International Society For Peritoneal Dialysis Research Articles

Nursing management of catheter-related non-infectious complications of PD: Your questions answered.

A review from the last seven years (August 2016-July 2023) of questions posted to the International Society for Peritoneal Dialysis (ISPD) website "Questions about PD" by nurses and physicians from around the world revealed that 19 of the questions were associated with optimal approaches for preventing, assessing, and managing issues related to PD catheter non-infectious complications. Our review focused on responses to these questions whereby existing best practice recommendations were considered, if available, relevant literature was cited and differences in international practices discussed. We combined similar questions, revised both the original questions and responses for clarity, as well as updated the references to these questions. PD catheter non-infectious complications can often be prevented or, with early detection, the potential severity of the complication can be minimized. We suggest that the PD nurse is key to educating the patient on PD about PD catheter non-infectious complications, promptly recognize a specific complication and bring that complication to the attention of the Home Dialysis Team. The questions posted to the ISPD website highlight the need for more education and resources for PD nurses worldwide on the important topic of non-infectious complications related to PD catheters, thereby enabling us to prevent such complications as PD catheter malfunction, peri-catheter leakage and infusion or drain pain, as well as recognize and resolve these issues promptly when they do arise, thus allowing patients to extend their time on PD therapy and enhance their quality of life whilst on PD.

Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry

A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion. Retrospective cohort study. Adults undergoing their first PD catheter insertion between November 1, 2011 and November 1, 2020, at 11 institutions in Canada and the US participating in the International Society for Peritoneal Dialysis (ISPD) North American Catheter Registry. Prior abdominal procedure(s), defined as any procedure that enters the peritoneal cavity. Primary outcome: time to the first of abandonment of the PD catheter, or interruption/termination of PD. rates of emergency room visits, hospitalizations, and procedures. Cumulative incidence curves were used to describe the risk over time and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes. A total of 855 patients met the inclusion criteria. Thirty-one percent had a history of a prior abdominal procedure and 20% experienced at least one PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome [Adjusted HR 1.12 (95% CI 0.68-1.84)]. Upper abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes. Observational study and cohort limited to sample of patients felt to be potential candidates for PD catheter insertion. A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to peritoneal dialysis.

PD peritonitis in patients undergoing capsule endoscopy: A descriptive study.

Peritoneal dialysis (PD) patients who undergo gastroendoscopy and colonoscopy are at increased risk of peritoneal dialysis-associated peritonitis (PD peritonitis) following the procedure (defined as occurring within 7 days of intervention). As per current International Society for PD (ISPD) guidelines, antibiotic prophylaxis is currently recommended pre-colonoscopy in PD patients given the risk of post-colonoscopy PD peritonitis. The risk of PD peritonitis in patients undergoing capsule endoscopy (CE) is unknown. This binational data-linkage study between the Australia and New Zealand Dialysis and Transplant Registry and all hospital admission data sets in Australia and New Zealand evaluated all patients with PD who underwent CE between 2006 and 2015. The objective of the study was to assess the risk of PD peritonitis in patients undergoing CE. Descriptive statistics were used to describe patient characteristics and clinical outcomes. Overall, 23 patients with PD underwent CE. Twelve patients underwent CE alone (i.e. no other concomitant procedures) and none of these patients experienced an episode of PD peritonitis. The remaining 11 patients underwent CE and other invasive endoscopic/abdominal surgical procedures, of whom 2 suffered PD peritonitis. CE is likely a relatively safe procedure in PD patients. PD patients undergoing CE may not require prior antibiotic prophylaxis. Given their relative safety, CE may be an appealing diagnostic tool in a select group of PD patients for the investigation of gastrointestinal disease.

Preporuke za dijagnostički i terapijski pristup infekcija povezanih sa peritonealnom dijalizom

Introduction: Patients with end-stage renal disease who start active treatment with peritoneal dialysis have an increased risk of developing infections. Methods: This paper will present information from relevant professional/scientific sources regarding modern diagnostic and therapeutic modalities for the treatment of infections in patients on peritoneal dialysis. Topic: Infections associated with peritoneal dialysis are: peritoneal catheter exit site infections, tunnel infections and peritonitis. The symptoms of the mentioned infections vary from mild ones such as erythema and secretion at the exit point of the peritoneal catheter to pronounced symptomatology in the development of peritonitis accompanied by abdominal pain and elevated body temperature. The most common cause of peritonitis is infection of the exit site of the catheter, and the two main causes of infection are Staphylococcus aureus and Pseudomonas aeruginosa. If the existence of an infection is suspected, it is necessary to sample the dialysate for cytological examination and culture and to take a swab of the exit site of the catheter. Treatment begins with empiric antibiotic therapy, then it is corrected according to the antibiogram, and the exit site is treated locally with an antibiotic. If there is no therapeutic response after five days of intraperitoneal therapy in peritonitis, it is recommended to remove the catheter. Conclusion: According to the current guidelines of the International Society for Peritoneal Dialysis (ISPD), timely prevention of infections, diagnosis and treatment of peritoneal dialysis-related infections are necessary to prolong patient survival.

Microbiology and Antimicrobial Resistance Profile of Infectious Peritonitis: A Cohort Study with 10-year Follow-up

Abstract Objectives: Peritoneal dialysis (PD) is a feasible option for patients with renal failure, but infectious peritonitis has long been a common complication in PD. The purpose of the current study was to provide epidemiological data about the rate, microbiology profile, and antimicrobial susceptibility pattern of infectious peritonitis in adult PD patients in Saudi Arabia. Materials and Methods: A descriptive study was performed. Demographics and diagnostic data of adult PD patients between 2009 and 2019 were collected. The infectious peritonitis episodes were explained per patient and the microbiology profile along with antimicrobial susceptibility testing results were analyzed. Results: One hundred renal failure adult patients underwent PD during 2009–2019, with 55.0% were female. Ninety-three infectious peritonitis episodes were identified in 52 patients and the overall peritonitis rate was 0.56 episodes per patient-year. Gram-positive bacteria were more responsible (61.3%) for infectious peritonitis than Gram-negative bacteria (37.6%) and expressed more antimicrobial resistance patterns. Coagulase-negative Staphylococci were the most frequently isolated Gram-positive bacteria from the PD fluid culture (27.9%). Acinetobacter baumannii, followed by Pseudomonas luteola, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most common Gram-negative bacteria identified at 6.5%, 5.4%, 5.4%, and 5.4%, respectively, with susceptibility patterns detected against most of the antimicrobials tested. Conclusions: The overall rate of infectious peritonitis was 0.56 episodes per patient-year, which is higher than the reported target published by the International Society for PD. More intense training programs and establishment of a national infectious peritonitis registry are recommended to minimize infection risk and improve patients’ quality of life.

A population-based study on the incidence and aetiology of infectious complications in peritoneal dialysis in South Sweden

Background Peritonitis is a major cause of morbidity in peritoneal dialysis (PD) and an independent risk factor for elevated all-cause mortality. The aims of this study were to report the incidence, trend, aetiology, and antimicrobial susceptibility of PD-associated peritonitis and catheter-related infections in South Sweden between 2011–2020. Methods This population-based observational cohort study included all patients with PD between the years 2011–2020 in the county of Skåne. Data was accessed through the Swedish Renal Registry and the Department of Clinical Microbiology in Lund. Definitions issued by the International Society for Peritoneal Dialysis were implemented to assess PD-associated infections. Results Medical records of 675 paediatric and adult PD patients were eligible for inclusion. Of those, 208 (31%) were female and the median age was 67 years (range 0-91). The overall rate of PD-peritonitis was 0.38 episodes per year at risk. Out of 484 episodes of peritonitis, 61% (n = 295) were caused by Gram-positive bacteria. There were 289 occurrences of exit site infections, of which most (n = 152, 53%) were Gram-positive. Tunnel infections occurred in 16 episodes and were caused by S. aureus or P. aeruginosa. Among all isolates, 37 were of MRSE, four of ESBL-producing E. coli, and one of MRSA. Conclusion The crude rate of PD-peritonitis was stable during the study period. Gram-positive bacteria dominated the microbial aetiology, and antibiotic resistance was limited. It is important to monitor the aetiology, incidence, and resistance rates in PD-associated infections, to base empirical antibiotic regimens and facilitate prevention.

Multi-center, pragmatic, cluster-randomized, controlled trial of standardized peritoneal dialysis (PD) training versus usual care on PD-related infections (the TEACH-PD trial): trial protocol

BackgroundPeritoneal dialysis (PD)-related infections, such as peritonitis, exit site, and tunnel infections, substantially impair the sustainability of PD. Accordingly, PD-related infection is the top-priority research outcome for patients and caregivers. While PD nurse trainers teach patients to perform their own PD, PD training curricula are not standardized or informed by an evidentiary base and may offer a potential approach to prevent PD infections. The Targeted Education ApproaCH to improve Peritoneal Dialysis outcomes (TEACH-PD) trial evaluates whether a standardized training curriculum for PD nurse trainers and incident PD patients based on the International Society for Peritoneal Dialysis (ISPD) guidelines reduces PD-related infections compared to usual training practices.MethodsThe TEACH-PD trial is a registry-based, pragmatic, open-label, multi-center, binational, cluster-randomized controlled trial. TEACH-PD will recruit adults aged 18 years or older who have not previously undergone PD training at 42 PD treatment units (clusters) in Australia and New Zealand (ANZ) between July 2019 and June 2023. Clusters will be randomized 1:1 to standardized TEACH-PD training curriculum or usual training practice. The primary trial outcome is the time to the first occurrence of any PD-related infection (exit site infection, tunnel infection, or peritonitis). The secondary trial outcomes are the individual components of the primary outcome, infection-associated catheter removal, transfer to hemodialysis (greater than 30 days and 180 days), quality of life, hospitalization, all-cause death, a composite of transfer to hemodialysis or all-cause death, and cost-effectiveness. Participants are followed for a minimum of 12 months with a targeted average follow-up period of 2 years. Participant and outcome data are collected from the ANZ Dialysis and Transplant Registry (ANZDATA) and the New Zealand Peritoneal Dialysis (NZPD) Registry. This protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.DiscussionTEACH-PD is a registry-based, cluster-randomized pragmatic trial that aims to provide high-certainty evidence about whether an ISPD guideline-informed standardized PD training curriculum for PD nurse trainers and adult patients prevents PD-related infections.Trial registrationClinicalTrials.gov NCT03816111. Registered on 24 January 2019.

Peritoneal Dialysis Patient Training Program to Enhance independence and Prevent Complications: A Scoping Review.

Peritoneal dialysis (PD) training is essential to ensure patient independence and prevent life-threatening complications, such as peritonitis. The International Society for Peritoneal Dialysis (ISPD) recommends that every PD unit worldwide implement local PD training programs with the goal of improving self-care capabilities. This scoping review aims to give an overview of recent literature and recommendations on PD training programs aiming to improve the quality of care and outcomes for PD patients. The literature search was conducted using the PC (Population, Concept) approach. The population of interest in this study is PD patients, and the study concept is the PD training program. Several databases were used to conduct the literature search, including PubMed, Science Direct, and CINAHL. The search process began from July 2022 until January 2023. The inclusion criteria for the search included research articles and recommendations. The search yielded 22 articles recommending training programs lasting from 5-8 days, with 1-3-hour sessions and a nurse-to-patient ratio of 1:1. A cumulative training time of 15 hours or more is recommended to enhance patient independence and reduce peritonitis rates. Home-based or in-unit PD training, conducted by experienced nurses using adult learning strategies, has shown significant value in improving self-care and preventing peritonitis. Evaluating training outcomes should encompass knowledge, skills, and attitudes, and the impact on peritonitis rates. Training programs should be flexible and consider physiological and psychosocial barriers to achieving the best results. There are a variety of strategies for dialysis training concerning duration, session length, patient-to-trainer ratio, timing, methods, location, compliance, and the need for retraining. More evidence is needed to assess the impact of PD patient training programs on self-care capabilities and peritonitis incidence. Future studies should investigate the effects of training programs on compliance, self-efficacy, and patient and nurse perspectives.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. PD catheter placement in Japan was proven to be safe and appropriate.

The Removal of Uremic Solutes by Peritoneal Dialysis.

Peritoneal dialysis (PD) is now commonly prescribed to achieve target clearances for urea or creatinine. The International Society for Peritoneal Dialysis has proposed however that such targets should no longer be imposed. The Society's new guidelines suggest rather that the PD prescription should be adjusted to achieve well-being in individual patients. The relaxation of treatment targets could allow increased use of PD. Measurement of solute levels in patients receiving dialysis individualized to relieve uremic symptoms could also help us identify the solutes responsible for those symptoms and then devise new means to limit their accumulation. This possibility has prompted us to review the extent to which different uremic solutes are removed by PD.

PERITONEAL DIALYSIS-ASSOCIATED PERITONITIS : A SYSTEMATIC REVIEW

Background: Peritoneal dialysis is infectious and non-infectious. Peritoneal dialysis causes catheter exit, tube tunnel, and peritonitis. Noninfectious consequences of peritoneal dialysis include catheter malfunction, external leakage, abdominal wall anomalies, scrotal edoema, pleural-peritoneal fistulas, failed ultrafiltration, and encapsulated sclerosis. PD complications include peritonitis. The International Society for Peritoneal Dialysis (ISPD) offers specific recommendations on PD-associated peritonitis prevention and treatment, however clinical practise differs greatly amongst dialysis units. Aim: This article examines the link between peritoneal dialysis and peritonitis and presents its findings. Methods: By evaluating the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 standards, this study demonstrated that it met all of the requirements. This enabled the researchers to ensure that the study was as up to date as feasible. Publications published between 2000 and 2023 were included in the search strategy, which included a variety of electronic reference databases (including Pubmed and SagePub). We did not consider review papers, duplicate publications, or half completed articles. Result: In the PubMed database, the results of our search brought up 133 articles, whereas the results of our search on SagePub brought up 69 articles. The results of the search conducted for the last year of 2000 yielded a total of 20 articles for PubMed and 8 articles for SagePub. In the end, we compiled a total of 21 papers, six of which came from PubMed and three of which came from SagePub. We included nine research that met the criteria. Conclusion: Gram-positive bacteria are the most common cause of Parkinson's disease-associated peritonitis. Despite the high frequency of PD-associated peritonitis, it has a high cure rate.

INCIDENCE, CLINICAL OUTCOME AND CHANGES OF PERITONEAL MEMBRANE TRANSPORT STATUS IN TREATED CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) RELATED PERITONITIS

Peritoneal dialysis-related peritonitis remains the most common complication and a key barrier to peritoneal dialysis’ long-term success. The present study aimed to report on the incidence of peritonitis and clinical outcomes in CKD patients on CAPD at a hospital in Vietnam’s south and evaluate the peritoneal membrane transport status before and after peritonitis therapy. This study was a cross-sectional study involving 141 participants sampled from the warded adult patients at An Giang center general hospital, in Vietnam. Peritonitis rate was measured in terms of incidences per patient-year. Dialysis fluid was drawn under aseptic conditions and treated using a culture approach to identify bacteria. The response treatment time for each episode of peritonitis after receiving empirical antibiotic medication. We use Peritoneal Equilibration Test (PET) to determine the peritoneal transport status. Peritonitis was found in 29.8% of the cases. The number of episodes of peritonitis per patient-year was 0.035. Negative bacteria account for 81.0 percent of all cases tested. It took an average of 3 to 5 days for a clinical response. Before and after peritonitis, there was no statistically significant connection between transport status groups. The rate of peritonitis identified in this study was significantly lower than that recommended by the International Society for Peritoneal Dialysis (ISPD) recommendations. More research is needed to fully understand the variables that influence the clinical outcomes of peritonitis and the remaining function of the peritoneal membrane.

July Meeting Announcements

October 7-10, 2023, Academy of Nutrition and Dietetics, Food and Nutrition Conference and Expo (FNCE) 2023, Colorado Convention Center, Denver, CO. www.eatright.org/FNCE or call 800-877-1600 ext. 4862. October 14-16, 2023, American Nephrology Nurses Association (ANNA) Fall Meeting, Hilton Chicago, Chicago, IL. www.annanurse.org/events/2023-nephrology-nursing-practice-management-leadership-conference or call 888-600-2662. November 2-5, 2023, American Society of Nephrology (ASN) Kidney Week 2023, Pennsylvania Convention Center, Philadelphia, PA. www.asn-online.org/education or call 866-849-8868. April 13-16, 2024, International Society of Nephrology (ISN) World Congress of Nephrology 2024, Buenos Aires, Argentina. Visit www.theisn.org/wcn. April 14-17, 2024, American Nephrology Nurses Association (ANNA) 2024 Natl Symp Caribe Royale All Suite Hotel Convention Cent Orlando, FL. www.ananurse.org/events/2024-national-symposium or call 888-600-2662 May 14-18, 2024, National Kidney Foundation (NKF) Spring Clinical Meeting, Long Beach, CA. Visit www.kidney.org. or call 800-622-9010. May 23-26, 2024, 61st European Renal Association-European Dialysis and Transplantation Association (ERA-EDTA) Congress, Stockholmsmassan, Stockholm, Sweden, [email protected]. August 28-31, 2024, International Society on Renal Nutrition and Metabolism, 21st Congress of the International Society of Renal Nutrition and Metabolism, Hyderabad, India. www.icrnm2024.com. September 26-29, 2024, International Society for Peritoneal Dialysis, 40th Anniversary Congress, Dubai, UAE. www.ispd.org/dubai2024.

Intraperitoneally Administered Vancomycin in Patients with Peritoneal Dialysis-Associated Peritonitis: Population Pharmacokinetics and Dosing Implications.

Peritonitis is a limiting complication of peritoneal dialysis, which is treated by intraperitoneal administration of antibiotics. Various dosing strategies are recommended for intraperitoneally administered vancomycin, which leads to large differences in intraperitoneal vancomycin exposure. Based on data from therapeutic drug monitoring, we developed the first-ever population pharmacokinetic model for intraperitoneally administered vancomycin to evaluate intraperitoneal and plasma exposure after dosing schedules recommended by the International Society for Peritoneal Dialysis. According to our model, currently recommended dosing schedules lead to possible underdosing of a large proportion of patients. To prevent this, we suggest avoiding intermittent intraperitoneal vancomycin administration, and for the continuous dosing regimen, we suggest a loading dose of 20 mg/kg followed by maintenance doses of 50 mg/L in each dwell to improve the intraperitoneal exposure. Vancomycin plasma level measurement on the fifth day of treatment with subsequent dose adjustment would prevent it from reaching toxic levels in the few patients who are susceptible to overdose.

May Meeting Announcements

May 7-10, 2023, American Nephrology Nurses Association 2023 National Symposium, Renaissance Palm Springs & Palm Springs Convention Center, Palm Springs, California. www.annanurse.org/events/2023-national-symposium or call 888-600-2662. June 3-7, 2023, American Transplant Congress 2023, San Diego Convention Center, San Diego, California. www.atcmeeting.org/# or call 703-414-7870. June 15-18, 2023, 60th European Renal Association-European Dialysis and Transplantation Association Congress, Milano Convention Center, Milan, Italy. [email protected]. October 7-10, 2023, Academy of Nutrition and Dietetics, Food and Nutrition Conference and Expo 2023, Colorado Convention Center, Denver, Colorado. www.eatright.org/FNCE or call 800-877-1600 ext. 4862. October 14-16, 2023, American Nephrology Nurses Association Fall Meeting, Hilton Chicago, Chicago, Illinois. www.annanurse.org/events/2023-nephrology-nursing-practice-management-leadership-conference or call 888-600-2662. November 2-5, 2023, American Society of Nephrology Kidney Week 2023, Pennsylvania Convention Center, Philadelphia, Pennsylvania. www.asn-online.org/education or call 866-849-8868. May 14-18, 2024, National Kidney Foundation Spring Clinical Meeting, Long Beach, California. Visit www.kidney.org. or call 800-622-9010. August 28-31, 2024, International Society on Renal Nutrition and Metabolism, 21st Congress of the International Society of Renal Nutrition and Metabolism, Hyderabad, India. www.icrnm2024.com. September 26-29, 2024, International Society for Peritoneal Dialysis, 40th Anniversary Congress, Dubai, the United Arab Emirates. www.ispd.org/dubai2024.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

Deprescribing the Kt/V Target for Peritoneal Dialysis in the United States: The Path Toward Adopting International Standards for Dialysis Adequacy.

PD effluent specimen collection: Your questions answered.

When a patient on peritoneal dialysis (PD) presents with suspected PD-related peritonitis (e.g. cloudy PD fluid and abdominal pain), one of the most important initial aspects of management is for the nephrology nurse/home dialysis nurse to collect PD effluent specimens for white blood cells count, Gram stain, culture and sensitivity for inspection and to send for laboratory testing before antibiotics are started. A review by seven members of the International Society for Peritoneal Dialysis (ISPD) Nursing Committee of all 133 questions posted to the ISPD website 'Questions about PD' over the last 4 years (January 2018-December 2021), revealed 97 posted by nephrology nurses from around the world. Of these 97 questions, 10 were noted to be related to best practices for PD effluent specimen collection. For our review, we focused on these 10 questions along with their responses by the members of the ISPD 'Ask The Experts Team', whereby existing best practice recommendations were considered, if available, relevant literature was cited and differences in international practice discussed. We revised the original responses for clarity and updated the references. We found that these 10 questions were quite varied but could be organised into four categories: how to collect PD effluent safely; how to proceed with PD effluent collection; how to collect PD effluent for assessment; and how to proceed with follow-up PD effluent collection after intraperitoneal antibiotics have been started. In general, we found that there was limited evidence in the PD literature to answer several of these 10 questions posted to the ISPD website 'Questions about PD' by nephrology nurses from around the world on this important clinical topic of best practices for PD effluent specimen collection. Some of these questions were also not addressed in the latest ISPD Peritonitis Guidelines. Moreover, when polling members of our ISPD Nursing Committee we found when answering a few of these questions, nursing practice varied within and among countries. We encourage PD nurses to conduct their own research on this important topic, focusing on areas where research evidence is lacking.

Optimal peritoneal fluid white blood cell count for diagnosis of peritonitis in peritoneal dialysis patients.

The diagnosis of peritonitis among peritoneal dialysis (PD) patients is based on clinical presentation, dialysis effluent white blood cell (WBC) count, and dialysis effluent culture. Peritoneal fluid WBC count is very important in the initial diagnosis of peritonitis. The purpose of this work was to determine the optimal number of peritoneal WBCs with different clinical presentations at admission to define PD-related peritonitis. Medical records of chronic PD patients who underwent work-up for suspected peritonitis between 2008 and 2019 were reviewed retrospectively. Results of all peritoneal WBC count tests during this period were collected. Clinical manifestations and follow-up analysis of each peritoneal WBC count were performed. The peritoneal WBC count cutoff of 100/μL recommended by International Society for Peritoneal Dialysis provided specificity of only 35%. Increasing peritoneal WBC count cutoff to 150, 200, and 250/μL provided sensitivity around 98% and gradually increasing specificity. The chi-square automatic interaction detector model of statistical analysis determined that peritoneal WBC count below 230/μL combined with absence of inflammatory markers (fever, increased C-reactive protein) ruled out peritonitis with 99.8% sensitivity. Peritoneal fluid WBC count cutoff of 230/μL provided specificity of 89% and good positive and negative likelihood scores of 8.3 and 0.03, respectively. Peritoneal fluid polymorphonuclear count has lower discriminating ability for peritonitis compared to peritoneal fluid WBC count. Increasing peritoneal fluid WBC count cutoff to 230/μL in suspected PD-related peritonitis could improve specificity without compromising the sensitivity of the test.

MO1051: Standardized Simulation Education Program with Summative Assessment on Exchange Procedure of Ultrabag System for Peritoneal Dialysis: Innovations in Practical Recommendations

Abstract BACKGROUND AND AIMS Inexperience in practicing peritoneal dialysis (PD) and lack of standard education program under the instruction of qualified renal nurses are known causes of peritonitis in patients with chronic renal failure [1]. Thus far, the standardized and validated curriculum for Continuous Ambulatory Peritoneal Dialysis (CAPD) training has not been well-established under simulation-based education model [2]. We aimed i) to develop a well-structured and standardized educational training program on exchange procedure of Ultrabag system and ii) to evaluate the degree of acquisition in domains of cognitive (knowledge) and psychomotor (skills) by summative assessment using valid and reliable knowledge evaluation index and performance checklist. METHOD Following an invention of 3D-printed CAPD device, ‘Helping Hands’ in closed system operation, the Renal Unit in the Department of Medicine and Multi-Disciplinary Simulation and Skills Centre (MDSSC) in Queen Elizabeth Hospital (QEH) formulated a standard 5-day CAPD training to equip PD patients with knowledge and skills for safe Ultrabag exchange. In order to optimize training effectiveness and assessment standards, the program was designed with ‘6 (+2 additional) guiding questions’ from the International Society for Peritoneal Dialysis (ISPD) document [3]. Scoring Checklist with specific and relevant items, such as fixation of the connecting catheter, parallel point-to-point connection and procedures in placing disinfection cap, could strengthen internal validity. RESULTS In 2021, 17 CAPD patients with partial impairment in vision (12, 71%) or eye-hand coordination (13, 77%) attended this education program. Post-training assessment showed that participants had improved cognitive knowledge (M = 71%; A Grade (>80 marks) = 5, 29% B Grade (60–80 marks) = 9, 53%; C Grade (<60 marks) = 3, 18%) and psychomotor skills (100% achievement in simulation task). Except for 1 participant who required additional training session and re-assessment, 94% of them passed the simulation examination by completing all procedures without any assistance in one-take. A validated educator-guided scheme of psychomotor skills in proper use of CAPD is recommended with six operational phases: CONCLUSION Repetitive performance in task-specific procedure of bag exchange, coupled with constructive feedback from experienced renal nurse educators and well-validated assessment (with a standardized scoring sheet and checklist), resulted in improved skill performance. The training program, correspondent with traditional concept of Miller's pyramid (1990), demonstrated how CAPD novice turns skillful user by developing competence in cognition with factual knowledge of dialysis (‘Knows’) and verbalization of rationale and flows of PD (‘Knows How’); and competence in behavior with simulation practice with CAPD device (‘Shows’) and summative assessment demonstrating mastery of safe bag exchange skills to be integrated into everyday practice (‘Does’). Further studies may be warranted to investigate whether knowledge and skills acquired before use of CAPD could be carried over time and on how education program accounts for risk minimization of CAPD-related peritonitis and survival rate.

Establishing a Core Outcome Measure for Peritoneal Dialysis-related Peritonitis: A Standardized Outcomes in Nephrology—Peritoneal Dialysis Consensus Workshop Report

IntroductionPeritoneal dialysis (PD)-related peritonitis is one of the leading causes of discontinuation of PD and is considered a critically important outcome for patients on PD. However, there is no universally accepted method of measuring this outcome in clinical trials.MethodsWe convened an online consensus workshop to establish a core outcome measure for PD-related peritonitis in clinical trials.ResultsA total of 53 participants, including 18 patients and caregivers, from 12 countries engaged in breakout discussions in this workshop. Transcripts were analyzed thematically. We identified the following 3 themes: (i) feasibility and applicability across diverse settings, which reflected the difficulty with implementing laboratory-based measures in resource-limited environments; (ii) ensuring validity, which included minimizing false positives and considering the specificity of symptoms; and (iii) being meaningful and tangible to patients, which meant that the measure should be easy to interpret, reflect the impact that symptoms have on patients, and promote transparency by standardizing the reporting of peritonitis among dialysis units.ConclusionA core outcome measure for PD-related peritonitis should include both symptom-based and laboratory-based criteria. Thus, the International Society for Peritoneal Dialysis (ISPD) definition of peritonitis is acceptable. However, there should be consideration of reporting suspected peritonitis in cases where laboratory confirmation is not possible. The measure should include all infections from the time of catheter insertion and capture both the rate of infection and the number of patients who remain peritonitis free. A core outcome measure with these features would increase the impact of clinical trials on the care and decision-making of patients receiving PD.