Exit-site Infection Research Articles

Mycobacteria avium-related peritonitis in a patient undergoing peritoneal dialysis: case report and review of the literature

BackgroundMycobacteria avium (M. avium) is a species of ubiquitous slowly growing nontuberculous mycobacteria. It causes opportunistic infections. However, M. avium-related peritonitis in peritoneal dialysis (PD) patients is rare.Case presentationA 51-year-old female end-stage kidney disease patient undergoing PD was admitted for a noninfectious complication. She presented catheter exit site drainage and slightly increased PD effluent white cell count (WCC) with polymorphonuclear predominance on admission. Exit site infection and PD-related peritonitis were diagnosed. Repeated cultures of effluent and drainage were negative. Initial empirical antibiotics and further adjustment were not rewarding. PD was terminated 2 weeks later, however, shortly the patient developed stupor, high fever, peritoneal irritation, and spontaneous chylous ascites, and showed elevated ascitic adenosine deaminase (ADA). The manifestations persisted and the patient’s general condition deteriorated despite intensified antibiotic therapy. Massive parallel sequencing identified M. avium in ascites on hospital day 25, and 4-drug treatment with azithromycin, amikacin, rifampin, and ethambutol was initiated. Nevertheless, the patient died from sepsis on hospital day 30.ConclusionsWe report a case of PD-related M. avium peritonitis. Prolonged culture-negative peritonitis, chylous ascites, and elevated ascitic ADA may hint the possibility of mycobacterial infections. Diagnostic method allowing prompt identification of the pathogen is warranted. The prognosis can be extremely poor, and the prophylaxis and treatment should be better defined.

Office-Based Tunneled Hemodialysis Catheter Removals: Evaluating Safety, Quality, and Cost

<h3>Introduction/Objective</h3> Many surgical procedures have moved from the hospital environment to an office-based setting, giving providers and patients more flexibility without sacrificing safety nor quality of care. Dialysis patients are in a more vulnerable state and the chance of significant secondary morbidies are increased. Tunneled hemodialysis catheters (TDC's) are used for temporary dialysis access ports, commonly serving as a placeholder until an AV graft ormaturated fistula is ready for hemodialysis. Prolonged use of TDC's has an increased risk of bacteremia, catheter malfunction, sepsis, exit site infections, catheter fracture, and are also associated with increased mortality rates. Bedside removal of TDC's has been deemed a safe procedure in previous studies. Office-based settings are able to provide another site-of-service that could expedite and improve access to care. <h3>Methods</h3> A retrospective review of our office based TDC removals. All patients who had TDC removals from 1/22/2007 to 4/7/2020 were identified (13-year period). Procedures were performed in a vascular surgery in-office setting with sterile technique. The data recorded included: date of procedure, patient name, sex of patient, post-procedural complications, dateof last follow-up, performing physician, and whether the patient is deceased. Complications during and post procedure were recorded. Follow-up visits were done by means of office visitsand telephone encounters. Post-operative follow-up protocol for this study include the initial nurse visit (usually 1 week following the procedure), the subsequent 2 clinical post-proceduralencounters, and the last visit that the patient had at the office. <h3>Results</h3> A total of 524 TDC removals were performed from January 2007 to April 2020 (13-year period). 498 had follow-up. The average follow-up of patients after the procedure was 2.5 yrs. 33/429 patients had complications reported (7.69%). 69 of the patients who followed up were on paper charts that could not be accessed. Complications were classified as exit site erythema (n=13, 3.0%), infection (n=7, 1.6%), bruising (n=7, 1.6%), drainage without infection (n=2, 0.47%), and tenderness (n=4, 0.93%). Infection=assessed by physician and placed on antibiotics.None of the patients required hospitalization post-procedure due to procedural-related complications nor were there any procedural-related mortalities. The national average outpatient/ASC cost for TDC removal is $461 versus an average in-hospital cost of $733 (https://www.medicare.gov/procedure-price-lookup/cost/36589). Our office-setting average (per 60 min case) cost was $241.33. (Physician fee $143, Supplies $65, Staffing $20, Room $33.33/hour). Cost was evaluated per hour, so if the procedure can be performed faster thenthe costs will be less. Room costs are from patient entry to patient exit. <h3>Conclusion</h3> Hemodialysis patients need better access to care. TDC's should be removed as soonas possible, due to the high rate of complications associated with them. The office-setting provides an easier and expedited access for TDC removals in hemodialysis patients compared tothe hospital setting. TDC catheter removals are able to be taken out safely in an office-based setting. Offices provide low morbidity rate: 7.69%, all of which were minor, and none required hospital admission. There were no mortalities associated with the procedure. The office setting is more cost effective than the hospital setting for TDC removals: $461 ASC/ Hospital Outpatient vs. $733 in- hospital, and our costs being $ 241.33 per hour. TDC removals should be performed in a physician's office to provide a safer more cost-effective option for hemodialysis patients and the healthcare system.

Medicazione a base d’argento nella gestione dell’emergenza cutanea

Introduction: Exit-site (ES) and tunnel infections are the main infectious complication in peritoneal dialysis (PD); they also are risk factors for the development of peritonitis, for catheter removal and for dialysis drop-out. Up to now, besides the recommendations of the Guidelines there is no uniformity, nor on the classification, nor on the treatment strategies of the infected ES. Recent experiences are reported with alternative types of dressings that aim to reduce the incidence of ES infection and consequently of the subcutaneous tunnel. Methods: The Tuscan group conducted a retrospective observational study of 10 patients on PD who, showing signs of a suspected but not ascertained infection (negative microbiological culture), such as redness, edema, secretion, scab, had been medicated with silver-ions releasing Exit-Pad Ag. The aim was to evaluate and classify the evolution of ES lesions, in order to confirm the preventive efficacy of the silver-ions releasing dressing compared to the traditional ones. Results: After 4 weeks of treatment with Exit Pad Ag maintained in situ for 72 h, 6 patients no longer had any signs of inflammation. In 2 cases, several weeks of treatment were necessary to achieve a complete recovery, while in 2 other cases the signs of inflammation became negative in less time (2 weeks, 1 week). Conclusions: With the utilization of an alternative dressing such as Exit-Pad Ag on PD patients showing early signs of inflammation, the onset of a true infection can be prevented, with a progressive improvement of the ES.

Ventricular Assist Device Driveline Infections: A Systematic Review.

Infection is the most common complication in patients undergoing ventricular assist device (VAD) implantation. Driveline exit site (DLES) infection is the most frequent VAD infection and is a significant cause of adverse events in VAD patients, contributing to morbidity, even mortality, and repetitive hospital readmissions. There are many risk factors for driveline infection (DLI) including younger age, smaller constitution of patients, obesity, exposed velour at the DLES, longer duration of device support, lower cardiac index, higher heart failure score, DLES trauma, and comorbidities such as diabetes mellitus, chronic kidney disease, and depression. The incidence of DLI depends also on the device type. Numerous measures to prevent DLI currently exist. Some of them are proven, whereas the others remain controversial. Current recommendations on DLES care and DLI management are predominantly based on expert consensus and clinical experience of the certain centers. However, careful and uniform DLES care including obligatory driveline immobilization, previously prepared sterile dressing change kits, and continuous patient education are probably crucial for prevention of DLI. Diagnosis and treatment of DLI are often challenging because of certain immunological alterations in VAD patients and microbial biofilm formation on the driveline surface areas. Although there are many conservative and surgical methods described in the DLI treatment, the only possible permanent solution for DLI resolution in VAD patients is heart transplantation. This systematic review brings a comprehensive synthesis of recent data on the prevention, diagnostic workup, and conservative and surgical management of DLI in VAD patients.

Epidemiology, management, and prevention of exit site infections in peritoneal dialysis patients.

Exit site infection (ESI) is a leading complication of peritoneal dialysis (PD), at an incidence of 0.6 episodes per year in the United States, and a major risk factor for catheter removal and peritonitis. An estimated 20% of all peritonitis cases are preceded by an ESI, with up to 50% of Staphylococcus aureus peritonitis associated with ESI. Gram-negative ESIs are less associated with succeeding peritonitis than their gram-positive counterparts, though when present, are associated with a lower peritonitis cure rate. The rate of catheter removal for refractory ESI is relatively highest in ESI due to mycobacteria (up to 40%), S. aureus (35%), Pseudomonas aeruginosa (28%), followed by Corynebacterium, Serratia, and fungi. In review of relevant literature, we found no prophylactic benefit of dressings over nondressings, specific antiseptics over normal saline, or topical honey over topical antibiotic prophylaxis, and thus recommend individualized exit site hygiene. We found topical gentamicin effective for prevention of most ESIs, including gram-negative ESIs, and thus recommend consideration of prophylactic topical gentamicin in areas of high gram-negative peritonitis incidence. With long-term use, observational studies detect up to 25% of gram-positive and 14% of gram-negative ESIs may be mupirocin and gentamicin resistant, respectively. We review empiric and targeted ESI management, including indications for ultrasound, anti-VMRSA, anti-Pseudomonal, and anti-mycobacterial antibiotic use, and catheter removal. We recommend further investigation into the earlier use of second-line treatment agents and the utility of treating post-infectious exit site colonization as avenues to decrease refractory and repeat ESI.

Clinical course of peritoneal dialysis-related peritonitis due to non-tuberculosis mycobacterium – A single centre experience spanning 20 years

Peritoneal dialysis (PD)-related peritonitis caused by non-tuberculous mycobacteria (NTM) are difficult to diagnose, is associated with significant morbidity and mortality, and clinical course remains unclear. We determined the prevalence and clinical course of peritonitis caused by these organisms through our kidney registry over 20-year period. We reviewed all patients with NTM peritonitis identified in our tertiary centre between July 2000 and July 2020. The demographic characteristics, microbiological and clinical outcomes were examined. Among 27 patients identified, 20 patients presented with abdominal pain and all had cloudy peritoneal fluid. Twenty-one cases had concomitant exit site infection and 14 cases had prior antibiotic use. The majority of the cases are caused by Mycobacterium chelonae (37%) and Mycobacterium fortuitum (29.7%), with most being resistant to fluoroquinolones (59.3%) and cefoxitin (73.1%). They are all sensitive to amikacin otherwise. None of the cases achieve primary response at day 10 and 20 cases resulted in Tenckhoff catheter removal. Only two of them were able to resume PD. Eight patients died in our cohort. The presence of exit site infection, the use of prior antibiotics and topical disinfectants did not associate with a poorer outcome. NTM peritonitis remains difficult to treat and often with a delay in diagnosis. Refractory peritonitis with negative culture and a poor response to standard antibiotics should raise a possibility of NTM infection and prompt catheter removal and an expert with experience treating NTM infections should be consulted.

Comparison of 2% Chlorhexidine Gluconate in 70% Alcohol and 10% Povidone-Iodine Used for Port Catheter Dressing Changes in Pediatric Hematology-Oncology Patients: A Prospective Observational Study.

Objective:This study aimed to compare the effectiveness of 2% chlorhexidine gluconate in 70% alcohol with that of 10% povidone-iodine, for dressing changes in pediatric hematology–­oncology patients with port catheters, in preventing catheter-related bloodstream infection (CRBSI). Methods:In this prospective, multicenter, observational, and cross-sectional study, 45 patients (25 patients for chlorhexidine, 20 patients for povidone-iodine) with port catheters were evaluated from January 2018 to May 2019. The sociodemographic, clinical, and port catheter-related variables were evaluated. The mean age of the patients was 6.28 ± 4.58 years, and 60% of patients were female.Results:Among the patients whose dressings were changed using 2% chlorhexidine gluconate in 70% alcohol, the mean number of dressing changes was 39.52 ± 29.7 and the rates of exit-site infection and CRBSI were 20% (2.37/1000 catheter-days) and 16% (1.90/1000 catheter-days), respectively. Among the patients whose dressings were changed using 10% povidone-iodine, the mean number of dressing changes was 48.0 ± 31.48 and the rates of exit-site infection and CRBSI were 15% (1.59/1000 catheter-days) and 10% (1.06/1000 catheter-days), respectively. None of the patients developed pocket infections. The rates of CRBSI and exit-site infections were not different between the 2 antiseptic solutions.Conclusion:This study found no differences between the effectiveness of 2% chlorhexidine in 70% alcohol and that of 10% povidone-iodine solution in preventing CRBSI. Therefore, both solutions can be used in dressing changes.

Minimally invasive peritoneal dialysis catheter insertions with concomitant cholecystectomy or hernioplasty: Surgical technique and our experiences.

Peritoneal dialysis is a well-accepted replacement therapy in patients with end-stage renal disease. There are many different options adopted on how to insert a peritoneal dialysis catheter. In our institution, a laparoscopic insertion has become the method of choice for providing peritoneal dialysis access in adult patients. The aim of this study was to analyze surgical outcomes of patients after laparoscopically assisted placement of a PD catheter some of them after concomitant cholecystectomy or hernioplasty. We have evaluated 70 consecutive patients from 1st of October 2015 to 30th of April 2020 who underwent laparoscopic insertion of a peritoneal dialysis catheter. Demographic data, details about surgery and about peri- and postoperative complications were gathered. Out of 70 enrolled patients, 15 had gallstones (21%) and underwent concomitant laparoscopic cholecystectomy. Three patients (4%) had abdominal wall hernia and underwent concomitant hernioplasty. We observed no perioperative complications connected with any of the performed procedures. There was one early postoperative complication: an early leak of dialysate fluid. Late complications were observed in nine patients (13%): mechanical catheter problems (two patients), peritonitis (three patients), skin exit-site infections (two patients), peri-catheter leak (one patient), and port-site hernia (one patient). For all patients with concomitant gallbladder disease or abdominal wall hernias we suggest to perform synchronous surgeries, due to finding no more complications after concomitant procedures in comparison to patients in whom only a PD catheter was inserted. Concomitant procedures are done to spare patients two separate procedures and to avoid possible complications. We also suggest using the cholecystectomy first, PD catheter insertion second approach for having excellent peri- and postoperative results.

Effectiveness of a continuous interactive communication system for home care nursing assistance of peritoneal dialysis

BackgroundThe Japanese population is aging quickly. New methods of supporting peritoneal dialysis (PD) for elderly patients are essential if we are to increase the number of such patients.MethodsWe established a two-way communication system between a central hospital and stations for visiting nurses. Home care nurses provided physicians at the central hospital with clinical findings for patients undergoing assisted PD. We compared 11 patients undergoing PD assisted by home care nurses in continuous interactive communication with the central hospital (cases) with 11 patients undergoing unassisted PD who were matched by sex, primary disease, estimated glomerular filtration rate at the start of PD, and age at the start of PD (controls). The variables compared were hospitalization due to heart failure, exit-site infection, peritonitis, and the composite of these causes during a 1-year period. In addition, we compared patient clinical factors between groups.ResultsAlthough differences in the number of hospitalizations attributable to exit-site infection, peritonitis, and heart failure were not significant, the difference in the number of hospitalizations attributable to a composite of these causes was significant. Exit-site scores were significantly better in the case group than in the control group.ConclusionsPD assisted by home care nurses using an established continuous interactive communication system was associated with significantly better exit-site scores. Fewer cases than controls were hospitalized.

Venous access devices for the delivery of long-term chemotherapy: the CAVA three-arm RCT

Venous access devices are used for patients receiving long-term chemotherapy. These include centrally inserted tunnelled catheters or Hickman-type devices (Hickman), peripherally inserted central catheters (PICCs) and centrally inserted totally implantable venous access devices (PORTs). To evaluate the clinical effectiveness, safety, cost-effectiveness and acceptability of these devices for the central delivery of chemotherapy. An open, multicentre, randomised controlled trial to inform three comparisons: (1) peripherally inserted central catheters versus Hickman, (2) PORTs versus Hickman and (3) PORTs versus peripherally inserted central catheters. Pre-trial and post-trial qualitative research and economic evaluation were also conducted. This took place in 18 UK oncology centres. Adult patients (aged ≥ 18 years) receiving chemotherapy (≥ 12 weeks) for either a solid or a haematological malignancy were randomised via minimisation. Hickman, peripherally inserted central catheters and PORTs. A composite of infection (laboratory confirmed, suspected catheter related and exit site infection), mechanical failure, venous thrombosis, pulmonary embolism, inability to aspirate blood and other complications in the intention-to-treat population. Overall, 1061 participants were recruited to inform three comparisons. First, for the comparison of peripherally inserted central catheters (n = 212) with Hickman (n = 212), it could not be concluded that peripherally inserted central catheters were significantly non-inferior to Hickman in terms of complication rate (odds ratio 1.15, 95% confidence interval 0.78 to 1.71). The use of peripherally inserted central catheters compared with Hickman was associated with a substantially lower cost (-£1553) and a small decrement in quality-adjusted life-years gained (-0.009). Second, for the comparison of PORTs (n = 253) with Hickman (n = 303), PORTs were found to be statistically significantly superior to Hickman in terms of complication rate (odds ratio 0.54, 95% confidence interval 0.37 to 0.77). PORTs were found to dominate Hickman with lower costs (-£45) and greater quality-adjusted life-years gained (0.004). This was alongside a lower complications rate (difference of 14%); the incremental cost per complication averted was £1.36. Third, for the comparison of PORTs (n = 147) with peripherally inserted central catheters (n = 199), PORTs were found to be statistically significantly superior to peripherally inserted central catheters in terms of complication rate (odds ratio 0.52, 95% confidence interval 0.33 to 0.83). PORTs were associated with an incremental cost of £2706 when compared with peripherally inserted central catheters and a decrement in quality-adjusted life-years gained (-0.018) PORTs are dominated by peripherally inserted central catheters: alongside a lower complications rate (difference of 15%), the incremental cost per complication averted was £104. The qualitative work showed that attitudes towards all three devices were positive, with patients viewing their central venous access device as part of their treatment and recovery. PORTs were perceived to offer unique psychological benefits, including a greater sense of freedom and less intrusion in the context of personal relationships. The main limitation was the lack of adequate power (54%) in the non-inferiority comparison between peripherally inserted central catheters and Hickman. In the delivery of long-term chemotherapy, peripherally inserted central catheters should be considered a cost-effective option when compared with Hickman. There were significant clinical benefits when comparing PORTs with Hickman and with peripherally inserted central catheters. The health economic benefits were less clear from the perspective of incremental cost per quality-adjusted life-years gained. However, dependent on the willingness to pay, PORTs may be considered to be cost-effective from the perspective of complications averted. The deliverability of a PORTs service merits further study to understand the barriers to and methods of improving the service. This trial is registered as ISRCTN44504648. This project was funded by the National Institute for Health Research (NHIR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 47. See the NIHR Journals Library website for further project information.

Two decades of analysis of peritonitis in peritoneal dialysis in Andalusia: Epidemiological, clinical, microbiological and progression aspects

BackgroundThis study focuses on the main complication associated with peritoneal dialysis, peritonitis. Its relevance derives from its high morbidity, the negative effect it has on the peritoneum as a dialysis membrane and its financial cost. MethodsAnalytical, non-interventional, observational cohort study, whose main objective is the analysis of peritonitis in patients on peritoneal dialysis in Andalusia from 1 January 1999 to 31 December 2017, with a total of 2904 peritonitis cases. The database used is the Andalusian Autonomous Transplant Coordination Information System (SICATA). ObjectivesTo ascertain how the rate of peritonitis is evolving in our community, analyse descriptive data pertaining to patients and peritonitis, ascertain the course of these infectious complications and analyse the factors that influence these cases of peritonitis and their outcomes: germ, hospitalisation and date. ResultsThe rate of peritonitis decreased progressively during the study period, from 0.7 peritonitis per patient in 1999 to 0.33 at the end of the period. Most infections were treated on an outpatient basis (72.5%). The most common germs were Gram-positive (55.9%), including coagulase-negative staphylococci (28.1%). Most cases of peritonitis progressed to healing (77.8%). The factors that significantly influence the need for hospitalisation and peritonitis progression were the causative germ and associated exit site infection. ConclusionsIn our population, the rate of peritonitis decreased progressively during the study period, meeting guideline recommendations.

Repeat exit site infection in peritoneal dialysis patient with polycythemia vera \u2013 a case report

BackgroundInfectious complications of peritoneal dialysis (PD) remain a common cause of catheter loss and discontinuation of PD. Exit site infection (ESI) constitutes a significant risk factor for PD-related peritonitis and determination of predisposing states is relevant. We here present a case of repeat ESI due to Pseudomonas aeruginosa in a PD patient with skin changes in the course of polycythemia vera (PV).Case presentationA 73-year-old PD patient with chronic kidney disease secondary to renal amyloidosis and ankylosing spondylitis, presented to the nephrology unit with signs of ESI. In 2006 he was diagnosed with PV and since then has was successfully treated with hydroxyurea; however, he reported recurrent episodes of developing skin nodules in the course of the disease. Exit site swab yielded Pseudomonas aeruginosa and the infection developed in the ulcerated PV nodule that appeared in exit site 2 weeks earlier. Patient was treated with intraperitoneal amikacin and oral ciprofloxacin, however, due to neurological complications, the treatment had to be interrupted and finally catheter was removed. Similar episode of ESI with Pseudomonas aeruginosa developed in the patient two years earlier and also required catheter removal.ConclusionThis is the first case report demonstrating the development of ESI on the polycythemia vera skin lesion in this area. Skin manifestations of PV might be a predisposing factor to ESI in PD patients.

Clinical and microbiological factors predicting outcomes of nonfermenting gram-negative bacilli peritonitis in peritoneal dialysis

Peritonitis due to gram-negative bacilli (GNB), particularly nonfermenting GNB (NF-GNB), is a serious complication of peritoneal dialysis with a low resolution rate. Beyond the patient’s condition, microbiological properties such as antimicrobial resistance, biofilm production and other virulence factors can explain the poor outcomes. This study aimed to evaluate the influence of patient condition, microbiological characteristics, including biofilm production, and treatment on peritonitis outcome. We reviewed the records of 62 index episodes caused by NF-GNB that occurred between 1997 and 2015 in our center. The etiologies were species of Pseudomonas (51.6%), Acinetobacter (32.2%), and other NF-GNB (16.1%). There was a high (72.9%) proportion of biofilm producer lineages. The in vitro susceptibility rate of Pseudomonas spp. to amikacin, ciprofloxacin, and ceftazidime was significantly greater than that of Acinetobacter spp. and other species; however, there was a similar low resolution rate (< 45%) among the episodes attributable to them. Preexisting exit-site infection was independently associated with nonresolution. No other factor, including biofilm production, was associated with the outcome. The higher in vitro susceptibility of Pseudomonas compared to other NF-GNB that presented a similar resolution rate suggests that bacterial virulence factors such as biofilms can act in concert, thereby worsening the outcome.

Effect of Ventricular Assist Device Self-care Simulation-Based Mastery Learning on Driveline Exit Site Infections: A Pilot Study.

Ventricular assist device simulation-based mastery learning (SBML) results in better patient and caregiver self-care skills compared with usual training. The aim of this study was to evaluate the effect of SBML on driveline exit site infections. We compared the probability of remaining infection free at 3 and 12 months between patients randomized to SBML or usual training. The SBML-training group had no infections at 3 months and 2 infections at 12 months, yielding a Kaplan-Meier estimate of the probability of remaining infection free of 0.857 (95% confidence interval [CI], 0.692-1.00) at 12 months. The usual-training group had 6 infections at 3 months with no additional infections by 12 months. Kaplan-Meier estimates of remaining infection free at 3 and 12 months were 0.878 (95% CI, 0.758-1.00) and 0.748 (95% CI, 0.591-0.946), respectively. Time-to-infection distributions for SBML versus usual training showed a difference in 12-month infection rates of 0.109 (P = .07). Ventricular assist device self-care SBML resulted in fewer 12-month infections.

MO786HEPARIN VERSUS SODIUM BICARBONATE CATHETER LOCK SOLUTION: AN ALTERNATIVE LOCK HEMODIALYSIS CATHETER?

Abstract Background and Aims Infections and thrombosis of central venous catheter (CVC) in hemodialysis patients are the major causes of catheter loss resulting in hospitalization and increased costs. Interdyalitic catheter lock solutions, usually heparin, avoid these complications. Among the many, sodium bicarbonate has been proved as effective and safe catheter lock solution due to its antimicrobial and antithrombotic properties. The aim of this study was to compare the efficacy of two different CVC lock solution: sodium heparin versus sodium bicarbonate, to prevent catheter–related thrombosis and infection in hemodialysis patients Method They were enrolled, in a 12 months case-control study, 17 hemodialysis patients with tunneled hig-flux CVC (femoral or internal jugular). Each patient was evaluated in its common treatment for CVC dysfunction (Qb, CVC that works in reverse branches during the hemodialysis session, use of urokinase or extra lock with sodium heparin or 4% citrate) and infection (WBC count, C reactive protein -CRP, bloodstream culture, exit-site infection -ESI) during standard sodium heparin CVC lock solution (hep-lock), for the first 6 months, and then, during sodium bicarbonate lock solution (10 mEq/10 ml, bic-lock) for following 6 months. aPTT, PLT, Hct and albumin are also montly evaluated. Type and anticoagulant dose during hemodialysis sessions were unchanged over the study as well as any antiplatelet/anticogulant home therapy. Results Fifteen patients on 17 completed the study and the main results are reported in table 1. There were no significant differences between patients on demographics and number of catheter days treatments for both study periods. The blood flow was similar in either study phases and stable during the hemodialysis sessions (Qb 225±13 ml/m’ at 2-hours vs 225±15 ml/min at start of dialysis), even the use of reverse branches was similar. Hep-lock showed a lower usage of extra lock drug in comparison with Bic-lock (0,4% vs 3,1%, p&amp;lt;0,05), data confirmed also for Urokinase (1,9% vs 3,4%, p=0,274). None bloodstream are registred while ESI and WBC count show no significant differences between two study periods. No HD catheter was loss during the study due to thrombosis or infection. Finally, Hct, CRP and Albumin was found slightly lower on Bic-lock phase. Conclusion There is no CVC ideal lock solution and although sodium bicarbonate is inexpensive and readily avalaible our data shows better CVC performances with sodium heparin.

MO885APP BASED DOCUMENTATION AND SUPPORT OF A GERMAN HOME DIALYSIS PROGRAMM - A PILOT STUDY

Abstract Background and Aims Telemedicine is advancing. However, studies that examine the integration into home dialysis care are still scarce. This multicenter, Germany-wide prospective observational pilot-study investigated the effects, acceptance and usability of an app as a new care concept compared to conventionally cared-for patients. Method Here, we employed the “DiaApp”, a tablet based documentation, communication, information and supply ordering system developed by the PHV – a non-profit dialysis network in Germany with around 7,000 patients. During a pilot rollout phase of the app between 2018 and 2019, 25 patients participated in four dialysis practices. Participants were free to choose between app use (app) and the previous paper-based documentation (control). We collected prospective data on demographics, adverse events as well as questionnaires regarding quality of life (KDQL v1.3), affinity for technology (TA-EG), satisfaction with the app (UTAUT), and self-confidence in dealing with chronic illness (SES6G). Furthermore, 5 app users were interviewed in a qualitative interview over 90 min about their attitude towards technology, illness and the app. Results Of the 25 participants, 13 used the app (52%). App users tended to be younger, more likely to be male (60.0%) and on peritoneal dialysis (n=15, 60.0%). Median age and dialysis vintage for app users and controls were 51 (38-60; 0) vs. 59 (37-64; 1) years and 51.5 (34-68; 3) vs. 38 (28-66; 5) months, respectively. Mean follow-up durations were 6.5 months and 12 months. All participants continued to use the app. One exit site infection (app), 3 hospitalizations (peritonitis and shunt revision, controls; inguinal hernia, app) and no serious app-related adverse event occurred. App users exhibited small trends (n.s.) towards lower quality of life (median SF-12 physical composite app: 43, IQR 40-48 controls: 47, IQR 38-50; SF-12 mental composite median app: 53, IQR 35-55; controls: 56, IQR 42-59;) greater self-confidence in managing chronic illness (SESG6 Score app: 7.33, IQR: 6-8.83; controls:7.17, IQR 6-7.83) and higher affinity for technology (in all four TA-EG dimensions). App users were more likely to have completed a master’s degree, while non-users mostly had a bachelor's degrees (Chi-square 14.183, df 6, p=0.028). Overall, the educational level of participants was high. There was a tendency (n.s.) for actual app users to have slightly lower performance expectations (median control arm 5.5 vs. app arm 5.88 on a Likert scale 1-7), a slightly higher assessment of their own and other available resources (supportive conditions median control arm 6 vs. app arm 6.67 on a Likert scale 1-7). In the qualitative interviews, all app users surveyed stated that they regularly used digital offerings in all areas of their lives. Therefore, expectations were similar to other apps to be more efficient in terms of time, material and effort than paper-based documentation. The attitude towards the app was that towards an auxiliary tool, “it should simply work”, and found it to be useful. Patients disliked the necessity of a dedicated (in this case a tablet) device for running the app. Information about the disease was more likely to be outside of the app in e.g. the internet. Conclusion In this study, we found no significant differences between app users and controls. No adverse events occurred. Via trends and interviews, the picture emerges that an upcoming, younger generation of dialysis patients appreciates the advantages of flexible home dialysis procedures and, as in other areas of life, expects simple, digital and thus resource-saving options for self-management and communication. At the same time, such applications are also subject to the expectations of digital user experiences from other areas of life. This poses enormous challenges for the often-costly development of such applications by non-commercial providers and limited number of target audiences.

MO686THE EFFECT OF A CONTINUOUS TRAINING PROGRAM ON PERITONEAL DIALYSIS PATIENTS' SURVIVAL

Abstract Background and Aims Peritoneal Dialysis (PD) is a well-established method for dialysis of end stage kidney disease patients. Peritoneal membrane alters with time from several causes such as bioincompatible PD solutions, uremia, and the cumulative effect of peritonitis episodes. Each center follows a specific training program to prevent the appearance of peritonitis episodes. The aim of this study was to retrospectively evaluate the influence of proper and continuous training on the mortality of peritoneal dialysis patients. Method This is a single center retrospective study of 133 PD patients conducted for the time period 2009 – 2019 (10 years). The training course was taught one-on-one, nurse-to-patient at the initiation of dialysis and then once every 6 months at their regular visit or sooner if there was a peritonitis episode. The program included a rated questioner based on the Canadian Association of Nephrology Nurses for Nursing Standards and Practice Recommendations published on August 2008. The patients were divided into two groups according to the mean value (34) of their questioner sum (QS). Group A included 69 patients with mean age of 66 ± 15 years (36 M, 33 F) with mean PD duration of 45 ± 30 months and they achieved a score less than 34. Group B included 64 patients with mean age of 61 ± 18 years (42 M, 22 F) with mean PD duration of 62± 32 months and they achieved a score greater than 34. The cumulative all-cause survival of the PD patients was calculated by Kaplan Meier, was compared using Long Rang analysis and was also adjusted for their age, gender, the modality of PD applied, the presence of Diabetes and their level of education. Using Cox Regression, we tried to find independent risk factors such as the score they achieved in the questioner. The two groups were compared also for their overhydration and their frequency appearance of peritonitis or exit site infection. Results The cumulative survival using Kaplan-Meier analysis revealed statistically significant deference between the two groups (Log Rank p&amp;lt;0.001) with Group B (QS&amp;gt;34) achieving better survival. When the survival was adjusted for age, sex, Diabetes, PD modality the result remains the same. Trying to find among the total of our patients the possible risk factors for mortality, using Cox Regression analysis, their QS score (representing their training level for PD) was statistically significant (HR 0,931 {0.892, 0.971}, p=0.001) independent risk factor, as well as age and PD modality, for our patient survival. Additionally, Group B (QS&amp;gt;34) had statistically significant a smaller number of peritonitis episodes (p&amp;lt;0.001) and presence of peripheral edema (p&amp;lt;0.001). Conclusion In our study we concluded that continuous and monitored training of peritoneal dialysis patients has a significant effect on their survival and the frequency of peritonitis appearance.

MO699PERITONITIS RISK OF PD MODALITIES AND TECHNICAL SURVIVAL ACCORDING TO BASELINE PERITONEAL TRANSPORT STATUS

Abstract Background and Aims The PD modality is usually modulated according to the PET and dialysis adequacy during follow-up but, initial modality choice generally depends on patient preferences and lifestyle regardless of patients’ baseline transport status. However, the relationship between baseline transport status, the PD modality chosen, and technical survival is not well established. Peritonitis is one of the leading causes of technical failure, hospitalization, and death in PD. While obesity, low albumin levels, exit-site infections, and nasal staphylococcus carriage are well-defined risk factors for peritonitis, some suggest CAPD could be another risk factor due to increased daily connection to PD. Many studies indicated that CAPD and APD have similar technical survival rates. In this study, we aimed to identify the impact of the baseline transport status on technical survival of CAPD and APD. We also investigated peritonitis risk of modalities considering all defined risk factors. Method This is a retrospective, single-center, cohort study of incident adult PD patients followed-up between January 2010 and January 2020. One hundred and thirty-six patients, followed-up for at least three years, were included. Patients with malignancy and who had less than 1.7 Kt/V per week were excluded. Peritonitis is defined according to the "International Society Peritoneal Dialysis" guideline. According to the baseline PET, patients were divided into two groups as follows; 1) high or high average transporters and 2) low or low average transporters. Risk factors for peritonitis, five years, and overall technical survival of both modalities according to baseline transport status were determined. Results The mean age was 35.5±12 years, and the median follow-up time was 47 (36-178) months. Sixty-six (48%) of the patients were female. Patients' first-year Kt/V per week was 2.18±0.4, and the mean ultrafiltration was 0.9±0.4 liters. 26 (19%) of the patients had diabetes mellitus, 57(42%) patients had hypertension, and 27 (20%) of the patients had a history of hemodialysis of more than three months. 89 (65%) of the patients were performing CAPD, 59 (66%) of whom were low or low-average transporters. 47(35%) of patients were performing APD and 28(60%) of whom were high or high-average transporters. During the follow-up, a total of 71 peritonitis episodes were observed, and the incidence of peritonitis was 0.13 episodes/year. Univariate logistic regression analysis showed that CAPD, low education level (being primary school graduate or illiterate), HD treatment before PD, and bathing less than once per week were associated with peritonitis risk. However, multivariate analysis of associated factors demonstrated that only CAPD was a significant risk factor for peritonitis [odds ratio:2.360 (95% confidence interval:1.075-5.180), p=0.03]. Kaplan-Meier survival analysis showed that low or low-average transporters and high or high-average transporters had similar technical survival rates in both CAPD or APD at the end of three years (figure 1). Similar rates were found in overall survival. Conclusion In our study, APD and CAPD patients had similar technical survival regardless of the peritoneal transport characteristics. However, CAPD was found to be a factor for peritonitis. Thus, it may be appropriate to initiate the PD treatment with APD modality and evaluate patients to switch modalities with PET only in case of peritoneal dialysis inadequacy.

Variation in Peritoneal Dialysis–Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Peritoneal dialysis (PD)-associated peritonitis is a significant PD-related complication. We describe the likelihood of cure after a peritonitis episode, exploring its association with various patient, peritonitis, and treatment characteristics. Observational prospective cohort study. 1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States. Patient characteristics (demographics, patient history, laboratory values), peritonitis characteristics (organism category, concomitant exit-site infection), dialysis center characteristics (use of icodextrin and low glucose degradation product solutions, policies regarding antibiotic self-administration), and peritonitis treatment characteristics (antibiotic used). Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode. Mixed-effects logistic models. Overall, 65% of episodes resulted in a cure. Adjusted odds ratios (AOR) for cure were similar across countries (range, 54%-68%), by age, sex, dialysis vintage, and diabetes status. Compared with Gram-positive peritonitis, the odds of cure were lower for Gram-negative (AOR, 0.41 [95% CI, 0.30-0.57]), polymicrobial (AOR, 0.30 [95% CI, 0.20-0.47]), and fungal (AOR, 0.01 [95% CI, 0.00-0.07]) peritonitis. Odds of cure were higher with automated PD versus continuous ambulatory PD (AOR, 1.36 [95% CI, 1.02-1.82]), facility icodextrin use (AOR per 10% greater icodextrin use, 1.06 [95% CI, 1.01-1.12]), empirical aminoglycoside use (AOR, 3.95 [95% CI, 1.23-12.68]), and ciprofloxacin use versus ceftazidime use for Gram-negative peritonitis (AOR, 5.73 [95% CI, 1.07-30.61]). Prior peritonitis episodes (AOR, 0.85 [95% CI, 0.74-0.99]) and concomitant exit-site infection (AOR, 0.41 [95% CI, 0.26-0.64]) were associated with a lower odds of cure. Sample selection may be biased and generalizability may be limited. Residual confounding and confounding by indication limit inferences. Use of facility-level treatment variables may not capture patient-level treatments. Outcomes after peritonitis vary by patient characteristics, peritonitis characteristics, and modifiable peritonitis treatment practices. Differences in the odds of cure across infecting organisms and antibiotic regimens suggest that organism-specific treatment considerations warrant further investigation.

Does minimally invasive approach reduce risk of infection after ventricular assist device implantation?

We analyzed patients with left ventricular assist device (LVAD) related and specific infection, and aimed to determine whether surgical technique implantation affect the frequency of infection. We retrospectively analyzed the data of 99 patients who received LVAD at our department between June 2013 and June 2019. Patients were divided into two groups according to the surgical technique. Group A (n = 58) was conventional sternotomy (CS) and group B (n = 41) was on-pump minimally invasive left thoracotomy (MILT). Demographics, preoperative risk factors, LVAD infections, surgical incision site, driveline site, and outcomes were compared between these two groups. Mean follow up time was 589 ± 480 (31-2171) days. Infection was detected in 34% (41/99) of LVAD patients. Admission to emergency department and intensive care unit (ICU) in last 6 months were significantly higher in MILT group. There was no difference between the two groups in terms of driveline exit site infection (CS: 28%, MILT: 27%) (p > 0.05). Seven (17%) patients had infection in the thoracotomy incision site area in the MILT group. The rate of ICU hospitalization in the last 6 months was seen as the only independent risk factor increasing the frequency of infection (R = 0.30; p = 0.016). Survival analysis at 60 days, 1 year and 2 years showed no difference between the two groups (p = 0.09). Despite advances in pump technology and surgical technique, infection is still an important cause of mortality and morbidity.