Peritoneal Dialysis International最新文献

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.

BackgroundThis study aims to describe patient and nurse trainer perspectives on a structured training programme for peritoneal dialysis (PD) as part of the Targeted Education ApproaCH to improve Peritoneal Dialysis outcomes (TEACH-PD) trial.MethodsTwo semi-structured interviews were conducted with 13 patients receiving PD and 10 PD nurses involved in training patients in PD before and after receiving training at 2 dialysis units. Transcripts were analysed thematically.ResultsFive themes were identified: (1) clear, comprehensive and culturally appropriate (clarity of content and wording to prevent disengagement, gauging patient progress, sufficiency, succinctness and flow); (2) competing priorities and burden (clinical emergencies and tasks taking priority, overwhelmed by amount of content, time pressure demands); (3) improving patient outcomes and safety (ability to assess safety, patient empowerment and personal responsibility, fostering trust and patient wellbeing, increasing technique survival, minimising risk of infection); (4) individualising the approach for patients (setting an appropriate pace, adapting to preferred learning styles, attuning to comprehension and literacy, symptoms and complications limiting capacity for learning) and (5) strengthening competence (motivation for continued learning, putting learning into practice, relevance to real-world practice, requiring structure and consistency, self-efficacy and confidence in problem solving).ConclusionPatients felt that their training was sufficient and reported feeling confident about doing PD themselves. The adult learning focus of the modules helped the nurse trainers to better adapt their teaching approaches to patients' individual needs. TEACH-PD training programmes were viewed as an opportunity to upskill nurses involved in patient training and as flexible enough to be adapted to the individual needs of patients. However, nurses also highlighted challenges related to the volume of content to be covered and time constraints due to competing clinical demands.

BackgroundGlucose and insulin blood levels are well known altering factors for 18F-fluoro-2-deoxy-2-d-glucose positron emission tomography-computed tomography ([18F]-FDG PET-CT) interpretability in peritoneal dialysis (PD) patients. A potential influence of glucose-based solutions and Icodextrin in PD patients has not been studied. The aim of this study was to assess PET-CT interpretability in PD patients according to the osmotic agent used in the dialysis fluid (Icodextrin vs. glucose) and the timing of dialysate infusion before imaging.MethodsWe searched for all PET-CT performed on individuals receiving PD between January 2020 and March 2024 at Cliniques universitaires Saint-Luc, Brussels, Belgium. Peritoneal membrane characteristics, data regarding dialysis solutions, PET-CT parameters and results were collected. We analyzed available data regarding insulinemia and glycemia during a PD exchange.ResultsFourteen PET-CTs were available for study of which four were performed on PD patients with a glucose-based solution dwell at imaging, six with Icodextrin, and three with an empty abdomen. Data regarding the presence or absence of PD fluid was missing for one patient. The only uninterpretable exam was performed on a patient injected with [18F]-FDG 86 min after an exchange with a glucose-based solution. All other exams in the glucose-based group were interpretable with a mean PD fluid infusion to [18F]-FDG injection time of 186 min. All PET-CTs in patients with an Icodextrin dwell were interpretable.ConclusionIn this small PD cohort, PET-CT interpretability appears preserved with Icodextrin dwells and may be adequate with glucose-based solutions if sufficient time elapses, requiring confirmation in larger studies.

BackgroundPeritoneal dialysis (PD) is commonly performed using either intermittent or tidal exchanges, whereas other exchange techniques such as continuous flow PD are little used. Previous research indicated that stirring the intra-peritoneal dialysate markedly increases small solute clearances. Here, we tested the hypothesis that stirring of the dialysate increases small solute clearances by using a novel exchange technique where the dialysate is pulsed back and forth during the treatment without addition of fresh fluid.MethodsPD was performed in anesthetized Sprague-Dawley rats with either no pulsations (20 mL fill volume), 2 mL (10%) pulses (21 mL fill volume), or 5 mL (25%) pulses (22.5 mL fill volume) utilizing a pulse flow rate of 5 mL/min. The higher fill volume for the pulsed treatments compensates for the fact that the average intra-peritoneal volume would otherwise be lower in pulsed treatments. Water and solute transport were closely monitored during the treatment.ResultsNet ultrafiltration decreased significantly during pulsed PD with the 25% pulse volume. The 60 min sodium dip was unaltered, whereas the fluid absorption rate was increased for the 25% group. Solute clearances did not significantly differ between groups, except for a slightly lower calcium clearance in the 25% group.ConclusionOur data indicate that stirring the dialysate using pulsed exchanges does not provide any advantage compared to conventional exchange techniques. In contrast, pulsed treatments had slightly lower ultrafiltration and small solute transport. The present findings may have implications regarding the choice of tidal volume in automated PD, favoring smaller tidal volumes.

Peritoneopericardial leakage is a rare but important complication of peritoneal dialysis. Peritoneal scintigraphy is reported to be effective in diagnosing the peritoneopericardial communication. Although switching to hemodialysis is commonly recommended, reducing exchange volumes and performing peritoneal dialysis in an upright sitting position may also be considered particularly in pediatric patients. Here we presented a 10-year-old girl in whom peritoneopericardial leakage was demonstrated with peritoneal scintigraphy and was successfully managed by conservative approach.

Baclofen is a gamma-aminobutyric acid agonist that is commonly and widely used for the treatment of muscle spasticity. Given its predominant kidney excretion, patients with reduced kidney function are at particular risk of drug accumulation and toxicity, with neurotoxicity in the form of drowsiness, encephalopathy, seizures, and coma being the most reported clinical features. In addition to the importance of early identification of baclofen toxicity and drug discontinuation, dialysis can effectively accelerate baclofen elimination given its small molecule weight, and the relatively low volume of distribution and weak protein binding. While several cases of baclofen-induced toxicity have been reported in hemodialysis patients, the literature on baclofen toxicity in individuals receiving peritoneal dialysis (PD) is limited. Here, we present a case of baclofen-induced encephalopathy in a PD patient following a single dose of baclofen. In this case, our patient was managed by continuous (24 h) automated PD, with complete recovery of neurological status within three days.

IntroductionLarger fill volumes in peritoneal dialysis (PD) typically improve small solute clearance and water removal, and vice versa-but the relationship between intraperitoneal volume and the capacities for solute and water transport in PD has been little studied. Here, it is proposed that this relative relationship is described by a simple ratio (Volume_new/Volume_old)^2/3 up to a critical break-point volume, beyond which further volume increase is less beneficial in terms of solute and water removal.MethodTo scrutinize this hypothesis, experiments were conducted in a rat model of PD alongside a retrospective analysis of data from a prior clinical study. Rats underwent PD with either three consecutive fills of 8 + 8 + 8 mL (n = 10) or 12 + 12 + 12 mL (n = 10), with 45-minute dwell time intervals. This approach yielded 60 estimations of water and solute transport, characterized by osmotic conductance to glucose and solute diffusion capacities, respectively.ResultsComparative analysis of the predictive efficacy of the two models-the simple ratio versus the break-point model-was performed using Monte Carlo cross-validation. The break-point model emerged as a superior predictor for both water and solute transfer, demonstrating its capability to characterize both experimental data from rats and clinical data from patients.ConclusionThe present analysis indicates that relatively simple calculations can be used to approximate clinical effects on solute and water removal when prescribing a lower or higher fill volume to patients with PD.