Advances in peritoneal dialysis. Conference on Peritoneal Dialysis最新文献

Peritoneal dialysis (PD) dosing is determined by urea clearance scaled to total body water (TBW). However, studies delivering greater peritoneal Kt/V urea have failed to demonstrate improved survival. Body surface area (BSA) has been suggested as an alternative scaling factor. Cellular metabolism generates toxins, and thus total energy expenditure (TEE) might be a preferable scaling factor. Because TEE is cumbersome to determine, we set out to determine the association of anthropomorphic scaling factors with TEE.The TEE was determined using the Recent Physical Activity Questionnaire combined with resting energy expenditure by validated equations that use doubly labelled isotopic water and body composition by multi-frequency bioimpedance.In 148 adult PD patients [97 men (65.5%)], mean age was 60.6 ± 20.6 years, and median PD treatment duration was 9.1 months (range: 3.5 - 25.2 months). Mean weight in the group was 73.6 ± 16.7 kg, body mass index (BMI) was 26.0 ± 4.9 kg/m², and BSA was 1.86 ± 0.24 m². The mean TEE was 1974 ± 414 kcal daily, and it correlated with BMI (men: r = 0.48, p < 0.001; women r = 0.36, p = 0.018), BSA (men: r = 0.56; women: r = 0.63; both p < 0.001), and TBW (men: r = 0.62; women: r = 0.65; both p < 0.001). Skeletal muscle mass correlated with BMI (men: r = 0.48; women: r = 0.50), BSA (men: r = 0.72; women: r = 0.63), and TBW (men: r = 0.98; women: r = 0.99), all p < 0.001.Comparing scaling factors, correlations with TEE were stronger for TBW and BSA than for BMI. Skeletal muscle mass was most strongly associated with TBW. Our study did not demonstrate any advantage for BSA compared with TBW as a scaling factor to adjust the dose of PD.

Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telemedicine is the use of electronic communications for the exchange of medical information from one site to another to improve a patient's clinical health status.Several studies show that, by providing better patient oversight and communication, telehealth in PD enhances patient care, outcomes, quality of care, and satisfaction. Associated benefits include increased patient retention to home dialysis, reduced use of hospital services, and reduced costs of care.The sustainability of telehealth had been limited by reimbursement and regulatory restrictions. The Centers for Medicare and Medicaid Services (CMS) limited services related to end-stage renal disease by providing reimbursement for telehealth only in rural areas or counties outside of a metropolitan statistical area. Moreover, the dialysis facility and the patient's home were not approved as originating sites. However, effective January 1, 2019, those restrictions will be lifted. Telehealth will require that home dialysis patients be established with 3 initial face-to-face monthly clinical assessments without the use of telehealth; after those initial 3 months, a face-to-face visit at least once every 3 consecutive months will be required. Claims can be submitted using designated Current Procedural Terminology codes and modifiers.The actual extension of telehealth to home dialysis patients will depend on the details of forthcoming CMS regulations.

In this retrospective study, the safety of initiating peritoneal dialysis (PD) immediately after percutaneous PD catheter insertion was evaluated. Patients who underwent peritoneal catheter insertion and then immediately began dialysis treatment were included in the study. Patient age, sex, treatment modalities, and method of catheter insertion were recorded.Acute PD was performed in 33 patients (age: 57.7 ± 16.7 years; 21 men, 12 women). Catheters were inserted percutaneously in 28 patients and surgically in 5 patients. The PD modalities used were continuous ambulatory PD in 18 patients, automated PD in 11 patients, and both modalities in 4 patients. Acute PD was started within 24 hours of catheter insertion. Leaks occurred in 8 patients who had catheters inserted percutaneously (28.5%). Peritonitis occurred in 1 patient. No complications were observed in 24 patients. Leaks were fully resolved for patients kept in a supine position, with fill volumes reduced to 500 mL - 700 mL and the dwell period decreased to 60 minutes from 120 minutes. Leaks were not observed in the patients when the fill volume was increased by 200 mL and the dwell period was increased by 30 minutes every 2 days to reach 1300 mL and 180 minutes by the 7th day.Immediate-start dialysis after percutaneous peritoneal catheter insertion seems safe when performed in a supine position with low-volume exchanges and short dwell times.

Exit-site infection poses a risk for peritonitis and can shorten peritoneal dialysis (PD) vintage. A loose fit of the skin around the catheter at the exit site can push bacteria surrounding the catheter into the subcutaneous tunnel. Negative-pressure wound therapy (NPWT) has been used to hasten healing of the wound after an operation or to treat pressure ulcers. We hypothesized that NPWT could speed the healing of the exit site and tighten the fit of the skin around the catheter. Using a V.A.C. Therapy system [vacuum-assisted closure (KCI, San Antonio, TX, U.S.A.)], NPWT was therefore applied in 9 patients for 1 - 2 weeks after the PD catheter insertion operation. Results in those patients were compared with results in patients who did not receive NPWT.The healed exit site was classified as either tightly fitted (when the skin was tightly connected around the PD catheter) or loosely fitted (when the skin was not tightly connected around the catheter). The relevant data were retrieved from the medical record and analyzed retrospectively.Patients who received NPWT had a tight exit site after 1 - 2 weeks. Those who did not receive NPWT did not have a tight exit site after 1 - 2 weeks. No bleeding was observed in patients receiving NPWT. Bleeding from the exit site after the catheter insertion operation was observed in 3 patients not receiving NPWT.Because we use a fine trocar to make the subcutaneous catheter tunnel, bleeding from the vasculature can often be observed. That bleeding could be minimized with the application of NPWT. Negative pressure could also hasten wound healing and result in a tight fit of the skin around the catheter within in 1 - 2 weeks compared with the 1 month typically required with the use of conventional film dressings.Negative-pressure wound therapy is beneficial for creating a tight fit of the skin to the catheter within 1 - 2 weeks and might reduce the number of exit-site and tunnel infections, which could result in a reduction in the peritonitis rate.

Healing Touch therapies use a practitioner's intentional placement of hands to influence the patient's energy fields to promote self-healing. In the changing climate of health care, in which the patient experience increasingly drives reimbursements, it is vital to find unique and meaningful ways beyond traditional medical therapies to ensure positive patient experiences. To that end, our peritoneal dialysis clinic staff adopted Jean Watson's theoretical framework, by which patients are treated as whole unique individuals with a "multidimensional system of energy, with a consciousness that can be affected by another to promote well-being." In a rapidly growing urban clinic of more than 100 patients, our nurses identified the need to provide more ways to improve patient care.Staff were educated on ways to set positive intentions for patient contacts and to incorporate patient narratives into contact. Optional daily prayer was initiated, and patients were invited to attend a new support group for peritoneal dialysis patients and their families. In addition, a preliminary pilot provided Healing Touch treatments to interested patients. That pilot was associated with improvement in 4 of 5 measured categories. Fatigue and pain decreased by 46% and 68% respectively. Stress and anxiety fell by 49%, and a large drop of 84% in depression was observed. Nausea was unchanged.

Adequate nutrition and growth is vital in pediatrics. Breast milk alone might not be able to satisfy the nutrition needs of an infant with renal disease. Similac PM 60/40 (Abbott Laboratories, Abbott Park, IL, U.S.A.) is a low-iron infant formula indicated for infants who would benefit from a lowered mineral intake. It is the only infant formula marketed in the United States for infants with renal impairment. The objective of the present case study was to examine whether Renastart, a pediatric renal formula (Nestlé Health Science, Florham Park, NJ, U.S.A.), could be used alongside expressed breast milk (EBM) to meet the nutritional needs of an infant with renal disease, while maintaining normal serum electrolytes.A 9-month-old infant received EBM with Similac PM 60/40 treated with Kayexalate (Concordia Pharmaceuticals, Bridgetown, Barbados) because of hyperkalemia. That formulation was not well tolerated, and the infant's growth trajectory declined. The infant was then switched to EBM with Renastart. During this intervention, growth trends; formula volume; kilocalories and protein grams consumed per kilogram weight; episodes of emesis; serum Na, K+, Ca, and phosphorus; blood urea nitrogen; and creatinine were collected.Results showed an increase of formula intake, an improvement in weight and linear growth, and normal serum levels of Na, K+, and Ca, but low serum phosphorus.A combination of Renastart and EBM can be safely and effectively used to meet the needs of an infant with renal disease. Close monitoring of protein intake and electrolytes is necessary, and supplementation with phosphorus should be considered. Larger studies are needed to further confirm the benefits of Renastart in infants.

Coagulopathies and bleeding disorders can affect dialysis outcomes by increasing the thrombosis risk at the arteriovenous access or by causing prolonged bleeding at access or catheter sites. We present the case of a 68-year-old woman with combined antiphospholipid syndrome and factor XI deficiency, with chronic prolongation of activated partial thromboplastin time that was not correctable with fresh-frozen plasma (FFP).The patient had a history of stroke, but was not on antiplatelet therapy because of mucocutaneous bleeding events. She had progressive renal failure attributed to her autoimmune disease, and a decision was made to pursue peritoneal dialysis (PD) when she reached end-stage kidney disease. She was admitted to the hospital the day before her planned PD catheter placement and was transfused with FFP and platelets before placement of a temporary hemodialysis catheter. One session of hemodialysis was performed to minimize uremic platelet dysfunction. The patient was given additional FFP and platelets at the time of PD catheter placement; desmopressin was not used. No thrombotic or bleeding complications occurred, and at 8 months out, the patient has been doing well on PD.In summary, careful perioperative planning led to successful PD initiation in a patient with combined bleeding and clotting disorders.

Peritoneal dialysis (PD) is recognized as an excellent method of dialysis because the therapy is gentle, continuous, and cost-effective. However, a large number of patients must unfortunately transfer from PD to hemodialysis because of peritonitis or fluid overload in the early phase after PD initiation. In the present study, we reviewed clinical indicators before PD initiation to try to identify predictive factors for early withdrawal from PD.For this retrospective cohort study at two hospitals between March 2003 and October 2016, we defined withdrawal from PD as the induction of combination therapy, transfer to hemodialysis, or death. Data about clinical indicators before PD induction-namely age, sex, presence of diabetes mellitus, past history of cardiovascular disease (CVD), body mass index, primary kidney disease, and blood biochemistry-were collected from medical records. The primary outcome was duration of PD until withdrawal.We analyzed 151 PD patients (median age: 62.5 years; 94 men; 74 with diabetes mellitus; median duration of PD: 30.2 months). Univariate Cox regression analysis showed that the hazard ratio (HR) for withdrawal was 1.08 [95% confidence interval (CI): 1.04 to 1.12; p < 0.001] per 1 mg/L increase in β₂-microglobulin (β₂MG), 0.65 (95% CI: 0.46 to 0.93; p = 0.02) per 1 g/dL decrease in serum albumin, and 1.07 (95% CI: 1.02 to 1.11; p = 0.01) per 1 g per gram creatinine increase in daily urinary protein excretion. Using multivariate Cox regression analysis, β₂MG (HR: 1.08; 95% CI: 1.04 to 1.12; p < 0.001) and past history of CVD (HR: 1.47; 95% CI: 1.02 to 2.13; p = 0.04) were factors predictive for withdrawal from PD. Kaplan-Meier analysis showed that the technique survival rate was significantly different in the two groups defined as having a serum β₂MG level above or below the measured median (p = 0.047).Serum β₂MG at PD initiation and past history of CVD are high-risk factors for withdrawal from PD. Special focus should be placed on the care and management of patients found to have a high risk of withdrawal at the time of PD induction.

Peritoneal dialysis (PD) is an excellent treatment option for the patients with end-stage renal disease, having been shown to yield improved patient satisfaction and economic benefit. Many surgeons and physicians believe that patients with prior abdominal surgeries or other abdominal complications are not viable candidates for PD and that prevalent PD patients needing abdominal surgery should be switched to hemodialysis. The purpose of the present review is to address those misconceptions.Our review of literature shows that, when appropriately planned, PD can still be an acceptable option for patients with end-stage renal disease and certain abdominal complications, including abdominal surgery, provided that the peritoneum is not compromised. Anticipating complications-and changing the PD prescription accordingly-can allow many such patients to continue PD without any interruption, thus maintaining their lifestyle and avoiding an increase in medical expense.