Introduction
The adoption of the International Society for Peritoneal Dialysis guideline of using mupirocin ointment has been limited by fear of developing mupirocin-resistant organisms. We performed ...a surveillance program of a large peritoneal dialysis (PD) unit.
Methods
We performed 1,175 surveillance swabs from anterior nares, PD catheter exit site, groin, and axilla, from 240 patients. The mean interval between swabs was 3.3 months.
Results
Colonization by Staphylococcus aureus (S. aureus) or Pseudomonas species was 9.5% and 10.9%, respectively. Despite adopting a universal policy of applying mupirocin to PD catheter exit sites in 2001, no instances of mupirocin-resistant S. aureus were identified. Moreover, patients who grew S. aureus from surveillance swabs did not experience higher peritonitis rates than those with “no growth.” This was in contrast to patients who grew Pseudomonas or enteric organisms. There were no differences in patient demographics for those who grew S. aureus, Pseudomonas, or enteric organisms (compared with “no-growth” patients).
Conclusion
Our results suggest that the application of mupirocin ointment appeared to minimize peritonitis of patients colonized with S. aureus. The use of mupirocin in this patient cohort has not led to mupirocin resistance. The increased peritonitis rate of patients who grew Pseudomonas or enteric organisms is of interest. We propose that greater attention to hygiene and catheter care in these patients is warranted. The increasing use of paid healthcare workers attending patients daily to help perform PD (assisted PD) gives an opportunity for us to address these wider issues.
Fluid status is an independent predictor of mortality in dialysis patients. Current methods of fluid assessment have several limitations.
An ideal method should be cheap, portable, easy to perform ...without extensive training, reproducible and determines patients' excess or deficit of total body water. Bioimpedance analysis (BIA) fulfils many of these criteria and can give additional information on fat and lean tissue composition. The accuracy and precision of BIA has been shown to be equivalent to the 'gold standard' direct estimation techniques.
Although there remains some concern about its validity in dialysis patients, fluid overload determined by BIA has been shown to predict mortality. BIA-guided fluid management appears superior to conventional fluid management in achieving clinically important outcomes such as reduction in blood pressure, left ventricular mass index, and arterial stiffness. Accurate setting of dry weight might also help preserve residual renal function by limiting episodes of dehydration. Nevertheless, as with all new technologies, there are issues that still need to be resolved. This will be achieved only with larger prospective interventional studies to explore its specific roles in dialysis cohorts.
Background
Bioimpedance spectroscopy (BIS), ultrasound lung comets (ULC) and serum biomarkers (N‐terminal pro–brain natriuretic peptide, NT‐proBNP) have all been used to assist clinicians to ...determine hydration status in dialysis patients.
Methods
We performed simultaneous BIS, ULC and NT‐proBNP measurements in 27 peritoneal dialysis patients to determine the concordance of the three methods.
Results
Patients with evidence of increasing lung congestion (as determined by ultrasound) were more likely to be diabetic, have systolic hypertension and have higher NT‐proBNP (r = 0.65, P < 0.0005). Although there was a trend for patients with high ULC to be overhydrated as determined by BIS, this did not reach statistical significance. Moreover, the correlation between BIS and NT‐proBNP (though statistically significant at r = 0.47, P < 0.02) appeared to be weaker.
Conclusion
BIS and ULC may be complementary, providing different information, whereas BIS may be more specific to hydration. ULC and NT‐proBNP may indicate left ventricular failure coexisting with overhydration.
Summary at a Glance
We assessed fluid status in 27 peritoneal dialysis patients using bioimpedance spectroscopy (BIS), lung ultrasound (ULC) and N‐terminal pro–brain natriuretic peptide (NT‐proBNP). BIS and ULC appear to be complementary, although BIS may be more specific for hydration status, whereas ULC and NT‐proBNP appear to be more specific for left ventricular dysfunction with pulmonary fluid overload.
Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis. In this review, we describe the clinical picture and histologic changes to the peritoneal membrane ...that are associated with EPS and provide an update on current diagnosis and management. We also discuss the recent studies that have suggested that the use of more biocompatible solutions containing lower concentrations of glucose degradation product that often are pH neutral in combination with a change in clinical practice (reducing glucose exposure and monitoring peritoneal membrane function) might ameliorate peritoneal degeneration, reduce the incidence of EPS, and minimize the severity of the disease.
Aim
To determine if patients with failing kidney transplants who opt to have peritoneal dialysis (PD) have poor short‐term PD technique survival and increased rates of peritonitis.
Methods
We ...performed a retrospective analysis comparing 50 consecutive patients starting PD after a failed kidney transplant to 93 incident patients starting PD (matching for age, gender, diabetes causing renal failure, ethnicity and year of starting PD).
Results
The mean follow‐up period was 26 months. PD technique survival was lower for the post‐transplant cohort. However, this did not appear to be related to PD peritonitis risk; infection rate was lower in the post‐transplant group albeit not statistically significant (1 in 23.6 patient months vs 1 in 22.5 patient months). There were no differences in the proportion of Gram positive: Gran negative: Culture Negative infections. The only fungal peritonitis occurred in a Control patient. Results of baseline Peritoneal Equilibration Tests were not different; D/Pcr was 0.69 for post‐TP versus 0.64 for Control (P = ns), and net UF was 250 mL for post‐TP versus 310 mL for Control (P = ns). PET results after 12 months were also similar.
Conclusion
Our study found a small but significantly higher rate of PD technique failure in the post‐transplant cohort, but this did not appear to be related to peritonitis rates or peritoneal membrane function. Further studies are required to explore reasons for PD technique failure in patients who have had kidney transplant, but our study supports the use of PD in selected patient from this cohort.
Summary at a Glance
The authors looked at the outcomes of patients initiated on PD after a failed renal transplant and found that these patients have a higher technique failure rate that was independent of peritonitis.
Peritoneal dialysis is the archetypal home-based therapy and is often favoured by patients. However, as patients with end-stage renal failure become more elderly, with more co-morbidity, their ...dependence on carers to provide physical, emotional and logistical support increases. The effect of this chronic burden has not been systematically studied. We have prospectively studied patients with end-stage renal failure starting peritoneal dialysis and their carers over a 1-year period. We selected a cohort of caregivers that are actively involved with the care of their partners’ dialysis. Quality of Life (QoL) assessed by SF-36 questionnaires showed the patients and carers had impairment of QoL at the start of dialysis. As expected, the baseline QoL Physical Component Scores highly correlated with co-morbidity and assessment of functional capacity. Scores of all QoL domains improved after 1 year and this reached statistical significance for social functioning for both patients and carers. When we compared carers of highly dependent patients (required to perform daily dialysis) with carers of less dependent patients, we noted that the former had a statistically significant worsening of their mental health but other parameters were not different. We have shown that despite increasing the burden for caregivers, with careful selection, education and support, we did not adversely impact on the QoL of carers whilst there was some evidence of improvement, especially in social functioning. This gives reassurance that establishing dependent patients on PD is compatible with a holistic approach to the patients and their families.
Malnutrition and protein energy wasting (PEW) determined by Subjective Global Assessment (SGA) is associated with increased mortality. There is an inverse relationship between body mass and ...overhydration in dialysis patients. Is the predictive accuracy of SGA (for death) independent of hydration status? Can bioimpedance spectroscopy analysis of lean tissue index (LTI) and fat tissue index (FTI) accurately identify dialysis patients with protein energy wasting and increased mortality?
We report an observational study of 455 peritoneal dialysis (PD) patients.
We found that 96 patients (21%) were malnourished (SGA score between 1 and 5), and 192 (42%) had LTI values below 10th centile (age, gender adjusted). FTI was significantly lower in the SGA-defined malnourished cohort. By contrast, there was an inverse relationship between LTI and FTI. Malnourished (by SGA) patients were significantly more overhydrated (P < .0001), but SGA remained highly predictive of survival in multivariate analysis that included hydration status (hazard ratio: 3.12, 95% confidence interval 1.86-5.23, P < .0001). Obesity (patients with the highest 20% FTI) predicted survival (hazard ratio of death was 0.47, 95% confidence interval 0.16-0.85, P < .02) on univariate but not multivariate analysis.
We have confirmed that SGA is an accurate predictor of mortality in PD patients, and its predictive value is independent of the hydration status. Predictive power of SGA was not affected when LTI and FTI were included in multivariate analysis. Patients with low LTI were different from patients with low SGA (associated with high FTI). Sensitivity and specificity of Body Composition Monitor to diagnose patients with low SGA readings were poor (area under the curve for receiver operator characteristics analysis 0.66). The phenomenon of reverse epidemiology (high FTI predicting a survival advantage) was found in our PD cohort.
Introduction:
Cardiovascular mortality remains high among peritoneal dialysis (PD) patients. Several small studies have suggested that PD patients are volume expanded, and as such this could be a ...cardiovascular risk factor. We therefore wished to investigate factors which could lead to extracellular water (ECW) expansion.
Methods:
Retrospective cross-sectional audit of 600 prevalent, adult PD patients attending two tertiary university PD centers, with corresponding assessments of PD adequacy, transport status, and multifrequency bioimpedance measurements of extracellular water to total body water (ECW/TBW).
Results:
600 PD patients, median age 57.5 (46.9–67.9) years, 54% male, 31% diabetic, 47.6% Caucasoid, median PD vintage 16 (3.7–38) months, (64% prescribed icodextrin, 34% hypertonic glucose dialysates, and 74% antihypertensive medications). Mean ECW 15.1±0.2 L, ICW 20±0.2 L, ECW/TBW ratio 0.437±0.007. On multivariate analysis %ECW/TBW was associated with age (F=13.1 β=0.045 p=0.000), number of antihypertensive medications (F=10.3 β=0.43 p=0.001), log CRP (F=12.9 β=1.3 p=0.000), and negatively with serum albumin (F=25 β=-0.22 p=0.000), and residual renal function (urine volume mL F=9.96 β=-0.001 p=0.002) (weekly Kt/Vurine F=8.82 β=-2.05, p=0.003).
Conclusions:
Overhydration as assessed by ECW/TBW is prevalent in adult PD patients, and is associated with loss of residual renal function, inflammation, malnutrition and hypertension – as assessed by antihypertensive medications. As this was a retrospective cross-sectional audit, whether loss of residual renal function, inflammation, and protein energy wasting lead to volume expansion remains to be determined in prospective longitudinal studies.
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