Incremental peritoneal dialysis in incident end-stage kidney disease patients.

BACKGROUND: This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre. METHODS: ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed. RESULTS: One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m2. The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year. CONCLUSIONS: Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Analysis of a COVID-19 compartmental model: a mathematical and computational approach.

In this note, we consider a compartmental epidemic mathematical model given by a system of differential equations. We provide a complete toolkit for performing both a symbolic and numerical analysis of the spreading of COVID-19. By using the free and open-source programming language Python and the mathematical software SageMath, we contribute for the reproducibility of the mathematical analysis of the stability of the equilibrium points of epidemic models and their fitting to real data. The mathematical tools and codes can be adapted to a wide range of mathematical epidemic models.

A Single-Center Retrospective Study on the Initiation of Peritoneal Dialysis in Patients With Cardiorenal Syndrome and Subsequent Hospitalizations.

BACKGROUND: Inotropic dependence and diuretic resistance in patients with cardiorenal syndrome (CRS) lead to frequent hospitalizations and are associated with high mortality. Starting peritoneal dialysis (PD) acutely (within 2 weeks of a heart failure hospitalization) offers effective volume removal without hemodynamic compromise in this population. There is little data on this approach in the North American literature. OBJECTIVE: To determine whether volume-overloaded patients with CRS on maximal doses of diuretic therapy had reduced hospitalization for heart failure following PD initiation. DESIGN: Retrospective cohort study. SETTING: Academic hospital network (University Health Network, Toronto, Ontario). PATIENTS: Patients with CRS receiving a bedside catheter and starting PD within 2 weeks of insertion at the University Health Network from January 1, 2013, to December 31, 2018. METHODS AND MEASUREMENTS: Data for heart failure-related hospitalizations and length of stay 6 months before and after PD initiation were collected. Patients who died, switched to hemodialysis, or were transferred to another facility within 6 months of starting PD were excluded from the analysis. RESULTS: We identified 31 patients with CRS who had a bedside PD catheter inserted. The average age of patients was 66.0 ± 13.0 years. There were 7 (22.6%) deaths and 4 (12.9%) transfers to other programs or hemodialysis within 6 months of catheter insertion. After exclusion, we analyzed hospitalization and length of stay data for 20 patients. The hospitalization rate 6 months before PD initiation was 6.9 admissions per 1000 patient-days. This decreased to 2.5 admissions per 1000 patient-days after PD initiation. In addition, there was also a significant reduction in the average length of stay per hospitalization (24.1-3.9 days; P = .001). LIMITATIONS: Our study did not assess the severity of heart failure symptoms using a standardized functional classification system. We did not assess quality of life and illness intrusiveness scores before and after starting dialysis, nor did we capture non-heart-failure-related hospitalizations or external admissions at other hospital sites. We limited eligibility to clinically stable patients with no prior major abdominal surgical history in a single Canadian PD program using bedside ultrasound approach for catheter insertions by experienced nephrologists and included a small number of patients. CONCLUSIONS: Volume-overloaded patients with CRS receiving maximal diuretic therapy have lower hospitalization rates and shorter stays after initiation of PD. The development of a bedside PD catheter insertion program and close collaboration between nephrology and cardiology services may facilitate acute start dialysis in this population.

CONTEXTE: La dépendance inotrope et la résistance aux diurétiques entraînent de fréquentes hospitalisations et sont associées à une mortalité élevée chez les patients atteints du syndrome cardio-rénal (SCR). Dans cette population, l'amorce de la dialyse péritonéale (DP) en temps opportun, soit dans les deux semaines suivant une hospitalisation pour insuffisance cardiaque, permet d'éliminer efficacement la surcharge liquidienne sans compromettre l'hémodynamie. On trouve toutefois peu de données sur cette approche dans la littérature nord-américaine. OBJECTIF: Déterminer si les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques sont hospitalisés moins souvent pour insuffisance cardiaque après l'amorce de la DP. TYPE D'ÉTUDE: Une étude de cohorte rétrospective. CADRE: Un réseau de centres hospitaliers universitaires (University Health Network) de Toronto (Ontario). SUJETS: Des patients atteints du SCR, hospitalisés au University Health Network entre le 1er janvier 2013 et le 31 décembre 2018, à qui on avait installé un cathéter de DP au chevet et qui avaient amorcé un traitement de dialyse dans les deux semaines suivant l'insertion. MÉTHODOLOGIE: On a recueilli les données sur les hospitalisations pour insuffisance cardiaque et la durée des séjours dans les six mois avant et après l'initiation de la PD. Les patients décédés, passés à l'hémodialyse ou ayant été transférés vers un autre centre dans les six mois suivant l'amorce de la PD ont été exclus de l'analyse. RÉSULTATS: Nous avons identifié 31 patients atteints du SCR, âgés en moyenne de 66,0 ±13,0 ans, à qui un cathéter de DP avait été installé au chevet. Dans les six mois suivant l'insertion du cathéter, sept patients (22,6 %) sont décédés et quatre (12,9 %) ont été transférés dans un autre centre ou sont passés à l'hémodialyse. À la suite de ces exclusions, l'analyse a porté sur les hospitalisations et les durées de séjour de 20 patients. Le taux d'hospitalisation dans les six mois précédant l'initiation de la DP s'établissait à 6,9 admissions par 1 000 jours-patient; un taux qui est passé à 2,5 admissions par 1 000 jours-patient une fois la DP amorcée. On a également observé une réduction significative de la durée moyenne du séjour, celle-ci étant passée de 24,1 à 3,9 jours (p=0,001). LIMITES: La gravité des symptômes de l'insuffisance cardiaque n'a pas été évaluée à l'aide d'un système de classification fonctionnel normalisé. Les scores de la qualité de vie et du caractère intrusif de la maladie n'ont pas été évalués avant et après l'amorce de la dialyse. Les données des hospitalisations non liées à l'insuffisance cardiaque et des admissions externes dans d'autres sites n'ont pas été colligées. L'admissibilité a été limitée aux patients cliniquement stables et sans antécédent de chirurgie abdominale majeure. Les participants provenaient d'un seul programme canadien de DP où la méthode d'insertion du cathéter utilise une approche par ultrasons pratiquée par un néphrologue expérimenté. Enfin, l'étude porte sur un faible échantillon de sujets. CONCLUSION: Les patients atteints du SCR et présentant une surcharge volémique qui reçoivent une dose maximale de diurétiques ont été moins souvent hospitalisés à la suite de l'amorce de la DP. Le développement d'un programme d'insertion du cathéter de DP au chevet du patient et une collaboration étroite entre les services de cardiologie et de néphrologie pourraient faciliter l'amorce rapide de la dialyse dans cette population.

Rate of Decline of Residual Kidney Function Before and After the Start of Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: There is a paucity of information on whether peritoneal dialysis (PD) slows the decline of residual kidney function (RKF) compared to the natural slope of RKF decline prior to dialysis start. Our aim was to analyze the RKF decline before and after initiating PD, and to determine the principal factors affecting this decline during the PD period. ♦ METHODS: We determined individual glomerular filtration rates (GFR) for approximately 12 months before and after PD in 77 new PD patients in a large academic medical center (2008 - 2012). The GFR was estimated by the Modification of Diet in Renal Disease (MDRD) equation in the predialysis period and by averaging 24-hour urine creatinine and urea clearances in the PD period. The rate of RKF decline was calculated using unadjusted linear regression analysis. Wilcoxon signed rank test was used to compare RKF decline before and after PD initiation. Multivariate linear regression was used to identify independent risk factors for RKF decline in the PD phase. ♦ RESULTS: A significantly slower mean rate of RKF decline was observed in the PD period compared with the predialysis period (-0.21 ± 0.30 vs -0.59 ± 0.55 mL/min/1.73 m(2)/month, p < 0.01). Higher baseline RKF, higher serum phosphate, and older age were independently associated with faster decline of RKF (all p < 0.01). ♦ CONCLUSIONS: In patients with advanced chronic kidney disease, initiating PD was associated with a slower rate of RKF decline compared to the rate in the predialysis period.

Analysis of Hospitalization after Peritoneal Dialysis Catheter Implantation.

UNLABELLED: ♦ BACKGROUND: Implantation of the peritoneal dialysis catheter (PDC), usually an elective procedure, may necessitate unexpected hospitalization and even transfer to intensive care due to the multiple comorbidities and inherent instability of the end-stage renal disease patient. Information on hospitalization after PDC implantation is limited and details about the reason for hospitalization are lacking. ♦ METHODS: We performed a cohort study in consecutive patients who underwent PDC implantation at a single institution from September 2007 to September 2013. Clinical characteristics of enrolled patients, technique of the implantation procedure, and all-cause unexpected hospitalization and morbidity within 14 days after implantation were analyzed. ♦ RESULTS: Excluding the patients with pre-arranged admission, a total of 246 patients receiving 252 PDC implantations during the 6 years were studied. After 39 procedures (15.5%), patients had an unexpected hospital stay or re-admission due to operative complications (33.3%), worsening of disease (35.9%), or a single-night hospital stay for observation (30.8%). Compared with discharged patients, the patients with unexpected hospitalization were older (p = 0.001), experienced higher rates of previous episodes of heart failure (p = 0.006) and heart disease (p < 0.001), had more use of general anesthesia (GA) (p = 0.046), underwent more added procedures during the implantation (p = 0.02), and had more episodes of flow obstruction and peritonitis after implantation (p = 0.012 and p < 0.001, respectively). Using a multivariable logistic regression, we showed that age, cardiac morbidity, use of general anesthesia, PDC flow problems and peritonitis after implantation were independent predictors of all-cause unexpected hospitalization. ♦ CONCLUSIONS: For the first time, our study analyzed the predictors of unplanned hospitalization after PDC implantation and identified the salient risk factors. Increased focus to identify patients at greatest risk for hospitalization, evaluation of processes of care, and implementation of preventive strategies may be helpful to reduce unplanned hospitalization after catheter insertion.

Streptococcal PD peritonitis--a 10-year review of one centre's experience.

BACKGROUND: Detailed descriptive studies focusing on streptococcal peritonitis in patients on peritoneal dialysis are lacking. Most of the current information is available through isolated case reports. METHODS: We conducted a retrospective analysis of our peritoneal dialysis (PD) peritonitis database over the last decade to study the clinical profile and treatment outcomes of streptococcal peritonitis. RESULTS: A total of 68 patients (age: 57.12 +/- 16.6 years; male: 58.7%) with 104 episodes of streptococcal peritonitis (11.7% of total peritonitis) were identified. Of the patients, 18 (26.4%) were considered immunocompromised [failed renal transplant, systemic lupus erythematosus (SLE)] and 28 (41.1%) had diabetes. Streptococcus viridans accounted for the majority (94 episodes: 90.3%) of the streptococcal peritonitis. One patient developed S. viridans peritonitis after dental cleaning without antibiotic prophylaxis. Two (1.9%) infections with S. agalactiae and S. bovis each and seven (6.7%) with non-haemolytic Streptococcus were noted. Three patients had hospital-acquired infection. Twenty-six (25%) episodes needed 8 +/- 5.9 days of hospitalization. Concurrent infection with two organisms accounted for 17 (16.3%) episodes. Cefazolin (71) and vancomycin (29) were the primary antibiotics used for the treatment. Five episodes needed two antibiotics and one patient required antifungal treatment. A third of the patients (33.3%) had peritonitis that resolved slowly, although the majority of those (94%) did ultimately resolve with antibiotics alone. Five (4.8%) episodes required removal of the PD catheter. Three of them were associated with dual infections (one each with yeast, Stenotrophomonas and Enterococcus). Relapse occurred in eight (7.6%) episodes, and 11 (10.5%) recurred over the period from 4 weeks to 6 months after treatment. CONCLUSIONS: Streptococci remain a significant cause of PD peritonitis. Viridans strep is the primary subtype responsible. Isolated infections with these organisms are associated with slower response, good outcome and higher rates of recurrence.