Peritoneal Dialysis Unit Research Articles

YAŞLI SON DÖNEM BÖBREK HASTALARINDA ASİSTE PERİTON DİYALİZİNİN KARŞILAŞTIRILMASI

Aim: There has been a steady increase in the number of elderly patients with end-stage renal disease (ESRD) receiving renal replacement therapy (RRT). We aimed to compare the efficiency and complications between individual and family member-assisted PD in a patient group with geriatric ESRD.
 Method: This retrospective study included 50 patients > 65 years of age who received CAPD treatment between 2017-2019 in the peritoneal dialysis unit. Before dialysis modality selection, patients' functional status was evaluated with the 6-item activities of daily living (ADL) and 8-item instrumental daily living activities (IADL). Their three years’ follow-up results were evaluated in terms of dialysis efficiency parameters and dialysis complications.
 Results: There was no statistical difference between the two groups regarding their age, gender, and biochemical data. There was also no difference between edema, exit-site infection, and leakage; however, a significant difference was observed between the total number of peritonitis and the time until the first peritonitis attack. The time until the first peritonitis attack was shorter in the APD group than in the other group. Besides, the number of total peritonitis attacks was higher in the assisted PD group.
 Conclusion: The elderly ESRD population is increasing, and PD use is declining worldwide. However, if APD is not done well, it may not be an effective strategy to reverse this decline and provide safe and successful treatment to many frail, elderly patients.

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

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

A Case of Peritoneal Dialysis-Related Peritonitis Caused by Ewingella americana

Peritoneal dialysis (PD)-related peritonitis is a frequent complication. PD units should be aware of all possible pathogens and share their experience about prevention and optimal management. Uncommon bacteria, a special group with crescent incidence in PD practice, may require singular considerations. A case of peritonitis due to Ewingella americana, a rare human pathogen, is reported, with a favorable outcome. To date, only three other cases have been described in the literature. New evidence is necessary for a better understanding of this pathogen and its consequences in PD modality.

POS-679 SWEET HYDROTHORAX: A PERITONEAL DIALYSIS DILEMMA

Hydrothorax is a rare and serious complication in the patient treated with peritoneal dialysis (PD). It consists of pleuro peritoneal communication through the porous diaphragmatic leak. Its diagnosis is challenging as it may be wrongly considered as fluid overload. It may lead to vicious circle because hypertonic glucose peritoneal solutions may be used thus aggravating surcharge. case report A 45-year-old male with end stage chronic kidney disease secondary to IgA nephropathy, 4 years after starting automated peritoneal dialysis (APD) contacted our institution’s PD unit with complaints of cough and dyspnoea. He has past medical history of hypertension, 2 episodes of peritonitis successfully treated.Clinical examination revealed oedema of the lower extremities and reduced auscultation sounds in the right lower lung. Residual diuresis was absent. Chest radiography confirmed right pleural effusion.Thorax computed tomography showed a massive pleural effusion with right lower-lobe atelectasis and evidence of multiple defects in the diaphragmatic dome with a diaphragm that is shriveled at the right cardiophrenic angle. The thoracentesis drained 1.7L of pleural fluid during the following days.Laboratory findings demonstrated a transudative effusion with the chemical component of pleural fluid similar to PD fluid.We did not find any sign of peritonitis, hypoalbuminaemia, infectious or neoplastic diseases. However, echocardiography revealed cardiac failure. Patient was switched to hemodialysis and intensive ultrafiltration was performed. This case describes an unusual presentation of hydrothorax in the context of peritoneal dialysis. Switchto hemodialysis is frequently necessary temporarily or definitively. All clinicians prescribing peritoneal dialysis should be aware of this complication to avoid delayed diagnosis.

POS-700 MANAGEMENT OF PERITONITIS IN PATIENTS ON AUTOMATED PERITONEAL DIALYSIS IN AUSTRALIA AND NEW ZEALAND

In the absence of evidence and guidelines on the management of peritoneal dialysis (PD)-associated peritonitis in patients on automated peritoneal dialysis (APD), variations in clinical practice potentially exist between PD units which could affect clinical outcomes. This study aimed to document current practices of treating PD-associated peritonitis in patients on APD across Australia and New Zealand and reasons for any practice variations using a cross-sectional online survey.

POS-913 COVID-19 INCIDENCE AND OUTCOMES IN PERITONEAL DIALYSIS UNIT IN SFAX (TUNISIA) AT THE HEIGHT OF THE PANDEMIC

The 2019 coronavirus (COVID-19) is a viral infection caused by a new coronavirus that is affecting the entire world. Patients in dialysis are particularly vulnerable because of their multiple co-morbidities and immunosuppression. We report in our study the incidence and the course of COVID-19 in peritoneal dialysis (PD) unit at the height of the pandemic.

POS-954 COVID-19 IN PATIENTS ON PERITONEAL DIALYSIS

After first being identified in Wuhan, China in December 2019, the novel Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 quickly became a global pandemic. In Malaysia, the general population mortality rate is approximately 1.63% whereas in dialysis patients the mortality rate goes up to 21%, almost similar as data in Italy at the height of the pandemic. In the Nephrology Department Hospital Kuala Lumpur, the Peritoneal Dialysis Units cater for approximately 430 patients on peritoneal dialysis.

Practice variations in antibiotic administration for the management of peritonitis in patients on automated peritoneal dialysis in Australia and New Zealand.

In the absence of guidelines on the management of peritoneal dialysis (PD)-associated peritonitis in patients on automated peritoneal dialysis (APD), variations in clinical practice potentially exist between PD units that could affect clinical outcomes. This study aimed to document the current practices of treating PD-associated peritonitis in patients on APD across Australia and New Zealand and the reasons for practice variations using a cross-sectional online survey. Of the 62 PD units, 34 medical leads (55%) responded to the survey. When treating APD-associated peritonitis, 21 units (62%) continued patients on APD and administered intraperitoneal (IP) antibiotics in manual daytime exchanges; of these, 17 (81%) considered allowing at least 6 h dwell time for adequate absorption of the IP antibiotics as an important reason for adding manual daytime exchange. Nine units (26%) temporarily switched patients from APD to continuous ambulatory peritoneal dialysis (CAPD); of these, five (55%) reported a lack of pharmacokinetic (PK) data for IP antibiotics in APD, four (44%) reported a shortage of APD-trained nursing staff to perform APD exchanges during hospitalisation and three (33%) reported inadequate time for absorption of IP antibiotics on APD as important reasons for their practice. Four units (12%) continued patients on APD and administered IP antibiotics during APD exchanges; of these, three (75%) believed that PK data available in CAPD could be extrapolated to APD. This study demonstrates wide variations in the management of APD-associated peritonitis in Australia and New Zealand; it points towards the lack of PK on antibiotics used to treat peritonitis as an important reason underpinning practice variations.

Barriers to pre-dialysis education in hemodialysis patients with end-stage renal disease in Kingdom of Saudi Arabia

Background: Adequate pre-dialysis education was found to help patients select the best modality at the time dialysis is needed. Objectives: To identify the barriers to pre-dialysis education in the nephrology clinics among end-stage renal disease (ESRD) in the Kingdom of Saudi Arabia (KSA). Methods: We did a multi-center, cross-sectional study on 221 patients. A questionnaire was used to collect data about patients’ demographics, the primary cause of renal failure, and barriers to pre-dialysis education in the nephrology clinic. We selected the healthcare providers randomly from the same centers. Results: The leading cause of renal failure was diabetes mellitus (DM) in 24.9% of the Patient participants. About 64.7% were with hemodialysis, and 35.3% had peritoneal dialysis. The distance to the nephrology clinic is more than 50 km, about 63.7%. About 65.2% have followed up in the CKD clinic, and dietitians have seen 64.3% in the clinic. Dialysis educators.s have previously seen 59.7%. About 68.8% of the participants had the chance to understand dialysis modality before the commencement of treatment. The barriers from healthcare participants point out are 43.5 % of participants have no CKD clinic, 74% are without a multidisciplinary team, 61% evaluate more than 15 patients every clinic, and 43.5% assess patients with advanced chronic kidney disease every three months or more. 47.8% found many services in their hospital required to refer patients to another hospital because lack of nephrologists per 74% of participants, and 39% of them indicated no peritoneal dialysis unit. And 47.8% found no sociopsychology services play a role as a barrier. Conclusion: The barriers to pre-dialysis education studied in this paper from patients and healthcare providers points. That included the deficiency of a formal structured multidisciplinary chronic kidney disease clinic, lack of psychosocial support for CKD patients, and patients required to travel between hospitals more than 50 kilometers to get renal services. Key words: barriers, pre-dialysis, education, hemodialysis, ESRD, Saudi Arabia.

COVID-19 vaccine hesitancy and response to a simple educational intervention in patients attending an outpatient dialysis unit in Johannesburg, South Africa

Background: Patients living with kidney failure are at risk of severe COVID-19 disease. However, vaccination reduces transmission and severity of disease. The uptake of COVID-19 vaccination in South Africa remains poor, suggesting a requirement for novel recruitment strategies. We examined COVID-19 vaccine hesitancy in an urban dialysis population in Johannesburg, South Africa, and investigated the efficacy of an educational intervention on vaccination intention. Methods: One hundred and four participants were recruited from outpatient haemo- and peritoneal dialysis units at the Helen Joseph Hospital. Participants completed anonymous, self-administered questionnaires analysing their acceptance of and concerns regarding COVID-19 vaccination before and after dissemination of the South African Nephrology Society SARS-CoV-2 vaccine information brochure. Results: Seventy-two participants (69%) were unvaccinated against SARS-CoV-2; 23 (22%) indicated unwillingness to undergo vaccination. Vaccine side effects, safety and perceived risk of SARS-CoV-2 transmission by vaccination were important factors in hesitancy. A small proportion believed that COVID-19 was not a serious threat to personal health. News media was an important information source for vaccine-hesitant respondents; prior healthcare worker counselling reduced hesitancy (OR 0.175, 95% CI 0.039–0.784; P = 0.023). The information brochure reduced concerns about vaccine side effects (P = 0.028), increasing vaccination intention to 84%. In-centre vaccination was additionally identified as a strategy to reduce hesitancy (OR 0.053, 95% CI 0.012–0.221; P &lt; 0.001). Conclusions: This first analysis in an urban dialysis population in South Africa highlights factors contributing to vaccine hesitancy. Simple educational interventions capitalising on trust in healthcare workers and improved vaccine accessibility may increase vaccine uptake. Keywords: COVID-19, vaccine hesitancy, dialysis

Patient and Clinician Perspectives on the use of Remote Patient Monitoring in Peritoneal Dialysis.

Background:Numerous factors influence patient recruitment to, and retention on, peritoneal dialysis (PD), but a major challenge is a perceived “inaccessibility” to treating clinicians. It has been suggested that remote patient monitoring (RPM) could be a means of improving such oversight and, thereby, uptake of PD.Objective:To describe patient and clinician perspectives toward RPM and the use of applications (Apps) suitable for mobiles, tablets, or computers to support the provision of PD care.Design:Qualitative design using semi-structured interviews.Setting:All patient participants perform PD treatment at home under the oversight of an urban PD unit in Sydney, Australia. Patient and clinician interviews were conducted within the PD unit.Participants:14 participants (5 clinicians [2 nephrologists, 3 PD nurses] and 9 patients treated with PD).Methods:Semi-structured interviews were conducted using interview guides tailored for clinician and patient participants. Transcripts were coded and analyzed by a single researcher using thematic analysis.Results:Six themes were identified: perceived benefits of RPM implementation (offering convenience and efficiency, patient assurance through increased surveillance, more complete data and monitoring adherence), uncertainty regarding data governance (protection of personal data, data reliability), reduced patient engagement (transfer of responsibility leading to complacency), changing patient-clinician relationships (reduced patient-initiated communication, the need to maintain patient independence), increased patient and clinician burden (inadequate technological literacy, overmanagement leading to frequent treatment changes), and clinician preference influencing patient behavior.Limitations:The interviews were conducted in English only and with participants from a single urban dialysis unit, which may limit generalizability.Conclusions:For patients and clinicians, advantages from the use of RPM in PD may include increased patient confidence and assurance, improved treatment oversight, more complete data capture, and overcoming barriers to data documentation. Careful patient selection and patient and clinician education may help to optimize the benefits of RPM, maintain patient independence, and reduce the risks of patient disengagement. The use of an App may support RPM; however, participants expressed concerns about increasing the burden on some patients through the use of unfamiliar technology.Human Research Ethics Committee Approval Number:CH62/6/2019-028

Regular at-home abdominal paracentesis via Tenckhoff catheter in patients with refractory congestive heart failure.

Peritoneal dialysis (PD) is increasingly used for the long-term management of refractory congestive heart failure (CHF). Patients with severe CHF and ascites were treated with regular at-home abdominal paracentesis via Tenckhoff catheter. We investigated the outcome of those patients, aiming to identify potential prognostic factors for longer survival. Patients with refractory CHF referred by cardiologists to the PD unit from years 2009 to 2019 and treated with regular at-home abdominal paracentesis via Tenckhoff catheter without peritoneal exchanges, were enrolled into this prospective observational study. From the total of 69 refractory CHF patients treated with PD, 18 (26%) were managed with regular at-home abdominal paracentesis via Tenckhoff catheter and improved without the need for peritoneal exchanges for fluid removal (no peripheral oedema or pulmonary congestion) or for solutes removal. Median survival of severe CHF patients treated with abdominal paracentesis was 13.5months (0-34months). Long-term survivors demonstrated significant improvement in the New York Heart Association (NYHA) functional class, improvement in kidney function and decrease in serum C-reactive protein (CRP) and Brain natriuretic peptide (BNP) compared with their baseline status. A subgroup of patients with shorter survival were more likely to have evidence of liver cirrhosis and significantly lower serum sodium compared with patients with longer survival. Refractory CHF patients with massive ascites could be successfully treated with regular at-home abdominal paracentesis via Tenckhoff catheter. This treatment provides a useful alternative to periodical percutaneous paracentesis on as-needed basis.

Peritoneal access – a pressing problem

In Portugal, as well as in Europe, peritoneal dialysis (PD) use remains low. Reorganization of PD units including a well -structured peritoneal access management protocol are fundamental to improve the take -up of this therapy. We analyzed the procedure and outcomes in a PD unit, addressing two key quality questions: at which level of estimated glomerular filtration rate (eGFR) were patients referred to peritoneal catheter placement and whether if it was timely placed. We retrospectively evaluated all patients submitted to catheter placement between 2017 and June 2020. We analyzed the patient journey from Kidney Replacement Therapies (KRT) Option Appointment, until PD start, as well as demographic and clinical variables, including eGFR at four time points (KRT Options Appointment, PD unit evaluation, catheter placement, and PD start). To explore the adequacy of catheter placement schedule, we compared the characteristics of the patients who started PD within 90 days of catheter placement (Early group), and of those who started after the first 90 days (Late group). We analyzed 48 patients in the Early and 27 in the Late group. The Early group presented a lower eGFR on KRT Options Appointment, with timely intervention: eGFR at catheter placement averaged 8.0 ± 2.1 mL/min/1,72m2. PD start occurred at 7.0 ± 1.9 and 8.0 ± 2.4 mL/min/1.72m2, in the Early and Late group, respectively. None of the patients suffered an urgent transition to HD by CVC. Four patients started PD less than 15 days after catheter placement, all of them without complications. PD patients’ admission involves specific tasks. Administrative tools or indicators to evaluate those processes are lacking. A peritoneal access clinic would allow the formalization of this circuit, allowing a quality and equitable approach to dialysis access. We suggest a structured pathway for peritoneal access management.

MO707MICROBIOLOGY, CLINICAL SPECTRUM AND OUTCOME OF INFECTIOUS PERITONITIS IN PATIENTS ON AUTOMATED PERITONEAL DIALYSIS

Abstract Background and Aims Automated peritoneal dialysis (APD) is a renal replacement therapy that offers patients various advantages such autonomy and comfort. Peritoneal dialysis-related infectious peritonitis (IP) is the most common and severe complication of APD. It is the main cause of technique failure and transfer to hemodialysis and can even be life-threatening. Given the seriousness of this complication, it is necessary to establish preventive strategies and adapt the therapeutic management.The aim of this study was to determine the microbiological and clinical profile of IP, to specify its causes its rate and outcome in patients treated by DPA at the unit of Charles Nicolle hospital in Tunis between January 2000 and December 2018. Method We conducted a single-center descriptive retrospective study in the peritoneal dialysis (PD) unit of Charles Nicolle Hospital in Tunis. We identified the episodes of IP occurring in patients treated with APD during the period from January 2000 to December 2018. We studied the clinical, biological and evolutionary aspects of IP. Results APD was used in 85% of patients treated at our PD unit during the study period. 322 episodes of IP occurred in 183 patients, that was an IP rate of 0.1 episodes/patient-year. 58% of patients treated with DPA have not presented IP. The mean age of the patients who presented PI was 43 years +/- 15(Extreme: 17-77) with a sex-ratio of 1.23. 74% of patients had a professional activity. 98% of patients had co-morbidities dominated by hypertension (88%), dyslipidemia(73%) and diabetes(16%) with a median Charlson score of 2[2-3] (Extremes: 2-9). Their average Body Mass Index was 24kg/m2+/-5. 33% of the patients were smokers. The average training duration before starting APD was 13days+/-5. The IP were evenly distributed according to seasons (27% occurred in autumn, 26% in spring, 25% in summer and 22% in winter). IP were: a 1st episode in 55% of cases, a new episode in 30% of cases, a relapse in 10% of cases, a recidivism in 3% of cases and a recurrence in 2% of cases. Fever was present in 34% of patients, abdominal pain in 75% of them. The dialysate was cloudy in 98% of cases. The median number of leukocytes in the PD fluid was 380/mm3(Range: 15-8000)with a mean% of neutrophils of 73%+/- 27. Dialysate culture was positive in 60% of cases, negative in 38% of cases and contaminated in 2% of cases. Among the positive cultures, only one was fungal (Candida albicans). Bacterial IP were distributed as follows: 64% Cocci Gram+ dominated by Staphylococcus aureus (48%), 34% Bacillus Gram- (mainly Klebsiella pneumoniae (21%) and Pseudomonas (21%)), 2 cases of Bacillus Gram+ (Corynebacterium afermentans and Lactobacillus) and 2 cases of polymicrobial culture (Cocci Gram+ and Bacillus Gram-).IP was of unknown cause in 48% of cases, related to an asepsis lack in 19% of cases, the orifice infection in 18% of cases and tunnelitis in 2% of cases. The other causes were essentially endogenous. Probabilistic antibiotic therapy was effective in 34% of cases. An adaptation according to the microbiological results was carried out in 19% of cases. Hospitalization was required in 10% of patients. 20% of peritonitis was refractory. Catheter ablation was performed in 14% of patients.IP caused the death of 8 patients and represented 37% of the causes of transfer to hemodialysis. Conclusion IPs are a turning point for the survival of the patient and the technique. Knowing the microbiological profile of these infections will make therapeutic interventions precocious and effective in order to preserve the prognosis of patients in APD at the short and long term.

MO696INCREMENTAL PERITONEAL DIALYSIS: BENEFICIAL EFFECTS

Abstract Background and Aims Incremental peritoneal dialysis (Incr_Dial) is a renal replacement therapy strategy based on lower dose prescription rather than the standard “full dose” (Full_Dial). Individualized clearance goals were achieved combining residual renal function (RRF) and peritoneal clearance. Maintaining RRF is a crucial issue to peritoneal dialysis (PD) patients and the best PD strategy to preserve it is subject to debate. The aim of this study is to compare Incr_Dial and Full_Dial in terms of RRF preservation and other clinical outcomes. Method This was a single-center, retrospective descriptive study. We included a cohort of incident and prevalent adult PD patients in the PD Unit between January – December of 2020. Patients without a follow-up &amp;lt; six months and who started PD at another center were excluded. Patients were assigned according to their first PD protocol in two groups – Group A: Incr_Dial protocol (continuous ambulatory PD: less than four dwells daily, less than 2 L dwell volumes, less than seven days a week treatment, or some combination of these; automated PD: without a long dwell, less than 10 L daily delivered by cycler and day dwells, treatment for less than 7 days a week or some combination of these); Group B: Full_Dial protocol. Statistical analysis was performed using SPSS 20.0. Statistical significance level p &amp;lt;0.05. Results Among 84 PD patients, 68% underwent incremental PD (Group A) and 31% underwent conventional full-dose PD (Group B). The mean age was 55.9±15.4 years, 60.7% were male and 32.5% diabetic. There were no statistically significant differences between the two groups regarding: demographic characteristics, comorbidities (diabetes, hypertension, cardiac insufficiency or ischemic heart disease) and drugs (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and/or loop diuretics). The median Incr_Dial duration to achieve PD full dose was 10.2 months (IQ 5.1-17). At the beginning of PD, there was no statistically significant difference in diuresis between both groups (A: 1.79L vs B: 1.2L, p=0.07), however after 6 months of PD there was a superior urinary output in Group A (A: 1.67L vs B: 1.1L, p=0.037). Group A (Incr_Dial) was also associated with a superior renal clearance of creatinine at the beginning (A: 81 L/sem/1.73m2 vs B: 56.8L/sem/1.73m2, p=0.021) and after 12 months (A: 70.7L/sem/1.73m2 vs B: 26.3 L/sem/1.73m2, p&amp;lt;0.01); and superior Kt/V renal/week at the beginning (A: 1.48 vs B: 1.02, p=0.02) and after 12 months (A: 1.28 vs B: 0.49, p&amp;lt;0.001). There are no differences between mortality (A: 1.9% vs B: 12%, p=0.094), peritonitis-free time (A: 158 days vs B: 236 days, p=0.133) and the numbers of peritonitis per year (A: 0.32 vs B: 0.5, p=0.940). However, the rate of hospital admissions per year was lower in Group A (A: 0.22 vs B: 0.70, p=0.001). Conclusion Incremental PD is a safe strategy of renal replacement therapy to start PD. In our PD population, it showed similar patient survival rates and a significantly less hospital admissions. Incremental PD was also beneficial for preserving RRF when compared to full-dose PD.

MO720SARS-COV2 INFECTION IN THE POPULATION ON PERITONEAL DIALYSIS

Background and AimsThe novel coronavirus disease 2019 (COVID-19) has now spread to the entire world as a highly contagious pandemic. The disease has proved to be more serious in populations with underlying diseases like kidney diseases, diabetes, or cardiovascular diseases. People with end-stage renal disease are known for their weakened immune systems and vulnerability to different types of infections. Recent studies have shown high prevalence and poor prognosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in hemodialysis patients, but its effect on peritoneal dialysis (PD) patients is still unknown.The aim of this study was to investigate the clinical, biological, and scannographic particularities and the prognosis of SARS-CoV-2 infection in patients on PD.MethodWe conducted a monocentric descriptive study including all the confirmed cases of SARS-CoV-2 infection in the PD unit of the Nephrology department in Charles Nicolle Hospital. The first confirmed case was in March 2019 and our study period ended in January 2021. We used Real-Time Reverse Transcriptase polymerase chain reaction (RT- PCR) to confirm SARS-CoV-2 infection after nasopharyngeal swabbing.ResultsEight patients were included: 7 men and 1 woman. The mean age was 40.25 years-old [22-60]. All the patients were hypertensive, 2 of them were diabetics and 3 of them had cardiac pathologies: coronary heart disease in 2 patients and atrial fibrillation in the other patient. One patient had history deep vein thrombosis. All the patients were on automated PD with an average duration of PD of 40.56 months [1-84]. Two of them had history of peritonitis. Regarding the revealing symptoms of COVID-19, all the patients suffered from asthenia, a deterioration of general condition was observed in 7 patients, dry cough was also present in 7 patients, 4 patients described muscle and body aches, 3 patients reported diarrhea and vomiting, dyspnea was observed in 2 patients, only one patient reported loss of taste and smell, and fever was present in only one case.Two patients had low peripheral oxygen saturation (70% and 88%). All the patients had lymphopenia with an average of 557 [900-280]. C-reactive protein was high in 6 patients with an average of 84.7 mg/l. Chest computed tomography (CT) scan was practiced in 3 patients, it was positive in all of them with average extent of damage of 60%. Four patients were admitted in hospital and one of them in the intensive care unit (ICU) for high oxygen needs. All the patients received azithromycin, and vitamin C and D and zinc supplementation. A preventive dose of heparin was prescribed in 5 patients. No patient required intubation. No patient had thromboembolic complications. Six patients fully recovered since more than one month. Regarding the other two patients we have a follow-up of only one week since the beginning of symptoms, one of them is pauci-symptomatic and the other one is still admitted in the ICU.ConclusionAccording to our findings, patients on PD are not at increased risk for severe illness from COVID-19 or other adverse outcomes.

Opinion: Peritoneal Dialysis In Pakistan: An Insider’s View. State of Affairs and Planning?

Pakistan has an estimated population of 212 million while the incidence of end stage renal disease in Pakistan is 100 patients per million; hence approximately 22,000 patients require maintenance dialysis to sustain life in our country. Remarkably peritoneal dialysis (PD) as a form of maintenance renal replacement is utilized in less than one per cent of these patients. In the absence of a formal dialysis registry, we place the total number of chronic ambulatory peritoneal dialysis patients (CAPD) in Pakistan at approximately 76 excluding holiday patients who are visiting from abroad (*This figure was estimated by enquiring the total number of patients each PD units care in Pakistan. This figure was corroborated with the sole distributor of CAPD fluids in Pakistan.).

POS-670 Severe Stenotrophomonas maltophilia peritonitis in a patient receiving peritoneal dialysis

Stenotrophomonas maltophilia (S.maltophilia) is an aerobic, non-fermentative, Gram-negative bacillus. It behaves like an opportunistic pathogen affecting individuals with severe debilitation or immunosuppression. In peritoneal dialysis (PD), S.maltophilia peritonitis is associated with a pejorative prognosis and loss of peritoneal catheter in front of its common resistance to different groups of antibiotics including beta-lactams, aminoglycosides and fluoroquinolones. We report a case of S.maltophilia infection related to continuous ambulatory peritoneal dialysis (CAPD) in our PD unit. It's about a 44-year-old female patient receiving peritoneal dialysis since 6 years. She had a past history of hypertension and chronic hepatitis C. It was her first episode of peritonitis after 6 years undergoing peritoneal dialysis. She consulted our PD unit for vomiting, fever, and abdominal pain. At the exam, she was painful, temperature was at 36.5 blood pressure was at 9/5. Blood test and peritoneal fluid analyses were performed. The fluid was turbid, we found 300 cells/mm3 in the peritoneal effluent with 100 % polymorph nuclear. Laboratory data showed C reactive protein at 389, white blood cells at 8700, with a hypokalemia due to abundant diarrhea. The patient was at her third day of antibiotherapy by intra peritoneal gentamycin (0.6mg/kg) prescribed in the emergency room. Our attitude was to continue intra peritoneal gentamycin until 5days, and add intra peritoneal ceftazidim (1g/d) and prophylaxis of fungal peritonitis by fluconazole that was subsequently stopped.Peritoneal fluid culture was positive for a multiresistant S. maltophilia sensitive to ceftazidim and trimethoprim-sulfamethoxazole that was added to the previous treatment. We had an initial transient improvement: decrease of diarrhea with negative culture of peritoneal fluid. (130 nucleated cells with 92% PMN). Unfortunately, after more than 3 weeks of antibiotherapy the cell count increased again(2700 nucleated cells with 100% PMN) and a stenotophomonas maltophila was isolated again in the peritoneal fluid that is why it was decided to remove the peritoneal catheter and transfer the patient definitely to hemodialysis. S.maltophilia has been increasingly recognized as a nosocomial pathogen in patients with immunodepression. It's an uncommon cause of peritonitis in patients under peritoneal dialysis, but it is always a therapeutic challenge because of its resistance to several antibiotics. In many cases the removal of the peritoneal catheter is required . The prognosis of this peritonitis is usually poor and a prolonged attempt of antibiotic treatment would make them prone to further opportunistic infection without saving the catheter. Immune dysfunction due to uremia, anemia, malnutrition … and also, an indwelling peritoneal catheter may be predisposing factors for the S. maltophilia infection in patients undergoing peritoneal dialysis.

POS-651 PERITONEAL DIALYSIS-RELATED PERITONITIS IN BRUNEI DARUSSALAM: A 10.5-YEARS NATIONWIDE EXPERIENCE

Brunei Darussalam has one of the world’s highest incidence and prevalence of kidney failure. Since the implementation of peritoneal dialysis (PD) preference policy in 2014, there has been an increasing uptake of PD in Brunei. All the PD patients in the country are managed in a dedicated PD unit. Here we report for the first-time data on the peritonitis rates, microbiology, initial treatment patterns and outcomes of PD-related peritonitis in Brunei. This was a retrospective observational analysis of all peritonitis in Brunei from 1st January 2010 to 30th June 2020, identified from the monthly peritonitis database. Data collected include demographics, etiology of the kidney failure, microbiology of the peritonitis episodes, the initial antibiotics regimen and the outcomes of the peritonitis episodes. There were 229 peritonitis episodes detected in 110 patients (56 male and 54 female). The most common etiology of the kidney failure was diabetes (47.3%). 79% of the PD catheters were inserted laparoscopically and 21% were inserted peritoneoscopically. Majority (87%) of these patients were using automated PD. The mean age at peritonitis was 49 years old. The mean PD vintage at peritonitis was 3 years. 21 (9.2%) patients had peritonitis within 3 months of starting PD. The overall rate of peritonitis in these patients was 0.33 episodes per patient year, of which 35.3%, 33.3%, 22.1%, 7.4%, 1.5% and 0.5% were due to culture-negative, gram-positive, gram-negative, polymicrobial, fungi and mycobacterium respectively. Of these 229 peritonitis episodes, 179 (78%) recovered, 32 (14%) resulted in PD catheter removal and 18 (8%) resulted in death. Coagulase negative staphylococcus (20.8%) was the most frequently implicated organism followed by Staphylococcus aureus (17.4%) and Streptococcus species (11.4%). However, over the years, there were increasing proportions of gram-negative organisms isolated as shown in Figure 1. Of all the gram-negative organisms, 93% were sensitive to ceftazidime which was appropriately used together with cefazolin as the initial empirical antibiotics. Compared with culture-negative peritonitis, the relative risks of PD catheter removal were 3.4, 5.0, 13.8 and 13.8 in gram-negative, polymicrobial, fungal and mycobacterial peritonitis respectively. Compared with culture-negative peritonitis, the relative risks of death were 6.4 and 8.0 in polymicrobial and fungal peritonitis respectively. Focused experience from a dedicated PD unit for the whole country has translated into favorable peritonitis outcomes compared to many small units in other countries. Our overall peritonitis rate is lower than the standard set by the International Society of Peritoneal Dialysis (ISPD). Like many countries, the patterns of isolated organisms from the peritonitis have changed over the years, with an increasing proportion of gram-negative organisms, possibly related to more widespread use of mupirocin prophylaxis on exit sites. This trend is worrying as our data shows that gram-negative peritonitis portends a worse outcome with a higher PD technique failure.

POS-640 FUNGAL PERITONITIS IN AUTOMATED PERITONEAL DIALYSIS : AN 18-YEAR SINGLE CENTRE EVALUATION

Infectious peritonitis is the most serious complication of peritoneal dialysis (PD). Its origin is often bacterial. Fungal peritonitis (FP) is rare but always devastating, accounting for high rates of technique failure, morbidity and mortality. It is therefore important to know its microbiological and clinical profile and its evolution in order to establish preventive and therapeutic strategies. The aim of our study is to determine the FP frequency and to describe its clinical, microbiological and therapeutic aspects in patients treated with automated peritoneal dialysis (APD), APD being the most frequent PD modality in our centre. This was a single-centre retrospective study carried out in the PD unit of Charles Nicolle Hospital in Tunis from January 01, 2000 to December 31, 2018, on patients treated with APD and having presented at least one fungal peritonitis. Clinical, biochemical characteristics and detailed data on peritonitis episodes were recorded. Six cases of FP were identified, ie 3% of all infectious peritonitis that occurred during the study period. The patients' sex ratio was 2. Their mean Charlson score at onset of APD was 3 [Extremes: 2-6]. Only one patient was diabetic. Their mean age at the time of peritonitis was 40 +/- 16 years. Candida albicans was the most frequently (50%) detected yeast followed by candida non albicans (2 patients). Aspergillus has been isolated in one patient. This group experienced an average of 2 bacterial peritonitis before FP. All FP were preceded by bacterial peritonitis: In five patients, they were diagnosed following refractory peritonitis mainly due to Enterobacteria (4 patients). In one case, the patient had a history of three episodes of bacterial peritonitis, FP presented as a new episode of infectious peritonitis occurring 5 months after the third peritonitis. All Candida peritonitis were treated with intravenous fluconazole for an average of 13 days. Aspergillary peritonitis was treated with amphotericin B for 15 days. The PD catheter was removed in all cases. Four patients were transferred to hemodialysis. APD was retried in the other two patients. They were switched to hemodialysis after 1 and 7 months, respectively, of placement of the second PD catheter for loss of ultrafiltration and catheter dysfunction. FP are certainly rare, but they are an ineluctable cause of PD failure.