Acute kidney injury in Indigenous Australians in the Kimberley: age distribution and associated diagnoses.

OBJECTIVE: To describe the frequencies of acute kidney injury (AKI) and of associated diagnoses in Indigenous people in a remote Western Australian region. DESIGN: Retrospective population-based study of AKI events confirmed by changes in serum creatinine levels. SETTING, PARTICIPANTS: Aboriginal and Torres Strait Islander residents of the Kimberley region of Western Australia, aged 15 years or more and without end-stage kidney disease, for whom AKI between 1 June 2009 and 30 May 2016 was confirmed by an acute rise in serum creatinine levels. MAIN OUTCOME MEASURES: Age-specific AKI rates; principal and other diagnoses. RESULTS: 324 AKI events in 260 individuals were recorded; the median age of patients was 51.8 years (IQR, 43.9-61.0 years), and 176 events (54%) were in men. The overall AKI rate was 323 events (95% CI, 281-367) per 100 000 population; 92 events (28%) were in people aged 15-44 years. 52% of principal diagnoses were infectious in nature, including pneumonia (12% of events), infections of the skin and subcutaneous tissue (10%), and urinary tract infections (7.7%). 80 events (34%) were detected on or before the date of admission; fewer than one-third of discharge summaries (61 events, 28%) listed AKI as a primary or other diagnosis. CONCLUSION: The age distribution of AKI events among Indigenous Australians in the Kimberley was skewed to younger groups than in the national data on AKI. Infectious conditions were common in patients, underscoring the significance of environmental determinants of health. Primary care services can play an important role in preventing community-acquired AKI; applying pathology-based criteria could improve the detection of AKI.

Does the intravascular volume status in haemodialysis patients measured by inferior vena cava ultrasound correlate with bioimpedance spectroscopy?

AIMS AND OBJECTIVES: To evaluate the accuracy of traditional clinical predialytic fluid assessment by renal nurses and the efficacy of 2 additional fluid assessment methods focussing on the potential preventative effect for intradialytic hypotension (IDH). BACKGROUND: Predialytic fluid assessment remains a daily challenge for renal nurses, when aiming for adverse event free haemodialysis treatments. Adding further objective parameters obtained through noninvasive methods into pre- and intradialytic fluid assessment could potentially improve health outcomes for haemodialysis patients. DESIGN: Comparative, observational study of three fluid assessment methods on their reliability on volume status and correlation to clinical outcomes. METHODS: Clinical predialytic nursing fluid assessments in 30 haemodialysis patients were compared with additional initial bioimpedance spectroscopy (BIS) measurements, and 3 serial intradialytic ultrasound scans of the inferior vena cava (IVC-US) performed by a second renal nurse concurrently during the same session. A retrospective data analysis compared all measurements in each individual for the predictive value for IDH. A STROBE checklist for observational cohort studies was used for the reporting of results. RESULTS: Seven subjects experienced episodes of symptomatic intradialytic hypotension (S-IDH), which would have been anticipated by IVC-US or by BIS in 5 patients (71%). Using an algorithm to predict IDH would have provided a sensitivity of 100% and specificity of 95%. CONCLUSION: Both additional fluid assessment methods would have provided critical information before and during each haemodialysis session. Therefore, we consider them as being potentially effective for the prevention of intradialytic hypotension, with IVC-US being similar to BIS. RELEVANCE TO CLINICAL PRACTICE: Traditional clinical nursing fluid assessment methods in haemodialysis patients do not provide sufficient information to prevent episodes of IDH. Additional objective fluid assessment methods are useful and likely to lead to improved health outcomes in HD patients when applied by renal nurses. A combination of IVC-US, MAP and BIS has potential to reduce the risk of IDH events in HD patients significantly.

Measuring the prevalence of intradialytic hypotension in a satellite dialysis clinic: Are we too complacent?

AIMS AND OBJECTIVES: To measure the prevalence of symptomatic (S-IDH) and asymptomatic intradialytic hypotension (A-IDH) or postdialysis overhydration in a satellite haemodialysis clinic in Western Australia. BACKGROUND: Intradialytic hypotension is one of the most common side effects of haemodialysis caused by ultrafiltration provoking a temporary volume depletion. The prevalence of asymptomatic hypotension during dialysis has been rarely reported, but is considered to have the same negative consequences as symptomatic hypotension on various end organs like the brain and the gastrointestinal tract. DESIGN: Observational study on a retrospective 3-month period of nursing recorded fluid-related adverse events. METHODS: Data collection on the occurrence of S-IDH and A-IDH during a total of 2,357 haemodialysis treatments in 64 patients. Body weight of patients at the time of cessation of treatment was recorded, and patients, whose weight exceeded their ideal body weight by at least 0.5 kg, were classified as overhydrated. Data analysis was performed using spss version 24 software. RESULTS: Symptomatic intradialytic hypotension was the most common adverse event measured in this cohort, and occurred during 221 (9.4%) of all treatments, whereas asymptomatic intradialytic hypotension occurred in 88 (3.7%) of all treatments. The total occurrence of intradialytic hypotension was 13.1%, and symptomatic was observed in 30 patients, implying that nearly every second patient had at least one symptomatic episode within 3 months. Overhydration occurred in a total of 103 (4.4%) of all treatments, and involved 17 patients. CONCLUSIONS: Symptomatic and asymptomatic intradialytic hypotension were the most commonly observed adverse events in this cohort; overhydration occurrence was considerably less common. RELEVANCE TO CLINICAL PRACTICE: The high occurrence of hypotension-related events demonstrates that ultrafiltration treatment goals in satellite dialysis clinics are sometimes overestimated, resulting in regular significant symptomatic episodes for the patient. Raising the awareness of the prevalence of IDH amongst renal nurses could be an essential initial step before collectively preventative strategies in haemodialysis satellite units are implemented.

Preferred Fourth-Line Pharmacotherapy for Resistant Hypertension: Are We There Yet?

Resistant hypertension (RH) is defined as blood pressure (BP) that remains above target levels despite adherence to at least three different antihypertensive medications, typically including a diuretic. Epidemiological studies estimate that RH is increasing in prevalence, and is associated with detrimental health outcomes. The pathophysiology underlying RH is complex, involving multiple, overlapping contributors including activation of the renin-angiotensin aldosterone system and the sympathetic nervous system, volume overload, endothelial dysfunction, behavioural and lifestyle factors. Hypertension guidelines currently recommend specific pharmacotherapy for 1st, 2nd and 3rd-line treatment, however no specific fourth-line pharmacotherapy is provided for those with RH. Rather, five different antihypertensive drug classes are generally suggested as possible alternatives, including: mineralocorticoid receptor antagonists, α1-adrenergic antagonists, α2-adrenergic agonists, ß-blockers, and peripheral vasodilators. Each of these drug classes vary in their efficacy, tolerability and safety profile. This review summarises the available data on each of these drug classes as a potential fourth-line drug and reveals a lack of robust clinical evidence for preferred use of most of these classes in the setting of RH. Moreover, there is a lack of direct comparative trials that could assist in identifying a preferred fourth-line pharmacologic approach and in providing evidence for hypertensive guidelines for adequate treatment of RH.

Reflecting on Students' Experiences of an Innovative Teaching Model During Aged Care Visit in Clinical Placements: A Qualitative Pilot Study.

Purpose: Clinical placement teaching could be challenging due to time constraints, lack of effective teaching models and consensus approaches. Learner-centred approach facilitated deeper learning by demonstrating "seeing-patients-under-supervision" being ideal during Residential-Aged-Care-Facility (RACF)-visit in GP clinical placements. The study aimed to reflect on the students' experiences in aged-care visits by applying an innovative teaching model of "students-being-the-GP-clinician-in-charge-of-RACF-visit-ward-round-under-the-supervision-of-clinical-supervisor". Through students' reflections, this study identified 12 commonly managed RACF problems to be introduced into the curriculum to optimise clinical reasoning learning during RACF-visit. Methods: This qualitative study used online surveys and interviews. All participating students reported all the encountered cases during the RACF visit through an online survey. The participating students acted as GP in charge of all clinical interactions with patients, caregivers, and nurses during RACF visits and final management plan discussions with GP supervisors to ensure clinical-service safety and teaching-and-learning quality. The interview questionnaires applied standard-and-open-ended-questions to examine the impact of this innovative teaching model on clinical-reasoning-learning, clinical-competence-improvement, Objective Structured Clinical Exam (OSCE) preparation, limitations-from-students'-patients'-and-supervisors' perspectives, and intern readiness. Results: An online survey summarising students' encountered cases was returned by 30 students. The 12 most commonly-managed problems were tabulated. Falls, urinary tract infections, and behavioural and psychological symptoms of dementia were the three most commonly-managed problems. All thirty students' reflections indicated the positive impact of the innovative-teaching-models on "Improving-Clinical-Reasoning-Learning", "Enhancing-Clinical-Competency", "Enriching-Salient-Learning-Points", "Facilitating-Feedback-Discussion-with-Supervisor", "Strengthening-OSCE-exam-preparation", "Understanding-the-Limitation-from-students'-patients'-and-supervisors'-perspectives", "Enabling-intern-readiness". Twelve students' individual reflections were demonstrated. Conclusion: This qualitative pilot study demonstrated through students' reflection that "Student-doctor-in-charge-of-nursing-home-round" is an innovative teaching model for clinical reasoning learning. This model extended the concepts of "cognitive-apprenticeship" in the context of modern medical education. Students' reflections and summary of commonly managed problems indicated the need for further study to verify the feasibility of implementing this teaching model in the formal curriculum and creating a RACF-visit-specific curriculum for students.

End-stage kidney disease due to scleroderma--outcomes in 127 consecutive ANZDATA registry cases.

BACKGROUND: Scleroderma is an uncommon cause of end-stage kidney disease (ESKD) which carries significant morbidity and mortality risks. The aim of this study was to determine the prevalence, treatment and outcomes of scleroderma patients with ESKD. METHODS: A study was conducted of all ESKD patients enrolled in the ANZDATA registry, who commenced dialysis between 15 May 1963 and 31 December 2005, and remained on dialysis for at least 90 days. RESULTS: Of the 40 238 patients who commenced dialysis during the study period, 127 (0.3%) patients had ESKD secondary to scleroderma. Scleroderma ESKD patients were more likely than other ESKD patients to be female (72% versus 43%, P < 0.001), Caucasian (98% versus 79%, P < 0.001) and of lower BMI (22.7 ± 4.7 versus 26.0 ± 5.9, P < 0.001) with a higher prevalence of chronic lung disease (36 versus 14%, P < 0.001) and lower prevalence of diabetes mellitus (10% versus 32%, P < 0.001) and coronary artery disease (23% versus 35%, P = 0.01). Median survival was significantly shorter in scleroderma ESKD (2.43 years, 95% confidence interval (CI) 1.75-3.11 years) than other ESKD (6.02 years, 95% CI 5.89-6.14 years, log-rank score 55.7, P < 0.001). Renal recovery was more likely in scleroderma patients (10% versus 1%, P < 0.001) with a shorter time to recovery. Scleroderma was found to be an independent predictor for mortality (HR 2.47, 95% CI 1.99-3.05) and renal recovery (HR 11.1, 95% CI 6.37-19.4). Five year deceased donor and live donor renal allograft survival rates of recipients with scleroderma were 53 and 100%, respectively. CONCLUSIONS: Scleroderma is an uncommon cause of ESKD, which is associated with increased risks of both spontaneous renal recovery and mortality.

Encapsulating peritoneal sclerosis: incidence, predictors, and outcomes.

Encapsulating peritoneal sclerosis is a complication of peritoneal dialysis characterized by persistent, intermittent, or recurrent adhesive bowel obstruction. Here we examined the incidence, predictors, and outcomes of encapsulating peritoneal sclerosis (peritoneal fibrosis) by multivariate logistic regression in incident peritoneal dialysis patients in Australia and New Zealand. Matched case-control analysis compared the survival of patients with controls equivalent for age, gender, diabetes, and time on peritoneal dialysis. Of 7618 patients measured over a 13-year period, encapsulating peritoneal sclerosis was diagnosed in 33, giving an incidence rate of 1.8/1000 patient-years. The respective cumulative incidences of peritoneal sclerosis at 3, 5, and 8 years were 0.3, 0.8, and 3.9%. This condition was independently predicted by younger age and the duration of peritoneal dialysis, but not the rate of peritonitis. Twenty-six patients were diagnosed while still on peritoneal dialysis. Median survival following diagnosis was 4 years and not statistically different from that of 132 matched controls. Of the 18 patients who died, only 7 were attributed directly to peritoneal sclerosis. Our study shows that encapsulating peritoneal sclerosis is a rare condition, predicted by younger age and the duration of peritoneal dialysis. The risk of death is relatively low and not appreciably different from that of competing risks for mortality in matched dialysis control patients.

Predictors, treatment, and outcomes of non-Pseudomonas Gram-negative peritonitis.

Non-Pseudomonas Gram-negative (NPGN) peritonitis is a frequent, serious complication of peritoneal dialysis; however, previous reports have been limited to small, single-center studies. To gain insight on the frequency, predictors, treatment, and outcomes of NPGN peritonitis, we analyzed data in the ANZDATA registry of all adult Australian peritoneal dialysis patients over a 39-month period using multivariate logistic and multilevel Poisson regressions. There were 837 episodes of NPGN peritonitis (23.3% of all peritonitis) that occurred in 256 patients. The most common organism isolated was Escherichia coli, but included Klebsiella, Enterobacter, Serratia, Acinetobacter, Proteus, and Citrobacter, with multiple organisms identified in a quarter of the patients. The principal risk factor was older age, with poorer clinical outcome predicted by older age and polymicrobial peritonitis. The overall antibiotic cure rate was 59%. NPGN peritonitis was associated with significantly higher risks of hospitalization, catheter removal, permanent transfer to hemodialysis, and death compared to other organisms contributing to peritonitis. Underlying bowel perforation requiring surgery was uncommon. Hence, we show that NPGN peritonitis is a frequent, serious complication of peritoneal dialysis, which is frequently associated with significant risks, including death. Its cure with antibiotics alone is less likely when multiple organisms are involved.

Culture-negative peritonitis in peritoneal dialysis patients in Australia: predictors, treatment, and outcomes in 435 cases.

BACKGROUND: Reports of culture-negative peritoneal dialysis (PD)-associated peritonitis have been sparse, conflicting, and limited to small single-center studies. The aim of this investigation is to examine the frequency, predictors, treatment, and outcomes of culture-negative PD-associated peritonitis. STUDY DESIGN: Observational cohort study using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. SETTING & PARTICIPANTS: All Australian PD patients between October 1, 2003, and December 31, 2006. PREDICTORS: Demographic, clinical, and facility variables. OUTCOMES & MEASUREMENTS: Culture-negative PD-associated peritonitis occurrence, relapse, hospitalization, catheter removal, hemodialysis transfer, and death. RESULTS: Of 4,675 patients who received PD in Australia during the study period, 435 episodes of culture-negative peritonitis occurred in 361 individuals. Culture-negative peritonitis was not associated with demographic or clinical variables. A history of previous antibiotic treatment for peritonitis was more common with culture-negative than culture-positive peritonitis (42% vs 35%; P = 0.01). Compared with culture-positive peritonitis, culture-negative peritonitis was significantly more likely to be cured using antibiotics alone (77% vs 66%; P < 0.001) and less likely to be complicated by hospitalization (60% vs 71%; P < 0.001), catheter removal (12% vs 23%; P < 0.001), permanent hemodialysis therapy transfer (10% vs 19%; P < 0.001), or death (1% vs 2.5%; P = 0.04). Relapse rates were similar between the 2 groups. Patients with relapsed culture-negative peritonitis were more likely to have their catheters removed (29% vs 10% [P < 0.001]; OR, 3.83; 95% CI, 2.00-7.32). Administration of vancomycin or cephalosporin in the initial empiric antibiotic regimen and the timing of catheter removal were not significantly associated with clinical outcomes. LIMITATIONS: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Culture-negative peritonitis is a common complication with a relatively benign outcome. A history of previous antibiotic treatment is a significant risk factor for this condition.

Polymicrobial peritonitis in peritoneal dialysis patients in Australia: predictors, treatment, and outcomes.

BACKGROUND: The study aim was to examine the frequency, predictors, treatment, and clinical outcomes of peritoneal dialysis-associated polymicrobial peritonitis. STUDY DESIGN: Observational cohort study using ANZDATA (The Australia and New Zealand Dialysis and Transplant Registry) data. SETTING & PARTICIPANTS: All Australian peritoneal dialysis patients between October 2003 and December 2006. PREDICTORS: Age, sex, race, body mass index, baseline renal function, late referral, kidney disease, smoking status, comorbidity, peritoneal permeability, center, state, organisms, and antibiotic regimen. OUTCOMES & MEASUREMENTS: Polymicrobial peritonitis occurrence, relapse, hospitalization, catheter removal, hemodialysis transfer, and death. RESULTS: 359 episodes of polymicrobial peritonitis occurred in 324 individuals, representing 10% of all peritonitis episodes during 6,002 patient-years. The organisms isolated included mixed Gram-positive and Gram-negative organisms (41%), pure Gram-negative organisms (22%), pure Gram-positive organisms (25%), and mixed bacteria and fungi (13%). There were no significant independent predictors of polymicrobial peritonitis except for the presence of chronic lung disease. Compared with single-organism infections, polymicrobial peritonitis was associated with higher rates of hospitalization (83% vs 68%; P < 0.001), catheter removal (43% vs 19%; P < 0.001), permanent hemodialysis transfer (38% vs 15%; P < 0.001), and death (4% vs 2%; P = 0.03). Isolation of fungus or Gram-negative bacteria was the primary predictor of adverse clinical outcomes. Pure Gram-positive peritonitis had the best clinical outcomes. Patients who had their catheters removed >1 week after polymicrobial peritonitis onset were significantly more likely to be permanently transferred to hemodialysis therapy than those who had earlier catheter removal (92% vs 81%; P = 0.05). LIMITATIONS: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Polymicrobial peritonitis can be treated successfully using antibiotics alone without catheter removal in most cases, particularly when only Gram-positive organisms are isolated. Isolation of Gram-negative bacteria (with or without Gram-positive bacteria) or fungi carries a worse prognosis and generally should be treated with early catheter removal and appropriate antimicrobial therapy.

Superior survival of high transporters treated with automated versus continuous ambulatory peritoneal dialysis.

BACKGROUND: Automated peritoneal dialysis (APD) is widely recommended for the management of high transporters by the International Society of Peritoneal Dialysis (ISPD), although there have been no adequate studies to date comparing the outcomes of APD and continuous ambulatory peritoneal dialysis (CAPD) in this high risk group. METHODS: The relative impact of APD versus CAPD on patient and technique survival rates was examined by both intention-to-treat (PD modality at Day 90) and 'as-treated' time-varying Cox proportional hazards model analyses in all patients who started PD in Australia or New Zealand between 1 April 1999 and 31 March 2004 and who had baseline peritoneal equilibration tests confirming the presence of high peritoneal transport status. RESULTS: During the study period, 4128 patients commenced PD. Of these, 628 patients were high transporters on PD at Day 90 (486 on APD and 142 on CAPD). Compared to high transporters treated with CAPD, APD-treated high transporters were more likely to be younger and Caucasian, and less likely to be diabetic. On multivariate intention-to-treat analysis, APD treatment was associated with superior survival [adjusted hazard ratio (HR) 0.56, 95% confidence interval (CI) 0.35-0.87] and comparable death-censored technique survival (HR 0.88, 95% CI 0.64-1.21). Superior survival of high transporters treated with APD versus CAPD was also confirmed in supplemental as-treated analysis (HR 0.72, 95% CI 0.54-0.96), matched case-control analysis (HR 0.60, 95% CI 0.36-0.96) and subgroup analysis of high transporters treated entirely with APD versus those treated entirely with CAPD (HR 0.29, 95% CI 0.14-0.60). There were no statistically significant differences in patient survival or death-censored technique survival between APD and CAPD for any other transport group, except for low transporters, who experienced a higher mortality rate on APD compared with CAPD (HR 2.19, 95% CI 1.02-4.70). CONCLUSIONS: APD treatment is associated with a significant survival advantage in high transporters compared with CAPD. However, APD treatment is associated with inferior survival in low transporters.

Enterococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 116 cases.

UNLABELLED: Background. Enterococcal peritonitis is a serious complication of peritoneal dialysis (PD), although reports of this condition in the literature are exceedingly limited. Methods. The frequency, predictors, treatment and clinical outcomes of enterococcal peritonitis were investigated in all 4675 patients receiving PD in Australia between 1 October 2003 and 31 December 2006. Results. One hundred and sixteen episodes of enterococcal peritonitis occurred in 103 individuals. Enterococcal peritonitis tended to be associated with older age, Maori and Pacific Islander racial origin, renovascular disease and coronary artery disease. Polymicrobial peritonitis, defined as recovery of two or more organisms from dialysate effluent, was significantly more common when an Enterococcus species was isolated than when it was not (45% vs 5%, respectively, P < 0.001, odds ratio 13.4, 95% CI 9.45-19.0). Although international guidelines recommend intraperitoneal ampicillin therapy, only 8% of patients with pure enterococcal peritonitis were treated with this agent, whilst the majority (78%) received vancomycin monotherapy. Overall, 59 (51%) patients with enterococcal peritonitis were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The sole independent predictor of adverse clinical outcomes was recovery of additional (non-Enterococcus) organisms. Polymicrobial enterococcal peritonitis was associated with very high rates of hospitalization (83%), catheter removal (52%), permanent haemodialysis transfer (50%) and death (5.8%). In contrast, clinical outcomes were broadly comparable for pure enterococcal and non-enterococcal peritonitis (hospitalization 75% vs 69%, respectively; catheter removal 25% vs 21%; permanent haemodialysis transfer 17% vs 17%; death 1.6% vs 2.2%) although worse than non-enterococcal Gram-positive peritonitis (63%, 12%, 3% and 0.6%, respectively). Removal of the PD catheter within 1 week of enterococcal peritonitis onset was associated with a lower probability of permanent haemodialysis transfer than later removal (74% vs 100%, P = 0.03). CONCLUSIONS: Enterococcal peritonitis is associated with an increased risk of catheter removal, permanent haemodialysis transfer and death, particularly when other organisms are isolated in the same episode.

Coagulase-negative staphylococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 936 cases.

BACKGROUND: Coagulase-negative staphylococcal (CNS) peritonitis is the most common cause of peritoneal dialysis (PD)-associated peritonitis. Previous reports of this important condition have been sparse and generally limited to single-centre studies. METHODS: The frequency, predictors, treatment and clinical outcomes of CNS peritonitis were examined by multivariate logistic regression and multilevel Poisson regression in all adult PD patients in Australia between 2003 and 2006. RESULTS: A total of 936 episodes of CNS peritonitis (constituting 26% of all peritonitis episodes) occurred in 620 individuals. The observed rate of CNS peritonitis was 0.16 episodes per patient-year. Lower rates of CNS peritonitis were independently predicted by Asian racial origin (adjusted odds ratio [OR], 0.52; 95% CI, 0.35-0.79), renovascular nephrosclerosis (OR, 0.40; 95% CI, 0.18-0.86), early referral to a renal unit prior to dialysis commencement (OR, 0.38; 95% CI, 0.19-0.79) and treatment with automated PD at any time during the PD career (OR, 0.79; 95% CI, 0.66-0.96). The majority of CNS peritonitis episodes were initially treated with intraperitoneal vancomycin or cephazolin in combination with gentamicin. This regimen was changed in 533 (57%) individuals after a median period of 3 days, most commonly to vancomycin monotherapy. The median total antibiotic course duration was 14 days. Compared with other forms of peritonitis, CNS episodes were significantly more likely to be cured by antibiotics alone (76 vs 64%, P < 0.001) and less likely to be complicated by hospitalization (61 vs 73%, P < 0.001), catheter removal (10 vs 26%, P < 0.001), temporary haemodialysis (2 vs 5%, P < 0.001), permanent haemodialysis transfer (9 vs 21%, P < 0.001) and death (1.0 vs 2.7%, P = 0.002). CNS peritonitis was also associated with a shorter duration of hospitalization, a longer time to catheter removal and a shorter duration of temporary haemodialysis. Catheter removal and permanent haemodialysis transfer were independently predicted by polymicrobial peritonitis and initial empiric administration of vancomycin (compared with cephalosporins). CNS peritonitis was associated with a higher relapse rate (17 vs 13%, P = 0.003) and relapsed CNS peritonitis was associated with a higher catheter removal rate (22 vs 7%, P < 0.001). Repeat peritonitis occurred in 194 (31%) individuals and the highest risk was in the second month after completion of antibiotic treatment for CNS peritonitis (OR, 1.87; 95% CI, 1.39-2.51 compared with >2 months). CONCLUSIONS: CNS peritonitis is a common complication with a relatively benign outcome compared with other forms of PD-associated peritonitis. Relapsed and repeat peritonitis are relatively common and are associated with worse outcomes.

Predictors and outcomes of fungal peritonitis in peritoneal dialysis patients.

Fungal peritonitis is a serious complication of peritoneal dialysis but previous reports on this have been limited to small, single-center studies. Using all Australian peritoneal dialysis patients, we measured predictors, treatments, and outcomes of this condition by logistic regression and multilevel, multivariate Poisson regression. This encompassed 66 centers over a 4-year period that included 162 episodes of fungal peritonitis (4.5% of all peritonitis episodes) that occurred in 158 individuals. Candida albicans (25%) and other Candida species (44%) were the most common fungi isolated. Fungal peritonitis was independently predicted by indigenous race and prior treatment of bacterial peritonitis. Peritonitis episodes occurring after 7 and 60 days of treatment for previous bacterial peritonitis decreases in the probability of fungal peritonitis 23 and 6%, respectively. Compared with other organisms, fungal peritonitis was associated with significantly higher rates of hospitalization, catheter removal, transfer to permanent hemodialysis, and death. The risks of repeat fungal peritonitis and death were lowest with catheter removal combined with antifungal therapy when compared to either intervention alone. Our study shows that fungal peritonitis is a serious complication of peritoneal dialysis and should be strongly suspected in the context of recent antibiotic treatment for bacterial peritonitis.

Associations of dialysis modality and infectious mortality in incident dialysis patients in Australia and New Zealand.

BACKGROUND: The aim of the present investigation is to compare rates, types, causes, and timing of infectious death in incident peritoneal dialysis (PD) and hemodialysis (HD) patients in Australia and New Zealand. STUDY DESIGN: Observational cohort study using the Australian and New Zealand Dialysis and Transplant Registry data. SETTING & PARTICIPANTS: The study included all patients starting dialysis therapy between April 1, 1995, and December 31, 2005. PREDICTOR: Dialysis modality. OUTCOMES & MEASUREMENTS: Rates of and time to infectious death were compared by using Poisson regression, Kaplan-Meier, and competing risks multivariate Cox proportional hazards model analyses. RESULTS: 21,935 patients started dialysis therapy (first treatment PD, n = 6,020; HD, n = 15,915) during the study period, and 1,163 patients (5.1%) died of infectious causes (PD, 529 patients; 7.6% versus HD, 634 patients; 4.2%). Incidence rates of infectious mortality in PD and HD patients were 2.8 and 1.7/100 patient-years, respectively (incidence rate ratio PD versus HD, 1.66; 95% confidence interval [CI], 1.47 to 1.86). After performing competing risks multivariate Cox analyses allowing for an interaction between time on study and modality because of identified nonproportionality of hazards, PD consistently was associated with increased hazard of death from infection compared with HD after 6 months of treatment (<6 months hazard ratio [HR], 1.08; 95% CI, 0.76 to 1.54; 6 months to 2 years HR, 1.31; 95% CI, 1.09 to 1.59; 2 to 6 years HR, 1.51; 95% CI, 1.26 to 1.80; >6 years HR, 2.76; 95% CI, 1.76 to 4.33). This increased risk of infectious death in PD patients was largely accounted for by an increased risk of death caused by bacterial or fungal peritonitis. LIMITATIONS: Patients were not randomly assigned to their initial dialysis modality. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Dialysis modality selection significantly influences risks, types, causes, and timing of fatal infections experienced by patients with end-stage kidney disease in Australia and New Zealand.

Corynebacterium peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 82 cases.

BACKGROUND: Infection due to Corynebacterium species has been reported with increasing frequency over recent decades. The impacts of enhanced laboratory detection together with widespread use of new peritoneal dialysis (PD) connection technology and antimicrobial prophylaxis strategies on Corynebacterium PD-associated peritonitis have not been well studied. METHODS: We investigated the frequency, predictors, treatment and clinical outcomes of Corynebacterium peritonitis in all Australian adult patients involving 66 centres who were receiving PD between 1 October 2003 and 31 December 2006. RESULTS: Eighty-two episodes of Corynebacterium peritonitis (2.3% of all peritonitis episodes) occurred in 65 (1.4%) PD patients. Ten (15%) patients experienced more than one episode of Corynebacterium peritonitis and additional organisms were isolated in 12 (15%) episodes of Corynebacterium peritonitis. The incidence of Corynebacterium peritonitis was significantly and independently predicted only by BMI: RR 2.72 (95% CI 1.38-5.36) for the highest tertile BMI compared with the lowest tertile. The overall cure rate with antibiotics alone was 67%, which was similar to that of peritonitis due to other organisms. Vancomycin was the most common antimicrobial agent administered in the initial empiric and subsequent antibiotic regimens, although outcomes were similar regardless of antimicrobial schedule. Corynebacterium peritonitis not infrequently resulted in relapse (18%), repeat peritonitis (15%), hospitalization (70%), catheter removal (21%), permanent haemodialysis transfer (15%) and death (2%). The individuals who had their catheters removed more than 1 week after the onset of Corynebacterium peritonitis had a significantly higher risk of permanent haemodialysis transfer than those who had their catheters removed within 1 week (90% versus 43%, P < 0.05). CONCLUSIONS: Corynebacterium is an uncommon but significant cause of PD-associated peritonitis. Complete cure with antibiotics alone is possible in the majority of patients, and rates of adverse outcomes are comparable to those seen with peritonitis due to other organisms. Use of vancomycin rather than cephazolin as empiric therapy does not impact outcomes, and a 2-week course of antibiotic therapy appears sufficient. If catheter removal is required, outcomes are improved by removing the catheter within 1 week of peritonitis onset.

Recovery of renal function in end-stage renal failure--comparison between peritoneal dialysis and haemodialysis.

BACKGROUND: Recovery of dialysis-independent renal function in long-term dialysis patients has not been studied extensively. The aim of this study was to investigate the effect of dialysis modality on the likelihood, timing and durability of recovery of dialysis-independent renal function. METHODS: The study reviewed all patients in Australia and New Zealand who commenced dialysis for treatment of end-stage renal disease (ESRD) between 1963 and 2006. Dialysis modality was assigned at 90 days. A supplementary analysis was also conducted using a contemporary cohort that included data on comorbidities, smoking and eGFR at dialysis onset. RESULTS: During the study period, 15 912 individuals received peritoneal dialysis (PD) and 23 658 received haemodialysis (HD). Renal recovery occurred in 176 (1.1%) PD and 244 (1.0%) HD patients. Using multivariate Cox proportional hazards regression analyses, dialysis modality was not independently predictive of time to renal recovery (HR 0.92, 95% CI 0.76-1.13, P = 0.4). Recovery was significantly more likely in patients with higher baseline eGFR, with no hypertension or peripheral vascular disease, and with certain causes of kidney failure (autoimmune renal disease, haemolytic uraemic syndrome, interstitial nephritis, obstructive uropathy, paraproteinaemia and renovascular nephrosclerosis). Recovery was less likely in Maori/Pacific Islanders and polycystic kidney disease. Among patients who recovered, 328 (78%) subsequently experienced renal death, mostly within the first year. The duration of renal recovery was not associated with initial dialysis modality (OR 0.82, 95% CI 0.50- 1.32). CONCLUSIONS: Dialysis modality is not associated with the likelihood, timing or durability of spontaneous recovery of dialysis-independent renal function in patients thought to have ESRD.

Streptococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 287 cases.

BACKGROUND: There has not been a comprehensive, multi-centre study of streptococcal peritonitis in patients on peritoneal dialysis (PD) to date. METHODS: The predictors, treatment and clinical outcomes of streptococcal peritonitis were examined by binary logistic regression and multilevel, multivariate poisson regression in all Australian PD patients involving 66 centres between 2003 and 2006. RESULTS: Two hundred and eighty-seven episodes of streptococcal peritonitis (4.6% of all peritonitis episodes) occurred in 256 individuals. Its occurrence was independently predicted by Aboriginal or Torres Strait Islander racial origin. Compared with other organisms, streptococcal peritonitis was associated with significantly lower risks of relapse (3% vs 15%), catheter removal (10% vs 23%) and permanent haemodialysis transfer (9% vs 18%), as well as a shorter duration of hospitalisation (5 vs 6 days). Overall, 249 (87%) patients were successfully treated with antibiotics without experiencing relapse, catheter removal or death. The majority of streptococcal peritonitis episodes were treated with either intraperitoneal vancomycin (most common) or first-generation cephalosporins for a median period of 13 days (interquartile range 8-18 days). Initial empiric antibiotic choice did not influence outcomes. CONCLUSION: Streptococcal peritonitis is a not infrequent complication of PD, which is more common in indigenous patients. When treated with either first-generation cephalosporins or vancomycin for a period of 2 weeks, streptococcal peritonitis is associated with lower risks of relapse, catheter removal and permanent haemodialysis transfer than other forms of PD-associated peritonitis.

Preventing AVF thrombosis: the rationale and design of the Omega-3 fatty acids (Fish Oils) and Aspirin in Vascular access OUtcomes in REnal Disease (FAVOURED) study.

BACKGROUND: Haemodialysis (HD) is critically dependent on the availability of adequate access to the systemic circulation, ideally via a native arteriovenous fistula (AVF). The Primary failure rate of an AVF ranges between 20-54%, due to thrombosis or failure of maturation. There remains limited evidence for the use of anti-platelet agents and uncertainty as to choice of agent(s) for the prevention of AVF thrombosis. We present the study protocol for a randomised, double-blind, placebo-controlled, clinical trial examining whether the use of the anti-platelet agents, aspirin and omega-3 fatty acids, either alone or in combination, will effectively reduce the risk of early thrombosis in de novo AVF. METHODS/DESIGN: The study population is adult patients with stage IV or V chronic kidney disease (CKD) currently on HD or where HD is planned to start within 6 months in whom a planned upper or lower arm AVF is to be the primary HD access. Using a factorial-design trial, patients will be randomised to aspirin or matching placebo, and also to omega-3 fatty acids or matching placebo, resulting in four treatment groups (aspirin placebo/omega-3 fatty acid placebo, aspirin/omega-3 fatty acid placebo, aspirin placebo/omega-3 fatty acid, aspirin/omega-3 fatty acid). Randomisation will be achieved using a dynamic balancing method over the two stratification factors of study site and upper versus lower arm AVF. The medication will be commenced pre-operatively and continued for 3 months post surgery. The primary outcome is patency of the AVF at three months after randomisation. Secondary outcome measures will include functional patency at six and twelve months, primary patency time, secondary (assisted) patency time, and adverse events, particularly bleeding. DISCUSSION: This multicentre Australian and New Zealand study has been designed to determine whether the outcome of surgery to create de novo AVF can be improved by the use of aspirin and/or omega-3 fatty acids. Recently a placebo-controlled trial has shown that clopidogrel is effective in safely preventing primary AVF thrombosis, but ineffective at increasing functional patency. Our study presents significant differences in the anti-platelet agents used, the study design, and surgical and patient demographics that should contribute further evidence regarding the efficacy of anti-platelet agents. TRIAL REGISTRATION: Australia & New Zealand Clinical Trials Register (ACTRN12607000569404).