Peritoneal Dialysis International最新文献

BackgroundThe impact of incremental peritoneal dialysis (PD) on outcomes is poorly understood, and there is a paucity of evidence informing best practices regarding the dialysis dose at the commencement of PD. This international prospective cohort study aimed to compare PD prescription practices at dialysis commencement and their subsequent association with clinical outcomes.MethodsAdult patients who started PD for less than three months at the time of enrolment in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) between 1 January 2014 and 31 December 2017 were included. Patients were defined as initiating incremental PD if prescribed a total of <4 exchanges/day for continuous ambulatory peritoneal dialysis (CAPD) or, with dry days or having PD less than seven days per week for automated peritoneal dialysis (APD). All other prescriptions were considered standard PD. The primary outcome was the transfer to haemodialysis (HD). Secondary outcomes included peritonitis rate, time to first peritonitis and mortality. Logistic regression analysed PD uptake and the Cox proportional hazards regression model analysed HD transfer, peritonitis and patient survival.ResultsOverall, 1365 PD patients from 128 facilities across seven countries were included. Fewer individuals started on incremental PD than standard PD (37% vs 63%, p < 0.001). Higher incremental PD uptake was associated with receiving treatment in Japan (odds ratio [OR] 2.35, 95% CI 1.05-5.26, p = 0.04; ref: Canada), age >75 years (OR 1.51, 95% CI 1.02-2.24, p = 0.04), icodextrin use (OR 8.54, 95% CI 6.26-11.64, p < 0.001), lower serum creatinine concentration at PD start (OR 1.01, 95% CI 1.01-1.01, p = 0.007) and higher number of PD patients at a facility (OR 1.01, 95% CI 1.00-1.01, p = 0.02). Crude HD transfer rates for the incremental and standard PD groups were 0.14 (95% CI, 0.12-0.16) and 0.15 (95% CI, 0.13-0.17) per patient-year of follow-up, respectively (incidence rate ratio [IRR], 0.93; 95% CI, 0.75-1.15; p = 0.49). There was no significant difference in the hazard of HD transfer between the incremental and standard PD groups (hazard ratio [HR] 0.87, 95% CI 0.68-1.12, p = 0.29). There were also no differences between the two groups concerning peritonitis and mortality.ConclusionsIncremental PD start was prescribed in approximately one-third of patients and, in low certainty evidence, was associated with comparable risks of HD transfer, peritonitis and death.

IntroductionThe clinical outcomes of starting peritoneal dialysis (PD) in kidney failure patients according to different break-in periods are not well established. Our aim was to assess whether the strategy of PD initiation interferes with clinical outcomes over the initial 180 days.MethodsThis retrospective study included incident kidney failure patients starting PD at a single center (November 2016-July 2022). Patients were divided into three groups: (1) Urgent-start (US-PD), initiated within 3 days after catheter insertion without prior hemodialysis (HD); (2) Early-start (ES-PD), initiated between 3-14 days, including those with ≤30 days of prior HD; (3) Planned-start (Plan-PD), initiated after 15 days without prior HD. Mechanical and infectious complications, hospitalizations, mortality, and time on PD were compared at 180 days. Patient dropout was defined as the discontinuation of PD due to death or transfer to HD.ResultsA total of 211 patients were included: 118 (55.9%) US-PD, 46 (21.9%) ES-PD, and 47 (22.2%) Plan-PD. Among ES-PD patients, 15 (32.6%) had prior HD (<30 days - median time 19 days). Catheter insertion was mostly performed by nephrologists (60.6%) using the modified Seldinger technique (59.2%). Early complications included catheter dysfunction, which occurred in 12.7% of the overall cohort (17.8% in US-PD vs. 4.3% in ES-PD vs. 8.5% in Plan-PD; p = 0.04), and leakage, observed in 7.1% of the overall cohort (9.3% in US-PD vs. 6.5% in ES-PD vs. 2.1% in Plan-PD; p = 0.26). Later complications, hospitalizations, mortality, and time on PD did not differ significantly between groups. Peritonitis, poor education, and hospitalization were associated with dropout.ConclusionAlthough initiating PD within 72 h of catheter insertion was associated with more mechanical complications in our study, it resulted in similar clinical outcomes to Planned-start PD patients within the first 6 months of therapy, making it a viable option for urgent dialysis initiation in kidney failure patients.

This case report describes a 66-year-old male on continuous cycling peritoneal dialysis (PD) with polycythemia vera and type 2 diabetes. He presented with culture-negative PD-associated peritonitis secondary to splenic infarcts and further accompanied by a splenic vein thrombosis and posterior brain circulation infarcts. His abdominal pain was atypical for peritonitis, being mild and localized to the left side, with an unremitting course despite several treatment attempts with appropriate antimicrobial coverage. An extensive workup for thromboembolic causes was unremarkable. Initially, the patient was started on aspirin and later treated with hydroxyurea and long-term warfarin. His PD catheter was removed due to concerns about an underlying biofilm, and a new one was inserted one month later, while on temporary hemodialysis, without recurrence. This case highlights that non-infectious, culture-negative PD peritonitis related to splenic infarction should be considered in patients with left-sided abdominal pain, poor clinical response to appropriate antibiotics and significant risk factors for thromboembolic events, such as hematologic disorders like polycythemia vera and splenomegaly. Maintaining a high clinical suspicion can prevent unnecessary antibiotic use and reduce repeated exposure to intravenous contrast for imaging studies. Early initiation of long-term anticoagulation might also prevent futile PD catheter removal if subsequent clinical improvement is obtained.

We appreciate Dr Akcay's insightful comments. His observations provide valuable context and highlight important considerations for future research. We hope our work will serve as a foundation for further investigation into sex-associated risks in peritoneal dialysis and contribute to optimizing high-quality patient care for all individuals. Looking ahead, future studies should integrate dialysis-specific measures, explore mechanistic pathways, and incorporate patient-centered outcomes to better characterize sex-associated differences in peritoneal dialysis.

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.