Peritoneal Dialysis International最新文献

IntroductionTherapy alerts during automated peritoneal dialysis (APD) can cause significant disruptions to patients' sleep and quality of life and may portend poorer outcomes. Understanding the relationship between alert frequency during this early period and longer-term PD outcomes is important.MethodsFollowing the probabilistic linkage of Vantive's Sharesource database to the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the relationship between alert frequency in the first 30 days of APD and PD discontinuation. We included adult patients in Australia and New Zealand who commenced APD with the Vantive Homechoice Claria cycler over 2019-2023 and continued for at least 30 days. The average alerts per treatment in the first 30 days were divided into quartiles and time to PD discontinuation (inclusive of HD transfer and death), HD transfer only, and infective and non-infective HD transfer were modelled as outcomes.ResultsThe cohort was 1880 patients, 65% male, and median age at PD commencement of 58 years. Overall PD continuation at 1,2, and 3 years was 78%, 56% and 41%, with HD transfer rates at 14%, 23% and 27%. Higher rates of HD transfer in the first 12 months were seen in the groups with a higher average alert number. Within 12 months, there was a progressive risk of non-infective HD transfer with increasing 30-day alert quartile.ConclusionAlert burden in the first 30 days is a risk factor for HD transfer in the first 12 months, and resolving underlying issues early may help to improve PD continuation.

BackgroundPeritoneal dialysis (PD)-associated peritonitis is a major complication in PD and may require abdominal imaging to identify the intra-abdominal pathology, though its clinical utility remains unclear.MethodsThis retrospective, single-center study included all episodes of PD-associated peritonitis that occurred between January 2013 and July 2024. The primary objective was to identify factors predicting the use of abdominal imaging during peritonitis episodes.ResultsA total of 691 episodes of peritonitis occurred in 376 PD patients during the study period. Of these, 354 episodes (51%) were subjected to abdominal imaging, which revealed 102 episodes (29%) suggestive of enteric or other secondary peritonitis. The most common abnormal imaging findings were colitis or enteritis, followed by ileus or intestinal obstruction. Imaging findings indicating the need for urgent medical or surgical attention were observed in 27 episodes of peritonitis (7.6%). Imaging was more frequently performed in peritonitis episodes caused by polymicrobial enteric bacteria (adjusted odds ratio [AOR]: 4.49; 95% CI [2.13-9.48]), single enteric bacteria (AOR: 2.02; 95% CI [1.31-3.13]), and fungi (AOR: 7.77; 95% CI [2.48-24.29]), compared to nonenteric bacteria. Hypotension (AOR: 6.19; 95% CI [2.81-13.66]), cloudy effluent (AOR: 1.91; 95% CI [1.30-2.80]), and higher PD effluent cell counts at presentation (AOR: 1.03; 95% CI [1.01-1.05]) were all significantly associated with imaging. Only polymicrobial infection involving enteric bacteria (AOR: 2.65; 95% CI [1.28-5.50]) was significantly associated with abnormal imaging findings suggestive of secondary or enteric peritonitis. Furthermore, polymicrobial infections with enteric bacteria (AOR: 9.17; 95% CI [3.29-25.50]), fungal infections (AOR: 5.25; 95% CI [1.26-21.96]), and hypotension (AOR: 2.77; 95% CI [1.08-7.07]; p = .03) were significantly associated with critical imaging findings.ConclusionImaging in PD peritonitis was primarily performed based on causative organisms or clinical features. Only polymicrobial enteric peritonitis, fungal infections, and hypotension were significantly associated with critical imaging findings. Future prospective studies are required to improve diagnostic accuracy and guide imaging decisions in PD-related peritonitis.

Peritoneal dialysis (PD) has important disadvantages compared to hemodialysis, including low plasma clearance and limited technique survival. A new device for sorbent-assisted (continuous flow) peritoneal dialysis (SAPD) has been designed that is based on continuous recirculation of peritoneal dialysate via a single-lumen peritoneal catheter with regeneration of spent dialysate by sorbents. SAPD treatment may enhance plasma clearance of uremic solutes by increasing the mass transfer area coefficient and maintenance of a high plasma-to-dialysate concentration gradient. In addition, SAPD treatment may preserve integrity of the peritoneal membrane for a longer period of time by avoiding the need for high initial glucose concentrations and by reducing the number of exchanges and (dis)connections of the peritoneal catheter, which may lower the risk of peritonitis. The primary aim of this first-in-human clinical trial is to evaluate the (short-term) clinical safety and performance of SAPD treatment in a small group (n = 12) of stable adult PD patients in a clinical setting (proof of concept). Key secondary objectives include an evaluation of efficacy in terms of plasma clearance, ultrafiltration, and patient tolerance.

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.

BackgroundRenin-angiotensin system inhibitors (RASi) offer important benefits for patients on peritoneal dialysis (PD), particularly in preserving residual kidney function and peritoneal membrane integrity. Despite these benefits, concerns about hyperkalemia and hypotension often limit clinical practice utilization.ObjectivesTo achieve a 20% increase in RASi utilization among eligible patients on PD at an academic hospital in Toronto, Canada through a quality improvement initiative.MethodsWe conducted a pre-intervention analysis through retrospective chart review from July 2022 to September 2023. We implemented a "PD Passport," a clinical documentation tool used by clinic staff in each visit to highlight missed RASi prescription opportunities. The primary outcome measure was RASi utilization at 6-month post-implementation. Process measures included PD passport completion rates, while balancing measures tracked rates of symptomatic hypotension and hyperkalemia.ResultsAmong 63 patients on PD (mean age 58.7 years, 55.6% male), baseline RASi utilization was 41%. Following implementation, RASi utilization increased to 59% by October 2024, representing a 17% increase but falling short of the 20% target. There were no significant differences in mean systolic blood pressure (125.71 ± 4.19, 125.64 ± 7.02 mmHg; p = 0.653), mean serum potassium (4.34 mmol/L, 4.31 mmol/L; p = 0.662), and mean urine output (915.2 mL, 921.8 mL; p = 0.881) before and after the intervention.ConclusionsThe PD Passport initiative substantially increased RASi utilization by 17% without compromising patient safety, as evidenced by stable blood pressure and potassium levels. While falling slightly short of our 20% target, this structured documentation approach effectively bridges the gap between evidence and practice, demonstrating the value of targeted tools in enhancing guideline-concordant care for PD patients.

This letter comments on the study by Thongprayoon et al., which examines sex disparities in outcomes among patients undergoing peritoneal dialysis (PD). While the analysis of a large national dataset offers valuable insights, the absence of dialysis-specific parameters such as residual renal function and dialysis vintage may limit causal interpretation. The finding that women were less likely to switch to hemodialysis, particularly younger patients without cardiovascular disease, is noteworthy. Complementary Australian registry data indicate that men are more likely to discontinue PD due to inadequate dialysis, mediated mainly by comorbidities. Together, these findings emphasize that sex differences in PD outcomes are multifactorial and shaped by comorbidity and care delivery rather than sex alone.

Life participation has been identified as a critically important core outcome to be reported in all trials in people receiving peritoneal dialysis (PD). Life participation is defined as the ability to participate in meaningful activities such as work (e.g. employment, housework, study), family, social (e.g. time with friends) and leisure (travel, hobbies, exercise) activities. However, life participation is rarely and inconsistently reported in trials in PD. The standardised outcomes in nephrology-life participation (SONG-LP) instrument was validated in adult kidney transplant recipients and demonstrated internal consistency and test-retest reliability. In this article, we outline the rationale and process for validating the SONG-LP instrument in people receiving PD.