Optimizing peritoneal dialysis catheter placement.

Long-term success of peritoneal dialysis as a kidney replacement therapy requires a well-functioning peritoneal dialysis catheter. With ongoing reductions in infectious complications, there is an increased emphasis on the impact of catheter-related and mechanical complications. There is currently a marked variation in the utilization of various types of catheters (double cuff vs single cuff, coiled tip vs straight tip), methods of catheter insertion (advanced laparoscopic, open surgical dissection, image guided percutaneous, blind percutaneous), timing of catheter insertion, location of catheter placement (pre-sternal v. abdominal) and peri-operative practices. Specialized approaches to catheter placement in clinical practice include use of extended catheters and embedded catheters. Marked variations in patient lifestyle preferences and comorbidities, specifically in high acuity patient populations (polycystic kidney disease, obesity, cirrhosis) necessitate individualized approaches to catheter placement and care. Current consensus guidelines recommend local procedural expertise, consideration of patient characteristics and appropriate resources to support catheter placement and long-term functioning. This review focuses on an overview of approaches to catheter placement with emphasis on a patient-centered approach.

Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023.

The last few years have seen several developments in the field of peritoneal dialysis (PD), including successful use of acute PD, increasing emphasis on home dialysis utilization, and improved understanding of models of peritoneal solute transfer. This installment of AJKD's Core Curriculum in Nephrology emphasizes the latest data available for prevention and management of infectious and noninfectious complications of PD. Through case vignettes, appropriate strategies for diagnosis and care of patients with PD peritonitis are reviewed as well as noninfectious complications evident in clinical practice including complications from increased intra-abdominal pressure, namely pericatheter and abdominal leaks, hernia formation, and complications from pleuroperitoneal communication (hydrothorax). Although rates of incisional hernias and pericatheter leaks have decreased with improved peritoneal dialysis catheter insertion techniques, these mechanical complications continue to be common occurrences and are reviewed via pertinent clinical vignettes which aim to address and discuss common implications of these scenarios. Finally, this Core Curriculum article covers a practical overview of peritoneal dialysis catheter dysfunction.

Vaccination in kidney disease: what did we learn from COVID-19 pandemic.

PURPOSE OF REVIEW: Patients with kidney disease were prioritized during COVID-19 vaccination efforts. Initial data on vaccine seroconversion and efficacy were confounded by heterogeneous vaccination regimens as well as response assessments. Recent data have addressed responses to evolving vaccine regimens, and addressed concerns in this high-risk population. RECENT FINDINGS: mRNA vaccines BNT162b2 (Pfizer/BioNTech), mRNA1273 (Moderna) were the predominant vaccines used in two and three-dose regimens. Although population-based studies show reduced rates of seroconversion in kidney disease cohorts, there continues to be evolving efficacy largely due to emerging variants, and utilization of ongoing vaccine development. Recommendations on vaccination regimens now exclude use of monovalent mRNA vaccines, with bivalent vaccines are now the preferred effective vaccination. Individualization and adjustment of immunosuppressive drugs is recommended for maximal serological response in transplant recipients and patient with autoimmune kidney diseases. SUMMARY: Waning responses to initial vaccination regimen, as well as emerging variants of concern have resulted in multiple dose regimens being investigated in patient with kidney disease. Use of bivalent mRNA vaccine is now recommended for initial as well as subsequent vaccine doses.

Approach to Electrolyte Abnormalities, Prerenal Azotemia, and Fluid Balance.

Volume and electrolyte evaluation and management is seen frequently in primary care practices. Some of the most common abnormalities encountered in outpatient practices are prerenal azotemia, dysnatremias, and altered potassium levels. Perturbations in volume or electrolyte concentrations can lead to serious organ dysfunction as well as hemodynamic collapse. This review focuses on the maintenance and regulation of intravascular volume and electrolytes, specifically sodium and potassium.

Counteracting the Metabolic Effects of Glucose Load in Peritoneal Dialysis Patients; an Exercise-Based Approach.

Glucose-based peritoneal dialysis (PD) solutions are the predominantly used dialysate in PD patients. Glucose absorption has been shown to be associated with several unfavorable metabolic complications. Several studies have shown positive effects of exercise in end-stage renal disease patients. This paper provides an overview of glucose-associated metabolic complications, and proposed exercise regimens to counteract the caloric load associated with glucose absorption.

Role of Doppler echocardiography for cardiac output assessment in Fontan patients.

BACKGROUND: To determine (1) correlation between Doppler stroke volume index (SVI) and cardiac magnetic resonance imaging (CMRI) SVI and (2) association between Doppler SVI and Fontan-associated diseases (FAD) and Fontan failure. METHODS: Review of Fontan patients who underwent same-day CMRI and transthoracic echocardiography (TTE), 2005 to 2015. We defined FAD as cardiac thrombus, protein-losing enteropathy, arrhythmia, and hospitalization for heart failure. Fontan failure was defined as Fontan conversion or revision, heart transplantation or listing, or death. RESULTS: Fifty-three patients with systemic left ventricle (LV) underwent 86 sets of TTE/CMRI. Mean (SD) age 31 (6) years. SVI (45 [16] vs 42 [13] mL/m2), CI (3.0 [1.1] vs 2.8 [0.8] L min-1 m-2), and ejection fraction (53 [4]% vs 51 [5]%) were similar for both modalities (P>.05 for all). Doppler SVI correlated with CMRI (r=0.68; P<.001). Sixteen patients had cirrhosis, and these patients had a higher CI (3.9 [0.9] vs 2.8 [1.0] L min-1 m-2; P<.01). Among the 37 patients without cirrhosis, Doppler SVI <39 mL/m2 was associated with FAD (odds ratio [OR], 2.11; 95% confidence limit, 1.26-3.14; P=.02); Fontan failure was more common in patients with CI was <2.5 L min-1 m-2 (3/9 [33%] vs 0/28 [0%], P=.01). Another 11 patients with systemic right ventricle (RV) underwent 17 sets of TTE/CMRI, mean (SD) age 17 (3) years, and CMRI SVI also correlated with Doppler SVI (r=0.75; P<.001). CONCLUSION: Doppler SVI correlated with CMRI SVI in patients with systemic LV and systemic RV. The association between output measures (SVI and CI) and FAD were seen only in single LV patients (single RV patients not assessed for this outcome due to small numbers). An association between low Doppler CI and Fontan failure was suggested in a small number of single LV patients.

The use of iodinated contrast media in patients with end-stage renal disease.

Iodinated contrast agents are well tolerated in ESRD patients. Certain types of ICM, i.e., LOCM and the nonionic agents are associated with better safety profiles. Current available evidence, although not optimal, does not support the need for additional hemodialysis for ICM removal to preserve residual renal function or to treat other potential toxicities of ICM. However, limiting exposure to ICM is a prudent measure in ESRD patients given ICM's potential toxicity; close monitoring of patients with poor cardiac function is also recommended in subjects receiving higher doses of ICM, especially those receiving HOCM.