Can economic incentives increase the use of home dialysis?

There are advantages to home dialysis for patients, and kidney care programs, but use remains low in most countries. Health-care policy-makers have many levers to increase use of home dialysis, one of them being economic incentives. These include how health-care funding is provided to kidney care programs and dialysis facilities; how physicians are remunerated for care of home dialysis patients; and financial incentives-or removal of disincentives-for home dialysis patients. This report is based on a comprehensive literature review summarizing the impact of economic incentives for home dialysis and a workshop that brought together an international group of policy-makers, health economists and home dialysis experts to discuss how economic incentives (or removal of economic disincentives) might be used to increase the use of home dialysis. The results of the literature review and the consensus of workshop participants were that financial incentives to dialysis facilities for home dialysis (for instance, through activity-based funding), particularly in for-profit systems, could lead to a small increase in use of home dialysis. The evidence was less clear on the impact of economic incentives for nephrologists, and participants felt this was less important than a nephrologist workforce in support of home dialysis. Workshop participants felt that patient-borne costs experienced by home dialysis patients were unjust and inequitable, though participants noted that there was no evidence that decreasing patient-borne costs would increase use of home dialysis, even among low-income patients. The use of financial incentives for home dialysis-whether directed at dialysis facilities, nephrologists or patients-is only one part of a high-performing system that seeks to increase use of home dialysis.

Lower serum magnesium is associated with vascular calcification in peritoneal dialysis patients: a cross sectional study.

BACKGROUND: Coronary artery calcification (CAC) is highly prevalent among dialysis patients and is associated with increased cardiovascular and all cause mortality. Magnesium (Mg) inhibits vascular calcification in animal and in-vitro studies but whether the same effect occurs in humans is uncertain. METHODS: A single centre cross-sectional study of 80 prevalent peritoneal dialysis (PD) patients; on PD only for a minimum of 3 months. A radiologist blinded to patient status calculated their abdominal aortic calcification (AAC) scores on lateral lumbar spine radiographs, a validated surrogate for CAC. RESULTS: Eighty patients provided informed consent and underwent lumbar spine radiography. The mean serum Mg was 0.8 mmol/L (standard deviation 0.2) and mean AAC score 8.9 (minimum 0, maximum 24). A higher serum Mg level was associated with a lower AAC score (R 2 = 0.06, unstandardized coefficient [B] = -7.81, p = 0.03), and remained after adjustment for age, serum phosphate, serum parathyroid hormone, low-density lipoprotein cholesterol, smoking history, and diabetes (model adjusted R 2 = 0.36, serum Mg and AAC score B = -11.44, p = 0.00). This translates to a 0.1 mmol/L increase in serum Mg being independently associated with a 1.1-point decrease in AAC score. CONCLUSIONS: Our findings suggest that Mg may inhibit vascular calcification. If this association is replicated across larger studies with serial Mg and vascular calcification measurements, interventions that increase serum Mg and their effect on vascular calcification warrant further investigation in the PD population.

Meal phosphate variability does not support fixed dose phosphate binder schedules for patients treated with peritoneal dialysis: a prospective cohort study.

BACKGROUND: Removal of phosphate by peritoneal dialysis is insufficient to maintain normal serum phosphate levels such that most patients must take phosphate binders with their meals. However, phosphate 'counting' is complicated and many patients are simply prescribed a specific dose of phosphate binders with each meal. Therefore, our primary objective was to assess the variability in meal phosphate content to determine the appropriateness of this approach. METHODS: In this prospective cohort study, adult patients with ESRD treated with peritoneal dialysis and prescribed phosphate binder therapy were eligible to participate. Participants were excluded from the study if they were unable to give consent, had hypercalcemia, were visually or hearing impaired or were expected to receive a renal transplant during the time of the study. After providing informed consent, patients kept a 3-day diet diary that included all foods and beverages consumed in addition to portion sizes. At the same time, patients documented the amount of phosphate binders taken with each meal. The phosphate content of the each meal was estimated using ESHA Food Processor SQL Software by a registered dietitian. Meal phosphate and binder variability were estimated by the Intra Class Correlation Coefficient (ICC) where 0 indicates maximal variability and 1 indicates no variability. RESULTS: Seventy-eight patients consented to participate in the study; 18 did not complete the study protocol. The patients were 60 (± 17) years, predominately male (38/60) and Caucasian (51/60). Diabetic nephropathy was the most common cause of end stage kidney disease. The daily phosphate intake including snacks ranged from 959 ± 249 to 1144 ± 362 mg. The phosphate ICC by meal: breakfast 0.63, lunch 0.16; supper 0.27. The phosphate binder ICC by meal: breakfast 0.68, lunch 0.73, supper 0.67. CONCLUSION: The standard prescription of a set number of phosphate binders with each meal is not supported by the data; patients do not appear to be adjusting their binders to match the meal phosphate content. An easy to use phosphate counting program that assists the patient in determining the appropriate amount of phosphate binder to take may enhance phosphate control.

Predictors of serum vancomycin levels in peritoneal dialysis-associated peritonitis.

BACKGROUND: Intraperitoneal (IP) vancomycin is often first-line empiric therapy for peritoneal dialysis (PD) peritonitis; however, whether dosing should be adjusted for patient-specific characteristics remains unclear. We sought to identify factors associated with the day 3 vancomycin serum level in patients receiving vancomycin for PD peritonitis. METHODS: Retrospective single-centre adult cohort of 58 patients with PD peritonitis treated with IP vancomycin between January 2016 and May 2022. Linear regression was used to examine the association between day 3 vancomycin level and candidate predictors including age, sex, weight, glomerular filtration rate (GFR), urea and creatinine clearance (total, residual, dialysate), PD modality, peritoneal solute transfer rate and initial vancomycin dose. Logistic regression was used to evaluate the likelihood of achieving a level (≥15 mg/L) associated with these predictor variables. RESULTS: A 2-g loading dose was given in 51 cases, and 38 patients (66%) had a therapeutic day 3 level. Each 5 mg/kg increase in initial vancomycin dose was associated with a 1.38 mg/L (95% confidence interval 0.52, 2.23) increase in day 3 level. Each 1 mL/min increase in GFR was associated with a 0.29 mg/L decrease (95% confidence interval 0.05, 0.52) in day 3 level. The likelihood of achieving a therapeutic level was approximately four times higher with an initial dose of ≥25 mg/kg compared to <25 mg/kg (odds ratio 3.75, 95% confidence interval 1.05, 13.46). CONCLUSIONS: Following an average 2-g vancomycin loading dose for suspected PD peritonitis, one-third of patients were subtherapeutic on day 3. GFR and weight-based dosing were independently associated with day 3 vancomycin level, and their consideration could improve the likelihood of achieving an early therapeutic level.

The Association Between Serum Vancomycin Level and Clinical Outcome in Patients With Peritoneal Dialysis Associated Peritonitis.

Introduction: Intraperitoneal (IP) vancomycin is often first-line empiric therapy and then maintenance therapy for peritoneal dialysis (PD) peritonitis. However, how vancomycin serum levels correlate with clinical outcomes remains unclear. Methods: We conducted a retrospective single-center adult cohort study of 98 patients with PD peritonitis treated with IP vancomycin between January 2016 and May 2022. The association between nadir vancomycin level and cure was evaluated in a logistic regression model, first unadjusted and then adjusted for age, sex, weight, glomerular filtration rate (GFR), and total number of days on PD. Vancomycin was assessed both as a continuous exposure (per 1 mg/l increase) and as a categorical exposure (<15 mg/l vs. ≥15 mg/l). A receiver operating characteristic curve (ROC) was created to explore nadir vancomycin level thresholds in an attempt to identify an optimal target level during treatment. Results: Of the patients, 81% achieved cure, and patients with nadir vancomycin level ≥15 mg/l were 7.5 times more likely to experience cure compared to those with a nadir level <15 mg/l (odds ratio [OR] 7.58, 95% confidence interval [CI] 1.71-33.57, P = 0.008). Weight, GFR, days on PD, sex, and age were not independently associated with outcome. The vancomycin level with the greatest discriminatory capacity for cure on the ROC analysis was 14.4 mg/l. Conclusion: Increasing IP vancomycin serum levels are associated with increased odds of cure; and maintaining vancomycin serum levels above 14-15 mg/l throughout the course of PD peritonitis treatment is likely to improve clinical outcomes.

Hypercreatinemia: think beyond acute kidney injury.

Urinary bladder rupture associated with severe hypercreatinemia is a rare clinical presentation. We herein report a 60-year-old interesting patient who was found to have intraperitoneal bladder rupture and pseudo-renal failure. High rate of suspicion and timely diagnosis is the key in management of this condition, which led to complete recovery in our patient.

Masked Hypertension: Lessons for the Future.

Masked hypertension (MH) is a commonly overlooked phenotype of hypertension in practice. Lifestyle factors and conditioned stress response specific to out of clinic blood pressure readings may be the mechanisms leading to this phenomenon. 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring in an out of office setting are required for its reliable diagnosis. MH has a high risk of progressing to sustained hypertension with comparable cardiovascular and mortality risk. In this review, we discuss current evidence-based perspectives on definition, pathological mechanisms, risk factors, screening, clinical implications, and treatment of MH.

Retrospective study of patients on hybrid dialysis: Single-center data from North America.

Hybrid dialysis involves combining peritoneal and hemodialysis (HD) in patients with end-stage renal disease. Its reported use is quite limited outside of Japan. We present a retrospective review of 18 patients at our center that received this therapy and describe their ultimate disposition. We observed that 39% of the population on hybrid dialysis ultimately transitioned to full in center HD, 28% continue until death, and 33% either transition to home HD or received a transplant. In our center, hybrid dialysis was successful as a bridging therapy or in balancing continuation of dialysis with quality of life among those with a limited prognosis.

Prediction of Progression in Polycystic Kidney Disease Using the Kidney Failure Risk Equation and Ultrasound Parameters.

BACKGROUND: The kidney failure risk equation (KFRE) is a validated risk algorithm for predicting the risk of kidney failure in chronic kidney disease (CKD) patients regardless of etiology. Patients with autosomal dominant polycystic kidney disease (AD-PCKD) experience long disease trajectories and as such identifying individuals at risk of kidney failure would aid in intervention. OBJECTIVE: To examine the utility of the KFRE in predicting adverse kidney outcomes compared with existing risk factors in a cohort of patients with AD-PCKD. METHODS: Retrospective cohort study of AD-PCKD patients referred to a tertiary care center with a baseline kidney ultrasound and a KFRE calculation. Cox proportional hazards were used to examine the association of the KFRE and composite of an eGFR decline of >30% or the need for dialysis/transplantation. Discrimination and calibration of a parsimonious fully adjusted model and a model containing only total kidney volume (TKV) with and without the addition of the KFRE was determined. RESULTS: Of 340 patients with AD-PCKD eligible, 221 (65%) met inclusion criteria. Older age, cardiac disease, cancer, higher systolic blood pressure, albuminuria, lower eGFR and a higher initial TKV were more common in patients with a higher KFRE. A total of 120 events occurred over a median patient follow-up time of 3.2 years. KFRE was independently associated with the composite kidney outcome. Addition of the KFRE significantly improved discrimination and calibration in a TKV only model and a fully adjusted model. CONCLUSIONS: In a diverse, referral population with AD-PCKD, the KFRE was associated with adverse kidney outcomes and improved risk prediction.

CONTEXTE: L'équation KFRE (kidney failure risk equation) est un algorithme validé pour prédire le risque de défaillance rénale chez les patients atteints d'IRC, quelle que soit l'étiologie. Les patients souffrant de polykystose rénale autosomique dominante (ADPKD) connaissent une longue trajectoire de maladie et, à ce titre, le dépistage des individus présentant un risque élevé d'insuffisance rénale pourrait faciliter les interventions. OBJECTIF: Examiner l'efficacité de la KFRE à prédire le risque d'issues rénales défavorables dans une cohorte de patients atteints d'ADPKD comparativement aux facteurs de risque existants. MÉTHODOLOGIE: Cette étude de cohorte rétrospective porte sur des patients atteints d'ADPKD aiguillés vers un centre de soins tertiaires avec une échographie rénale de référence et un calcul de KFRE. Un modèle de risques proportionnels de Cox a été employé pour analyser la relation entre la KFRE et un déclin composite du DFGe supérieur à 30% ou le besoin de dialyse ou de transplantation. La discrimination et la calibration d'un modèle parcimonieux entièrement corrigé et d'un modèle ne tenant compte que du volume rénal total (VRT), avec ou sans l'ajout de la KFRE, ont été déterminées. RÉSULTATS: Des 340 patients atteints d'ADPKD et admissibles à l'étude, 221 (65%) satisfaisaient les critères d'inclusion. Les patients présentant un résultat élevé à la KFRE étaient souvent plus âgés et étaient plus fréquemment atteints des troubles suivants: maladies cardiovasculaires, cancer, pression systolique élevée, albuminurie, faible DFGe et VRT initial plus élevé. Un total de 120 événements sont survenus au cours de la période de suivi médiane (3,2 ans). La KFRE a été associée de façon indépendante à l'issue rénale composite. L'ajout de la valeur de KFRE a considérablement amélioré la discrimination et la calibration des deux modèles employés (VRT seulement et modèle entièrement corrigé). CONCLUSION: L'utilisation de la KFRE a été associée à des issues rénales défavorables et à une meilleure prédiction du risque d'insuffisance rénale dans une population de référence diversifiée composée de patients atteints d'ADPKD.

Performance of the Kidney Failure Risk Equation by Disease Etiology in Advanced CKD.

BACKGROUND AND OBJECTIVES: The kidney failure risk equation is a clinical tool commonly used for prediction of progression from CKD to kidney failure. The kidney failure risk equation's accuracy in advanced CKD and whether this varies by CKD etiology remains unknown. This study examined the kidney failure risk equation's discrimination and calibration at 2 and 5 years among a large tertiary care population with advanced CKD from heterogeneous etiologies. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study included 1293 patients with advanced CKD (median eGFR 15 ml/min per 1.73 m2) referred to the Ottawa Hospital Multi-Care Kidney Clinic between 2010 and 2016, with follow-up clinical data available through 2018. Four-variable kidney failure risk equation scores for 2- and 5-year risks of progression to kidney failure (defined as dialysis or kidney transplantation) were calculated upon initial referral and correlated with the subsequent observed kidney failure incidence within these time frames. Receiver operating characteristic curves and calibration plots were used to measure the discrimination and calibration of the kidney failure risk equation both in the overall advanced CKD population and by CKD etiology: diabetic kidney disease, hypertensive nephrosclerosis, GN, polycystic kidney disease, and other. Pairwise comparisons of the receiver operating characteristic curves by CKD etiology were performed to compare kidney failure risk equation discrimination. RESULTS: The kidney failure risk equation provided adequate to excellent discrimination in identifying patients with CKD likely to progress to kidney failure at the 2- and 5-year time points both overall (2-year area under the curve, 0.83; 95% confidence interval, 0.81 to 0.85; 5-year area under the curve, 0.81; 95% confidence interval, 0.77 to 0.84) and across CKD etiologies. The kidney failure risk equation displayed adequate calibration at the 2- and 5-year time points both overall and across CKD etiologies (Hosmer-Lemeshow P≥0.05); however, the predicted risks of kidney failure were higher than the observed risks across CKD etiologies with the exception of polycystic kidney disease. CONCLUSIONS: The kidney failure risk equation provides adequate discrimination and calibration in advanced CKD and across CKD etiologies.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in peritoneal dialysis: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely used in clinical practice. The safety and efficacy of these agents in peritoneal dialysis (PD) patients are unclear. OBJECTIVES: We conducted a systematic review to study the safety and efficacy of ACEI and ARB use in PD patients. Primary outcome measures were mortality and cardiovascular (CV) events; secondary outcome measures were renal function, proteinuria, hyperkalemia, and erythropoietin requirement at 3 months. METHODS: We searched Medline, EMBASE, Cochrane Central Register of Controlled Trials, trial registry Web sites, reference lists of eligible and review articles, as well as abstracts from the American Society of Nephrology and Canadian Society of Nephrology meetings. To be eligible, studies had to be randomized controlled trials that allocated PD patients to ACEI and ARB use or to placebo or other antihypertensive medications, included adult patients, and reported on at least one of the outcome measures. RESULTS: 418 citations were identified. Four met the eligibility criteria. Three examined CV events and mortality, of which two studies did not have any events. The third showed no statistically significant difference between control and treatment groups in either CV events or mortality: odds ratio 1.56 [95% confidence interval (CI) 0.24 - 10.05] for mortality and odds ratio 1.00 (95% CI 0.19 - 5.40) for CV events. Two studies reported renal function at 12 months and the weighted mean difference was 0.91 mL/minute/1.73 m(2) (95% CI 0.14 - 1.68), favoring ACEI and ARB use. CONCLUSIONS: In PD patients, evidence for the use of ACEIs and ARBs for reduction of mortality and CV events is lacking. Limited data suggest that they slow the loss of residual renal function.

Successful Initiation of Dialysis with a 20-Year-Old Buried Peritoneal Dialysis Catheter: Case Report and Literature Review.

Buried peritoneal dialysis (PD) catheters are typically inserted several weeks or months before the anticipated need for dialysis. Occasionally, renal function unexpectedly stabilizes after the surgery, and a patient may go years before the catheter is needed. We report a case of successful initiation of PD with a twenty-year-old buried catheter. We outline the steps needed to optimize the catheter function and review the benefits of the buried PD catheter.

Characteristics and Outcomes of Exit Sites of Buried Peritoneal Dialysis Catheters: A Cohort Study.

Buried peritoneal dialysis (PD) catheters are placed months before dialysis is needed and the exit site is created when the catheter is dissected out at the initiation of dialysis. In contrast, the exit site of an unburied catheter is created by the surgeon at the time of insertion. We reviewed all patients who initiated PD at our center over a 2-year period. At each clinic visit, exit sites were subjectively classified into standard predefined groups. Outcomes of interest were the frequency of perfect exit sites at 2, 6, and 12 months and rate of exit-site infections (ESIs) at 90 days. One hundred and seventy-seven patients initiated PD during the period of interest, and 169, 157, and 144 remained on PD at 2, 6, and 12 months, respectively. Ninety-three patients had buried catheters, and 76 patients had unburied catheters. Both groups had similar frequency of perfect appearance of exit sites at 2, 6, and 12 months (37/93 vs 41/76 at 2 months; 54/87 vs 43/70 at 6 months; 50/ 81 vs 35/ 63 at 12 months in buried and unburied groups, respectively). More patients with buried catheters had ESIs in the first 3 months (7/93 vs 1/76, p = 0.059). We conclude that exit sites of buried PD catheters do not differ qualitatively from those of unburied catheters. The trend towards more ESIs with buried catheters suggests that there may be clinical consequences of the tissue trauma at time of exteriorization.

End-Stage Kidney Disease in Patients With Autosomal Dominant Polycystic Kidney Disease: A 12-Year Study Based on the Canadian Organ Replacement Registry.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease, with afflicted patients often progressing to end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT). As the timelines to ESKD are predictable over decades, it follows that ADPKD patients should be optimized regarding kidney transplantation, home dialysis therapies, and vascular access. OBJECTIVES: To examine the association of kidney transplantation, dialysis modalities, and vascular access in ADPKD patients compared with a matched, non-ADPKD cohort. SETTING: Canadian patients from 2001-2012 excluding Quebec. PATIENTS: All adult incident ESKD patients who received dialysis or a kidney transplant. MEASUREMENTS: ADPKD as defined by the treating physician. METHODS: ADPKD and non-ADPKD patients were propensity score (PS) matched (1:4) using demographics, comorbidities, and lab values. Conditional logistic regression and Cox proportional hazards models were used to examine associations with kidney transplantation (preemptive or any), dialysis modality (peritoneal, short daily, home, or in-center hemodialysis [HD]), vascular access (arteriovenous fistula [AVF], permanent or temporary central venous catheter [CVC]), and dialysis survival. RESULTS: We matched 2120 ADPKD (99.9%) with 8283 non-ADPKD with no significant imbalances between the groups. ADPKD was significantly associated with preemptive kidney transplantation (odds ratio [OR] = 7.13, 95% confidence interval [CI] = 5.74-8.87), any kidney transplant (OR = 2.37, 95% CI = 2.14-2.63), and initial therapy of nocturnal daily HD (OR = 2.74, 95% CI = 1.38-5.44), whereas in-center intermittent HD was significantly less likely in the ADPKD population (OR = 0.59, 95% CI = 0.54-0.65). There was no difference in peritoneal dialysis (PD) as initial RRT but lower use of any PD among the ADPKD group (OR = 0.85, 95% CI = 0.77-0.95). ADPKD patients were significantly more likely to have an AVF (OR = 3.25, 95% CI = 2.79-3.79) and less likely to have either a permanent (OR 0.68, 95% CI 0.59-0.78) or temporary (OR = 0.49, 95% CI = 0.41-0.59) CVC as compared with the non-ADPKD cohort. Survival on either in-center HD or PD was better for ADPKD patients (HD: hazard ratio [HR] 0.48, 95% CI 0.44-0.53; PD: HR 0.73, 95% CI 0.60-0.88). LIMITATIONS: Conservative care patients were not captured; despite PS matching, the possibility of residual confounding remains. CONCLUSIONS: ADPKD patients were more likely to receive a kidney transplant, use home HD, dialyze with an AVF, and have better survival relative to non-ADPKD patients. Conversely, they were less likely to receive PD either as initial therapy or anytime during ESKD. This may be attributed to higher transplantation or clinical decision-making processes susceptible to education and intervention.

CONTEXTE: La maladie polykystique rénale autosomique dominante chez l'adulte (MPRAD) est la maladie rénale héréditaire la plus fréquente. Les patients qui en sont atteints développent souvent une insuffisance rénale terminale (IRT) et nécessitent une thérapie de remplacement rénal (TRR). Étant donné que l'évolution vers l'IRT est prévisible sur plusieurs décennies, on devrait préparer la voie vers la greffe rénale, la dialyse à domicile et l'accès vasculaire pour les patients atteints de la MPRAD. OBJECTIFS: L'étude visait à comparer l'association avec la greffe rénale, les modalités de dialyse et l'accès vasculaire entre les patients atteints et non atteints. CADRE DE L'ÉTUDE: L'étude s'est tenue entre 2001 et 2012 auprès de patients canadiens hors Québec. PATIENTS: Ont été inclus dans l'étude tous les patients adultes nouvellement atteints d'IRT qui ont reçu de la dialyse ou une greffe rénale. MESURES: La maladie polykystique autosomique dominante des reins, telle que diagnostiquée par le médecin traitant. MÉTHODOLOGIE: On a effectué l'appariement par scores de propension des patients MPRAD avec les sujets non-MPRAD (ratio 1:4) selon leur profil démographique, leurs comorbidités et leurs résultats de laboratoire. Avec des modèles conditionnels de régression logistique et de risques proportionnels de Cox, on a déterminé l'association avec la greffe rénale (préventive et tous types confondus), la modalité de dialyse (péritonéale, quotidienne courte, à domicile ou en centre), l'accès vasculaire (fistule artérioveineuse [FAV], cathéter veineux central [CVC] temporaire ou permanent) et de la survie du patient dialysé. RÉSULTATS: Nous avons jumelé 2 120 patients MPRAD (99,9 %) à 8 283 patients non-MPRAD. Les deux groupes ne présentaient aucun déséquilibre notable. La MPRAD a été associée de façon significative à la greffe rénale préemptive (RC : 7,13; IC 95 % : 5,74-8,87), à tout type de greffe rénale (RC : 2,37; IC 95 % : 2,14-2,63) et à une thérapie initiale par hémodialyse quotidienne nocturne (RC : 2,74; IC 95 % : 1,38-5,44); alors que l'hémodialyse intermittente en centre s'est avérée beaucoup moins probable chez les patients MPRAD (RC : 0,59; IC 95 % : 0,54-0,65). Aucune différence n'a été observée en ce qui concerne le recours à la dialyse péritonéale (DP) comme TRR initiale, mais l'utilisation de la DP chez les patients du groupe MPRAD était inférieure (RC : 0,85; IC 95 % : 0,77-0,95). Pour ce qui est de l'accès vasculaire, les patients MPRAD étaient significativement plus susceptibles d'avoir recours à une FAV (RC : 3,25; IC 95 % : 2,79-3,79) et moins enclins à choisir le CVC permanent (RC : 0,68; IC 95 % : 0,59-0,78) ou temporaire (RC : 0,49; IC 95 % : 0,41-0,59) que le groupe témoin. Les perspectives de survie des patients, que ce soit avec l'hémodialyse (HD) en centre ou avec la DP, étaient meilleures pour le groupe MPRAD (RR : 0,48; IC 95 % : 0,44-0,53 pour l'HD; RR : 0,73; IC 95 % : 0,60-0,88 pour la DP). LIMITES DE L'ÉTUDE: Les patients suivis pour des soins conservateurs n'ont pas été pris en compte; et bien que nous ayons jumelé les sujets par scores de propension, un facteur confusionnel résiduel pourrait subsister. CONCLUSION: Les patients atteints de la MPRAD sont plus susceptibles de recourir à une greffe rénale, à l'hémodialyse à domicile et à un accès vasculaire par FAV; ils ont aussi de meilleures chances de survie que les patients non-MPRAD. Inversement, ils étaient moins susceptibles d'être traités par dialyse péritonéale, tant comme traitement initial qu'à n'importe quel autre moment en IRT. Ceci pourrait être attribuable au plus grand nombre de greffes ou à des processus décisionnels cliniques davantage portés vers la formation et l'intervention.

The Risk of Adverse Events in Patients With Polycystic Kidney Disease With Advanced Chronic Kidney Disease.

BACKGROUND: Polycystic kidney disease (PKD) leads to progressive chronic kidney disease (CKD) with a subsequent risk of adverse events such as cardiac disease, infections, end-stage kidney disease (ESKD), and mortality. OBJECTIVES: To determine the risks of CKD-related adverse outcomes in patients with PKD compared with patients without PKD. SETTING: Canadian study of prediction of death, dialysis and interim cardiovascular events (CanPREDDICT) was a prospective pan-Canadian cohort study from 2008-2013 involving 28 facilities with adjudicated outcomes. PATIENTS: Adult CKD patients (estimated glomerular filtration rate [eGFR] = 15-45 mL/min/1.73 m2) under the care of a nephrologist. MEASUREMENTS: Polycystic kidney disease as identified by the treating physician. METHODS: Patients with PKD (PKD) and non-PKD were propensity score (PS) matched (1:4) using demographics, comorbidities, and laboratory values. We used conditional Cox proportional hazards models to examine the risk of cardiac disease (defined as coronary artery disease or congestive heart failure), infection, ESKD, or all-cause mortality in patients with PKD compared with no PKD. RESULTS: Among a total of 2370 patients, 105 with PKD were matched with 416 without PKD with a baseline mean age and eGFR of 62.6 years and 27.8 mL/min, respectively. During 1680 person-years of follow time (median follow-up: 3.8 years), there were a total of 43 cardiac, 83 ESKD, 117 infectious, and 39 all-cause mortality events. PKD was associated with a higher risk of cardiac events (9.5% vs 7.9%, hazard ratio [HR] = 1.46, 95% confidence interval [CI] = 1.04-2.04) and ESKD (25.7% vs 13.5%, HR = 2.00, 95% CI = 1.33-3.01), and with similar risks for infection (21.9% vs 22.6%, HR = 1.16, 95% CI = 0.75-1.82) or all-cause mortality (6.7% vs 7.7%, HR = 0.87, 95% CI = 0.40-1.91) compared with non-PKD. There were no differences in the types of infections (urinary, respiratory, hematologic, or other) between the 2 groups (P = .585). CONCLUSIONS: Patients with PKD with advanced CKD are at a potentially higher risk of ESKD and cardiac events compared with patients without PKD. These findings, if confirmed in larger cohorts, suggest that monitoring and treatment for adverse outcomes in patients with PKD, especially related to cardiac disease, may be beneficial.

CONTEXTE: La maladie polykystique des reins (MPR) mène à l'insuffisance rénale chronique (IRC) progressive, laquelle augmente à son tour la probabilité d'apparition de pathologies subséquentes, notamment cardiopathie, infections et insuffisance rénale terminale (IRT), ainsi que le risque de décès du patient. OBJECTIFS DE L'ÉTUDE: L'étude visait à évaluer le risque de survenue d'une pathologie associée à l'IRC chez les patients atteints d'une MPR en comparaison avec les patients non atteints d'une MPR. CADRE ET TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte prospective pancanadienne, la CanPREDDICT (Canadian Study of Prediction of Death, Dialysis and Interim Cardiovascular Events). L'étude s'est tenue entre 2008 et 2013 au sein de 28 établissements, et les issues étaient rigoureusement définies et jugées par un comité. PARTICIPANTS: Des patients adultes atteints d'IRC (DFGe = 15-45 mL/min/1,73 m2) suivis par un néphrologue. MESURE: La maladie polykystique des reins (MPR) telle que diagnostiquée par le médecin traitant. MÉTHODOLOGIE: Le jumelage des patients atteints de la maladie polykystique rénale autosomique dominante (MPRAD) avec les sujets contrôles s'est fait sur la base du score de propension dans un rapport d'un pour quatre (1:4). Les autres critères employés pour le jumelage étaient le profil démographique des patients, leurs comorbidités et leurs résultats de laboratoire. Des modèles conditionnels des risques proportionnels de Cox ont été utilisés pour évaluer le risquei) de développer une cardiopathie (coronopathie ou insuffisance cardiaque congestive) ouii) une infection ouiii) une évolution vers l'IRT, de même queiv) le risque de mortalité (toutes causes confondues), dans les deux groupes de patients. RÉSULTATS: Parmi les 2 370 participants, 105 atteints de MPR ont été jumelés à 416 patients non atteints. L'âge initial moyen des participants était de 62,6 ans et leur DFGe moyen se situait à 27,8 mL/min/1,73 m2. Au cours des 1 680 années-personnes de suivi (suivi moyen de 3,8 ans par patient), on a répertorié 43 cas de cardiopathie et 117 cas d'infection; 83 patients ont développé une IRT et 39 sont décédés (toutes causes confondues). La MPR a été associée à un risque plus élevé de cardiopathie (9,5 % [MPR] c. 7,9 % [non MPR]; RR : 1,46; IC à 95 % : 1,04-2,04) et d'évolution vers l'IRT (25,7 % [MPR] c. 13,5 % [non MPR]; RR : 2,00; IC à 95 % : 1,33-3,01) par rapport aux patients non atteints. Les risques d'infection (21,9 % [MPR] c. 22,6 % [non MPR]; RR : 1,16; IC à 95 % : 0,75-1,82) et de mortalité toutes causes confondues (6,7 % [MPR] c. 7,7 % [non MPR]; RR : 0,87; IC à 95 %; 0,40-1,91) se sont toutefois avérés similaires dans les deux groupes. De plus, aucune différence n'a été observée selon le type d'infection (urinaire, respiratoire, hématologique ou autre) entre les deux groupes (P = 0,585). CONCLUSION: Les patients atteints d'un stade avancé d'IRC et d'une MPR sont plus à risque d'évoluer vers l'IRT ou de développer une cardiopathie que les patients non atteints d'une MPR. Ces résultats, s'ils sont confirmés par des études sur cohortes plus nombreuses, suggèrent que le suivi et le traitement des pathologies associés à la MPR sur la santé des patients, particulièrement la cardiopathie, pourraient s'avérer bénéfiques.

Individual patient variability with the application of the kidney failure risk equation in advanced chronic kidney disease.

The Kidney Failure Risk Equation (KFRE) predicts the need for dialysis or transplantation using age, sex, estimated glomerular filtration rate (eGFR), and urine albumin to creatinine ratio (ACR). The eGFR and ACR have known biological and analytical variability. We examined the effect of biological and analytical variability of eGFR and ACR on the 2-year KFRE predicted kidney failure probabilities using single measure and the average of repeat measures of simulated eGFR and ACR. Previously reported values for coefficient of variation (CV) for ACR and eGFR were used to calculate day to day variability. Variation was also examined with outpatient laboratory data from patients with an eGFR between 15 and 50 mL/min/1.72 m2. A web application was developed to calculate and model day to day variation in risk. The biological and analytical variability related to ACR and eGFR lead to variation in the predicted probability of kidney failure. A male patient age 50, ACR 30 mg/mmol and eGFR 25, had a day to day variation in risk of 7% (KFRE point estimate: 17%, variability range 14% to 21%). The addition of inter laboratory variation due to different instrumentation increased the variability to 9% (KFRE point estimate 17%, variability range 13% to 22%). Averaging of repeated measures of eGFR and ACR significantly decreased the variability (KFRE point estimate 17%, variability range 15% to 19%). These findings were consistent when using outpatient laboratory data which showed that most patients had a KFRE 2-year risk variability of ≤ 5% (79% of patients). Approximately 13% of patients had variability from 5-10% and 8% had variability > 10%. The mean age (SD) of this cohort was 64 (15) years, 36% were females, the mean (SD) eGFR was 32 (10) ml/min/1.73m2 and median (IQR) ACR was 22.7 (110). Biological and analytical variation intrinsic to the eGFR and ACR may lead to a substantial degree of variability that decreases with repeat measures. Use of a web application may help physicians and patients understand individual patient's risk variability and communicate risk (https://mccudden.shinyapps.io/kfre_app/). The web application allows the user to alter age, gender, eGFR, ACR, CV (for both eGFR and ACR) as well as units of measurements for ACR (g/mol versus mg/g).

Successful Treatment of PD Peritonitis Due to Morganella morganii Resistant to Third-Generation Cephalosporins - A Case Report.

Morganella morganii is a rare cause of peritonitis in patients on peritoneal dialysis (PD). Most of the reported cases have resorted to a switch to hemodialysis. We herein report a case of peritonitis due to M. morganii resistant to third-generation cephalosporins, which was treated successfully with intraperitoneal (IP) tobramycin followed by oral ciprofloxacin. Early microbiologic diagnosis is essential in the treatment of peritonitis from rare microorganisms such as Morganella morganii, and appropriate antibiotic therapy is the key to avoiding catheter loss and subsequent switch to hemodialysis.

Technique survival with Serratia peritonitis.

Despite a decreasing incidence, peritonitis remains an important cause of peritoneal dialysis (PD) technique failure and transfer to hemodialysis. Infection with Serratia spp. has been suggested to be associated with a poor technique outcome in PD. We examined the data at our center to see if patients with Serratia peritonitis had a similar poor outcome. In this retrospective study, we reviewed all PD patients who presented at our center with peritonitis from January 1996 to December 2003. The case records of patients in whom the infecting organism was identified as Serratia were evaluated. We recorded age at the time of peritonitis and at the start of PD, sex, presence of diabetes mellitus, PD modality at the time of peritonitis, and duration of PD before the onset of peritonitis. For each episode of peritonitis, we recorded the type and duration of antibiotic therapy and the outcome. Over the study period, 52% of all peritonitis episodes involved gram-positive organisms; 29%, gram-negative organisms; and 19%, other organisms. Serratia spp. accounted for 16 episodes (3.68%). These 16 episodes of peritonitis occurred in 12 patients, with 3 repeat infections and 1 relapsing infection. The distribution between the sexes was equal, and the median age at diagnosis was 67 years (range: 37-79 years). Four patients with diabetes accounted for 6 of the 16 episodes (37.5%). In 7 episodes (43.8%), a Serratia exit-site infection preceded the peritonitis. In 4 episodes, catheter removal was required. A fifth patient developed sepsis and died. Technique survival was therefore 68.8% (11 of 16 episodes). We also compared the outcomes of different initial antibiotic regimens. With an initial regimen based on cefazolin-ceftazidime, as suggested in the 2000 guidelines of the International Society for Peritoneal Dialysis, technique survival was 60% (3 of 5 episodes). When the initial regimen included an aminoglycoside, the technique survival was 80% (8 of 10 episodes). Serratia-induced peritonitis was associated with a technique survival of 68.8% at our center.