Peritoneal Dialysis International最新文献

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.

Sorbent peritoneal dialysis (SPD) removes a tidal volume of spent dialysate, passing it through sorbent layers before infusing replacement electrolytes and dextrose to regenerate dialysate. We examine the five devices using SPD in published literature, reviewing their design, dialysis clearance, and ultrafiltration (UF) capacity-Automated Wearable Artificial Kidney (AWAK), now called Viva Kompact since 2024, Carry Life System PD/Carry Life UF, Wearable Artificial Kidney (WEAKID), Vicenza Wearable Artificial Kidney (ViWAK), and Renart-PD. Carry Life devices and Viva Kompact have reported on human trials, WEAKID and Renart-PD on animal studies, while ViWAK has published in vitro data. All devices have published data on dialysis clearance capabilities. WEAKID and Carry Life PD achieved a high dialysate:plasma concentration gradient for small solutes. Viva Kompact and Renart-PD reported stable or lower serum concentrations of urea, creatinine, phosphate, and β2-microglogulin following treatments. ViWAK demonstrated removal of creatinine, B2 microglobulin, and angiogenin to <10% of pre-treatment levels. UF capacity remains unknown for many devices. In human trials, Carry Life UF has achieved 863 mL UF in a 5-h treatment with the addition of 20 g/h of glucose to 1.5% dextrose dialysate. Viva Kompact has demonstrated 877 mL UF in a 9-h treatment using 1.5% dextrose dialysate in an animal model, comparable to 10-h APD, with the addition of 6.6 g/h glucose. Both devices have demonstrated improved UF per gram of glucose used. The expected use of these devices varies greatly, from an adjunct to currently available treatments to a complete replacement for current modalities. Large-scale, human studies are needed to determine their role in the future of PD delivery.

BackgroundChronic kidney disease and end-stage renal disease (ESRD) significantly burden the U.S. healthcare system. Despite its benefits, such as cost savings and increased autonomy, peritoneal dialysis (PD) is underutilized. This study examines how state and ESRD network-level variations impact PD utilization across the United States, addressing a gap in previous investigations that have not fully disentangled the effects of measurable patient-level factors from harder-to-capture influences.MethodsWe analyzed publicly available data from the United States Renal Data System, Centers for Medicare and Medicaid Services, and the U.S. Census Bureau covering 50 states and two territories (2015-2020). Multi-level Beta regression models assessed how state-level predictors are associated with PD utilization, accounting for state and network-level variations. Ranked random effects were compared to 2020 PD rates to identify overperforming or underperforming regions.ResultsBetween 2015 and 2020, PD utilization rose from 9.6% to 12.8%. The proportions of incident dialysis patients who were male, ≥ 65 years, and White, respectively, and dialysis facilities per 100,000 people did not significantly affect PD utilization, whereas population density was significantly negatively associated. The final model revealed that unmeasured variations in PD utilization were significantly explained by both state (intraclass correlation coefficient (ICC) = 0.47) and network (ICC = 0.53) factors.ConclusionThe chosen demographic, provider, and geographical factors explain only 18.5% of PD utilization. About half of the remaining variation resides at the state level and half at the ESRD network level, verifying the importance of unmeasured factors at both levels. We provide adjusted PD utilization rankings-identifying overperforming and underperforming states and networks-where future research can identify disparate effective and ineffective regional policies with the aim of optimizing PD uptake.

Mycobacterium tuberculosis (MTB)-related peritonitis is a rare but serious complication in patients receiving maintenance peritoneal dialysis (PD). Early diagnosis is difficult due to the low sensitivity and delayed results of conventional microscopy and culture methods. MTB polymerase chain reaction (PCR) testing in PD effluent is recommended as a diagnostic adjunct, but real-world data remain limited. We conducted a 20-year single-centre retrospective study in a tuberculosis-endemic region to evaluate the diagnostic accuracy and clinical utility of MTB-PCR in PD effluent. Among 372 tests, MTB-PCR demonstrated sensitivity 50%, specificity 100%, negative-predictive value 94.6% and positive-predictive value 100%, using diagnoses based on a composite of clinical and laboratory criteria as the reference standard. Sensitivity showed a numerical trend of improvement from 33.3% with earlier assays to 50-85.7% with newer assays. Of 72 patients with culture-confirmed MTB-PD peritonitis, 13 (18.1%) were diagnosed via MTB-PCR. Compared to those diagnosed by non-PCR methods, MTB-PCR-diagnosed patients had shorter time to anti-tuberculosis treatment initiation (median 8 vs. 22 days, p ≤ 0.001) and shorter hospital stay from presentation to treatment (median 8 vs. 17 days, p = 0.008). They also had a numerically lower rate of PD catheter removal prior to treatment initiation [0/13 (0%) vs. 9/53 patients (17.0%), p = 0.186]. Rates of permanent transfer to haemodialysis and all-cause mortality at 1 year were similar among the two groups. These findings suggest a role for early MTB-PCR testing in suspected MTB-PD peritonitis. Further studies are needed to confirm the findings and optimize diagnostic strategies.

Identifying risk factors that pre-dispose people on peritoneal dialysis (PD) to develop exit site infections (ESIs) may help improve prevention and treatment. Given the differences anatomically, hormonally and of the microbiota profile between males and females, we hypothesised that there is a difference in ESI incidence, outcomes, and the epidemiology of organism-specific ESI between males and females. This study was a retrospective case note review of all PD patients at our centre between 2012 and 2024. Of the 486 patients on PD, 202 (42%) were female and 273 positive swabs from 151 patients were identified (0.18 patient episodes/year). We found no statistically significant difference in the incidence of ESI between sexes in our cohort. Gram-positive organisms accounted for 126/273 (46.2%) of all ESI swabs, suggesting that current empiric antibiotic therapy potentially offers effective treatment for less than half of ESI only. We found significant morbidity from ESI: 39 (14%) patients developed peritonitis and 40 (15%) required catheter removal. Sex had no influence on ESI incidence, microbiology of infection or outcome.