Fungal peritonitis in peritoneal dialysis: a 34-year single centre evaluation.

BACKGOUND: Fungal peritonitis (FP) is one of the most important causes of peritoneal dialysis (PD) failure, often burdened by increased morbility and mortality. This study evaluates the clinical course of FP cases that arose between 1983 and 2016 in a single PD unit. METHODS: We conducted a retrospective observational analysis of FP episodes recorded in the Baxter POET (Peritonitis Organism Exit sites Tunnel infections) registry and clinical records. FP incidence rate, PD and patients' survival and clinical characteristics of the study population were analysed, taking into account the evolution of clinical practice during the study period as a result of technical innovation, scientific evidence and guideline history. RESULTS: Fourteen FP cases (2.8%) were detected. The overall incidence of PD peritonitis was one episode/27 patient-months. Candida parapsilosis was the most frequently (50%) detected yeast. Seventy-five per cent of cases were considered secondary FP. This group experienced 2.6±1.7 bacterial peritonitis before FP, most frequently due to Staphylococcus and Enterococcus species. Most patients were treated with fluconazole for ≥8 days. All subjects were hospitalized for a median time of 25 days. Tenckhoff catheter removal occurred in all cases of FP and all patients were transferred to haemodialysis. Two patients died. From December 2010 to December 2016, no FP episodes were recorded. CONCLUSIONS: FP is confirmed as a significant cause of PD drop out and increases patients' mortality risk. Prompt diagnosis of FP, targeted antifugal therapy and rapid PD catheter removal are essential strategies for improved patient and PD survival.

Laparoscopic Surgery in Patients on Peritoneal Dialysis: A Review of the Literature.

Peritoneal dialysis (PD) is an effective renal replacement therapy for the treatment of end-stage renal disease. Patients on PD undergoing abdominal open surgery often fail to resume PD. Laparoscopic surgery has recently become a serious alternative to open surgery in patients on PD to treat different abdominal pathologies. However, only a few studies have reported successful procedures without Tenckhoff catheter removal. The aim of this review is to describe how a laparoscopic technique can allow PD patients to deal with abdominal surgery without shifting to hemodialysis. Only 50 cases of laparoscopic surgical intervention in PD patients have been published to our knowledge. These case series largely concern laparoscopic cholecystectomies, appendectomies, nephrectomies, colectomies, and bariatric procedures. The reported cases show how laparoscopic surgery can be accepted as a valid option for several abdominal surgical procedures in patients on PD with good outcomes and early resumption of PD.

Laparoscopic Left Hemicolectomy for Colon Cancer in Peritoneal Dialysis Patients: A Valid and Safe Surgical Technique to Ensure Peritoneal Dialysis Survival.

A laparoscopic approach represents an effective alternative to open surgery in patients undergoing peritoneal dialysis (PD). In these patients, conventional thinking provides for removal of the peritoneal catheter during left colon resections because of higher risk of patient contamination and peritonitis. The present paper describes 3 cases of laparoscopic left hemicolectomy for colon cancer performed in PD patients without complications and without peritoneal catheter removal, leading to subsequent early PD resumption.Three normotype PD patients affected by early-stage sigmoid colon adenocarcinoma (T1-T2, M0, N0) underwent integrated surgical and nephrological management to reduce peritoneum stress, infective risk and postoperative complications. The day before surgery, patients were shifted to isovolumetric hemodialysis through tunneled central venous catheter. All patients underwent laparoscopic left hemicolectomy without Tenckhoff catheter removal. The postoperative period was uneventful, with concomitant antibiotic prophylaxis until the fifth day after surgery. Flushing of the PD catheter was performed twice a week postoperatively. Peritoneal dialysis was recovered 4 weeks after surgery in 2 cases with a well-maintained dialytic adequacy. One patient did not proceed to PD due to improvement of renal function after surgery.In selected PD patients, a minimally invasive surgical approach combined with careful nephrological management may represent a valid and safe strategy to treat early-stage colon cancer, avoiding PD drop-out.

[Phosphate binders in renal patients: a point estimate from rationale, through evidences to the real world setting]. / Quali risultati abbiamo ottenuto sino a oggi con i chelanti del fosforo? Razionali, evidenze e mondo reale.

Phosphate binders represent a common intervention in renal patients affected by chronic kidney disease and mineral bone disorder (CKD-MBD). Although counteracting P overload through binders adoption is argued by a physiology-driven approach, the efficacy of this intervention on hard endpoints remains poorly evident. The inconsistencies between rationale and methodological weakness, concerning the clinical relevance of P binding in chronic kidney disease, will be herein discussed with special focus on the need of a multi-factorial treatment against CKD-MBD, which is currently more achievable due to the variety of P binders and the rapid evolution of nutritional therapy, dialysis techniques and nursing science.

[Quality end of life in uremic patients: theory and practice]. / Qualità del fine vita nel paziente uremico: dalla teoria alla pratica.

The rate of fragile elderly patients affected by chronic kidney disease stage 5-5D is rapidly increasing. The decision making process regarding the start and the withdrawal of dialysis is often difficult for all those involved: patients, relatives, nephrologists and renal nurses. Therefore nephrologists and renal nurses are called to rapidly improve their theoretical and practical competence about the end-of-life care. The quality of clinical intervention and management requires a sound expertise in the ethical, legal, organizational and therapeutic aspects, not trivial nor even deductible from purely private and individual opinions nor from traditional medical practice. The present paper discusses the ethical and legal implications related to the start rather than to withdrawn from dialysis, preferring a non-dialysis medical treatment and / or palliative care. Operational aspects regarding the regional network of palliative care, the path of shared decision making process and a systematic approach to optimize medical and nursing interventions through the Liverpool Care Pathway program are discussed thereafter.

The interview with a patient on dialysis: feeling, emotions and fears.

This study has been performed in the Nephrology and Dialysis Unit, in Desio Hospital, Italy. The aim of this study is to evaluate, starting from research questions, which information is given to patient in the pre-dialysis colloquia for his/her chosen dialysis methods. Moreover, the study evaluated feelings, emotions and fears since the announcement of the necessity of dialysis treatment. The objective of the study was reached through the interview with patients on dialysis. The fact-finding survey was based on the tools of social research, as the semi-structured interview. Instead of using the questionnaire, even though it make it easier to collect larger set of data, the Authors decided to interview patients in person, since the interview allows direct patient contact and to build a relationship of trust with the interviewer, in order to allow patient explain better his/her feeling.

[Treatment of atrial fibrillation in dialyzed patients: the role of oral anticoagulants. The nephrologist's point of view]. / Terapia della fibrillazione atriale nei pazienti dializzati: ruolo degli anti coagulanti orali. Il punto di vista del nefrologo.

Atrial fibrillation is the most frequent arrhythmia in patients on dialysis. Whereas it is associated with a higher thromboembolic risk in the general population, this association has not been unequivocally confirmed in dialysis patients. Furthermore, the potential benefits of oral anticoagulant therapy in uremia have been recently reviewed, given the increased risk of bleeding in these patients. Cardiologic guidelines to guide the choice of oral anticoagulant therapy by stratifying the thromboembolic and hemorrhagic risks were developed in the general population and their generalization to dialysis patients has not been validated. This paper will discuss the association between atrial fibrillation and thromboembolic risk in dialysis, presenting some strategies to evaluate the risk-benefit balance of oral anticoagulant therapy in dialysis patients affected by atrial fibrillation.

Severe reversible acute renal failure in idiopathic nephrotic syndrome.

BACKGROUND: Only few cases of acute renal failure (ARF) requiring dialysis have been reported in patients with idiopathic nephrotic syndrome (NS). This study aims to better define the clinical outcome and treatment of this condition. METHODS: A pilot enquiry regarding the occurrence of ARF requiring dialysis in patients with NS and biopsy proven minimal changes (MC) or focal segmental glomerulosclerosis (FSGS) was conducted among 5 nephrology centers. RESULTS: From 1996-2006, 6 patients with idiopathic NS (4 MC, 2 FSGS) developed ARF requiring dialysis early after onset of NS. At presentation all but 1 patient had elevated blood pressure. Patients were treated with dialysis from 7-40 days. All achieved complete or partial remission after 4-8 weeks of steroids. Recovery of renal function paralleled with the reduction of proteinuria. At renal biopsy proximal tubules showed a large amount of protein droplets, flattening of epithelial cells, and focal detachment of cells from the basal membrane. After a follow-up of 24-60 months, 5 patients had a relapse. Of these 4 were responsive to steroids, while one progressed to dialysis after an episode of hemolytic uremic syndrome related to cyclosporine treatment. ARF did not recur. CONCLUSION: ARF requiring dialysis is a rare and unexpected complication of idiopathic NS occurring in most cases early after presentation. These patients are sensitive to steroids that should be administered as promptly as possible in view of the potential noxious effect of protein overload on proximal tubular cells.

What is the link between poor ultrafiltration and increased mortality in anuric patients on automated peritoneal dialysis? Analysis of data from EAPOS.

BACKGROUND: Primary analysis of the European Automated Peritoneal Dialysis Outcomes Study (EAPOS) found that patients with daily ultrafiltration (UF) below a predefined target of 750 mL at baseline experienced increased mortality and continuing low UF over 2 years. SETTING: Multicenter, prospective observational study of prevalent, functionally anuric patients on automated peritoneal dialysis (APD) treated to predefined standards. METHODS: Secondary data analysis to determine clinical covariates that might support a link between poor UF and outcome, including pattern of comorbidity, prescription, nutrition as determined by Subjective Global Assessment (SGA), membrane function, and blood pressure (BP). Ultrafiltration was treated as a categorical (comparing patients above and below target at baseline) and continuous dependent variable in univariate and multivariate regression. The relationship between BP and survival was also explored. RESULTS: Of 177 patients recruited from 28 centers across Europe, 43 were below the UF target at baseline. Compared to those above target, there were no differences in the spread of comorbidity, type of APD prescription, SGA, BP, hemoglobin, HCO3, or parathyroid hormone, at baseline or at any later time. At baseline, plasma calcium and, at 12 months, plasma phosphate were lower in the low UF group. There was a weak positive correlation between baseline systolic or diastolic BP and UF, which remained on multivariate analysis but accounted for just 9% of the variability in BP. There was no clear relationship between baseline BP and survival, although, if anything, low BP was associated with earlier death. Poor UF was associated with lower mean dialysate glucose concentration during the first 4 months and with consistently worse membrane function. CONCLUSIONS: The increased mortality associated with poor UF is likely multifactorial and not easily explained by clear differences in comorbidity, nutritional state, or other indices of treatment at baseline. The lower plasma phosphate suggests a subsequent fall in appetite. Poor BP control is unlikely to be the explanation, and a link between lower BP, reduced UF, and earlier death is suggested. Failure to achieve adequate UF due to worse membrane function remains an important and potentially reversible or preventable cause.

The efficacy and safety of once-weekly and once-fortnightly subcutaneous epoetin beta in peritoneal dialysis patients with chronic renal anaemia.

BACKGROUND: Reducing the dosage frequency of subcutaneous epoetin in peritoneal dialysis (PD) patients is convenient and should improve patient satisfaction and, possibly, compliance. We investigated if a weekly dosage of epoetin beta in PD patients safely maintained haemoglobin (Hb) concentrations equivalent to those obtained with previous twice- or thrice-weekly administration. In addition, we investigated if a fortnightly dosage of epoetin beta was safe and as effective as previous weekly administration. METHODS: After a 4 week run-in period, PD patients were switched to either weekly or fortnightly epoetin beta administration, depending on their previous treatment schedules, for 25 weeks. RESULTS: The per-protocol cohort included 128 patients, of whom 54 received epoetin beta once weekly and 74 once fortnightly. The mean change in Hb concentration from baseline over weeks 13-25 and the 90% confidence intervals (CIs) remained within the target range (10-12 g/dl) and specified equivalence (+/-0.75 g/dl) limits in the weekly (-0.34 g/dl; 90% CI: -0.14 to -0.54 g/dl) and fortnightly (-0.39 g/dl; 90% CI: -0.24 to -0.55 g/dl) cohorts. The mean change from baseline in the epoetin beta dose was 1.4 IU/kg/week (90% CI: -3.8 to 6.6 IU/kg/week; 2%) in the weekly cohort and 4.4 IU/kg/week (90% CI: 1.7-7.2 IU/kg/week; 13%) in the fortnightly cohort. Both treatment regimens were well tolerated. CONCLUSIONS: In stable PD patients switched from twice- or thrice-weekly to weekly epoetin beta treatment, Hb concentrations could be maintained within the specified range over 25 weeks without significant change in their mean epoetin beta doses. In patients switched from weekly to fortnightly treatment, Hb concentrations could also be maintained over 25 weeks. There was a small increase in the mean dose during this period, but >/=50% of patients could be maintained without dose increase. Reducing dosage frequency may improve compliance in PD patients who self-administer their epoetin.

Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trial.

BACKGROUND: In chronic nephropathies, inhibition of angiotensin-converting enzyme (ACE) is renoprotective, but can further renoprotection be achieved by reduction of blood pressure to lower than usual targets? We aimed to assess the effect of intensified versus conventional blood-pressure control on progression to end-stage renal disease. METHODS: We undertook a multicentre, randomised controlled trial of patients with non-diabetic proteinuric nephropathies receiving background treatment with the ACE inhibitor ramipril (2.5-5 mg/day). We randomly assigned participants either conventional (diastolic <90 mm Hg; n=169) or intensified (systolic/diastolic <130/80 mm Hg; n=169) blood-pressure control. To achieve the intensified blood-pressure level, patients received add-on therapy with the dihydropyridine calcium-channel blocker felodipine (5-10 mg/day). The primary outcome measure was time to end-stage renal disease over 36 months' follow-up, and analysis was by intention to treat. FINDINGS: Of 338 patients who were randomised, three (two assigned intensified and one allocated conventional blood-pressure control) never took study drugs and they were excluded. Over a median follow-up of 19 months (IQR 12-35), 38/167 (23%) patients assigned to intensified blood-pressure control and 34/168 (20%) allocated conventional control progressed to end-stage renal disease (hazard ratio 1.00 [95% CI 0.61-1.64]; p=0.99). INTERPRETATION: In patients with non-diabetic proteinuric nephropathies receiving background ACE-inhibitor therapy, no additional benefit from further blood-pressure reduction by felodipine could be shown.

Intraperitoneal hydrostatic pressure and flow characteristics of peritoneal catheters in automated peritoneal dialysis.

BACKGROUND: In automated peritoneal dialysis (APD) one of the most important factors that influence the efficiency of the treatment is the total volume of dialysate infused per session and the dwell time. This study is aimed at examining the relationships between i.p. pressure (IPP), dialysate flow characteristics, and different dialysate fill volumes in order to optimize APD. METHODS: We studied 20 patients who received APD, with the standard fill volume (2 l, A), or individualized fill volumes based on the patient's body surface area (2.5 l/BSA/1.73 m, B) or on body weight (40 ml/kg body weight, C). The patient's tolerance to a given fill volume was evaluated by measuring IPP, and catheter flow characteristics were evaluated by an automated machine. RESULTS: IPP increased with the increase of the infused volume of dialysate (P < 0.05) and tended towards a positive relationship with the patient's body mass index (BMI: A vs IPP: R = 0.39, P = 0.0019; B vs IPP: R = 0.66, P = 0.0012; C vs IPP R = 0.55, P = 0.009). We also found a relationship between fill volume, BMI and IPP: IPP = 1.0839 + 0.53 (beta) x BMI + 0.211 (beta) x fill volume (R = 0.65; r(2) = 0.40 P < 0.01). The mean IPP with different dialysate fill volumes tended to be related to the volume of dialysate drained at the transition point (R = 0.37; P < 0.05). The pre-transition flow rate/mean IPP ratio tended towards a positive relationship with the volume of dialysate drained at the transition point (R = 0.35, P < 0.05), the transition time (R = 0.34; P < 0.05) and a negative one with the transition volume (R = -0.35, P = 0.05). CONCLUSION: It is possible to customize APD, where the tidal percentage coincides with the transition point for a given catheter and a specific initial dialysate fill volume, the tolerance of which can be measured by assessing IPP.