Fasting blood glucose level and risk of all-cause and cause-specific mortality in peritoneal dialysis patients.

BACKGROUND: Glycemic control is crucial in peritoneal dialysis (PD) patients with diabetes. Although fasting blood glucose (FBG) is the most commonly used index to measure blood glucose levels, there is currently no evidence supporting the association between FBG level and mortality risk in PD patients. METHODS: A total of 3548 diabetic PD patients between 2002 and 2018 were enrolled from the National Health Insurance Service database of Korea. We investigated the association between FBG levels and the risk of all-cause and cause-specific mortality. RESULTS: Patients with FBG levels 80-99 mg/dL exhibited the highest survival rates, whereas those with FBG levels ≥180 mg/dL had the lowest survival rates. Compared with FBG levels 80-99 mg/dL, the adjusted hazard ratios and 95% confidence interval for all-cause mortality significantly increased as follows: 1.02 (0.87-1.21), 1.41 (1.17-1.70), 1.44 (1.18-2.75), and 2.05 (1.73-2.42) for patients with FBG 100-124 mg/dL, FBG 125-149 mg/dL, FBG 150-179 mg/dL, and FBG ≥180 mg/dL, respectively. The risk for all-cause mortality also showed an increasing pattern in patients with FBG levels <80 mg/L. The risk of cardiovascular death significantly increased as FBG levels exceeded 125 mg/dL. However, the risk of infection-related and malignancy-related deaths did not show a significant increase with increasing FBG levels. CONCLUSION: There was an increase in the risk of all-cause mortality as FBG levels exceeded 125 mg/dL in PD patients with diabetes, and the risk of cardiovascular death showed a strong correlation with FBG levels compared with other causes of death.

Inflammation and all-cause mortality in patients undergoing peritoneal dialysis.

OBJECTIVE: This study aimed to evaluate inflammatory biomarkers in patients undergoing peritoneal dialysis and investigate their association with all-cause mortality or transfer to hemodialysis. METHODS: This prospective cohort study included 43 patients undergoing peritoneal dialysis. Plasma levels of cytokines were measured using flow cytometry and capture enzyme-linked immunosorbent assay. Biomarkers were categorized based on their respective median values. Survival analysis was conducted using the Kaplan-Meier estimator, considering two outcomes: all-cause mortality and transfer to hemodialysis. RESULTS: After adjusting for confounding factors, plasma levels above the median of the levels of CCL2 and plasma, as well as below the median of TNF-α, and the median of dialysate IL-17 levels, were associated with an increased risk of experiencing the specified outcomes after approximately 16 months of follow-up. CONCLUSION: These findings suggest that inflammatory biomarkers may be a valuable tool for predicting all-cause mortality and transfer to hemodialysis in patients undergoing peritoneal dialysis.

Abnormal iron status is associated with an increased risk of mortality in patients on peritoneal dialysis.

BACKGROUND AND AIMS: Iron deficiency is prevalent, but there is limited data about the relationship between iron status and poor outcomes in chronic kidney disease patients undergoing peritoneal dialysis (PD). We aimed to investigate the association between iron status and mortality in PD patients. METHODS AND RESULTS: This retrospective study was conducted on incident PD patients from January 2006 to December 2016 and followed up until December 2018. Patients were categorized into four groups according to baseline serum transferrin saturation (percent) and ferritin levels (ng/ml): reference (20-30%, 100-500 ng/ml), absolute iron deficiency (<20%, <100 ng/ml), function iron deficiency (FID) (<20%, >100 ng/ml), and high iron (>30%, >500 ng/ml). Among the 1173 patients, 77.5% had iron deficiency. During a median follow-up period of 43.7 months, compared with the reference group, the FID group was associated with increased risk for all-cause [adjusted hazard ratio (aHR) 1.87, 95% confidence interval (95% CI) 1.05-3.31, P = 0.032], but not cardiovascular (CV) mortality. Additionally, the high iron group had a more than four-fold increased risk of both all-cause and CV mortality [aHR 4.32 (95% CI 1.90-9.81), P < 0.001; aHR 4.41 (95% CI 1.47-13.27), P = 0.008; respectively]. CONCLUSION: FID and high iron predict worse prognosis of patients on PD.

Outcome and Safety of Unplanned-Start Peritoneal Dialysis according to Break-In Periods: A Systematic Review and Meta-Analysis.

INTRODUCTION: The best timing of peritoneal dialysis (PD) initiation after catheter implantation is still controversial. It is necessary to explore whether there exists a waiting period to minimize the risk of complications. METHODS: A systematic review and meta-analysis were searched in multiple electronic databases published from inception to February 29, 2020, to identify cohort studies for evaluating the outcome and safety of unplanned-start PD (<14 days after catheter insertion). Risks of bias across studies were evaluated using Newcastle-Ottawa Quality Assessment Scale. RESULTS: Fourteen cohort studies with a total of 2,401 patients were enrolled. We found that early-start PD was associated with higher prevalence of leaks (RR: 2.67, 95% CI, 1.55-4.61) and omental wrap (RR: 3.28, 95% CI, 1.14-9.39). Furthermore, patients of unplanned-start PD in APD group have higher risk of leaks, while those in CAPD group have a higher risk of leaks, omental wrap, and catheter malposition. In shorter break-in period (BI) group, the risk of suffering from catheter obstruction and malposition was higher for patients who started dialysis within 7 days after the surgery than for patients within 7-14 days. No significant differences were found in peritonitis (RR: 1.00; 95% CI, 0.78-1.27) and exit-site infections (RR: 1.12; 95% CI, 0.72-1.75). However, shorter BI was associated with higher risk of mortality and transition to hemodialysis (HD) while worsen early technical survival, with pooled RR of 2.14 (95% CI, 1.52-3.02), 1.42 (95% CI, 1.09-1.85) and 0.95 (95% CI, 0.92-0.99), respectively. CONCLUSIONS: Evidence suggests that patients receiving unplanned-start PD may have higher risks of mechanical complications, transition to HD, and even mortality rate while worsening early technical survival, which may not be associated with infectious complications. Rigorous studies are required to be performed.

Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single centre in Turkey

Background/aim: The aim of this study was to evaluate the clinical outcomes and identify the predictors of mortality in peritoneal dialysis patients. Materials and methods: Medical records of all incident peritoneal dialysis (PD) patients followed up between January 2011 and May 2019 were reviewed retrospectively. All patients were followed up until death, renal transplantation, transfer to haemodialysis or the end of the study. Results: A total of 242 patients were included in the study. The incidence of peritonitis was 0.18 (ranging from 0 to 14.9) episodes per patient year. Death occurred in 28% (n: 68) of cases. Age, diabetes mellitus, malignancy and refractory heart failure were independent risk factors for all-cause mortality according to multivariate analysis. The presence of comorbid disease and diabetes mellitus and patients aged > 65 years were associated with increased risk of mortality and decreased patient survival. Peritonitis history was associated with increased risk of mortality. Between peritonitis and peritonitis-free group, there was no significant difference in Kaplan-Meier curves in terms of patient survival. Conclusion: This is the first study to define 9-year mortality predictors in PD patients in our centre. Although peritonitis is the most feared complication of PD, our study showed that peritonitis did not reduce patient survival.

Albumin-globulin ratio and mortality in patients on peritoneal dialysis: a retrospective study.

BACKGROUND: Albumin-globulin ratio (AGR), a variable based on serum albumin and non-albumin proteins, has been demonstrated as a predictor of mortality in patients with malignant neoplasm. The aim of this study was to evaluate the prognostic value of AGR on peritoneal dialysis (PD) patients. METHODS: We retrospectively analyzed 602 incident PD patients from January 1st, 2008, to December 31st, 2017, at our center and followed them until December 31st, 2018. Kaplan-Meier curves and multivariate Cox regression models were applied to analyze the association between AGR and all-cause of mortality and cardiovascular mortality. RESULTS: The median follow-up time was 32.17 (interquartile range = 32.80) months. During follow-up, 131 (21.8%) patients died, including 57 patients (43.5%) who died due to cardiovascular diseases. Kaplan-Meier curves showed that patients with AGR > 1.26 had better rates of survival than those with AGR ≤ 1.25 (p < 0.001). After adjusting for potential confounders, the lower AGR level was significantly associated with an increased all-cause and cardiovascular mortality [hazard ratio (HR): 1.57, 95% confidence interval (CI): 1.07-2.32, p = 0.022 and HR: 2.01, 95% CI: 1.10-3.69, p = 0.023 respectively]. CONCLUSIONS: Patients with a low AGR level had an increased all-cause and cardiovascular mortality. AGR may be a useful index in identifying patients on PD at risk for CVD and all-cause of mortality.

Seasonal variations in cause-specific mortality and transition to renal replacement therapy among patients with end-stage renal disease.

Despite some studies showing seasonal variations in mortality and the transition to renal replacement therapy in patients with end-stage renal disease, detailed evidence is still scarce. We investigated seasonal variations in patients with end-stage renal disease using a large Japanese database for dialysis patients. We compared the fractions of all-cause and cause-specific mortality and the transition to renal replacement therapy among seasons and performed a mixed-effects Poisson regression analysis to compare the mortality among seasons after adjustment for some variables. The initiation of hemodialysis was highest in winter and lowest in summer. Seasonality in the initiation of peritoneal dialysis and transition to kidney transplantation differed from hemodialysis. All-cause mortality was highest in the winter and lowest in the summer. Death from coronary artery disease, heart failure, cerebral hemorrhage, and infectious pneumonia had similar seasonality, but death from cerebral infarction, septicemia, or malignant tumor did not have similar seasonality. In conclusion, the initiation of hemodialysis, all-cause mortality, and mortality from coronary heart disease, heart failure, cerebral hemorrhage, and infectious pneumonia were significantly highest in winter and lowest in summer. However, the initiation of peritoneal dialysis, transition to kidney transplantation, or mortality from cerebral infarction, septicemia, or malignant tumor did not have similar seasonal variations.

Hemodialysis and peritoneal dialysis access related outcomes in the pediatric and adolescent population.

BACKGROUND: There is paucity of comparative data on the objective performance of arteriovenous fistulas (AVF), grafts (AVG), hemodialysis (HD) catheter and peritoneal dialysis (PD) catheter in the pediatric population. METHODS: A retrospective analysis of all patients <21 years in the United States Renal Database System who had an AVF, AVG, HD catheter or PD catheter placed for dialysis access between 1/2007 and 12/2014 was performed. Multivariable cox regression was used to evaluate mortality, patency (primary, primary-assisted and secondary), maturation and catheter survival. RESULTS: The 11,575 patients studied comprised of 9445 (82%) HD, 1435 (12%) PD, 528 (4.6%) HD to PD and 167 (1.4%) PD to HD patients. The HD subcohort comprised of 1296 (13.7%) AVF initiates, 199 (2.1%) AVG initiates, 1347 (14.3%) AVF converts after initial HD catheter use, 292 (3.1%) AVG converts and 6311 (67%) patients who persistently utilized HD catheters. There was no difference between PD and HD in patients 0-5 (aHR: 1.36; 95% CI: 0.89-2.07; P = 0.15) and 6-12 years (aHR: 1.05; 95% CI: 0.72-1.52; P = 0.8). However, PD was associated with 73% and 76% increase in mortality relative to HD among patients in the 13-17 (aHR: 1.73; 95% CI: 1.35-2.21; P < 0.001) and 18-20 (aHR: 1.76; 95% CI: 1.38-2.24; P < 0.001) age categories. AVG was associated with 78% increase in mortality compared to AVF (aHR: 1.78; 95% CI: 1.41-2.25; P < 0.001). Persistent use of HD catheters was associated with 29% increase in mortality (aHR: 1.29; 95% CI: 1.07-1.57; P = 0.009) compared to initiation and persistent use of AVF. Conversion from HD catheter to AVF was associated with 66% decrease in mortality compared to persistent HD catheter use (aHR: 0.34; 95% CI: 0.28-0.40; P < 0.001). Primary, primary assisted and secondary patency were higher for AVF compared to AVG. CONCLUSION: There was no difference in risk adjusted mortality between HD and PD in children less than 13 years. PD is associated with higher mortality compared to HD in adolescents. Initiation of HD with AVF is associated with better patency and patient survival relative to AVG and persistent use of HD catheters in pediatric patients irrespective of transplant potential. Conversion from HD catheter to AVF or AVG in patients who inevitably initiate HD with a catheter is associated with better survival compared to persistent HD catheter use. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Influence of Peritoneal or Hemodialysis on Results of Simultaneous Pancreas and Kidney Transplant.

OBJECTIVES: The influence of peritoneal dialysis on outcomes after simultaneous pancreas and kidney transplant is still vague. In addition, whether peritoneal dialysis leads to a higher risk of infectious complications and higher mortality rates in these transplant patients has not been unambiguously confirmed. In this study, our aim was to verify whether dialysis type determined outcomes on the pancreas graft and whether dialysis type was a risk factor for graftectomy or recipient death. MATERIALS AND METHODS: Our study group included 44 simultaneous pancreas and kidney transplant patients. Analyzed parameters included type and duration of dialysis treatment, age, sex, long-term pancreas graft survival and patient survival, overall mortality, and number of graftectomies. RESULTS: Of 44 patients, 3 (7%) required a graftectomy. Mortality rate of the group was 5%. Of 44 patients, 33 had hemodialysis and 11 had peritoneal dialysis. In those who had hemodialysis, the mean duration of renal replacement therapy was 30.5 months, which was significantly longer than duration for those who had peritoneal dialysis (20.4 mo; P < .01). There were 3 graftectomies and 1 death in the hemodialysis group. In the peritoneal dialysis group, there were no graftectomies and 1 death, with no significant differences in the number of graftectomies and mortality rates between the groups. Long-term survival also did not differ between the groups. CONCLUSIONS: We found that type of dialysis did not affect outcomes in our group of simultaneous pancreas and kidney transplant patients. Before transplant, each patient requires an individual approach to treatment. The type of dialysis performed should not be viewed as a contradiction for transplant.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy. METHODS: We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters. RESULTS: More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group. CONCLUSIONS: Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

A comparison of technique survival in Canadian peritoneal dialysis and home hemodialysis patients.

BACKGROUND: High discontinuation rates remain a challenge for home hemodialysis (HHD) and peritoneal dialysis (PD). We compared technique failure risks among Canadian patients receiving HHD and PD. METHODS: Using the Canadian Organ Replacement Register, we studied adult patients who initiated HHD or PD within 1 year of beginning dialysis between 2000 and 2012, with follow-up until 31 December 2013. Technique failure was defined as a transfer to any alternative modality for a period of ≥60 days. Technique survival between HHD and PD was compared using a Fine and Gray competing risk model. We also examined the time dependence of technique survival, the association of patient characteristics with technique failure and causes of technique failure. RESULTS: Between 2000 and 2012, 15 314 patients were treated with a home dialysis modality within 1 year of dialysis initiation: 14 461 on PD and 853 on HHD. Crude technique failure rates were highest during the first year of therapy for both home modalities. During the entire period of follow-up, technique failure was lower with HHD compared with PD (adjusted hazard ratio = 0.79; 95% confidence interval 0.69-0.90). However, the relative technique failure risk was not proportional over time and the beneficial association with HHD was only apparent after the first year of dialysis. Comparisons also varied among subgroups and the superior technique survival associated with HHD relative to PD was less pronounced in more recent years and among older patients. Predictors of technique failure also differed between modalities. While obesity, smoking and small facility size were associated with higher technique failure in both PD and HHD, the association with age and gender differed. Furthermore, the majority of discontinuation occurred for medical reasons in PD (38%), while the majority of HHD patients experienced technique failure due to social reasons or inadequate resources (50%). CONCLUSIONS: In this Canadian study of home dialysis patients, HHD was associated with better technique survival compared with PD. However, patterns of technique failure differed significantly among these modalities. Strategies to improve patient retention across all home dialysis modalities are needed.

Long-term remission of bilateral Wilms tumors that developed from premature separation of chromatids/mosaic variegated aneuploidy syndrome due to bilateral nephrectomy and peritoneal dialysis.

We report a 38-month-old Japanese male with premature chromatid separation/mosaic variegated aneuploidy syndrome bearing biallelic BUB1B germline mutations who suffered from bilateral Wilms tumor. After right nephrectomy, dactinomycin monotherapy was administered for the left Wilms tumor; however, severe adverse reaction prevented the patient from receiving further chemotherapy. Left nephrectomy was then performed without postoperative chemotherapy. The patient survived for 15 months after bilateral nephrectomy without peritoneal relapse, metastasis of Wilms tumor, or the occurrence of rhabdomyosarcoma and maintained a good quality of life while receiving peritoneal dialysis at home.

Peritoneal Dialysis Vs Diuretics in Children After Congenital Heart Surgery.

BACKGROUND: This study sought to evaluate outcomes of patients undergoing congenital heart surgery who underwent peritoneal dialysis (PD) vs a diuretic regimen. METHODS: This study conducted a comprehensive search in Medline, EMBASE, Scopus, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews from the databases' inception through April 24, 2018. Independent reviewers selected studies and extracted data. A random effects meta-analysis was performed to pool the outcomes of interest across studies. RESULTS: A total of 8 studies (2 prospective studies, 2 randomized clinical trials, and 4 retrospective studies) with 507 patients were included in this review. A total of 204 (40%) patients underwent PD, whereas the remaining patients underwent fluid removal with diuretics. The analyses demonstrated a significantly shorter time of mechanical ventilation in those patients who underwent PD (mean difference, -1.25 days; 95% confidence interval, -2.18 to -0.33; P = .008) and increased odds of mortality (odds ratio, 2.27; 95% confidence interval, 1.13 to 4.56; P = .02) compared with the diuretic group. No differences were identified in terms of incidence of negative fluid balance by postoperative day 1, presence of peritonitis, and intensive care unit length of stay. CONCLUSIONS: The meta-analysis did not identify differences between the 2 groups with regard to negative fluid balance after postoperative day 1, incidence of peritonitis, or length of intensive care unit stay. There is a need for large, prospective, multicenter studies to evaluate the benefits and complications associated with PD use further in selected children after congenital heart surgery. Because some of the outcomes were present in only 2 studies, results from the pooled analysis may be underpowered.

Icodextrin Is Associated with a Lower Mortality Rate in Peritoneal Dialysis Patients.

Background:Icodextrin (ICO) improves fluid removal in peritoneal dialysis (PD) patients. However, whether physiological benefits of ICO translate into patient survival remains unclear. We examine the association of ICO and clinical outcomes.Methods:We identified patients who initiated long-term PD from the National Health Insurance Research Database of Taiwan. We matched ICO users with non-users according to propensity score and survival status when ICO was prescribed. We utilized time-dependent analyses to avoid immortal time bias. Additional competing risk models were utilized for the outcomes except for death. The outcomes of interest were time to death, technique failure, peritonitis, major adverse cardiovascular events (MACE), and hospitalization.Results:A total of 4,914 PD patients were enrolled and 2,836 PD patients (57.7%) were identified as ICO users. The ICO users had significantly better overall survival (hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.63 - 0.86), especially among early ICO users (HR 0.64; 95% CI 0.54 - 0.77, p value for interaction: 0.007). The ICO users were associated with higher risk of peritonitis (subdistribution HR 1.22, 95% CI 1.06 - 1.14) and hospitalization (subdistribution HR 1.14, 95% CI 1.05 - 1.24), considering competing risk of death. However, when considering ICO use as a time-varying covariate, ICO users shared similar risks for technique failure, peritonitis, MACE, and hospitalization as non-users. The effect of ICO on mortality was especially prominent among those early users.Conclusions:After adjustments for immortal time biases, ICO users were significantly associated with approximately 20% reduction in mortality, especially among early users.

Outcomes for peripheral vascular intervention and lower extremity bypass in kidney transplant recipients are superior to outcomes of patients remaining on dialysis.

BACKGROUND: Improved survival is reported for patients with end-stage renal disease who are kidney transplant recipients (KTRs) compared with dialysis-dependent patients (DDPs). Whether amputation-free survival (AFS) and freedom from major adverse limb events (MALEs) after peripheral vascular intervention (PVI) or lower extremity bypass (LEB) are superior after renal transplantation remains incompletely defined. METHODS: A retrospective cohort study was undertaken of KTRs and DDPs undergoing infrainguinal PVI or LEB for symptoms of limb-threatening ischemia recorded in the Vascular Quality Initiative from 2003 to 2017. Primary outcomes were AFS and freedom from MALEs along with their components of assisted primary patency, limb salvage, and patient survival. The χ2 tests and independent samples t-tests were used to compare demographic variables. Kaplan-Meier survival analyses were used to estimate outcomes, and Cox regression analyses were used to confirm independent predictors of outcome. RESULTS: There were 2707 PVI (351 KTRs and 2356 DDPs) and 1444 LEB (198 KTRs and 1246 DDPs) procedures performed for limb-threatening ischemia. Chronic obstructive pulmonary disease, congestive heart failure, female patients, and African Americans were more common among the DDP group, as were lower preoperative hemoglobin values and older age. After PVI, KTRs had better AFS than DDPs (42% vs 66% at 1 year, 15% vs 26% at 2 years; hazard ratio [HR], 1.91; 95% confidence interval [CI], 1.38-2.64; P < .001) and fewer MALEs (53% vs 64% at 1 year, 35% vs 49% at 18 months; HR, 1.71; 95% CI, 1.25-2.34; P = .001). PVI outcomes, AFS, and freedom from MALEs were driven primarily by differences in limb salvage and patient survival but not assisted primary patency. After LEB, KTRs also displayed improved AFS compared with DDPs (44% vs 65% at 1 year, 10% vs 36% at 3 years; HR, 2.32; 95% CI, 1.41-3.81; P = .001), driven by patient survival but not limb salvage, whereas differences in freedom from MALEs did not attain statistical significance (67% vs 58%; P = .08). CONCLUSIONS: For patients with end-stage renal disease, subsequent kidney transplantation was associated with better AFS and freedom from MALEs after PVI but only improved AFS after LEB. Open or endovascular revascularization can be advocated in patients with limb-threatening ischemia who have received kidney transplantation to a greater degree than in those who remain dialysis dependent.

Outcomes of patients with autosomal-dominant polycystic kidney disease on peritoneal dialysis: A meta-analysis.

BACKGROUND: Complications related to peritoneal dialysis (PD) in patients with autosomal-dominant polycystic kidney disease (ADPKD), including intraperitoneal rupture of renal cyst, hernia, membrane failure and peritonitis, have been reported. However, long-term clinical outcomes of ADPKD patients on PD remain unclear. We performed this meta-analysis to assess the risks of death, technique failure and peritonitis in ADPKD patients on PD. METHODS: A systematic review was conducted using MEDLINE, EMBASE and Cochrane databases from inception to October 2017 to identify studies that evaluated the outcomes of ADPKD patients on PD, including the risks of death, technique failure and peritonitis. Non-ADPKD patients on PD were used as controls. Effect estimates from the individual study were extracted and combined using the random-effect, generic inverse variance method of DerSimonian and Laird. RESULTS: Twelve cohort studies with a total of 14 673 patients on PD (931 ADPKD and 13 742 non-ADPKD patients) were enrolled. Compared with non-ADPKD status, ADPKD was associated with significantly decreased mortality risk with pooled odds ratio (OR) of 0.68 (95% confidence interval (CI), 0.53-0.86; I2 = 0). There were no associations of ADPKD with the risks of technique failure of PD and peritonitis with pooled OR of 0.93 (95% CI, 0.79-1.10; I2 = 0) and 0.88 (95% CI, 0.75-1.05; I2 = 0), respectively. We found no publication bias as assessed by Egger's regression asymmetry test, with P = 0.90, 0.28 and 0.60 for the risks of mortality, technique failure and peritonitis in ADPKD patients on PD, respectively. CONCLUSION: Compared with non-ADPKD patients on PD, our study demonstrates that ADPKD patients on PD have 0.68-fold decreased mortality risk. There are no associations of ADPKD status with the risks of technique failure or peritonitis.

Renal Replacement Therapy Modalities in Critically Ill Children.

OBJECTIVES: The objective of this study is to describe the relative frequency of use of continuous renal replacement therapy, intermittent hemodialysis, and peritoneal dialysis and to analyze characteristics and outcomes of critically ill children receiving renal replacement therapies admitted to PICUs that participate in the Virtual PICU (VPS LLC, Los Angeles, CA) registry. DESIGN: Retrospective, database analysis. SETTING: PICUs that participate in the Virtual PICU (VPS LLC) registry. PATIENTS: Critically ill children admitted to PICUs that participate in the Virtual PICU (VPS LLC) registry and received renal replacement therapy from January 1, 2009, to December 31, 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 7,109 cases (53% males) received renal replacement therapy during the study period. The median age was 72.3 months (interquartile range, 8.4-170 mo) and median length of stay was 8.7 days (interquartile range, 3.3-21.2 d). Caucasians comprised 42% of the cohort and blacks and Hispanics were 16% each. Continuous renal replacement therapy was used in 46.5%, hemodialysis in 35.5% and peritoneal dialysis in 18%. Of the 7,109 cases, 1,852 (26%) were postoperative cases (68% cardiac surgical) and 981 (14%) had a diagnosis of cancer. Conventional mechanical ventilation was used in 64%, high-frequency oscillatory ventilation in 12%, noninvasive ventilation in 24%, and extracorporeal membrane oxygenation in 5.8%. The overall mortality was 22.3%. Patients who died were younger 40.8 months (interquartile range, 1.5-159.4 mo) versus 79.9 months (interquartile range, 12.6-171.7 mo), had a longer length of stay 15 days (interquartile range, 7-33 d) versus 7 days (interquartile range, 3-18 d) and higher Pediatric Index of Mortality 2 score -2.84 (interquartile range, -3.5 to -1.7) versus -4.2 (interquartile range, -4.7 to -3.0) (p < 0.05). On multivariate logistic regression analysis, higher mortality was associated with the presence of cancer (32.7%), previous ICU admission (32%), requiring mechanical ventilation (33.7%), receiving high-frequency oscillatory ventilation (67%), or extracorporeal membrane oxygenation (58.4%), admission following cardiac surgical procedure (29.4%), and receiving continuous renal replacement therapy (38.8%), and lower mortality was associated with hemodialysis (9.8%), and peritoneal dialysis (12.3%) (p < 0.0001). CONCLUSIONS: Continuous renal replacement therapy is an increasingly prevalent renal replacement therapy modality used in critically ill children admitted to an ICU. Higher mortality rate with the use of continuous renal replacement therapy should be interpreted with caution.

Prognostic factors in patients undergoing early-start peritoneal dialysis within 24 h after catheter insertion

This study aimed to investigate the clinical characteristics, prognosis, and factors for survival of patients who underwent early-start peritoneal dialysis (PD) within 24 h after catheter insertion three years after PD. This study was conducted from January 1, 2013 to December 31, 2017. All adult patients who were diagnosed with end-stage renal disease (ESRD) and underwent PD for the first time within 24 h after catheter insertion in our hospital were included. All patients with PD were followed-up until they withdrew from PD, switching to hemodialysis, were transferred to other medical centers, underwent renal transplantation, died or were lost to follow-up, or continued to undergo dialysis until the end of the study period. The follow-up observation lasted three years. The number of eligible patients was 110, and switching to hemodialysis and death were the main reasons for patients to withdraw from PD. The 1-, 2-, and 3-year technical survival rates of patients were 89.1, 79.1, and 79.1% respectively, while the 1-, 2- and 3-year survival rates were 90, 81.8, and 81.8%, respectively. The Charlson comorbidity index, age, hemoglobin, serum albumin, diabetic nephropathy, chronic glomerulonephritis, and hypertensive renal damage were independent risk factors that affected the prognosis of PD patients. Under the condition of ensuring the quality of the PD catheter insertion, early-start PD within 24 h after catheter insertion is a safe treatment approach for ESRD patients.

Comparing dialysis centre mortality outcomes across Australia and New Zealand: identifying unusually performing centres 2008-2013.

BACKGROUND: Comparing the mortality profiles of dialysis centres is important to ensure that high standards of care are maintained. We compare the performance of dialysis centres in Australia and New Zealand in their treatment of haemodialysis patients, accounting for the competing risks of kidney transplantation and transfer to peritoneal dialysis. METHODS: Observational cohort study. We included data from all adult patients (5574 patients) commencing haemodialysis at home or in a facility between 2008 and 2010 across 62 dialysis centres, from the Australia and New Zealand Dialysis and Transplant Registry. Standardised mortality ratios were calculated by estimating mortality probabilities from a pooled random effects logistic regression model, accounting for the competing risk of transplantation using an inverse probability weighting approach. Models were adjusted for patient comorbidities, sex, height, weight, late referral to a nephrologist, age, race, primary kidney disease, smoking status, and serum creatinine (µmol/l). RESULTS: Two dialysis centres were found to have relatively higher levels of risk-adjusted mortality lying outside the prediction intervals for "usual" performance. Risk adjusted mortality rates were not associated with centres' compliance with guidelines for vascular access and biochemical and haematological targets. CONCLUSIONS: We demonstrate that standardised mortality ratios are useful to identify facilities that have statistically outlying mortality risk. Our criterion for determining whether a centre has better or worse performance than expected is statistical, and thus analyses such as ours can serve only as a screening tool, and are only one aspect of assessment of "quality" of performance.

Current Status of Peritoneal Dialysis in Japan.

BACKGROUND: As an effective renal replacement therapy, peritoneal dialysis (PD) is as important as hemodialysis (HD) and renal transplantation. PD is beneficial for social rehabilitation and home medical care. However, in Japan, there are fewer PD patients than HD patients. SUMMARY: According to the JSDT 2015 registry, PD patients accounted for only 2.9% of all dialysis patients, and they have been gradually decreasing since 2009. One of the reasons why PD is not widely used in Japan is that there is insufficient evidence supporting its use. In this review, some recent reports about changes and challenges of PD, including survival rates, residual renal function, peritonitis, encapsulating peritoneal sclerosis (EPS), and combination therapy are summarized. These also indicate some problems and strategies related to PD treatment in Japan. According to the PDOPPS study, the incidence of peritonitis and culture-negative peritonitis was higher in Japan than in other countries. Further, the International Society of Peritoneal Dialysis (ISPD) Recommendation about peritonitis and catheter-related infection that topical application of antibiotic cream or ointment to the catheter exit site should be used daily could be a strategy for decreasing the incidence of peritonitis. The prevention and treatment of EPS are other challenges in PD. An EPS recommendation was published by the ISPD in 2017. Although the Next PD study showed that the occurrence of EPS is now decreasing compared to the time when acidic dialysates were used, the predictors for the development of EPS and strategies to reduce EPS have not been established. Peritoneal pathological parameters of groups that did and did not develop EPS were compared using peritoneal biopsy tissues at the time of cessation of PD, and it was found that the L/V ratio could be an independent predictor of EPS development. In Japan, 20% of PD patients are receiving combination therapy, which shows promising results. However, some problems, such as the risk of EPS, still limit long-term PD. Key Messages: PD treatment is changing as patients' situations change and with advances in technology. It is necessary to translate evidence to Japan from overseas reports and ISPD guidelines.