Flexibility in peritoneal dialysis prescription: Impact on technique survival.

BACKGROUND: Patient burnout is a major cause of technique failure on peritoneal dialysis (PD). Reducing the PD prescription on an individual basis, dependent upon residual kidney function (RKF), may have a role in prolonging time on PD by reducing dialysis burden. This retrospective study aimed to determine the safety and impact of flexible PD prescribing on technique and patient survival. METHODS: All patients (186) from our centre starting PD from 1st January 2012 to 31st December 2016 were included. Data on dialysis prescription were collected for each patient from the time they had started PD, and dialysis adequacy measured regularly (3-6 monthly) using PD Adequest. RESULTS: Median age at start of dialysis was 61 years. Only 49% started on PD 7 days a week and this dropped to 27% at 3 months following the first clearance test. Over 90% achieved creatinine clearance > 50 L/week/1.73 m2 up to 2 years of follow-up, with 87% achieving this standard at 3 years. Patient and technique survival at 1, 2 and 3 years were 91%, 81%, and 72%, and 89%, 87% and 78% respectively. Factors on univariate analysis affecting technique survival included increasing age (HR 0.98, p = 0.04, 95% CI (0.96-0.999)), two or more episodes of PD-associated peritonitis (HR 4.52, p = 0.00, 95% CI (1.87-10.91)) and increasing PD intensity (HR 3.30, p = 0.02, 95% CI (1.22-8.93)). After multivariate adjustment which included baseline kidney function, low PD intensity continued to be associated with better technique survival (HR 0.17, p = 0.03, 95% CI (0.03-0.85)). CONCLUSION: Tailoring the PD prescription to RKF enables days off dialysis while still maintaining recommended levels of small solute clearance. This approach reduces dialysis burden and is associated with higher technique survival.

Repeat Peritoneal Dialysis Exit-Site Infection: Definition and Outcomes.

Background:The most common complication of peritoneal dialysis (PD) is infection. Despite this, there are no clear guidelines for the management of repeat exit-site infection (ESI), and best practice is not known. We describe our unit's experience of repeat ESI and clinical outcomes in this cohort.Methods:Retrospective case note review of all PD patients with positive ESI swabs at our center between 1 January 2012 and 1 January 2018. Patients were included in the study if they had 2 or more ESI with the same organism within a 12-month period and an initial positive response to antibiotic therapy.Results:Overall, 31 of 248 patients had repeat ESI. The 2 most common causative organisms were Staphylococcus aureus (n = 16, 52%) and Pseudomonas aeruginosa (n = 10, 32%). Twenty (65%) patients developed subsequent peritonitis. The infection resolved with further antibiotics alone in 10 (32%) patients and in 6 patients after PD catheter exchange. The PD catheter was removed in 16 (52%) patients (including 5 after an initial catheter exchange) requiring transfer to hemodialysis (HD). Six (19%) patients died within 12 months of repeat ESI. Both repeat Pseudomonas aeruginosa and Staphylococcus aureus infections were associated with high rates of dialysis modality change (70% and 50%, respectively).Conclusion:We have developed the first definition for repeat ESI. Repeat ESI is clinically important and results in significant morbidity and mortality. Following repeat ESI, peritonitis rates are high and a significant number of patients switch dialysis modality. Studies are needed to determine whether interventions such as early catheter exchange would improve outcomes.

Pseudomonas exit-site infection: treatment outcomes with topical gentamicin in addition to systemic antibiotics.

BACKGROUND: Although, Pseudomonas exit-site infection (ESI) is recognized as a major complication of peritoneal dialysis (PD) with high risk of catheter loss due to refractory/recurrent infection or peritonitis, there is remarkably little literature about treatment outcomes. International Society for Peritoneal Dialysis guidelines advise the use of one to two antibiotics; in addition, we change standard exit-site care by stopping prophylactic mupirocin and starting regular use of gentamicin 1% cream. METHODS: Retrospective review of outcomes of Pseudomonas ESI from January 2012 to March 2015. RESULTS: During the study period, a total of 135 patients were on PD with an overall incidence of any ESI of 0.36/patient-year. There were 14 patients with ESI episodes with Pseudomonas with a rate of 0.12/patient-year. In total, 13 of 14 patients with ESI episodes were treated with oral ciprofloxacin and/or intraperitoneal (IP) gentamicin or ceftazidime, plus topical gentamicin, with a success rate of 38% (5/13). One patient had gentamicin-resistant Pseudomonas species and was treated successfully with topical polymyxin/bacitracin cream. Median follow-up time in cured patients was 385 days (range 74-1107). Six patients had associated with Pseudomonas peritonitis, four during follow-up and two at initial presentation. Three patients had recurrent ESI with Pseudomonas, with one successfully re-treated with topical and IP gentamicin. In total, in only 50% of the patients was Pseudomonas ESI successfully treated. Five of the patients (36%) changed modality to permanent haemodialysis following catheter removal. CONCLUSION: Eradication of Pseudomonas ESI remains difficult even with the addition of topical gentamicin to the exit site. There should be a low threshold for catheter replacement.

Evaluation of physical symptoms in patients on peritoneal dialysis.

Introduction. Little is known about physical symptoms in peritoneal dialysis (PD) Patients. This study aims to determine the prevalence of symptoms (general and abdominal) in PD patients. Methods. A cross-sectional study, with subsequent followup, using an author-designed 21 symptoms questionnaire (15 nonabdominal and 6 abdominal). Each symptom was assessed on a scale 0-3 for severity (none-severe) and frequency (never-every day). Results. We studied 41 patients, mean age 60 ± 15 years, 56% male, 19.5% diabetics, and 51.5% on APD. Mean number of symptoms was 9.5 ± 3.9 and total symptoms score was 28.5 ± 12 with abdominal scores of 6.4 ± 4.8. Most frequent symptoms were lack of energy, itching, cramps, poor sleep, and loss of appetite. A second evaluation in 20 patients disclosed no statistical difference between the first and second assessments, or between subgroups. Cramps were the only symptoms which decreased over time (P = 0.120). Lack of energy did not correlate with haemoglobin, neither did itching with phosphate level. Conclusions. Physical symptoms are frequent and troublesome; they relate to advanced kidney disease and not specifically to PD. Symptoms remain stable over time and do not appear to relate to dialysis parameter markers.

Empirical aminoglycosides for peritonitis do not affect residual renal function.

BACKGROUND: Aminoglycosides have been proven to be an efficacious treatment for peritonitis in peritoneal dialysis patients for many years. Consequently, they have been recommended in previous guidelines for the empirical treatment of peritonitis. However, with the increasing emphasis on preserving residual renal function (RRF), there has been concern about the nephrotoxic potential of these compounds. The 2000 International Society of Peritoneal Dialysis (ISPD) guidelines recommended that aminoglycosides not be used in patients with RRF, and that ceftazidime be used instead. In 1997, in response to the 1996 ISPD guidelines, we changed our peritonitis regimen from vancomycin and ciprofloxacin to cefazolin and gentamicin. The aim of this study is to compare the change in renal function occurring after treatment of peritonitis with and without gentamicin. METHODS: Using 6-monthly urine and dialysis clearance measurements, preperitonitis and postperitonitis RRF (mean of 24-hour urea and creatinine clearance) were determined for 70 peritonitis episodes treated with the aminoglycoside-based regimen (group A), 61 episodes treated without aminoglycosides (group B), and 74 control patients without peritonitis (group C). RESULTS: Group A had mean declines in estimated glomerular filtration rate and urine output of -0.08 +/- 0.50 mL/min/mon and -8.82 +/- 88.09 mL/24 h/mon compared with -0.17 +/- 0.27 mL/min/mon and -34.68 +/- 69.58 mL/24 h/mon in group B and -0.20 +/- 0.39 mL/min/mon and -14.61 +/- 77.33 mL/24 h/mon in group C, respectively. There were no significant differences between groups. CONCLUSION: In our patients, there was no evidence of an accelerated decline in RRF when using an empirical regimen containing aminoglycosides for peritonitis. Because there are few data to contradict this finding, we recommend the continued use of these drugs in peritonitis regimens, even in patients with significant RRF.

Treatment and outcome of peritonitis in automated peritoneal dialysis, using a once-daily cefazolin-based regimen.

OBJECTIVE: We determined the effectiveness of a once-daily cefazolin-based regimen in treating automated peritoneal dialysis (APD) peritonitis. DESIGN: We carried out a retrospective analysis of all APD peritonitis episodes treated with a once-daily cefazolin protocol. SETTING: The study was performed in a peritoneal dialysis unit in a tertiary care hospital. PATIENTS AND METHODS: We studied 60 episodes of primary peritonitis in 40 patients on APD. Each patient was treated with a vancomycin-free regimen consisting of intraperitoneal cefazolin (1.5 g IP) with gentamicin IP administered in the daytime exchange. The main outcome measures were successful treatment of peritonitis, removal of peritoneal catheter, relapse of peritonitis, and patient death. RESULTS: Gram-positive infections occurred in 35 episodes (58.3%), gram-negative Infections in 10 episodes (16.7%), culture-negative infections in 14 episodes (23.3%), and a yeast infection in 1 episode (1.7%). Of the 60 episodes, 47 (78.3%) were successfully treated. In 10 episodes (16.7%), catheters were removed (9 for treatment failure, 1 for yeast infection). Four patients (8%) had a relapse of infection within 4 weeks of completing antibiotic therapy. One patient (1.7%) died. CONCLUSIONS: Our results demonstrate that once-daily cefazolin with gentamicin IP is an effective treatment for APD peritonitis, with the advantage of being easy to administer and enabling patients to remain on APD during treatment.