Peritoneal Dialysis Exit-Site Care Protocols in Portugal and Its Association with Catheter-Related Infections.

INTRODUCTION: Exit-site infection (ESi) prevention is a key factor in lowering the risk of peritonitis. This study aimed to evaluate the associations between exit-site (ES) care protocols and the annual incidence rates of ESi and peritonitis in Portugal. METHODS: We performed a national survey using two questionnaires: one about the incidence of catheter-related infections and the other characterizing patients' education and ES care protocols. RESULTS: In 2017 and 2018, 14 Portuguese units followed 764 and 689 patients. ESi incidence rate was 0.41 episodes/year, and the peritonitis incidence rate was 0.37. All units monitor catheter-related infections on a yearly basis, use antibiotic prophylaxis at the time of catheter placement, and treat nasal carriage of S. aureus, although with different approaches. Screening for nasal carriage of S. aureus is performed by 12 units, and daily topical antibiotic cream is recommended by 6 out of 14 of the units. We did not find statistical differences in ESi/peritonitis, comparing these practices. The rate of ESis was lower with nonocclusive dressing immediately after catheter insertion, bathing without ES dressing, with the use of colostomy bags in beach baths and was higher with the use of bath sponge. The peritonitis rate was lower with bathing without ES dressing and if shaving of the external cuff was performed in the presence of chronic ESi. CONCLUSIONS: We found potential proceedings associated with ESi and peritonitis. A regular national audit of peritoneal dialysis units is an important tool for clarifying the best procedures for reduction of catheter-related infections.

Availability of assisted peritoneal dialysis in Europe: call for increased and equal access.

BACKGROUND: Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilized in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries. METHODS: Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow and their top three priorities. RESULTS: Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD, with all respondents mentioning the need for nephrology team education and/or patient education and involvement in dialysis modality decision making. CONCLUSIONS AND CALL TO ACTION: Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and in all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policymakers and healthcare providers to develop and support assistance for PD.

Peritoneal Protein Loss, Leakage or Clearance In Peritoneal Dialysis, Where Do We Stand?

Peritoneal protein loss (PPL) through peritoneal effluent has been a well-recognized detrimental result of peritoneal dialysis (PD) treatment since its inception. Investigation has focused mainly on PPL quantitative and qualitative determinations and evaluation of its prognostic value.A comprehensive review of the pathophysiology of PPL (3-pore model revisited), methods of quantification, dialysate protein composition, and impact on clinical outcomes is presented herein. The author summarizes a brief analysis of associated cardiovascular disease and nutritional consequences, exploring the controversial cause-effect on mortality and technique failure.Therapeutic modalities aiming to reduce PPL (angiotensin-converting enzyme inhibitors [ACEI]s and vitamin D therapies) were explored, although it is unclear whether PPL represents a valid therapeutic target or, on the other hand, is solely a manifestation of endothelial dysfunction.

Early fungal infection in an aortic prosthesis with probable cerebral metastasis: the success of a conservative strategy.

Infection of an aortic prosthesis presents a diagnostic and therapeutic challenge. Fungal infections are rarely described and among these Candida spp. are the most prevalent agents. Although the therapeutic approach to prosthetic bacterial infection may be conservative, in the case of fungal etiology, surgery, such as the removal and substitution of the device, debridement and repair of the infected prosthesis is usually warranted. The authors describe the case of a 48-year-old man, with a thoraco-abdominal aneurysm of the aorta, submitted to surgery for insertion of a prosthetic aortic duct. The procedure was made difficult by Candida albicans empyema associated with an aortic prosthesis infection that was complicated by probable cerebral metastasis. Antifungal therapy was the initial option, as the steady clinical, laboratory and radiological improvement deferred a surgical intervention. This case demonstrates the success of a conservative approach in a very serious fungal infection of a thoraco-abdominal aorta prosthesis.

Statins for renal patients: a fiddler on the roof?

Atherosclerotic cardiovascular disease is the main cause of morbidity and mortality in chronic kidney disease patients. There is a raft of evidence showing that in the general population dyslipidaemia is associated with an increased risk of cardiovascular events, as well as with a greater prevalence of chronic kidney disease. Consequently, the use of statins in the general population with dyslipidaemia is not controversial. Nevertheless, the benefits of statins in patients with chronic kidney disease are more elusive. The authors review the possible effects of statins on the progression of renal disease and cardiovascular events in chronic kidney disease patients.

Over ten-year kidney graft survival determinants.

Kidney graft survival has been mainly evaluated using an up to 10-year threshold. Instead, in this study our aim was to evaluate predictive variables that impact long-term kidney graft survival (≥10 years). We enrolled 892 patients in our analysis: 638 patients with functioning graft at 10 years PT and 254 patients with graft failure at 10 years PT (considering patient death with a functioning graft <10 years PT as graft failure). Between groups comparisons were done using Mann-Whitney and chi-square test. To determine independent predictive variables for long-term graft survival a multivariate-adjusted logistic regression was performed. Significant predictors of long term graft survival were lower 12-month PT creatinine (OR = 0.26, P < 0.001), lower donor age (OR = 0.98, P = 0.004), shorter time on dialysis (OR = 0.93, P = 0.044), recipient positive CMV IgG (OR = 1.59, P = 0.040), absence of AR episodes (OR = 1.57, P = 0.047), 0 to 1 (versus 2) HLA-B mismatch (OR = 1.80, P = 0.004), and recipients male gender (OR = 1.84, P = 0.005). Our results show that an early KT, younger donor age, and an optimal first year graft function are of paramount importance for long-term graft survival. Measures that address these issues (careful donor selection, preemptive KT, and effective immunosuppressive protocols) are still warranted.

[Obesity and the kidney]. / O risco renal da obesidade.

Obesity represents an important risk factor for the development of chronic kidney disease (CKD), due to its known strong association with diabetes mellitus and hypertension, the two major causes of CKD, but also as an independent renal risk factor. This direct relationship between obesity and kidney injury has been undervalued. The aim of this revisión is to point out the mechanisms of kidney injury induced by obesity, underline the importance of this association and alert for the prevention, education and treatment of the obese patient, as a way to control this heavy modifiable risk factor.