Evaluation of a single-item screening question to detect limited health literacy in peritoneal dialysis patients.

Studies have shown that a single-item question might be useful in identifying patients with limited health literacy. However, the utility of the approach has not been studied in patients receiving maintenance peritoneal dialysis (PD). We assessed health literacy in a cohort of 31 PD patients by administering the Rapid Estimate of Adult Literacy in Medicine (REALM) and a single-item health literacy (SHL) screening question "How confident are you filling out medical forms by yourself?" (Extremely, Quite a bit, Somewhat, A little bit, or Not at all). To determine the accuracy of the single-item question for detecting limited health literacy, we performed sensitivity and specificity analyses of the SHL and plotted the area under the receiver operating characteristic (AUROC) curve using the REALM as a reference standard. Using a cut-off of "Somewhat" or less confident, the sensitivity of the SHL for detecting limited health literacy was 80%, and the specificity was 88%. The positive likelihood ratio was 6.9. The SHL had an AUROC of 0.79 (95% confidence interval: 0.52 to 1.00). Our results show that the SHL could be effective in detecting limited health literacy in PD patients.

Incidence of encapsulating peritoneal sclerosis at a single U.S. university center.

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis. Few data are available from the United States about the incidence of EPS over time. To examine that question, we retrospectively examined our PD registry, in existence for 30 years, to identify patients with EPS. All other data were collected prospectively. We asked a radiologist to review all computed tomography (CT) scans taken at the time of EPS diagnosis. Incidence of EPS in our 676 patients was 1.2%, but rose to 15% after 6 years, and 38% after 9 years on PD. Peritonitis rates were not high in patients that developed EPS. Scoring of CT scans confirmed the diagnosis of EPS in all patients. Treatment was variable, but in recent years, steroids and tamoxifen were generally used when EPS was recognized. Mortality related to EPS was 38%. Several years after diagnosis, 3 patients are still alive; none is on total parenteral nutrition. In summary, the risk of EPS is low early in the course of PD, but increases progressively at 6 years and beyond. Imaging by CT is useful for diagnosing EPS. Our preliminary results suggest that steroids and tamoxifen are beneficial. Multicenter studies on this serious problem are needed.

Technology-assisted cognitive-behavioral therapy intervention for end-stage renal disease.

Technology-assisted cognitive-behavioral therapy (CBT) interventions have been conducted for symptoms including depression, pain, and fatigue in patients with chronic illnesses but not in end-stage renal disease (ESRD). The purpose of this study was to pilot the feasibility and acceptability of a technology-assisted CBT intervention in ESRD patients on hemodialysis (HD), share design and implementation lessons learned, and provide preliminary results on changes in select patient-reported symptoms. This was a single-center pilot feasibility study of adult ESRD patients on HD. Study eligibility required clinically elevated levels of at least one symptom (depression, pain, or fatigue). Patients met weekly with a CBT therapist for eight sessions, each 45-60 min, during HD sessions via a video-conferencing platform. Symptom questionnaires were completed at baseline and 3 months follow-up. Of 10 patients screened, 100% screened positive for at least one symptom, 100% of eligible patients consented, and eight (of 10) completed the intervention (mean age 59 years, 50% male, 50% African American). Patient adherence and satisfaction was high, and seven of the eight patients completed all eight prescribed sessions. Minimal interference with HD was reported. Preliminary results indicate no statistically significant changes in depression, fatigue, or pain at follow-up. However, there was small improvement in SF-36 Physical Component score [t(7) = -2.60, p = .035], and four of the six patients (67%) with clinically elevated pain at baseline reported improvement at follow-up. A technology-assisted CBT intervention for ESRD patients was feasible, well-accepted, and required minimal additional resources in the HD setting. Larger, adequately powered clinical trials are needed to evaluate the effect on ESRD patient-reported outcomes.

Restoring glucose uptake rescues neutrophil dysfunction and protects against systemic fungal infection in mouse models of kidney disease.

Disseminated candidiasis caused by the fungus Candida albicans is a major clinical problem in individuals with kidney disease and accompanying uremia; disseminated candidiasis fatality is twice as common in patients with uremia as those with normal kidney function. Many antifungal drugs are nephrotoxic, making treatment of these patients particularly challenging. The underlying basis for this impaired capacity to control infections in uremic individuals is poorly understood. Here, we show in multiple models that uremic mice exhibit an increased susceptibility to systemic fungal infection. Uremia inhibits Glut1-mediated uptake of glucose in neutrophils by causing aberrant activation of GSK3ß, resulting in reduced ROS generation and hence impaired killing of C. albicans in mice. Consequently, pharmacological inhibition of GSK3ß restored glucose uptake and rescued ROS production and candidacidal function of neutrophils in uremic mice. Similarly, neutrophils isolated from patients with kidney disease and undergoing hemodialysis showed similar defect in the fungal killing activity, a phenotype rescued in the presence of a GSK3ß inhibitor. These findings reveal a mechanism of neutrophil dysfunction during uremia and suggest a potentially translatable therapeutic avenue for treatment of disseminated candidiasis.

Clinical outcomes in peritoneal dialysis: impact of continuous quality provement initiatives.

The Kidney Disease Outcomes Quality Initiative guidelines for peritoneal dialysis (PD) emphasize the need for quality improvement interventions to improve outcomes in PD. Here, we report 17 years experience of initiatives focused on lowering peritonitis rates in a single PD program. This institutional review board-approved retrospective analysis used a PD registry containing prospectively collected data on patient demographics, initial Charlson comorbidity index (CCI), peritonitis, and clinical outcomes, including reasons for transfer to hemodialysis. Periods were analyzed based on quality initiatives: 1990 - 1991, baseline; 1992 - 1995, randomized controlled trial of exit-site infection prophylaxis comparing mupirocin cream applied daily to the exit site with oral cyclical (every 12 weeks) rifampin; 1996 - 1999, compact assist device introduced for spiking on the cycler; 2000 - 2004, randomized controlled trial comparing daily gentamicin cream with mupirocin as exit-site prophylaxis; and 2005 - 2007, gentamicin prophylaxis implemented as routine care (2005) and retraining of all patients (2006). Infection rates and technique failure rates in each period were compared with baseline rates using incident rate ratio analysis. A total of 382 PD patients were evaluated [median age: 50 years (range: 18 - 90 years); 54% women; 19% African American; 36% with diabetes; median CCI: 5 (range: 2 - 14)]. The peritonitis rate declined from 0.5 episodes per year at risk in 1990 - 1991 to 0.25 episodes per year at risk in 2005 - 2007 (p < 0.004). The exit-site infection rate declined from 0.72 episodes per year at risk to 0.1 episodes per year at risk over the same period (p < 0.0001). The percentage of patients transferring to hemodialysis did not change significantly over time (overall 14%, varying from 12% to 17% annually), nor did the mortality rate, which varied from 115 per 1000 years to 171 per 1000 years. We conclude that quality improvement initiatives can reduce infection rates in PD patients.

Improvement in Pittsburgh Symptom Score index after initiation of peritoneal dialysis.

The Kidney Disease Outcomes Quality Initiative (K/ DOQI) 2006 recommended a minimum weekly Kt/V of 1.7 for peritoneal dialysis (PD) patients while emphasizing the importance of keeping the patient free of uremic symptoms. We examined a symptom score index [Pittsburgh Symptom Score (PSS)] designed to evaluate uremic symptoms to determine if the score improved in the first year of PD. The PSS is a 10-symptom (fatigue, trouble sleeping, difficulty concentrating, restless legs, change in taste, loss of appetite, nausea or vomiting, pruritus, bone pain, muscle pain or weakness) questionnaire that uses a Likert scale of 0 (none) to 5 (severe). From January 1, 2003, to December 31, 2006, incident PD patients completed the PSS at 0, 3, 6, 9, and 12 months. Patients were excluded from analysis if they had been on PD for less than 6 months or on hemodialysis 6 months or more before starting PD. Prevalences of individual symptoms at 1 year and at baseline were compared using the chi-square test. Differences in PSS at the various time intervals were compared using the sign test. The study included 45 patients [51% women; 31% African Americans; 33% with diabetes; mean age: 58.0 years (range: 30 - 89 years); mean initial Charlson Comorbidity Index: 5 (range: 2 - 11)]. Initial median total score improved to 8 from 12 (p = 0.005) by 3 months, with no further improvement. Improvements occurred in change in taste (p = 0.029 at 3 months), difficulty concentrating (p = 0.04 at 6 months), itching (p = 0.007 at 3 months), loss of appetite (p = 0.009 at 3 months), muscle pain or weakness (p = 0.002 at 3 months), sleep disturbance (p = 0.04 at 9 months), and restless legs (p = 0.026 at 9 months). Fatigue, bone pain, and nausea or vomiting scores were low at the start and did not significantly change over the first year. Significant decreases in symptom prevalence were seen in difficulty concentrating (p = 0.03), change in taste (p = 0.005), loss of appetite (p = 0.04), and muscle pain or weakness (p = 0.02) at 1 year. Initiation of PD results in improvement in the prevalence and severity of most uremic symptoms by 3 to 9 months and is maintained at 12 months. We recommend routine checklist evaluation of symptoms at regular clinical intervals.

Urea for the Treatment of Hyponatremia.

BACKGROUND AND OBJECTIVES: Current therapies for hyponatremia have variable effectiveness and tolerability, and in certain instances, they are very expensive. We examined the effectiveness, safety, and tolerability of urea for the treatment of inpatient hyponatremia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We identified all patients hospitalized at the University of Pittsburgh Medical Center between July 2016 and August 2017 with hyponatremia (plasma sodium <135 mEq/L) who received urea, including a subgroup of patients who received urea as the sole drug therapy for hyponatremia (urea-only treated). We matched urea only-treated patients to a group of patients with hyponatremia who did not receive urea (urea untreated) and compared changes in plasma sodium at 24 hours and the end of therapy as well as the proportion of patients who achieved plasma sodium ≥135 mEq/L. We abstracted data on adverse events and reported side effects of urea. RESULTS: Fifty-eight patients received urea (7.5-90 g/d) over a median of 4.5 (interquartile range, 3-8) days and showed an increase in plasma sodium from 124 mEq/L (interquartile range, 122-126) to 131 mEq/L (interquartile range, 127-134; P<0.001). Among 12 urea only-treated patients, plasma sodium increased from 125 mEq/L (interquartile range, 122-127) to 131 mEq/L (interquartile range, 129-136; P=0.001) by the end of urea therapy. There was a larger increase in plasma sodium at 24 hours in urea only-treated patients compared with urea-untreated patients (2.5 mEq/L; interquartile range, 0-4.5 versus -0.5 mEq/L; interquartile range, -2.5 to 1.5; P=0.04), with no difference in change in plasma sodium by the end of therapy (6 mEq/L; interquartile range, 3.5-10 versus 5.5 mEq/L; interquartile range, 3-7.5; P=0.51). A greater proportion of urea only-treated patients achieved normonatremia, but this difference was not statistically significant (33% versus 8%; P=0.08). No patients experienced overly rapid correction of plasma sodium, and no serious adverse events were reported. CONCLUSIONS: Urea seems effective and safe for the treatment of inpatient hyponatremia, and it is well tolerated.

Objective and subjective sleep disorders in automated peritoneal dialysis.

BACKGROUND: Automated peritoneal dialysis (APD) is one of the fastest growing dialysis modalities. It is unknown whether sleep and mood are disturbed while performing repeated overnight exchanges. OBJECTIVES: In this report, we aim to describe and compare the prevalence of sleep-disordered breathing (SDB), periodic limb movements (PLMS), poor sleep quality (SQ), and depression among APD patients compared with stages 3b-5 (estimated glomerular filtration rate ≤44 ml/min/1.73 m2) chronic kidney disease (CKD) and hemodialysis (HD) patients. DESIGN: This is a cross-sectional, descriptive study. SETTING: Study participants were recruited from outpatient nephrology clinics, local dialysis centers, and the Thomas E. Starzl Transplant Institute in Western Pennsylvania between April 2004 and July 2009. PATIENTS: There were 186 participants in this study including 22 APD patients, 89 CKD patients, and 75 HD patients. MEASUREMENTS: In-home polysomnography was performed and two questionnaires were completed, the Pittsburgh Sleep Quality Index (PSQI) and the Patient Health Questionnaire-9 (PHQ-9). METHODS: SDB and PLMS were quantified by in-home unattended polysomnography; poor SQ was defined by a score >5 on the PSQI, and the presence of moderate to severe depression was defined by a score >5 on the PHQ-9. RESULTS: The APD patients had a median age of 37.5 years, were predominantly female (72.7 %), and had a median body mass index (BMI) of 23.8 kg/m2. In univariate analyses, APD patients had significantly lower apnea-hypopnea index compared to HD patients by 12.2 points (likelihood ratio test p = 0.008) and revealed the least percent of TST with nocturnal hypoxemia compared to CKD patients by 2.7 points, respectively (likelihood ratio test p = 0.01). The APD group had also significantly greater stages 3 to 4 sleep compared to the CKD patients by 8.6 points (likelihood ratio test p = 0.009). In multivariate analyses and after adjustment for age, gender, race, and BMI, both APD and HD patients had higher average PSQI scores than CKD patients by 2.54 and 2.22 points, respectively (likelihood ratio test p = 0.005). No other comparisons of sleep parameters among groups reached statistical significance. LIMITATIONS: The limitations of this study are the small sample size of the APD population and the demographic and clinical differences among the three study groups. CONCLUSIONS: Despite differences in univariate analyses, after multivariate adjustment, APD patients had similar sleep parameters and sleep architecture and as poor SQ and symptoms of depression as HD patients. Future studies with larger APD cohorts are needed.

MISE EN CONTEXTE: La dialyse péritonéale automatisée (DPA) est l'une des méthodes de traitement pour l'insuffisance rénale terminale connaissant la plus forte croissance. Toutefois, l'influence de la pratique répétée de cette procédure sur la qualité du sommeil et sur l'humeur du patient demeure peu documentée. OBJECTIFS DE L'ÉTUDE: L'étude visait à caractériser et à définir la prévalence de troubles respiratoires du sommeil, de mouvements involontaires des membres, d'effets sur la qualité du sommeil et de symptômes dépressifs chez les patients sous DPA en comparaison avec la prévalence de ces mêmes paramètres chez les patients souffrant d'insuffisance rénale chronique (eDFG à ≤44 ml/min/1.73 m2) et chez les patients sous hémodialyse. CADRE ET TYPE D'ÉTUDE: Il s'agit d'une étude transversale descriptive qui s'est tenue dans l'ouest de la Pennsylvanie (États-Unis) entre avril 2004 et juillet 2009. Le recrutement des participants s'est effectué au sein des patients en consultation externe des cliniques de néphrologie, dans les centres de dialyses régionaux et au Thomas E. Starzl Transplant Institute. PARTICIPANTS: Un total de 186 patients a pris part à cette étude, parmi lesquels on comptait 22 patients sous traitement par DPA, 89 patients en situation d'insuffisance rénale chronique et 75 patients sous hémodialyse. MESURES: La cueillette des données incluait des mesures de polysomnographie effectuées à domicile par les patients ainsi que les réponses fournies à deux questionnaires : le Pittsburgh Sleep Quality Index (PSQI) et le Patient Health Questionnaire-9 (PHQ-9). RÉSULTATS: La cohorte de patients sous DPA se constituait en majorité de femmes (72,3 %) de 37,5 ans d'âge médian et dont l'indice de masse corporelle (IMC) se situait en moyenne à 23,8 kg/m2. Les analyses univariées ont démontré un index apnées-hypopnées inférieur de 12,2 points (p = 0,0008) et un plus faible pourcentage de troubles du sommeil avec hypoxémie nocturne par 2,7 points (p = 0,01) chez les patients sous DPA en comparaison avec les patients sous hémodialyse. Les analyses multivariées, après correction en fonction de l'âge, du sexe, de l'origine ethnique et de l'IMC des participants, ont quant à elles démontré que les patients sous DPA et sous hémodialyse ont obtenu des résultats plus élevés au questionnaire PSQI que les patients souffrant d'insuffisance rénale chronique, avec des moyennes supérieures de 2,54 et 2,22 points respectivement (p = 0,005). La comparaison entre les différents groupes en ce qui concerne les autres paramètres mesurés n'a pas atteint le degré de signification statistique. LIMITES DE L'ÉTUDE: Les données recueillies au cours de cette étude concernent un faible échantillon de patients sous DPA. De plus, en raison des grandes différences notées dans les données cliniques et démographiques des trois groupes de patients qui la constituaient, la cohorte étudiée manquait d'uniformité. CONCLUSIONS: En dépit des différences notées dans les analyses univariées et de l'obligation d'effectuer des corrections dans les analyses multivariées, les résultats montrent que les patients sous DPA ne présentent pas de différences significatives pour les paramètres de sommeil mesurés. Les patients sous DPA maintiennent des paramètres et une architecture de sommeil semblables à ceux mesurés chez les patients sous traitement par hémodialyse : la qualité du sommeil demeure faible, mais ils ne présentent pas plus de symptômes de dépression. Des études de plus grande envergure sont requises afin de mieux définir l'influence de la DPA sur la qualité du sommeil et sur l'humeur des patients qui la pratiquent.

Avoiding harm in peritoneal dialysis patients.

This review is focused on minimizing complications and avoiding harm in peritoneal dialysis (PD) patients. Issues related to planning for PD are covered first, with emphasis on PD versus hemodialysis outcomes. Catheter types and insertion techniques are described next, including relevant recommendations by the International Society for Peritoneal Dialysis. A brief review of both noninfectious and infectious complications follows, with emphasis on cardiovascular and metabolic complications. Finally, recommendations for preventing PD-related infections are provided. In conclusion, with proper catheter insertion technique, good training, and attention to detail during the tenure in PD, excellent outcomes can be obtained in a well-informed motivated patient.