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Peritoneal Dialysis International :... Dec 2023Intraperitoneal antibiotics may be required daily for up to three weeks to treat peritoneal dialysis (PD)-related peritonitis. In some jurisdictions, antibiotic-admixed...
BACKGROUND
Intraperitoneal antibiotics may be required daily for up to three weeks to treat peritoneal dialysis (PD)-related peritonitis. In some jurisdictions, antibiotic-admixed PD solutions are required to be used within 24 h due to concerns regarding microbial contamination and growth. This requires patients to attend the PD unit daily or alternatively for staff to perform home delivery with associated transport, staffing and cost implications.
OBJECTIVE
The aim of this study was to determine if significant microbial growth occurs in PD solutions following their injection with antibiotic or sterile water.
METHODS
Twelve PD solution bags were admixed with cefazolin sodium 1 g, diluted in 10 mL sterile water, while a further 12 PD solution bags were admixed with 10 mL sterile water using aseptic technique (AT) under supervision. All bags were stored at room temperature. Three bags from each experimental group were sampled for microbiologic culture at 0-, 24-, 48- and 72-h intervals.
RESULTS
One sterile water admixed bag sampled at 24 h yielded a . after microbiologic culture. A repeat specimen from the same bag at day nine returned a negative culture result. All other sterile water and cefazolin admixed bags returned negative culture results at all time points.
CONCLUSIONS
Antibiotic-admixed PD solutions prepared using AT and stored at room temperature remained sterile for up to 72 h. This suggests that patients can be safely issued with a supply of antibiotic-admixed PD bags for up to three days at a time.
PubMed: 38115707
DOI: 10.1177/08968608231213736 -
Peritoneal Dialysis International :... Jan 2024Despite several advantages compared to haemodialysis (HD), peritoneal dialysis (PD) remains an underused dialysis technique due to its high technique failure rate...
BACKGROUND
Despite several advantages compared to haemodialysis (HD), peritoneal dialysis (PD) remains an underused dialysis technique due to its high technique failure rate related to membrane fibrosis and peritonitis events. Previous work has suggested a harmful role for the complement system in these processes, highlighting the need for a more comprehensive examination in PD.
METHODS
Plasma levels of C1q, mannose-binding lectin (MBL), Properdin, Factor D, C3d/C3-ratio and soluble membrane attack complex (sC5b-9) were determined in PD patients ( = 55), HD patients ( = 41), non-dialysis chronic kidney disease (CKD) patients ( = 15) and healthy controls ( = 14). Additionally, C1q, MBL, Properdin, Factor D and sC5b-9 levels were assessed in the peritoneal dialysis fluid (PDF). In a subgroup, interleukin-6, matrix metalloproteinase-2 (MMP-2), myeloperoxidase (MPO) and elastase were measured in the PDF.
RESULTS
PD patients had significantly higher systemic levels of sC5b-9 compared to healthy controls, CKD and HD patients ( < 0.001). Plasma levels of C1q and C3d/C3-ratios were significantly associated with systemic sC5b-9 levels ( < 0.001). Locally, sC5b-9 was detected in the PDF of all PD patients, and levels were approximately 33% of those in matched plasma, but they did not correlate. In the PDF, only Properdin levels remained significantly associated with PDF sC5b-9 levels in multivariate analysis ( < 0.001). Additionally, PDF levels of sC5b-9 positively correlated with elastase, MPO and MMP-2 levels in the PDF ( < 0.01).
CONCLUSIONS
Our data reveal both systemic and local complement activation in PD patients. Furthermore, these two processes seem independent considering the involvement of different pathways and the lack of correlation.
Topics: Humans; Peritoneal Dialysis; Matrix Metalloproteinase 2; Properdin; Complement Factor D; Complement C1q; Complement Activation; Dialysis Solutions; Renal Insufficiency, Chronic; Pancreatic Elastase
PubMed: 37794761
DOI: 10.1177/08968608231198984 -
Peritoneal Dialysis International :... Mar 2024Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and...
BACKGROUND
Mineral bone disorder (MBD) in chronic kidney disease (CKD) is associated with high symptom burden, fractures, vascular calcification, cardiovascular disease and increased morbidity and mortality. CKD-MBD studies have been limited in peritoneal dialysis (PD) patients. Here, we describe calcium and parathyroid hormone (PTH) control, related treatments and mortality associations in PD patients.
METHODS
We used data from eight countries (Australia and New Zealand (A/NZ), Canada, Japan, Thailand, South Korea, United Kingdom, United States (US)) participating in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) among patients receiving PD for >3 months. We analysed the association of baseline PTH and albumin-adjusted calcium (calcium) with all-cause mortality using Cox regression, adjusted for potential confounders, including serum phosphorus and alkaline phosphatase.
RESULTS
Mean age ranged from 54.6 years in South Korea to 63.5 years in Japan. PTH and serum calcium were measured at baseline in 12,642 and 14,244 patients, respectively. Median PTH ranged from 161 (Japan) to 363 pg/mL (US); mean calcium ranged from 9.1 (South Korea, US) to 9.8 mg/dL (A/NZ). The PTH/mortality relationship was U-shaped, with the lowest risk at PTH 300-599 pg/mL. Mortality was nearly 20% higher at serum calcium 9.6+ mg/dL versus 8.4-<9.6 mg/dL. MBD therapy prescriptions varied substantially across countries.
CONCLUSIONS
A large proportion of PD patients in this multi-national study have calcium and/or PTH levels in ranges associated with substantially higher mortality. These observations point to the need to substantially improve MBD management in PD to optimise patient outcomes.
LAY SUMMARY
Chronic kidney disease-mineral bone disorder (MBD) is a systemic condition, common in dialysis patients, that results in abnormalities in parathyroid hormone (PTH), calcium, phosphorus and vitamin D metabolism. A large proportion of peritoneal dialysis (PD) patients in this current multi-national study had calcium and/or PTH levels in ranges associated with substantially higher risks of death. Our observational study design limits our ability to determine whether these abnormal calcium and PTH levels cause more death due to possible confounding that was not accounted for in our analysis. However, our findings, along with other recent work showing 48-75% higher risk of death for the one-third of PD patients having high phosphorus levels (>5.5 mg/dL), should raise strong concerns for a greater focus on improving MBD management in PD patients.
PubMed: 38501163
DOI: 10.1177/08968608241235516 -
Journal of Artificial Organs : the... Sep 2023Various benefits have been attached to purifying the dialysis fluid used for hemodialysis therapy. The central dialysis fluid delivery system can treat approximately 50...
Effectiveness of combination of heat water disinfection, continuous water circulation, and minimalized dead space for dialysis piping in maintaining ultrapure dialysis fluid and preventing biofilm formation in a central dialysis fluid delivery system.
Various benefits have been attached to purifying the dialysis fluid used for hemodialysis therapy. The central dialysis fluid delivery system can treat approximately 50 dialysis patients simultaneously and is convenient to operate. In contrast, the dialysis fluid supply piping is complicated, and bacterial growth can cause biofilms. This study aimed to develop sustainable cleaning strategies to solve the complicated dialysis fluid piping, which is a weakness of the central dialysis fluid delivery system, and provide ultrapure dialysis fluid for a long term. Combination of heat water disinfection, continuous water circulation, and minimalized dead space in the dialysis piping were designed for a central dialysis fluid delivery system and used in a clinic for 6 years. As an index of water purification, endotoxin concentrations and microbial colony counts in reverse osmosis water and dialysis fluid were measured. In addition, we performed scanning electron microscopy of the silicon tube surface that had been used for 5 years to confirm the presence or absence of biofilm formation. For 6 years, endotoxin concentrations and microbial colonies were not detected in reverse osmosis water and dialysis fluid using the multiple-patient dialysis fluid supply equipment. The purity of the dialysis fluid was maintained. No biofilm formation was observed by scanning electron microscopy. Combination of heat water disinfection, continuous water circulation, and minimalized dead space designs for dialysis piping can supply ultrapure dialysis fluid with minimal biofilm formation in the piping in the long term.
Topics: Humans; Renal Dialysis; Disinfection; Water; Hot Temperature; Dialysis Solutions; Endotoxins
PubMed: 36074207
DOI: 10.1007/s10047-022-01362-z -
Pediatric Nephrology (Berlin, Germany) Dec 2023About 10% of all home peritoneal dialysis regimens in children with chronic kidney disease stage 5 are reported to involve some form of a tidal peritoneal dialysis (TPD)...
About 10% of all home peritoneal dialysis regimens in children with chronic kidney disease stage 5 are reported to involve some form of a tidal peritoneal dialysis (TPD) prescription. Despite this, there remain several gaps in how pediatric nephrologists approach the use of TPD. This stems from a combination of factors such as the confusing technical terminology pertaining to TPD, seemingly conflicting data on the risks, benefits, and indications for TPD, and lastly, limited published guidelines on the practical aspects of how to write a TPD prescription, based on the indication, in children. Our educational review, using evidence-based data, attempts to bridge this gap and provide an easy-to-use guide on the key practical aspects of TPD in children.
Topics: Humans; Child; Dialysis Solutions; Peritoneal Dialysis; Peritoneum; Kidney Failure, Chronic; Hemodialysis, Home
PubMed: 36780006
DOI: 10.1007/s00467-023-05898-x -
Journal of the American Society of... Feb 2024This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance... (Observational Study)
Observational Study
SIGNIFICANCE STATEMENT
This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance hemodialysis patients. Using a large multinational cohort of 68,196 patients, we found that lower dialysate sodium concentrations (≤138 mmol/L) were independently associated with higher mortality compared with higher dialysate sodium concentrations (>138 mmol/L). The risk of death was lower among patients exposed to higher dialysate sodium concentrations, regardless of plasma sodium levels. These results challenge the prevailing assumption that lower dialysate sodium concentrations improve outcomes in hemodialysis patients. The study confirms that until robust evidence from randomized trials that are underway is available, nephrologists should remain cautious in reconsideration of dialysate sodium prescribing practices to optimize cardiovascular outcomes and reduce mortality in this population.
BACKGROUND
Excess mortality in hemodialysis (HD) patients is largely due to cardiovascular disease and is associated with abnormal fluid status and plasma sodium concentrations. Ultrafiltration facilitates the removal of fluid and sodium, whereas diffusive exchange of sodium plays a pivotal role in sodium removal and tonicity adjustment. Lower dialysate sodium may increase sodium removal at the expense of hypotonicity, reduced blood volume refilling, and intradialytic hypotension risk. Higher dialysate sodium preserves blood volume and hemodynamic stability but reduces sodium removal. In this retrospective cohort, we aimed to assess whether prescribing a dialysate sodium ≤138 mmol/L has an effect on survival outcomes compared with dialysate sodium >138 mmol/L after adjusting for plasma sodium concentration.
METHODS
The study population included incident HD patients from 875 Fresenius Medical Care Nephrocare clinics in 25 countries between 2010 and 2019. Baseline dialysate sodium (≤138 or >138 mmol/L) and plasma sodium (<135, 135-142, >142 mmol/L) concentrations defined exposure status. We used multivariable Cox regression model stratified by country to model the association between time-varying dialysate and plasma sodium exposure and all-cause mortality, adjusted for demographic and treatment variables, including bioimpedance measures of fluid status.
RESULTS
In 2,123,957 patient-months from 68,196 incident HD patients with on average three HD sessions per week dialysate sodium of 138 mmol/L was prescribed in 63.2%, 139 mmol/L in 15.8%, 140 mmol/L in 20.7%, and other concentrations in 0.4% of patients. Most clinical centers (78.6%) used a standardized concentration. During a median follow-up of 40 months, one third of patients ( n =21,644) died. Dialysate sodium ≤138 mmol/L was associated with higher mortality (multivariate hazard ratio for the total population (1.57, 95% confidence interval, 1.25 to 1.98), adjusted for plasma sodium concentrations and other confounding variables. Subgroup analysis did not show any evidence of effect modification by plasma sodium concentrations or other patient-specific variables.
CONCLUSIONS
These observational findings stress the need for randomized evidence to reliably define optimal standard dialysate sodium prescribing practices.
Topics: Humans; Dialysis Solutions; Retrospective Studies; Kidney Failure, Chronic; Renal Dialysis; Sodium
PubMed: 37967469
DOI: 10.1681/ASN.0000000000000262 -
Journal of General Internal Medicine May 2024The sodium-glucose cotransporter type 2 inhibitor dapagliflozin reduces the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
The sodium-glucose cotransporter type 2 inhibitor dapagliflozin reduces the risk of progressive kidney disease and cardiovascular events in patients with chronic kidney disease, with and without type 2 diabetes. Whether its effects are uniform across the spectrum of age and among men and women is unknown.
OBJECTIVE
We performed a pre-specified analysis in DAPA-CKD to evaluate efficacy and safety of dapagliflozin according to baseline age and sex.
DESIGN
Prospective randomized placebo-controlled trial.
PARTICIPANTS
A total of 4304 adults with chronic kidney disease (estimated glomerular filtration rate (eGFR) 25-75 mL/min/1.73 m; urinary albumin-to-creatinine ratio 200-5000 mg/g) with and without type 2 diabetes.
INTERVENTION
Dapagliflozin 10 mg versus placebo once daily.
MAIN MEASURES
Primary endpoint was a composite of ≥ 50% sustained eGFR decline, end-stage kidney disease, and kidney or cardiovascular death. Secondary endpoints included kidney composite endpoint (same as primary composite endpoint but without cardiovascular death), cardiovascular composite endpoint (hospitalized heart failure or cardiovascular death), and all-cause mortality.
KEY RESULTS
Median follow-up was 2.4 years. Absolute risks of cardiovascular composite endpoint and all-cause mortality were higher in older patients. Absolute risk of kidney composite endpoint was highest in patients < 50 years (10.7 and 6.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively) and lowest in patients ≥ 80 years (3.0 and 1.2 per 100 patient-years in the placebo and dapagliflozin groups, respectively). There was no evidence of heterogeneity of the effects of dapagliflozin on the primary or secondary endpoints based on age or sex. Neither age nor sex modified the effects of dapagliflozin on total or chronic eGFR slope.
CONCLUSIONS
Dapagliflozin reduced the risks of mortality, cardiovascular events, and CKD progression in older patients, including in septuagenarians and octogenarians who comprised 25% of participants. Ageism and/or therapeutic nihilism should not discourage the use of dapagliflozin in older women and men who are likely to experience considerable benefit.
TRIAL REGISTRY
clinicaltrials.gov NIH TRIAL REGISTRY NUMBER: NCT03036150.
Topics: Humans; Glucosides; Benzhydryl Compounds; Male; Female; Renal Insufficiency, Chronic; Middle Aged; Aged; Prospective Studies; Diabetes Mellitus, Type 2; Sodium-Glucose Transporter 2 Inhibitors; Age Factors; Sex Factors; Glomerular Filtration Rate; Adult; Double-Blind Method; Treatment Outcome; Follow-Up Studies; Aged, 80 and over
PubMed: 38097862
DOI: 10.1007/s11606-023-08397-9 -
Clinical Journal of the American... Jun 2024Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in... (Review)
Review
Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in many countries. However, it can be associated with unexpected interruptions to or discontinuation of therapy. Timely diagnosis and resolution are required to minimize preventable modality change to hemodialysis. This review covers mechanical complications, including leaks, PD hydrothorax, hernias, dialysate flow problems, PD-related pain, and changes in respiratory mechanics. Most mechanical complications occur early, either as a result of PD catheter insertion or the introduction of dialysate and consequent increased intra-abdominal pressure. Late mechanical complications can also occur and may require different treatment.
Topics: Humans; Peritoneal Dialysis; Hydrothorax; Kidney Failure, Chronic; Dialysis Solutions; Respiratory Mechanics; Hernia; Risk Factors
PubMed: 38190178
DOI: 10.2215/CJN.0000000000000417 -
Journal of Renal Nutrition : the... Nov 2023Recent surveys highlight gross workforce shortage of dietitians in global kidney health and significant gaps in renal nutrition care, with disparities greater in... (Review)
Review
BACKGROUND
Recent surveys highlight gross workforce shortage of dietitians in global kidney health and significant gaps in renal nutrition care, with disparities greater in low/low-middle income countries.
OBJECTIVE
This paper narrates ground experiences gained through the Palm Tocotrienols in Chronic Hemodialysis (PaTCH) project on kidney nutrition care scenarios and some Asian low-to-middle-income countries namely Bangladesh, India, and Malaysia.
METHOD
Core PaTCH investigators from 3 universities (USA and Malaysia) were supported by their postgraduate students (n = 17) with capacity skills in kidney nutrition care methodology and processes. This core team, in turn, built capacity for partnering hospitals as countries differed in their ability to deliver dietitian-related activities for dialysis patients.
RESULTS
We performed a structural component analyses of PaTCH affiliated and nonaffiliated (Myanmar and Indonesia) countries to identify challenges to kidney nutrition care. Deficits in patient-centered care, empowerment processes and moderating factors to nutrition care optimization characterized country comparisons. Underscoring these factors were some countries lacked trained dietitians whilst for others generalist dietitians or nonclinical nutritionists were providing patient care. Resolution of some challenges in low-to-middle-income countries through coalition networking to facilitate interprofessional collaboration and task sharing is described.
CONCLUSIONS
We perceive interprofessional collaboration is the way forward to fill gaps in essential dietitian services and regional-based institutional coalitions will facilitate culture-sensitive capacity in building skills. For the long-term an advanced renal nutrition course such as the Global Renal Internet Course for Dietitians is vital to facilitate sustainable kidney nutrition care.
Topics: Humans; Nutritional Status; Delivery of Health Care; Surveys and Questionnaires; Renal Dialysis; Kidney; Nutritionists
PubMed: 37597574
DOI: 10.1053/j.jrn.2023.08.003 -
Journal of Medical Genetics Sep 2023A small but significant reduction in left ventricular (LV) mass after 18 months of migalastat treatment has been reported in Fabry disease (FD). This study aimed to...
BACKGROUND
A small but significant reduction in left ventricular (LV) mass after 18 months of migalastat treatment has been reported in Fabry disease (FD). This study aimed to assess the effect of migalastat on FD cardiac involvement, combining LV morphology and tissue characterisation by cardiac magnetic resonance (CMR) with cardiopulmonary exercise testing (CPET).
METHODS
Sixteen treatment-naïve patients with FD (4 women, 46.4±16.2 years) with cardiac involvement (reduced T1 values on CMR and/or LV hypertrophy) underwent ECG, echocardiogram, troponin T and NT-proBNP (N-Terminal prohormone of Brain Natriuretic Peptide) assay, CMR with T1 mapping, and CPET before and after 18 months of migalastat.
RESULTS
No change in LV mass was detected at 18 months compared to baseline (95.2 g/m (66.0-184.0) vs 99.0 g/m (69.0-121.0), p=0.55). Overall, there was an increase in septal T1 of borderline significance (870.0 ms (848-882) vs 860.0 ms (833.0-875.0), p=0.056). Functional capacity showed an increase in oxygen consumption (VO) at anaerobic threshold (15.50 mL/kg/min (13.70-21.50) vs 14.50 mL/kg/min (11.70-18.95), p=0.02), and a trend towards an increase in percent predicted peak VO (72.0 (63.0-80.0) vs 69.0 (53.0-77.0), p=0.056) was observed. The subset of patients who showed an increase in T1 value and a reduction in LV mass (n=7, 1 female, age 40.5 (28.6-76.0)) was younger and at an earlier disease stage compared to the others, and also exhibited greater improvement in exercise tolerance.
CONCLUSION
In treatment-naïve FD patients with cardiac involvement, 18-month treatment with migalastat stabilised LV mass and was associated with a trend towards an improvement in exercise tolerance. A tendency to T1 increase was detected by CMR. The subset of patients who had significant benefits from the treatment showed an earlier cardiac disease compared to the others.
TRIAL REGISTRATION NUMBER
NCT03838237.
Topics: Humans; Female; Adult; Fabry Disease; Heart Diseases; Magnetic Resonance Imaging; 1-Deoxynojirimycin; Predictive Value of Tests
PubMed: 36669872
DOI: 10.1136/jmg-2022-108768