Uptake and Outcomes of Peritoneal Dialysis among Aboriginal and Torres Strait Islander People: Analysis of Registry Data.

Introduction: Peritoneal dialysis (PD) enables people to use kidney replacement therapy (KRT) outside of healthcare-dependent settings, a strong priority of Aboriginal and Torres Strait Islander people. Methods: We undertook an observational study analyzing registry data to describe access to PD and its outcome as the first KRT among Aboriginal and Torres Strait Islander people between January 1, 2004 and December 31 2020. Results: Out of 4604 Aboriginal and Torres Strait Islander people, reflecting 10.4% of all Australians commencing KRT, PD was the first KRT modality among 665 (14.4%). PD utilization was 17.2% in 2004 to 2009 and 12.7% in 2016 to 2020 (P = 0.002); 1105 episodes of peritonitis were observed in 413 individuals, median of 3 (interquartile range [IQR], 2-5) episodes/patient. The crude peritonitis rate was 0.53 (95% confidence interval [CI], 0.50-0.56) episodes/patient-years without any significant changes over time. The median time to first peritonitis was 1.1 years. A decrease in the peritonitis incidence rate ratio (IRR) was observed in 2016 to 2020 (IRR, 0.63 [95% CI, 0.52-0.77], P < 0.001) compared to earlier eras (2010-2015: IRR, 0.90 [95% CI, 0.76-1.07], P = 0.23; Ref: 2004-2009). The cure rates decreased from 80.0% (n = 435) in 2004 to 2009, to 70.8% (n = 131) in 2016 to 2020 (P < 0.001). Conclusion: Aboriginal and Torres Strait Islander people who utilized PD as their first KRT during 2004 to 2020 recorded a higher peritonitis rate than the current benchmark of 0.4 episodes/patient-years. The cure rates have worsened recently, which should be a big concern. There is an exigent need to address these gaps in kidney care for Aboriginal and Torres Strait Islander people.

PD-Buddy: A Feasibility Study of Mobile Health to Support the Management of Peritoneal Dialysis.

People experiencing peritoneal dialysis (PD) are expected to document considerable clinical information at home, yet timely and accurate data collection, and sharing of data with their health team is associated with challenges. Mobile health technologies present an opportunity to bridge home and hospital care. PD-Buddy is a novel smartphone and web-based platform which guides people experiencing PD through their dialysis treatment. The platform was tested in a feasibility study with (n=33) people attending a Peritoneal Dialysis Clinic in Brisbane, Australia. The study evaluated adoption and satisfaction of the system among users (patients and clinicians), as well as infection rates. Findings indicate PD-Buddy to be a user-friendly solution that could expand access to, and improve, the quality of healthcare for people experiencing PD. It could reduce burdens for regional and remote populations, such as travelling to receive specialty care, and improve monitoring, timeliness, and communications with and within their care teams.

Associations of neutral pH, low-GDP peritoneal dialysis solutions with patient survival, transfer to haemodialysis and peritonitis.

BACKGROUND: Peritoneal dialysis (PD) solutions containing low levels of glucose degradation products (GDPs) are associated with attenuation of peritoneal membrane injury and vascular complications. However, clinical benefits associated with neutral-pH, low-GDP (N-pH/L-GDP) solutions remain unclear. METHODS: Using data from the Australia and New Zealand Dialysis and Transplant Registry, we examined the associations between N-pH/L-GDP solutions and all-cause mortality, cause-specific mortality, transfer to haemodialysis (HD) for ≥30 days and PD peritonitis in adult incident PD patients in Australia and New Zealand between 1 January 2005 and 31 December 2020 using adjusted Cox regression analyses. RESULTS: Of 12 814 incident PD patients, 2282 (18%) were on N-pH/L-GDP solutions. The proportion of patients on N-pH/L-GDP solutions each year increased from 11% in 2005 to 33% in 2017. During the study period, 5330 (42%) patients died, 4977 (39%) experienced transfer to HD and 5502 (43%) experienced PD peritonitis. Compared with the use of conventional solutions only, the use of any form of N-pH/L-GDP solution was associated with reduced risks of all-cause mortality {adjusted hazard ratio [aHR] 0.67 [95% confidence interval (CI) 0.61-0.74]}, cardiovascular mortality [aHR 0.65 (95% CI 0.56-0.77)], infection-related mortality [aHR 0.62 (95% CI 0.47-0.83)] and transfer to HD [aHR 0.79 (95% CI 0.72-0.86)] but an increased risk of PD peritonitis [aHR 1.16 (95% CI 1.07-1.26)]. CONCLUSIONS: Patients who received N-pH/L-GDP solutions had decreased risks of all-cause and cause-specific mortality despite an increased risk of PD peritonitis. Studies assessing the causal relationships are warranted to determine the clinical benefits of N-pH/L-GDP solutions.

Association of Incremental peritoneal dialysis with residual kidney function decline in patients on peritoneal dialysis: The balANZ trial.

BACKGROUND: Incremental peritoneal dialysis (PD), defined as less than Full-dose PD prescription, has several possible merits, including better preservation of residual kidney function (RKF), lower peritoneal glucose exposure and reduced risk of peritonitis. The aims of this study were to analyse the association of Incremental and Full-dose PD strategy with RKF and urine volume (UV) decline in patients commencing PD. METHODS: Incident PD patients who participated in the balANZ randomised controlled trial (RCT) (2004-2010) and had at least one post-baseline RKF and UV measurement was included in this study. Patients receiving <56 L/week and ≥56 L/week of PD fluid at PD commencement were classified as Incremental and Full-dose PD, respectively. An alternative cut-point of 42 L/week was used in a sensitivity analysis. The primary and secondary outcomes were changes in measured RKF and daily UV, respectively. RESULTS: The study included 154 patients (mean age 57.9 ± 14.1 years, 44% female, 34% diabetic, mean follow-up 19.5 ± 6.6 months). Incremental and Full-dose PD was commenced by 45 (29.2%) and 109 (70.8%) participants, respectively. RKF declined in the Incremental group from 7.9 ± 3.2 mL/min/1.73 m2 at baseline to 3.2 ± 2.9 mL/min/1.73 m2 at 24 months (p < 0.001), and in the Full-dose PD group from 7.3 ± 2.7 mL/min/1.73 m2 at baseline to 3.4 ± 2.8 mL/min/1.73 m2 at 24 months (p < 0.001). There was no difference in the slope of RKF decline between Incremental and Full-dose PD (p = 0.78). UV declined from 1.81 ± 0.73 L/day at baseline to 0.64 ± 0.63 L/day at 24 months in the Incremental PD group (p < 0.001) and from 1.38 ± 0.61 L/day to 0.71 ± 0.46 L/day in the Full-dose PD group (p < 0.001). There was no difference in the slope of UV decline between Incremental and Full-dose PD (p = 0.18). CONCLUSIONS: Compared with Full-dose PD start, Incremental PD start is associated with similar declines in RKF and UV.

Associations, microbiology and outcomes of pre-training peritoneal dialysis-related peritonitis.

BACKGROUND: Pre-training peritonitis (PTP), defined as peritonitis that occurred after catheter insertion and before peritoneal dialysis (PD) training, is increasingly recognized as a risk factor for adverse patient outcomes, yet poorly understood with limited studies conducted to date. This study was conducted to identify the associations, microbiologic profiles and outcomes of PTP compared to post-training peritonitis. METHODS: This single-centre, case-control study involved patients with kidney failure who had PD as their first kidney replacement therapy and had experienced an episode of PD peritonitis between 1 January 2005 and 31 December 2015. Individuals experiencing their first episode of peritonitis were included in the study and categorized according to whether it occurred pre- or post-training. The primary outcome was peritonitis cure rates and composite outcome of hemodialysis (HD) transfer for ≥30 days or death. The secondary outcomes included catheter removal and refractory peritonitis rates. RESULTS: Among 683 patients who received PD for the first time, 121 (17.7%) had PTP while 265 (38.8%) had post-training peritonitis. PTP patients were more likely to have had exit-site infection (ESI) prior to peritonitis (24.8% compared to 17% in the post-training peritonitis group, p = 0.2). Culture-negative peritonitis was significantly more common in the PTP patients (53.7%) than in the post-training group (27.3%, p < 0.001). The cure was achieved in 68.9% of cases and was not significantly different between the PTP and post-training peritonitis groups (66.1% vs. 70.2%; OR 0.83, 95% CI 0.51-1.35). Lower odds of cure were associated with peritonitis caused by moderate and high severity organisms (OR 0.49, 95% CI 0.29-0.85; OR 0.18, 95% CI 0.08-0.43, respectively). Composite outcome of HD transfer or death was more commonly observed among patients with PTP (87.5% vs. 75.8%; OR 2.2, 95% CI 1.20-4.48) in whom significantly shorter median time to HD transfer was observed (PTP 10.7 months vs. post-training peritonitis 21.9 months, p < 0.0001). CONCLUSIONS: PTP is a common condition that is highly associated with preceding ESI, is frequently culture-negative and is associated with worse composite outcome of HD transfer or death. PTP rates should be routinely monitored and reported by PD units for continuous quality improvement.

Range and consistency of gastrointestinal outcomes reported in peritoneal dialysis trials: A systematic review.

BACKGROUND: Gastrointestinal (GI) health is considered vital to the success of peritoneal dialysis (PD) and is critically important to patients, caregivers and clinicians. However, the multiplicity of GI outcome measures in trials undermines the ability to evaluate the frequency, impact and treatment of GI symptoms in patients receiving PD. Therefore, this study aimed to assess the range and consistency of GI outcomes reported in contemporary PD trials. STUDY DESIGN: Systematic review. SETTING AND POPULATION: Individuals with kidney failure requiring PD. SELECTION CRITERIA: All randomised controlled trials involving patients on PD, identified from the PUBMED, EMBASE and COCHRANE Central Registry of controlled Trials (CENTRAL) database, from January 2010 to July 2022. INTERVENTIONS: Any PD-related intervention. OUTCOMES: The frequency and characteristics of GI outcome measures were analysed and classified. RESULTS: Of the 324 eligible PD trials, GI outcomes were only reported in 61 (19%) trials, mostly as patient-reported outcomes (45 trials; 74%). The most frequently reported outcomes were nausea in 27 (43%), diarrhoea in 26 (43%), vomiting in 22 (36%), constipation in 21 (34%) and abdominal pain in 19 (31%) of trials. PD peritonitis was the primary non-GI outcome reported in 24 (40%) trials, followed by death in 13 (21%) trials) and exit-site infection in 9 (15%) trials). Across all trials, 172 GI outcome measures were extracted and grouped into 29 different outcomes. Nausea and diarrhoea contributed to 16% and 15% of GI outcomes, respectively, while vomiting, constipation and abdominal pain contributed to 13%, 12% and 12%, respectively. Most (90%) GI outcomes were patient-reported adverse effects with no defined metrics. Faecal microbiome was reported as the primary study outcome in 3 (100%) trials using the subjective global assessment score, GI symptom rating scale and faecal microbiological and biochemical analysis. Two trials reported nausea as a primary study outcome using symptom assessment score (SAS) and kidney disease quality of life-short-form-36. One trial each reported anorexia and abdominal pain as the primary study outcome using SAS. Bowel habits, constipation and stool type were also reported as the primary study outcome in one trial each using the Bristol stool form scale. GI bleeding was reported as the secondary outcome in three (37%) out of eight trials reporting it. LIMITATIONS: Restricted sampling frame to focus on contemporary trials. CONCLUSIONS: Despite the clinical importance of GI outcomes among patients on PD, they are reported in only 19% of PD trials, using inconsistent metrics, often as patient-reported adverse events. Efforts to standardise GI outcome reporting are critical to optimising comparability, reliability and value of trial evidence to improve outcomes for patients receiving PD.

Study of early complications associated with peritoneal dialysis catheters: an analysis of the New Zealand Peritoneal Dialysis Registry data.

INTRODUCTION: Early peritoneal dialysis catheter (PDC)-related complications are frequent and make an important contribution to long-term PD survival. We aimed to analyse the incidence and specific causes of early PDC-related complications. METHODS: This study was conducted from January 2001 to December 2012, utilising the New Zealand PD Registry (NZPDR) data. The objectives of this study were to analyse the incidence and causes of PDC-related complications within 4 weeks and 3 months of insertion. A logistic regression analysis was conducted to analyse any demographic or clinical risk factors of early PDC-related complications. RESULTS: Of the 2573 PDC insertions during this period, majority 88% were surgically inserted. The number of complication within 4 weeks ranged from minimum of 20% to a maximum of 34% annually, with infections and flow dysfunctions leading the causes. There has been a minor drop in the infection rates from 19 to 16% (p = 0.21), and flow dysfunction from 12 to 9% (p = 0.16), from 2001 to 2012. A reduced odds of early complication was noted in elderly individuals above 60 years age, with odds ratio of (OR) of 0.73 (95% CI 0.53-0.99), while as higher odds of early complications were recorded in female gender, OR 1.41 (95% CI 1.06-1.88). Of the 10% of patients who failed to initiate PD within 90 days, flow dysfunction contributed to 32%, followed by infectious and surgical causes in 16% and 15%, respectively. The median time from insertion of PDC to initiation of PD was 17 days (interquartile range of 14-24 days) CONCLUSIONS: Improvements in PDC insertion techniques and reduction in infection rates may result in improvements in long-term PD technique survival.

Predictors of technique failure and mortality on peritoneal dialysis: An analysis of New Zealand peritoneal dialysis registry data.

AIM: Technique failure is a major disadvantage associated with peritoneal dialysis (PD). This study aimed to analyse the demographic and risk predictors of technique failure and mortality in patients on PD. METHODS: All incidental PD patients registered on the New Zealand Peritoneal dialysis registry (NZPDR) from January 1995 to December 2014 were included in the study. The primary outcomes were time to technique failure and its specific causes, while as the secondary outcome was time to death. Risk predictors of technique failure and mortality were analysed using multivariate Cox proportional hazards (PH) regression model. Besides, competitive risk regression analysis was undertaken to analyse the effect of death as a competing event to technique failure. RESULTS: Of 6379 patients, there were 2993 (46.9%) episodes of technique failure and 2684 (42%) deaths. The crude technique failure and mortality rates were 165 ± 5.90 and 147.9 ± 5.50 (mean ± SD)/1000 patient-years, respectively. Hazards of technique failure were lower in older individuals above 60 years, HR 0.72 (95% CI 0.67-0.79), larger centres, HR 0.89 (95% CI 0.79-1.00) and higher with coiled catheters, HR 1.26 (95% CI 1.16-1.37). Early nephrology referral, continuous ambulatory peritoneal dialysis (CAPD) and Asian ethnicities were associated with better technique survival. Infections were the major cause of technique failure (58.4%) with peritonitis being the leading cause (30.2%). CONCLUSION: There are multiple factors associated with risk of technique failure, therefore it is persuasive to construct a mathematical model for early prediction, for a planned transition to HD.

Rothia mucilaginosa: a rare cause of peritoneal dialysis-related peritonitis.

We report a peritoneal dialysis-related peritonitis infection with Rothia mucilaginosa (R. mucilaginosa), a Gram-positive germ belonging to the normal flora of the human oral cavity. Successful treatment was achieved by intraperitoneal administration of cephazolin. This case report illustrates the potential virulence of R. mucilaginosa in patients on peritoneal dialysis. We propose to routinely perform specific staining and prolonged culturing techniques for unusual germs such as R. mucilaginosa in patients with peritoneal dialysis-related peritonitis.

Recommendations for fasting in Ramadan for patients on peritoneal dialysis.

INTRODUCTION: The month of Ramadan holds great religious and social significance for Muslims all over the world. The aim of the present study was to provide a modified dialysis schedule for peritoneal dialysis (PD) patients that allows for fasting and that minimizes the effect on the patient's general health and volume status. METHODS: We observed 31 patients under treatment at the PD unit of King Khalid University Hospital, King Saud University, Riyadh. During the 3 - 4 weeks before the start of Ramadan, all patients were counseled individually and in detail about the possibility of fasting. They were also provided with clear instructions about fluid intake (up to 1 L daily) and avoiding a high-potassium diet. Of the 31 patients, 18 (10 women, 8 men) elected to fast during the month of Ramadan. The mean duration of fast in the study year (2009) in Riyadh, Saudi Arabia, was about 14 hours: from 0415 h (before sunrise) to 1800 h (after sunset). Depending on membrane type and patient preference, the fasting group was shifted to one of two regimens: Modified continuous ambulatory PD (8 patients): 3 exchanges during the night (1.36% or 2.27%), and icodextrin for a long dwell during the day. The first dialysis exchange was performed immediately after breaking the fast (1900 h), and the next at 2300 h. The final exchange was performed in the early morning before sunrise (0300 h), when the icodextrin was infused. Modified continuous cycling PD (10 patients): exchanges (1.36% or 2.27%) were performed over 6 - 7 hours, and icodextrin was infused for a long dwell during the day. The patient connected to the cycler at 2000 h or 2100 h, and therapy finished at nearly 0300 h, with icodextrin as the last fill. RESULTS: Of the study patients, 2 were admitted because of peritonitis (1 in each modality group), and the modified therapy was discontinued. In the modified CCPD group, 1 patient (on PD for 1 month before Ramadan) developed PD-related pleural effusion (proved by pleural fluid analysis), and PD was consequently discontinued. Hypotension developed in 2 patients of the CAPD group and 1 of the CCPD group during the first 2 weeks. In the CCPD group, 1 patient presented with lower limb edema and mild fluid overload. Overall, PD patients that opted to fast during Ramadan did not experience any serious morbidity or deterioration in renal function during their period of observance. No biochemical parameters or clearance studies showed a statistically significant p value. CONCLUSIONS: In view of the study findings, we conclude that most stable patients on PD can fast, provided that they strictly adhere to their medications and dialysis therapy in addition to the dietary restrictions. These patients should be followed closely to detect any complications and to ensure that adequate fluid and electrolyte balance are maintained.

Effects of concomitant hepatitis C virus infection in patients with underlying lupus nephritis on long-term renal outcome.

BACKGROUND: Despite recent advances in the management of lupus nephritis (LN), these unfortunate patients are at a higher risk of developing chronic kidney disease (CKD). Concomitant chronic hepatitis C virus (HCV) infection is associated with adverse outcome in patients with LN and further compounds the risk as some of these patients choose to undergo kidney transplantation in the near future. Objectives. The aim of the present study is to evaluate the long-term impact of chronic HCV infection in patients with underlying Class IV LN on renal function, progression to end-stage renal disease (ESRD) and patient survival. METHODS: Retrospective analysis of the medical records of 134 nondialysis-dependent patients with biopsy-proven World Health Organization Class IV LN with chronic HCV infection was done from January 1995 to January 2008 at King Khalid University Hospital, Riyadh, Saudi Arabia. Primary and the secondary end points were death or the development of ESRD. The patients were followed over a period of 6.7 ± 3.3 (1-14.4) years. RESULTS: From a total of 134 biopsy-proven Class IV LN patients, 15 (11.2%) patients were HCV positive of which 2 (13.3%) patients were male and 13 (86.7%) patients were female. One hundred and nineteen (88.8%) patients were HCV negative of which 17 (14.3%) were male and 102 (85.7%) were female. The mean age was 32.47 ± 11.8 years. Eight (53.3%) patients in the HCV-positive group versus 19 (22.6%) patients in the HCV-negative group progressed to severe renal impairment with serum creatinine >350 µmol/L (P = 0.024). A total of 8 (53.3%) patients in the HCV-positive group versus 18 (17.3%) in HCV-negative group progressed to ESRD (P = 0.005). The mean creatinine clearance was higher (43.3 ± 33 mL/min) in the HCV-negative LN group at last follow-up than in the HCV-positive patients (25 ± 34.9 mL/min) with a statistically significant P-value of 0.0463. Five patients (33.3%) with HCV-positive LN died in comparison to eight (7.6%) patients who were HCV negative P = 0.03; however, the cause of hospital mortality was mainly cardiovascular disease (CVD) and infection and none of the patients died of chronic liver disease, although there was significant deterioration of the liver function at the end of the study. Kaplan-Meier survival estimates showed a significantly inferior renal function and rapid deterioration to ESRD in LN patients with concomitant HCV infection, with a dialysis free survival of 95 and 80% for the HCV-negative group and 90 and 65% for the HCV-positive groups at the end of 5 and 10 years respectively, with a highly significant P-value of <0.05 at the end of 10 years. CONCLUSION: The present study highlights that concomitant HCV infection in patients with LN is associated with worse renal outcome, higher rate of progression to ESRD and reduced patient survival.

Hepatitis C and kidney disease.

Multiple extrahepatic manifestations have been associated with chronic hepatitis C, the most important among them being cryoglobulinemia, glomerulonephritis, porphyria cutanea tarda, lichen planus, seronegative arthritis, and lymphoproliferative disorders as in the sudies of Bonkovsky and Mehta (2001) and El-Serag et al. (2002). We will discuss in this paper chronic hepatitis C- related kidney disease and course and management of patients with chronic hepatitis C in special circumstances like hemodialysis and kidney transplantation.

Adverse impact of pretransplant polyoma virus infection on renal allograft function.

BACKGROUND: BK polyoma virus (BKV) has emerged as an important cause of acute and chronic allograft injury in renal transplant recipients. Reactivation of latent infection requires reduction in cell-mediated immunity. We hypothesized that BKV could get reactivated in the urinary tract of patients with end-stage renal disease (ESRD) and impact the allograft function after these individuals undergo transplantation. METHODS: We prospectively examined the urine specimens of 68 ESRD patients and their donors for BKV inclusion containing decoy cells with Papanicoulau staining and immunohistochemistry. Polymerase chain reaction was carried out to confirm the presence of viral DNA. Urine examination was repeated 3-9 months after transplantation and during episodes of graft dysfunction. All graft dysfunction episodes were investigated by biopsy. BKV-associated nephropathy was confirmed by immunoperoxidase staining. Graft loss and doubling of serum creatinine were the study end-points. RESULTS: Decoy cells were detected in 22 ESRD patients and four donors (P < 0.0001). All 22 continued decoy cell excretion after transplantation and two fresh excreters were noted. Patients exhibiting decoy cells had more frequent graft dysfunction episodes (67% vs 30%, P = 0.003) and higher serum creatinine value (P < 0.001). About 33% patients achieved the combined end-points in the BK viruria group, compared with 11% in the non-decoy cell excreters (P = 0.03). Histologically proved BKV nephropathy was noted in 7% cases; all decoy cell excreters. CONCLUSION: We conclude that reactivation of latent BKV infection can occur in ESRD and confers an increased risk of graft dysfunction after transplantation. The mechanism of graft dysfunction in decoy cell excreters who do not develop overt nephropathy needs more studies.

Horner's syndrome following internal jugular vein dialysis catheter insertion.

Common complications that can occur following internal jugular vein catheterization used for hemodialysis (HD) include internal carotid artery puncture, thrombosis, and infection. We present a case of Horner's syndrome following internal jugular venous cannulation as a possible complication.

Oxalosis presenting as early renal allograft failure.

Hyperoxaluria can result in the deposition of oxalate in bones, arteries, eyes, heart, nerves, kidneys and other structures when there is a reduction in glomerular filtration rate. Liver and kidney transplantation is curative for patients with Type I primary hyperoxaluria. Here we report a case of recurrent oxalosis in a post-transplant kidney with early graft failure in an adult male.