Peritoneal Dialysis International最新文献

Peritoneal dialysis (PD) patients are at risk of muscle wasting and clinical guidelines recommend assessing dietary intake, by calculating protein equivalent of nitrogen appearance (PNA) to assure adequate intake. As the PNA equations were developed some time ago based on continuous ambulatory PD (CAPD) treatments, we re-evaluated them by comparing dietary recall protein intake. Dietary histories were obtained from 42 PD patients, mean age 62.2 ± 15.8 years, 58.1% male, 41.9% white, 39.5% treated with CAPD, median dialysis vintage 13.2 (3.1-23.3) months when attending for routine outpatient peritoneal membrane testing. Dietary protein intake (DPI), median 50.8 (37.5-71.5) g/day was determined with the Nutrics software program^®, and using PNA equations, DPI varied from 32.6 (31-34.3) to 68.8 (58.7-86.3) g/day. Bland Altman bias ranged from -22.8 ± 23.4 to +12.0 ± 24.6 g/day, with the older equations tending to underestimate and the more recent equations overestimating dietary recall DPI. There was systematic bias with the older equations, particularly as DPI increased. Although there was a wide variation, the two equations exhibiting least variation with dietary DPI were: PNA=15.1 + (0.195 × 24-h combined urinary and peritoneal urea mmol) + (24-h combined urinary and peritoneal protein loss), and PNA = 20.1 + (0.209 × 24-h combined urinary and peritoneal urea mmol), with a mean bias of +6.3 and +7.8 g/day compared to dietary DPI, and negative nitrogen balance of -1.7 and 2.6 g/day, respectively. Our study would suggest that the most used PNA equations may overestimate DPI in many patients and potentially result in unrecognised protein malnutrition.

BackgroundStrengthening peritoneal dialysis (PD) utilization in Germany is crucial to ensure dialysis care for patients with kidney failure in an aging population with a predicted decline in the number of health care professionals. PD catheter implantations are a key indicator for the utilization of PD. We performed the first comprehensive study on PD catheter implantation rates and inpatient outcomes in Germany.MethodsFor this retrospective study we queried the diagnosis related group statistics of the Federal Statistical Office of Germany for the years 2011 to 2021, which includes demographics and information on the medical course from all German inpatient cases.ResultsDuring the observation period, 14,158 PD catheters were implanted, with an average of 1272 ± 127 (mean ± standard deviation) per year. Nationally, annual implantation rates were stable, without notable changes over time. Notably, there were significant regional differences in implantation rates within Germany. The average patient age at the time of PD catheter implantation was 59.7 years, with a male-to-female ratio of 1.7:1. During the hospital stay for PD catheter implantation, 517 patients (3.7%) died. Centers with higher implantation rates had more favorable outcomes. Age, number of comorbidities and certain comorbidities (e.g., cancer and heart failure) were associated with higher mortality. The length of stay in the hospital for PD catheter implantation was 19.5 (±22.3) days.ConclusionOur analysis reveals that relatively few PD catheters are implanted in Germany each year. Over the observation period, there was no substantial increase, indicating a continued underutilization of PD in Germany.

BackgroundThis study was carried out to evaluate the association between the peritoneal dialysis (PD) centre volume and the risk of transfer to haemodialysis (HD).MethodsThis retrospective analysis used the French Language Peritoneal Dialysis Registry data of incident adult patients between 2002 and 2018. Centre volume was defined by the number of patients starting PD by centre and by year; PD centres were separated in 2 groups with a cut-off value of 10 new patients by year and by centre based on the graphical representation of the regression spline. A mixed Cox model was used to estimate the role of the centre volume on the centre effect. A Cox model was performed to assess the association between the centre volume and the cause-specific risk of transfer to HD.ResultsOf the 15653 patients included, 4293 (27%) started PD in a centre with a volume greater than 10. The transfer to HD heterogeneity between centre was reduced by the centre volume (variance reduction of 13%). In the multivariable analysis, the centre volume was associated with lower risk of transfer to HD (cause-specific hazard ratio (cs-HR): 0.86, 95% confidence interval (CI): [0.80-0.92]), but not with the risk of death (cs-HR: 1.06 [95% CI: 1.00-1.13]) or kidney transplantation (cs-HR: 0.97 [95% CI: 0.90-1.06]). Centre volume was associated with lower risk of transfer to HD due to small solute clearance or inadequate ultrafiltration (cs-HR = 0.80 [95% CI: 0.72-0.89]), but was not associated with transfer to HD by peritonitis (cs-HR: 0.97 [95% CI: 0.82-1.16]), or catheter-related issues (cs-HR: 0.85 [95% CI: 0.67-1.09]).ConclusionsThe centre volume reduced the risk of transfer to HD due to small solute clearance or inadequate ultrafiltration. At the centre level, quality improvement programme should focus on PD prescription. Networking between centres may improve the outcome on PD.

BackgroundPeritoneal dialysis (PD) is a home-based treatment for kidney failure, offering significant social, economic and environmental advantages over haemodialysis (HD). It allows patients greater independence and flexibility, can reduce healthcare costs in some settings, and is reported to generate a smaller environmental footprint compared to HD. However, despite this, its environmental impact, particularly in terms of resource use and waste generation, is an area of growing concern. Evaluating PD through a sustainability lens, considering environmental, social, health and economic dimensions is crucial to improving its long-term viability and reducing the healthcare sector's environmental footprint.MethodsAn LCA of the PD treatment pathway was conducted at the Nephrology Dialysis and Kidney Transplantation Unit, 'Azienda Ospedaliero-Universitaria (AOU), Policlinico di Modena, Italy. Data were collected between April and July 2024 and was categorised into 17 PD-related procedures. Key activities assessed were electricity use, resource consumption (procurement), water consumption, patient and staff travel and waste disposal. Flow diagrams were created to model the PD pathway and product components were dismantled and weighed to determine material contributions. Environmental impacts were analysed using OpenLCA and the Ecoinvent database.ResultsAutomated peritoneal dialysis (APD) treatments produced greater emissions than continuous ambulatory peritoneal dialysis (CAPD), primarily due to higher electricity consumption and the use of polyvinylchloride. APD generated 3267 kg CO₂e annually compared to 2975 kg CO₂e for CAPD. Monthly patient examinations contributed 250 kg CO₂e per year, largely from travel. CAPD produced more healthcare waste (320 kg), leading to 810 kg CO₂e emissions, while APD waste emissions were lower at 374 kg CO₂e. Incremental dialysis approaches showed substantial reductions, with emissions falling to 1642 kg CO₂e (APD) and 1517 kg CO₂e (CAPD). The most impactful materials included polyethylene and PVC, with plastic components contributing significantly to overall emissions.ConclusionThis comprehensive life cycle assessment (LCA) highlights the environmental challenges associated with PD, particularly in waste generation and resource use. Key areas for improvement include reducing single-use plastic reliance, increasing recycling efforts and integrating energy-efficient solutions. This study provides a foundation for targeted sustainability interventions in PD and contributes to the broader goals of the KitNewCare project, which aims to optimise health outcomes while minimising environmental impacts in kidney care.

Acyclovir and valacyclovir have been widely used for the treatment of herpes virus infections, including herpes zoster, with generally favorable outcomes. However, in patients with chronic kidney disease, particularly those undergoing peritoneal dialysis or hemodialysis treatment, neurotoxicity can be a significant complication as renal excretion is the primary elimination pathway. Here, we report three cases of automated peritoneal dialysis patients treated for herpes zoster who developed neurotoxicity following acyclovir or valacyclovir administration. Symptoms appeared 2 to 4 days after treatment initiation. They included mental confusion, psychomotor agitation, dizziness, dysgeusia, anosmia, blurred vision, gait instability, hallucinations, dysarthria, paresis, involuntary lower-limb movements, ataxia, and anorexia. Neurological symptoms gradually resolved after drug discontinuation, alongside complete regression of zoster lesions. Despite decades of clinical experience and numerous reports, acyclovir and valacyclovir-induced neurotoxicity continue to occur in patients with severe renal impairment. This report underscores the importance of dose adjustment and close monitoring, emphasizing that neurotoxicity, although rare, can occur even at apparently safe doses in patients undergoing peritoneal dialysis.

Peritoneal dialysis (PD) is an effective home-based renal replacement therapy, comparable in efficacy to hemodialysis (HD). Despite its advantages, the prevalence of PD in Morocco remains below 1% of dialysis patients, primarily due to limited training and awareness. This cross-sectional study aimed to evaluate the training needs related to PD among Moroccan nephrologists and nurses and to identify key topics relevant to the local context. An online survey was conducted between July and August 2022, collecting 125 responses-primarily from females and over 78% from nephrologists. Findings revealed that only 23% of respondents currently practice PD, predominantly those over 40 years old, with 65% having received initial PD training. While 40% perceived PD as less efficient than HD, over 78% acknowledged that PD offers a better quality of life. An overwhelming 95% expressed a need for further PD training. The most common challenges identified were peritonitis and catheter management, with catheter insertion emerging as the most prioritized practical skill. Statistical analysis indicated that while theoretical topics such as peritonitis and catheter-related complications are essential for nephrologists without PD practice, practical training in catheter insertion is crucial across all participants. Enhancing PD training is highly needed in Morocco, especially for young nephrologists and have to focus on catheter insertion with an objective to increase PD prevalence up to 10%.

Peritoneal dialysis-associated peritonitis (PD peritonitis) is a serious complication of PD, with fungal cases carrying high morbidity and mortality. We report a 65-year-old female with PD peritonitis caused by Ulocladium, a filamentous fungus not previously implicated in the literature. She was asymptomatic at presentation but noticed black spots in her PD catheter lumen; effluent analysis confirmed peritonitis. Initial cultures grew nonspecific mold, prompting treatment initiation with intravenous liposomal amphotericin B and PD catheter removal. Final cultures identified Ulocladium spp., sensitive to amphotericin B, and treatment continued for four weeks. The patient successfully resumed PD after treatment. This case highlights the need for clinicians to maintain a high index of suspicion for fungal PD peritonitis in patients undergoing PD, and the importance of early initiation of systemic antifungals and prompt catheter removal to improve outcomes.

Care teams and patients want to know what happens next, and researchers have put together a lot of tools, such as predictive models, to help them predict the future. While these researchers are well-intentioned, the tools they develop are not always helpful. Most researchers know enough to perform various tests of their predictive models, such as statistical tests that answer the question: "Are the predictions based on this model better than a coin flip?" We urge researchers to add another test to their existing lists: "Does this model tell care teams anything they don't already know?"

Background and objectivesIron plays a critical role beyond erythropoiesis, yet the prognostic significance of iron deficiency (ID) independent of anemia remains poorly defined in the peritoneal dialysis (PD) population. This study aimed to evaluate the association between iron status, specifically transferrin saturation (TSAT), and mortality in PD patients, independent of hemoglobin levels.Design, setting, participants, and measurementsWe conducted a retrospective cohort study of 11,013 adults who initiated PD at a large US dialysis network between December 2004 and January 2011. Patients had at least 180 days on PD and baseline data on TSAT, ferritin, hemoglobin, albumin, and white blood cell count. The primary outcome was all-cause mortality. Broadly adjusted associations between iron parameters and mortality were assessed using Cox proportional hazards models and restricted cubic splines, with adjustments for demographic, clinical, treatment-related, and laboratory variables including hemoglobin and ESA use.ResultsIron deficiency, defined as TSAT ≤20%, was present in 10% of patients at PD initiation. The cohort was 54% male and 70% Caucasian, with a mean age of 55 years; 39% had diabetes. While 91% received erythropoiesis-stimulating agents, only 34% received IV iron. After comprehensive adjustment, TSAT ≤20% remained independently associated with increased mortality (adjusted HR: 1.26; 95% CI: 1.12-1.42). Spline analyses showed a sharp rise in mortality risk at TSAT levels below 25%. Ferritin was inconsistently associated with mortality risk. During follow-up, 2704 deaths occurred (24.6% of the cohort) over a median 440-day follow-up.ConclusionsIron deficiency is common in incident PD patients and is associated with increased mortality risk, independent of anemia. These findings challenge current anemia-centric treatment paradigms and suggest that iron status, particularly TSAT, should be routinely assessed in PD patients regardless of hemoglobin levels. A prospective, randomized trial is warranted to evaluate whether proactive iron management improves outcomes in this population.

BackgroundThe global water crisis poses challenges for water-intensive sectors, such as healthcare. In Mexico, continuous ambulatory peritoneal dialysis (CAPD) is used by almost half of patients on renal replacement therapy, generating significant volumes of peritoneal dialysis effluent (PDE) that are discarded without reuse. Unlike haemodialysis effluents, whose reuse has already been demonstrated, PDE lacks technical evidence regarding its biochemical and microbiological safety for potential non-potable applications. The objective of this study was to biochemically and microbiologically characterise the PDE generated by patients with chronic kidney disease in CAPD, comparing them with treated wastewater (TWW) and analysing their potential for non-potable reuse.MethodsPDEs obtained from CAPD patients were studied and compared with 18 TWW samples from urban and industrial plants. Biochemical parameters (glucose, creatinine, urea, uric acid, electrolytes, pH, and residual chlorine) and microbiological parameters (mesophilic bacteria, gram negative, gram positive, coliforms, and fungi) were analysed using automated methods and classical culture, respectively. Student's t test (p < 0.05) was used to determine significant differences between groups.ResultsThe PDE showed significantly higher concentrations of glucose (>750 mg/dL), urea, creatinine, and electrolytes compared to TWW (p < 0.0001), reflecting its hyperosmolar nature. The pH was neutral (∼7) and there was no residual chlorine. The complete absence of cultivable microbiological load in PDE was highlighted, unlike TWW, which presented significant elevated bacterial and fungal counts. These findings suggest a favourable microbiological profile of PDE, but a limiting biochemical load for its direct reuse.ConclusionPDE has potential for non-potable reuse, especially in agricultural or industrial applications, but requires advanced treatment such as reverse osmosis, nanofiltration, ultrafiltration, among others, to remove its high solute load. It is essential to create a specific regulatory framework for the reuse of this type of effluent, provided its safety is guaranteed.