Efficacy of Prophylactic Antibiotics at Peritoneal Catheter Insertion on Early Peritonitis: Data from the Catheter Section of the French Language Peritoneal Dialysis Registry.

BACKGROUND: International guidelines recommend the use of a prophylactic antibiotic before the peritoneal dialysis (PD) catheter can be inserted. The main objective of this study was to assess whether this practice is associated with a lower risk of early peritonitis and to estimate the magnitude of the centre effect. METHODS: A retrospective, multi-centric study was conducted, in which data from the French Language Peritoneal Dialysis Registry was analysed. Patients were separated into 2 groups based on whether or not prophylactic antibiotics were used prior to catheter placement. RESULTS: Out of the 2,014 patients who had a PD catheter placed between February 1, 2012 and December 31, 2014, 1,105 were given a prophylactic antibiotic. In a classical logit model, the use of prophylactic antibiotics was found to protect the individual against the risk of early peritonitis (OR 0.67, 95% CI 0.49-0.92). However, this association lost significance in a mixed logistic regression model with centre as a random effect: OR 0.73 (95% CI 0.48-1.09). Covariates associated with the risk of developing early peritonitis were age over 65: OR 0.73 (95% CI 0.39-0.85), body mass index over 35 kg/m2: OR 1.99 (95% CI 1.13-3.47), transfer to PD due to graft failure: OR 2.24 (95% CI 1.22-4.11), assisted PD: OR 1.96 (95% CI 1.31-2.93), and the use of the Moncrief technique: OR 3.07 (95% CI 1.85-5.11). CONCLUSION: There is a beneficial effect of prophylactic antibiotic used prior to peritoneal catheter placement, on the occurence of early peritonitis. However, the beneficial effect could be masked by a centre effect.

[Negative impact of COVID-19 pandemic on peritonitis rate in peritoneal dialysis patients: Pleading for a continuous educational training]. / Conséquences de la pandémie de COVID-19 sur le taux de péritonites de dialyse péritonéale : plaidoyer pour une formation continue ininterrompue.

BACKGROUND: Peritonitis is a common complication of chronic peritoneal dialysis treatment contributing to both technique failure and/or death. Little is effectively known about the actual benefits of a continuous training program on peritonitis rates. In the present study, we measured the impact of our patients' training protocol on peritonitis rates. We further studied which consequences the COVID-related disruption of our follow-up program had on peritonitis rates. METHODS: We present our yearly peritonitis rates since our patients' training and retraining program was implemented in 2010. We then focused our study on three consecutive years: 2019, 2020 (emergence of COVID-19), and 2021, collecting microbiological data from each peritonitis episode. Statistical analysis were used to corroborate our findings. RESULTS: Since 2010, peritonitis rates declined linearly (R2=0,6556; df=8; P<0.01) until its nadir in 2019 with 4 peritonitis episodes. The majority of infections were then treated in the outpatient Clinic. In 2020, our continuous technique evaluation decreased by 51% and 28 peritonitis episodes occurred, 47% secondary to strict cutaneous bacteria's, and 31% gastro-intestinal, irrespective of patients' experience or peritoneal dialysis modality. The hospitalization rate reached 71%. Having restored our protocol, we decreased peritonitis rates by 50% in 2021. CONCLUSIONS: Risk factors for peritonitis are identifiable and modifiable and require sustained intervention, continuous visual monitoring and training. These interventions significantly reduce peritonitis rates. Any brief interruption to patients' technique evaluation may elevate peritonitis rates significantly.

A combined crystalloid and colloid pd solution as a glucose-sparing strategy for volume control in high-transport apd patients: a prospective multicenter study.

BACKGROUND: Evidence is accumulating that the continuous exposure to high glucose concentrations during peritoneal dialysis (PD) is an important cause of ultrafiltration (UF) failure. The cornerstone of prevention and treatment of UF failure is reduction of glucose exposure, which will also alleviate the systemic impact of significant free glucose absorption. The challenge for the future is to discover new therapeutic strategies to enhance fluid and sodium removal while diminishing glucose load and exposure using combinations of available osmotic agents. OBJECTIVES: To investigate in patients on automated PD (APD) with a fast transport pattern whether there is a glucose-sparing advantage to replacing 7.5% icodextrin (ICO) during the long dwell with a mixed crystalloid and colloid PD fluid (bimodal UF) in an attempt to promote daytime UF and sodium removal while diminishing the glucose strength of the dialysate at night. DESIGN: A 2 parallel arm, 4 month, prospective nonrandomized study. SETTING: PD units or university hospitals in 4 French and Belgian districts. RESULTS: During the 4-month intervention period, net UF and peritoneal sodium removal during the long dwell when treated by bimodal UF was about 2-fold higher than baseline (with ICO). The estimated percent change (95% confidence interval) from baseline in net daytime UF for the bimodal solution was 150% (106% - 193%), versus 18% (-7% - 43%) for ICO (p < 0.001). The estimated percent change from baseline in peritoneal sodium removal for the bimodal solution was 147% (112% - 183%), versus 23% (-2% - 48%) for ICO (p < 0.001). The estimated percent change from baseline in UF efficiency (24-hour net UF divided by the amount of glucose absorbed) was significantly higher (p < 0.001) when using the bimodal solution was 71%, versus -5% for ICO. CONCLUSION: Prescription of bimodal UF during the day in APD patients offers the opportunity to optimize the long dwell exchange in a complete 24-hour APD cycle. The current study demonstrated that a bimodal solution based on the mixing of glucose (2.6%) and icodextrin (6.8%) achieved the double target of significantly improving UF and peritoneal sodium removal by exploring a new concept of glucose-sparing PD therapy.

OPG, RANK-L, bone metabolism, and BMD in patients on peritoneal dialysis and hemodialysis.

OBJECTIVES: Bone turnover is regulated locally by osteoprotegerin (OPG) and receptor activator of NFkappaB ligand (RANK-L); it is not known how the circulating concentrations of these cytokines reflect renal osteodystrophy. METHODS: We measured serum OPG, RANK-L, parathyroid hormone (iPTH), collagen C-terminal cross-linked telopeptide (betaCrossLaps), and bone densitometry (BMD) in 79 patients with end-stage renal disease (ESRF) undergoing dialysis. A hand X-ray of these patients was also analyzed. Controls were 65 healthy subjects. RESULTS: ESRF patients had high OPG and RANK-L levels; RANK-L was higher in hemodialysis than in peritoneal dialysis. OPG and RANK-L did not depend on iPTH. The bone markers were significantly increased and correlated with serum iPTH, but not with OPG or RANK-L; neither OPG nor RANK-L correlated significantly with BMD. OPG was significantly higher in patients with acro-osteolysis. CONCLUSIONS: OPG and RANK-L serum concentrations do not strongly reflect bone status in ESRF. However, OPG was significantly higher in patients with acro-osteolysis.

Bone cytokines and renal osteodystrophy in peritoneal dialysis patients.

Bone turnover is regulated by local concentrations of cytokines such as osteoprotegerin (OPG) and receptor activator of nuclear factor kappaB ligand (RANKL). It is not known whether these cytokines can predict renal osteodystrophy in peritoneal dialysis (PD) patients. We measured serum levels of OPG, RANKL, intact parathyroid hormone (iPTH), calcium, phosphorus, and biologic parameters of bone turnover [carboxy-terminal propeptide of type I procollagen (PICP) and beta-crosslaps (betaCL)] in 21 PD patients and 42 healthy subjects matched for age and sex, who served as controls. Bone mineral density (BMD) was also evaluated (Z-scores) in the PD patients. Circulating levels of OPG were significantly higher in PD patients than in healthy subjects (p < 0.001). Mean levels of RANKL did not differ from normal. However, RANKL levels were increased in the group of patients with iPTH levels above 322 pg/mL. Biologic parameters of bone turnover (PICP and betaCL) were significantly increased in PD patients (p < 0.001). We found a positive correlation between serum levels of betaCL and iPTH. At several skeletal sites, betaCL also correlated with the BMD Z-score. No correlations were observed between OPG, RANKL, PICP, betaCL, CaxP, or time on dialysis. Circulating levels of OPG and RANKL do not reflect bone status in PD patients. The value of betaCL is a good marker of bone resorption that correlates with iPTH and BMD.

Clinical experience with two physiologic bicarbonate/lactate peritoneal dialysis solutions in automated peritoneal dialysis.

UNLABELLED: Clinical experience with two physiologic bicarbonate/lactate peritoneal dialysis solutions in automated peritoneal dialysis. BACKGROUND: Patients on automated peritoneal dialysis (APD) usually receive larger volumes of dialysis solution and more frequent, shorter exchanges than patients on continuous ambulatory peritoneal dialysis (CAPD), and therefore are likely to derive greater benefit from more physiologic solutions. METHODS: Peritoneal dialysis solutions containing 25 mmol/L bicarbonate and either 10 or 15 mmol/L lactate were compared with standard lactate solutions (35 or 40 mmol/L) in two prospective, open-label studies of patients on APD. Each study included a 2-week baseline period (lactate solution), a 6-week treatment period (bicarbonate/lactate solution), and a 2-week follow-up period (same lactate solution as baseline). Biochemical analyses and assessments of vital signs and safety parameters were conducted at baseline, every 2 weeks during treatment, and at the end of the follow-up period. A product use questionnaire was administered in one study at the end of treatment. RESULTS: A statistically significant rise in plasma bicarbonate (approximately 2 mmol/L) occurred when patients switched from a lactate solution to the bicarbonate/lactate solution with equimolar buffer concentration (P < 0.001 for each solution). Plasma bicarbonate decreased by 1.16 mmol/L after a switch from lactate 40 mmol/L to bicarbonate/lactate 35 mmol/L (P < 0.001). When patients switched to bicarbonate/lactate 35, the majority of individual venous plasma bicarbonate values were in the normal range. A switch from a lower calcium (1.25 mmol/ L) lactate solution to a higher calcium (1.75 mmol/L) lactate/bicarbonate solution resulted in a statistically significant rise in serum calcium (0.06 mmol/L, P < 0.018). The product use questionnaire revealed improvements in symptoms, including reduced pain on infusion. CONCLUSION: Bicarbonate/lactate solutions may be used safely and effectively in patients on APD. The availability of 2 formulations with different buffer and calcium content provides flexibility for the control of acidosis as well as calcium balance.

Perceptive barriers to peritoneal dialysis implementation: an opinion poll among the French-speaking Belgian nephrologists.

Although peritoneal dialysis (PD) is recognized as an effective renal replacement therapy (RRT) alternative to haemodialysis (HD), its prevalence is around 15% in most of the industrialized countries. In the French-speaking part of Belgium, PD is clearly underused with a prevalence of 8.7% in 2009. The main objectives of this work were to evaluate the nephrologists' perceived obstacles to PD implementation and reflect on possible actions towards PD development. A computer-based 33-item questionnaire was sent by e-mail to all nephrologists affiliated to the French-speaking association. Among 120 adult nephrologists targeted by this inquiry, 97 completed the online questionnaire (response rate 80.8%). Among them, 29% had little experience with PD (treating less than five patients) and 39% reported no specific training with this modality of RRT. However, 88% of responders claimed PD prevalence should be around 20-25%. Half of the responders would choose PD as a first RRT option if they required RRT for themselves. The three main reasons given to the low prevalence of PD were an easy access to HD, patient refusal and lack of nephrologist motivation. Almost all the nephrologists insisted on the need for a dedicated nursing team delivering an effective educational programme and PD management and care. They believe that PD could and should be implemented in Belgium. Enhanced nephrologist motivation and training in PD were identified as predominant factors to be upgraded, as well as patient education programmes.

Heparin-binding haemagglutinin, a new tool for the detection of latent Mycobacterium tuberculosis infection in hemodialysis patients.

BACKGROUND: Patients with end-stage renal disease (ESRD) and latently infected with Mycobacterium tuberculosis (LTBI) are at higher risk to develop tuberculosis (TB) than healthy subjects. Interferon-gamma release assays (IGRAs) were reported to be more sensitive than tuberculin skin tests for the detection of infected individuals in dialysis patients. METHODS: On 143 dialysis patients prospectively enrolled, we compared the results from the QuantiFERON®-TB Gold assay (QFT), to those of an IGRA in response to in vitro stimulation of circulating mononuclear cells with the mycobacterial latency antigen Heparin-Binding Haemagglutinin purified from Mycobacterium bovis BCG (native HBHA, nHBHA). RESULTS: Seven patients had a past history of active TB and 1 had an undetermined result with both IGRAs. Among the other 135 patients, 94 had concordant results with the QFT and nHBHA-IGRA, 40.0% being negative and therefore not latently infected, and 29.6% being positive and thus LTBI. Discrepant results between these tests were found for 36 patients positive only with the nHBHA-IGRA and 5 only with the QFT. CONCLUSIONS: The nHBHA-IGRA is more sensitive than the QFT for the detection of LTBI dialysis patients, and follow-up of the patients will allow us to define the clinical significance of discrepant results between the nHBHA-IGRA and the QFT.

Madura's foot in a renal transplant patient: report of a case.

A 40-year-old kidney transplant male recipient was hospitalized for chronic abscess of the right foot in a context of immunodepression. The patient came from Djibouti and was in Belgium for a few days. He presented a right foot with a swelling localized on the first metatarsophalangeal joint which was excoriated (Figures 1 and 2) and was self-treated ineffectively with various local antiseptics for several months. He was in the operating room for an open biopsy done by plantar and dorsal approach to confirm the fungal infection. Treatment was not started with oral itraconazole because of the good evolution of the lesion. Pain diminished after a few days, and the patient was able to walk after a few weeks.

Plasma osteoprotegerin is an independent risk factor for mortality and an early biomarker of coronary vascular calcification in chronic kidney disease.

BACKGROUND: Cardiovascular disease is the major cause of morbidity and mortality in chronic kidney disease (CKD) and early biomarkers are required which can predict disease and death in such patients. The aim of our study was to investigate if osteoprotegerin (OPG) could be a predictor of coronary artery calcification (CAC) and mortality in CKD. METHODS: A total of 77 outpatients (32 with pre-dialysis CKD and 45 undergoing hemodialysis) were followed-up during 2 years. Measurements of CAC were performed using Siemens Multidetector CT software and calcium scores were measured according to the Agatston method. RESULTS: OPG was an independent predictor of the Agatston score for CAC and correlated with the degree of CAC in pre-dialysis patients. A two-sample t-test characterized survivors as having a better glomerular filtration rate, lower Agatston scores, and lower serum levels of OPG. Kaplan-Meier survival curves separated survivors from non-survivors at plasma OPG cut-off levels of <3.1 ng/mL. A multivariable logistic regression analysis showed that OPG was an independent predictor of mortality from all causes in CKD patients. CONCLUSIONS: OPG predicted mortality in CKD patients and could be a valuable biomarker in early detection of CAC in these patients.

Cutaneous Mycobacterium chelonae infection extending distally in a hemodialysed patient.

We report a case of a cutaneous Mycobacterium chelonae infection on the dorsum of the forearm of a patient undergoing chronic hemodialysis. The infection showed a linear and distal extension. This unusual distal dissemination was apparently secondary to a venous reflux, a circulatory repercussion of the patient's arteriovenous fistula.

Pharmacokinetics of atorvastatin and its metabolites after single and multiple dosing in hypercholesterolaemic haemodialysis patients.

BACKGROUND: Patients with chronic renal failure commonly suffer from a secondary form of complex dyslipidaemia, and may benefit from lipid-lowering treatment. Atorvastatin has been shown to reduce efficiently the levels of atherogenic lipoproteins also in patients with renal failure, but pharmacokinetic data in haemodialysis patients are lacking. METHODS: In this study, hypercholesterolaemic haemodialysis patients received 40 mg (n=12) or 80 mg (n=11) atorvastatin once daily, first as a single dose and then continuously for 2 weeks. Plasma levels of atorvastatin and its active and inactive metabolites were measured by LC/MS/MS, and pharmacokinetic parameters (C(max), t(max), AUC, t(1/2)) compared between single and multiple dosing, and between the different doses. RESULTS: The pharmacokinetic parameters of the parent drug atorvastatin acid were not significantly different after single and 2-week multiple dosing; they showed dose-proportionality between the 40 and 80 mg dose, and were comparable to findings in healthy volunteers. Dose-proportionality and absence of accumulation was also observed for the major active metabolite ortho-hydroxy-atorvastatin and the inactive metabolites atorvastatin lactone and ortho-hydroxy-atorvastatin lactone, but the levels of the active metabolite were relatively lower, and the inactive metabolites higher, compared with healthy volunteers. The para-hydroxy-metabolites constituted only a minor pathway in atorvastatin's metabolic elimination. Haemodialysis did not cause enhanced clearance of atorvastatin or its metabolites, the drug was well tolerated and there were no serious adverse events. CONCLUSION: While subtle differences may exist in the metabolic processing of atorvastatin in haemodialysis patients, active drug did not accumulate nor did it show enhanced elimination, and levels were comparable to those measured in healthy volunteers. Therefore there is no need to adapt atorvastatin dosage in this particular patient population.