Utility of 'back-up' arterio-venous fistulae in patients on peritoneal dialysis and use of haemodialysis catheters.

BACKGROUND: Patients undergoing peritoneal dialysis may require unanticipated transfer to haemodialysis. Back up fistula are often created in selected patients. These may help reduce the infective burden of haemodialysis (HD) catheter. AIM: To study the utility of back-up arterio-venous fistulae (AVF) in patients initiated on peritoneal dialysis (PD) and to determine the rates of HD catheter use in patients requiring conversion to HD. METHODS: Data on HD transfer and HD catheter usage were retrospectively analysed in all patients initiating PD between January 2010 and December 2014 at Royal Adelaide Hospital (RAH; universal back-up AVF creation at PD commencement) and Princess Alexandra Hospital (PAH; selective back-up AVF creation in 'high risk' patients). RESULTS: A total of 374 patients initiated PD during the study period: 142 in RAH group and 232 in PAH group. The groups were reasonably comparable, except that RAH patients were more likely to be older, Caucasian and diabetic. Transfer to HD occurred in 33 (23%) patients in RAH group and 99 (43%) in the PAH group with respective median times to HD transfer of 289 and 295 days. HD catheter usage was required at the time of HD transfer in 11 (33%) patients at RAH and 64 (65%) in patients at PAH (P < 0.001). AVF complications occurred in 13 (9%) patients in RAH group (fistuloplasty n = 8, transposition n = 2, ligation due to ischaemia n = 2 and construction of new AVF n = 1). CONCLUSION: Patients undergoing PD frequently require urgent unanticipated transfer to HD and back-up AVF can be successfully utilised in this setting in the majority of cases, which in turn can reduce the infective burden of HD catheter exposure.

Association of biocompatible peritoneal dialysis solutions with peritonitis risk, treatment, and outcomes.

BACKGROUND AND OBJECTIVES: The effect of biocompatible peritoneal dialysis (PD) solutions on PD-related peritonitis is unclear. This study sought to evaluate the relationship between use of biocompatible solutions and the probability of occurrence or clinical outcomes of peritonitis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study included all incident Australian patients receiving PD between January 1, 2007, and December 31, 2010, using Australia and New Zealand Dialysis and Transplant Registry data. All multicompartment PD solutions of neutral pH were categorized as biocompatible solutions. The independent predictors of peritonitis and the use of biocompatible solutions were determined by multivariable, multilevel mixed-effects Poisson and logistic regression analysis, respectively. Sensitivity analyses, including propensity score matching, were performed. RESULTS: Use of biocompatible solutions gradually declined (from 7.5% in 2007 to 4.2% in 2010), with preferential use among smaller units and among younger patients without diabetes mellitus. Treatment with biocompatible solution was associated with significantly greater overall rate of peritonitis (0.67 versus 0.47 episode per patient-year; incidence rate ratio, 1.49; 95% confidence interval [CI], 1.19 to 1.89) and with shorter time to first peritonitis (hazard ratio [HR], 1.48; 95% CI, 1.17 to 1.87), a finding replicated in propensity score-matched cohorts (HR, 1.36; 95% CI, 1.09 to 1.71). CONCLUSIONS: In an observational registry study, use of biocompatible PD solutions was associated with higher overall peritonitis rates and shorter time to first peritonitis. Further randomized studies adequately powered for a primary peritonitis outcome are warranted.

Daily variation in death in patients treated by long-term dialysis: comparison of in-center hemodialysis to peritoneal and home hemodialysis.

BACKGROUND: There has been little study to date of daily variation in cardiac death in dialysis patients and whether such variation differs according to dialysis modality and session frequency. STUDY DESIGN: Observational cohort study using ANZDATA (Australia and New Zealand Dialysis and Transplant) Registry data. SETTING & PARTICIPANTS: All adult patients with end-stage kidney failure treated by dialysis in Australia and New Zealand who died between 1999 and 2008. PREDICTORS: Timing of death (day of week), dialysis modality, hemodialysis (HD) session frequency, and demographic, clinical, and facility variables. OUTCOMES & MEASUREMENTS: Cardiac and noncardiac mortality. RESULTS: 14,636 adult dialysis patients died during the study period (HD, n = 10,338; peritoneal dialysis [PD], n = 4,298). Cardiac death accounted for 40% of deaths and was significantly more likely to occur on Mondays in in-center HD patients receiving 3 or fewer dialysis sessions per week (n = 9,503; adjusted OR, 1.26; 95% CI, 1.14-1.40; P < 0.001 compared with the mean odds of cardiac death for all days of the week). This daily variation in cardiac death was not seen in PD patients, in-center HD patients receiving more than 3 sessions per week (n = 251), or home HD patients (n = 573). Subgroup analyses showed that deaths related to hyperkalemia and myocardial infarction also were associated with daily variation in risk in HD patients. This pattern was not seen for vascular, infective, malignant, dialysis therapy withdrawal, or other deaths. LIMITATIONS: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. Possible type 2 statistical error due to limited sample size of home HD and enhanced-frequency HD cohorts. CONCLUSIONS: Daily variation in the pattern of cardiac deaths was observed in HD patients receiving 3 or fewer dialysis sessions per week, but not in PD, home HD, and HD patients receiving more than 3 sessions per week.

Effects of climatic region on peritonitis risk, microbiology, treatment, and outcomes: a multicenter registry study.

BACKGROUND: The impact of climatic variations on peritoneal dialysis (PD)-related peritonitis has not been studied in detail. The aim of the current study was to determine whether various climatic zones influenced the probability of occurrence or the clinical outcomes of peritonitis. METHODS: Using ANZDATA registry data, the study included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. Climatic regions were defined according to the Köppen classification. RESULTS: The overall peritonitis rate was 0.59 episodes per patient-year. Most of the patients lived in Temperate regions (65%), with others residing in Subtropical (26%), Tropical (6%), and Other climatic regions (Desert, 0.6%; Grassland, 2.3%). Compared with patients in Temperate regions, those in Tropical regions demonstrated significantly higher overall peritonitis rates and a shorter time to a first peritonitis episode [adjusted hazard ratio: 1.15; 95% confidence interval (CI): 1.01 to 1.31]. Culture-negative peritonitis was significantly less likely in Tropical regions [adjusted odds ratio (OR): 0.42; 95% CI: 0.25 to 0.73]; its occurrence in Subtropical and Other regions was comparable to that in Temperate regions. Fungal peritonitis was independently associated with Tropical regions (OR: 2.18; 95% CI: 1.22 to 3.90) and Other regions (OR: 3.46; 95% CI: 1.73 to 6.91), where rates of antifungal prophylaxis were also lower. Outcomes after first peritonitis episodes were comparable in all groups. CONCLUSIONS: Tropical regions were associated with a higher overall peritonitis rate (including fungal peritonitis) and a shorter time to a first peritonitis episode. Augmented peritonitis prophylactic measures such as antifungal therapy and exit-site care should be considered in PD patients residing in Tropical climates.

End-stage kidney disease due to haemolytic uraemic syndrome--outcomes in 241 consecutive ANZDATA registry cases.

BACKGROUND: The aim of this study was to investigate the characteristics and outcomes of patients receiving renal replacement therapy for end-stage kidney disease (ESKD) secondary to haemolytic uraemic syndrome (HUS). METHODS: The study included all patients with ESKD who commenced renal replacement therapy in Australia and New Zealand between 15/5/1963 and 31/12/2010, using data from the ANZDATA Registry. HUS ESKD patients were compared with matched controls with an alternative primary renal disease using propensity scores based on age, gender and treatment era. RESULTS: Of the 58422 patients included in the study, 241 (0.4%) had ESKD secondary to HUS. HUS ESKD was independently associated with younger age, female gender and European race. Compared with matched controls, HUS ESKD was not associated with mortality on renal replacement therapy (adjusted hazard ratio [HR] 1.14, 95% CI 0.87-1.50, p = 0.34) or dialysis (HR 1.34, 95% CI 0.93-1.93, p = 0.12), but did independently predict recovery of renal function (HR 54.01, 95% CI 1.45-11.1, p = 0.008). 130 (54%) HUS patients received 166 renal allografts. Overall renal allograft survival rates were significantly lower for patients with HUS ESKD at 1 year (73% vs 91%), 5 years (62% vs 85%) and 10 years (49% vs 73%). HUS ESKD was an independent predictor of renal allograft failure (HR 2.59, 95% CI 1.70-3.95, p < 0.001). Sixteen (12%) HUS patients experienced failure of 22 renal allografts due to recurrent HUS. HUS ESKD was not independently associated with the risk of death following renal transplantation (HR 0.92, 95% CI 0.35-2.44, p = 0.87). CONCLUSIONS: HUS is an uncommon cause of ESKD, which is associated with comparable patient survival on dialysis, an increased probability of renal function recovery, comparable patient survival post-renal transplant and a heightened risk of renal transplant graft failure compared with matched ESKD controls.

The effects of living distantly from peritoneal dialysis units on peritonitis risk, microbiology, treatment and outcomes: a multi-centre registry study.

BACKGROUND: The aim of the study was to determine whether distance between residence and peritoneal dialysis (PD) unit influenced peritonitis occurrence, microbiology, treatment and outcomes. METHODS: The study included all patients receiving PD between 1/10/2003 and 31/12/2008, using ANZDATA Registry data. RESULTS: 365 (6%) patients lived ≥100 km from their nearest PD unit (distant group), while 6183 (94%) lived <100 km (local group). Median time to first peritonitis in distant patients (1.34 years, 95% CI 1.07-1.61) was significantly shorter than in local patients (1.68 years, 95% CI 1.59-1.77, p = 0.001), whilst overall peritonitis rates were higher in distant patients (incidence rate ratio 1.32, 95% CI 1.20-1.46). Living ≥100 km away from a PD unit was independently associated with a higher risk of S. aureus peritonitis (adjusted odds ratio [OR] 1.64, 95% CI 1.09-2.47). Distant patients with first peritonitis episodes were less likely to be hospitalised (64% vs 73%, p = 0.008) and receive antifungal prophylaxis (4% vs 10%, p = 0.01), but more likely to receive vancomycin-based antibiotic regimens (52% vs 42%, p < 0.001). Using multivariable logistic regression analysis of peritonitis outcomes, distant patients were more likely to be cured with antibiotics alone (OR 1.55, 95% CI 1.03-2.24). All other outcomes were comparable between the two groups. CONCLUSIONS: Living ≥100 km away from a PD unit was associated with increased risk of S. aureus peritonitis, modified approaches to peritonitis treatment and peritonitis outcomes that were comparable to, or better than patients living closer to a PD unit. Staphylococcal decolonisation should receive particular consideration in remote living patients.

Recent peritonitis associates with mortality among patients treated with peritoneal dialysis.

Peritonitis is a major complication of peritoneal dialysis, but the relationship between peritonitis and mortality among these patients is not well understood. In this case-crossover study, we included the 1316 patients who received peritoneal dialysis in Australia and New Zealand from May 2004 through December 2009 and either died on peritoneal dialysis or within 30 days of transfer to hemodialysis. Each patient served as his or her own control. The mean age was 70 years, and the mean time receiving peritoneal dialysis was 3 years. In total, there were 1446 reported episodes of peritonitis with 27% of patients having ≥ 2 episodes. Compared with the rest of the year, there were significantly increased odds of peritonitis during the 120 days before death, although the magnitude of this association was much greater during the 30 days before death. Compared with a 30-day window 6 months before death, the odds for peritonitis was six-fold higher during the 30 days immediately before death (odds ratio, 6.2; 95% confidence interval, 4.4-8.7). In conclusion, peritonitis significantly associates with mortality in peritoneal dialysis patients. The increased odds extend up to 120 days after an episode of peritonitis but the magnitude is greater during the initial 30 days.

Weekend compared with weekday presentations of peritoneal dialysis-associated peritonitis.

OBJECTIVE: Management of peritoneal dialysis (PD)-associated peritonitis requires timely intervention by experienced staff, which may not be uniformly available throughout the week. The aim of the present study was to examine the effects of weekend compared with weekday presentation on peritonitis outcomes. METHODS: The study, which used data from the Australia and New Zealand Dialysis and Transplant Registry, included all Australian patients receiving PD between 1 October 2003 and 31 December 2008. The independent predictors of weekend presentation and subsequent peritonitis outcomes were assessed by multivariate logistic regression. RESULTS: Peritonitis presentation rates were significantly lower on Saturdays [0.46 episodes per year; 95% confidence interval (CI): 0.42 to 0.49 episodes per year] and on Sundays (0.43 episodes per year; 95% CI: 0.40 to 0.47 episodes per year) than all other weekdays; they peaked on Mondays (0.76 episodes per year; 95% CI: 0.72 to 0.81 episodes per year). Weekend presentation with a first episode of peritonitis was independently associated with lower body mass index and residence less than 100 km away from the nearest PD unit. Patients presenting with peritonitis on the weekend were significantly more likely to be hospitalized [adjusted odds ratio (OR): 2.32; 95% CI: 1.85 to 2.90], although microbial profiles and empiric antimicrobial treatments were comparable between the weekend and weekday groups. Antimicrobial cure rates were also comparable (79% vs 79%, p = 0.9), with the exception of cure rates for culture-negative peritonitis, which were lower on the weekend (80% vs 88%, p = 0.047). Antifungal prophylaxis was less likely to be co-prescribed for first peritonitis episodes presenting on weekdays (OR: 0.68; 95% CI: 0.05 to 0.89). CONCLUSIONS: Patients on PD are less likely to present with peritonitis on the weekend. Nevertheless, the microbiology, treatment, and outcomes of weekend and weekday PD peritonitis presentations are remarkably similar. Exceptions include the associations of weekend presentation with a higher hospitalization rate and a lower cure rate in culture-negative infection.

Seasonal variation in peritoneal dialysis-associated peritonitis: a multi-centre registry study.

BACKGROUND: The role of seasonal variation in peritoneal dialysis (PD)-related peritonitis has been limited to a few small single-centre studies. METHODS: Using all 6610 Australian patients receiving PD between 1 October 2003 and 31 December 2008, we evaluated the influence of seasons on peritonitis rates (Poisson regression) and outcomes (multivariable logistic regression). RESULTS: The overall rate of peritonitis was 0.59 episodes per patient-year of treatment. Using winter as the reference season, the peritonitis incidence rate ratios (95% confidence interval) for summer, autumn and spring were 1.02 (0.95-1.09), 1.01 (0.94-1.08) and 0.99 (0.92-1.06), respectively. Significant seasonal variations were observed in the rates of peritonitis caused by coagulase-negative Staphylococci (spring and summer peaks), corynebacteria (winter peak) and Gram-negative organisms (summer and autumn peaks). There were trends to seasonal variations in fungal peritonitis (summer and autumn peaks) and pseudomonas peritonitis (summer peak). No significant seasonal variations were observed for other organisms. Peritonitis outcomes did not significantly vary according to season. CONCLUSIONS: Seasonal variation has no appreciable influence on overall PD peritonitis rates or clinical outcomes. Nevertheless, significant seasonal variations were observed in the rates of peritonitis due to specific microorganisms, which may allow institutions to more precisely target infection control strategies prior to higher risk seasons.

Use of aminoglycosides for peritoneal dialysis-associated peritonitis does not affect residual renal function.

BACKGROUND: Aminoglycosides offer several potential benefits in their treatment of peritoneal dialysis (PD)-associated peritonitis, including low cost, activity against Gram-negative organisms (including Pseudomonas aeruginosa), synergistic bactericidal activity against some Gram-positive organisms (such as Staphylococci) and relatively low propensity to promote antimicrobial resistance. However, there is limited conflicting evidence that aminoglycosides may accelerate loss of residual renal function (RRF) in PD patients. The aim of this study was to study the effect of aminoglycoside use on slope of decline in RRF. METHODS: The study included 2715 Australian patients receiving PD between October 2003 and December 2007 in whom at least two measurements of renal creatinine clearance were available. Patients were divided according to tertiles of slope of RRF decline (rapid, intermediate and slow). The primary outcome was the slope of RRF over time in patients who received aminoglycosides for PD peritonitis versus those who did not. RESULTS: A total of 1412 patients (52%) experienced at least one episode of PD peritonitis. An aminoglycoside was used as the initial empiric antibiotic in 1075 patients. The slopes of RRF decline were similar in patients treated and not treated with at least one course of aminoglycoside (median [interquartile range] -0.26 [-1.17 to 0.04] mL/min/1.73 m(2)/month versus -0.22 [-1.11 to 0.01] mL/min/1.73 m(2)/month, P = 0.9). The slopes of RRF decline were also similar in patients receiving repeated courses of aminoglycoside. CONCLUSIONS: Empiric treatment with aminoglycoside for peritonitis was not associated with an adverse effect on RRF in PD patients.

Repeated peritoneal dialysis-associated peritonitis: a multicenter registry study.

BACKGROUND: Determinants and outcomes of peritoneal dialysis (PD)-associated peritonitis occurring within 4 weeks of completion of therapy of a prior episode caused by the same (relapse) or different organism (recurrence) recently have been characterized. However, determinants and outcomes of peritonitis occurring more than 4 weeks after treatment of a prior episode caused by the same (repeated) or different organism (nonrepeated) are poorly understood. STUDY DESIGN: Observational cohort study using Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. SETTING & PARTICIPANTS: All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of repeated or nonrepeated peritonitis. PREDICTORS: Repeated versus nonrepeated peritonitis, according to International Society of PD (ISPD) criteria. OUTCOMES & MEASUREMENTS: Relapse, hospitalization, catheter removal, hemodialysis transfer, and death. RESULTS: After a peritonitis episode, the probability that a subsequent episode represented repeated rather than nonrepeated peritonitis was highest in the second month (41%), then progressively decreased to a stable level of 14% from 6 months onward. When first episodes of repeated (n = 245) or nonrepeated peritonitis (n = 824) were analyzed, repeated peritonitis was predicted independently by a shorter elapsed time from the prior episode (adjusted OR per day elapsed, 0.91; 95% CI, 0.88-0.94). Staphylococcus aureus and coagulase-negative staphylococcus were isolated more frequently in repeated peritonitis, whereas Gram-negative, streptococcal, and fungal organisms were recovered more frequently in nonrepeated peritonitis. Using multivariate logistic regression, repeated peritonitis was associated independently with higher relapse (OR, 5.41; 95% CI, 3.72-7.89) and lower hospitalization rates (OR, 0.63; 95% CI, 0.46-0.85), but catheter removal, hemodialysis transfer, and death rates similar to nonrepeated peritonitis. LIMITATIONS: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Repeated and nonrepeated peritonitis episodes are caused by different spectra of micro-organisms and have different outcomes. Study findings suggest that the ISPD definition for repeated peritonitis should be limited to 6 months.

Effect of dialysis modality on survival of hepatitis C-infected ESRF patients.

BACKGROUND AND OBJECTIVES: Hepatitis C virus (HCV) infection is associated with increased mortality and morbidity in end-stage renal failure (ESRF) patients. Despite a lower incidence and risk of transmission of HCV infection with peritoneal dialysis (PD), the optimal dialysis modality for HCV-infected ESRF patients is not known. The aim of this study was to evaluate the impact of dialysis modality on the survival of HCV-infected ESRF patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The study included all adult incident ESRF patients in Australia and New Zealand who commenced dialysis between January 1, 1994, and December 31, 2008, and were HCV antibody-positive at the time of dialysis commencement. Time to all-cause mortality was compared between hemodialysis (HD) and PD according to modality assignment at day 90, using Cox proportional hazards model analysis. RESULTS: A total of 424 HCV-infected ESRF patients commenced dialysis during the study period and survived for at least 90 days (PD n = 134; HD n = 290). Mortality rates were comparable between PD and HD in the first year (10.7 versus 13.8 deaths per 100 patient-years, respectively; adjusted hazard ratio [HR] 0.65, 95% CI 0.34 to 1.26) and thereafter (20 versus 15.9 deaths per 100 patient-years, respectively; HR 1.27, 95% CI 0.86 to 1.88). CONCLUSIONS: The survival of HCV-infected ESRF patients is comparable between PD and HD.

Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients.

We analyzed data from the Australia and New Zealand Dialysis and Transplant Registry for 1 October 2003 to 31 December 2008 with the aim of describing the nature of peritonitis, therapies, and outcomes in patients on peritoneal dialysis (PD) in Australia. At least 1 episode of PD was observed in 6639 patients. The overall peritonitis rate was 0.60 episodes per patient-year (95% confidence interval: 0.59 to 0.62 episodes), with 6229 peritonitis episodes occurring in 3136 patients. Of those episodes, 13% were culture-negative, and 11% were polymicrobial. Gram-positive organisms were isolated in 53.4% of single-organism peritonitis episodes, and gram-negative organisms, in 23.6%. Mycobacterial and fungal peritonitis episodes were rare. Initial antibiotic therapy for most peritonitis episodes used 2 agents (most commonly vancomycin and an aminoglycoside); in 77.2% of episodes, therapy was subsequently changed to a single agent. Tenckhoff catheter removal was required in 20.4% of cases at a median of 6 days, and catheter removal was more common in fungal, mycobacterial, and anaerobic infections, with a median time to removal of 4 - 5 days. Peritonitis was the cause of death in 2.6% of patients. Transfer to hemodialysis and hospitalization were frequent outcomes of peritonitis. There was no relationship between center size and peritonitis rate. The peritonitis rate in Australia between 2003 and 2008 was higher than that reported in many other countries, with a particularly higher rate of gram-negative peritonitis.

Relapsing and recurrent peritoneal dialysis-associated peritonitis: a multicenter registry study.

BACKGROUND: The causes, predictors, treatment, and outcomes of relapsed and recurrent peritoneal dialysis (PD)-associated peritonitis are poorly understood. STUDY DESIGN: Observational cohort study using Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data. SETTING & PARTICIPANTS: All Australian PD patients between October 1, 2003, and December 31, 2007, with first episodes of peritonitis. PREDICTORS: Demographic, clinical, and facility variables and type of peritonitis; relapse (same organism or culture-negative episode occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); recurrence (different organism occurring within 4 weeks of completion of therapy of a prior episode or 5 weeks if vancomycin used); control (first peritonitis episode without relapse or recurrence). OUTCOMES & MEASUREMENTS: Hospitalization, catheter removal, hemodialysis therapy transfer, death. RESULTS: Of 6,024 PD patients studied, first episodes of relapsed, recurrent, and control peritonitis occurred in 356, 165, and 2,021 patients, respectively. Coagulase-negative staphylococci and Staphylococcus aureus accounted for 48% of relapsing peritonitis (adjusted OR, 1.26 [95% CI, 0.94-1.70] and 1.54 [95% CI, 1.08-2.19], respectively), but were much less likely to be isolated in recurrent peritonitis. Recurrent peritonitis was associated more frequently with fungi (13%; OR, 2.16; 95% CI, 1.12-4.17). The empirical antimicrobial approaches to relapsing and recurrent peritonitis were similar and their subsequent clinical outcomes were comparable. Compared with uncomplicated peritonitis, relapsed and recurrent peritonitis were associated with higher rates of catheter removal (22% vs 30% vs 37%, respectively; P < 0.001) and permanent hemodialysis therapy transfer (20% vs 25% vs 32%; P < 0.001), but similar rates of hospitalization (73% vs 70% vs 70%) and death (2.8% vs 2.0% vs 1.2%). LIMITATIONS: Limited covariate adjustment. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Relapsed and recurrent peritonitis are caused by different spectra of micro-organisms, but are not readily clinically distinguishable at presentation. Empirical treatment with broad-spectrum antibiotics and subsequent adjustment according to antimicrobial susceptibilities results in similar clinical outcomes, albeit with appreciably higher rates of catheter removal and hemodialysis therapy transfer than for uncomplicated peritonitis.

End-stage kidney disease due to scleroderma--outcomes in 127 consecutive ANZDATA registry cases.

BACKGROUND: Scleroderma is an uncommon cause of end-stage kidney disease (ESKD) which carries significant morbidity and mortality risks. The aim of this study was to determine the prevalence, treatment and outcomes of scleroderma patients with ESKD. METHODS: A study was conducted of all ESKD patients enrolled in the ANZDATA registry, who commenced dialysis between 15 May 1963 and 31 December 2005, and remained on dialysis for at least 90 days. RESULTS: Of the 40 238 patients who commenced dialysis during the study period, 127 (0.3%) patients had ESKD secondary to scleroderma. Scleroderma ESKD patients were more likely than other ESKD patients to be female (72% versus 43%, P < 0.001), Caucasian (98% versus 79%, P < 0.001) and of lower BMI (22.7 ± 4.7 versus 26.0 ± 5.9, P < 0.001) with a higher prevalence of chronic lung disease (36 versus 14%, P < 0.001) and lower prevalence of diabetes mellitus (10% versus 32%, P < 0.001) and coronary artery disease (23% versus 35%, P = 0.01). Median survival was significantly shorter in scleroderma ESKD (2.43 years, 95% confidence interval (CI) 1.75-3.11 years) than other ESKD (6.02 years, 95% CI 5.89-6.14 years, log-rank score 55.7, P < 0.001). Renal recovery was more likely in scleroderma patients (10% versus 1%, P < 0.001) with a shorter time to recovery. Scleroderma was found to be an independent predictor for mortality (HR 2.47, 95% CI 1.99-3.05) and renal recovery (HR 11.1, 95% CI 6.37-19.4). Five year deceased donor and live donor renal allograft survival rates of recipients with scleroderma were 53 and 100%, respectively. CONCLUSIONS: Scleroderma is an uncommon cause of ESKD, which is associated with increased risks of both spontaneous renal recovery and mortality.

Peritoneal dialysis practice in Australia and New Zealand: a call to action.

Peritoneal dialysis technique survival in Australia and New Zealand is lower than in other parts of the world. More than two-thirds of technique failures are related to infective complications (predominantly peritonitis) and 'social reasons'. Practice patterns vary widely and more than one-third of peritoneal dialysis units do not meet the International Society of Peritoneal Dialysis minimum accepted peritonitis rate. In many cases, poor peritonitis outcomes reflect significant deviations from international guidelines. In this paper we propose a series of practical recommendations to improve outcomes in peritoneal dialysis patients through appropriate patient selection, prophylaxis and treatment of infectious complications, investigation of social causes of technique failure and a greater focus on patient education and clinical governance.

Predictors, treatment, and outcomes of non-Pseudomonas Gram-negative peritonitis.

Non-Pseudomonas Gram-negative (NPGN) peritonitis is a frequent, serious complication of peritoneal dialysis; however, previous reports have been limited to small, single-center studies. To gain insight on the frequency, predictors, treatment, and outcomes of NPGN peritonitis, we analyzed data in the ANZDATA registry of all adult Australian peritoneal dialysis patients over a 39-month period using multivariate logistic and multilevel Poisson regressions. There were 837 episodes of NPGN peritonitis (23.3% of all peritonitis) that occurred in 256 patients. The most common organism isolated was Escherichia coli, but included Klebsiella, Enterobacter, Serratia, Acinetobacter, Proteus, and Citrobacter, with multiple organisms identified in a quarter of the patients. The principal risk factor was older age, with poorer clinical outcome predicted by older age and polymicrobial peritonitis. The overall antibiotic cure rate was 59%. NPGN peritonitis was associated with significantly higher risks of hospitalization, catheter removal, permanent transfer to hemodialysis, and death compared to other organisms contributing to peritonitis. Underlying bowel perforation requiring surgery was uncommon. Hence, we show that NPGN peritonitis is a frequent, serious complication of peritoneal dialysis, which is frequently associated with significant risks, including death. Its cure with antibiotics alone is less likely when multiple organisms are involved.

Coagulase-negative staphylococcal peritonitis in Australian peritoneal dialysis patients: predictors, treatment and outcomes in 936 cases.

BACKGROUND: Coagulase-negative staphylococcal (CNS) peritonitis is the most common cause of peritoneal dialysis (PD)-associated peritonitis. Previous reports of this important condition have been sparse and generally limited to single-centre studies. METHODS: The frequency, predictors, treatment and clinical outcomes of CNS peritonitis were examined by multivariate logistic regression and multilevel Poisson regression in all adult PD patients in Australia between 2003 and 2006. RESULTS: A total of 936 episodes of CNS peritonitis (constituting 26% of all peritonitis episodes) occurred in 620 individuals. The observed rate of CNS peritonitis was 0.16 episodes per patient-year. Lower rates of CNS peritonitis were independently predicted by Asian racial origin (adjusted odds ratio [OR], 0.52; 95% CI, 0.35-0.79), renovascular nephrosclerosis (OR, 0.40; 95% CI, 0.18-0.86), early referral to a renal unit prior to dialysis commencement (OR, 0.38; 95% CI, 0.19-0.79) and treatment with automated PD at any time during the PD career (OR, 0.79; 95% CI, 0.66-0.96). The majority of CNS peritonitis episodes were initially treated with intraperitoneal vancomycin or cephazolin in combination with gentamicin. This regimen was changed in 533 (57%) individuals after a median period of 3 days, most commonly to vancomycin monotherapy. The median total antibiotic course duration was 14 days. Compared with other forms of peritonitis, CNS episodes were significantly more likely to be cured by antibiotics alone (76 vs 64%, P < 0.001) and less likely to be complicated by hospitalization (61 vs 73%, P < 0.001), catheter removal (10 vs 26%, P < 0.001), temporary haemodialysis (2 vs 5%, P < 0.001), permanent haemodialysis transfer (9 vs 21%, P < 0.001) and death (1.0 vs 2.7%, P = 0.002). CNS peritonitis was also associated with a shorter duration of hospitalization, a longer time to catheter removal and a shorter duration of temporary haemodialysis. Catheter removal and permanent haemodialysis transfer were independently predicted by polymicrobial peritonitis and initial empiric administration of vancomycin (compared with cephalosporins). CNS peritonitis was associated with a higher relapse rate (17 vs 13%, P = 0.003) and relapsed CNS peritonitis was associated with a higher catheter removal rate (22 vs 7%, P < 0.001). Repeat peritonitis occurred in 194 (31%) individuals and the highest risk was in the second month after completion of antibiotic treatment for CNS peritonitis (OR, 1.87; 95% CI, 1.39-2.51 compared with >2 months). CONCLUSIONS: CNS peritonitis is a common complication with a relatively benign outcome compared with other forms of PD-associated peritonitis. Relapsed and repeat peritonitis are relatively common and are associated with worse outcomes.