Challenges and possible solutions to peritoneal dialysis use in Nigeria.

INTRODUCTION: Peritoneal dialysis is a form of renal replacement therapy that is both effective and relatively affordable. Peritoneal dialysis (PD) was first used in Nigeria as a treatment option for renal failure. Its use was first reported in Nigeria in 1969 and became more widespread in the 80s and 90s. Haemodialysis, which is capital intensive to set up and requires infrastructures and facilities such as electricity, intense water consumption and buildings, seems to have upstaged peritoneal dialysis both in demand and supply. METHODS: This cross-sectional study is a convenient survey of nephrologists, renal technicians and nurses in Nigeria. We used a structured, self-administered questionnaire on a cross-section of members and associate members attending a national nephrology association meeting. RESULTS: There were 68(54.4%) doctors, 43(27.2%) nurses, and 14(11.2%) renal technicians, all from medical institutions with renal treatment programs who participated in the study. The most common problems encountered with PD use are financial constraints (51.7%), inadequate fluid supply (50%), frequent line blockage (22.4%) and frequent infections (17.2%). Reasons attributed to the stoppage of PD in the centres included lack of PD fluids (50.8%), unavailability of PD catheters (22.8%), lack of expert personnel to train (15.8%). CONCLUSION: Main challenges to peritoneal dialysis use in Nigeria include limited experience and training and availability and cost of consumables. Effort to overcome the factors militating against its use should be positively pursued so that peritoneal dialysis will be re-integrated into the mainstream of renal replacement therapy once more.

Ensuring Sustainability of Continuous Kidney Replacement Therapy in the Face of Extraordinary Demand: Lessons From the COVID-19 Pandemic.

With the exponential surge in patients with coronavirus disease 2019 (COVID-19) worldwide, the resources needed to provide continuous kidney replacement therapy (CKRT) for patients with acute kidney injury or kidney failure may be threatened. This article summarizes subsisting strategies that can be implemented immediately. Pre-emptive weekly multicenter projections of CKRT demand based on evolving COVID-19 epidemiology and routine workload should be made. Corresponding consumables should be quantified and acquired, with diversification of sources from multiple vendors. Supply procurement should be stepped up accordingly so that a several-week stock is amassed, with administrative oversight to prevent disproportionate hoarding by institutions. Consumption of CKRT resources can be made more efficient by optimizing circuit anticoagulation to preserve filters, extending use of each vascular access, lowering blood flows to reduce citrate consumption, moderating the CKRT intensity to conserve fluids, or running accelerated KRT at higher clearance to treat more patients per machine. If logistically feasible, earlier transition to intermittent hemodialysis with online-generated dialysate, or urgent peritoneal dialysis in selected patients, may help reduce CKRT dependency. These measures, coupled to multicenter collaboration and a corresponding increase in trained medical and nursing staffing levels, may avoid downstream rationing of care and save lives during the peak of the pandemic.

Urgent Peritoneal Dialysis in Patients With COVID-19 and Acute Kidney Injury: A Single-Center Experience in a Time of Crisis in the United States.

At Montefiore Medical Center in The Bronx, NY, the first case of coronavirus disease 2019 (COVID-19) was admitted on March 11, 2020. At the height of the pandemic, there were 855 patients with COVID-19 admitted on April 13, 2020. Due to high demand for dialysis and shortages of staff and supplies, we started an urgent peritoneal dialysis (PD) program. From April 1 to April 22, a total of 30 patients were started on PD. Of those 30 patients, 14 died during their hospitalization, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Although the PD program was successful in its ability to provide much-needed kidney replacement therapy when hemodialysis was not available, challenges to delivering adequate PD dosage included difficulties providing nurse training and availability of supplies. Providing adequate clearance and ultrafiltration for patients in intensive care units was especially difficult due to the high prevalence of a hypercatabolic state, volume overload, and prone positioning. PD was more easily performed in non-critically ill patients outside the intensive care unit. Despite these challenges, we demonstrate that urgent PD is a feasible alternative to hemodialysis in situations with critical resource shortages.

Zero balance ultrafiltration using dialysate during nationwide bicarbonate shortage: a retrospective analysis.

BACKGROUND: Zero balance ultrafiltration (Z-BUF) utilizing injectable 8.4% sodium bicarbonate is utilized to treat hyperkalemia and metabolic acidosis associated with cardiopulmonary bypass (CPB). The nationwide shortage of injectable 8.4% sodium bicarbonate in 2017 created a predicament for the care of cardiac surgery patients. Given the uncertainty of availability of sodium bicarbonate solutions, our center pro-actively sought a solution to the sodium bicarbonate shortage by performing Z-BUF with dialysate (Z-BUF-D) replacement fluid for patients undergoing cardiopulmonary bypass. METHODS: Single-center, retrospective observational evaluation of the first 46 patients at an academic medical center who underwent Z-BUF using dialysate over a period of 150 days with comparison of these findings to a historical group of 39 patients who underwent Z-BUF with sodium chloride (Z-BUF-S) over the preceding 150 days. The primary outcome was the change in whole blood potassium levels pre- and post-Z-BUF-D. Secondary outcomes included changes in pre- and post-Z-BUF-D serum bicarbonate levels and the amount of serum bicarbonate used in each Z-BUF cohort (Z-BUF-D and Z-BUF-S). RESULTS: Z-BUF-D and Z-BUF-S both significantly reduced potassium levels during CPB. However, Z-BUF-D resulted in a significantly decreased need for supplemental 8.4% sodium bicarbonate administration during CPB (52 mEq ± 48 vs. 159 mEq ± 85, P < 0.01). There were no complications directly attributed to the Z-BUF procedure. CONCLUSION: Z-BUF with dialysate appears to be analternative to Z-BUF with sodium chloride with marked lower utilization of intravenous sodium bicarbonate.

Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management.

Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.

The present status of and perspectives on home hemodialysis therapy in Japan.

Home hemodialysis (HHD) is one of the best choices for improving the quality of life and survival rate of dialysis patients because it can lead to longer and more frequent dialysis programs to aid in achieving adequate dialysis. There were 461 dialysis patients treated with HHD as of the end of 2013 in Japan, comprising only 0.1% of all dialysis patients in this country. Although this is a very small expansion rate, the number of HHD patients has been rapidly increasing in recent years. The Japanese Society for Home Hemodialysis was established in 1998 and formed the following 3 working groups to survey various problems underlying current HHD: Patient Registry, Supply and Waste, and Self-pay Burden. In order to achieve a successful HHD program in Japan, there are several issues to be resolved, including the development of standard recruitment and education programs, optimization of the composition of dialysis fluid, sufficient reimbursement for HHD, and the establishment of a business model for HHD similar to that for peritoneal dialysis.

Shortage of Peritoneal Dialysis Solution and the Food and Drug Administration's Response.

Although the number of new drug shortages has been lower in recent years than in the past, severe shortages have occurred that have affected large numbers of patients. A new law entitled the Food and Drug Administration Safety and Innovation Act was enacted in July of 2012, which requires companies to notify the Food and Drug Administration of anticipated shortages. This notification requirement has allowed the Food and Drug Administration to work closely with manufacturers earlier to mitigate and, often, prevent shortages. However, not all shortages are able to be prevented, and the shortage of peritoneal dialysis solution is one that has had a significant effect on patients. The Food and Drug Administration continues to use all available tools to address this shortage with manufacturers, including temporary availability of imported peritoneal dialysis solution from Ireland. Mitigating shortages is a top priority for the Food and Drug Administration, and communication with all stakeholders is essential.

Impact of computerized order entry and pre-mixed dialysis solutions for continuous veno-venous hemodiafiltration on selection of therapy for acute renal failure.

To investigate the impacts of availability of pre-mixed solutions and computerized order entry on nephrologists' choice of the initial mode of renal replacement therapy in acute renal failure. We studied 898 patients with acute renal failure in 3 consecutive eras: era 1 (custom-mixed solution; n = 309), era 2 (pre-mixed commercial solution; n = 324), and era 3 (post-computerized order entry; n = 265). The proportion of patients treated with renal replacement therapy and the time from consult to initiation of continuous renal replacement therapy was similar in the 3 eras. Following introduction of the pre-mixed solution, the proportion of patients treated with continuous renal replacement therapy increased (20% vs. 33%; p < 0.05), it was initiated at a lower serum creatinine (353 ± 123 µmol/L vs. 300 ± 80 µmol/L; p < 0.05) and in older patients (53 ± 12 vs. 61 ± 14 years; p < 0.05). There was a progressive increase in the use of continuous veno-venous hemodialysis (18% vs. 79% vs. 100%; p < 0.05) and in the total prescribed flow rate (1,382 ± 546 vs. 2,324 ± 737 vs. 2,900 ± 305 mL/hr 3; p < 0.05). There was no significant impact on mortality. The availability of a pre-mixed solution increases the likelihood of initiating continuous renal replacement therapy in acute renal failure, initiating it at a lower creatinine and for older patients, use of continuous veno-venous hemodialysis and higher prescribed continuous renal replacement therapy dose. Computerized order entry implementation is associated with an additional increase in the use of continuous veno-venous hemodialysis, higher total prescribed dialysis dose, and use of CRRT among an increasing number of patients not on mechanical ventilation. The effect of these changes on patient survival is not significant.

Comparison of peritoneal dialysis solutions.

The composition of peritoneal dialysis solutions to a great extent, determine their effectiveness and safety. Many of the factors that determine the bioincompatibility of peritoneal dialysis fluids have been recently identified. This knowledge is essential to modify the manufacturing processes and in the quest for more biocompatible solutions. A description of the available peritoneal dialysis fluids in the United States and a comparison of their formulations are provided.

Influencia de factores exógenos en la capacidad de proliferación ex vivo de las células mesoteliales obtenidas de efluente de pacientes tratados con diálisis peritoneal crónica / Influence of different pharmacological agents in the ex vivo proliferation of mesothelial cells obtained from the peritoneal effluent of patients treated with peritoneal dialysis

Las células mesoteliales (CM) constituyen la primera barrera de la membrana peritoneal con lo que contacta el líquido de diálisis. El objetivo de este estudio es explorar in vitro la capacidad de determinados agentes farmacológicos de modificar la proliferación ex vivo de las CM procedentes del efluente peritoneal de pacientes tratados con diálisis peritoneal (DP). Material y Métodos: Se han realizado 30 cultivos de CM procedentes de efluente peritoneal nocturno. Las CM tras su identificación se subcultivan en placas de 24 pocillos a las que se añadieron los agentes seleccionados. La capacidad proliferativa mesotelial se estimó en el día 16º a la vez que se evaluó la morfología celular. Los agentes fueron seleccionados por su potencial influencia en las CM y por ser utilizados en pacientes en DP. Se analizaron los efectos de la insulina, IGF-1, tamoxifeno, labetalol, carvedilol, enalapril y losartán. Resultados: La insulina ejerció un efecto dosis respuesta sobre el crecimiento de CM aumentado por la concentración de suero bovino fetal (SBF). Este efecto cesa a concentraciones de 100 μg/ml, observándose posteriormente un efecto negativo. El IGF-1 no afectó a la proliferación mesotelial. El tamoxifeno solamente afectó a la capacidad proliferativa mesotelial a concentraciones muy elevadas. El labetalol no modifica el crecimiento mesotelial dentro del rango terapéutico, pero a concentraciones de 40 μg/ml muestra una influencia negativa protegida por el incremento en la concentración de SBF y a partir de 100 μg/ml produce un efecto letal sobre la CM. Estos efectos se reproducen con el carvedilol. El enalapril y el losartán se comportaron como agentes antiproliferativos a nivel mesotelial. Este efecto se acentúa en presencia de angiotensina II, siendo letal con dosis crecientes. En conclusión el estudio de los cultivos de CM tomadas del efluente peritoneal de pacientes en DP es útil para analizar los efectos sobre la proliferación celular que pueden tener diferentes agentes administrados a estos pacientes. Los agentes exógenos analizados influyen de diferente manera en la capacidad de proliferación de las células mesoteliales, siendo recomendable investigar la relación de estos hallazgos con lo que realmente ocurre in vivo

Mesothelial cells (MC) are the first peritoneal membrane barrier in contact with dialysate. The aim of this study was to analyze the in vitro capacity of different pharmacological agents to modify the ex vivo proliferation of MC obtained from the peritoneal effluent of patients treated with peritoneal dialysis (PD). Material and Methods: Thirty cultures of MC taken from nocturnal peritoneal effluent were performed. After identification, MC are subcultured in 24 multi-well plates, adding the different exogenous agents. Proliferative capacity and cell morphology were estimated on day 16th of culture. The agents evaluated were insulin, IGF-1, tamoxifen, labetalol, carvedilol, enalapril and losartan. Results: Insulin shows a dose-dependent effect on MC growth, with a limit that is stimulated by the addition of fetal bovine serum (FBS). Concentrations higher than 100 μg/ml, are not associated with further growth, even with cell damage. In contrast, the wide range of IGF-1 dose used did not affect to MC proliferation. Tamoxifen causes negative effects on MC growth just a very high doses, not resembling doses in clinical practice. Labetalol does not modify MC proliferation used under therapeutic calculated range. However, concentrations higher than 40 μg/ml showed a negative influence on growth, behaving as lethal doses that over 100 μg/ml. The addition of FBS attenuates this effect. These effects were very similar to that caused by carvedilol addition. Enalapril and losartan act as antiproliferative agents for MC. This effect is potentiated with angiotensin II, reaching lethal concentrations increasing the dose. In conclusion, mesothelial cell growth ex vivo taken from nocturnal peritoneal effluent on PD patients is an useful tool to explore the effects of any pharmacological agent on the biology of the cell of the peritoneum. The agents used had any influence in the proliferation capacity of mesothelial cells