Peritoneal Dialysis in Figures

 

References:
Peritoneal Dialysis Prescription and Adequacy in Clinical Practice: Core Curriculum 2023

Special post by 

Lakshmi Kannan, MBBS, MD, 

Department of Nephrology, Pikeville Medical Center

Adjunct Faculty, University of Pikeville Kentucky College of Osteopathic Medicine

Kentucky, USA

2020: What a year for Nephrology

As we enter the end of 2020( finally), we are starting to see some hope for the vaccines as a lifeline as we enter the rising COVID-19 surge.  For nephrology, 2020 has been a positive and negative year. 

Let's start with the negatives:
1. Covid19 led to development of more AKI than we had imagined and several of those patients dying as a result. Very few survived the RRT-related AKI
2. Our dialysis patients had a tough battle leading to an increased mortality
3. Many transplant centers were on hold and several on the wait list had a high mortality and so did some of our transplant patients.
4. All conferences and meetings were virtual( taking away the networking opportunity for many)
5. All fellowship interviews went virtual( hard to assess candidates candidly)
6. Research ( non covid19) came to a halt and or was interrupted 

But there is a silver lining to the COVID19 pandemic for nephrology:

1. Increased data and outcomes research on AKI as a result of the pandemic
2. Rise of HOME dialysis ( which was dormant for years) came more to the forefront( including acute PD)
3. Rise of the Nephrologists as front line COVID19 warriors leading to perhaps more applications this year
4. SGLT2i studies infiltrating NEJM multiple times making a mark on diabetic and non diabetic kidney disease
5. Novel therapeutics in autoimmune renal diseases are on a rise
6. Virtual conferences allowed for more quicker and swifter transfer of knowledge ( and more attendance)
7. Collaboration on research rose super fast with trials such as STOP-COVID
8. Gender and Ethnic diversity was evident in Kidney week this year and kept it's strength in 2020
9. More incentives and compensations increases for nephrologists will reign in 2021
10. Increase interest in subspecialization in Nephrology 

Topic Discussion: ESRD patients and COVID-19

While we saw several rising cases of AKI associated with COVID-19, the ESKD population was also vulnerable to this virus. With COVID-19, we didn't know if we would see worsening effects on ESRD or beneficial ( given a not so robust immune system in ESRD).  But the proximity and being in a closed dialysis unit did put most of them at risk. 

Studies from China and Europe on ESKD patients with COVID-19 were limited to small numbers and single centers. One of the first studies from US from CUMC was limited by less then 100 patients as well. It did show poor outcomes of 59 patients where 31% had died.

A Study from UK did discuss the concerns for an urban dialysis center ( on risk of hospitalizations). Of 1530 patients (median age 66 years; 58.2% men) receiving dialysis, 300 (19.6%) developed COVID-19 infection, creating a large demand for isolated outpatient dialysis and inpatient beds. An analysis that included 1219 patients attending satellite dialysis clinics found that older age was a risk factor for infection. COVID-19 infection was substantially more likely to occur among patients on in-center dialysis compared with those dialyzing at home. 

A study from the Bronx in NY also showed poor outcomes for hospitalized ESKD patients. Elevated inflammatory markers were associated with in hospital death.

Another UK study also found a high prevalence of seropositivity in the outpatient dialysis units. 

Alberici et al.describe their clinical experience with MHD patients cared for at 4 outpatient dialysis facilities that are part of the Brescia Renal COVID Task Force. In a period of 1 month, viral positivity was detected in 94 of their 643 ESRD HD patients (15%). Important findings in the study were the mild form of symptomatology at presentation, the high rate of overall mortality (29%), and emergence of usual risk factors for mortality and acute respiratory distress syndrome in SARS-CoV-2–positive HD patients. In addition, although certain patients were deemed more stable and were managed in the outpatient facility, 3 of those subsequently died, and a substantial portion had significant worsening of their symptoms.

Goicoechea et al. describe the clinical course and outcomes of 36 patients from 2 dialysis facilities caring for 282 patients that were admitted to a tertiary hospital in Madrid based on positive reverse transcription polymerase chain reaction for SARS-CoV-2. They report a mortality rate of 30.5%, and 33% of their patients required mechanical ventilation. 

At our health system of over 23 hospitals in NY, we decided to compare the outcomes of ESKD patients to non ESKD patients. The data was from 13 hospitals and our final cohort had 419 (4%) with ESKD and 10,063 (96%) without ESKD.This is the largest study to date.

What did we find:( similar tweetorial by first author Jia Ng)

I want to share our new paper “Outcomes of patients with ESKD hospitalized with COVID-19”. @kidney_int @hofstrakidney @hofstramed @jam_hirsch @rimdamyeloma @mala_sachdeva @sfishbane @kdjhaveri Susana Hong

https://t.co/B2jd3RO4lt
[THREAD] pic.twitter.com/4S03hTRHAo

— Jia Hwei Ng, MD, MSCE (@jiahweing) August 16, 2020

1. Patients with ESKD were older, had a greater percentage self-identified as Black, and more comorbid conditions.

2. Patients with ESKD had a higher rate of in-hospital death than those without (31.7% vs 25.4%), odds ratio 1.38, 95% confidence interval 1.12 - 1.70). This increase rate remained after adjusting for demographic and comorbid conditions (adjusted odds ratio 1.37, 1.09 - 1.73).

3. Patients with ESKD had similar rates of mechanical ventilation as those without ESKD (89 [21.2%] vs 2076 [20.6%]). There was no difference in the odds of mechanical ventilation between the groups.

4. The odds of length of stay of seven or more days was higher in the group with compared to the group without ESKD in both the crude (1.62, 95%CI 1.27 - 2.06) and in the adjusted analysis (1.57, 95% 1.22 - 2.02)

5. We conducted stratified analyses to investigate the risk factors of death in the subgroups of ESKD and the non-ESKD separately, with the hypothesis that the risk factors of death and the magnitude of risk factors would differ between the two groups.

6. For patients without ESKD, the independent risk factors for in-hospital death increased age, male sex, cardiovascular disease, cancer, requiring ventilation, requiring vasoactive meds, high blood urea nitrogen, low albumin, high CRP and high ferritin.

7. The diagnosis of hypertension and use of an ACE inhibitor or ARB were associated with a lower risk of in-hospital death in the non-ESKD group.

8. Among patients with ESKD, independent risk factors for in-hospital death were increased age, requiring ventilation and lymphopenia, elevated BUN and high serum ferritin. Black race was associated with a significantly lower risk of death among patients with ESKD.

9. The protective effect of HTN in the non-EKSD group, and the protective effect of Black race in the ESKD group defy easy explanation. Perhaps APOL1 has some protective cardiac effect?

10. This is a large cohort of hospitalized patients with #COVID-19 comparing ESKD and non-ESKD in a diverse patient population. We had prespecified operational definitions for exposures, covariates and outcomes, as well as rigorous adjudication by two independent reviewers for ESKD exposure.

11. What limitations do we have?--Despite the larger size of this study compared to other reports, the ESKD sample may still have been relatively underpowered to find other statistically significant risk factors in mortality. Also there was inability to adjust for remdesivir and dexamethasone. As the evidence of these 2 drugs came after the surge of #COVID-19 cases in our health system, only a small proportion of patients received these drugs.

12. We had 11 PD patients in our admitted cohort. This was also published in a special report as well. Of 419 hospitalized patients with ESKD, 11 were on chronic PD therapy (2.6%). Among those 11, 3 patients required mechanical ventilation, 2 of whom died. Of the entire cohort, 9 of the 11 patients (82%) were discharged alive. While fever was a common presentation, more than half of our patients also presented with diarrhea. Interestingly, 3 patients were diagnosed with culture-negative peritonitis during their hospitalization. Seven patients reported positive SARS-CoV-2 exposure from a member of their household.

In conclusion, among patients hospitalized with COVID-19, those with ESKD had a higher rate of in-hospital death compared to those without ESKD. 

Two recent studies also show the outpatient HD infection and admission rates. A study published in AJKD from Canada showed from universal screening, 4.6% were infected. 

Another French study in KI showed a low incidence of infection of 3.3% in a large >40,000 dialysis patients. Older age, low albumin, and cardiac disease were risk factors for mortality. 

Taken together, the results suggest both a need for further research and the continued need for careful infection control procedures in the ESKD population at risk for #COVID-19.

Topic Discussion: Icodextrin and it's important pseudo-lab effects

Icodextrin is a glucose polymer used in peritoneal dialysis to help in improved clearance and ultrafiltration. Laboratory and metabolic effects of icodextin is important to know( especially the effect on glucose, Na and serum osmolarity)

There are a few that are important to remember

1.      The predominant circulating metabolites of icodextrin are maltose , maltotriose , and maltotetraose, with little glucose released in the systemic circulation due to the absence of circulating maltase. The release of glucose from the metabolized polymers occurs predominantly during the intra-cellular metabolism of maltose or other polymers by way of cellular enzymes involved in carbohydrate metabolism.

2.       The “glucose load” arising from the use of icodextrin is “functionally invisible” to the peritoneal cavity and systemic circulation, and its predominant systemic exposure is intracellular.

3.      In contrast to the acute hyperglycemia and hyperinsulinemia associated with glucose-based solutions, icodextrin does not lead to hyperglycemia or hyperinsulinemia following its intraperitoneal administration. 

4.      Point of care glucose testing might not be accurate when using icodextrin and serum glucose values should be used for insulin management.  Maltose interferes with glucose assays that utilize glucose dehydrogenase enzymes of the pyrroloquinolinequinone class (GDH PQQ), causing falsely elevated readings. The overestimation of glycemia is likely due to the presence of maltose and other oligosaccharide metabolites of icodextrin in the systemic circulation and the reaction of GDH-PQQ with the free reducing group of the glucose molecule located at the end of each saccharide chain.

5.      The decline in serum sodium and chloride associated with icodextrin therapy is caused mainly by a dilutional effect resulting from blood levels of icodextrin metabolites, particularly maltose and maltotriose. The presence of osmotically active particles in the vascular compartment is sufficient to cause a slight shift in water from the interstitial and cellular compartments to the vascular compartment, resulting in the dilutional hyponatremia (sometimes called hypertonic hyponatremia). It is like having hyperglycemia or mannitol induced hyponatremia.  

6.      Use of icodextrin has been associated with a slight increase in plasma osmolality in some studies. It can last up to 2 weeks after discontinuing icodextrin

7.      A small increase in mean serum alkaline phosphatase  has been reported in some studies of icodextrin Increases in alkaline phosphatase are not associated with true liver or billiary disease.

8.      Icodextrin interferes with amylase activity measurements by acting as a competitive inhibitor in the amylase activity assay.

Topic Discussion: Hemo peritoneum in PD

Etiologies for Bloody Peritoneal Dialysate( as little as 2ml in a 1L PD solution will make it turn fully red)

Catheter related causes: Erosion of mesenteric vessel by Tenckhoff catheter

Obstetric and gynecologic: Menstruation, Ovulation,Hemorrhagic luteal cyst,Ovarian cyst rupture, Pregnancy (uterine tear)

Intra-abdominal: Renal cyst rupture, Acquired cystic kidney disease, Autosomal dominant polycystic kidney disease ,Liver or liver cyst rupture,Hepatic tumors,Hepatocarcinoma, Liver metastasis, Splenic rupture, Splenic infarct, Aneurysm rupture, Pericardiocentesis, Radiation, Colonoscopy

Bleeding diatheses: platelet dysfunction, Anemia

Infection: Cytomegalovirus infection, Peritonitis

Other: Retroperitoneal hematoma, Iliopsoas spontaneous hematoma

What to do while determining cause?

1.      Several rapid PD exchanges are performed to determine if bleeding is persistent or is an acute event( vasoconstriction from rapid exchanges helps control bleeding)

2.      Most of the causes are menstruation related or a capillary rupture. 

3.      Correct any coagulopathy ( uremic or bleeding diathesis)

4.      Addition of heparin 500 U/L PD fluid is recommended to prevent catheter malfunction due to a clot obstructing the flow of dialysate.

5.      With persistent hemoperitoneum, imaging might be needed.

A nice review can be found here. 

Clinical Case 77 Answers and Summary

A 56 y old on PD presents with PD peritonitis and bacteremia as well likely related to the peritonial infection. How would you treat?

The role of IV antibiotics in PD peritonitis has always been questions. A recent Cochrane review was done on this topic. They identified 36 studies (2089 patients): antimicrobial agents (30); urokinase (4), peritoneal lavage (1) intraperitoneal (IP) immunoglobulin (1). No superior antibiotic agent or combination of agents were identified. Primary response and relapse rates did not differ between IP glycopeptide-based regimens compared to first generation cephalosporin regimens, although glycopeptide regimens were more likely to achieve a complete cure (3 studies, 370 episodes: RR 1.66, 95% CI 1.01 to 3.58). IP antibiotics were superior to IV antibiotics in reducing treatment failure (1 study, 75 patients: RR 3.52, 95% CI 1.26 to 9.81). Based on one study, IP administration of antibiotics is superior to IV dosing for treating PD peritonitis. Intermittent and continuous dosing of antibiotics are equally efficacious.
What about bacteremia in addition to the PD peritonitis?  This is a hard question that hasn’t been looked at. A study did analyze the incidence rates and risks of bacteremia and HD and PD. Placement of a permanent access (fistula, graft, or PD catheter) prior to initiation of dialysis, smoking cessation, and better nutritional status (i.e. higher serum albumin) were associated with a reduced risk of bacteremia in dialysis patients. Higher serum albumin was also associated with a reduced bacteremia-associated mortality.
Two cases reports have looked at treating cases of peritonitis and bacteremia. Most used IP only but some had combo treatment. The jury is still out.
http://www.pdiconnect.com/content/31/3/366.long
http://www.pdiconnect.com/content/30/3/381.long

Sweet hydrothorax: A PD complication

Acute hydrothorax is an uncommon but a well-recognized complication of peritoneal dialysis. No single test is definitive for diagnosis. Diagnosis becomes a challenge.

Peritoneal dialysis-(PD) related hydrothorax was first reported in 1967 by Edward and Unger in JAMA( see attached). Transudative pleural effusion develops, more commonly involving the right side, and usually occurs immediately after starting PD or a few days later. The patients may remain asymptomatic or have sudden dyspnea, decrease in ultrafiltration, or pleuritic chest pain.

How do we diagnose it?

Presence of high pleural-fluid glucose concentration.

Pleural fluid concentration of glucose >300mg/dl might be diagnostic.

Others have hypothesized that, given dynamic movement of dialysate, an absolute glucose-concentration level cannot be used to diagnose PD-related hydrothorax. The pleural fluid-to-serum glucose concentration gradient of greater than 2.77 mmol/L (50 mg/dl) was proposed as the cut-off to diagnose the condition.

In general, any pleural-fluid glucose concentration greater than serum is considered to be highly supportive of PD-related hydrothorax.

Imaging:

1.Radionuclide scan (for example, Tc-99 m DTPA) is associated with sensitivity of 40% to 50%.
2.The methylene blue test has been used where its injected and dye is traced from the peritoneum to the pleura. In one study showed no sensitivity and is associated with a risk of chemical peritonitis.

Some case report examples in literature

http://www.pdiconnect.com/content/27/3/296.full.pdf

http://www.sciencedirect.com/science/article/pii/S1755001708001103

Check out this powershow that reviews the management of this entity.

The return of PD: Can PD strike back?

AKI is diagnosed. You need to start dialysis... can you use PD as an option? This was historically done but trends have changed and extracorporeal blood purification( CVVHDF, HD) gets offered only. A recent article in CJASN did a systematic review on this topic.  Based on their analysis, they found 24 studies that was good to evaluate and included 1556 patients.

Brief points
1. 13/24 studies were PD only with pooled mortality was 39.3%
2. In randomized trials, no difference in mortality between PD vs HD for AKI
3. But the trials were significantly had intertrial heterogeneity.
4. Most of the complications with PD were peritonitis
5. Low resource settings and developing countries had more experience on this use than developed countries. Studies from Europe and North America were very low numbers.

Fellowship training in US might play a significant role in this trend we are seeing in US. In US, 30% of new nephrologists felt competent with acute PD compared to 90% of new nephrologists felt competent for acute HD. Few years ago, we had presented an abstract NKF 2011(page 272) on health care professional dialysis choices in case they needed dialysis.  There is scarce data on what a heathcare professional
would choose for themselves. The survey  consisted of seven questions aimed at assessing choice a health care  provider would make for themselves. We posed these questions to  physicians, nephrologists,nurses,dialysis nurses and nephrology fellows  in training. What we found was that  51.2% of health care professionals chose PD to be their choice of therapy. Among those who  chose HD 87% chose one of Home HD modality with only 13%  choosing in-center HD; far from evident in our current US statistics for  ESRD patients. 45.7% chose Nocturnal Long HD(6-8 hr,3 times/wk)
,31.5% Daily Short Home HD(2-3 hr,5-6 times/wk), 9.8% Home HD (3 hr 3times/wk).70.5 % chose a modality based on a belief of better outcomes of one over the modality.57.3% responders reported the
quality of life to be the specific outcome which was better for the  modality they opted for with 35.4% choosing the modality based on better morbidity, mortality and survival data. In center HD was the
modality most health care providers were comfortable discussing with their patients with only 18.7 % being comfortable in discussing PD.

PD needs to strike back!

Tele-Nephrology? Pros and Cons

Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist. A recent study done in Netherlands showed that telenephrology consultations( done via phone remotely or video conferencing) looked at reduction of in person referrals and response time. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days.  Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure. The authors concluded that a web-based consultation system might reduce the number of referrals and is usable. Another study done in Russia also shows some promise.  A nice study from Canada showed that a positive response. The analysis of staff hours worked showed almost no increase following the introduction of telemedicine. Telemedicine is therefore feasible for follow-up care of remote chronic kidney disease patients.

Peritoneal dialysis seems to be a place where this might be very useful or home dialysis. Few papers have looked into positive aspects of this form of medicine. Remote monitoring of the patient on peritoneal dialysis offers the benefits of real-time monitoring and recording of the therapy and interactive interface with the nephrology team can allow both acute 'trouble shooting' for problems as well as a means to interact with the patient for their monthly evaluation. This remote monitoring may increase compliance. Recent advances in telemonitoring, remote network access and sensor technologies have made such remote monitoring of peritoneal dialysis therapy a potentially user friendly option. A recent review summarizes the pros and cons of using such techniques.

Other studies have shown otherwise. In France, the experience seemed unfruitful and had to be shut down.

Topic Discussion: ENCAPSULATING PERITONEAL SCLEROSIS (EPS)

Encapsulating Peritoneal Sclerosis (EPS), the most serious complication of peritoneal dialysis (PD) was recognized soon after PD was introduced. It is characterized by extensive intraperitoneal fibrosis and encasement of bowel loops. It is typically characterized by loss of ultrafiltration, resulting in fluid retention and edema. 

From the viewpoint of clinical presentation, it progresses to various stages from early phase of faint inflammation to fibrin exudates and active inflammation. This is followed by formation of encapsulating membrane and sustained inflammation. Finally, thickening occurs and there is moderate inflammation.

Development of EPS is associated with three main clinical factors: prolonged duration of PD, persistent

Or frequent bacterial or fungal peritonitis, and membrane failure. The cumulative duration of exposure to PD fluids is the dominant risk factor for EPS, but young age and kidney transplantation might also be risk factors

It can be diagnosed by above clinical features and radiologically by a CT scan which my show evidence of: Peritoneal thickening, peritoneal calcification, tethering and cocooning of bowel and small or large bowel obstruction.

Treatment usually consists of corticosteroids. Some case studies have used Tamoxifen. Surgical treatment consisting of surgical lysis of intestinal adhesions and stripping of fibrous cocoon has been indicated if there is recurrent bowel obstruction, failing nutritional status or failure to respond to medical therapy. Increase incidence has been noted after transplantation. Unclear why is that the case.

Good references:

http://www.ncbi.nlm.nih.gov/pubmed/11098928

http://ndt.oxfordjournals.org/content/22/8/2412.1.full

http://ndt.oxfordjournals.org/content/16/6/1304.full

Post by Dr.Divya Monga

Diabetes with Icodextrin Peritoneal Dialysis: Hypo- or Hyper-glycemia?

A 56 year-old male with a past medical history of insulin-requiring DM2, hypertension and ESRD on peritoneal dialysis with icodextrin was hospitalized for viral gastroenteritis. His GI symptoms were improving with symptomatic management but his glycemic control was worsening, with random capillary blood glucose values ranging from 180 to 300 mg/dL. He was maintained on regular insulin coverage based on a sliding-scale, with subsequent capillary blood glucose values between 150-180 mg/dL. The patient complained of recurrence of vague GI symptoms, which were attributed to the primary diagnosis of viral gastroenteritis. On the third day of hospitalization, he developed seizures and a 'code' was called. Bedside capillary blood glucose was 90 mg/dL.  His venous blood glucose was measured by the central laboratory as a part of the seizure work-up during the code, and was found to be 15 mg/dL. Administration of glucose led to resolution of his symptoms. 

Point-of-care testing with standard glucometers used in hospitals (Accucheck) results in spurious elevations in blood glucose levels in icodextrin-treated patients. Icodextrin may be absorbed in the systemic circulation and is hydrolyzed into maltose and maltotriose. Maltose accumulates in the systemic circulation because humans are deficient in maltase. Many bedside glucometers like Accucheck use the glucose dehydrogenase with pyrroquinolinequinone (PQQ) in their test strips, which identify the free reducing group of glucose at the end of the maltose molecule and thus overestimate the blood glucose levels. This overestimation, however, is not seen with the glucometers based on the glucose-oxidase enzymatic system (One-touch)

Overestimation of blood glucose levels could mask true hypoglycemia, or can result in inappropriate administration of insulin, leading to hypoglycemia, and if severe, even death. Therefore, patients on PD with icodextrin should either undergo central laboratory determination of blood glucose or should be allowed to use their own home glucometers. 

References: 

http://www.ncbi.nlm.nih.gov/pubmed/17513644

http://www.ncbi.nlm.nih.gov/pubmed/19602602

Post by,

Ritu Soni, MD

University of Pittsburgh Medical Center

eAJKD: Peritoneal Dialysis Strikes Back

In the United States, the number of patients who are offered peritoneal dialysis (PD) has declined over the last decade. The newer generation of Nephrologists may not feel as comfortable with this dialysis modality, and shy away from referring patients towards PD. Check out this latest post regarding an article that opens news ways to increase PD as an option for dialysis to the patients. Visit eAJKD page. 

ASN2011: Pearls on Peritoneal Dialysis

From the pre course on ASN 2011, on Dialysis Modalities

The following are different strategies to decrease risk of peritonitis; they are unrelated concepts.

 

1-Russo et al in KI did a multi center Italian study. 353 pts answered a questionnaire. 191 pts had home visits with a score card.  23% were non-compliant with exchange procedure. This was associated with increased peritonitis rates.  So it maybe worthwile retraining Pd patients for 4days yearly to decrease the risk.

 

2-Diverticulitis may be associated with increased peritonitis rates. 

 

3-Hypokalemia and constipation can cause peritonitis; Bacteria in the colon migrate across the visceral peritoneum and enter the peritoneal cavity which is filled with dialysis fluid which inhibits immune function.

 

4-We should use prophylaxis medications for GI procedures to decrease risk of infections.

 

5-Fix all hernias before starting PD. On exam, one needs to have patients stand to uncover hernias and leaks. Umbilical hernias may be the smallest but have the biggest risk of incarciration.

 

And one more interesting tit bit of information was a new way of reporting Peritonitis instead of N of months between episodes;  is to use the number of infections per year and this will help compare centers to each other and also get a sepecific bug rates internally and within centers. 

Post by 

Dr.Azzour Hazzan

Hofstra NSLIJ Nephrology

Patient Perspective: Give us the Choice by Kamal Shah

Give us the choice

Most people in India, when diagnosed with kidney failure are advised to get their fistula surgery done. Which is great in one way because the fistula, as we all know, is the gold standard when it comes to vascular access for hemodialysis.

However, I have often wondered why the PD catheter is not offered to the patient as an alternative to the fistula? Or a registration on the cadaver transplant list? Why is it almost always the fistula?

When I was diagnosed with kidney disease at the age of 22 in July 1997, I was given an AV shunt because my kidneys were expected to revive in a matter of weeks. Of course that never happened and I graduated to a fistula eventually - probably the first sign that my kidneys are not going to ‘jump back to life’! I got to know of PD only after my failed transplant, a good eighteen months after my initial diagnosis with kidney disease.

I have thought hard about why PD is not presented to patients as an initial option. In my case, it may not have made sense because of the perceived temporary nature of the condition. However, in a majority of other patients whose CKD is most definitely at stage 5 and he or she is going to need some form of RRT for the rest of his or life, PD is definitely an excellent option!

Then why this step-motherly treatment for this modality in India (and as I gather in many other parts of the world)?

One reason is patients themselves. I have talked to some patients about PD and find a reluctance to take care into their own hands. They are happy giving themselves up to the medical team and blame them for everything that is wrong with them. There is also the scare of infection. In India, very few patients on dialysis know about how rampant Hepatitis  C has become in dialysis units. With PD, yes, there is a risk of bacterial infection but the risk can be minimized if the patient is properly trained in aseptic techniques. With in-center hemodialysis, you are entirely at the mercy of the technicians and nurses. Hepatitis C is a very real danger due to their negligence.

Another reason could be nephrologists themselves. For some reason, nephrologists the world over have shied away from PD.

Another option that patients could be given is that of a transplant. Why wait even for a few months on dialysis? When the patient reaches Stage 5, start preparing for a transplant -  live related or cadaveric. Get everything in place and get a transplant as soon as necessary so that the patient does not need even a single session of dialysis.

These are all excellent options which the nephrologist must discuss with patients. All the options. Hemodialysis, Peritoneal Dialysis and a Transplant. The nephrologist (and possibly a trained counsellor) must explain all the three options well ahead of time and involve the patient and his or her family in the decision. Unlike today, when the nephrologist makes the decision for us.

It is my life. I want a say. Is this too much to ask?

By Kamal Shah

http://kamaldshah.com

http://dialysis.org.in

What Kamal is saying is not only true likely in India but in USA as well. This is an ongoing problem as more and more Younger Nephrologists don't feel well trained or comfortable in taking care of PD.  Meanwhile countries like Japan, have majority of their dialysis patients getting PD.  Economics or patient preferences- both might be a playing a role in this sad state of affairs.

CLINICAL CASE 42 : ANSWERS AND SUMMARY

Which of these is an indication for peritoneal catheter removal with DELAYED replacement back again?( as oppose to simultaneous replacement)- select multiple answers

Refractory Peritonitis	20 (35%)
Fungal Peritonitis	40 (70%)
Repeat Peritonitis	12 (21%)
Relapsing Peritonitis	15 (26%)
Enteric Peritonitis with clear bowel source	21 (36%)
Refractory exit site infection	24 (42%)

Indications for peritoneal catheter removal With delayed replacement are: Refractory peritonitis,
Enteric peritonitis with clear bowel source, Fungal peritonitis( which most of you got)
Indications for peritoneal catheter removal With simultaneous replacement are
Relapsing peritonitis,Repeat peritonitis and Refractory exit site infection.


Ref:
http://www.ncbi.nlm.nih.gov/pubmed/21801223

Curbside Consults

We often have asked these questions? and some of them have no answers in the literature and some have long winded opinions- and that's it.  These are practical questions that have come up at almost every institution. Take a look at some of them?
1. Do Dialysis patients need colonoscopies and mammograms?
2. When and how should immunosuppression be tapered in a failed transplanted kidney?
3. Should we give erythropoiesis stimulating agents to a dialysis patient who has cancer?
4.  When should a nephrectomy be done in a transplanted patient with a failed kidney?
5.  Is there a higher mortality in certain dialysis shifts?

Seminars in Dialysis August 2011 issue has these questions answered along with more such scenarios. This special issues is fantastic. It covers some major issues that we face all the time.
Take a look
http://onlinelibrary.wiley.com/doi/10.1111/sdi.2011.24.issue-4/issuetoc

Topic Discussion: Non glucose based solutions for Peritoneal Dialysis

Glucose based solutions are standard for PD.
Two non glucose based are also available: Icodextrin and amino acids.

1. EAPOS trial compared retrospectively on membrane function and it showed stable membrane function and better UF with the icodextrin arm
2. Exposure to hyperglycemia and subsequent effects of glucose absorption are less with these agents
3. No side effects are noted with these agents
4. No clinical data are present to support use of amino acids as membrane protectors
5. Cost of above agents are a lot and hence not used much in USA.

Something to ponder about
Check out the recent Seminars in Dialysis review on this topic by Peter Blake
http://www.ncbi.nlm.nih.gov/pubmed/21801231
http://www.ncbi.nlm.nih.gov/pubmed/16720998
http://www.ncbi.nlm.nih.gov/pubmed/15780118

TOPIC DISCUSSION: Adequacy of Dialysis HD vs. PD

For PD, the weekly goal is 1.7 which divided into 7 days is below 0.3 (if we were close to 2) and for HD the kt/v goal is 1.2 every treatment which divided into 2 days will give approx 0.6 per day so  questions arise?- 
Why are goals different and howcome the outcomes are same?

The goals to be achieved during hemodialysis are typically higher beacuse the 24 hour solute clearance that we get with PD is more "efficient" and gets more convective/middle molecular clearance. Comparable efficiency of all solute clearance on HD can only be achieved with higher kt/v for each treatment since they are short and intermittent in other words hemodialysis is less efficient if you will.

Complications of Peritoneal Dialysis

Complications of peritoneal dialysis

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