Peritoneal dialysis-related infections in elderly patients.

This review outlines the epidemiology, characteristics, risk factors, and prognosis of peritoneal dialysis (PD)-related peritonitis, PD catheter-related infections, and the effects of assisted PD in elderly patients from the Japanese perspective. Based on the literature, the incidence of peritonitis is likely to be higher in elderly patients than in younger patients. The most frequent causative bacteria in elderly patients are Gram-positive bacteria, as in adult PD patients, most commonly due to transcatheter infection. However, elderly patients may have difficulty recognizing cloudy drainage fluid due to decreased visual acuity. Hypokalemia, the use of gastric acid suppressants, prophylactic antibiotic use before endoscopy, biocompatible fluids and hypoalbuminemia considered modifiable risk factors for peritonitis. However, the mechanism by which treatment of hypokalemia prevents peritonitis is unknown. Currently, the relationship between gastric acid suppression therapy and peritonitis in elderly patients is debatable, with no evidence to strongly recommend uniform discontinuation of gastric acid suppression therapy. Exit-site infection (ESI) is a major risk factor for the development of peritonitis, and appropriate prevention and management of ESI may reduce infection-related hospitalizations in PD patients. Currently, no randomized, controlled trials have verified the effectiveness of antibiotic application for ESI in Japan, but results from other countries are awaited. In assisted PD, it is extremely important that family members, caregivers, and nurses who support the procedure receive sufficient education and training from medical professionals familiar with PD. Early detection and treatment of PD-related infections are required because the risk of death increases in elderly patients.

Upward-directed exit-site of the swan-neck catheter and "Easy-to-disinfect the backside area of exit-site" may prevent PD complications.

BACKGROUND: Upward-directed exit-site has been believed to be the worst for frequent ESI by an old retrospective study using straight catheters. No comparison study of 3 exit-site directions using swan-neck catheter has been performed regarding which direction is the best for our endpoints, Easy-to-see the backside area of exit-site: ESBE, Easy-to-disinfect the backside area of exit-site: EDBE, reduction of both exit-site infection (ESI), symptomatic catheter dislocation and peritonitis. METHODS: We assessed the relationship of exit-site direction with our endpoints in a quantitative cross-sectional, multicentered questionnaire survey. Patients who received either non-surgical catheter implantation or exit-site surgery were excluded. RESULTS: The numbers (percentage) of exit-site directions in included 291 patients were upward 79 (26.0), lateralward 108 (37.5) and downward 105 (36.5). Cochran-Armitage analysis showed a significant step-ladder increase in the prevalence of ESI as the direction changed from upward to lateralward to downward (0.15 ± 0.41, 0.25 ± 0.54, 0.38 ± 0.69 episodes/patient-year, p = 0.03). Multivariable regression analysis revealed the upward exit-site independently associates with both higher frequency of ESBE (OR 5.55, 95% CI 2.23-16.45, p < 0.01) and reduction of prevalence of ESI (OR 0.55, 95%CI 0.27-0.98, p = 0.04). Positive association between the prevalence of symptomatic catheter dislocation and ESI (OR 2.84, 95% CI 1.27-7.82, p = 0.01), and inverse association between EDBE and either prevalence of symptomatic catheter dislocation (OR 0.27, 95% CI 0.11-0.72) or peritonitis (OR 0.48, 95% CI 0.23-0.99) observed. CONCLUSION: Upward-directed swan-neck catheter exit-site may be the best for both ESBE and prevention of ESI. EDBE may reduce catheter dislocation and peritonitis. Symptomatic catheter dislocation may predict ESI.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study.

BACKGROUND: Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD. METHODS: This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3-5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics. RESULTS: Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy. CONCLUSION: Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3-5. TRIAL REGISTRATION: UMIN00004999.

Association between inpatient education program for patients with pre-dialysis chronic kidney disease and new-onset cardiovascular disease after initiating dialysis.

BACKGROUND: The association between inpatient education programs (IEPs) for patients with pre-dialysis chronic kidney disease (CKD) and new-onset cardiovascular disease (CVD) after initiating dialysis is unclear. METHODS: We conducted a retrospective cohort study between January 1, 2011 and December 31, 2018, evaluating CKD patients who were divided into two groups based on whether or not they participated in IEPs. The primary outcome was a new-onset CVD event after initiating dialysis. Cumulative incidence function was used to describe new-onset CVD considering the competing outcome of death. Additionally, Cox proportional hazards models were used to estimate the hazard ratio of new-onset CVD between IEP and non-IEP groups. RESULTS: Of the 493 patients, 131 (26.6%) patients had participated in IEPs. The IEP group had a significantly longer duration of CKD management by nephrologists (median 142 vs. 115 days, P = 0.007), lower rate of emergency hospital admissions (9.9% vs. 27.1%, P < 0.001), better ability to perform activities of daily living (Grade J; 81.6% vs. 69.1%, P = 0.046), higher rate of pre-placement of permanent vascular access or peritoneal dialysis catheters (82.4% vs. 59.4%, P < 0.001), and a higher serum albumin level at the beginning of dialysis (3.5 ± 0.5 vs. 3.3 ± 0.6 g/dL, P < 0.001). The cumulative incidence of new-onset CVD at three years after initiating dialysis in the IEP and non-IEP groups was 16.9% and 22.5%, respectively. The hazard ratio for new-onset CVD after initiating dialysis in the IEP group was 0.63 (95% CI: 0.41-0.97, P = 0.036). CONCLUSION: IEPs were associated with a lower rate of new-onset CVD after initiating dialysis.

Accidental removal of dialysis central venous catheter inserted for blood purification therapy: a single-center study.

BACKGROUND: Dialysis central venous catheters (DCs) are used for various blood purification therapies. Accidental removal of a DC is a potentially life-threatening event. However, the risk factors associated with accidental removal have rarely been discussed in the literature. METHODS: We performed a 5 year retrospective, single-center, cohort study of patients who were admitted to the ward other than intensive care units and were inserted DCs. We compared patient characteristics between patients who used DCs with and without a history of accidental removal. RESULTS: There were 17 cases of accidental removal (3.5%) out of 489 DC insertions during the observation period. There was no significant difference between patients with and without accidental removal in terms of age, sex, reason for DC insertion, catheter type, or insertion site. The presence of dementia was 35 and 11% (p = 0.006), and that of delirium was 88 and 13% (p < 0.0001) in those with and without accidental removal, respectively. The median days from insertion to accidental removal were 5 (range 0-21) days, and removal occurred mainly at night (71%). One patient with accidental removal developed hemorrhagic shock, but there no deaths occurred due to accidental removal. CONCLUSIONS: The present findings suggest that to prevent accidental removal, sufficient attention should be paid to delirium that occurs after admission as well to pre-existing dementia at the time of admission. As accidental removal occurs most commonly early after insertion and at night, special attention should be paid during these periods.

Impact of inpatient educational programs on mortality after the start of dialysis therapy.

BACKGROUND: Although inpatient educational programs (IEPs) for non-dialysis-dependent chronic kidney disease (CKD) have been reported to slow disease progression, their legacy effect on prognosis after the start of dialysis therapy is unclear. METHODS: Consecutive patients who started dialysis therapy between January 1, 2011 and December 31, 2018 were included in a single-center, retrospective, observational study. The patients were divided into two groups according to whether or not they participated in IEPs before dialysis introduction, and their background characteristics were compared. The survival rate for each group was calculated using the Kaplan-Meier method and compared by the log-rank test. Furthermore, the hazard ratio (HR) of IEP participation adjusted for confounding factors associated with mortality was calculated using Cox regression analysis. RESULTS: Of the 490 subjects (median age 69 years, 71.0% male), 129 patients (26.3%) participated in the IEP. At the start of dialysis, the IEP group had higher serum albumin (3.5 vs. 3.3 g/dL, p < 0.001) and lower serum total cholesterol levels (151 vs. 166 mg/dL, p = 0.0076) and the proportion of patients with independence in their daily living activities was high (p = 0.034). The median observation period was 3.4 years, during which 153 patients (31.2%) died. The 5-year survival rates were 81.0 and 61.5% in the IEP and non-IEP groups, respectively (p = 0.0038). Cox regression analysis revealed a HR for IEP of 0.57 (95% Confidence interval 0.37-0.88, p = 0.011). CONCLUSION: IEPs for CKD patients are associated with a more favorable prognosis after the start of dialysis.

Fact-finding survey on health literacy among Japanese predialysis chronic kidney disease patients: a multi-institutional cross-sectional study.

BACKGROUND: Low health literacy (HL) has been associated with poor chronic disease management and adverse outcomes. However, reports on HL in predialysis chronic kidney disease (CKD) patients are limited in Japan. METHODS: From August 2019 to February 2020, the European Health Literacy Survey (Japanese version) and a patient background survey (highest level of education, income, social activities, and exercise habit) were conducted on adult predialysis CKD patients. We compared clinical parameters in two groups according to the average HL score of a healthy Japanese population. In addition, a median value of 42 items was used as a cutoff for extracting CKD patient background factors associated with HL since HLS-EU-Q47 included five items related to physical activity and exercise. RESULTS: Valid responses were received from 200 patients. Median general HL index was 25.2 points. The high-HL group (≥ 25.3 points) showed a low proportion of male (56.7% vs. 70.9%, p = 0.038), high social activities (69.1% vs. 48.5%, p = 0.003), and high exercise habit (36.1% vs. 13.6%, p < 0.001). In the multivariate analysis, social activity [OR (95% CI); 2.12 (1.16-3.89), p = 0.015] and exercise habit [OR (95% CI); 2.39 (1.16-4.90), p = 0.018] were extracted as the only significant variable. CONCLUSIONS: HL in Japanese predialysis CKD patients was associated with high social activity and exercise habit.

Seasonality of peritoneal dialysis-related peritonitis in Japan: a single-center, 10-year study.

BACKGROUND: Peritonitis is one of the major complications of peritoneal dialysis (PD). Although several reports have indicated seasonality of peritonitis, the observation periods were short, and there were no reports from Japan. Therefore, the purpose of this study was to investigate the long-term seasonality of peritonitis in a single institution in Japan. METHODS: Of 126 patients who started PD in our hospital between January 1, 2009, and December 31, 2018, 25 patients (15 men, 10 patients with diabetes) developed peritonitis with a total of 42 episodes. The median age at onset was 63 years, and the median duration from the start of PD to the onset of peritonitis was 22 months. RESULTS: The 10-year incidence of peritonitis was 0.12 episodes per patient-year. Compared with the reference season of winter (December-February), the incidence rate ratios (95% confidence interval) for spring (March-May), summer (June-August), and autumn (September-November) were 1.75 (0.65-4.75), 1.56 (0.57-4.31), and 2.42 (0.94-6.23), respectively. In addition, no seasonality of Gram-positive and Gram-negative organisms was observed. CONCLUSION: No seasonality was evident in the incidence of PD-related peritonitis in our hospital over a 10-year period. These findings suggest that the development of peritonitis in Japanese PD patients is not affected by seasonality.

Inpatient educational program delays the need for dialysis in patients with chronic kidney disease stage G5.

BACKGROUND: Inpatient educational programs (IEPs) for patients with chronic kidney disease (CKD) decrease CKD progression. However, patients with end-stage kidney disease who started dialysis during the observation period were excluded from previous studies. METHODS: After adjusting for age, sex, baseline estimated glomerular filtration rate, hemoglobin level, and the presence of diabetes mellitus using 1:1 propensity score matching (caliper width of 0.008) in the groups that did and did not receive an IEP, we compared the time period from the beginning of CKD stage G5 to the start of dialysis and patient characteristics at the start of dialysis. RESULTS: Prior to matching, 41 patients received an IEP and 260 did not. After propensity score matching, the 41 patients who received an IEP had a longer period from the beginning of stage G5 to the start of dialysis (344 vs. 257 days, P = 0.011), shorter hospitalization period upon the start of dialysis (14 vs. 18 days, P = 0.015) compared with the 41 patients who did not receive an IEP. In addition, the proportion of patients with a planned start of dialysis tended to be higher in the IEP group (95.1 vs. 83.0%, P = 0.077). CONCLUSION: An IEP may delay the start of dialysis in patients with end-stage kidney disease, contribute to better preparation of vascular access placement and the smoother start of dialysis.

An inpatient educational program for chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is a significant health problem in Japan, and prevention programs to slow disease progression are necessary. In this study, we evaluated the effectiveness of a 1-week inpatient education program, delivered during the predialysis stage of CKD, in slowing the deterioration in renal function over the subsequent 2 years, and identified factors influencing the program's effectiveness. METHODS: We retrospectively evaluated the estimated glomerular filtration rate (eGFR) of 105 consecutive patients who completed the program, at the following time points: 6 months prior to program initiation, at program initiation and, at 6, 12, 18, and 24 months after the program. To identify factors predictive of program effectiveness, we classified patients into a Responder and Non-responder group. RESULTS: In comparison with the rate of deterioration in renal function (mL/min/1.73 m2/year) before admission, the rate slowed at 6, 12, 18 and 24 months after discharge (all p < 0.01). A urinary protein (UP) level <0.5 g/gCr and CKD stages 4-5 were predictive of a slowing of CKD progression after the education program. CONCLUSIONS: Although the effectiveness of our program declined over time, it did produce an overall slowing in the rate of renal function deterioration over the 2-year period of observation after discharge. This slowing of CKD progression was more pronounced in patients with low UP levels, indicating that education programs should be considered while these levels are still low. Furthermore, the program still offers benefits to patients with CKD stages 4-5.

The impact of the combination of kidney and physical function on cognitive decline over 2 years in older adults with pre-dialysis chronic kidney disease.

BACKGROUND: No longitudinal study has investigated the impact of combination of kidney function (KF) and physical function (PF) on cognitive decline in these patients. METHODS: We conducted a 2-year prospective cohort study enrolling 131 patients ≥ 65 years with pre-dialysis chronic kidney disease (CKD). We assessed cognitive function with the Japanese version of the Montreal Cognitive Assessment (MoCA-J). We calculated %MoCA-J based on the rate of change between baseline and follow-up MoCA-J scores, and defined cognitive decline over 2 years as a %MoCA-J of less than the first quartile value. We defined eGFR ≥ 30 as mild-to-moderate and eGFR < 30 mL/min per 1.73 m2 as severe. In addition, low PF was defined as low handgrip strength (< 26 for men and < 18 kgf for women) and/or low gait speed (< 0.8 m/s). Patients were classified into four groups: group 1, patients with mild-to-moderate impairment in KF and high PF; group 2, with mild-to-moderate impairment in KF and low PF; group 3, with severe impairment in KF and high PF; and group 4, with severe impairment in KF and low PF. RESULTS: Eighty-four patients completed follow-up assessment. Multivariate logistic regression analysis showed that the combination of severe impairment in KF and low PF was significantly associated with cognitive decline (odds ratio 5.73). However, no significant cognitive decline was observed in patients with either severe impairment in KF or low PF alone. CONCLUSIONS: We may need to focus on maintaining PF in older patients with advanced CKD may help to prevent cognitive decline.

Mild cognitive impairment in older adults with pre-dialysis patients with chronic kidney disease: Prevalence and association with physical function.

AIM: Chronic kidney disease (CKD) is a risk factor for declining cognitive and physical function. However, the prevalence of mild cognitive impairment (MCI) and its relationship with physical function is not clear. Therefore, our aim was to evaluate the prevalence of MCI and the relationship between MCI and physical function among older adults with pre-dialysis CKD. METHODS: We conducted a cross-sectional study of 120 patients, aged ≥65 years (mean age, 77.3 years), with pre-dialysis CKD but without probable dementia (Mini Mental State Examination <24). MCI was evaluated using the Japanese version of the Montreal Cognitive Assessment (MoCA-J). For analysis, patients were classified into two cognitive function groups: normal (MoCA-J ≥ 26) and MCI (MoCA-J < 26). Physical, clinical, and biochemical parameters were compared between the groups. Logistic and linear regression analyses were used to evaluate the specific association between cognitive and physical function. RESULTS: Seventy-five (62.5%) patients belonged to the MCI group. Significant differences between the two groups were identified for gait speed, balance, age, and haemoglobin concentration. After adjustment for covariates, only gait speed was significantly associated with MCI (odds ratio, 0.06; 95% confidence interval, 0.009-0,411). CONCLUSION: The prevalence of MCI among older adults with pre-dialysis CKD was as high as 62.5%. The association between MCI and reduced gait speed supports the possible interaction between physical and cognitive functions and the need for early screening.

Combined cyclosporine and prednisolone therapy using cyclosporine blood concentration monitoring for adult patients with new-onset minimal change nephrotic syndrome: a single-center pilot randomized trial.

BACKGROUND: Minimal change nephrotic syndrome (MCNS) responds well to steroids, but some patients show frequent relapses. Long-term steroid administration leads to various adverse effects. We previously reported the effectiveness in refractory nephrosis patients of administrating microemulsified CyA (ME-CyA) once before meals and setting the target value of the CyA blood concentration at 2 h after ME-CyA administration (C2) to 600-1200 ng/ml. On this trial we evaluate the effectiveness and safety of ME-CyA for suppressing relapse of adult new-onset MCNS patients using C2 monitoring. METHODS: Adult new-onset MCNS patients were randomly allocated to a ME-CyA + prednisolone group ("CyA + PSL") (n = 11) and a PSL-alone group ("PSL-alone") (n = 10). The drug administration period was 18 months followed by an observation period of 12 months. RESULTS: The duration of remission tended to be longer in CyA + PSL with C2 >600 ng/ml than in PSL-alone (P = 0.112). The relapse rate up to 18 months was significantly lower in CyA + PSL with C2 >600 ng/ml than in PSL-alone (P = 0.02). C2 was significantly higher in the patients with no relapse at 18 months than that in the patients with relapse (P = 0.048). In CyA + PSL, the total dose of PSL was significantly reduced compared with PSL-alone (P = 0.002). Cosmetic adverse effects tended to be fewer in CyA + PSL. CONCLUSIONS: The combination treatment regimen of ME-CyA and PSL with C2 >600 ng/ml has potential to be an important treatment option for adult new-onset MCNS patients. However, after ME-CyA dosage reduction and discontinuation, the relapse rate increased. It is thus necessary to establish a better dose-reduction method.

Interventional nephrology: current status and clinical impact in Japan.

BACKGROUND: Current status and clinical significance of interventional nephrology has not been reported from Japan. METHODS: Questionnaires were mailed twice to the directors of all 534 Japanese certificated nephrology training institutions in 2014. The main questions were current performance, categorized annual procedure volume and managers of peritoneal dialysis (PD) access, vascular access (VA) surgery, endovascular intervention, and kidney biopsy. Frequencies of nephrologist involvement between high volume center and low volume center and association between the level of nephrologists' involvement to each procedure and annual procedure volume were examined. RESULTS: 332 (62.2%) institutions answered performance of all procedures and 328 (61.4%) institutions answered all procedure volume. Kidney biopsy, VA surgery, endovascular intervention and PD access surgery were performed by any doctors in 94.2, 96.3, 88.4, and 76.2% and each involvement of nephrologist was 93.9, 54.1, 53.1 and 47.6%, respectively. Cochran-Armitage analyses demonstrated significant increases in all 4 procedure volume with greater management by nephrologists (p < 0.01). Nephrologists involvement to VA surgery associated with procedure volume increase in not only VA surgery, but also PD catheter insertion (p < 0.01) and kidney biopsy (p < 0.05). And nephrologists involvement to PD catheter insertion also associated with surgical volume increase in both VA surgery (p < 0.01) and endovascular intervention (p < 0.05). CONCLUSIONS: Main manager of all 4 procedures was nephrologist in Japan. Each procedure volume increased as nephrologists become more involved. Acquisition of one specific procedure by nephrologist associated with increase not only in this specific procedure volume, but also the other procedure volume.

Changes in Peritoneal Transport and Peritoneal Damage in Japanese Patients Undergoing Peritoneal Dialysis Using Neutral-pH Dialysate: A Retrospective Cohort Study at Two Centers.

The effects of medium- or long-term use of neutral-pH dialysate on peritoneal transport and peritoneal damage have not been sufficiently researched.We retrospectively evaluated time-dependent changes in the dialysate-to-plasma ratio of creatinine (D/P Cr) and biomarkers of peritoneal damage in the effluent of 65 patients who underwent peritoneal dialysis (PD) with neutral-pH dialysate, including 48 who underwent medium-term PD (≥3 years) and 17 who underwent long-term PD (≥5 years).Patients who underwent medium-term PD initially had a D/P Cr of 0.59 (range: 0.53 - 0.74), nonsignificantly changing to 0.65 (range: 0.55 - 0.73), 0.67 (range: 0.56 - 0.74), and 0.67 (range: 0.62 - 0.72) after 1, 2, and 3 years respectively (p = 0.30, p = 0.26, and p = 0.19). Patients who underwent long-term PD initially had a D/P Cr of 0.57 (range: 0.52 - 0.62), nonsignificantly changing to 0.61 (range: 0.52 - 0.69), 0.64 (range: 0.54 - 0.67), 0.62 (range: 0.57 - 0.66), 0.65 (range: 0.50 - 0.72), and 0.61 (range: 0.48 - 0.7) after 1, 2, 3, 4, and 5 years respectively (p = 0.49, p = 0.31, p = 0.24, p = 0.23, and p = 0.46). After 3 years, a significant increase in effluent hyaluronan (HA) from 90 ng/mL initially (range: 66 - 121 ng/mL) to 144 ng/ mL (range: 116 - 216 ng/mL) was observed (p = 0.04).No significant change in D/P Cr was observed in patients who underwent PD with neutral-pH dialysate. However, effluent HA, which is a biomarker for peritoneal damage, increased. In patients using neutral-pH dialysate, D/P Cr cannot be a biomarker for determining PD discontinuation within 5 years, but effluent HA might be useful.

Effects of home-based exercise on pre-dialysis chronic kidney disease patients: a randomized pilot and feasibility trial.

BACKGROUND: Only a few research is available on the effects of home-based exercise training on pre-dialysis chronic kidney disease (CKD) patients. Therefore, we aimed to elucidate the effect of home-based exercise therapy on kidney function and arm and leg muscle strength in pre-dialysis CKD patients. METHODS: Thirty-six male stage 3-4 pre-dialysis CKD patients (age, 68.7 ± 6.8 years; estimated glomerular filtration rate (eGFR), 39.0 ± 11.6 ml/min/1.73 m2) who were being treated as outpatients were included. The subjects were randomly assigned to an exercise intervention group (Ex group: 18) and a control group (C group: 18). The Ex group wore accelerometer pedometers and were instructed to perform home-based aerobic and resistance exercises, such as brisk walking for 30 min per day, for 12 months. The C group subjects wore accelerometer pedometers but received no exercise therapy guidance; the number of steps covered during normal daily activities was recorded for the C group. The outcome measures were changes in kidney function and handgrip and knee extension muscle strength. Values at the baseline (T1) and 12 months later (T2) were compared. RESULTS: There were no significant differences in baseline characteristics between the two groups; however, the C group was more physically active than the Ex group. Eight subjects dropped out, and 28 subjects (14 in each group) were included in the final analysis. Physical activity increased significantly only in the Ex group. Grip strength (F = 7.0, p = 0.01) and knee extension muscle strength (F = 14.3, p < 0.01) were found to improve only in the Ex group. Further, the changes in eGFR were not significantly different between the two groups (F = 0.01, p = 0.93). CONCLUSIONS: Home-based exercise therapy for pre-dialysis CKD patients was feasible and improved arm and leg muscle strength without affecting kidney function. TRIAL REGISTRATION: UMIN Clinical Trials Registry ( UMIN000005091 ). Registered 2/15/2011.

Early Postoperative Complications of Peritoneal Dialysis Catheter Surgery Conducted by Nephrologists: A Single-Center Experience Over an Eight-Year Period.

The results of several recent studies indicate that the practice of peritoneal dialysis catheter (PDC) insertion by nephrologists is safe. However, few studies have addressed the important issue of safety in surgeries related to PD, including PDC removal and other types of surgery. In the present study, we aimed to verify whether the incidence of early postoperative complications for surgical procedures related to PD and performed by nephrologists meets the audit standards of clinical practice guidelines for peritoneal access.Between April 2008 and July 2016 at our hospital, 282 patients underwent various types of PD-related surgery conducted by 17 nephrologists. The surgery types were the Moncrief-Popovich technique (n = 74), PDC exteriorization (n = 62), conventional laparotomy insertion (n = 29), PDC removal (n = 70), partial replacement (n = 32), unroofing or cuff shaving (n = 7), and others (n = 8).Bowel perforation and significant hemorrhage did not occur at the time of PDC insertion and removal. Although peritonitis was not evident, exit-site and tunnel infection within 2 weeks of PDC insertion by conventional laparotomy or exteriorization after the Moncrief-Popovich technique occurred in 3 of 91 patients (3.3%). The PDC malfunctioned in 2 of 103 patients (1.9%) after the Moncrief-Popovich technique because of PDC occlusion with a fibrin plug. Dialysate leaks occurred in 2 of 103 patients (1.9%). Partial replacement and unroofing or cuff shaving for refractory PDC infection and other type of surgeries were not associated with serious complications.The incidence of complications after surgery related to PD was low at our institution. The incidences of complications met the audit standards in the guidelines, indicating that surgery by nephrologists is safe and effective.

Predictive Factors for Withdrawal from Peritoneal Dialysis: A Retrospective Cohort Study at Two Centers in Japan.

Peritoneal dialysis (PD) is recognized as an excellent method of dialysis because the therapy is gentle, continuous, and cost-effective. However, a large number of patients must unfortunately transfer from PD to hemodialysis because of peritonitis or fluid overload in the early phase after PD initiation. In the present study, we reviewed clinical indicators before PD initiation to try to identify predictive factors for early withdrawal from PD.For this retrospective cohort study at two hospitals between March 2003 and October 2016, we defined withdrawal from PD as the induction of combination therapy, transfer to hemodialysis, or death. Data about clinical indicators before PD induction-namely age, sex, presence of diabetes mellitus, past history of cardiovascular disease (CVD), body mass index, primary kidney disease, and blood biochemistry-were collected from medical records. The primary outcome was duration of PD until withdrawal.We analyzed 151 PD patients (median age: 62.5 years; 94 men; 74 with diabetes mellitus; median duration of PD: 30.2 months). Univariate Cox regression analysis showed that the hazard ratio (HR) for withdrawal was 1.08 [95% confidence interval (CI): 1.04 to 1.12; p < 0.001] per 1 mg/L increase in ß2-microglobulin (ß2MG), 0.65 (95% CI: 0.46 to 0.93; p = 0.02) per 1 g/dL decrease in serum albumin, and 1.07 (95% CI: 1.02 to 1.11; p = 0.01) per 1 g per gram creatinine increase in daily urinary protein excretion. Using multivariate Cox regression analysis, ß2MG (HR: 1.08; 95% CI: 1.04 to 1.12; p < 0.001) and past history of CVD (HR: 1.47; 95% CI: 1.02 to 2.13; p = 0.04) were factors predictive for withdrawal from PD. Kaplan-Meier analysis showed that the technique survival rate was significantly different in the two groups defined as having a serum ß2MG level above or below the measured median (p = 0.047).Serum ß2MG at PD initiation and past history of CVD are high-risk factors for withdrawal from PD. Special focus should be placed on the care and management of patients found to have a high risk of withdrawal at the time of PD induction.