Peritonitis remains a common clinical problem for patients on peritoneal dialysis (PD). There are, however, retrospective studies with historical controls that suggest that biocompatible PD solutions ...may reduce the rates of peritonitis. We conducted a randomized controlled study comparing the use of biocompatible and conventional solutions, accumulating over 7000 patient-months experience. We included peritonitis episodes from patients who discontinued PD during the follow-up period. The study was powered to detect a reduction in the peritonitis rate of over half in the 267 randomized patients in demographically similar groups. There were no intergroup differences in PD technique survival irrespective of whether the outcome was censored for death. Peritonitis-free survival was 26.7 months using conventional compared to 23.1 months using biocompatible PD solutions. The peritonitis rates were also not statistically different when measured in patient-months. Thus, despite the finding of non-randomized studies suggesting benefits of the biocompatible PD solutions, we could not detect any clinically significant advantages in terms of technique survival or peritonitis. Although our study is the largest randomized study comparing different PD solutions to date, we do not exclude the possibility that our results are a consequence of the lack of statistical power. Meta-analysis of randomized control trials in this field is essential.
Background. Encapsulating peritoneal sclerosis (EPS) is a disease process that can occur as a complication of peritoneal dialysis (PD). The aim of this study was to make a general assessment of the ...clinical features, diagnosis, management and outcome of PD-related EPS cases from London and South-East England. Methods. Questionnaires were sent to 11 PD units in March 2007; cases were identified retrospectively. Outcome data on surviving patients were collected in March 2008. Results. A total of 111 patients were identified; the mean time on PD was 82 months (range 8–247). Mortality increased with length of time on PD, being 42% at <3 years (n = 12), 32% at 3–4 years (n = 19), 61% at 5–6 years (n = 31), 54% at 7–8 years (n = 24), 75% at 9–10 years (n = 8) and 59% at >10 years (n = 17). Twelve patients had no previous peritonitis episodes, 28 had one previous episode, 30 had two previous episodes and 33 had three or more previous episodes. Of the patients with PD details available, 41/63 were high (>0.81) transporters and 44/71 had ultrafiltration <1 l/24 h, but 7/63 were low average transporters (0.5–<0.65) and 27/71 had ultrafiltration >1 l/24 h and a few had significant residual renal function. Sixty-five (59%) patients had their PD discontinued prior to diagnosis (51 HD; 14 transplanted). CT scans were performed on 91 patients and laparotomy on 47 patients. Drug treatment consisted of tamoxifen, immunosuppression or both. The median survival was 15 months in patients treated with tamoxifen (n = 17), 12 months in patients treated with immunosuppression (n = 24) and 21 months in patients who received both (n = 13), against 13 months (n = 46) in patients who received no specific treatment. Adhesionolysis was performed in 5 patients, and 39 patients were given parenteral nutrition. The overall mortality was 53% with a median survival of 14 months and a median time to death of 7 months. Conclusion. This is one of the largest cohorts of patients with EPS in the literature. Long-term survival occurred in over 50%, regardless of the various treatments strategies undertaken by the centres.
Volume status can be difficult to assess in dialysis patients. Peripheral edema, elevated venous pressure, lung crackles, and hypertension are taught as signs of fluid overload, but sensitivity and ...specificity are poor. Bioimpedance technology has evolved from early single frequency to multifrequency machines which apply spectroscopic analysis (BIS), modeling data to physics-based mixture theory. Bioimpedance plots can aid the evaluation of hydration status and body composition. The challenge remains how to use this information to manage dialysis populations, particularly as interventions to improve over hydration, sarcopenia, and adiposity are not without side effects. It is therefore of no surprise that validation studies for BIS use in peritoneal dialysis patients are limited, and results from clinical trials are inconsistent and conflicting. Despite these limitations, BIS has clinical utility with potential to accurately evaluate small changes in body tissue components. This article explains the information a BIS plot ("picture") can provide and how it can contribute to the overall clinical assessment of a patient. However, it remains the role of the clinician to integrate information and devise treatment strategies to optimize competing patient risks, fluid and nutrition status, effects of high glucose PD fluids on membrane function, and quality of life issues.
Bioimpedance analysis is often routinely performed in any dialysis unit to guide fluid management but can provide a reproduceable assessment of fat and muscle mass. We wished to determine the ...clinical significance of low muscle or high fat mass and the determinants that influence their change.
We performed retrospective analysis of 824 patients on peritoneal dialysis who underwent routine repeated bioimpedance analysis measurements using the body composition monitor (BCM).
Lean tissue index (LTI) was an independent predictor of mortality when sex, age, PD vintage and diabetes status were included in the models (HR 0.93; 95% CI 0.86-1.00, p < 0.05) and when baseline serum albumin was included in a separate model (HR 0.86; 95% CI: 0.79-0.93, p < 0.001). High fat tissue index (FTI) was an independent predictor of mortality when demographic factors were included (HR 0.87; 95% CI: 0.78-0.97, p < 0.02), but not with the addition biochemical parameters. Changes in body composition of 206 patients over a 2-year follow-up period could not be predicted by baseline demographics, functional or biochemical assessments. However, there was a strong inverse relationship between changes in LTI and FTI. There were no associations between changes in body composition with prescribed dialysate glucose.
We showed body composition changes are common and complex. LTI was an independent predictor of survival. Changes in LTI and FTI could not be predicted by baseline parameters. BCM may be a sensitive and accurate tool to monitor changes in body composition during dialysis treatment.
Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated ...recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.
Graphical Abstract
This is a visual representation of the abstract.
These guidelines cover all aspects of the care of patients who are treated with peritoneal dialysis. This includes equipment and resources, preparation for peritoneal dialysis, and adequacy of ...dialysis (both in terms of removing waste products and fluid), preventing and treating infections. There is also a section on diagnosis and treatment of encapsulating peritoneal sclerosis, a rare but serious complication of peritoneal dialysis where fibrotic (scar) tissue forms around the intestine. The guidelines include recommendations for infants and children, for whom peritoneal dialysis is recommended over haemodialysis.Immediately after the introduction there is a statement of all the recommendations. These recommendations are written in a language that we think should be understandable by many patients, relatives, carers and other interested people. Consequently we have not reworded or restated them in this lay summary. They are graded 1 or 2 depending on the strength of the recommendation by the authors, and A-D depending on the quality of the evidence that the recommendation is based on.
There is a wide disparity in the use of automated peritoneal dialysis (APD) or continuous ambulatory peritoneal dialysis (CAPD) in the UK. This may be due to a perceived quality of life and technique ...survival advantage with APD, although evidence is lacking.
We conducted a single-centre retrospective study of incident end-stage renal disease initiating APD and CAPD with data collected prospectively over 5 years. PD modality was based on patient preference. Health status was assessed using SF-36 questionnaires at initial and 1-year follow-up appointments.
Three hundred and seventy-two patients were included: 194 patients chose APD, and 178 patients chose CAPD. CAPD patients were generally older and more dependent than APD patients. Univariate analysis for technique survival was inferior for CAPD (relative risk for failure 1.46, 95% CI 1.08-1.97). But on multivariate analysis when comorbidity was added into the model, PD modality was no longer a significant predictor of technique survival. There was no difference in decline in residual renal function. Baseline CAPD patients had worse health status (HS); mean (SEM) physical and social composite scores were 32.3 (0.9) vs 36.5 (0.9) and 33.3 (1.2) vs 40.3 (1.2). After 1 year, HS scores for CAPD and APD patients were similar, but the improvement in HS scores correlated with baseline scores (PD modality was not an independent predictor of the change in HS).
This study did not show any advantages of APD over CAPD in terms of technique survival or HS. There is no evidence to support physician bias towards one PD modality, and both should be available to allow patient choice.
It is becoming increasingly evident that the accurate assessment of hydration status is critical to care of a dialysis patient. Using the Body Composition Monitor, different parameters (overhydration ...(OH), extra-cellular water/total body water (ECW/TBW) or OH/ECW) have been proposed to indicate hydration status. We wished to determine which parameter (if any) was most predictive of all-cause mortality, and if this was independent of nutritional indices.
We performed a single-centre retrospective analysis of prospectively collected data of all peritoneal dialysis (PD) patients between 1 January 2008 and 30 March 2012. Record review was undertaken to establish patient survival, clinical and demographic data. Follow-up was continued even after PD technique failure (transfer to haemodialysis) and transplantation.
The study included 529 patients. OH index (OH and OH/ECW) was the independent predictor of mortality in multi-variate analysis. ECW/TBW as a continuous variable was not associated with increased risk of death. In contrast, patients that were severely overhydrated (highest 33%) had hazard ratios (HRs) that were statistically significant irrespective of the parameter used to define hydration. Using OH, severely overhydrated patients had an HR of 1.83 95% confidence interval (CI) 1.19-2.82, P < 0.01, OH/ECW: 2.09 (95% CI 1.36-3.20, P < 0.001) and ECW/TBW: 2.05 (95% CI 1.31-3.22, P < 0.005).
Our results also indicated that there was no influence of body mass index (BMI) on the hydration parameter OH/ECW. OH/ECW remained an independent predictor of mortality when the BMI and lean tissue index were included in multivariate model. However, it remains to be determined if correcting the OH status of a patient will lead to improvement in mortality.
Background
Fluid overload (FO) in peritoneal dialysis (PD) patients is associated with mortality. We explore if low daily sodium removal is an independent risk factor for mortality. We examined ...severely FO PD patients established for >1 year in expectation that PD prescription would have been optimized for solute clearance and ultrafiltration. We also wish to determine the relationship between kt/v and sodium removal.
Methods
Retrospective analysis of 231 PD patients with FO ≥2.0 L and compared with 218 PD patients who were euvolaemic throughout their PD treatment. Patients were followed up until death censored for transplantation.
Results
Mean daily sodium removal in overhydrated patients was only 75 mmoles (=1.7 g). CAPD usage was more common in patients with the highest sodium removal. Achievement of UK guidelines for solute clearance and daily fluid removal were not independent predictors of mortality. Markers of sarcopenia (low serum albumin and high CRP) were associated with increased mortality, but these parameters were not independent predictors in a model that included functional assessment (Karnofsky score). Daily sodium removal was not predictive of mortality but the imprecision of clinically used sodium assay should be noted. The correlation between Na and kt/v is statistically significant but R2 was weak at .07.
Conclusion
While diabetic males were more likely to become overhydrated, these factors did not increase mortality further. Traditional targets of ‘dialysis adequacy’ did not predict survival. Kt/v is not a good indicator of sodium removal which can be surprisingly low. Measuring sodium clearance may help clinicians optimize PD modality (CAPD vs. APD).
SUMMARY AT A GLANCE
This paper tackles the vexed issue of overhydration and sodium removal and how this might relate to mortality in PD patients. It points out that urea kinetic modelling and sodium removal are only weakly associated and describes in detail the difficulties in measuring and interpreting these measures as they apply to describing 'adequate' dialysis.
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