Hypokalemia is a common electrolyte abnormality in patients on peritoneal dialysis (PD) and has been associated with increased risks of peritonitis and death. Whether correction of hypokalemia ...improves these outcomes is unknown.
Multicenter, open-label, prospective, randomized controlled trial.
Adult (aged ≥18 years) PD patients with hypokalemia (defined as at least 3 values or an average value <3.5 mEq/L in the past 6 months). Randomization was stratified according to center and residual urine output (≤100 or >100 mL/day).
Random assignment to either protocol-based potassium supplementation (titratable dose of oral potassium chloride to maintain serum potassium of 4-5 mEq/L) or conventional potassium supplementation (reactive supplementation when serum potassium is <3.5 mEq/L) over 52 weeks. Treatment groups were compared using intention-to-treat analyses implemented using Cox proportional hazards regression.
The primary outcome was time from randomization to first peritonitis episode (any organism). Secondary outcomes were all-cause mortality, cardiovascular mortality, hospitalization, and conversion to hemodialysis.
A total of 167 patients with time-averaged serum potassium concentrations of 3.33 ± 0.28 mEq/L were enrolled from 6 PD centers: 85 were assigned to receive protocol-based treatment, and 82 were assigned to conventional treatment. The median follow-up time was 401 (IQR, 315-417) days. During the study period, serum potassium levels in the protocol-based treatment group increased to 4.36 ± 0.70 mEq/L compared with 3.57 ± 0.65 mEq/L in the group treated conventionally (mean difference, 0.66 95% CI, 0.53-0.79 mEq/L; P < 0.001). The median time to first peritonitis episode was significantly longer in the protocol-based group (223 IQR, 147-247 vs 133 IQR, 41-197 days, P = 0.03). Compared with conventional treatment, the protocol-based group had a significantly lower hazard of peritonitis (HR, 0.47 95% CI, 0.24-0.93) but did not differ significantly with respect to any of the secondary outcomes. Asymptomatic hyperkalemia (>6 mEq/L) without characteristic electrocardiographic changes occurred in 3 patients (4%) in the protocol-based treatment group.
Not double-masked.
Compared with reactive potassium supplementation when the serum potassium level falls below 3.5 mEq/L, protocol-based oral potassium treatment to maintain a serum potassium concentration in the range of 4-5 mEq/L may reduce the risk of peritonitis in patients receiving PD who have hypokalemia.
Registered at the Thai Clinical Trials Registry with study number TCTR20190725004.
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Hong Kong: Wake-Up Call Perl, Jeffrey M.
Common knowledge (New York, N.Y.),
04/2020, Volume:
26, Issue:
2
Journal Article
Peer reviewed
In this piece, the editor of
offers excerpts from his two-year correspondence with a reader in Hong Kong, who was drawn to arguments made in the journal about maintaining “quietism and resistance in ...the face of vile behavior.” In the summer and fall of 2019, during the insurrection in Hong Kong, his correspondent shifts rapidly from taking comfort in
’s defense of quietism to a full embrace of “uncivil disobedience.” She implies that the solidarity the editor expresses with Hong Kong is merely rhetorical, and he responds by writing this article and quoting in it the entire text of the 1984 Joint Declaration of the Chinese and British governments on the question of Hong Kong. The declaration’s guarantees of autonomy and civil rights appear in bold italics. The editor concludes by suggesting that it falls to the United Nations Security Council to enforce the terms of the treaty.
Approximately 11% of people with kidney failure worldwide are treated with peritoneal dialysis (PD). This study examined PD use and practice patterns across the globe.
A cross-sectional survey.
...Stakeholders including clinicians, policy makers, and patient representatives in 182 countries convened by the International Society of Nephrology between July and September 2018.
PD use, availability, accessibility, affordability, delivery, and reporting of quality outcome measures.
Descriptive statistics.
Responses were received from 88% (n=160) of countries and there were 313 participants (257 nephrologists 82%, 22 non-nephrologist physicians 7%, 6 other health professionals 2%, 17 administrators/policy makers/civil servants 5%, and 11 others 4%). 85% (n=156) of countries responded to questions about PD. Median PD use was 38.1 per million population. PD was not available in 30 of the 156 (19%) countries responding to PD-related questions, particularly in countries in Africa (20/41) and low-income countries (15/22). In 69% of countries, PD was the initial dialysis modality for≤10% of patients with newly diagnosed kidney failure. Patients receiving PD were expected to pay 1% to 25% of treatment costs, and higher (>75%) copayments (out-of-pocket expenses incurred by patients) were more common in South Asia and low-income countries. Average exchange volumes were adequate (defined as 3-4 exchanges per day or the equivalent for automated PD) in 72% of countries. PD quality outcome monitoring and reporting were variable. Most countries did not measure patient-reported PD outcomes.
Low responses from policy makers; limited ability to provide more in-depth explanations underpinning outcomes from each country due to lack of granular data; lack of objective data.
Large inter- and intraregional disparities exist in PD availability, accessibility, affordability, delivery, and reporting of quality outcome measures around the world, with the greatest gaps observed in Africa and South Asia.
Vaccination studies in the hemodialysis population have demonstrated decreased antibody response compared with healthy controls, but vaccine effectiveness for preventing SARS-CoV-2 infection and ...severe disease is undetermined.
We conducted a retrospective cohort study in the province of Ontario, Canada, between December 21, 2020, and June 30, 2021. Receipt of vaccine, SARS-CoV-2 infection, and related severe outcomes (hospitalization or death) were determined from provincial health administrative data. Receipt of one and two doses of vaccine were modeled in a time-varying cause-specific Cox proportional hazards model, adjusting for baseline characteristics, background community infection rates, and censoring for non-COVID death, recovered kidney function, transfer out of province, solid organ transplant, and withdrawal from dialysis.
Among 13,759 individuals receiving maintenance dialysis, 2403 (17%) were unvaccinated and 11,356 (83%) had received at least one dose by June 30, 2021. Vaccine types were BNT162b2 (
=8455, 74%) and mRNA-1273 (
=2901, 26%); median time between the first and second dose was 36 days (IQR 28-51). The adjusted hazard ratio (HR) for SARS-CoV-2 infection and severe outcomes for one dose compared with unvaccinated was 0.59 (95% CI, 0.46 to 0.76) and 0.54 (95% CI, 0.37 to 0.77), respectively, and for two doses compared with unvaccinated was 0.31 (95% CI, 0.22 to 0.42) and 0.17 (95% CI, 0.1 to 0.3), respectively. There were no significant differences in vaccine effectiveness among age groups, dialysis modality, or vaccine type.
COVID-19 vaccination is effective in the dialysis population to prevent SARS-CoV-2 infection and severe outcomes, despite concerns about suboptimal antibody responses.
Suffocation in the Polis Perl, Jeffrey M.
Common knowledge (New York, N.Y.),
04/2019, Volume:
25, Issue:
1-3
Journal Article
Peer reviewed
This introduction to the third and final part of the
symposium “Unsocial Thought, Uncommon Lives” (13:1 Winter 2007: 33–39) is reprinted here in a special issue of representative pieces from the ...journal’s first twenty-five years. The title is taken from an article by Isaiah Berlin in CK (7:3 Winter 1998: 186–214 and likewise reprinted in the anniversary issue). Perl’s essay argues against the Aristotelian (and, generally, commonsense) presumption that “man is a social animal” and explains that the CK symposium on unsocial thought was meant to substantiate that “societies do as a rule smother instinctive (along with distinctive) behaviors, but in the process they also as a rule incarnate the least respectable instincts with greater force than individuals can do independently. . . . If even heroism and altruism, let alone standard social conduct, are oblique expressions of aggression, cruelty, and the will to power (as the hermeneutics of suspicion maintains), then the obvious conclusion to reach is that human beings are not fit company for each other. . . . The standard means of veering off from this conclusion is to blame one’s own society, or aspects of contemporary society, and then to propose improvements. Historically, evidence suggests, efforts of this kind are (or else, become) opportunities for controversy and thus for exercise of the will to power. Social order is such that even the discussion of social order occasions conflict.” Perl goes on to argue that individualists and communitarians are “fundamentally in accord”: they are “teams” agreeing to the rules of a dubious conflict from which only “stylites, dendrites, and (on the hearty end of this spectrum) mendicants” have done what is required to exempt themselves.
Background
Extending technique survival on peritoneal dialysis (PD) remains a major challenge in optimizing outcomes for PD patients while increasing PD utilization. The primary objective of the ...Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) is to identify modifiable practices associated with improvements in PD technique and patient survival. In collaboration with the International Society for Peritoneal Dialysis (ISPD), PDOPPS seeks to standardize PD-related data definitions and provide a forum for effective international collaborative clinical research in PD.
Methods
The PDOPPS is an international prospective cohort study in Australia, Canada, Japan, the United Kingdom (UK), and the United States (US). Each country is enrolling a random sample of incident and prevalent patients from national samples of 20 to 80 sites with at least 20 patients on PD. Enrolled patients will be followed over an initial 3-year study period. Demographic, comorbidity, and treatment-related variables, and patient-reported data, will be collected over the study course. The primary outcome will be all-cause PD technique failure or death; other outcomes will include cause-specific technique failure, hospitalizations, and patient-reported outcomes.
Results
A high proportion of the targeted number of study sites has been recruited to date in each country. Several ancillary studies have been funded with high momentum toward expansion to new countries and additional participation.
Conclusion
The PDOPPS is the first large, international study to follow PD patients longitudinally to capture clinical practice. With data collected, the study will serve as an invaluable resource and research platform for the international PD community, and provide a means to understand variation in PD practices and outcomes, to identify optimal practices, and to ultimately improve outcomes for PD patients.
Full text
Available for:
NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Abstract Background Acute kidney injury frequently arises within an acute care hospitalization. Outcomes among acute kidney injury survivors following hospital discharge are poorly documented. ...Methods We conducted a population-based cohort study between 1996 and 2006 of all adult patients in Ontario with acute kidney injury who did not require in-hospital dialysis, and who survived free of dialysis ≥30 days after discharge. Those with acute kidney injury (n = 41,327) were matched 1:1 to patients without acute kidney injury during their index hospitalization. Matching was by age (±1 year), sex, history of chronic kidney disease, receipt of mechanical ventilation during the index hospitalization, and a propensity score for developing acute kidney injury. The primary outcome was subsequent need for chronic dialysis. The secondary outcomes were all-cause mortality and rehospitalization. Results Mean age was 70 years, and median follow-up was 2 years (maximum 10 years). The incidence of chronic dialysis was 1.78 per 100 person-years among those with acute kidney injury and 0.74 per 100 person-years among unaffected controls (adjusted hazard ratio HR; 2.70, 95% confidence interval CI, 2.42-3.00). Rates also were higher for all-cause mortality (15.34 vs 14.51 per-100 person-years; adjusted HR 1.10; 95% CI, 1.07-1.13) and rehospitalization (44.93 vs 37.18 per 100 person-years; adjusted HR 1.21; 95% CI, 1.18-1.24). Conclusion Even when acute dialysis is not required, survivors of acute kidney injury remain at higher risk of receipt of chronic dialysis thereafter. The absolute risk of death was more than 8 times the rate of chronic dialysis.
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