Jie Dong

ISPD Catheter-Related Infection Recommendations: 2017 Update

Department of Medicine and Therapeutics,1 Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Nephrology,2 University of Queensland at Princess Alexandra Hospital, Brisbane, Australia; Renal Electrolyte Division,3 University of Pittsburgh School of Medicine Pittsburgh, PA, USA; Renal Division,4 Department of Medicine, Peking University First Hospital, Beijing, China; Pontifícia Universidade Católica do Rio Grande do Sul,5 FAENFI, Porto Alegre, Brazil; Division of Nephrology,6 Nagoya University Graduate School of Medicine, Nagoya, Japan; Division of Nephrology,7 Bezmialem Vakif University, Medical Faculty, Istanbul, Turkey; Pontifícia Universidade Católica do Paraná,8 Curitiba, Brazil; Elisabeth Tweesteden Hospital,9 Nephrology Department and Internal Medicine, Tilburg, Netherlands; and Imperial College Renal and Transplant Centre,10 Hammersmith Hospital, London, UK ISPD GUIDELINES/RECOMMENDATIONS

Daily protein intake and survival in patients on peritoneal dialysis

BACKGROUNDnThe decreased protein intake may lead to protein-energy wasting and poor survival. It is unknown what the appropriate protein intake in patients on peritoneal dialysis (PD) is. We aimed to explore the appropriate levels of daily protein intake (DPI) in favor of outcome in a large PD cohort.nnnMETHODSnOur study enrolled 305 incident patients, who could be followed regularly. Demographic data were collected at baseline. Biochemical, dietary and nutritional data and dialysis adequacy were measured at the baseline and thereafter at regular intervals. Outcome events included all-cause death, cardiovascular disease (CVD) death and first-episode peritonitis.nnnRESULTSnA total of 127 patients died during the 44.5-month follow-up, 41.7% of whom died from CVD. A total of 129 cases first-episode peritonitis were observed. Patients with a high tertile of baseline DPI (≥ 0.94 g/kg/day) had significantly higher serum albumin, prealbumin, hemoglobin, lean body mass and handgrip strength compared to the low tertile group (≤ 0.73 g/kg/day) (P < 0.05-0.001). They also had significantly lower risk for all-cause, CVD death and first-episode peritonitis than the low tertile group adjusted for commonly recognized confounders. Although patients in the middle tertile of DPI (0.74-0.93 g/kg/day) did not show significant differences in the majority of nutritional markers, all-cause and CVD mortality compared to high tertile group, they had a trend to a negative nitrogen balance and similar risk for first-episode peritonitis to the low tertile group. The DPI included as a time-dependent variable could not predict any outcome events in multivariate Cox models.nnnCONCLUSIONSnOur study revealed that DPI <0.73 g/kg/day was associated with protein-energy wasting and worst outcome for PD patients. The DPI >0.94 g/kg/day was in favor of nutrition status and long-term outcome in this population.

The effectiveness of intensive nursing care on seasonal variation of blood pressure in patients on peritoneal dialysis

AIMnu2002 This article is a report of a study to reduce the seasonal variation of blood pressure in patients on peritoneal dialysis through an intensive programme of nursing care.nnnBACKGROUNDnu2002 The seasonal variation of blood pressure is a common phenomenon in patients on maintenance dialysis. Whether or not this variation can be reduced through a given intervention is unknown.nnnMETHODSnu2002 The programme of intensive nursing care including education on volume control, home blood pressure monitoring and intensified antihypertensive treatment, was implemented from December 2006. The blood pressure, fluid and sodium removal and defined daily doses of antihypertensive agents were measured at 1-monthly intervals and averagely quarterly for seasonal values for spring, summer, autumn and winter, respectively, before (December 2005-November 2006) and after intervention (December 2006-November 2007).nnnFINDINGSnu2002 A total of 76 clinically stable patients on peritoneal dialysis were enrolled and finally analysed. The mean age was 60·6 years, and dialysis duration was 23·2 months. Before intervention, there were important seasonal variations in systolic and diastolic blood pressure. After intensive nursing care was implemented, the seasonal variation of systolic blood pressure disappeared. The diastolic blood pressure still represented a season pattern, but the discrepancy between winter and summer decreased. There were no seasonal patterns of total fluid and sodium removal before and after intervention.nnnCONCLUSIONSnu2002 Intensive nursing care reduced the seasonal variation of blood pressure in patients on peritoneal dialysis. These data provided an evidence for implementing nurse-centred interventions in this population.

Peritoneal Protein Leakage, Systemic Inflammation, and Peritonitis Risk in Patients on Peritoneal Dialysis

♦ Background: Whether peritoneal protein leakage predicts risk for peritonitis in patients on peritoneal dialysis (PD) is unknown. In this observational cohort study, we aimed to determine that association and, further, to explore if it might be explained by systemic inflammation. ♦ Methods: We prospectively followed 305 incident PD patients to first-episode peritonitis, censoring, or the end of the study. Demographics, comorbidity score, biochemistry, and peritoneal protein clearance (PrC) were collected at baseline. The predictors of first-episode peritonitis were analyzed prospectively. ♦ Results: During follow-up, 14 868 patient months and 251 episodes of peritonitis were observed. The baseline PrC was 73.2 mL/day (range: 53.2 - 102 mL/day). Patients with a high PrC were prone to be older and malnourished. They also had a higher comorbidity score and higher C-reactive protein values. In 132 first episodes of peritonitis, baseline PrC was shown to be a significant independent predictor after adjustment for age, sex, body mass index, diabetes, residual renal function, hemoglobin, and peritoneal transport rate. Systemic inflammatory markers such as serum albumin, C-reactive protein, and interleukin-6 could not explain the association of PrC and high risk for peritonitis. ♦ Conclusions: Baseline peritoneal protein leakage was able to independently predict risk for peritonitis, which is not explained by systemic inflammation. The underlying mechanisms should be explored in future.

Clinical characteristics and outcomes of peritoneal dialysis-related peritonitis with different trends of change in effluent white cell count: a longitudinal study.

♦ Background: Effluent white cell count (WCC) is among the important prognostic factors for peritonitis outcome, but its trend has never been studied. We aimed to explore the clinical characteristics and outcomes of peritonitis episodes having different trends in effluent WCC change in the first 5 days. ♦ Methods: For each peritonitis episode, we examined the patient’s demographic and biochemical data, serial effluent WCC, and organisms cultured. Peritonitis-associated death and transfer to hemodialysis were defined as treatment failure. ♦ Results: Based on the trend of effluent WCC in the first 5 days, we divided 190 peritonitis episodes into group A (WCC persistently declined), group B (WCC declined after a transient increase), group C (WCC increased after a transient decline), and group D (WCC persistently increased). In group A, peritonitis was caused mostly by gram-positive organisms, and effluent WCC declined the most quickly, leading to a good prognosis. Although the elevation of effluent WCC was prolonged in group B, and the infections were, compared with those in group A, more often caused by gram-negative organisms, outcomes were not worse. In group C, the effluent WCC was more likely to be higher than 100/μL on day 5, and the infection was, compared with those in groups A and B, less likely to be caused by gram-positive organisms. Accordingly, membership in group C independently predicted the worst outcome of peritonitis even adjusted for age, sex, and causative organism. ♦ Conclusions: Different trends of change in effluent WCC during the early stage of peritonitis represent different clinical patterns and outcomes. Further investigation for optimizing outcomes is required.

Disease severity score could not predict the outcomes in peritoneal dialysis-associated peritonitis

BACKGROUNDnWe aim to explore if disease severity score (DSS) at onset is associated with dialysate white cell counts, the severity of causative organisms and the risk for treatment failure of peritoneal dialysis (PD)-associated peritonitis in an adult PD cohort.nnnMETHODSnOur prospective cohort study recorded all peritonitis episodes between 2008 and 2010. The DSS, demographic data and clinical characteristics were recorded at the onset of peritonitis. The dialysate cells were counted at regular intervals and organism culture were examined too. Treatment failure of peritonitis was defined as peritonitis-associated death and transfer to haemodialysis.nnnRESULTSnA total of 219 episodes of peritonitis in 146 PD patients were recorded, 21.9% of which resulted in treatment failure. There were no significant differences in dialysate white cell counts on the fifth and seventh day and the distribution of causative organism between groups with varied DSS level. DSS could not predict treatment failure including peritonitis-related death and transfer to haemodialysis after adjusting for age, gender, diabetes, dialysis duration, dialysate white cell count on the third day, the presence of Staphylococcus aureus, gram-negative organisms and polymicrobial organisms.nnnCONCLUSIONnOur study demonstrated that DSS at onset was not associated with prolonged elevation of dialysate white cell counts, severity of causative organisms and outcome of peritonitis episodes in adult PD patients.

Standardized Outcomes in Nephrology—Peritoneal Dialysis (SONG-PD): Study Protocol for Establishing a Core Outcome Set in PD

Background: Worldwide, approximately 11% of patients on dialysis receive peritoneal dialysis (PD). Whilst PD may offer more autonomy to patients compared with hemodialysis, patient and caregiver burnout, technique failure, and peritonitis remain major challenges to the success of PD. Improvements in care and outcomes are likely to be mediated by randomized trials of innovative therapies, but will be limited if the outcomes measured and reported are not important for patients and clinicians. The aim of the Standardised Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) study is to establish a set of core outcomes for trials in patients on PD based on the shared priorities of all stakeholders, so that outcomes of most relevance for decision-making can be evaluated, and that interventions can be compared reliably. Methods: The 5 phases in the SONG-PD project are: a systematic review to identify outcomes and outcome measures that have been reported in randomized trials involving patients on PD; focus groups using nominal group technique with patients and caregivers to identify, rank, and describe reasons for their choice of outcomes; semi-structured key informant interviews with health professionals; a 3-round international Delphi survey involving a multi-stakeholder panel; and a consensus workshop to review and endorse the proposed set of core outcome domains for PD trials. Discussion: The establishment of 3 to 5 high-priority core outcomes, to be measured and reported consistently in all trials in PD, will enable patients and clinicians to make informed decisions about the relative effectiveness of interventions, based upon outcomes of common importance.

Vitamin D status and mortality risk among patients on dialysis: a systematic review and meta-analysis of observational studies

BackgroundnVitamin D deficiency is highly prevalent in patients on dialysis. Although vitamin D deficiency is closely associated with cardiovascular disease (CVD) and high mortality in the general population, the relationship between serum 25-hydroxyvitamin D [25(OH)D] and all-cause and cardiovascular mortality in dialysis patients is uncertain. We aim to explore the relationship between serum 25(OH)D levels and all-cause and cardiovascular mortality in dialysis patients.nnnMethodsnThis is a systematic review and meta-analysis of clinical studies among patients receiving maintenance dialysis. We did a systematic literature search in PubMed and Embase to identify studies reporting the relationship between serum 25(OH)D levels and all-cause and cardiovascular mortality in patients on dialysis. The search was last updated on 10 February 2017.nnnResultsnThe study included 18 moderate to high-quality cohort studies with an overall sample of 14 154 patients on dialysis. The relative risk of all-cause mortality per 10 ng/mL increase in serum 25(OH)D level was 0.78 [95% confidence interval (CI) 0.71-0.86], although there was marked heterogeneity (I2=96%, P < 0.01) that was partly explained by differences in CVD prevalence, baseline parathyroid hormone level and dialysis duration among included studies. The relative risk of cardiovascular mortality per 10 ng/mL increase in serum 25(OH)D level was 0.71 (95% CI 0.63-0.79), with substantial heterogeneity (I2=74%, P=0.004) that was largely explained by differences in study type and serum 25(OH)D measurement method.nnnConclusionsnIn the present study, increased serum 25(OH)D level was significantly associated with lower all-cause mortality and lower cardiovascular mortality in dialysis patients.

Intraperitoneal Vancomycin Plus Either Oral Moxifloxacin or Intraperitoneal Ceftazidime for the Treatment of Peritoneal Dialysis-Related Peritonitis: A Randomized Controlled Pilot Study.

BACKGROUNDnIntraperitoneal administration of antibiotics is recommended as a first treatment for managing peritoneal dialysis (PD)-related peritonitis. However, the efficacy of oral administration of quinolones has not been well studied.nnnSTUDY DESIGNnRandomized controlled pilot study.nnnSETTING & PARTICIPANTSn80 eligible patients with PD-related peritonitis from Peking University First Hospital (40 in each arm).nnnINTERVENTIONnIntraperitoneal vancomycin, 1g, every 5 days plus oral moxifloxacin, 400mg, every day (treatment group) versus intraperitoneal vancomycin, 1g, every 5 days plus intraperitoneal ceftazidime, 1g, every day (control group).nnnOUTCOMESnThe primary end point was complete resolution of peritonitis, and secondary end points were primary or secondary treatment failure.nnnMEASUREMENTSnPD effluent white blood cell count.nnnRESULTSnBaseline demographic and clinical characteristics of the 2 groups were comparable. There were 24 and 22 Gram-positive organisms, 6 and 7 Gram-negative organisms, 9 and 10 culture-negative samples, and 1 and 1 fungal sample in the treatment and control groups, respectively. Complete resolution of peritonitis was achieved in 78% and 80% of cases in the treatment and control groups, respectively (OR, 0.86; 95% CI, 0.30-2.52; P=0.8). There were 3 and 1 cases of relapse in the treatment and control groups, respectively. Primary and secondary treatment failure rates were not significantly different (33% vs 20% and 10% vs 13%, respectively). In each group, there was 1 peritonitis-related death and 6 transfers to hemodialysis therapy. During the 3-month follow-up period, 7 and 3 successive episodes of peritonitis occurred in the treatment and control groups, respectively. Only 2 adverse drug reactions (mild nausea and mild rash, respectively) were observed in the 2 groups.nnnLIMITATIONSnSample size was relatively small and the eligibility ratio was low. Also, the number of peritonitis episodes was low, limiting the power to detect a difference between groups.nnnCONCLUSIONSnThis pilot study suggests that intraperitoneal vancomycin with oral moxifloxacin is a safe, well-tolerated, practical, and effective first-line treatment for PD-related peritonitis. Larger adequately powered clinical trials are warranted.

Are ACEI/ARBs associated with the decreased peritoneal protein clearance in long-term PD patients?

UNLABELLEDnObjective. Peritoneal protein clearance (PrC) is recognized as a new marker of systemic endothelial dysfunction and predictor of mortality in patients on peritoneal dialysis (PD). Given that angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) could improve endothelial dysfunction in the general population, we aim to explore whether this benefit is present in the PD population.nnnMETHODSnWe analysed data from a PD cohort with data prospectively collected. The PrC, defined daily doses (DDDs) of ACEI/ARBs, as well as other clinical variables were recorded at baseline and then repeatedly measured at 3- to 6-month intervals till to death or censoring. A total of 156 patients were treated with ACEI/ARBs with 0.60 of median time-averaged DDDs, the untreated group consisted of 149 patients who received none of the above drugs during the follow-up.nnnRESULTSnThe baseline and time-averaged PrC were 69.9 ± 34.7 mL/day and 75.2 ± 28.3 mL/day, respectively. Time-averaged PrC was an independent predictor of mortality adjusted for recognized confounders in a multivariate Cox regression model (P = 0.037). There were no significant differences in the time course of PrC (P = 0.82) and peritoneal protein loss (P = 0.83) between the ACEI/ARBs group and the untreated group after adjustment for age, gender, diabetes, baseline C-reactive protein, mean blood pressure and baseline PrC or baseline peritoneal protein loss in the generalized linear mixed model.nnnCONCLUSIONSnWe conclude that ACEI/ARBs did not correlate with a decreased PrC in this observational study. The effect of higher doses of ACEI/ARBs needs to be determined in future interventional studys.