Peritoneal dialysis-associated peritonitis outcomes reported in trials and observational studies: A systematic review

2020 ◽  
Vol 40 (2) ◽  
pp. 132-140 ◽  
Author(s):  
Muthana Al Sahlawi ◽  
Gregory Wilson ◽  
Belinda Stallard ◽  
Karine E Manera ◽  
Allison Tong ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Observational Studies ◽  
Randomized Trials ◽  
Primary Outcome ◽  
Large Variability ◽  
Continuous Quality ◽  
Improvement Measures ◽  
Refractory Peritonitis ◽  
Definition Of ◽  
Related Mortality

Background: Peritoneal dialysis (PD)-associated peritonitis carries significant morbidity, mortality, and is a leading cause of PD technique failure. This study aimed to assess the scope and variability of PD-associated peritonitis reported in randomized trials and observational studies. Methods: Cochrane Controlled Register of Trials, MEDLINE, and Embase were searched from 2007 to June 2018 for randomized trials and observational studies in adult and pediatric patients on PD that reported PD-associated peritonitis as a primary outcome or as a part of composite primary outcome. We assessed the peritonitis definitions used, characteristics of peritonitis, and outcome reporting and analysis. Results: Seventy-seven studies were included, three were randomized trials. Thirty-eight (49%) of the included studies were registry-based observational studies. Twenty-nine percent ( n = 22) of the studies did not specify how PD-associated peritonitis was defined. Among those providing a definition of peritonitis, three components were reported: effluent cell count ( n = 42, 54%), clinical features consistent with peritonitis (e.g. abdominal pain and/or cloudy dialysis effluent) ( n = 35, 45%), and positive effluent culture ( n = 19, 25%). Of those components, 1 was required to make the diagnosis in 6 studies (8%), 2 out of 2 were required in 22 studies (29%), 2 out of 3 in 11 studies (14%), and 3 out of 3 in 4 studies (5%). Peritonitis characteristics and outcomes reported across studies included culture-negative peritonitis ( n = 47, 61%), refractory peritonitis ( n = 42, 55%), repeat peritonitis ( n = 9, 12%), relapsing peritonitis ( n = 5, 7%), concomitant exit site ( n = 16, 21%), and tunnel infections ( n = 8, 10%). Peritonitis-related hospitalization was reported in 38% of the studies ( n = 29), and peritonitis-related mortality was variably defined and reported in 55% of the studies ( n = 42). Peritonitis rate was most frequently reported as episodes per patient year ( n = 40, 52%). Conclusion: Large variability exists in the definitions, methods of reporting, and analysis of PD-associated peritonitis across trials and observational studies. Standardizing definitions for reporting of peritonitis and associated outcomes will better enable assessment of the comparative effect of interventions on peritonitis. This will facilitate continuous quality improvement measures through reliable benchmarking of this patient-important outcome across centers and countries.

scholarly journals Relationship between initial peritoneal dialysis modality and risk of peritonitis

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Maiko Kokubu ◽  
Masaru Matsui ◽  
Takayuki Uemura ◽  
Katsuhiko Morimoto ◽  
Masahiro Eriguchi ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Lower Risk ◽  
Observational Studies ◽  
Primary Outcome ◽  
Propensity Scores ◽  
First Episode ◽  
Connection Type ◽  
Adjusted Model ◽  
The Relationship ◽  
Nara Prefecture

Abstract Peritonitis is a critical complication of peritoneal dialysis (PD). Investigators have reported the risk of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD) versus automated peritoneal dialysis (APD), but the available evidence is predominantly based on observational studies which failed to report on the connection type. Our understanding of the relationship between peritonitis risk and PD modality thus remained insufficient. We studied 285 participants who began PD treatment between 1997 and 2014 at three hospitals in Nara Prefecture in Japan. We matched 106 APD patients with 106 CAPD patients based on their propensity scores. The primary outcome was time to first episode of peritonitis within 3 years after PD commencement. In total, PD peritonitis occurred in 64 patients during the study period. Patients initiated on APD had a lower risk of peritonitis than did those initiated on CAPD in both the unadjusted and adjusted models. The hazard ratio (HR) and 95% confidence interval (CI) for the primary endpoint were 0.30 (0.17–0.53) in the fully adjusted model including connection type. In the matched cohort, APD patients had a significantly lower risk of peritonitis than did CAPD patients (log-rank: p < 0.001, HR 0.32, 95% CI 0.16–0.59). The weighting-adjusted analysis of the inverse probability of treatment yielded a similar result (HR 0.35, 95% CI 0.18–0.67). In conclusion, patients initiated on APD at PD commencement had a reduced risk of peritonitis compared with those initiated on CAPD, suggesting APD may be preferable for prevention of peritonitis among PD patients.

scholarly journals Scope and heterogeneity of outcomes reported in randomized trials in patients receiving peritoneal dialysis

2020 ◽  
Author(s):  
Karine E Manera ◽  
David W Johnson ◽  
Yeoungjee Cho ◽  
Benedicte Sautenet ◽  
Jenny Shen ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Patient Reported Outcomes ◽  
Randomized Trials ◽  
Primary Outcome ◽  
Median Number ◽  
Patient Reported Outcome ◽  
Patient Reported ◽  
Inform Decision Making ◽  
Solute Clearance

Abstract Background Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD). Methods We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics. Results From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13–37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once. Conclusions Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance.

Multicentre registry data analysis comparing outcomes of culture-negative peritonitis and different subtypes of culture-positive peritonitis in peritoneal dialysis patients

2020 ◽  
Vol 40 (1) ◽  
pp. 47-56 ◽  
Author(s):  
Htay Htay ◽  
Yeoungjee Cho ◽  
Elaine M Pascoe ◽  
Carmel Hawley ◽  
Philip A Clayton ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Primary Outcome ◽  
Catheter Removal ◽  
Dialysis Patients ◽  
Gram Positive ◽  
Pseudomonas Species ◽  
Gram Negative Organisms ◽  
Culture Positive ◽  
Culture Negative ◽  
Related Mortality

Background: The outcomes of culture-negative peritonitis in peritoneal dialysis (PD) patients have been reported to be superior to those of culture-positive peritonitis. The current study aimed to examine whether this observation also applied to different subtypes of culture-positive peritonitis. Methods: This multicentre registry study included all episodes of peritonitis in adult PD patients in Australia between 2004 and 2014. The primary outcome was medical cure. Secondary outcomes were catheter removal, hemodialysis transfer, relapsing/recurrent peritonitis and peritonitis-related death. These outcomes were analyzed using mixed effects logistic regression. Results: Overall, 11,122 episodes of peritonitis occurring in 5367 patients were included. A total of 1760 (16%) episodes were culture-negative, of which 77% were medically cured. Compared with culture-negative peritonitis, the odds of medical cure were lower in peritonitis caused by Staphylococcus aureus (adjusted odds ratio (OR) 0.62, 95% confidence interval (CI) 0.52–0.73), Pseudomonas species (OR 0.20, 95% CI 0.16–0.26), other gram-negative organisms (OR 0.48, 95% CI 0.41–0.56), polymicrobial organisms (OR 0.30, 95% CI 0.25–0.35), fungi (OR 0.02, 95% CI 0.01–0.03), and other organisms (OR 0.61, 95% CI 0.49–0.76), while the odds were similar in other (non-staphylococcal) gram-positive organisms (OR 1.11, 95% CI 0.97–1.28). Similar results were observed for catheter removal and hemodialysis transfer. Compared with culture-negative peritonitis, peritonitis-related mortality was significantly higher in culture-positive peritonitis except that due to other gram-positive organisms. There was no difference in the odds of relapsing/recurrent peritonitis between culture-negative and culture-positive peritonitis. Conclusion: Culture-negative peritonitis had superior outcomes compared to culture-positive peritonitis except for non-staphylococcal gram-positive peritonitis.

scholarly journals Extensive Variability in Platelet Count, Bleeding, and Quality of Life Outcome Measures in Adult and Pediatric Immune Thrombocytopenia: An Appraisal from a Critical Review of the Literature

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 45-46
Author(s):  
Hanny Al-Samkari ◽  
Alexandria Cronin ◽  
Donald M. Arnold ◽  
Francesco Rodeghiero ◽  
Rachael F. Grace
Keyword(s):  
Platelet Count ◽  
Treatment Response ◽  
Outcome Measures ◽  
Research Funding ◽  
Observational Studies ◽  
Randomized Trials ◽  
Platelet Response ◽  
Count Response ◽  
Definition Of

Introduction: Despite publication of standardized platelet count response definitions by the immune thrombocytopenia (ITP) International Working Group (IWG) in 2009, there remains considerable variability in the definition of platelet count outcomes across ITP studies. Moreover, there is no widely-accepted bleeding scale, health-related quality of life (HRQoL) inventories, or definition of remission for use in ITP patients, all critical outcome measures not addressed in the IWG Report. This heterogeneity makes comparison of response rates and outcomes between studies challenging. Therefore, to better understand current practices and inform future standardization efforts, we performed a systematic review of ITP studies to characterize how these outcomes have been measured in the decade following publication of the IWG Report. Methods: We performed a systematic review of PubMed/MEDLINE-indexed manuscripts published from January 1, 2010 through December 31, 2019 that described a platelet count, bleeding, and/or HRQoL measure in reflection of treatment response in adult and pediatric ITP. Following initial search, two authors (H.A. and R.G.) screened each abstract for inclusion, then read each included full text manuscript to collect outcome measures. Interventional studies with ≥10 patients and observational studies with ≥50 patients were included; manuscripts without abstracts and non-English language manuscripts were excluded. Results: Studies. The PubMed/MEDLINE search revealed 1562 manuscripts; following abstract screening and manuscript review, 168 manuscripts met inclusion criteria for the study. Of the 168 studies, 110 studies evaluated adults, 41 evaluated children, and 17 evaluated both adults and children; 99 were prospective (including 32 randomized trials) and 69 were retrospective observational studies. Platelet Outcomes. 141 studies (including 28 randomized trials, 53 non-randomized prospective studies and 60 retrospective observational studies) reported platelet response outcomes and 11 reported platelet count remission definitions. Of the 141 reporting response outcomes, 61 (43%) used IWG definitions and 80 (57%) did not. Of these 80 studies, there were a total of 21 distinct platelet count outcome definition schemes (Figure 1). The majority of randomized trials (22/28, 79%) and other prospective studies (37/53, 70%) did not use IWG definitions; instead, a plurality of these studies used a Plt ≥50 × 109/L to define a treatment response, without definitions for complete, partial, or minor response. Most retrospective observational studies (39/60, 65%), however, used IWG definitions. Of the 11 studies reporting remission definitions, a platelet count of ≥100 × 109/L with or without treatment over a time period of ≥6 months was the most commonly used definition of remission, although a minority of studies used thresholds of ≥50 × 109/L or ≥150 × 109/L. Bleeding Outcomes. Bleeding outcomes were reported in a systematic fashion in only a minority of studies (67/168, 36%), which used a total of 21 distinct bleeding outcome reporting schemes. A plurality of adult studies used the WHO Bleeding Scale and a plurality of pediatric studies used the Buchanan and Adix Score, Figure 2. HRQoL Outcomes. HRQoL outcomes were reported in a small minority of studies (15/168, 9%), which used a total of 8 different HRQoL instruments (6 adult instruments and 2 pediatric instruments), Table. Conclusions: Despite prior attempts to standardize evaluation of platelet response to treatment in ITP, there remains wide variability in the definition of both treatment response and remission. In particular, most prospective and randomized studies published following release of the 2009 IWG report have used study-specific platelet count response thresholds, whereas retrospective observational studies were much more likely to adopt the IWG-recommended platelet response definitions. Despite the fact that ITP is a bleeding disorder and its impact on HRQoL has been well-documented, most ITP studies published in the past decade did not evaluate bleeding in any systematic way and fewer still evaluated the impact of treatment on HRQoL. Further standardization of platelet count, bleeding, and HRQoL outcomes in both pediatric and adult ITP is greatly needed, especially for future randomized trials, to allow for more meaningful comparison of response rates and efficacy between studies. Disclosures Al-Samkari: Agios: Consultancy, Research Funding; Argenx: Consultancy; Amgen: Research Funding; Dova: Consultancy, Research Funding; Rigel: Consultancy. Arnold:Novartis: Consultancy, Research Funding; Amgen: Consultancy, Research Funding; Bristol Myers Squibb: Research Funding; Rigel: Consultancy; Principia: Consultancy. Grace:Novartis: Research Funding; Dova: Membership on an entity's Board of Directors or advisory committees; Pfizer: Research Funding; Agios: Research Funding.

Improving Technique Survival in Peritoneal Dialysis: What is Modifiable?

2009 ◽  
Vol 29 (2_suppl) ◽  
pp. 74-77 ◽  
Author(s):  
F. Fevzi Ersoy
Keyword(s):  
Quality Improvement ◽  
Peritoneal Dialysis ◽  
Continuous Quality Improvement ◽  
Dialysis Patients ◽  
Exit Site ◽  
Fungal Peritonitis ◽  
Technique Survival ◽  
Continuous Quality ◽  
Pdca Cycle ◽  
Definition Of

The continuous quality improvement approach in peritoneal dialysis practice necessitates definition of the factors and the procedures that may possibly be contributing to the final success of peritoneal dialysis. The philosophy of continuous quality improvement uses the Plan, Do, Check, Act (PDCA) cycle. To improve the procedures used during peritoneal dialysis, the first step is to create a plan, then to carry out the plan, to check it, and after the collection of satisfactory information, to execute the chosen improvement action. Several studies have identified the most frequent causes of transfer from PD to HD as infection, catheter problems, inadequate dialysis, and psychosocial factors, among others. According to training guidelines from the International Society for Peritoneal Dialysis, seven points are of major importance to decrease infection risks: exit-site care, catheter placement, antibiotic prophylaxis for procedures, prevention of bowel-source peritonitis, prevention of fungal peritonitis, and connection methods. On the other hand, other factors such as hypoalbuminemia, depression, and obesity should also be taken into consideration for better technique survival in peritoneal dialysis patients.

scholarly journals Persistent Postoperative Opioid Use

2020 ◽  
Vol 132 (6) ◽  
pp. 1528-1539 ◽  
Author(s):  
Naheed K. Jivraj ◽  
Faizal Raghavji ◽  
Jennifer Bethell ◽  
Duminda N. Wijeysundera ◽  
Karim S. Ladha ◽  
...  
Keyword(s):  
Observational Studies ◽  
Primary Outcome ◽  
Population Based ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Related Event ◽  
The Subject ◽  
Definition Of ◽  
Low Sensitivity

Abstract Background While persistent opioid use after surgery has been the subject of a large number of studies, it is unknown how much variability in the definition of persistent use impacts the reported incidence across studies. The objective was to evaluate the incidence of persistent use estimated with different definitions using a single cohort of postoperative patients, as well as the ability of each definition to identify patients with opioid-related adverse events. Methods The literature was reviewed to identify observational studies that evaluated persistent opioid use among opioid-naive patients requiring surgery, and any definitions of persistent opioid use were extracted. Next, the authors performed a population-based cohort study of opioid-naive adults undergoing 1 of 18 surgical procedures from 2013 to 2017 in Ontario, Canada. The primary outcome was the incidence of persistent opioid use, defined by each extracted definition of persistent opioid use. The authors also assessed the sensitivity and specificity of each definition to identify patients with an opioid-related adverse event in the year after surgery. Results Twenty-nine different definitions of persistent opioid use were identified from 39 studies. Applying the different definitions to a cohort of 162,830 opioid-naive surgical patients, the incidence of persistent opioid use in the year after surgery ranged from 0.01% (n = 10) to 14.7% (n = 23,442), with a median of 0.7% (n = 1,061). Opioid-related overdose or diagnosis associated with opioid use disorder in the year of follow-up occurred in 164 patients (1 per 1,000 operations). The sensitivity of each definition to identify patients with the composite measure of opioid use disorder or opioid-related toxicity ranged from 0.01 to 0.36, while specificity ranged from 0.86 to 1.00. Conclusions The incidence of persistent opioid use reported after surgery varies more than 100-fold depending on the definition used. Definitions varied markedly in their sensitivity for identifying adverse opioid-related event, with low sensitivity overall across measures. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

scholarly journals Clinical improvement of encapsulating peritoneal sclerosis after challenging course and 6 months of total parenteral nutrition in child with nephronophthisis: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Saeed Mohammed AlZabali ◽  
Abdulkarim AlAnazi ◽  
Khawla A. Rahim ◽  
Hassan Y. Faqeehi
Keyword(s):  
Peritoneal Dialysis ◽  
Parenteral Nutrition ◽  
Total Parenteral Nutrition ◽  
Bowel Perforation ◽  
Clinical Signs ◽  
Oral Intake ◽  
Pediatric Intensive Care ◽  
Abdominal Ultrasound ◽  
Peritoneal Dialysis Catheter ◽  
Refractory Peritonitis

Abstract Background Encapsulating peritoneal sclerosis is a rare but potentially lethal complication of long-term peritoneal dialysis that is associated with significant morbidity and mortality. The occurrence of encapsulating peritoneal sclerosis varies worldwide, but is increased in patients maintained on peritoneal dialysis for 5–8 years. The etiology of encapsulating peritoneal sclerosis remains unidentified, and a high index of clinical suspicion is required for diagnosis. Case presentation We report a 5-year-old Saudi female with end-stage renal disease secondary to nephronophthisis type 2. She underwent peritoneal dialysis for 30 months, with four episodes of peritonitis. She presented with clinical signs of peritonitis. Three days later, she developed septic shock, which required pediatric intensive care unit admission. The peritoneal dialysis catheter was removed because of refractory peritonitis. Her course was complicated by small bowel perforation, and severe adhesions were revealed on abdominal ultrasound and computed tomography, consistent with a diagnosis of EPS. This finding was later confirmed by diagnostic laparotomy performed twice and complicated by recurrent abdominal wall fistula. She received total parenteral nutrition for 6 months and several courses of antibiotics. The patient received supportive treatment including nutritional optimization and treatment for infection. No other treatments, such as immunosuppression, were administered to avoid risk of infection. Following a complicated hospital course, the patient restarted oral intake after 6 months of total parenteral nutrition dependency. Her abdominal fistula resolved completely, and she was maintained on hemodialysis for few years before she received a kidney transplant. Conclusion When treating patients using peritoneal dialysis, it is important to consider encapsulating peritoneal sclerosis with refractory peritonitis, which is not always easy to identify, particularly if the patient has been maintained on peritoneal dialysis for less than 3 years. Early identification of encapsulating peritoneal sclerosis and appropriate conservative treatment, including nutritional optimization and treatment of infections, are essential to achieve a better prognosis.

scholarly journals PRO: Carbapenems should be used for ALL infections caused by ceftriaxone-resistant Enterobacterales

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
David L Paterson ◽  
Burcu Isler ◽  
Patrick N A Harris
Keyword(s):  
Antibiotic Resistance ◽  
Observational Studies ◽  
Randomized Trials ◽  
Antibiotic Resistance Genes ◽  
Definitive Treatment ◽  
In Vitro Activity ◽  
Genes Encoding ◽  
Amoxicillin Clavulanate ◽  
Trial Outcomes

Abstract Ceftriaxone resistance in the Enterobacterales is typically the result of production of ESBLs or AmpC β-lactamases. The genes encoding these enzymes are often co-located with other antibiotic resistance genes leading to resistance to aminoglycosides, quinolones and trimethoprim/sulfamethoxazole. Carbapenems are stable to ESBLs and AmpC giving them reliable in vitro activity against producers of these β-lactamases. In contrast, piperacillin/tazobactam and amoxicillin/clavulanate are compromised by co-production of OXA-1, which is not inhibited by tazobactam or clavulanate. These in vitro findings provide an explanation for the MERINO trial outcomes, where 3.7% (7/191) randomized to meropenem died compared with 12.3% (23/187) randomized to piperacillin/tazobactam as definitive treatment of bloodstream infection due to ceftriaxone-resistant organisms. No randomized trials have yet put cefepime and carbapenems head to head, but some observational studies have shown worse outcomes with cefepime. We argue that carbapenems are the antibiotics of choice for ceftriaxone-resistant Enterobacterales.

scholarly journals Cefoperazone and sulbactam-related eosinophilic peritonitis: a case report and literature review

2021 ◽  
Vol 49 (6) ◽  
pp. 030006052110253
Author(s):  
Zi Wang ◽  
Zhiying Li ◽  
Suping Luo ◽  
Zhikai Yang ◽  
Ying Xing ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Blood Cells ◽  
White Blood Cells ◽  
Antibiotic Use ◽  
Absolute Count ◽  
Peritoneal Dialysate ◽  
Refractory Peritonitis ◽  
Technique Failure ◽  
Peritoneal Dialysis Effluent ◽  
Pathogenic Infection

Eosinophilic peritonitis (EP) is a well-described complication of peritoneal dialysis that occurs because of an overreaction to constituents that are related to the catheter or tubing, peritoneal dialysate, pathogenic infection, or intraperitoneal drug use. EP caused by antibiotic use is rare. We present the case of a patient with cefoperazone and sulbactam-related EP. A 59-year-old woman who was undergoing peritoneal dialysis presented with peritonitis with abdominal pain and turbid peritoneal dialysis. Empiric intraperitoneal cefazolin in combination with cefoperazone and sulbactam was started after peritoneal dialysis effluent cultures were performed. Her peritonitis achieved remission in 2 days with the help of cephalosporin, but she developed EP 1 week later, when her dialysate eosinophil count peaked at 49% of the total dialysate white blood cells (absolute count, 110/mm3). We excluded other possible causes and speculated that cefoperazone and sulbactam was the probable cause of EP. The patient continued treatment with cefoperazone and sulbactam for 14 days. EP resolved within 48 hours after stopping cefoperazone and sulbactam. Thus, EP can be caused by cefoperazone and sulbactam use. Physicians should be able to distinguish antibiotic-related EP from refractory peritonitis to avoid technique failure.

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