Serum vancomycin levels predict the short-term adverse outcomes of peritoneal dialysis–associated peritonitis

Background: The role of monitoring serum vancomycin levels during treatment of peritoneal dialysis (PD)–associated peritonitis is controversial. Substantial inter-individual variability may result in suboptimal serum levels despite similar dosing of vancomycin. The published predictors of suboptimal serum vancomycin levels remain limited. Methods: Data were retrospectively collected from 541 patients on continuous ambulatory peritoneal dialysis between 1 January 2018 and 31 December 312019. For gram-positive cocci and culture-negative peritonitis, we adopted a vancomycin administration and monitoring protocol. Short-term adverse outcomes of PD-associated peritonitis, including transfer to haemodialysis, death, persistent infection beyond planned therapy duration and relapse, were observed. The association between trough serum vancomycin levels and short-term adverse outcomes was evaluated. Results: Intraperitoneal vancomycin was used in 61 gram-positive cocci or culture-negative peritonitis episodes in 56 patients. Fourteen episodes of short-term adverse outcomes occurred in 12 patients, whose average trough serum vancomycin levels on day 5 of treatment were significantly lower than those who didn’t experience any adverse outcomes (8.4 ± 1.7 vs 12.5 ± 4.3 mg/L, p = 0.003). In gram-positive cocci or culture-negative peritonitis patients, those with higher day 5 trough serum vancomycin levels had a lower risk of short-term adverse outcomes (odds ratio: 0.6, 95% confidence interval: 0.4 to 0.9, p = 0.011). Receiver operating charecteristic curve (ROC) analyses showed that the day 5 trough serum vancomycin levels diagnostic threshold value for short-term adverse outcomes was 10.1 mg/L. After adjustments for gender, exchange volume and residual kidney function (RKF), baseline higher peritoneal transport was associated with a suboptimal (<10.1 mg/L) day 5 serum vancomycin level. Conclusions: Serum vancomycin levels are correlated with short-term adverse outcomes of PD-associated peritonitis, and higher peritoneal solute transport status is associated with suboptimal trough serum vancomycin levels on day 5.

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.

High versus low ultrafiltration rates during experimental peritoneal dialysis in rats: Acute effects on plasma volume and systemic haemodynamics

Introduction: Intradialytic hypotension is a common complication of haemodialysis, but uncommon in peritoneal dialysis (PD). This may be due to lower ultrafiltration rates in PD compared to haemodialysis, allowing for sufficient refilling of the blood plasma compartment from the interstitial volume, but the underlying mechanisms are unknown. Here we assessed plasma volume and hemodynamic alterations during experimental PD with high versus low ultrafiltration rates. Methods: Experiments were conducted in two groups of healthy Sprague-Dawley rats: one group with a high ultrafiltration rate ( N = 7) induced by 8.5% glucose and a low UF group ( N = 6; 1.5% glucose), with an initial assessment of the extracellular fluid volume, followed by 30 min PD with plasma volume measurements at baseline, 5, 10, 15 and 30 min. Mean arterial pressure, central venous pressure and heart rate were continuously monitored during the experiment. Results: No significant changes over time in plasma volume, mean arterial pressure or central venous pressure were detected during the course of the experiments, despite an ultrafiltration (UF) rate of 56 mL/h/kg in the high UF group. In the high UF group, a decrease in extracellular fluid volume of −7 mL (−10.7% (95% confidence interval: −13.8% to −7.6%)) was observed, in line with the average UF volume of 8.0 mL (standard deviation: 0.5 mL). Conclusion: Despite high UF rates, we found that plasma volumes were remarkably preserved in the present experiments, indicating effective refilling of the plasma compartment from interstitial tissues. Further studies should clarify which mechanisms preserve the plasma volume during high UF rates in PD.

Neobladder creation is still a conduit to peritoneal dialysis – Successful use of peritoneal dialysis after invasive bladder cancer

Peritoneal dialysis (PD) is as safe and more cost-effective than haemodialysis (HD). It also allows patients to undergo renal replacement therapy (RRT) from home. However, PD remains underutilised in many parts of the world. This is true in part because of many perceived relative contraindications to PD, including a history of prior major abdominal surgery. Prior major abdominal surgery is a concern for standard bedside or surgical catheter placement since these patients are at risk of having adhesions, which can complicate catheter placement. However, with laparoscopic advancements, prior major abdominal surgery is no longer even a relative contraindication to PD for skilled and experienced surgeons. We report the case of a male in his 70s with a history of cystoprostatectomy which was curative for a muscle invasive bladder carcinoma 5 years prior to his RRT. The patient had longstanding chronic kidney disease which worsened gradually. After receiving RRT education, the patient favoured PD. The catheter was placed despite the surgeon noting abdominal adhesions and the patient successfully underwent 12 months of PD which had a positive impact on his quality of life. He transferred to HD after contracting a complex PD-associated peritonitis. Thus, new research should be conducted to better understand the real impact of prior abdominal surgeries as a contraindication to PD, especially in centres where the surgeons have experience with advanced laparoscopy.

The effect of radiological imaging on treatment delay and hospitalisation in patients with peritoneal dialysis-related peritonitis: A secondary analysis of the PROMPT study

Background: In peritoneal dialysis-related peritonitis (peritonitis), delayed antibiotic therapy is associated with adverse outcomes. Identifying barriers to timely treatment may improve outcomes. Aim: To determine the impact of radiological investigations on treatment delay and predictors of hospitalisation and length of stay (LOS). Methods: Retrospective review of patients with presumed peritonitis in Western Australia. Results: In 153 episodes of peritonitis, 79 (51.6%) resulted in admission with a median LOS of 3 days (Q1, Q3: 1, 6). In a multivariable model, significant predictors of admission were abnormal exit-site (odds ration (OR) 5.7; 95% confidence interval (CI): 1.4, 23.6; p = 0.02), failure to detect a cloudy bag (OR 11.9; 95%CI: 3.2, 44.7; p < 0.001), female sex (OR 3.3; 95% CI: 1.4, 9.7; p = 0.027), radiological imaging within 24 h (OR 8.8; 95% CI: 2.2, 34.8; p = 0.002) and contact with ambulant care facility (OR 0.32, 95% CI: 0.11, 0.98; p = 0.04). Imaging within 24 h of presentation occurred in 41 (27%) episodes of peritonitis, mostly plain X-rays (91%), of which 83% were clinically irrelevant. Imaging performed within 24 h of presentation increased the median time to antibiotic treatment (2.9 h (Q1, Q3: 1.6, 6.4) vs 2.0 h (Q1, Q3: 1, 3.8; p = 0.046)). Imaging performed prior to administering antibiotics significantly increased the median time to treatment (4.7 h (Q1, Q3: 2.9, 25) vs 1.5 h (Q1, Q3: 0.75, 2.5; p < 0.001)) in those where imaging followed antibiotic treatment. Conclusions: Half of all presentations with peritonitis result in hospital admission. Radiological imaging was associated with an increased risk of hospitalisation, potentially contributes to treatment delay, and was mostly clinically unnecessary. When required, imaging should follow antibiotic therapy.

Development of an instrument to assess self-management capacity of patients receiving peritoneal dialysis: CAPABLE

Background: Treatment of kidney failure with peritoneal dialysis (PD) at home implies that the patient and/or their caregiver develop a series of skills and basic knowledge about this therapy. There is not a specific inventory of the patient’s abilities to safely perform the PD procedure at home. The objective of this study was to describe the development of an instrument that allows measuring the self-management capacity of patients receiving PD, locating the performance areas that justify the need for intervention by a caregiver. Methods: This is a qualitative study developed in three phases: The first phase was the identification of performance areas through bibliographic search and validation of the results with focus groups of experts in PD. The second phase was the design of a system to measure self-management capacities. The third phase was a pilot test of the preliminary version of the instrument applied in 20 incident PD patients. Results: Three domains were identified to evaluate the fundamental components of self-management capacity: cognitive and sensory, each one evaluated with four items and motor domain evaluated with eight items. After applying the instrument, we found that 15 patients (75%) did not require support from the caregiver in any of the items. PD patients and nurses found the tool valuable, easy to understand and applicable in the early evaluation of a PD patient. Conclusions: We developed an easy-to-administer instrument to measure the self-management capacity of patients receiving PD. This inventory could locate areas that require specific support from a caregiver. Planning an individualised and focused education and training process could result in better health outcomes.

Peritoneal dialysis in very low and extremely low birthweight infants: A pooled analysis

Background: Peritoneal dialysis (PD) represents an important therapeutic option in neonatal acute kidney injury (AKI), although evidence regarding its effects in preterm neonates remains unclear. The present study aims to evaluate the feasibility of PD in very low birthweight (VLBW) and extremely low birthweight (ELBW) infants and clarify the association of catheter choice with clinical outcomes. Methods: Medline, Scopus, Web of Science, Clinicaltrials.gov and CENTRAL databases were systematically searched from inception to 15 January 2021. Studies reporting individual participant data of VLBW and ELBW infants treated with PD were selected. Results: Overall, 20 studies were included comprising 101 patients. Catheter-related complications were significantly more frequent among ELBW infants (odds ratio: 5.18, 95% confidence intervals (CI): 1.23–29.09). After inverse probability treatment weighting, compared to drainage catheters, death risk was significantly lower with the use of PD (hazard ratio: 0.42, 95% CI: 0.19–0.90) but not vascular catheters (hazard ratio: 0.58, 95% CI: 0.28–1.20). Similarly, kidney function loss was significantly lower only with the implementation of PD catheters (hazard ratio: 0.44, 95% CI: 0.21–0.94). Conclusions: PD is a feasible kidney replacement therapy modality in VLBW and ELBW infants with AKI. The use of drainage catheters may be linked to significantly worse kidney recovery and overall survival rates, compared to PD catheters. Future cohorts should confirm the most appropriate catheter type and contribute to the standardisation of PD procedures.

Feasibility of percutaneous endoscopic gastrostomy insertion in children receiving peritoneal dialysis

Background: Peritoneal dialysis (PD) is the preferred dialysis modality for paediatric patients with end-stage kidney disease. Frequently, malnutrition is encountered. Percutaneous endoscopic gastrostomy (PEG) is the preferred mode of feeding because of its minimal invasive mode of placement and easy handling in daily life. However, reports of a high risk for early post-interventional peritonitis hampered this procedure during PD and controlled studies on the benefit of peri-interventional management to prevent peritonitis are lacking. Here, we report the safety profile of PEG insertion among a cohort of children on PD by using a prophylactic antibiotic and antifungal regimen as well as modification of the PD programme. Methods: We performed a single-centre analysis of paediatric PD patients receiving PEG placement between 2015 and 2020. Demographic data, peri-interventional prophylactic antibiotic and antifungal treatment as well as modification of the PD programme were gathered and the incidence of peritonitis within a period of 28 days after PEG was calculated. Results: Eight PD patients (median weight 6.7 kg) received PEG insertion. Antibiotic and antifungal prophylaxis were prescribed for median time of 4.0 and 5.0 days, respectively. After individual reduction of PD intensity, all patients continued their regular PD programme after a median of 6 days. One patient developed peritonitis within 24 h after PEG insertion and simultaneous surgery for hydrocele. Conclusions: Applying an antibiotic and antifungal prophylactic regime as well as an adapted PD programme may reduce the risk for peritonitis in paediatric PD patients who receive PEG procedure.