Peritoneal Dialysis International最新文献

Pleuroperitoneal communication affects 1.6%-10% of continuous ambulatory peritoneal dialysis (PD) patients and often leads to discontinuation of peritoneal dialysis. In pleuroperitoneal communication, an important aspect is not only the diagnosis but also the detection of the diaphragmatic defect. Traditional methods have often failed to detect small defects, which contributes to the recurrence of pleuroperitoneal communication. We present three cases of intractable diaphragmatic defects in pleuroperitoneal communication, successfully localized and treated using indocyanine green (ICG) fluorescence staining of peritoneal dialysate, visualized with an infrared camera. After detecting the defect, surgical repair involved defect plication and the application of talc for pleural adhesion. This approach enabled immediate and successful on-site repair, allowing all patients to resume peritoneal dialysis post-surgery. Even the smallest diaphragmatic defects were accurately identified using ICG fluorescence dye dissolved in peritoneal dialysate. This case series demonstrates that ICG fluorescence staining enhances the diagnosis and treatment of pleuroperitoneal communication by improving defect localization. Our protocol shows promise in increasing diagnostic accuracy, reducing recurrence rates, and helping patients maintain their preferred dialysis modality.

BackgroundPeritoneal dialysis (PD)-related pleuroperitoneal communication is strongly associated with PD discontinuation. Video-assisted thoracoscopic surgery (VATS) has emerged as a promising therapeutic approach. However, there are still challenges in detecting diaphragmatic defects under conventional thoracoscopy, and the repair methods vary significantly.MethodsWe have developed an intervention protocol for pleuroperitoneal communication that includes single-port VATS utilizing near-infrared fluorescence with indocyanine green, as well as the management of perioperative kidney care and PD reinitiation. Patients who underwent VATS for pleuroperitoneal communication repair from September 2022 to March 2024 were identified at a single center. The procedures and outcomes were evaluated, and the success rate of PD resumption was compared with that of a historical cohort treated with non-surgical therapies.ResultsA total of 6 patients underwent VATS. The age was 48.7 ± 11.8 years, 2 were female, and the PD vintage was 8.7 (2.0-28.4) months. Non-dialysis therapy (n = 4) or temporary hemodialysis (n = 2) was prescribed during PD suspension. Fluorescence thoracoscopy identified diaphragmatic defects in all patients, including lesions that were unrecognizable under white light. Mechanical pleurodesis by direct suture of the defects with local mechanical reinforcement was performed. All patients reinitiated PD 15-30 days postoperatively, with no recurrence during a follow-up of 17.0 ± 6.4 months. The success rate significantly exceeded that in the patients who underwent PD suspension or chemical pleurodesis (100% vs. 29%, p = 0.005).ConclusionsThe minimally invasive VATS integrating fluorescence with indocyanine green and pleurodesis with multiple mechanical reinforcements, along with appropriate perioperative care and an incremental approach to resume PD, was a reliable treatment for PD-related pleuroperitoneal communication.

Modality transitions are very common in patients undergoing peritoneal dialysis (PD); they can either occur before the initiation of PD, following its termination, or as a temporary interruption during PD treatment. Transfers to and from facility hemodialysis represent the majority of these transitions. In addition to their impact on the quality of life of patients and their caregivers, modality transitions are often linked with hospitalizations, mortality, and increased health expenditures. Yet, some of these transfers are unavoidable and should be considered as part of the "dialysis life plan" for patients receiving PD. In this review, we will present the epidemiology, risk factors, and clinical impacts of the most frequent transitions that PD patients experience. We will also discuss strategies to optimize the outcomes of patients undergoing modality transfers. Finally, we will review the evidence underlying the integrated home dialysis paradigm, in which patients transition from PD to home hemodialysis.

BackgroundPeritoneal dialysis (PD) is being promoted because it is cost-effective and has equivalent outcomes to facility-based hemodialysis (HD). Determining PD eligibility is critical but subjective, with high variability among renal programs. This study aimed to establish a predictive model for PD eligibility among individuals who started treatment with HD. A secondary objective was to identify predictors of PD eligibility and determine if eligible patients went on to receive PD.MethodsThis retrospective cohort study included individuals starting HD at multiple hospitals in Alberta, Canada, as part of the START program between 1 October 2016 and 31 March 2018. Twenty-seven predictors, including patient characteristics, laboratory values, and comorbidities, were considered in logistic regression modeling. The outcome variable was PD eligibility, as determined by a standardized interdisciplinary assessment. The model selection was based on the Akaike information criterion. The confusion matrix was used for each model to compare the predicted versus observed eligibility. The final model was calibrated and presented.ResultsAmong the 598 participants, 391 (65.4%) were considered eligible for PD. The logistic regression model achieved a modest performance in discriminating patients who were eligible for PD, with a high sensitivity of 91.3%, an accuracy of 0.68 (95% CI, 0.65-0.72), and an area under the receiver operating characteristic curve ranging from 0.69 to 0.71. Age (OR = 0.98; 95% CI, 0.97-0.99), body mass index (OR = 0.95; 95% CI, 0.93-0.97), starting dialysis in intensive care unit (OR = 0.53; 95% CI, 0.31-0.92), and polycystic kidney disease (OR = 0.37; 95% CI, 0.13-0.99) were statistically significant factors associated with a lower likelihood of being considered eligible for PD. Out of the 391 eligible PD patients, 87 (22.3%) received PD treatment within 6 months of starting HD.ConclusionsThe majority of patients starting HD were considered eligible for PD. Our model exhibits a high level of sensitivity and could serve as a valuable tool for screening potential candidates following the commencement of HD.

BackgroundPeritoneal dialysis (PD) offers comparable survival for acute kidney injury (AKI) as other kidney replacement therapies, but concerns about rigid catheter complications like peritonitis persist. This study evaluated outcomes of acute PD using rigid catheters in critically ill children, including peritonitis rates and mechanical complications.MethodsThis retrospective study analyzed data from consecutive pediatric patients (aged <18 years) admitted to our tertiary-level pediatric intensive care unit, who underwent acute PD using either rigid or improvised catheters, with each PD session limited to 72 h followed by re-insertion after 24 h if indicated. Data on primary diagnosis, PD indication, and laboratory parameters were collected from patient records and dialysis registers. Outcome measures, such as peritonitis rates and mechanical complications, were assessed.ResultsOver a 10-year span (January 2014-September 2023), 202 children, 57% males, with a median age of 11 (3.6, 30) months, underwent PD. PD was initiated for fluid overload in 65 (32%), persistent anuria in 51 (25.2%), and refractory hyperkalemia in 47 (23.3%). In 13 (6.4%) patients, PD was initiated for metabolic crisis in the absence of AKI. The median estimated glomerular filtration rate at PD initiation was 21.4 (13.2, 46.5) mL/1.73m²/min. A total of 250 PD sessions/catheter insertions were performed on 202 children, for a median duration of 72 (24, 72) hours. Fourteen (6.9%) children developed peritonitis. Among children who received PD for ≤ 72 h (n = 164), peritonitis frequency was 3%, while it was 15.7% in those with one catheter re-insertion (n = 19) and 31.5% in >1 catheter reinsertion (n = 19). The peritonitis rate-per-catheter was 3% in children with single catheter insertion (n = 164), and 10.4% in children with ≥ 1 catheter re-insertions (n = 38). Among six children, who had extended PD sessions (single PD session duration, irrespective of it being the first or subsequent catheter) of 84 [84,100] (median [IQR]) hours, 3 (50%) developed peritonitis. Mechanical complications included peritubal-leak 28 (13.8%), hemorrhagic effluent in 8 (3%), catheter dislodgement in 3 (1.5%), and PD catheter block in 13 (6.4%). One child (0.49%) developed intestinal perforation.ConclusionsAcute PD with a rigid catheter limited to 72 h appears safe and feasible in resource-constrained settings where soft Tenckhoff PD catheters are not easily available, though peritonitis rates increase with increasing cumulative duration on PD.

Peritoneal dialysis (PD) catheter placement is considered a controversial procedure in patients with a history of abdominal surgeries or peritonitis. In these subjects, video laparoscopic (VLS)-assisted placement under general anesthesia (GA) is the gold standard procedure. However, older multimorbid patients are at high risk for complications in GA. In our opinion, thoracic spinal anesthesia (TSA) instead of GA could also be used in older multimorbid patients undergoing PD. Here, we report five cases of older multimorbid end-stage kidney disease (ESKD) patients aged 79.6 ± 3.5 years with a history of abdominal surgery or peritonitis needing renal replacement therapy. Overall comorbidity was high (Cumulative Illness Rating Scale (CIRS) comorbidity index 4.0 ± 1.2 and CIRS severity index 2.1 ± 0.5). We placed the PD catheter in these patients using the VLS-assisted placement under TSA. All subjects underwent TSA performed at the T9-T10 thoracic level, obtaining optimal pain control and no periprocedural side effects. This is the first attempt to utilize the TSA in PD catheter VLS placement in very old multimorbid patients. Further studies could be useful to confirm whether TSA can be successfully used in VLS-assisted PD catheter placement, especially in subjects ineligible for GA such as older frailty patients.

BackgroundThere are several indices to predict survival at dialysis start but tools to predict mortality for prevalent patients are lacking. This study provides evidence for external validity of the Cohen model to assess 6-, 12-, and 18-months survival of prevalent peritoneal dialysis (PD) patients.MethodsProspective cohort study of 464 PD patients in a university-based program between 2015 and 2019. Survival probabilities were compared to observed survival. Discrimination and calibration were assessed through predicted risk-stratified observed survival, cumulative area under the curve, Somer's Dxy, and a calibration slope estimate.ResultsDiscrimination performance was moderate with c-statistic of 0.73 to 0.74 for all 3 time points. The model over predicted mortality risk with the best predictive accuracy for 6-month survival. The difference between observed and mean predicted survival at 6, 12, and 18 months was 3.1%, 5.5%, and 11.0%. Kaplan-Meier curves showed good discrimination between low- and high-risk patients with hazard ratios [95% confidence interval (CI)]: C4 vs C1 32.0 [4.3-236.5]. Miscalibration of the model was the greatest for the highest risk patient group in whom 12 and 18 months predicted survival was 15% and 28% lower than observed survival.ConclusionsThe Cohen prognostic model can identify PD patients at high risk for death over 6, 12, and 18 months. Given it overestimates mortality risk for the highest risk patients, care must be taken to not use predictions to withhold treatment but rather to risk stratify and identify those who may benefit from enhanced kidney supportive care. This miscalibration provides an imperative to refine the tool for PD patients.

BackgroundLocal and systemic side effects of glucose remain major limitations of peritoneal dialysis (PD). Glucose transport during PD is thought to occur via inter-endothelial pathways, but recent results show that phloretin, a general blocker of facilitative glucose channels (glucose transporters [GLUTs]), markedly reduced glucose diffusion capacity indicating that some glucose may be transferred via facilitative glucose channels (GLUTs). Whether such transport mainly occurs into (absorption), or across (trans-cellular) peritoneal cells is as yet unresolved.MethodsHere we sought to elucidate whether diffusion of radiolabeled ¹⁸F-deoxyglucose ([¹⁸F]-DG) in the opposite direction (plasma → dialysate) is also affected by GLUT inhibition. During GLUT inhibition, such transport may either be increased or unaltered (favors absorption hypothesis) or decreased (favors transcellular hypothesis). Effects on the transport of solutes other than [¹⁸F]-DG (or glucose) during GLUT inhibition indicate effects on paracellular transport (between cells) rather than via GLUTs.ResultsGLUT inhibition using phloretin markedly reduced [¹⁸F]-DG diffusion capacity, improved ultrafiltration (UF) rates and enhanced the sodium dip. No other solutes were significantly affected with the exception of urea and bicarbonate.ConclusionThe present results indicate that part of glucose is transported via the transcellular route across cells in the peritoneal membrane. Regardless of the channel(s) involved, inhibitors of facilitative GLUTs may be promising agents to improve UF efficacy in patients treated with PD.