RESUMO
BACKGROUND: The prevalence of peritoneal dialysis (PD) in Thailand is increasing rapidly in part because of Thailand's Peritoneal Dialysis First policy. PD is a home-based renal replacement therapy in which patients with chronic kidney disease perform up to 4 exchanges of dialysate fluid per day in the peritoneal cavity. Overhydration is one of the most common complications in patients on PD and is associated with increased morbidity and mortality. To monitor hydration status, patients collect hydration metrics, including body weight, blood pressure, urine output, and ultrafiltration volume, from each dialysis cycle and enter this information into a PD logbook. This information is reviewed bimonthly at PD clinic appointments. The chronic kidney disease-PD (CKD-PD) app with near-field communication (NFC) and optical character recognition (OCR) was developed to automate hydration metric collection. The information was displayed in the app for self-monitoring and uploaded to a database for real-time monitoring by the PD clinic staff. Early detection and treatment of overhydration could potentially reduce the morbidity and mortality related to overhydration. OBJECTIVE: This study aims to identify usability issues and technology adoption barriers for the CKD-PD app with NFC and OCR and a monitoring system and to use this information to make rapid cycle improvements. METHODS: A multidisciplinary team of nephrologists, PD clinic nurses, computer programmers, and engineers trained and observed 2 groups of 5 participants in the use of the CKD-PD app with NFC and OCR and a monitoring system. The participants were observed using technology in their homes in 3 phases. The data collected included the Unified Theory of Acceptance and Use of Technology questionnaire, think-aloud observation, user ratings, completion of hydration metrics, and upload of hydration metrics to the central database. These results were used by the team between phases to improve the functionality and usefulness of the app. RESULTS: The CKD-PD app with NFC and OCR and a monitoring system underwent 3 rapid improvement cycles. Issues were identified regarding the usability of the NFC and OCR data collection, app stability, user interface, hydration metric calculation, and display. NFC and OCR improved hydration metric capture; however, issues remained with their usability. App stability and user interface issues were corrected, and hydration metrics were successfully uploaded by the end of phase 3. Participants' scores on technology adoption decreased but were still high, and there was enthusiasm for the self-monitoring and clinical communication features. CONCLUSIONS: Our rapid cycle process improvement methodology identified and resolved key barriers and usability issues for the CKD-PD app with NFC and OCR and a monitoring system. We believe that this methodology can be accomplished with limited training in data collection, statistical analysis, and funding.
RESUMO
BACKGROUND: Based on current ISPD guidelines, it is unclear as to whether ceftazidime should be discontinued in subsequent management of culture-negative peritonitis if it is used as empirical gram-negative coverage. Herein, we aim to compare the clinical outcomes of cefazolin plus ceftazidime versus cefazolin alone. METHODS: This was a retrospective cohort study. Adult peritoneal dialysis (PD) patients who were diagnosed with culture-negative peritonitis between 2014 and 2020 were included. Patients were categorized into two groups according to treatment regimen. Primary response rate, peritonitis relapse rate, and time to primary response were compared. Factors that predicted primary response were determined using Cox regression analysis. RESULTS: A total of 58 patients were included in the study. Of these, 42 received cefazolin plus ceftazidime and 16 received cefazolin monotherapy. Overall, the mean age was 65.7±10.4 years. Most of the patients (81.3%) were prescribed continuous ambulatory peritoneal dialysis. Initial effluent WBC was 4211±10357 in the combination group and 3833±6931 cell/mm3 in the monotherapy group (p=0.89). There was no significant difference in primary response at day 5 between the two groups (95.2% in the combination group vs93.7% in the monotherapy group, p=0.82). However, cumulative probability of primary response by the Kaplan-Meier analysis in the combination group was higher than in the monotherapy group (p=0.02). Adjusted HR of serum potassium level to predict a primary response was 1.83 according to multivariate analysis (p=0.03). There was no difference between the two groups in terms of peritonitis relapse or catheter removal. CONCLUSION: This is the first study to compare clinical outcomes between cefazolin plus ceftazidime versus cefazolin monotherapy in culture-negative peritonitis. Our results suggest that if peritonitis is resolving at day 3, discontinuation of ceftazidime could yield favorable treatment outcomes and might be appropriate for subsequent management. However, the risk of not having gram-negative coverage should be considered.