Association between the use of exchange devices for peritoneal dialysis fluids and peritonitis incidence: A nationwide cohort study

Background: The use of exchange devices for peritoneal dialysis (PD) fluids is a common practice in Japan. Evidence on the effectiveness of exchange devices in preventing PD-related peritonitis is scarce. We evaluated the association between the use of exchange devices for PD fluids and peritonitis incidence. Methods: We retrospectively enrolled 3845 patients, aged ≥20 years, receiving PD for ≥3 months, with available data on the exchange procedure for PD fluids and peritonitis incidence that was obtained from the Japan Renal Data Registry, a nationwide annual survey. The patients were grouped according to whether the manual or device PD fluid exchange method was used. The onset of peritonitis was defined as a leukocyte count of >100/µL (neutrophils ≥50%) in PD effluents. We applied quasi-Poisson regression analyses to estimate the incidence rate ratio (IRR). Age, sex, PD vintage, body mass index, automated PD use, residual kidney function, comorbidities, haemoglobin and serum albumin were adjusted as potential confounders. Results: Older age, automated PD use, diabetes as comorbidity and lower haemoglobin levels were associated with the use of exchange devices for PD fluids. Patients using devices for PD fluid exchange (69.2%) had an increased risk of peritonitis of 37% (IRR: 1.37, 95% confidence interval (CI): 1.07–1.75) and 28% (IRR: 1.28, 95% CI: 1.00–1.63) in the crude and multivariate adjustment models, respectively. Conclusions: The use of exchange devices for PD fluids and peritonitis incidence showed no favourable association. There may remain possible residual confounding by indication.

Kocuria rosea Bacteremia in Chronic Kidney Disease Patient: A Rare Case Report

Kocuria sp. may cause bacteremia, peritonitis, brain abscesses, meningitis, endocarditis, and acute cholecystitis in immunocompromised individuals. Recent reports identified Kocuria rosea in bacteremia associated with in dwelling intravenous lines, continuous dialysis fluids etc. We report on the case of bacteremia caused by K.rosea, a gram-positive microorganism in a 65-year-old female with a known case of end-stage renal disease on hemodialysis. After Piperacillin and Tazobactam antibiotic treatment, the patient got cured of fever and infection. This report presents a rare case of K.rosea bacteremia successfully treated with common antibiotics. Proper identification systems should be there to know the cause of bacteremia. The bacteremia cases with rare organisms should not be ignored.

Effects of bicarbonate/lactate-buffered neutral peritoneal dialysis fluids on angiogenesis-related proteins in patients undergoing peritoneal dialysis

Background In order to facilitate the safe and long-term delivery of peritoneal dialysis (PD), it is necessary to improve the biocompatibility of peritoneal dialysis fluids (PDFs). The novel bicarbonate/lactate-buffered neutral PDFs (B/L-PDFs) are expected to be improved biocompatible. This study evaluated the biocompatibility of B/L-PDFs by analysis on the profile of angiogenesis-related proteins in drained dialysate of patients undergoing PD. Methods Concentrations of 20 angiogenesis-related proteins in the dialysate were semi-quantitatively determined using a RayBio® Human Angiogenesis Antibody Array and were compared between B/L-PDFs and conventional lactate-buffered neutral PDFs (L-PDFs). Results The expression of growth-related oncogene (GRO α/β/γ), which belongs to the CXC chemokine family, decreased significantly after use of the B/L-PDFs compared to the L-PDFs (P = 0.03). The number of the proteins with lower level in the B/L-PDFs compared with L-PDFs was significantly negatively correlated with the PD duration (Spearman ρ = − 0.81, P = 0.004). Conclusion This study suggested that B/L-PDFs are more biocompatible than conventional PDFs.

Hyaluronan reduces colitis-induced intraperitoneal inflammation during peritoneal dialysis

Background: Peritoneal dialysis induces the inflammatory response within the peritoneal cavity, which contributes to the progressive damage of the peritoneum. Due to close contact of the peritoneal cavity and the intestines, there is the possibility that the visceral disorders can affect the intraperitoneal inflammation during peritoneal dialysis. Objectives: Study of the effect of acute colitis on the intraperitoneal inflammation in conditions of peritoneal dialysis and evaluation of the protective effect of hyaluronan in that scenario. Methods: In rats with the dextran sulphate-induced colitis, 6-h peritoneal dialysis was performed with dianeal 2.5% +/− hyaluronan 10 mg/dL. In the control group, rats without colitis were studied. Peritoneal permeability and dialysate inflammation were studied at the end of the dialysate exchange. Results: In rats with colitis, intraperitoneal inflammatory reaction was increased as compared with the control group and reflected by the following studied parameters: dialysate cell count (+26%, p < 0.01), number of neutrophils (+75%, p < 0.01), generation of free radicals in the leukocytes (+70%, p < 0.05), dialysate level of elastase (+102%, p < 0.01), tumor necrosis factor α (+48%, p < 0.01) and monocyte chemoattractant protein-1 (+42%, p < 0.01). Drained dialysate volume was lower (−21%, p < 0.01) and peritoneal permeability increased in rats with colitis (+55%, p < 0.01). In animals with the hyaluronan supplemented dialysis fluids, the intensity of the intraperitoneal inflammation was reduced. Conclusions: Visceral inflammation during colitis induces the inflammatory reaction within the peritoneal cavity that may accelerate damage to the peritoneum. Supplementation of the dialysis fluid with hyaluronan reduces the intensity of that effect.

Metal cations promote α-dicarbonyl formation in glucose-containing peritoneal dialysis fluids

Heat sterilization of peritoneal dialysis fluids (PDFs) leads to the formation of glucose degradation products (GDPs), which impair long-term peritoneal dialysis. The current study investigated the effects of metal ions, which occur as trace impurities in the fluids, on the formation of six major α-dicarbonyl GDPs, namely glucosone, glyoxal, methylglyoxal, 3-deoxyglucosone, 3-deoxygalactosone, and 3,4-dideoxyglucosone-3-ene. The chelation of metal ions by 2-[bis[2-[bis(carboxymethyl)amino]ethyl]amino]acetic acid (DTPA) during sterilization significantly decreased the total GDP content (585 μM vs. 672 μM), mainly due to the decrease of the glucose-oxidation products glucosone (14 μM vs. 61 μM) and glyoxal (3 μM vs. 11 μM), but also of methylglyoxal (14 μM vs. 31 μM). The glucose-dehydration products 3-deoxyglucosone, 3-deoxygalactosone, and 3,4-dideoxyglucosone-3-ene were not significantly affected by chelation of metal ions. Additionally, PDFs were spiked with eleven different metal ions, which were detected as traces in commercial PDFs, to investigate their influence on GDP formation during heat sterilization. Iron(II), manganese(II), and chromium(III) had the highest impact increasing the formation of glucosone (1.2–1.5 fold increase) and glyoxal (1.3–1.5 fold increase). Nickel(II) and vanadium(III) further promoted the formation of glyoxal (1.3 fold increase). The increase of the pH value of the PDFs from pH 5.5 to a physiological pH of 7.5 resulted in a decreased formation of total GDPs (672 μM vs 637 μM). These results indicate that the adjustment of metal ions and the pH value may be a strategy to further decrease the content of GDPs in PDFs.

SP2 Management of ethylene glycol poisoning in an adolescent: a clinical pearl

Situation16 year old girl admitted with suspected ingestion of ethylene glycol. She was treated with fomepizole and continuous renal replacement therapy (CRRT).How the Pharmacy Team ContributedEthanol was prescribed until fomepizole arrived. The volume of ethanol to be administered was calculated wrongly by the consultant due to confusion about the available strength. The Paediatric Intensive Care Unit (PICU) pharmacist intervened and the correct dosage information was given.PICU pharmacist used Toxbase to determine the correct treatment of ethylene glycol poisoning and advised on dosing regime, including adjustment due to CRRT. The pharmacist facilitated prescribing on the electronic system (added drug to system, set up administration instructions and assisted with prescribing – pharmacist was not an Independent Prescriber). This allowed medical staff to concentrate on resuscitation, monitoring cardiac function, inserting intravenous lines and obtaining access for CRRT.The PICU pharmacist and pharmacy technician co-ordinated initial supply of fomepizole. Fomepizole is usually ordered directly from the manufacturer during office hours. The patient presented in the early evening so further supply had to be obtained from a hospital hundreds of miles away after referring to the Rarely Used Medicines list. Pharmacist contacted appropriate on-call pharmacist and arranged for transfer of medicines via courier. Pharmacy technician arranged for further supply form the manufacturer the following day.Pharmacy technician arranged supply of additional dialysis fluids for CRRT due to the higher than usual administration rate.Without contribution from the pharmacy team the patient is likely to have been given the wrong dose of ethanol and fomepizole, and there would have been delay in initiation of treatment followed by an interruption, as it was wrongly assumed that it was kept as stock in the adjoining ‘adult hospital’ and subsequent supply from a local hospital would not have been sought by ward staff until original supply ran out.OutcomeEthylene glycol poisoning was confirmed on laboratory testing. Levels of ethylene glycol fell steadily over 36 hours, allowing CRRT and fomepizole to stop. Patient was discharged from PICU after 48 hours with no apparent long-lasting effects, but was referred to various specialities including renal, gastroenterology and psychology.Patient and family denied knowledge of intentional or accidental ingestion. Police investigation was inconclusive.Lessons to be LearnedLarger supplies of fomepizole are now kept in stock within Health Board. Supplies were missing from emergency cupboards when stock was needed, despite being on stock lists, necessitating courier fees to transfer stock from elsewhere. Procedures reviewed to ensure that stock is available in emergency cupboards at all times.This patient demonstrated that current (target) stock levels of fomepizole were inadequate for providing treatment during CRRT as the required doses are substantially higher (administered every four hours rather than every twelve hours) and would have lasted less than 12 hours for this average sized teenager. National Rarely Used Medicines list was updated to reflect actual stock levels and other hospitals increased their stockholding due to the realisation that existing stock was inadequate and that further supplies were hard to obtain out of working hours.

Increasing the Magnesium Concentration in Various Dialysate Solutions Differentially Modulates Oxidative Stress in a Human Monocyte Cell Line

Oxidative stress is exacerbated in hemodialysis patients by several factors, including the uremic environment and the use of dialysis fluids (DFs). Since magnesium (Mg) plays a key role in modulating immune function and in reducing oxidative stress, we aimed to evaluate whether increasing the Mg concentration in different DFs could protect against oxidative stress in immunocompetent cells in vitro. Effect of ADF (acetate 3 mM), CDF (citrate 1 mM), and ACDF (citrate 0.8 mM + acetate 0.3 mM) dialysates with Mg at standard (0.5 mM) or higher (1, 1.25, and 2 mM) concentrations were assessed in THP-1 monocyte cultures. Reactive oxygen species (ROS) and malondialdehyde (MDA) levels were quantified under basal and uremic conditions (indoxyl sulfate (IS) treatment). Under uremic conditions, the three DFs with 0.5 mM Mg promoted higher ROS production and lipid damage than the control solution. However, CDF and ACDF induced lower levels of ROS and MDA, compared to that induced by ADF. High Mg concentration (1.25 and/or 2 mM) in CDF and ACDF protected against oxidative stress, indicated by reduced ROS and MDA levels compared to respective DFs with standard concentration of Mg. Increasing Mg concentrations in ADF promoted high ROS production and MDA content. Thus, an increase in Mg content in DFs has differential effects on the oxidative stress in IS-treated THP-1 cells depending on the dialysate used.