CKD is a global problem that causes significant burden to the healthcare system and the economy in addition to its impact on morbidity and mortality of patients. Around the world, in both developing ...and developed economies, the nephrologists and governments face the challenges of the need to provide a quality and cost-effective kidney replacement therapy for CKD patients when their kidneys fail. In December 2019, the 3rd International Congress of Chinese Nephrologists was held in Nanjing, China, and in the meeting, a symposium and roundtable discussion on how to deal with this CKD burden was held with opinion leaders from countries and regions around the world, including Australia, Canada, China, Hong Kong, Singapore, Taiwan, the UK, and the USA. The participants concluded that an integrated approach with early detection of CKD, prompt treatment to slow down progression, promotion of home-based dialysis therapy like peritoneal dialysis and home HD, together with promotion of kidney transplantation, are possible effective ways to combat this ongoing worldwide challenge.
Background
Patients on automated peritoneal dialysis (APD) may have greater exposure to glucose in the PD fluid than those on continuous ambulatory PD (CAPD). If this causes long-term damage to the ...peritoneal membrane, it will have implications for a patient's choice of modality.
Methods
Membrane function of long-term APD or CAPD patients was followed prospectively. The data were collected from electronic patient records in our unit from 2000 to 2014. The rate of change in membrane transport status (D/Pcr) and ultrafiltration (UF4) for each patient was calculated using the least square regression line equation.
Results
We identified 106 APD and 123 CAPD patients who had a mean of 8.4 peritoneal equilibration test (PET) over 5.6 years. No differences were found in the rate of changes in D/Pcr or UF4. Baseline solute clearance (Kt/V) was lower in APD patients (1.66 vs 1.76, p = 0.04). However, APD patients experienced incremental changes to dialysis prescription that resulted in a greater increase in Kt/V compared with CAPD patients.
Conclusion
This is the largest study comparing the long-term effect of APD vs CAPD prescriptions. Despite more glucose being prescribed, there were no differences in the evolution of peritoneal membrane transport characteristics. The lower baseline Kt/V of APD patients might be explained by our aggressive use of incremental APD (tidal with dry day). Despite greater glucose prescriptions, initiating patients on APD based on patient preference appears to be safe for the long-term integrity of the peritoneal membrane.
There is a general perception that patients with polycystic kidney disease on peritoneal dialysis have poor long-term technique survival. In order to test this opinion, we performed a retrospective ...analysis comparing results of 56 consecutive patients with polycystic kidney disease to 56 non-diabetic patients with bilateral small kidneys. The patient groups were all initiated on peritoneal dialysis over a 12 year period and matched for age, gender and years of end stage renal failure. After a mean follow-up period of 37 months the two groups were statistically indistinguishable in terms of mortality, kidney transplantation-censored technique survival, median death-censored technique survival, the number of patients switched permanently to hemodialysis due to technique failure and the rate of peritonitis. On Cox regression (multivariate) analysis, only the baseline serum albumin level was a significant and independent risk factor of death-censored technique failure. Our study found no difference in long term outcome of peritoneal dialysis therapy in patients with polycystic kidney disease compared to a non-diabetic matched control group.
Paradoxical reaction (also known as Jarisch–Herxheimer reaction) is a self-limited response to endotoxin released from dead bacteria after starting treatment and is characterized by constitutional ...symptoms such as fever, headache, dizziness and exacerbation of cutaneous lesions. We report a rare case of a 55-year-old gentleman, on peritoneal dialysis, who developed fever, dizziness and cloudy dialysate after starting anti-tuberculous treatment for disseminated tuberculous lymphadenitis. He was started on antibiotics for suspected peritoneal dialysis peritonitis and anti-tuberculosis treatment was continued. However, all his cultures turned out negative including peritoneal 16S ribosomal RNA. The diagnosis of paradoxical worsening following anti-tuberculosis treatment was made. His peritoneal dialysis was continued and he made full recovery after 8 months of therapy. This case highlights the fact that in a peritoneal dialysis patient, paradoxical reaction can present as cloudy dialysate with raised infective markers.
Euvolemia is an important adequacy parameter in peritoneal dialysis (PD) patients. However, accurate tools to evaluate volume status in clinical practice and data on volume status in PD patients as ...compared to healthy population, and the associated factors, have not been available so far.
We used a bio-impedance spectroscopy device, the Body Composition Monitor (BCM) to assess volume status in a cross-sectional cohort of prevalent PD patients in different European countries. The results were compared to an age and gender matched healthy population.
Only 40% out of 639 patients from 28 centres in 6 countries were normovolemic. Severe fluid overload was present in 25.2%. There was a wide scatter in the relation between blood pressure and volume status. In a multivariate analysis in the subgroup of patients from countries with unrestricted availability of all PD modalities and fluid types, older age, male gender, lower serum albumin, lower BMI, diabetes, higher systolic blood pressure, and use of at least one exchange per day with the highest hypertonic glucose were associated with higher relative tissue hydration. Neither urinary output nor ultrafiltration, PD fluid type or PD modality were retained in the model (total R² of the model = 0.57).
The EuroBCM study demonstrates some interesting issues regarding volume status in PD. As in HD patients, hypervolemia is a frequent condition in PD patients and blood pressure can be a misleading clinical tool to evaluate volume status. To monitor fluid balance, not only fluid output but also dietary input should be considered. Close monitoring of volume status, a correct dialysis prescription adapted to the needs of the patient and dietary measures seem to be warranted to avoid hypervolemia.
For the treatment of peritoneal dialysis-associated peritonitis (PDP), it has been suggested that serum concentrations of vancomycin be kept above 12 mg/L-15 mg/L. However, studies correlating ...vancomycin concentrations in serum and peritoneal dialysate effluent (PDE) during active infection are sparse. We undertook the present study to investigate this issue and to determine whether achieving the recommended serum level of vancomycin results in therapeutic levels intraperitoneally.
We studied patients treated with intraperitoneal (i.p.) vancomycin for non-gram-negative PDP. We gave a single dose (approximately 30 mg/kg) at presentation, and we subsequently measured vancomycin levels in PDE on day 5; we wanted to determine if efflux of vancomycin from serum to PDE during a 4-hour dwell was consistent and resulted in therapeutic levels.
Of the 48 episodes of PDP studied, serum vancomycin concentrations exceeding 12 mg/L were achieved in 98% of patients, but in 11 patients (23%), a PDE vancomycin level below 4 mg/L--the minimal inhibitory concentration (MIC) of many gram-positive organisms--was observed at the end of a 4-hour dwell on day 5. The correlation between the concentrations of vancomycin in serum and PDE (from efflux of antibiotic over 4 hours) was statistically significant, but poor (R(2) = 0.18).
Our data support the International Society for Peritoneal Dialysis statement that adequate serum vancomycin concentrations can be achieved with intermittent dosing (single dose every 5 days), but cannot guarantee therapeutic PDE levels in the treatment of PDP. Intermittent dosing of vancomycin may not consistently result in PDE concentrations markedly greater than MIC of many important pathogens. Although the clinical significance of this finding remains to be determined, it may be preferable to give smaller but more frequent doses of PDE vancomycin (continuous dosing) for adults with PDP (as is currently recommended for children).
Aim
Peritoneal dialysis peritonitis and fluid overhydration (OH) are frequent problems in peritoneal dialysis. The latter can cause gut wall oedema or be associated with malnutrition. Both may lead ...to increased peritonitis risk. We wished to determine if OH is an independent risk factor for peritonitis (caused by enteric organisms).
Methods
Retrospectively study of patients with >2 bioimpedance assessments (Body Composition Monitor). We compared peritonitis rates of patients with above or below the median time‐averaged hydration parameter (OH/extracellular water, OH/ECW). Multivariate analysis was performed to determine independent risk factors for peritonitis by enteric organism.
Results
We studied 580 patients. Peritonitis was experienced by 28% patients (followed up for an average of 17 months). The overall peritonitis rate was 1:34 patient months. Patients with low OH/ECW values had significantly lower rates of peritonitis from enteric organisms than overhydrated patients (incident rate ratio 1.53, 95% confidence interval 1.38–1.70, P < 0.001). Hydration remained an independent predictor of peritonitis from enteric organisms when multivariate model included demographic parameters (odds ratio for a 1% increment of OH/ECW was 1.05; 95% confidence interval 1.01–1.10, P < 0.02). However, including biochemical parameters of malnutrition reduced the predictive power of overhydration.
Conclusion
We found an association between overhydration and increased rates of peritonitis. While this may partly be due to the high co‐morbidity of patients (advanced age and diabetes), on multivariate analysis, only inclusion of nutritional parameters reduced this association. It remains to be determined if overhydration will prove to be a modifiable risk factor for peritonitis or whether malnutrition will prove to be more important.
Summary at a Glance
Fluid overload is a very important risk factor on all cause mortality and residual function. This paper tried to investigate how to measure a fluid status and avoid potential modifiable risk factor for peritonitis in patients on peritoneal dialysis. It is great benefit for peritoneal dialysis doctors in their clinical practice.
Background. There are few studies of the pharmacokinetics of vancomycin and gentamicin in peritoneal dialysis (PD) patients and the influence of antibiotic concentrations on treatment outcome. ...Concerns about resistance to ceftazidime and potential of aminoglycoside toxicity make the choice of empiric antibiotic difficult. Methods. We retrospectively collected data from 613 patients on PD between 1 June 2002 and 31 December 2005. During this time, we adopted a protocol that minimized aminoglycoside exposure to patients with residual renal function and carefully monitored serum antibiotic concentrations. Results. There were no statistical differences in mean day-5 vancomycin concentrations for continuous ambulatory peritoneal dialysis (CAPD) vs automated peritoneal dialysis (APD) and for anuric vs not-anuric patients. However, low levels (<12 mg/l) were recorded for 12.8% CAPD and 15% APD patients. These remained low at day 10 in 16% patients (25% if not anuric) despite incremental dosing. Vancomycin concentration did not predict cure or relapse of Gram-positive or culture-negative peritonitis. Gentamicin concentration (>2 mg/l in >50% patients) did not predict outcome of Gram-negative and culture-negative peritonitis. Moreover, cure rates were the same irrespective of whether gentamicin was continued for 14 days or was switched to ceftazidime after 5 days. Conclusion. We have confirmed that the International Society for Peritoneal Dialysis (ISPD) dosing guideline for vancomycin in CAPD and APD patients produces adequate serum concentrations of the antibiotics in the vast majority. However, large incremental dosing of vancomycin is needed if day-5 levels are low; especially for not-anuric patients. Whilst evidence of gentamicin toxicity in PD remains controversial, ISPD dosing regimen resulted in high levels for >50% patients. High gentamicin concentrations did not correlate with treatment success, but switching gentamicin to ceftazidime at day 5 appeared safe and limited aminoglycoside exposure. Increasing vancomycin and gentamicin concentrations do not appear to improve cure rates and alternative strategies (such as combination treatment) should be considered for future research.
PDF
