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.

[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.

Phosphate handling in CKD-MBD from stage 3 to dialysis and the three strengths of lanthanum carbonate.

INTRODUCTION: High phosphate levels are associated with unfavorable outcomes in ESRD. Recent data suggested that phosphate levels within the normal range are equally associated with poor outcomes in the community and CKD stage 3 - 4. Several concept papers support the potential role of phosphate load as a first-line toxin in the beginning of CKD-MBD processes via the activation of FGF23 cascade. Phosphate load is thereafter involved in the progression of vascular calcification (VC) and bone disorder typical of CKD-MBD. AREAS COVERED: Herein the authors cover the recent evidence on the pathophysiology of phosphate handling through the natural history of CKD, with particular emphasis on FGF23 cascade, its potential surrogate markers, VC and bone disorder. The major characteristics of lanthanum carbonate are therefore discussed, focusing on its potential advantages for the treatment of difficult cases in CKD-MBD. EXPERT OPINION: Lanthanum carbonate, being the most potent calcium-free phosphate binder available in clinical practice, could be decisive for those cases where controlling phosphate load is complicated by poor compliance to medications, stubborn high phosphorus intake, extended VC and bone disorders.