the prevention of peritonitis. The objective of this study conducted by the International Pediatric Peritoneal Dialysis Network (IPPN) was to investigate the training practices for pediatric PD and to evaluate the impact of these practices on the peritonitis and exit-site infection (ESI) rate.

METHODS

A questionnaire regarding details of the PD program and training practices was distributed to IPPN member centers, while peritonitis and ESI rates were either derived from the IPPN registry or obtained directly from the centers. Poisson univariate and multivariate regression was used to determine the training-related peritonitis and ESI risk factors.

RESULTS

Sixty-two of 137 centers responded. Information on peritonitis and ESI rates were available from fifty centers. Training was conducted by a PD nurse in 93.5% of centers, most commonly (50%) as an in-hospital program. The median total training time was 24 hours, with a formal assessment conducted in 88.7% and skills demonstration in 71% of centers. Home visits were performed by 58% of centers. Shorter (< 20 hours) training duration and lower number of training tools (both p < 0.02) were associated with higher peritonitis rate, after adjustment for proportion of treated infants and income of country of residence.

CONCLUSIONS

An association between training duration and the number of training tools represent potentially modifiable risk factors to reduce peritonitis rates within the pediatric PD population. A higher resolution version of the Graphical abstract is available as Supplementary information.

Rescue plan for CAPD peritonitis: Using ultrasonography as a guide on when to remove the catheter

INTRODUCTION

Ultrasound has been found to facilitate early identification of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

A retrospective analysis was carried out to evaluate the effectiveness of ultrasonography-guided removal of the Tenckhoff catheter in reducing complications like a shift to hemodialysis or death in CAPD patients.

RESULTS

The "peritonitis rescue plan" supported timely decision-making for the removal of the infected catheter and resulted in a lower peritonitis episode per patient per month ratio (from 1:36 to 1:122) in 2021, a lower death rate (from 19% to 6.6%) and lower incidences of shifts to hemodialysis (from 2%-9% to 0%) as compared to that before the implementation of the plan in 2019.

CONCLUSION

The implementation of the "peritonitis rescue plan" and the removal of the infected catheter within 3 days of peritonitis being detected was successful in improving the standard of care for patients undergoing CAPD.

Assessment of potential peritonitis risk factors in pediatric patients receiving maintenance peritoneal dialysis

BACKGROUND

Many recommendations regarding peritonitis prevention in international consensus guidelines are opinion-based rather than evidence-based. The aim of this study was to examine the impact of peritoneal dialysis (PD) catheter insertion technique, timing of gastrostomy placement, and use of prophylactic antibiotics prior to dental, gastrointestinal, and genitourinary procedures on the risk of peritonitis in pediatric patients on PD.

METHODS

We conducted a retrospective cohort study of pediatric patients on maintenance PD using data from the SCOPE collaborative from 2011 to 2022. Data pertaining to laparoscopic PD catheter insertion (vs. open), gastrostomy placement after PD catheter insertion (vs. before/concurrent), and no prophylactic antibiotics (vs. yes) were obtained. Multivariable generalized linear mixed modeling was used to assess the relationship between each exposure and occurrence of peritonitis.

RESULTS

There was no significant association between PD catheter insertion technique and development of peritonitis (aOR = 2.50, 95% CI 0.64-9.80, p = 0.19). Patients who had a gastrostomy placed after PD catheter insertion had higher rates of peritonitis, but the difference was not statistically significant (aOR = 3.19, 95% CI 0.90-11.28, p = 0.07). Most patients received prophylactic antibiotics prior to procedures, but there was no significant association between prophylactic antibiotic use and peritonitis (aOR = 1.74, 95% CI 0.23-13.11, p = 0.59).

CONCLUSIONS

PD catheter insertion technique does not appear to have a significant impact on peritonitis risk. Timing of gastrostomy placement may have some impact on peritonitis risk. Further study must be done to clarify the effect of prophylactic antibiotics on peritonitis risk. A higher resolution version of the Graphical abstract is available as Supplementary information.

Retraining programme for older patients undergoing peritoneal dialysis: A randomised controlled trial

BACKGROUND

Peritonitis is a common cause of hospitalisation and death among patients undergoing peritoneal dialysis. Periodic retraining is recommended to prevent peritonitis, especially in older adults.

OBJECTIVES

We evaluated the effectiveness of a retraining programme for reducing peritonitis and exit site infection rates in older adults on peritoneal dialysis. The cost-benefit ratio was also calculated.

DESIGN

A two-arm prospective randomised controlled trial.

PARTICIPANTS

One hundred and thirty patients aged 55 years or older were recruited. Participants were randomly assigned to the intervention or control group. While both groups received usual care, the intervention group received a retraining programme (a knowledge and practical assessment and a one-on-one retraining session) 90 days after starting home-based continuous ambulatory peritoneal dialysis therapy.

MEASUREMENTS

The outcomes included peritonitis rate, exit site infection rate and direct medical costs at 180, 270, and 360 days after starting home-based continuous ambulatory peritoneal dialysis therapy.

RESULTS

No significant differences were found in the baseline characteristics between groups. The peritonitis rates were 0.11 episodes per patient-year in the intervention group versus 0.13 in the control group. The incidence of exit site infection was 20.0% in the intervention group and 12.3% in the control group. The cost-benefit ratio of retraining was 1:9.6. None of the results were statistically significant.

CONCLUSIONS

The absence of statistical significance may be partly explained by the premature termination of the study. Large-scale multi-centre trials are warranted to examine the effectiveness of retraining. The timing and long-term effects of retraining also need to be examined.

Predictors of Surgical Site Infection in Contaminated Abdominal Surgical Wounds: Our Experience in Irrua Specialist Teaching Hospital

BACKGROUND

Secondary peritonitis is a common emergency surgical condition with varying aetiologies managed by surgeons all over the world. One important morbidity associated with it is postoperative surgical site infection (SSI). A better prevention strategy can be instituted if this complication in patients can be correctly predicted. The study aimed to identify factors in patients with peritonitis that have a significant bearing on the development of postoperative SSI.

METHOD

A total of fifty patients operated on for peritonitis in a period of one year were studied. Factors including age, gender, comorbidities, presenting symptoms, time of presentation, time of intervention, intraoperative findings, duration of surgery, and postoperative SSI were noted. Chi-square, Fisher's exact test and Student's t-test were used to test for association where appropriate and a p-value of < 0.05 was considered statistically significant.

RESULTS

Peritonitis was most commonly due to a ruptured appendix (46%) followed by perforated peptic ulcer disease (42%). The incidence of SSI was 44%. For the patients that developed SSI, the lowest rate was observed in cases of ruptured appendix (39.1%) and the highest in perforated gastric ulcer (64.3%) which was closely followed by perforated duodenal ulcer (57.1%). The association between the time of presentation and the occurrence of SSI was statistically significant (p = 0.028).

CONCLUSION

The SSI rate (44%) from peritonitis in our centre was quite high and the time of presentation played a crucial role. Prevention strategies focusing on predictors of SSI is necessary to reduce the rate of SSI in our setting.

The Effect of Continuing Nursing Intervention on Peritoneal Dialysis Patients and the Occurrence of Peritonitis: A Meta-Analysis

Background

Chronic kidney disease, affecting millions globally, has emerged as a significant health concern alongside tumors, diabetes, and cardiovascular diseases. Peritoneal dialysis is a widely used therapeutic intervention, but its effectiveness can be compromised by complications such as peritonitis.

Methods

We conducted a comprehensive search across eight international databases to obtain controlled trials evaluating the impact of continuous nursing on peritonitis occurrence in peritoneal dialysis patients. Following stringent quality assessment, data analysis was performed using RevMan 5.3 software.

Results

Our meta-analysis included 15 controlled trials. Of these, 13 reported peritonitis rates in both intervention and control groups. Continuous nursing was associated with a significant reduction in peritonitis incidence (OR: 0.32; 95% CI: 0.23,0.44) and complications (SMD: 3.21; 95% CI: 1.17,5.25; P = .01), as well as a decrease in serum creatinine levels (SMD: -130.06; 95% CI: -195.46,-64).

Conclusion

The findings of this study support the possibility that ongoing nursing is beneficial for the complications and creatinine for peritoneal dialysis patients.

Group A Streptococcus Primary Peritonitis in Children, New Zealand

Group A Streptococcus (GAS) primary peritonitis is a rare cause of pediatric acute abdomen (sudden onset of severe abdominal pain); only 26 pediatric cases have been reported in the English language literature since 1980. We discuss 20 additional cases of pediatric primary peritonitis caused by GAS among patients at Starship Children's Hospital, Auckland, New Zealand, during 2010-2022. We compare identified cases of GAS primary peritonitis to cases described in the existing pediatric literature. As rates of rates of invasive GAS increase globally, clinicians should be aware of this cause of unexplained pediatric acute abdomen.

Clinical impact of catheter insertion for peritoneal dialysis on patient survival and catheter-related complications

OBJECTIVES

The stepwise initiation of peritoneal dialysis (PD) using Moncrief and Popovich's technique (SMAP) for catheter insertion is recommended for the systemic introduction of PD and prevention of catheter-related infections. In this study, we investigated patient outcomes in patients who underwent insertion of a PD catheter with a direct method versus the SMAP method.

METHODS

We enrolled 295 consecutive patients who underwent PD as a primary renal replacement therapy and underwent insertion of a PD catheter at our institute between 2006 and 2021. We retrospectively reviewed their data and investigated patient outcomes, including mortality and PD catheter-related complications.

RESULTS

Median age at PD induction was 65 years in the direct insertion group and 65 years in the SMAP group (P = 0.80). The rate of PD introduction after emergency hemodialysis was significantly higher in the direct insertion group than in the SMAP group (P < 0.001). There was no significant difference in survival between the direct insertion and SMAP groups during the median follow-up period of 54 months (P = 0.12). Additionally, patients who transitioned to hemodialysis or kidney transplantation after PD showed significantly longer survival (P < 0.001). The incidence of PD catheter-related complications was not significantly different between the two groups. A body mass index ≥ 23 kg/m2 was an independent risk factor for peritonitis and exit-site infection (P = 0.006 and P = 0.011, respectively).

CONCLUSIONS

Planned sequential renal replacement therapy including hybrid hemodialysis, complete hemodialysis, and kidney transplantation after PD is important for improving patient outcomes. PD catheter insertion by SMAP may not be mandatory in our clinical practice.

Personality traits and peritoneal dialysis patients' prognosis

Objective: Peritoneal dialysis (PD) requires high patient conscientiousness. Therefore, we aimed to investigate the relationship between conscientiousness score and prognosis in PD patients.Methods: The ten-item Big Five Personality Inventory's Chinese version was used to assess the conscientiousness score. Basic clinical information, prior medical history, hematological examination results, the occurrence of the first peritonitis and catheter-related infection, the start of hemodialysis, and the time of renal transplantation were collected. The patients were split into two groups, high and low conscientiousness groups, based on the mean value of the conscientiousness score. The differences in prognostic indicators were compared between groups, and the association between conscientiousness score and prognostic indicators in PD patients was assessed.Results: Enrolled PD patients were divided into low conscientiousness group 103 and high conscientiousness group 98. There were significant differences in serum albumin (p = 0.021) and iPTH (p = 0.045) between the two groups. Multivariate Cox regression analysis identified conscientiousness score as an independent risk factor for the development of first peritonitis (HR = 0.558, 95% CI 0.400-0.779, p = 0.001) and first catheter-related infection (HR = 0.544, 95% CI 0.308-0.962, p = 0.036) in PD patients. Conscientiousness score (HR = 2.377, 95% CI 1.109-5.095, p = 0.026) was independently associated with renal transplantation.Conclusion: Conscientiousness personality is closely related to the prognosis of PD patients.

Elevated triglyceride-glucose index predisposes to the initial episode of peritonitis in chronic peritoneal dialysis patients

OBJECTIVE

The serum triglyceride-glucose (TyG) index is a marker of inflammation. However, the relationship between TyG index and peritoneal dialysis-related peritonitis (PDRP) is unclear. This study aimed to investigate the potential relationship between the baseline TyG index and the initial episode of PDRP.

METHODS

A total of 208 peritoneal dialysis (PD) patients were enrolled from January 1, 2012, to December 31, 2019 and followed up until December 31, 2022. They were divided into 2 groups according to the median TyG. The primary outcome was the occurrence of the initial episode of PDRP while on PD therapy. Kaplan-Meier curves and Cox regression analyses were used to examine the association between them.

RESULTS

Eighty-five initial episodes of PDRP were identified. The risk of PDRP was higher in the high-TyG index group (p = 0.030). Multivariate Cox regression analysis showed a higher risk of PDRP in patients with a high TyG index (HR = 1.800, 95% CI 1.511-2.815, p = 0.010).

CONCLUSION

The baseline serum TyG index was an independent risk factor for the initial episode of PDRP in chronic PD patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Training practices and peritonitis rates in children on maintenance peritoneal dialysis: results from the Standardizing Care to Improve Outcomes in Pediatric End Stage Kidney Disease (SCOPE) collaborative

BACKGROUND

Comprehensive training of children on peritoneal dialysis (PD) and their caregivers is crucial to minimize peritonitis risk. Few studies have evaluated the impact of training on infection, so many published recommendations rely on expert opinion. This study uses data from the SCOPE collaborative to examine the impact of compliance with 4 components of PD training on the risk for peritonitis.

METHODS

A retrospective cohort study of children enrolled in the SCOPE collaborative between 2011 and 2021 who received training prior to initiating PD. Compliance with 4 training components were assessed: performance of a home visit, 1:1 training, delaying training ≥ 10 days after PD catheter insertion and average individual training session length ≤ 3 h. Univariate and multivariable generalized linear mixed modeling were used to assess relationships between peritonitis ≤ 90 days after PD training and median days to peritonitis and compliance with each component as well as all-or-none compliance.

RESULTS

Among 1450 trainings, 51.7% had median session length ≤ 3 h, 67.1% delayed training ≥ 10 days after catheter insertion, 74.3% had a home visit and 94.6% had 1:1 training. Only 333 trainings (23%) were compliant with all 4 training components. There was no statistically significant association between compliance with individual components, or all-or-none compliance and either the percentage of catheters with peritonitis ≤ 90 days after training end or median days to peritonitis.

CONCLUSION

No associations between 4 PD training components and risk for peritonitis were found. SCOPE requires monthly review of PD catheter practices which may have decreased the impact of training non-compliance. A higher resolution version of the Graphical abstract is available as Supplementary information.

Body surface area and treatment failure in peritoneal dialysis-associated peritonitis

INTRODUCTION

This study mainly discussed the relationship between body surface area (BSA) and treatment failure of peritoneal dialysis-associated peritonitis (PDAP).

METHODS

The exposures were BSA grouped by the tertiles of BSA levels. The association between BSA and the risk of treatment failure in PDAP, defined as the temporary or permanent switch to hemodialysis and kidney transplantation, was evaluated in Cox proportional hazards models.

RESULTS

A total of 483 episodes in 285 patients were recorded in our center. As a three-level categorical variable, in reference to G3, the G1 of BSA displayed a 4.054-fold increased venture of treatment failure in a fully adjusted model. In sensitivity analysis, a lower value of BSA (G1) was identified as an independent risk factor for peritonitis episodes (odds ratio = 2.433, 95% confidence interval: 1.184-4.999, p = 0.015).

CONCLUSION

A lower level of body surface area was remarkably associated with a higher incidence of treatment failure among peritoneal dialysis-associated peritonitis episodes.

Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023

The last few years have seen several developments in the field of peritoneal dialysis (PD), including successful use of acute PD, increasing emphasis on home dialysis utilization, and improved understanding of models of peritoneal solute transfer. This installment of AJKD's Core Curriculum in Nephrology emphasizes the latest data available for prevention and management of infectious and noninfectious complications of PD. Through case vignettes, appropriate strategies for diagnosis and care of patients with PD peritonitis are reviewed as well as noninfectious complications evident in clinical practice including complications from increased intra-abdominal pressure, namely pericatheter and abdominal leaks, hernia formation, and complications from pleuroperitoneal communication (hydrothorax). Although rates of incisional hernias and pericatheter leaks have decreased with improved peritoneal dialysis catheter insertion techniques, these mechanical complications continue to be common occurrences and are reviewed via pertinent clinical vignettes which aim to address and discuss common implications of these scenarios. Finally, this Core Curriculum article covers a practical overview of peritoneal dialysis catheter dysfunction.

Risk factors for early dialysate leakage around the exit site after catheter placement in pediatric peritoneal dialysis: a single-center experience

BACKGROUND

Dialysate leakage, a major complication in peritoneal dialysis (PD), causes difficulty in continuing PD. However, literature evaluating risk factors for leakage in detail and the appropriate break-in period to avoid leakage in pediatric patients is scarce.

METHODS

We conducted a retrospective study on children aged < 20 years who underwent Tenckhoff catheter placement between April 1, 2002, and December 31, 2021, at our institution. We compared clinical factors between patients with and without leakage within 30 days of catheter insertion.

RESULTS

Dialysate leakage occurred in 8 of 102 (7.8%) PD catheters placed in 78 patients. All leaks occurred in children with a break-in period of < 14 days. Leaks were significantly more frequent in patients with low body weight at the catheter insertion, single-cuffed catheter insertion, a break-in period ≤ 7 days, and a long PD treatment time per day. Only one patient who had leakage with a break-in period > 7 days was neonate. PD was suspended in four of the eight patients with leakage and continued in the others. Two of the latter had secondary peritonitis, one of whom required catheter removal, and leakage improved in the remaining patients. Three infants had serious complications from bridge hemodialysis.

CONCLUSIONS

A break-in period of > 7 days and if possible 14 days is recommended to avoid leakage in pediatric patients. Whereas infants with low body weight are at high risk of leakage, their difficulty in inserting double-cuffed catheter, hemodialysis complications, and possible leakage even under long break-in period make prevention of leakage challenging.

Characteristics and outcomes of hospital-acquired and community-acquired peritonitis in patients on peritoneal dialysis: a retrospective cohort study

BACKGROUND

Peritonitis remains a significant complication of peritoneal dialysis. However, there is limited information on the clinical characteristics and outcomes of hospital-acquired peritonitis compared to community-acquired peritonitis in patients undergoing peritoneal dialysis. Furthermore, the microbiology and outcomes of community-acquired peritonitis may vary from hospital-acquired peritonitis. Therefore, the aim was to gather and analyse data to address this gap.

METHODS

Retrospective review of the medical records of all adult patients on peritoneal dialysis within the peritoneal dialysis units in four university teaching hospitals in Sydney, Australia, who developed peritonitis between January 2010 and November 2020. We compared the clinical characteristics, microbiology and outcomes of community-acquired peritonitis and hospital-acquired peritonitis. Community acquired peritonitis was defined as the development of peritonitis in the outpatient setting. Hospital-acquired peritonitis was defined as: (1) developed peritonitis anytime during hospitalisation for any medical condition other than peritonitis, (2) diagnosed with peritonitis within 7 days of hospital discharge and developed symptoms of peritonitis within 3 days of the hospital discharge.

RESULTS

Overall, 904 episodes of peritoneal dialysis-associated peritonitis were identified in 472 patients, of which 84 (9.3%) episodes were hospital-acquired. Patients with hospital-acquired peritonitis had lower mean serum albumin levels compared to those with community-acquired peritonitis(22.95 g/L vs. 25.76 g/L, p = 0.002). At the time of diagnosis, lower median peritoneal effluent leucocyte and polymorph counts were observed with hospital-acquired peritonitis compared to community-acquired peritonitis (1236.00/mm3 vs. 3183.50/mm3, p < 0.01 and 1037.00/mm3 vs. 2800.00/mm3, p < 0.01, respectively). Higher proportions of peritonitis due to Pseudomonas spp. (9.5% vs. 3.7%, p = 0.020) and vancomycin-resistant Enterococcus (2.4% vs. 0.0%, p = 0.009), lower rates of complete cure (39.3% vs. 61.7%, p < 0.001), higher rates of refractory peritonitis (39.3% vs. 16.4%, p < 0.001) and higher all-cause mortality within 30 days of peritonitis diagnosis (28.6% vs. 3.3%, p < 0.001) were observed in the hospital-acquired peritonitis group compared to the community-acquired peritonitis group, respectively.

CONCLUSIONS

Despite having lower peritoneal dialysis effluent leucocyte counts at the time of diagnosis, patients with hospital-acquired peritonitis had poorer outcomes, including lower rates of complete cure, higher rates of refractory peritonitis and higher rates of all-cause mortality within 30 days of diagnosis, compared to those with community-acquired peritonitis.

Simplified calculation of peritoneal dialysis-associated peritonitis rate: Accuracy of a recently developed estimating equation

Recently, we validated a simple method for estimating peritoneal dialysis (PD) peritonitis rate. Despite good agreement between estimates and gold-standard measurements in two large dialysis registries, the International Society of Peritoneal Dialysis (ISPD) was hesitant to recommend adoption of the estimating equation. Their perception is that inaccuracies, as small as they are, might still be detrimental to clinical decision-making. In this study, we apply new analyses to the original validation data sets. We quantify agreement using standards from the International Organization for Standardization (ISO). We also identify a subset of centres with poorest performance of the estimating equation and qualitatively assess the potential for compromised clinical decision-making associated with its use. Inter-assay % coefficient of variation between estimates and measurements was 4.2% in the Australia and New Zealand Dialysis and Transplant Registry and 4.6% in Le Registre de Dialyse Péritonéale de Langue Française, easily meeting ISO requirements. Mandel's h values and Grubb's tests confirmed more outlying estimates compared to the measurements, while Mandel's k values and Cochran's C tests showed that identical precision by the two methods. Misclassification of centres as being above versus below the ISPD standard of 0.4 episodes/patient-year occurred only with rates close to the threshold, affecting approximately 3% of patient-years. In the 26 (out of 268) centres with poorest performance of the estimating equation, examination of the time series of their annual PD peritonitis rate estimates/measurements showed that using estimates would not detrimental to clinical decision-making. In conclusion, the estimating equation is sufficiently accurate for routine clinical use.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Hospital-acquired peritonitis in patients on peritoneal dialysis: A call to action

Peritonitis remains a significant complication of peritoneal dialysis (PD), and severe episodes of peritonitis lead to structural and functional alterations of the peritoneal membrane, which can result in a permanent transfer to hemodialysis. Although PD is designed primarily to be delivered in the community setting, patients on PD get hospitalized for a number of reasons. In this commentary, we highlight the enormous risks each hospitalization has on the occurrence of peritonitis in patients on PD and the need to understand factors that predispose patients to hospital-acquired peritonitis. Furthermore, we suggest directions on several strategies that could not only reduce the risks of developing peritonitis but also improve outcomes of patients on PD who get hospitalized for an unrelated illness.

Low immunoglobulin G concentrations are not associated with an increased risk of peritoneal dialysis-related peritonitis

BACKGROUND

Peritonitis is a common and severe complication of peritoneal dialysis (PD) and is associated with high morbidity and sometimes also with mortality. Identification of risk factors, as well as protective mechanisms for peritonitis, is important to reduce peritonitis-induced morbidity. According to the current literature, IgG concentrations might be associated with peritonitis in PD-treated patients. In this study, we aimed to investigate possible associations between dialysate or serum IgG concentration and peritonitis risk in a longitudinal cohort of PD-treated patients.

MATERIALS AND METHODS

We analyzed prospectively collected data obtained during the first standard peritoneal permeability analysis (SPA), performed in incident PD patients, aged > 18 years who started PD treatment in our tertiary-care university hospital from January 1, 1994 until December 31, 2008. Patients were divided in groups according to dialysate or serum IgG concentrations and according to peritonitis incidence. A possible association between low dialysate or serum IgG concentrations and time to the first peritonitis episode was investigated using cox proportional hazard models.

RESULTS

120 patients were included in our analyses with a median follow-up time of 36 (16 - 92) months. No significant association between dialysate, nor serum IgG and time to peritonitis was found (HR 0.27 (95% CI 0.65 - 1.62), p = 0.911 and HR 0.87 (95% CI 0.70 - 1.68), p = 0.708, respectively). Moreover, IgG concentrations were not associated with peritonitis incidence, nor with the recurrence of peritonitis. Finally, we found no significant difference in dialysate or serum IgG concentrations between patients who remained peritonitis-free (58.0 ± 35.6 mg/L in dialysate, 11.1 ± 4.4 g/L in serum), and those who experienced a peritonitis episode during follow-up (59.5 ± 41.9 mg/L in dialysate, 10.3 ± 4.3 g/L in serum), respectively.

CONCLUSION

Dialysate or serum IgG are not major determinants of local peritoneal defense against peritonitis.

Bacterascites confers poor patient prognosis beyond MELD prediction

Spontaneous bacterial peritonitis (SBP) is a well-recognized clinical entity with a poor prognosis. In comparison, the prevalence, microbiological flora, and prognostic significance of bacterascites (BA) (the presence of organism on culture but ascitic PMN <250 cells/mm³) is largely unknown. We, therefore, assessed the prognosis and predictors of outcome in patients with BA in comparison with those with SBP. Ascitic fluid cultures from consecutive patients with cirrhosis from 2008 to 2018 were reviewed retrospectively, and patients with SBP and BA were identified. Baseline demographic, laboratory, and microbiological data were collated and analyzed as prognostic indicators, and clinical outcomes were recorded. Patients were censored at the time of LT, death, or last follow-up. For this study 176 and 213 cases of SBP and BA, respectively, were identified and included. Patients with SBP had significantly higher Model for End-Stage Liver Disease (MELD) ( p =<0.01), peripheral blood WCC ( p < 0.01), and higher rates of Enterobacteriaceae ( p < 0.01) and multi-drug resistant pathogens ( p < 0.01). Survival at 1 and 3 months was lower in patients with SBP ( p < 0.01) when compared with BA but at 6 months and beyond, no significant difference remained. After the exclusion of deaths within 30 days of presentation, survival between SBP and BA was equivocal at all time points. Mortality was substantially higher across all MELD groupings for both SBP and BA when compared with the predicted mortality calculated by the MELD score alone. BA has a negative impact on patient survival above that predicted by the MELD score. It has similar impact to SBP on patient survival beyond 1 month suggesting it should be seen as a poor prognostic marker and prompt consideration of LT where appropriate. Further studies evaluating the role of secondary prophylaxis in this group are required.

Peritoneal dialysis outcomes in a tertiary-level state hospital in Johannesburg, South Africa: Ethnicity and HIV co-infection do not increase risk of peritonitis or discontinuation

BACKGROUND

Peritoneal dialysis (PD) is a valuable means to increase access to kidney replacement therapy in South Africa (SA). An increased rate of modality discontinuation related to an increased risk of peritonitis in patients of black African ethnicity, in those with diabetes and in those living with HIV has previously been suggested, which may lead to hesitancy in adoption of 'PD first' programmes.

OBJECTIVES

To analyse the safety of a PD-first programme in terms of 5-year peritonitis risk and patient and modality survival at the outpatient PD unit at Helen Joseph Hospital, Johannesburg.

METHODS

After exclusions, clinical data from 120 patients were extracted for analysis. The effects of patient age at PD initiation, ethnicity, gender, diabetes mellitus and HIV infection on patient and modality survival and peritonitis risk were analysed using Cox proportional hazards modelling and logistic regression analysis. Five-year technique and patient Kaplan-Meier survival curves for peritonitis and comorbidity groups were compared using the Cox-Mantel test. The Mann-Whitney U-test and Fisher's exact test were used to compare continuous and categorical variables where appropriate.

RESULTS

Five-year patient survival was 49.9%. Black African ethnicity was associated with reduced mortality hazard (hazard ratio (HR) 0.33; 95% confidence interval (CI) 0.15 - 0.71; p=0.004), and patients with diabetes had poorer 5-year survival (19.1%; p=0.097). Modality survival at 5 years was 48.1%. Neither Black African ethnicity nor HIV infection increased the risk of PD discontinuation. Peritonitis was associated with increased modality failure (HR 2.99; 95% CI 1.31 - 6.87; p=0.009). Black African ethnicity did not increase the risk of peritonitis. HIV was not independently associated with an increased risk of peritonitis. Patient and PD survival were generally similar to other contemporaneous cohorts, and the peritonitis rate in this study was within the International Society for Peritoneal Dialysis acceptable range.

CONCLUSION

PD is a safe and appropriate therapy in a low socioeconomic setting with a high prevalence of HIV infection. Consideration of home circumstances and training in sterile technique reduce peritonitis risk and improve PD modality survival. Patients with diabetes may be at risk of poorer outcomes on PD.

Relationship between serum iPTH and peritonitis episodes in patients undergoing continuous ambulatory peritoneal dialysis

BACKGROUND

Peritonitis is considered as one of the most serious complications that cause hospitalization in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). There is limited evidence on the impact of the parathyroid hormone (PTH) on the first peritoneal dialysis (PD)-associated peritonitis episode. We aimed to investigate the influence of serum intact parathyroid hormone (iPTH) on peritonitis in patients undergoing PD.

METHODS

This was a retrospective cohort study. Patients undergoing initial CAPD from a single center in China were enrolled. The baseline characteristics and clinical information were recorded. The primary outcome of interest was the occurrence of the first PD-associated peritonitis episode. Five Cox proportional hazard models were constructed in each group set. In group set 1, all participants were divided into three subgroups by tertiles of the serum concentration of iPTH; in group set 2, all participants were divided into three subgroups based on the serum concentration of iPTH with 150 pg/ml interval (<150, 150-300, and >300 pg/ml). Hazard ratios and 95% confidence intervals (CIs) were calculated for each model. The multivariate linear regression analysis elimination procedure assessed the association between the clinical characteristics at baseline and the iPTH levels. Restricted cubic spline models were constructed, and stratified analyses were also conducted.

RESULTS

A total of 582 patients undergoing initial PD (40% women; mean age, 45.1 ± 11.5 years) from a single center in China were recruited. The median follow-up duration was 25.3 months. Multivariate Cox regression analysis showed that, in the fully adjusted model, a higher serum iPTH level (tertile 3, iPTH >300 pg/ml) was significantly associated with a higher risk of PD-associated peritonitis at 3 years [tertile 3: hazard ratio (HR) = 1.53, 95%CI = 1.03-2.55, p = 0.03; iPTH > 300 pg/ml: HR = 1.57, 95%CI = 1.08-2.27, p = 0.02]. The hazard ratio for every 100 pg/ml increase in serum iPTH level was 1.12 (95%CI = 1.05-1.20, p < 0.01) in the total cohort when treating iPTH as a continuous variable.

CONCLUSIONS

An elevated iPTH level was significantly associated with an increased risk of peritonitis in patients undergoing CAPD.

Clinical features and risk factors of catheter removal among 1062 episodes of peritoneal dialysis‐associated peritonitis: a multicenter 7‐year study

INTRODUCTION

Studies focusing on catheter removal and the pathogenic spectrum of peritoneal dialysis-associated peritonitis (PDAP) need to be updated.

METHODS

Data were collected from four peritoneal dialysis (PD) centers. Peritonitis rates were compared using Poisson regression and Logistic regression was used to examine the risk factors for catheter removal.

RESULTS

The PD duration (odds ratio [OR], 1.021; 95% confidence interval [CI], 1.010-1.032), number of previous PDAP episodes (OR, 1.267; 95% CI, 1.039-1.545), dialysate white cell count >100 × 10⁶ /L on Day 5 of PDAP (OR, 6.088; 95% CI, 3.277-11.312), Pseudomonas aeruginosa (OR, 4.122; 95% CI, 1.071-15.874) and polymicrobial infections (OR, 3.257; 95% CI, 1.519-6.982) were independent predictors of catheter removal (p < 0.05). The prevalence of polymicrobial peritonitis and fungal peritonitis has increased (p < 0.05).

CONCLUSION

Attention should be paid to patients with long PD duration or a history of previous episodes of PDAP characteristics.

Peritoneal videodialysis: first Italian audit

Conceived and developed since 2001 at the Alba Center, Videodialysis (VD) was used initially to prevent dropout in prevalent PD patients by guiding them in performing dialysis (VD-Caregiver). Subsequently, its use was extended to the clinical follow-up of critical patients (VD-Clinical), problems relating to transport to the Center (VD-Transport), and since 2016 for training/retraining all patients (VD-Training). Since 2017 other Centers have employed VD using modalities analyzed in this paper. Methods: the paper reports the findings of an Audit (February 2021) of the Centers using VD on 31-12-2020. The Centers provided the following information: the characteristics of the patients using VD; the main and secondary reasons for using VD, considering nursing home (VD-NH) patients separately; VD outcomes: duration, drop-out, peritonitis, patient/caregiver satisfaction (minimum: 1 - maximum: 10). Results: VD, which began between 09-2017 and 12-2019, has been used in 6 Centers for 54 patients at 31-12-2020 (age:71.8±12.6 years - M:53.7% - CAPD:61.1% - Assisted PD:70.3%). The most frequent reason has been VD-Training (70.4%), followed by VD-Caregiver (16.7%), VD-NH (7.4%), VD-Clinical (3.7%), and VD-Transport (1.9%), with differences between Centers. VD-Training is used most with self-care patients (93.8% - p<0.05), while with patients on Assisted PD it is associated with secondary reasons (95.7% - p<0.02). VD-Training (duration: 1-4 weeks) has always been completed successfully. No peritonitis was reported; satisfaction was 8.4±1.4. Conclusion: videodialysis is a flexible, effective, safe, and valued tool that can be employed using various modalities depending on the choice of the Center and the complexity of the patient.

[Peritoneal Dialysis in Italy: the 7th GSDP-SIN census 2019]

Objectives: Analysis of the results of the 7th National Census (Cs-19) of Peritoneal Dialysis in Italy, conducted in 2020-21 by the Peritoneal Dialysis Project Group of the Italian Society of Nephrology, for the year 2019. Materials and methods: The data was initially collected using specially designed software, which after entering the data of individual patients allows the aggregate extraction of the necessary information. The difficulties due to the COVID pandemic made it necessary to also use the traditional on-line questionnaire used previously. Of the 237 Centers envisaged, 198 responded, of which 177 with complete data for HD also in 2016. Results: Overall incidence and prevalence (31/12/2019) were respectively 1,363 (CAPD/APD = 741/622) and 3,922 (CAPD/APD = 1,857 / 2,065) patients. The percentage incidence and prevalence (177 Centers) decreased compared to 2016, respectively, from 23.8% to 22.1% and from 17.3% to 16.6%. 31.4% started PD incrementally in 60.3% of the Centers. The catheter is placed by the Nephrologist alone in 19.7%. Assisted PD is used by 24.5% of the prevalent patients, mostly (83.8%) by a family member. In 2019, the exit from PD (ep/100 years-pts: 11.6 in HD; 8.9 death; 6.0 Tx) is decreasing for all causes. The main cause of transfer to HD remains peritonitis (26.8%). The incidence of peritonitis in 2019 dropped further to 0.190 ep/year-pts as well as the incidence of new cases of EPS (0.103 ep/100 years-pts). Conclusions: The Cs-19 confirms the good results of the DP in Italy.

A comparative study on nosocomial and community-acquired spontaneous bacterial peritonitis in patients with liver cirrhosis at a university hospital

BACKGROUND

The serious nature of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and the need for timely effective empirical antibiotic therapy in the context of the global surge of antimicrobial resistance and changing epidemiology necessitate a periodic review of the local epidemiologic features of the disease.

AIM

The aim of the study is to investigate the differences in bacterial profile and antibiotic resistance between nosocomial and community-acquired SBP in patients with liver cirrhosis to guide empirical antibiotic choices for better outcomes.

METHODS

This cross-sectional study included 95 ascitic cirrhotic patients diagnosed with SBP. According to the setting in which the infection was acquired, the patients were divided into two groups: nosocomial and community-acquired SBP. The bacterial profile and rates of multidrug resistance (MDR) phenotype and the extended-spectrum β-lactamase (ESBL) production among Gram-negative isolates in both groups were compared.

RESULTS

Escherichia coli was the most frequently isolated bacteria (60% of all isolates) followed by Klebsiella pneumoniae (11.4%). Gram-positive bacteria were only isolated from nosocomial SBP cases; the most common was Staphylococcus aureus (11.4%) followed by coagulase-negative staphylococci (5.7%). High rates of resistance to third-generation cephalosporins, the first-line empirical treatment of SBP, were detected (76.6-100% in nosocomial isolates and 25-87% in community isolates). Carbapenems, amikacin and gentamycin showed good activity against Gram-negative bacilli in both nosocomial and community-acquired isolates. MDR bacteria, including ESBL-producing Enterobacteriaceae, were significantly associated with nosocomial SBP.

CONCLUSION

The significant increase in MDR phenotype and ESBL production among nosocomial isolates necessitates a change in the initial empirical therapy for nosocomial SBP and carbapenems seem good alternatives.

Influence of climatic factors on singlecenter peritoneal dialysisassociated peritonitis

OBJECTIVES

Peritoneal dialysis associated peritonitis (PDAP), one of the most common complications of peritoneal dialysis, is generally believed as an important factor causing technique failure and increasing hospital admission and fatality rate in peritoneal dialysis patients. Moreover, the prevention and treatment for PDAP have always been considered as an important link in clinical peritoneal dialysis. Thus, the study is performed to investigate the impact of climate factors on the incidence and prognosis of single-center PDAP in Hunan Province, China, which can provide a clinical basis for the prevention and treatment strategy for PDAP.

METHODS

A total of 885 patients on peritoneal dialysis, who were admitted to Department of Nephrology, Third Xiangya Hospital, Central South University (hereinafter referred to as our hospital) from January 1, 2009 to December 31, 2017, were enrolled as the subjects, and the demographic and clinical data for patients with PDAP from 2009 to 2017 as well as climate data of Hunan Province were collected.The patients were divided into different season groups, and the general information and clinical biochemical indicators in different season groups were compared. The incidence, the proportion of pathogenic bacteria and the clinical outcome of PDAP in the different season groups were compared. The risk factors of PDAP in different season groups were analyzed by using a multivariate logistic regression. Pearson's correlation analysis was used to analyze the correlations of the overall incidence of PDAP with the monthly mean temperature and the monthly mean humidity.

RESULTS

There were 448 cases of PDAP that occurred in the peritoneal dialysis center of our hospital from 2009 to 2017 (9 years), the incidence was 0.17 time/patient-years. The incidence of overall PDAP (0.246 time/patient-years) and the incidence of Gram-negative (G-) bacterial PDAP (0.048 time/patient-years) in the summer group were the highest compared with the other season groups, with significant difference (all P<0.05). Compared with the spring group (OR=0.321, 95% CI 0.144-0.713; P<0.01), the autumn group (OR=0.419, 95% CI 0.187, 0.937; P<0.05) and the winter group (OR=0.326; 95% CI 0.139, 0.763; P<0.05), the probability suffered from PDAP in the summer group were higher. The patients with low body mass index (BMI) in the spring group were more likely to suffer from PDAP in the summer group. The overall incidences of PDAP (r=0.258, P<0.05) and G- bacterial PDAP (r=0.278, P<0.05) were significantly positively correlated with the monthly mean temperature in Hunan Province, which was not correlated with the monthly average humidity. The overall cure rate of PDAP was 83%, and there was no difference in the treatment outcomes among the different season groups (all P>0.05).

CONCLUSIONS

The climate factors in Hunan, China have a significant impact on the incidence of PDAP in peritoneal dialysis patients in our hospital. Summer is the peak of PDAP, especially G- bacterial PDAP. Intestinal dysfunction and low BMI are risk factors for the onset of PDAP in summer. High temperature rather than high humidity is correlated with increased incidence of overall PDAP, especially for G- bacterial PDAP.

["Naked" exit-site for peritoneal dialysis catheters]

Exit site infections (ESI) and peritoneal catheter tunnel infections are strongly associated with peritonitis. Alternative exit-site dressings can include the use of water and soap and the absence of sterile gauze. This article reports our experience with "naked" exit-sites, meaning without any kind of gauze to cover them. From January 2017 to October 2020, we enrolled 38 patients of the Nephrology and Dialysis Unit of the "San Martino" Hospital in Belluno. Nine of these patients had a "naked" exit-site. At the end of the study, no significant differences were found in the percentage of ESI-free patients, in the incidence rate of ESI, in the relative risk of developing ESI and in the incidence rate of peritonitis.

Infection in Hospitalized Cirrhosis Patients: Changing Epidemiology and Clinical Features

BACKGROUND

Patients with cirrhosis are uniquely predisposed to infections, which can lead to acute decompensation and an increase in mortality rates. We hypothesized that not only are cirrhotic patients more likely to develop certain infections, but that specific infections are associated with poorer outcomes. Therefore, we aimed to examine the epidemiology, bacteriology, and outcomes of infections in cirrhotic patients admitted to the hospital.

METHODS

In this single center observational retrospective cohort study, we identified admissions in which patients had an infection from a group of all admissions of cirrhotics from 2011-2016. Infections were categorized by the primary source of infection, and rigorous clinical and bacteriologic definitions were used.

RESULTS

We identified 1,208 admissions in 877 unique patients during the study period. The most common infections identified were as follows: urinary tract infections (33%), pneumonia (23%), spontaneous bacterial peritonitis (14%), and bacteremia (11%). Gram-positive organisms were most commonly isolated in patients with spontaneous bacterial peritonitis and bacteremia, whereas gram-negative bacteria were most prevalent in urinary tract infections and pneumonia. Candida infections were common and identified in the following proportions: spontaneous bacterial peritonitis (16%), pneumonia (14%), bacteremia (13%), and urinary tract infections (9%). Pneumonia, spontaneous bacterial peritonitis, and meningitis were associated with increased mortality rates (29%, 32%, and 67%, respectively), compared to the overall mortality rate of 20% (p-value < 0.05).

CONCLUSIONS

In summary, infections were common in patients with cirrhosis and were associated with poor outcomes, particularly in the presence of evidence of sepsis. Spontaneous bacterial peritonitis and bacteremia are now most commonly due to gram-positive organisms and fungal infections appear to be rising in prevalence.

Gut microbial metabolite TMAO increases peritoneal inflammation and peritonitis risk in peritoneal dialysis patients

Trimethylamine-N-oxide (TMAO), a gut microbiota-produced metabolite, is accumulated in chronic kidney disease (CKD) patients. It is well known to contribute to CKD-related cardiovascular complications. However, the effect of TMAO on peritoneal dialysis (PD)-related peritonitis remains largely unknown. Here, we demonstrate that serum concentrations of TMAO were positively correlated with C-reactive protein levels, and the appearance rate of dialysate IL-6 and PAI-1, in PD patients. During the follow-up period of 28.3 ± 8.0 months, patients with higher TMAO levels (≥50 μM) had a higher risk of new-onset peritonitis (HR, 3.60; 95%CI, 1.18-10.99; P=0.025) after adjusting for sex, age, diabetes, PD duration, BUN, rGFR, C-reactive protein, BMI and β2-M. In CKD rat models, TMAO significantly promoted peritoneal dialysate-induced inflammatory cell infiltration, inflammatory cytokines production in the peritoneum. In vitro study revealed that TMAO directly induced primary peritoneal mesothelial cell necrosis, together with increased production of pro-inflammatory cytokines including CCL2, TNF-α, IL-6, and IL-1β. In addition, TMAO significantly increased TNF-α-induced P-selectin production in mesothelial cells, as well as high glucose-induced TNF-α and CCL2 expression in endothelial cells. In conclusion, our data demonstrate that higher levels of TMAO exacerbate peritoneal inflammation and might be a risk factor of incidence of peritonitis in PD patients.

Effect of Combining Conventional and Telehealth Methods on Managing Peritoneal Dialysis Patients: A Retrospective Single-Center Study

OBJECTIVE

This study aimed to explore follow-up mode changes for peritoneal dialysis (PD) patients and their effects on PD quality during the COVID-19 pandemic.

METHODS

A retrospective single-center study was conducted. All patients who received PD treatment at the Second Affiliated Hospital of Soochow University between January 2018 and March 2020 were enrolled in this study. Patient data during the first quarter of 2018 (Q1-2018), the first quarter of 2019 (Q1-2019), and the first quarter of 2020 (Q1-2020) were collected.

RESULTS

No significant differences were observed for any serum examinations in different follow-up periods (P > 0.05). A significantly reduced outpatient follow-up rate was observed in Q1-2020 compared with Q1-2018 and Q1-2019 (71.6% Vs 78.9% Vs 84.7%, P < 0.001), accompanied by a significantly increased remote follow-up rate (28.4% Vs 21.1% Vs 15.3%, P < 0.001). Compared with Q1-2018 and Q1-2019, the hospitalization rate (27.7% Vs 30.9% Vs 15.7%, P < 0.001) and the incidence of peritonitis (0.162 Vs 0.186 Vs 0.08 per patient-year, P < 0.001) decreased significantly in Q1-2020. PD patients had a significant decline in the drop-out rate for Q1-2020 compared with Q1-2019 (4.4% Vs 7.3% Vs 2.2%, P < 0.001). No differences in the incidence of catheter-related infections were observed. No significant differences were observed for any peritoneal dialysis key performance indicators (KPIs) between outpatient follow-up and remote follow-up patients.

CONCLUSION

During the COVID-19 pandemic (Q1-2020), our center practiced more remote follow-up procedures in PD patients. The hospitalization rate and peritonitis incidence were significantly decreased compared with the same time in previous years. No statistical differences were observed in other KPIs for peritoneal dialysis. This study shows that telehealth methods are a reasonable alternative to in-person care in the care/management of PD patients.

Peritoneal transport status and first episode of peritonitis: a large cohort study

BACKGROUND

Peritonitis is one of the most serious complications of peritoneal dialysis (PD). This study aimed to explore the relationship between peritoneal transport status and the first episode of peritonitis, as well as the prognosis of patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHOD

A retrospective cohort study was conducted, analyzing data of CAPD patients from 1st January 2009, to 31st December 2017. Baseline data within 3 months after PD catheter placement was recorded. Cox multivariate regression analysis was performed to determine the risk factors for the first episode of peritonitis, technique failure and overall mortality.

RESULTS

A total of 591 patients were included in our analysis, with a mean follow-up visit of 49 months (range: 27-75months). There were 174 (29.4%) patients who had experienced at least one episode of peritonitis. Multivariate Cox regression analysis revealed that a higher peritoneal transport status (high and high-average) (HR 1.872, 95%CI 1.349-2.599, p = 0.006) and hypoalbuminemia (HR 0.932,95% CI 0.896, 0.969, p = 0.004) were independent risk factors for the occurrence of the first episode of peritonitis. In addition, factors including gender (male) (HR 1.409, 95%CI 1.103, 1.800, p = 0.010), low serum albumin (HR 0.965, 95%CI 0.938, 0.993, p = 0.015) and the place of residence (rural) (HR 1.324, 95%CI 1.037, 1.691, p = 0.024) were independent predictors of technique failure. Furthermore, low serum albumin levels (HR 0.938, 95%CI 0.895, 0.984, p = 0.008) and age (>65years) (HR 1.059, 95%CI 1.042, 1.076, p < 0.001) were significantly associated with the risk of overall mortality of PD patients.

CONCLUSIONS

Baseline hypoalbuminemia and a higher peritoneal transport status are risk factors for the first episode of peritonitis. Factors including male gender, hypoalbuminemia, and residing in rural areas are associated with technique failure, while hypoalbuminemia and age (>65years) are predictors of the overall mortality in PD patients. Nevertheless, the peritoneal transport status does not predict technique failure or overall mortality of PD patients.

Association between the use of exchange devices for peritoneal dialysis fluids and peritonitis incidence: A nationwide cohort study

BACKGROUND

The use of exchange devices for peritoneal dialysis (PD) fluids is a common practice in Japan. Evidence on the effectiveness of exchange devices in preventing PD-related peritonitis is scarce. We evaluated the association between the use of exchange devices for PD fluids and peritonitis incidence.

METHODS

We retrospectively enrolled 3845 patients, aged ≥20 years, receiving PD for ≥3 months, with available data on the exchange procedure for PD fluids and peritonitis incidence that was obtained from the Japan Renal Data Registry, a nationwide annual survey. The patients were grouped according to whether the manual or device PD fluid exchange method was used. The onset of peritonitis was defined as a leukocyte count of >100/µL (neutrophils ≥50%) in PD effluents. We applied quasi-Poisson regression analyses to estimate the incidence rate ratio (IRR). Age, sex, PD vintage, body mass index, automated PD use, residual kidney function, comorbidities, haemoglobin and serum albumin were adjusted as potential confounders.

RESULTS

Older age, automated PD use, diabetes as comorbidity and lower haemoglobin levels were associated with the use of exchange devices for PD fluids. Patients using devices for PD fluid exchange (69.2%) had an increased risk of peritonitis of 37% (IRR: 1.37, 95% confidence interval (CI): 1.07-1.75) and 28% (IRR: 1.28, 95% CI: 1.00-1.63) in the crude and multivariate adjustment models, respectively.

CONCLUSIONS

The use of exchange devices for PD fluids and peritonitis incidence showed no favourable association. There may remain possible residual confounding by indication.

The Risk of Clostridioides difficile Infection in Cirrhotic Patients Receiving Norfloxacin for Secondary Prophylaxis of Spontaneous Bacterial Peritonitis-A Real Life Cohort

Background and Objectives: Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of liver cirrhosis. Antibiotic prophylaxis is effective but can lead to an increased incidence of Clostridioides difficile infection (CDI). The aim of this study was to evaluate the incidence of CDI and the risk factors in cirrhotic patients with a previous episode of SBP receiving norfloxacin as secondary prophylaxis. Materials and Methods: We performed a prospective, cohort study including patients with liver cirrhosis and SBP, successfully treated over a 2-year period in a tertiary university hospital. All the patients received secondary prophylaxis for SBP with norfloxacin 400 mg/day. Results: There were 122 patients with liver cirrhosis and SBP included (mean age 57.5 ± 10.8 years, 65.5% males). Alcoholic cirrhosis was the major etiology accounting for 63.1% of cases. The mean MELD score was 19.7 ± 6.1. Twenty-three (18.8%) of all patients developed CDI during follow-up, corresponding to an incidence of 24.8 cases per 10,000 person-years. The multivariate Cox regression analysis demonstrated that alcoholic LC etiology (HR 1.40, 95% CI 1.104-2.441, p = 0.029) and Child-Pugh C class (HR 2.50, 95% CI 1.257-3.850, p = 0.034) were independent risk factors for CDI development during norfloxacin secondary prophylaxis. The development of CDI did not influence the mortality rates in cirrhotic patients with SBP receiving norfloxacin. Conclusions: Cirrhotic patients with SBP and Child-Pugh C class and alcoholic liver cirrhosis had a higher risk of developing Clostridioides difficile infection during norfloxacin secondary prophylaxis. In patients with alcoholic Child-Pugh C class liver cirrhosis, alternative prophylaxis should be evaluated as SBP secondary prophylaxis.

Proton Pump Inhibitor Therapy Increases the Risk of Spontaneous Bacterial Peritonitis in Patients with HBV-Related Acute-on-Chronic Liver Failure

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). SBP significantly increases the mortality rate and medical costs. The association between proton pump inhibitor (PPI) use and SBP remains unclear. We conducted a retrospective study to investigate the association between PPI use and SBP in patients with HBV-related ACLF and to explore the risk factors for SBP.

METHODS

We compared the SBP incidence between the PPI and non-PPI groups before and after propensity score matching and explored the association between the duration and type of PPI and SBP occurrence. Risk factors for SBP occurrence were determined by univariate and multivariate logistic regression analysis.

RESULTS

The SBP incidence was higher in the PPI group than in the non-PPI group before and after propensity score matching. The SBP incidence increased for elevated MELD scores in PPI users. There was a similar SBP incidence in both different types and durations of PPI users. MELD score, old age, male sex, and high WBC count were significant independent risk factors for SBP in PPI users with HBV-related ACLF in the hospital.

CONCLUSIONS

PPI therapy increases the risk of SBP development in patients with HBV-related ACLF. MELD score, old age, male sex, and high WBC count could serve as predictors of SBP in PPI users. Caution should be taken regarding PPI use, especially for patients with MELD scores > 30.

Degree and duration of hypokalemia associated with peritonitis in patients undergoing peritoneal dialysis

BACKGROUND

Hypokalemia (LK) was associated with peritonitis in peritoneal dialysis (PD) patients, while the role of its degree and duration have not been fully established. Here, we conducted a retrospective cohort study to identify the relationships of LK degree and duration with peritonitis in PD patients.

METHODS

A total of 602 PD patients in our department from Jan 1st, 2009 to Dec 31st, 2019 entered the last analysis. Data were collected from their medical records. Serum potassium (SK) levels, degree of hypokalemia, and duration of hypokalemia were analysed with peritonitis. The time association of hypokalemia and peritonitis was also analysed.

RESULTS

There were totally 320 (53.7%) and 123 (20.7%) patients who had ever suffered from LK and serious hypokalemia (SLK) in the cohort. Only 6.82% and 0.5% of patients had LK and SLK at baseline, while the incidence increased and kept in 25%-32% and 5.5%-8.2% after PD. Both LK (HR 1.437, 95% CI 1.014-2.038, P = .042) and SLK (HR 2.021, 95% CI 1.429-2.857, P < .001) did correlate to peritonitis after adjusted analyses, while only SLK remained the significance at each follow-up point. The LK/SLK durations were 6 (3-12) and 6 (3-6) months, and only longer SLK duration correlated with peritonitis after adjusted analyses. After categorised, those LK durations more than 6 months and SLK durations more than 3 months presented a significant association with peritonitis. Of the patients who suffered from both hypokalemia and peritonitis, 70.4% patients' LK times were earlier than peritonitis time, while most SLK times (62.7%) were later. SLK also correlated with combined endpoint.

CONCLUSIONS

Hypokalemia degree and duration were tightly associated with peritonitis. Hypokalemia might be a causal factor of peritonitis, while peritonitis might also aggravate hypokalemia. We should manage SK as much as possible and avoid hypokalemia, especially serious hypokalemia in clinic practice.