Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol.

Background: People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms. Objective: The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis. Design: Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial. Setting: Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada. Participants: Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150). Intervention: Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention. Control: Usual hemodialysis care (no exercise program). Measurements: Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality. Methods: Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution. Limitations: The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted. Conclusions: The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

Contexte: Les personnes sous hémodialyse éprouvent un grand nombre de symptômes qui contribuent à un faible état fonctionnel et à une mauvaise qualité de vie liée à la santé. La prise en charge des symptômes est une priorité pour les personnes sous hémodialyse, mais les traitements efficaces sont limités. De nouvelles preuves montrent que l'adoption d'un programme d'exercice permettrait d'améliorer plusieurs symptômes courants liés à la dialyse. Objectifs: Le principal objectif de cette étude est d'évaluer l'effet d'un programme de rééducation par l'exercice sur le fardeau des symptômes chez les personnes recevant une hémodialyse d'entretien. Conception: Essai clinique prospectif randomisé-contrôlé, en aveugle, en parallèle 1:1 et ouvert, multicentrique. Cadre: Trois unités d'hémodialyse de Winnipeg, au Manitoba (Canada). Sujets: Des adultes atteints d'insuffisance rénale terminale qui reçoivent des traitements d'hémodialyse d'entretien en centre depuis plus de trois mois et qui présentent au moins un symptôme lié à la dialyse, tel qu'indiqué par un score de gravité de l'indice des symptômes de la dialyse (Dialysis Symptom Index) supérieur à zéro (n = 150). Intervention: Programme supervisé de rééducation par l'exercice d'une durée de 26 semaines et 60 minutes de vélo trois fois par semaine pendant l'hémodialyse. L'intensité et la durée de l'exercice ont été supervisées par un kinésiologue qui les a ensuite personnalisées en fonction de la forme physique initiale du participant en prévoyant une progression graduelle tout au long de l'intervention. Groupe témoin: Soins habituels d'hémodialyse (sans programme d'exercice). Mesures: Notre principal critère de jugement est un changement dans le fardeau lié aux symptômes après 12 semaines, tel que mesuré par le score de gravité de l'indice des symptômes de dialyse (ISD). Les critères d'évaluation secondaires comprennent un changement du score modifié de gravité de l'ISD (portant sur 10 symptômes les plus plausibles de s'améliorer avec l'exercice), la modification du score de gravité de l'ISD après 26 et 52 semaines, le temps de récupération après l'hémodialyse, la qualité de vie liée à la santé mesurée par le questionnaire EQ5D-5L, le comportement lié à l'activité physique mesuré par autoévaluation (questionnaire Godin-Shepherd) et par accéléromètre triaxial, la capacité d'effort (test de marche navette), la fragilité (Fried), le sentiment d'efficacité autodéclaré face à l'exercice, ainsi que les hospitalisations et la mortalité à un an. Méthodologie: Les changements pour le principal critère de jugement seront comparés entre les groupes par un test t bilatéral indépendant ou un test U de Mann-Whitney en fonction de la distribution des données, ainsi qu'à l'aide de modèles linéaires mixtes généralisés avec un point temporel de l'étude comme effet aléatoire et corrigé en fonction du score ISD initial. Les changements dans les résultats secondaires seront comparés entre les groupes au fil du temps à l'aide des tests statistiques paramétriques et non paramétriques appropriés selon le type de données et la distribution. Limites: Les restrictions liées à la pandémie de COVID-19 dans notre établissement ont retardé le recrutement des cibles et empêché pendant 15 mois la collecte de données sur les résultats mesurés par l'accéléromètre et les mesures de la fonction physique, soit jusqu'à ce que les restrictions soient levées. Conclusion: L'adoption d'un programme de rééducation par l'exercice visant à réduire le fardeau lié aux symptômes chez les personnes sous hémodialyse peut améliorer les symptômes courants observés dans cette population et se traduire par une amélioration de la qualité de vie et une réduction de l'invalidité et de la morbidité à long terme. Il convient de noter que cet essai pragmatique, avec son intervention d'exercice standardisée adaptable à la condition physique initiale de la personne, comble une lacune importante dans les soins cliniques des patients sous hémodialyse et dans nos connaissances actuelles.

Clinical Blood Isolates from Hemodialysis Patients: Distribution of Organisms and Antimicrobial Resistance, 2007-2014.

BACKGROUND: Given the morbidity and mortality associated with bloodstream infections in hemodialysis patients, understanding the microbiology is essential to optimizing treatment in this high-risk population. OBJECTIVES: To conduct a retrospective surveillance study of clinical blood isolates from adult hemodialysis patients, and to predict the microbiological coverage of empiric therapies for bloodstream infections in this population. METHODS: Clinical blood isolate data were collected from the 4 main outpatient hemodialysis units in Winnipeg, Manitoba, from 2007 to 2014. The distribution of organisms and antimicrobial susceptibilities were characterized. When appropriate, changes over time were tested using time series analysis. Study data were used to predict and compare the microbiological coverage of various empiric therapies for bloodstream infections in hemodialysis patients. RESULTS: The estimated annual number of patients receiving chronic hemodialysis increased steadily over the study period (p < 0.001), whereas the number of blood isolates increased initially, then decreased significantly, from 180 in 2011 to 93 in 2014 (p = 0.04). Gram-positive bacteria represented 72.6% (743/1024) of isolates, including Staphylococcus aureus (36.9%, 378/1024) and coagulase-negative staphylococci (23.1%, 237/1024). Only 26.1% (267/1024) of the isolates were gram-negative bacteria, the majority Enterobacteriaceae. The overall rate of methicillin resistance in S. aureus was 17.5%, and although annual rates were variable, there was a significant increase over time (p = 0.04). Antibiotic resistance in gram-negative bacteria was relatively low, except in Escherichia coli, where 13.5% and 16.2% of isolates were resistant to ceftriaxone and ciprofloxacin, respectively. Empiric therapy with vancomycin plus an agent for gram-negative coverage was predicted to cover 98.8% to 99.7% of blood isolates from hemodialysis patients, whereas cefazolin plus an agent for gram-negative coverage would cover only 67.5% to 68.4%. CONCLUSIONS: In an era of increasing antimicrobial resistance, data such as these and ongoing surveillance are essential components of antimicrobial stewardship in the hemodialysis population.

CONTEXTE: Étant donné la morbidité et la mortalité associées aux infections du sang parmi les patients en hémodialyse, la compréhension de la microbiologie est essentielle à l'optimisation du traitement de cette population exposée à un risque élevé. OBJECTIFS: Mener une étude de surveillance rétrospective des isolats de sang cliniques des patients adultes en hémodialyse et prédire la couverture microbiologique des thérapies empiriques contre les infections du sang dans cette population. MÉTHODES: Les données relatives aux isolats de sang cliniques ont été recueillies dans les quatre unités ambulatoires principales d'hémodialyse à Winnipeg (Manitoba), entre 2007 et 2014. La caractérisation a porté sur la distribution des organismes et les susceptibilités aux antimicrobiens. L'évolution dans le temps a été testée au besoin à l'aide d'une analyse chronologique. Les données de l'étude ont permis de prédire et de comparer la couverture microbiologique de diverses thérapies empiriques contre les infections du sang pour les patients en hémodialyse. RÉSULTATS: On estime que le nombre annuel de patients recevant une hémodialyse chronique a augmenté régulièrement au cours de la période de l'étude (p < 0,001); le nombre d'isolats de sang a tout d'abord augmenté, puis il a grandement diminué: de 180 en 2011, il est passé à 93 en 2014 (p = 0,04). Les bactéries à Gram positif représentaient 72,6 % (743/1024) des isolats, y compris les Staphylococcus aureus (36,9 %, 378/1024) et les staphylocoques à coagulase négative (23,1 %, 237/1024). Seulement 26,1 % (267/1024) des isolats étaient des bactéries à Gram négatif, la majorité desquelles étant des Enterobacteriaceae. Le taux général de résistance à la méticilline de S. aureus était de 17,5 %, et bien que les taux annuels étaient variables, une augmentation importante a été observée avec le temps (p = 0,04). La résistance aux antibiotiques des bactéries à Gram négatif était relativement faible, sauf Escherichia coli, où respectivement 13,5 % et 16,2 % des isolats étaient résistants à la ceftriaxone et à la ciprofloxacine. On prévoyait que la thérapie empirique à la vancomycine associée à un agent pour la couverture à Gram positif couvrirait de 98,8 % à 99,7 % des isolats de sang des patients en hémodialyse, tandis que la céfazoline associée à un agent de la couverture à Gram négatif ne couvrirait que 67,5 % à 68,4 %. CONCLUSIONS: À une époque qui se caractérise par une augmentation de la résistance aux antimicrobiens, des données comme celles-ci et celles portant sur la surveillance continue sont des composantes essentielles de la bonne gestion de l'utilisation des antimicrobiens pour les patients adultes en hémodialyse.

Patterns of emergency department utilization by patients on chronic dialysis: A population-based study.

IMPORTANCE: Patients on dialysis are often elderly and frail, with multiple comorbid conditions, and are heavy users of Emergency Department (ED) services. However, objective data on the frequency and pattern of ED utilization by dialysis patients are sparse. Such data could identify periods of highest risk for ED visits and inform health systems interventions to mitigate these risks and improve outcomes. OBJECTIVE: To describe the pattern and frequency of presentation to ER by dialysis patients. DESIGN: Retrospective cohort study using administrative data collected over ten years (2000-2009) in the Province of Manitoba, Canada. SETTING: Patients presenting to any of 9 ED's in Winnipeg and Brandon Manitoba. These departments serve >90% of the population of Manitoba, Canada (population 1.2 million). PARTICIPANTS: All patients presenting to an ED in any of 9 emergency departments in Manitoba, Canada. EXPOSURE: Dialysis status. MAIN OUTCOMES: Presentation to the ED. RESULTS: Over 2.1 million ED visits by more than 1.2 million non-dialysis patients and 17,782 ED visits by 3257 dialysis patients were included. Dialysis patients presented 8.5 times more frequently to the ED than the general population (age and sex adjusted, p<0.001). For dialysis patients, ED utilization was significantly higher following the long interdialytic interval (33.6% higher Mondays and 19.5% higher Tuesdays vs. other days of the week, p<0.001) and was 10-fold higher in the 7 days before and after the initiation of dialysis. CONCLUSION AND RELEVANCE: The heavy use of ED services by dialysis patients spikes upward following the long interdialytic interval and also in the week before and after dialysis initiation. The relative risks associated with these vulnerable periods were much higher than those reported for clinical patient characteristics. We propose that intrinsic gaps in the structure of care delivery (e.g. 3 times a week dialysis, imperfect surveillance and clinical monitoring of patients with low GFR) may be the fundamental drivers of this periodicity. Strategies to mitigate this excess health risk are needed.

Association between Duration of Predialysis Care and Mortality after Dialysis Start.

BACKGROUND AND OBJECTIVES: Early nephrology referral is recommended for people with CKD on the basis of observational studies showing that longer nephrology care before dialysis start (predialysis care) is associated with lower mortality after dialysis start. This association may be observed because predialysis care truly reduces mortality or because healthier people with an uncomplicated course of disease will have both longer predialysis care and lower risk for death. We examined whether the survival benefit of longer predialysis care exists after accounting for the potential confounding effect of disease course that may also be affected by predialysis care. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a retrospective cohort study and used data from 3152 adults with end stage kidney failure starting dialysis between 2004 and 2014 in five Canadian dialysis programs. We obtained duration of predialysis care from the earliest nephrology outpatient visit to dialysis start; markers of disease course, including inpatient or outpatient dialysis start and residual kidney function around dialysis start; and all-cause mortality after dialysis start. RESULTS: The percentages of participants with 0, 1-119, 120-364, and ≥365 days of predialysis care were 23%, 8%, 10%, and 59%, respectively. When we ignored markers of disease course as in previous studies, longer predialysis care was associated with lower mortality (hazard ratio120-364 versus 0-119 days, 0.60; 95% confidence interval, 0.46 to 0.78]; hazard ratio≥365 versus 0-119 days, 0.60; 95% confidence interval, 0.51 to 0.71; standard Cox model adjusted for demographics and laboratory and clinical characteristics). When we additionally accounted for markers of disease course using the inverse probability of treatment weighted Cox model, this association was weaker and no longer significant (hazard ratio120-364 versus 0-119 days, 0.84; 95% confidence interval, 0.60 to 1.18; hazard ratio≥365 versus 0-119 days, 0.88; 95% confidence interval, 0.69 to 1.13). CONCLUSIONS: The association between longer predialysis care and lower mortality after dialysis start is weaker and imprecise after accounting for patients' course of disease.

Microbiological Trends and Antimicrobial Resistance in Peritoneal Dialysis-Related Peritonitis, 2005 to 2014.

♦ BACKGROUND: Information related to the microbiology of peritonitis is critical to the optimal management of patients receiving peritoneal dialysis (PD). The goal was to characterize the microbiological etiology and antimicrobial susceptibilities of PD-related peritonitis (PDRP) from 2005 to 2014, inclusive. ♦ METHODS: The distribution of organisms in culture-positive PDRP was described for new episodes and relapse infections, and further detailed for monomicrobial and polymicrobial peritonitis. Annual and overall rates of PDRP were also characterized. Antimicrobial susceptibility rates were calculated for the most common and significant organisms. ♦ RESULTS: We identified 539 episodes of PDRP including 501 new and 38 relapse infections. New episodes of peritonitis were associated with a single organism in 85% of cases, and 44% of those involved staphylococci. Polymicrobial PDRP was more likely to involve gram-negative organisms, observed in 58% versus 24% of monomicrobial infections. Antimicrobial resistance was relatively stable from 2005 to 2014. Methicillin resistance was present in 57% of Staphylococcus epidermidis and 20% of other coagulase-negative staphylococci. Methicillin-resistant Staphylococcus aureus (MRSA) accounted for only 11% of S. aureus peritonitis compared with 2% in our previous study of PDRP from 1991 to 1998. Ciprofloxacin resistance in Escherichia coli increased from 3% in our previous study to 24% in 2005 - 2014. ♦ CONCLUSIONS: This study characterizes important differences in the distribution of organisms in new episodes of PDRP and relapse infections, as well as monomicrobial versus polymicrobial peritonitis. It also shows relatively stable rates of antimicrobial resistance from 2005 to 2014, but some increases compared with our previous study.

A before and after cross-sectional analysis of a public health campaign to increase kidney health awareness in a Canadian province.

BACKGROUND: Chronic kidney disease (CKD) has a major impact on patient health and health system resources. The prevalence of kidney disease is increasing, with Manitoba being one of the provinces in Canada with the highest per capita rate of CKD and end stage renal disease (Anonymous, Canadian organ replacement register annual report: treatment of end-stage organ failure in Canada, 2001-2010, 2011). In 2011, a public health campaign to promote kidney health, by increasing awareness of CKD and its risk factors, was created to target high-risk individuals such as First Nations and those with hypertension and diabetes in urban and rural/remote Manitoba. In this study, we aimed to determine the effectiveness of this public health campaign on increasing the awareness of CKD. METHODS: Our public health campaign ran in March 2011, and employed a multifaceted approach with radio, television, internet, and print advertisements. Campaign awareness and understanding of the public health message were assessed with a telephone omnibus survey of randomly selected individuals with a Manitoba area code during February and April 2011. A before and after cross-sectional analysis was utilized to measure the effect of exposure to the campaign in telephone respondents. RESULTS: 1606 individuals participated in the survey (804 pre and 802 post). Overall awareness of the campaign messaging increased from 7% pre campaign to 25% in the post campaign period. Approximately two-thirds of respondents correctly identified a main theme message of the campaign. Awareness improved across most subgroups surveyed aside from those with lower education and income. CONCLUSIONS: Our study demonstrates the effective reach of our campaign and its relative effectiveness at raising awareness of chronic kidney disease and its risk factors.

Pasteurella species peritoneal dialysis-associated peritonitis: Household pets as a risk factor.

BACKGROUND: Pasteurella species are Gram-negative coccobacilli that are a part of the normal oropharyngeal flora of numerous domestic animals. They have been recognized as a rare but significant cause of peritonitis in patients undergoing peritoneal dialysis (PD). A consensus about management strategies for PD-associated peritonitis caused by Pasteurella species currently does not exist. METHODS: The microbiological database serving the Manitoba Renal Program was searched from 1997 to 2013 for cases of Pasteurella species PD-associated peritonitis, and charts were reviewed. PubMed was searched for case reports and data were abstracted. RESULTS: Seven new local cases and 30 previously reported cases were analyzed. This infection is clinically similar to other forms of PD peritonitis, with household pet exposure appearing to be the strongest risk factor. Cats are the most commonly implicated pet. Direct contact between the pet and the equipment was commonly reported (25 of 37 patients) but was not necessary for infection to develop. The mean duration of treatment was 15 days. Complication rates were low, with only 11% of patients requiring PD catheter removal. There was no mortality reported. CONCLUSION: Pasteurella species are a rare cause of PD-associated peritonitis that can be successfully treated with a two-week course of intraperitoneal antibiotics with a high likelihood of catheter salvage.

HISTORIQUE: Les espèces de Pasteurella sont des coccobacilles à Gram négatif qui font partie de la flore oropharyngée normale de nombreux animaux domestiques. Ils constituent une cause de péritonite rare, mais importante, chez les patients sous dialyse péritonéale (DP). Il n'y a pas de consensus quant aux stratégies de prise en charge de la péritonite associée à la dialyse péritonéale causée par les espèces de Pasteurella. MÉTHODOLOGIE: Les chercheurs ont exploré la base de données microbiologiques du Programme de lutte contre la maladie du rein du Manitoba de 1997 à 2013 pour déceler les cas de péritonite associée à la DP causée par les espèces de Pasteurella et ont examiné leur dossier. Ils ont fouillé PubMed pour trouver des rapports de cas et en ont extrait des données. RÉSULTATS: Les chercheurs ont analysé sept nouveaux cas locaux et 30 anciens cas. Cette infection est similaire sur le plan clinique à d'autres formes de péritonite associée à la DP, dont le principal facteur de risque semble être l'exposition à un animal domestique. Les chats sont les plus en cause. On signale souvent un contact direct entre l'animal et le matériel (25 patients sur 37), mais il n'est pas nécessaire pour provoquer l'infection. Le traitement durait en moyenne 15 jours. Le taux de complications était faible, puisque seulement 11 % des patients ont dû faire retirer leur cathéter de DP. Aucun décès n'a été signalé. CONCLUSION: Les espèces de Pasteurella sont de rares causes de péritonite associée à la DP qu'on peut soigner par un traitement de deux semaines aux antibiotiques intrapéritonéaux. Ce traitement s'associe à une forte probabilité de sauvegarder le cathéter.

Impact of modality choice on rates of hospitalization in patients eligible for both peritoneal dialysis and hemodialysis.

BACKGROUND: Hospitalization rates are a relevant consideration when choosing or recommending a dialysis modality. Previous comparisons of peritoneal dialysis (PD) and hemodialysis (HD) have not been restricted to individuals who were eligible for both therapies. ♢ METHODS: We conducted a multicenter prospective cohort study of people 18 years of age and older who were eligible for both PD and HD, and who started outpatient dialysis between 2007 and 2010 in four Canadian dialysis programs. Zero-inflated negative binomial models, adjusted for baseline patient characteristics, were used to examine the association between modality choice and rates of hospitalization. ♢ RESULTS: The study enrolled 314 patients. A trend in the HD group toward higher rates of hospitalization, observed in the primary analysis, became significant when modality was treated as a time-varying exposure or when the population was restricted to elective outpatient starts in patients with at least 4 months of pre-dialysis care. Cardiovascular disease, infectious complications, and elective surgery were the most common reasons for hospital admission; only 23% of hospital stays were directly related to complications of dialysis or kidney disease. ♢ CONCLUSIONS: Efforts to promote PD utilization are unlikely to result in increased rates of hospitalization, and efforts to reduce hospital admissions should focus on potentially avoidable causes of cardiovascular disease and infectious complications.

Cost analysis of an intravenous to subcutaneous epoetin α conversion.

BACKGROUND/AIMS: A cost analysis of a conversion from intravenous (IV) to subcutaneous (SC) epoetin α in patients receiving chronic in-center hemodialysis (HD). METHODS: This retrospective analysis compared epoetin α drug costs during a 6-month period of IV usage (July to December 2010, period 1) to a 6-month period of SC usage (July to December 2011, period 2) in four large in-center HD units. Data were collected from quarterly counts of HD patients receiving epoetin α and monthly inventory billing records. RESULTS: 622 HD patients who received IV epoetin α (period 1) were compared to 609 HD patients who received SC epoetin α (period 2). A 12.6% decrease in dose was observed. The average weekly cost of epoetin α was USD 173.02 per patient during the IV period versus USD 151.20 per patient during the SC period. This equated to a yearly cost savings of USD 1,135 per patient with SC epoetin α. CONCLUSION: The switch from IV to SC epoetin α was successfully implemented in all four centers and realized significant cost savings.

Randomized, controlled trial of glucose-sparing peritoneal dialysis in diabetic patients.

Glucose-containing peritoneal dialysis solutions may exacerbate metabolic abnormalities and increase cardiovascular risk in diabetic patients. Here, we examined whether a low-glucose regimen improves metabolic control in diabetic patients undergoing peritoneal dialysis. Eligible patients were randomly assigned in a 1:1 manner to the control group (dextrose solutions only) or to the low-glucose intervention group (IMPENDIA trial: combination of dextrose-based solution, icodextrin and amino acids; EDEN trial: a different dextrose-based solution, icodextrin and amino acids) and followed for 6 months. Combining both studies, 251 patients were allocated to control (n=127) or intervention (n=124) across 11 countries. The primary endpoint was change in glycated hemoglobin from baseline. Mean glycated hemoglobin at baseline was similar in both groups. In the intention-to-treat population, the mean glycated hemoglobin profile improved in the intervention group but remained unchanged in the control group (0.5% difference between groups; 95% confidence interval, 0.1% to 0.8%; P=0.006). Serum triglyceride, very-low-density lipoprotein, and apolipoprotein B levels also improved in the intervention group. Deaths and serious adverse events, including several related to extracellular fluid volume expansion, increased in the intervention group, however. These data suggest that a low-glucose dialysis regimen improves metabolic indices in diabetic patients receiving peritoneal dialysis but may be associated with an increased risk of extracellular fluid volume expansion. Thus, use of glucose-sparing regimens in peritoneal dialysis patients should be accompanied by close monitoring of fluid volume status.

Underutilization of peritoneal dialysis: the role of the nephrologist's referral pattern.

BACKGROUND: The incidence of end-stage renal disease is increasing, placing a tremendous burden on health care resources. Peritoneal dialysis (PD) is cheaper than hemodialysis and has many potential advantages and few contraindications as an initial modality selection. This study examined differences in patient PD attempt rates between nephrologists using technique survival and mortality as outcomes. METHODS: We performed a retrospective review of the Manitoba Renal Program databases from January 2004 to January 2010. Analysis of 630 patients who commenced dialysis and had demographic data available was performed. A genetic matching algorithm was used to balance potential differences between patient characteristics. Each nephrologist was then compared against their peers to calculate a PD attempt rate. The highest attempt rate group was compared with the lowest. RESULTS: When comparing PD attempt rates between groups, all the results were significant. PD technique survival at >90 days showed no significant differences (P = 0.42). Patient mortality at >90 days was also not significant when comparing groups (P = 0.14). CONCLUSIONS: Our data suggest that when comparing the low- with high-attempt groups, the factors limiting PD utilization do not include on-site availability of PD, case mix, funding, patient location or reimbursement. Aggressive approaches of starting more patients on PD did not lead to lower technique survival or higher mortality rates. If the PD attempt rate was maximized, a significant amount of money and resources could be saved or directed toward helping a larger population without significant harm to patients.

Frequency and microbiology of peritonitis and exit-site infection among obese peritoneal dialysis patients.

BACKGROUND: Data on obesity as a risk factor for peritonitis and catheter infections among peritoneal dialysis (PD) patients are limited. Furthermore, little is known about the microbiology of PD-related infections among patients with a high body mass index (BMI). METHODS: Using a cohort that included all adult patients residing in the province of Manitoba who received PD during the period 1997 - 2007, we studied the relationship between BMI and PD-related infections. After categorizing patients into quartiles of BMI, a multivariate Cox regression model was used to determine the independent relationship between BMI and peritonitis or exit-site infection (ESI). We also studied whether increasing BMI was associated with a propensity to infections with particular organisms. RESULTS: Among 990 PD patients, 938 (95%) had accurate BMI data available. Those 938 patients experienced 1338 peritonitis episodes and 1194 exit-site infections. In unadjusted analyses, patients in the highest BMI quartile (median: 33.5; interquartile range: 31.9 - 36.4) had an increased risk of peritonitis overall, and also an increased risk of peritonitis with gram-positive organisms and coagulase-negative Staphylococcus (CNS). After multivariate adjustment for age, sex, diabetes, cause of renal disease, Aboriginal race, PD modality, and S. aureus nasal carriage, the relationship between overall peritonitis risk and BMI disappeared, but the increased risk of CNS peritonitis among patients in the highest BMI quartile persisted (hazard ratio: 1.80; 95% confidence interval: 1.06 to 3.06; p = 0.03). There was no increased risk of ESI among patients in the highest BMI quartile on univariate analysis or after multivariate adjustment. CONCLUSIONS: Among Canadian PD patients, obesity was not associated with an increased risk of peritonitis overall, but may be associated with a higher risk of CNS peritonitis.

High rates of mortality and technique failure in peritoneal dialysis patients after critical illness.

INTRODUCTION: Little is known regarding the causes and outcomes of peritoneal dialysis (PD) patients admitted to the intensive care unit (ICU). We explored the outcomes of technique failure and mortality in a cohort of PD patients admitted to the ICU. METHODS: Using a provincial database of 990 incident PD patients followed from January 1997 to June 2009, we identified 90 (9%) who were admitted to the ICU. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. The Cox proportional hazards and competing risk methods were used to investigate associations. RESULTS: Compared with other patients, those admitted to the ICU had been on PD longer (p < 0.0001) and were more often on continuous ambulatory PD (74.2% vs 25.8%, p = 0.016). Cardiac problems were the most common admitting diagnosis (50%), followed by sepsis (23%), with peritonitis accounting for 69% of the sepsis admissions. The 1-year mortality was 53.3%, with 12% alive and converted to hemodialysis, and one third remaining alive on PD. In multivariate Cox modeling, age [hazard ratio (HR): 1.01; 95% confidence interval (CI): 0.99 to 1.03], white blood cell count (HR: 1.02; 95% CI: 1.00 to 1.04), temperature (HR: 0.75; 95% CI: 0.61 to 0.92), and peritonitis (1.64; 95% CI: 1.21 to 2.22) at admission to the ICU were associated with the composite outcome of technique failure or death. In a competing risk analysis, the risk for death was 30%, and for technique failure, 36% at 1 year. CONCLUSIONS: Patients on PD have high rates of death and technique failure after admission to the ICU.

Choosing peritoneal dialysis reduces the risk of invasive access interventions.

BACKGROUND: Patients choosing between hemodialysis (HD) and peritoneal dialysis (PD) should be well informed of the risks and benefits of each modality. Invasive access interventions are important outcomes because frequent interventions lower patient's quality of life and consume limited resources. The objective of this study was to compare the risk of access interventions between the two modalities. METHODS: Three hundred and sixty-nine incident chronic dialysis patients were prospectively enrolled at four Canadian centers that were eligible for both modalities, received at least 4 months of pre-dialysis care and started dialysis electively as an outpatient. Two hundred and twenty-four (61%) chose PD and 145 (39%) chose HD. Patients were followed for an average of 1.3 years (range 0.07-3.6 years). RESULTS: In the PD group, there were fewer access interventions (2.5 versus 3.1 interventions per patient, adjusted odds ratio of 0.79 for PD versus HD, P = 0.005) and a lower intervention rate (2.3 versus 1.9 per patient-year, adjusted rate ratio of 0.81 for PD versus HD, P = 0.04). PD catheters were less likely to experience primary failure (4.6 versus 32%, P < 0.0001), showed a trend toward lower intervention rates during use (0.8 versus 1.2 per patient-year, P = 0.06), and had equal patency compared to fistulae (1-year patency of 84 versus 88%, P = 0.48). Patients managed exclusively with HD catheters (28% of the HD group) required 1.7 interventions per patient and an intervention rate of 1.9 per patient-year. CONCLUSION: Patients who choose PD require fewer access interventions to maintain dialysis access than patients choosing HD.

The role of functional status in discharge to assisted care facilities and in-hospital death among dialysis patients.

BACKGROUND: Functional status is an important component in the assessment of hospitalized patients. We set out to determine the scope, severity, and prognostic significance of impaired functional status in acutely hospitalized dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 1,286 hospitalized dialysis patients admitted and discharged from 1 of 11 area hospitals in Manitoba, Canada, from September 2003 to September 2010 with an activity of daily living (ADL) assessment within 24 hours of admission. PREDICTOR: The 12-point ADL score assesses 6 domains (bathing, toileting, dressing, incontinence, feeding, and transferring) and scores them as independent or supervision only (score, 0), partial assistance (1), and full assistance (2). Thus, higher score indicates worse functional status. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. OUTCOMES: Multivariable logistic regression and Cox proportional hazards assessed the association between functional status, in-hospital death, and discharge to an assisted care facility. RESULTS: During the study period, 250 (19.4%) and 72 (5.6%) patients experienced the outcomes of in-hospital death or discharge to an assisted care facility. Abnormalities in functional status were present in >70% of the cohort. ADL score within 24 hours of admission combined with age differentiated risks of death and discharge to an assisted care facility home, ranging from 4.8%-46.6% and 0.6%-17.8%, respectively. After adjustment, ORs of death and discharge to an assisted care facility were 1.16 (95% CI, 1.11-1.22; P < 0.001; C statistic = 0.79) and 1.25 (95% CI, 1.14-1.36; P < 0.001; C statistic = 0.91) per 1-point increase in ADL score, respectively. Findings were consistent after accounting for the competing outcomes of in-hospital death or discharge to an assisted care facility versus discharge to home. LIMITATIONS: A 1-time measurement of ADLs could not differentiate temporary from long-term deterioration in functional status. CONCLUSIONS: Impaired functional status is common at the time of admission in the dialysis population. A single ADL score measurement at admission combined with age is highly predictive of poor outcomes in the hospitalized dialysis population.

Perceived barriers to guidelines in peritoneal dialysis.

BACKGROUND: Little is known regarding barriers to guideline adherence in the nephrology community. We set out to identify perceived barriers to evidence-based medicine (EBM) and measurement of continuous quality indicators (CQI) in an international cohort of peritoneal dialysis (PD) practitioners. METHODS: Subscribers to an online nephrology education site (Nephrology Now) were invited to participate in an online survey. Nephrology Now is a non-profit, monthly mailing list that highlights clinically relevant articles in nephrology. Four hundred and seventy-five physicians supplying PD care participated in an online survey assessing their use of EBM and CQI in their PD practice. Ordinal logistic regression was utilized to determine relationships between baseline characteristics and EBM and CQI practices. RESULTS: The majority of physicians were nephrologists (89.7%), and 50.4% worked in an academic centre. Respondents were from the following geographic regions: 13.5% Canadian, 24% American, 23.8% European, 4.4% Australian, 5.3% South American, 10.7% African and 12.2% Asian. Adherence to PD clinical practice guidelines were generally strong; however, lower adherence was associated with countries with lower healthcare expenditure, not using personal digital assistant (PDA), the longer the physician had been practising and smaller (< 20 patients per centre) PD practice. CONCLUSIONS: International variation in guideline adherence may be influenced by a country's healthcare expenditure, physician's PDA use and experience, and size of PD practice which may impact future guideline development and implementation.

Peritonitis and exit site infections in First Nations patients on peritoneal dialysis.

BACKGROUND AND OBJECTIVES: First Nations (FN) patients on peritoneal dialysis experience poor outcomes. Whether discrepancies exist regarding the microbiology, rate of infections, and outcomes between FN and non-FN peoples remains unknown. Design, setting, participants, & measures: All adult peritoneal dialysis patients (n = 727) from 1997 to 2007 residing in Manitoba, Canada, were included. Parametric and nonparametric tests were used as necessary. Negative binomial regression was used to determine the relationship of rates of exit site infections (ESIs) and peritonitis between FN and non-FN peoples. RESULTS: A total of 161 FN and 566 non-FN subjects were included in the analyses. The unadjusted relative rates of peritonitis and ESIs in FN subjects were 132.7 and 86.0/100 patient-years compared with 87.8 and 78.2/100 patient-years in non-FN populations, respectively. FN subjects were more likely to have culture-negative peritonitis (36.5 versus 20.8%, P < 0.0001) and Staphylococcus ESIs (54.1 versus 32.9%, P < 0.0001). The crude and adjusted rates of peritonitis were higher in FN subjects for total episodes and culture-negative and gram-negative peritonitis. Catheter removal because of peritonitis was similar in both groups (42.9 versus 38.1% for FN and non-FN subjects, respectively; P = 0.261). CONCLUSIONS: FN patients experience higher rates of peritonitis and similar rates of ESIs compared with non-FN patients. Interventions to improve outcomes and prevent infections should specifically be targeted to the FN population.

Adverse outcomes among Aboriginal patients receiving peritoneal dialysis.

BACKGROUND: The Aboriginal population in Canada experiences high rates of end-stage renal disease and need for dialytic therapies. Our objective was to examine rates of mortality, technique failure and peritonitis among adult aboriginal patients receiving peritoneal dialysis in the province of Manitoba. We also aimed to explore whether differences in these rates may be accounted for by location of residence (i.e., urban versus rural). METHODS: We included all adult patients residing in the province of Manitoba who received peritoneal dialysis during the period from 1997-2007 (n = 727). We extracted data from a local administrative database and from the Canadian Organ Replacement Registry and the Peritonitis Organism Exit-sites/Tunnel infections (POET) database. We used Cox and logistic regression models to determine the relationship between outcomes and Aboriginal ethnicity. We performed Kaplan-Meier analyses to examine the relationship between outcomes and urban (i.e., 50 km or less from the primary dialysis centre in Winnipeg) versus rural (i.e., more than 50 km from the centre) residency among patients who were aboriginal. RESULTS: One hundred sixty-one Aboriginal and 566 non-Aboriginal patients were included in the analyses. Adjusted hazard ratios for mortality (HR 1.476, CI 1.073-2.030) and adjusted time to peritonitis (HR 1.785, CI 1.352-2.357) were significantly higher among Aboriginal patients than among non-Aboriginal patients. We found no significant differences in mortality, technique failure or peritonitis between urban- or rural-residing Aboriginal patients. INTERPRETATION: Compared with non-Aboriginal patients receiving peritoneal dialysis, Aboriginal patients receiving peritoneal dialysis had higher mortality and faster time to peritonitis independent of comorbidities and demographic characteristics. This effect was not influenced by place of residence, whether rural or urban.

Impact of contraindications, barriers to self-care and support on incident peritoneal dialysis utilization.

BACKGROUND: Targets for peritoneal dialysis (PD) utilization may be difficult to achieve because many older patients have contraindications to PD or barriers to self-care. The objectives of this study were to determine the impact that contraindications and barriers to self-care have on incident PD use, and to determine whether family support increased PD utilization when home care support is available. METHODS: Consecutive incident dialysis patients were assessed for PD eligibility, offered PD if eligible and followed up for PD use. All patients lived in regions where home care assistance was available. RESULTS: The average patient age was 66 years. One hundred and ten (22%) of the 497 patients had absolute medical or social contraindications to PD. Of the remaining 387 patients who were potentially eligible for PD, 245 (63%) had at least one physical or cognitive barrier to self-care PD. Patients with barriers were older, weighed less and were more likely to be female, start dialysis as an inpatient and have a history of vascular disease, cardiac disease and cancer. Family support was associated with an increase in PD eligibility from 63% to 80% (P = 0.003) and PD choice from 40% to 57% (P = 0.03) in patients with barriers to self-care. Family support increased incidence PD utilization from 23% to 39% among patients with barriers to self-care (P = 0.009). When family support was available, 34% received family-assisted PD, 47% received home care-assisted PD, 12% received both family- and home care-assisted PD, and 7% performed only self-care PD. Incident PD use in an incident end-stage renal disease (ESRD) population was 30% (147 of the 497 patients). CONCLUSIONS: Contraindications, barriers to self-care and the availability of family support are important drivers of PD utilization in the incident ESRD population even when home assistance is available. These factors should be considered when setting targets for PD.