Associations, microbiology and outcomes of pre-training peritoneal dialysis-related peritonitis.

BACKGROUND: Pre-training peritonitis (PTP), defined as peritonitis that occurred after catheter insertion and before peritoneal dialysis (PD) training, is increasingly recognized as a risk factor for adverse patient outcomes, yet poorly understood with limited studies conducted to date. This study was conducted to identify the associations, microbiologic profiles and outcomes of PTP compared to post-training peritonitis. METHODS: This single-centre, case-control study involved patients with kidney failure who had PD as their first kidney replacement therapy and had experienced an episode of PD peritonitis between 1 January 2005 and 31 December 2015. Individuals experiencing their first episode of peritonitis were included in the study and categorized according to whether it occurred pre- or post-training. The primary outcome was peritonitis cure rates and composite outcome of hemodialysis (HD) transfer for ≥30 days or death. The secondary outcomes included catheter removal and refractory peritonitis rates. RESULTS: Among 683 patients who received PD for the first time, 121 (17.7%) had PTP while 265 (38.8%) had post-training peritonitis. PTP patients were more likely to have had exit-site infection (ESI) prior to peritonitis (24.8% compared to 17% in the post-training peritonitis group, p = 0.2). Culture-negative peritonitis was significantly more common in the PTP patients (53.7%) than in the post-training group (27.3%, p < 0.001). The cure was achieved in 68.9% of cases and was not significantly different between the PTP and post-training peritonitis groups (66.1% vs. 70.2%; OR 0.83, 95% CI 0.51-1.35). Lower odds of cure were associated with peritonitis caused by moderate and high severity organisms (OR 0.49, 95% CI 0.29-0.85; OR 0.18, 95% CI 0.08-0.43, respectively). Composite outcome of HD transfer or death was more commonly observed among patients with PTP (87.5% vs. 75.8%; OR 2.2, 95% CI 1.20-4.48) in whom significantly shorter median time to HD transfer was observed (PTP 10.7 months vs. post-training peritonitis 21.9 months, p < 0.0001). CONCLUSIONS: PTP is a common condition that is highly associated with preceding ESI, is frequently culture-negative and is associated with worse composite outcome of HD transfer or death. PTP rates should be routinely monitored and reported by PD units for continuous quality improvement.

Early and Late Patient Outcomes in Urgent-Start Peritoneal Dialysis.

BACKGROUND: Significant interest in the practice of urgent-start peritoneal dialysis (PD) is mounting internationally, with several observational studies supporting the safety, efficacy, and feasibility of this approach. However, little is known about the early complication rates and long-term technique and peritonitis-free survival for patients who start PD urgently (i.e. within 2 weeks of catheter insertion), compared to those with a conventional start. METHODS: This single-center, matched case-control study evaluated patients commencing PD between 2010 and 2015. Urgent-start PD patients were matched 1:3 with conventional-start PD controls based on diabetic status and age. The primary outcomes were early complications, both following catheter insertion and PD commencement (within 4 weeks). Secondary outcomes included technique and peritonitis-free survival. RESULTS: A total of 104 patients (26 urgent-start, 78 conventional-start) were included. Urgent-start patients were more likely to be referred late, initiate PD in hospital, and be prescribed lower initial exchange volumes (p < 0.01). They experienced more frequent leaks post-catheter insertion (12% vs 1%, p = 0.047) and more frequent catheter migration following commencement of PD (12% vs 1%, p = 0.047). There were no significant differences in the rates of overall or infectious complications. Kaplan-Meier estimates of technique survival and time to first episode of peritonitis were comparable between the groups. CONCLUSION: Compared with conventional-start PD, urgent-start PD has acceptably low early complication rates and similar long-term technique survival. Urgent-start PD appears to be a safe way to initiate urgent renal replacement therapy in patients without established dialysis access.