Practice variations in antibiotic administration for the management of peritonitis in patients on automated peritoneal dialysis in Australia and New Zealand

In the absence of guidelines on the management of peritoneal dialysis (PD)-associated peritonitis in patients on automated peritoneal dialysis (APD), variations in clinical practice potentially exist between PD units that could affect clinical outcomes. This study aimed to document the current practices of treating PD-associated peritonitis in patients on APD across Australia and New Zealand and the reasons for practice variations using a cross-sectional online survey. Of the 62 PD units, 34 medical leads (55%) responded to the survey. When treating APD-associated peritonitis, 21 units (62%) continued patients on APD and administered intraperitoneal (IP) antibiotics in manual daytime exchanges; of these, 17 (81%) considered allowing at least 6 h dwell time for adequate absorption of the IP antibiotics as an important reason for adding manual daytime exchange. Nine units (26%) temporarily switched patients from APD to continuous ambulatory peritoneal dialysis (CAPD); of these, five (55%) reported a lack of pharmacokinetic (PK) data for IP antibiotics in APD, four (44%) reported a shortage of APD-trained nursing staff to perform APD exchanges during hospitalisation and three (33%) reported inadequate time for absorption of IP antibiotics on APD as important reasons for their practice. Four units (12%) continued patients on APD and administered IP antibiotics during APD exchanges; of these, three (75%) believed that PK data available in CAPD could be extrapolated to APD. This study demonstrates wide variations in the management of APD-associated peritonitis in Australia and New Zealand; it points towards the lack of PK on antibiotics used to treat peritonitis as an important reason underpinning practice variations.

Current clinical practice in adapted automated peritoneal dialysis (aAPD)—A prospective, non-interventional study

Adapted automated peritoneal dialysis (aAPD), comprising a sequence of dwells with different durations and fill volumes, has been shown to enhance both ultrafiltration and solute clearance compared to standard peritoneal dialysis with constant time and volume dwells. The aim of this non-interventional study was to describe the different prescription patterns used in aAPD in clinical practice and to observe outcomes characterizing volume status, dialysis efficiency, and residual renal function over 1 year. Prevalent and incident, adult aAPD patients were recruited during routine clinic visits, and aAPD prescription, volume status, residual renal function and laboratory data were documented at baseline and every quarter thereafter for 1 year. Treatments were prescribed according to the nephrologist’s medical judgement in accordance with each center’s clinical routine. Of 180 recruited patients, 160 were analyzed. 27 different aAPD prescription patterns were identified. 79 patients (49.4%) received 2 small, short dwells followed by 3 long, large dwells. During follow-up, volume status changed only marginally, with visit mean values ranging between 1.59 (95% confidence interval: 1.19; 1.99) and 1.97 (1.33; 2.61) L. Urine output and creatinine clearance decreased significantly, accompanied by reductions in ultrafiltration and Kt/V. 25 patients (15.6%) received a renal transplant and 15 (9.4%) were changed to hemodialysis. Options for individualization offered by aAPD are actually used in practice for optimized treatment. Changes observed in renal function and dialysis efficiency measures reflect the natural course of chronic kidney disease. No safety events were observed during the study period.

Difference in perception of advantages and disadvantages of automated peritoneal dialysis for patients undergoing peritoneal dialysis: a conjoint analysis

Background In Japan, only less than 3% of patients undergoing maintenance dialysis select peritoneal dialysis (PD) as the mode of renal replacement therapy. Half of patients undergoing PD use a cycler for automated PD (APD). However, it remains unclear what patients undergoing PD regard as the benefits of APD. The purpose of this study was to objectively clarify what patients undergoing PD regard as the advantages and disadvantages of APD. Methods We designed case simulations that varied according to 6 characteristics of PD, such as the adequacy of dialysis and frequency of bag exchange, and created 16 simulation cards for conjoint analysis. For each case vignette, the respondents were asked to indicate whether they would receive this modality of PD on a 5-point scale. Results Thirty-two patients undergoing PD were recruited for this study and completed conjoint analysis simulation questionnaires. The factor with the highest importance in evaluating the modality of PD was the frequency of bag exchange among all participants. When participants were divided into those undergoing APD and continuous ambulatory PD (CAPD), the factor was different between them; that is, the low frequency of bag exchange is regarded as an advantage of APD for patients undergoing APD, while the large-sized cycler device is regarded as a disadvantage of APD for those undergoing CAPD. Conclusions The perception of advantages and disadvantages of APD differed between patients undergoing APD and CAPD; the former focus on the frequency of bag exchange, whereas the latter focused the size of device.

Ultrafiltration in Patients on Automated Peritoneal Dialysis with Homechoice Claria connected to Sharesource: A Pilot Study

Introduction: Fluid overload is an unavoidable problem in patients on peritoneal dialysis (PD) and is associated with poor outcomes. The aim of our study was to estimate ultrafiltration (UF) under different dextrose concentrations and clarify possible predictors of UF.Materials and methods: Seventy patients, with 1848 daily treatment records and 8266 single dwells on automated PD through Homechoice Claria with Sharesource were followed in October 2020 and categorized into 2 groups according to the dextrose concentration (group D1.5% and D2.5%). Baseline characteristics, peritoneal membrane characteristics, and daily PD treatment records from Sharesource were obtained. We compared UF under the different conditions.Results: Multivariate linear regression revealed that the mean fill volume (FV) per cycle (p=0.006) and dextrose concentration (p=0.000) were independent predictors of UF. The mean night UF per cycle, the mean night UF corrected by FV per cycle, and the mean night UF corrected by FV and dwelling time (DT) per cycle were 95.8 ml, 5.5%, and 5.0 ‱/minutes in group D1.5% and 220.3 ml, 12.0%, and 11.6 ‱/minutes in group D2.5%, respectively. After an approximately 120-minute DT, there was a trend toward higher UF in the low peritoneal permeability group and lower UF in the high peritoneal permeability group.Conclusion: This retrospective study presents precise UF measurements with two solutions at different dextrose concentrations and four peritoneal transport levels. UF is positively correlated with DT and FV of the dialysate within a reasonable range. High peritoneal permeability is associated with decreased UF, and low peritoneal permeability requires a longer DT to reach the maximal UF.