Unusual cases of peritonitis: A case series of five patients.

INTRODUCTION: Peritonitis is a complication in patients on peritoneal dialysis that frequently results from touch contamination. Most cases of peritoneal dialysis-related peritonitis are caused by skin organisms. Herein, we are presenting a series of peritonitis cases with unusual organisms in a single home dialysis center at an academic hospital in New York City. METHODS: The records of five patients with an unusual cause of peritonitis were reviewed by a clinician. We have chronologically tabulated the cell count of the dialysate, microbiologic cultures, and antibiotics received by each patient. Additionally, both a table and figure detail the microbiologic organisms that our dialysis unit encountered over the 3-year period concurrent with the infections reported. RESULTS: The first patient presented with refractory polymicrobial peritonitis due to a liver abscess. Another patient presented with diverticulitis and developed enteric peritonitis with various organisms. The following patient had peritonitis in the setting of bowel pathologies and from Rhizobium after exposure to plants. The next patient developed Pasteurella peritonitis from his cat. The final patient developed multiple episodes of peritonitis from organisms including flora native to soil and water. CONCLUSION: These uncommon cases of peritonitis with unusual circumstances bring awareness to various elements that can lead to peritonitis.

Comparing the effect of peritoneal dialysis cycler type on patient-reported satisfaction, support needs and treatments.

BACKGROUND: Most patients on peritoneal dialysis (PD) in the United States choose automated PD via cyclers. Cyclers have evolved considerably over time with older versions (e.g. HomeChoice Pro) replaced by more sophisticated and technologically advanced versions (e.g. Amia). Understanding the effect that different cyclers and their features have on patient treatments and support needs is important.  METHODS: Single center study with retrospective and prospective arms. Retrospective arm: Patients > 18 years old, on Amia or HomeChoice Pro (HC) for ≥ 3 months between 8/1/17 and 1/31/18. Number of office/telephone encounters, PD-related emergency room visits/hospitalizations, PD training days, and dialysis adequacy (Kt/V) were recorded. Prospective arm: Patients > 18 years old, on Amia or HC for ≥ 3 months between 9/1/19 and 2/29/20 were surveyed on their comfort, troubleshooting, satisfaction and reported assistance needed with their cyclers. RESULTS: Retrospective arm: 43 patients on AMIA and 27 patients on HC. Number of PD training days, Kt/Vs achieved, PD-related telephone/office encounters, and PD-related emergency room visits/hospitalizations were all similar. Prospective Arm: 32 patients on AMIA and 6 patients on HC. Higher rate of patient comfort with AMIA, but similar overall patient satisfaction with both cyclers. No difference in terms of patient-reported troubleshooting issues requiring assistance. CONCLUSIONS: Despite the difference in features provided between the 2 cyclers, patient overall satisfaction rates were high irrespective of the PD cycler. The HomeChoice Pro and AMIA cycler patients had a similar number of PD training days, PD-related telephone/office encounters, and PD-related emergency room visits/hospitalizations. TRIAL REGISTRATION: This study was approved by the Icahn School of Medicine at Mount Sinai Institutional Review Board (IRB-17-02704).

Use of peritoneal dialysis for acute kidney injury during the COVID-19 pandemic in New York City: a multicenter observational study.

To demonstrate feasibility of acute peritoneal dialysis (PD) for acute kidney injury during the coronavirus disease 2019 (COVID-19) pandemic, we performed a multicenter, retrospective, observational study of 94 patients who received acute PD in New York City in the spring of 2020. Patient comorbidities, severity of disease, laboratory values, kidney replacement therapy, and patient outcomes were recorded. The mean age was 61 ± 11 years; 34% were women; 94% had confirmed COVID-19; 32% required mechanical ventilation on admission. Compared to the levels prior to initiation of kidney replacement therapy, the mean serum potassium level decreased from 5.1 ± 0.9 to 4.5 ± 0.7 mEq/L on PD day 3 and 4.2 ± 0.6 mEq/L on day 7 (P < 0.001 for both); mean serum bicarbonate increased from 20 ± 4 to 21 ± 4 mEq/L on PD day 3 (P = 0.002) and 24 ± 4 mEq/L on day 7 (P < 0.001). After a median follow-up of 30 days, 46% of patients died and 22% had renal recovery. Male sex and mechanical ventilation on admission were significant predictors of mortality. The rapid implementation of an acute PD program was feasible despite resource constraints and can be lifesaving during crises such as the COVID-19 pandemic.

Home Dialysis: A Majority Chooses It, a Minority Gets It.

INTRODUCTION: When choosing a modality for outpatient renal replacement therapy, patients and medical providers have 3 options to choose from in-center hemodialysis (HD), home HD (HHD), and peritoneal dialysis (PD). In 2017, just over 10% of incident ESKD patients were on a home dialysis modality. We set out to determine outcomes of dialysis modality education in both pre-dialysis and dialysis patients. Moreover, we examined barriers that preclude patients from choosing home dialysis. METHODS: This was a single-center, retrospective study looking at patients who were referred to the CKD educator for dialysis modality education between January 1, 2019, and March 31, 2020. Patient demographics, preferred language of communication, stage of renal disease, and reasons for patients' refusal to undertake a home dialysis modality were recorded. Patients' average household income and driving distance to our home dialysis unit were calculated using their home zip code. RESULTS: 167 patients were referred for CKD education. Mean age was 60 years, and 59% male, 42% African American, 22% White, 7% Asian, and 28% were Hispanic or Latino. Only 23% of the total cohort chose in-center HD, while 74% chose a home dialysis modality (59% PD and 15% HHD), and the remaining patients remained undecided. 56% of in-center HD patients chose a home dialysis modality. The most commonly cited barriers to home dialysis were lack of a care partner, lack of home space, and patient preference. LIMITATIONS: Over 90% of our patients reside in NY City where home space is limited. We require in our home HD program that patients have a trained care partner present during their treatments. We cannot assume that all CKD stage-4 patients or higher were either referred for CKD education or followed through on the referral. CONCLUSIONS: A large discrepancy between informed patients' choices and the reality of the current dialysis landscape. Absence of a care partner, lack of home space, and patients not deemed appropriate surgical candidates were the main driving forces in their not opting for a home modality.

Utilization of peritoneal dialysis in the United States: Reasons for underutilization, specifically in New York State and the boroughs of New York City.

Peritoneal dialysis (PD) is currently underutilized in the United States (US), even within resource-rich neighborhoods. We analyzed data from US Renal Data Service to determine PD utilization within the US, New York State (NYS), selected boroughs within New York City (NYC), and Boston, Massachusetts. We then compared the odds of selecting PD with hemodialysis (HD) and analyzed how diabetes mellitus status, age >65 years, gender, and race influenced PD utilization between 2010 and 2016. We then compared a high-volume PD center (HVC) with a low-volume PD center (LVC). The odds of starting PD vs HD were as follows: Brooklyn 0.30 (0.25-0.36; <0.0001), Bronx 0.56 (0.47-0.67; <0.0001), Queens 0.66 (0.54-0.80; <0.0001), and Manhattan 0.61 (0.52-0.71; <0.0001). In 2016, the odds of starting PD compared with the rest of the US were as follows: Brooklyn 0.14 (0.08-0.22; <0.0001), Bronx 0.39 (0.27-0.56; <0.0001), Queens 0.32 (0.23-0.45; <0.0001), Manhattan 0.54 (0.36-0.79; 0.002), and Boston 0.89 (0.58-1.4; 0.624). Analysis of influencing factors showed that only age >65 significantly (<0.0001) influenced PD modality selection in Brooklyn and Boston. Differences between HVC and LVC in terms of modality transition, peritonitis rate, or provider:patient ratio were not statistically significant. Factors that influence PD utilization in urban neighborhoods are discussed and remediation measures are proposed.

Patient-Centric User-Interface in Automated Peritoneal Dialysis: Impact on Training and Outcomes at a Single Center.

BACKGROUND: AMIA cycler is a new automated peritoneal dialysis (APD) system, which was approved by FDA in 2015, which is more patient centric due to its features of voice guidance and touch screen. We retrospectively studied if these patient-centric features translated into better patient outcomes. METHODS: We compared 18 patients on AMIA cycler to 18 patients on conventional APD system. Data regarding training duration, dialysis adequacy, laboratory data, and peritonitis incidence were obtained using chart review and compared between the 2 groups. RESULTS: The AMIA group had 33% reduction in the duration of training period compared to the conventional group. All other end points including dialysis adequacy, electrolytes, peritonitis incidence, exit site infections, and dropout rates were not found to be different between both the groups. CONCLUSION: AMIA cycler is superior to the conventional cycler in significantly reducing the training time while having similar clinical outcomes. Further studies are needed to validate this data.

Retinoic acid improves nephrotoxic serum-induced glomerulonephritis through activation of podocyte retinoic acid receptor α.

Proliferation of glomerular epithelial cells, including podocytes, is a key histologic feature of crescentic glomerulonephritis. We previously found that retinoic acid (RA) inhibits proliferation and induces differentiation of podocytes by activating RA receptor-α (RARα) in a murine model of HIV-associated nephropathy. Here, we examined whether RA would similarly protect podocytes against nephrotoxic serum-induced crescentic glomerulonephritis and whether this effect was mediated by podocyte RARα. RA treatment markedly improved renal function and reduced the number of crescentic lesions in nephritic wild-type mice, while this protection was largely lost in mice with podocyte-specific ablation of Rara (Pod-Rara knockout). At a cellular level, RA significantly restored the expression of podocyte differentiation markers in nephritic wild-type mice, but not in nephritic Pod-Rara knockout mice. Furthermore, RA suppressed the expression of cell injury, proliferation, and parietal epithelial cell markers in nephritic wild-type mice, all of which were significantly dampened in nephritic Pod-Rara knockout mice. Interestingly, RA treatment led to the coexpression of podocyte and parietal epithelial cell markers in a small subset of glomerular cells in nephritic mice, suggesting that RA may induce transdifferentiation of parietal epithelial cells toward a podocyte phenotype. In vitro, RA directly inhibited the proliferation of parietal epithelial cells and enhanced the expression of podocyte markers. In vivo lineage tracing of labeled parietal epithelial cells confirmed that RA increased the number of parietal epithelial cells expressing podocyte markers in nephritic glomeruli. Thus, RA attenuates crescentic glomerulonephritis primarily through RARα-mediated protection of podocytes and in part through the inhibition of parietal epithelial cell proliferation and induction of their transdifferentiation into podocytes.

Performance Evaluation of an Automated Peritoneal Dialysis Solution Generation System in Patients Using Automated Peritoneal Dialysis.

Introduction: Most patients on peritoneal dialysis (PD) in the United States are on automated PD (APD) utilizing several liters of PD solution daily for their treatment. The ordering, delivery, and storage of PD solutions can be challenging and is an important factor that can dissuade patients from doing PD. The generation of PD solutions at home is a strategy that could potentially be used to overcome this problem. The APD Solution Generation System (SGS) allowed for PD solution generation using tap water in patients' homes. Methods: In this study, we set out to evaluate the performance of the SGS in prevalent, adult patients with end-stage kidney disease, who are on maintenance PD. We evaluated the primary safety (microbiological testing) and efficacy (chemical composition) of the product water generated by the SGS device. Results: Twenty-two patients from 12 different United States centers were enrolled, of which 14 patients completed the study. The results of the primary safety and efficacy end point analyses of the product water showed that all 64 samples met the International Organization for Standardization (ISO) specifications. Secondary safety analysis found a total of 34 adverse events (AEs) in 12 patients. Of these AEs, 3, namely, culture negative peritonitis, bacterial peritonitis, and atrial fibrillation were deemed serious treatment-emergent AEs. Conclusion: This study demonstrated that the SGS can successfully generate PD solution in patients' homes, while meeting chemical composition and ISO microbiological standards. Lessons learned from this clinical trial will be useful in optimizing product development and future clinical trials.

Health care cost accounting in the Indian hospital sector.

Setting reimbursement rates in national insurance schemes requires robust cost data. Collecting provider-generated cost accounting information is a potential mechanism for improving the cost evidence. To inform strategies for obtaining cost data to set reimbursement rates, this analysis aims to describe the role of cost accounting in public and private health sectors in India and describe the importance, perceived barriers and facilitators to improving cost accounting systems. In-depth interviews were conducted with 11 key informants. The interview tool guide was informed by a review of published and grey literature and government websites. The interviews were recorded as both audio and video and transcribed. A thematic coding framework was developed for the analysis. Multiple discussions were held to add, delete, classify or merge the themes. The themes identified were as follows: the status of cost accounting in the Indian hospital sector, legal and regulatory requirements for cost reporting, challenges to implementing cost accounting and recommendations for improving cost reporting by health care providers. The findings indicate that the sector lacks maturity in cost accounting due to a lack of understanding of its benefits, limited capacity and weak enforcement of cost reporting regulations. Providers recognize the value of cost analysis for investment decisions but have mixed opinions on the willingness to gather and report cost information, citing resource constraints and a lack of trust in payers. Additionally, heterogeneity among providers will require tailored approaches in developing cost accounting reporting frameworks and regulations. Health care cost accounting systems in India are rudimentary with a few exceptions, raising questions about how to source these data sustainably. Strengthening cost accounting systems in India will require standardized data formats, integrated into existing data management systems, that both meet the needs of policy makers and are acceptable to hospital providers.

Establishing national hospital costing systems: insights from the qualitative assessment of cost surveillance pilot in Indian hospitals.

OBJECTIVE: The Indian Government launched Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), the world's largest health insurance scheme, in 2018. To reform pricing and gather evidence on healthcare costs, a hospital cost-surveillance pilot was initiated among PM-JAY empanelled hospitals. We analysed the process and challenges from both healthcare providers and payer agency's perspectives and offer recommendations for implementing similar systems in lower- and middle-income countries. DESIGN: We employed an open-ended, descriptive and qualitative study design using in-depth interviews (IDI) as the data collection strategy. SETTINGS: The interviews were conducted in both virtual and face-to-face modes depending on the convenience of the participants. The IDIs for the National Health Authority (NHA) officials and all providers in Kerala were conducted virtually, while face-to-face interviews were conducted and in Haryana and Chhattisgarh. PARTICIPANTS: Staff from 21 hospitals in three states (Haryana, Chhattisgarh and Kerala), including officials from State Health Agency (n=5) and NHA (n=3) were interviewed. RESULTS: The findings highlight significant challenges in reporting cost data at the hospital level. These include a shortage of trained staff, leading to difficulties in collecting comprehensive and high-quality data. Additionally, the data collection process is resource-intensive and time-consuming, putting strain on limited capacity. Operational issues with transaction management system, such as speed, user-friendliness and frequent page expirations, also pose obstacles. Finally, current patient records data has gaps, in terms of quantity and quality, to be directly put to use for pricing. CONCLUSION: Accurate cost data is vital for health policy decisions. Capacity building across healthcare levels is needed for precise cost collection. Integration into digital infrastructure is key to avoid burdening providers and ensure quality data capture.

The Role of Kt/V and Creatinine clearance on Assisting Optimization of Serum Phosphorus Levels among Patients on PD.

BACKGROUND: Hyperphosphatemia is associated with poor outcome and is still very common in peritoneal dialysis (PD) patients. Since peritoneal phosphate clearance is closer to peritoneal creatinine clearance than urea clearance, we hypothesized that weekly creatinine clearance (CrCl) could be a better marker of serum phosphate in PD. METHODS: In a retrospective observational study, data from adult PD patients were collected across five institutions in North and South America: LATAM, RRI, Mount Sinai Hospital, Hospital Civil de Guadalajara, and the BRAZPD cohort. All centers analyzed routinely available laboratory data, with exclusions for missing data on serum phosphate, CrCl, or urea Kt/V. A unified statistical protocol was employed across centers. Linear mixed-effect models examined associations between longitudinal serum phosphate levels, CrCl, and Kt/V. Adjustments were made for age, gender, and baseline phosphate binder usage. Mixed-effects meta-analysis determined the pooled effect size of CrCl and Kt/V on serum phosphate trajectories, adjusted for confounders. RESULTS: There were 16,796 incident PD patients analyzed. Age, BMI, gender, PD modality, Kt/V and CrCl as well as serum phosphate varied significantly across the different cohorts, but >70% had residual renal function. For most cohorts, both CrCltotal and urea Kt/V associated negatively with serum phosphorus levels, and log-likelihood ratio tests demonstrate that models including CrCltotal have more predictive information than those including only urea Kt/V for the largest cohorts. Models including CrCltotal increase information predicting longitudinal serum phosphate levels irrespective of baseline urea Kt/V, age, use of phosphorus binder, and gender. CONCLUSIONS: CrCl was not more accurate in predicting serum phosphate than urea Kt/V, but its inclusion in multivariable models predicting serum phosphate added accuracy. In conclusion, both creatinine clearance and Kt/V are associated with phosphate levels, and using both biomarkers, instead of just one, may better assist in the optimization of serum phosphate levels.

Outcomes of PD for AKI treatment during COVID-19 in New York City: A multicenter study.

BACKGROUND: The high incidence of acute kidney injury (AKI) requiring dialysis associated with COVID-19 led to the use of peritoneal dialysis (PD) for the treatment of AKI. This study aims to compare in-hospital all-cause mortality and kidney recovery between patients with AKI who received acute PD versus extracorporeal dialysis (intermittent haemodialysis and continuous kidney replacement therapy). METHODS: In a retrospective observational study of 259 patients with AKI requiring dialysis during the COVID-19 surge during Spring 2020 in New York City, we compared 30-day all-cause mortality and kidney recovery between 93 patients who received acute PD at any time point and 166 patients who only received extracorporeal dialysis. Kaplan-Meier curves, log-rank test and Cox regression were used to compare survival and logistic regression was used to compare kidney recovery. RESULTS: The mean age was 61 ± 11 years; 31% were women; 96% had confirmed COVID-19 with median follow-up of 21 days. After adjusting for demographics, comorbidities, oxygenation and laboratory values prior to starting dialysis, the use of PD was associated with a lower mortality rate compared to extracorporeal dialysis with a hazard ratio of 0.48 (95% confidence interval: 0.27-0.82, p = 0.008). At discharge or on day 30 of hospitalisation, there was no association between dialysis modality and kidney recovery (p = 0.48). CONCLUSIONS: The use of PD for the treatment of AKI was not associated with worse clinical outcomes when compared to extracorporeal dialysis during the height of the COVID-19 pandemic in New York City. Given the inherent selection biases and residual confounding in our observational study, research with a larger cohort of patients in a more controlled setting is needed to confirm our findings.

Utilising low-cost, easy-to-use microscopy techniques for early peritonitis infection screening in peritoneal dialysis patients.

Peritoneal dialysis (PD) patients are at high risk for peritonitis, an infection of the peritoneum that affects 13% of PD users annually. Relying on subjective peritonitis symptoms results in delayed treatment, leading to high hospitalisation costs, peritoneal scarring, and premature transition to haemodialysis. We have developed and tested a low-cost, easy-to-use technology that uses microscopy and image analysis to screen for peritonitis across the effluent drain tube. Compared to other technologies, our prototype is made from off-the-shelf, low-cost materials. It can be set up quickly and key stakeholders believe it can improve the overall PD experience. We demonstrate that our prototype classifies infection-indicating and healthy white blood cell levels in clinically collected patient effluent with 94% accuracy. Integration of our technology into PD setups as a screening tool for peritonitis would enable earlier physician notification, allowing for prompt diagnosis and treatment to prevent hospitalisations, reduce scarring, and increase PD longevity. Our findings demonstrate the versatility of microscopy and image analysis for infection screening and are a proof of principle for their future applications in health care.

The story of Notch and chronic kidney disease.

PURPOSE OF REVIEW: The Notch pathway is an evolutionary conserved cell-cell communication mechanism that plays a key role in kidney development. Here, we will discuss a number of recently published papers describing the role of Notch signaling in kidney development, homeostasis, injury and repair. RECENT FINDINGS: Recent gene expression studies identified regulation of the Notch pathway in patients with chronic kidney disease (CKD). Mechanistic experiments performed using transgenic and knock-out mouse models indicate that Notch plays an important functional role in the development of proteinuria and renal fibrosis. Inhibition of the Notch pathway ameliorated diabetic kidney disease, nephrotic syndrome and fibrosis in different rodent models. SUMMARY: An increasing amount of evidence suggests that Notch plays a role in CKD development. Understanding the role of Notch signaling in the kidney can aid in the development of new therapeutics for CKD.

Acute Kidney Injury and Advanced Kidney Disease in the COVID-19 Pandemic: Proceedings From a National Kidney Foundation Symposium.

The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented and historic public health crisis that continues to expand and evolve. The National Kidney Foundation held a 2-part continuing medical education live virtual symposium on July 16 and July 24, 2020, to address the multiple challenges of COVID-19 in the context of advanced chronic kidney disease. Faculty addressed the pathophysiology, impact, risks, and management of COVID-19 as it relates to advanced kidney disease. Testing, risk mitigation, and inpatient and outpatient management were also addressed. This concise review addresses major findings of the symposium along with certain updates regarding vaccinations since then. These findings include: (1) severe COVID-19 infection has been associated with acute kidney injury, (2) it is essential to prevent and actively manage acute kidney injury to decrease mortality in these critically ill patients, (3) management of patients with advanced kidney disease should be geared toward minimizing their risk for exposure while making sure they are receiving adequate treatments, and (4) patients with kidney disease, especially ones in advanced stages, should be prioritized for vaccination.