Kidney involvement in systemic light-chain amyloidosis (AL-SA) is associated with rapidly declining kidney function and increased mortality. The optimal kidney replacement therapy for AL-SA patients has not been ascertained. There is some suggestion that peritoneal dialysis (PD) may be safer than intermittent hemodialysis (iHD) for these patients. However, the clinical course of these patients can be rather complex and daunting, both for the patient and for the treating physicians. There is also a lack of data describing the associated challenges and outcomes, especially with respect to the use of chemotherapy, hematopoietic stem cell transplantation (HSCT), and kidney transplantation (KT) in patients with AL-SA who are on PD for end stage kidney disease (ESKD). We present the interesting case of a 41-year-old patient on PD for ESKD due to AL-SA, for which she underwent chemotherapy and HSCT. She ultimately was able to receive a successful KT. Through this case, we aim to highlight the complexities involved in the treatment journey of patients with AL-SA and kidney disease. We present evidence for greater hemodynamic stability with PD as compared to iHD and thus gentler ultrafiltration, information on anticancer agent dosing for PD, and finally offer hope for the feasibility of PD and KT to support a better quality of life for AL-SA patients with kidney disease.

RATIONALE & OBJECTIVE:The occurrence and consequences of peritoneal dialysis (PD)-associated peritonitis limit its use in populations with kidney failure. Studies of large clinical populations may enhance our understanding of peritonitis. To facilitate these studies we developed an approach to measuring peritonitis rates using Medicare claims data to characterize peritonitis trends and identify its clinical risk factors.STUDY DESIGN:Retrospective cohort study of PD-associated peritonitis.SETTING & PARTICIPANTS:US Renal Data System standard analysis files were used for claims, eligibility, modality, and demographic information. The sample consisted of patients receiving PD treated at some time between 2013 and 2017 who were covered by Medicare fee-for-service (FFS) insurance with paid claims for dialysis or hospital services.EXPOSURES/PREDICTORS:Peritonitis risk was characterized by year, age, sex, race, ethnicity, vintage of kidney replacement therapy, cause of kidney failure, and prior peritonitis episodes.OUTCOME:The major outcome was peritonitis, identified using ICD-9 and ICD-10 diagnosis codes. Closely spaced peritonitis claims (30 days) were aggregated into 1 peritonitis episode.ANALYTICAL APPROACH:Patient-level risk factors for peritonitis were modeled using Poisson regression.RESULTS:We identified 70,271 peritonitis episodes from 396,289 peritonitis claims. Although various codes were used to record an episode of peritonitis, none was used predominantly. Peritonitis episodes were often identified by multiple aggregated claims, with the mean and median claims per episode being 5.6 and 2, respectively. We found 40% of episodes were exclusively outpatient, 9% exclusively inpatient, and 16% were exclusively based on codes that do not clearly distinguish peritonitis from catheter infections/inflammation ("catheter codes"). The overall peritonitis rate was 0.54 episodes per patient-year (EPPY). The rate was 0.45 EPPY after excluding catheter codes and 0.35 EPPY when limited to episodes that only included claims from nephrologists or dialysis providers. The peritonitis rate declined by 5%/year and varied by patient factors including age (lower rates at higher ages), race (Black > White>Asian), and prior peritonitis episodes (higher rate with each prior episode).LIMITATIONS:Coding heterogeneity indicates a lack of standardization. Episodes based exclusively on catheter codes could represent false positives. Peritonitis episodes were not validated against symptoms or microbiologic data.CONCLUSIONS:PD-associated peritonitis rates decline over time and were lower among older patients. A claims-based approach offers a promising framework for the study of PD-associated peritonitis.

Peritoneal dialysis (PD)-associated peritonitis (peritonitis) is an important outcome to patients, caregivers, and kidney health professionals in the multinational Standardized Outcomes in Nephrology (SONG) PD initiative ( 1 Manera K.E. Johnson D.W. Craig J.C. Shen J.I. Ruiz L. Wang A.Y. et al. Patient and Caregiver Priorities for Outcomes in Peritoneal Dialysis: Multinational Nominal Group Technique Study. Clinical journal of the American Society of Nephrology : CJASN. 2019; 14: 74-83https://doi.org/10.2215/cjn.05380518 Crossref PubMed Scopus (0) Google Scholar ). Peritonitis carries substantial morbidity and is a leading cause of premature transition to in-center hemodialysis (ICHD) ( 2 Al Sahlawi M. Zhao J. McCullough K. Fuller D.S. Boudville N. Ito Y. et al. Variation in Peritoneal Dialysis-Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS). American journal of kidney diseases : the official journal of the National Kidney Foundation. 2022; 79: 45-55.e1https://doi.org/10.1053/j.ajkd.2021.03.022 Abstract Full Text Full Text PDF Scopus (23) Google Scholar , 3 Mujais S. Microbiology and outcomes of peritonitis in North America. Kidney international Supplement. 2006; : S55-62https://doi.org/10.1038/sj.ki.5001916 Abstract Full Text Full Text PDF Scopus (100) Google Scholar , 4 Ghali J.R. Bannister K.M. Brown F.G. Rosman J.B. Wiggins K.J. Johnson D.W. et al. Microbiology and outcomes of peritonitis in Australian peritoneal dialysis patients. Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis. 2011; 31: 651-662https://doi.org/10.3747/pdi.2010.00131 Crossref PubMed Scopus (159) Google Scholar ). In the end-stage renal disease (ESRD) quality incentive program, the Centers for Medicare & Medicaid Services (CMS) incorporated bloodstream infections (BSIs) in ICHD patients as a quality measure in 2012, with data being reported to Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) surveillance system. This has led to reduced infection rates among ICHD patients ( 5 Patel P.R. Yi S.H. Booth S. Bren V. Downham G. Hess S. et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2013; 62: 322-330https://doi.org/10.1053/j.ajkd.2013.03.011 Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar , 6 Yi S.H. Kallen A.J. Hess S. Bren V.R. Lincoln M.E. Downham G. et al. Sustained Infection Reduction in Outpatient Hemodialysis Centers Participating in a Collaborative Bloodstream Infection Prevention Effort. Infect Control Hosp Epidemiol. 2016; 37: 863-866https://doi.org/10.1017/ice.2016.22 Crossref PubMed Scopus (22) Google Scholar ). In PD patients, a formal surveillance system for nationwide reporting of PD-related peritonitis is needed. Here, we developed a uniform widescale peritonitis reporting mechanism based on current International Society for Peritoneal Dialysis (ISPD) peritonitis guidelines to evaluate its implementation in The Optimizing Prevention of PD-Associated Peritonitis in the US (OPPUS) study facilities as a test of the feasibility of standardized peritonitis reporting.

Key Points In a large multinational cohort of PD patients, any GAS use was not associated with an increased risk of all-organism peritonitis. For peritonitis, risks were particularly high among certain classes of organisms particularly for Gram-negative, enteric, and streptococcal peritonitis episodes. The association with enteric peritonitis appeared to be stronger among H2RA users. Background Peritonitis is a major peritoneal dialysis–related complication. We determined whether gastric acid suppression (GAS) (proton pump inhibitor [PPI] or histamine-2 receptor antagonists [H2RAs]) use was associated with all-cause and organism-specific peritonitis in peritoneal dialysis patients. Methods In the Peritoneal Dialysis Outcomes and Practice Patterns Study (595 facilities, eight countries, years 2014–2022), associations between GAS use and time to first episode of all-cause peritonitis were examined using Cox proportional hazards models. The primary exposure of interest was GAS and secondarily PPI or H2RA use. Secondary outcomes were organism-specific peritonitis, peritonitis cure rates, and death. Results Among patients ( N =23,797) at study baseline, 6020 (25.3%) used PPIs, and 1382 (5.8%) used H2RAs. Overall risks of GAS use and peritonitis risk (adjusted hazard ratio [AHR]=1.05, 95% confidence interval [CI], 0.98 to 1.13]) and use of PPI (AHR 1.06 [95% CI, 0.99 to 1.14]) or H2RA (AHR 1.02 [95% CI, 0.88 to 1.18]) did not reach statistical significance. In organism-specific analyses, GAS users displayed higher peritonitis risks for Gram-negative (AHR 1.29, 95% CI, 1.05 to 1.57), Gram-positive (AHR 1.15, 95% CI, 1.01 to 1.31), culture-negative (AHR 1.20, 95% CI, 1.01 to 1.42), enteric (AHR 1.23, 95% CI, 1.03 to 1.48), and particularly Streptococcal (AHR 1.47, 95% CI, 1.15 to 1.89) peritonitis episodes. GAS was also associated with higher overall mortality (AHR 1.13 [95% CI, 1.05 to 1.22]). Conclusion The association between GAS use and peritonitis risk was weaker (hazard ratio [HR] 1.05 [0.98 to 1.13]) than for streptococcal (HR 1.57 [1.15 to 1.89]) and Gram-negative (HR 1.29 [1.05 to 1.57]) peritonitis. A better understanding of mechanisms surrounding the differential effects of GAS subtype on peritonitis risks is needed. Clinicians should be cautious when prescribing GAS. The impact of GAS deprescribing on peritonitis risk requires further evaluation.

Peritoneal dialysis (PD)-associated peritonitis is a serious complication of PD and prevention and treatment of such is important in reducing patient morbidity and mortality. The ISPD 2022 updated recommendations have revised and clarified definitions for refractory peritonitis, relapsing peritonitis, peritonitis-associated catheter removal, PD-associated haemodialysis transfer, peritonitis-associated death and peritonitis-associated hospitalisation. New peritonitis categories and outcomes including pre-PD peritonitis, enteric peritonitis, catheter-related peritonitis and medical cure are defined. The new targets recommended for overall peritonitis rate should be no more than 0.40 episodes per year at risk and the percentage of patients free of peritonitis per unit time should be targeted at >80% per year. Revised recommendations regarding management of contamination of PD systems, antibiotic prophylaxis for invasive procedures and PD training and reassessment are included. New recommendations regarding management of modifiable peritonitis risk factors like domestic pets, hypokalaemia and histamine-2 receptor antagonists are highlighted. Updated recommendations regarding empirical antibiotic selection and dosage of antibiotics and also treatment of peritonitis due to specific microorganisms are made with new recommendation regarding adjunctive oral N-acetylcysteine therapy for mitigating aminoglycoside ototoxicity. Areas for future research in prevention and treatment of PD-related peritonitis are suggested.

ABSTRACT Background The effects of training practices on outcomes of patients receiving peritoneal dialysis (PD) are poorly understood and there is a lack of evidence informing best training practices. This prospective cohort study aims to describe and compare international PD training practices and their association with peritonitis. Methods Adult patients on PD <3 months participating in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) were included. Training characteristics (including duration, location, nurse affiliation, modality, training of family members, use of individual/group training and use of written/oral competency assessments) were reported at patient and facility levels. The hazard ratio (HR) for time to first peritonitis was estimated using Cox models, adjusted for selected patient and facility case-mix variables. Results A total of 1376 PD patients from 120 facilities across seven countries were included. Training was most commonly performed at the facility (81%) by facility-affiliated nurses (87%) in a 1:1 setting (79%). In the UK, being trained by both facility and third-party nurses was associated with a reduced peritonitis risk [adjusted HR 0.31 (95% confidence interval 0.15–0.62) versus facility nurses only]. However, this training practice was utilized in only 5 of 14 UK facilities. No other training characteristics were convincingly associated with peritonitis risk. Conclusions There was no evidence to support that peritonitis risk was associated with when, where, how or how long PD patients are trained.

RATIONALE & OBJECTIVE: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.STUDY DESIGN:Observational prospective cohort study.SETTING & PARTICIPANTS:1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States.EXPOSURE: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).OUTCOME:Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode.ANALYTICAL APPROACH:Mixed-effects logistic models.RESULTS: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.LIMITATIONS: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.CONCLUSIONS: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.

Introduction: Peritoneal 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.Methods: We convened an online consensus workshop to establish a core outcome measure for PD -related peritonitis in clinical trials.Results: A 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 mini-mizing 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.Conclusion: A 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 perito-nitis 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.

While interest in peritoneal dialysis (PD) is growing in many parts of the world given its patient-centric approach and favorable cost profile, peritonitis remains a major problem. Some risk factors have been identified, but many of these are not modifiable. One that deserves closer scrutiny is hypokalemia, which has been associated with an increased risk for peritonitis.1-3 The impact of treatment of hypokalemia on peritonitis risk has not been previously closely examined.

Abstract It is unclear if the pharmacokinetics of vancomycin are the same during automated peritoneal dialysis (APD), where cycler exchanges may affect the systemic, peritoneal, and urinary disposition of drug. We conducted a prospective pharmacokinetic study evaluating the pharmacokinetics of vancomycin in plasma, dialysis fluid, and urine in peritonitis‐negative patients on APD. Patients underwent four drug‐free exchanges with 1.5% or 2.5% dextrose following the initial dwell period. Plasma, dialysis fluid, and urine was collected over the course of 7 days for pharmacokinetic analysis. Four patients completed the study with no adverse events. Following a median (range) dwell of 14.6 (14.2–17.6 h), the mean (±SD) observed maximum plasma concentration was 28.7 ± 4.9 mg/L with a mean bioavailability of 98.5 ± 1.4% prior to starting the cycler. The overall mean total plasma clearance estimated from study start to completion was 7.6 ± 1.2 ml/min. Mean total clearance during the dialytic exchange was 13.6 ± 4.9 ml/min. In patients with residual renal function, the mean vancomycin renal clearance was 3.1 ± 1.5 ml/min, representing 21.4%–58.9% of the overall total plasma clearance during the study period. Despite the small sample size, this pilot study suggests that the dwell time has important implications for systemic vancomycin exposure, time to therapeutic plasma concentration, and dosing. Dose is driven by dwell time, whereas the cycler determines the dosing interval. Rapid exchanges from APD will determine the frequency of dosing rather than the adequacy of absorption when vancomycin is given in the peritoneum.

See Clinical Research on Page 1062 See Clinical Research on Page 1062 The use of home dialysis, specifically peritoneal dialysis (PD), is increasing in many areas of the world. Advantages of PD compared with in-center hemodialysis (HD) are myriad, including patient empowerment, preservation of residual kidney function, improvement in post-transplant outcomes, and reduction of financial health care burden.1Chaudhary K. Sangha H. Khanna R. Peritoneal dialysis first: rationale.Clin J Am Soc Nephrol. 2011; 6: 447-456https://doi.org/10.2215/CJN.07920910Crossref PubMed Scopus (153) Google Scholar, 2Jain D. Haddad D.B. Goel N. Choice of dialysis modality prior to kidney transplantation: does it matter?.World J Nephrol. 2019; 8: 1-10https://doi.org/10.5527/wjn.v8.i1.1Crossref PubMed Google Scholar, 3Klarenbach S. Manns B. Economic evaluation of dialysis therapies.Semin Nephrol. 2009; 29: 524-532https://doi.org/10.1016/j.semnephrol.2009.06.009Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar A 2019 United States (US) executive order included an ambitious goal of 80% of new patients with end-stage kidney disease (ESKD) to receive home dialysis or kidney transplantation to be reached by 2025. Because many patients on PD require transfer to HD, logically, an increased number of patients using PD for dialysis initiation will result in increasing number of transfers to HD each year. The initial period on HD for incident ESKD has consistently been shown to have higher mortality risk than subsequent periods.4Robinson B.M. Zhang J. Morgenstern H. et al.Worldwide, mortality risk is high soon after initiation of hemodialysis.Kidney Int. 2014; 85: 158-165https://doi.org/10.1038/ki.2013.252Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar Furthermore, the mortality risk for incident ESKD may be underestimated in the United States Renal Data System (USRDS) data o to early ascertainment bias where deaths occurring within the initial 90-day window of initiation are not always included.5Foley R.N. Chen S.C. Solid C.A. et al.Early mortality in patients starting dialysis appears to go unregistered.Kidney Int. 2014; 86: 392-398https://doi.org/10.1038/ki.2014.15Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar Details on mortality risk after transition from PD to HD for prevalent ESKD have not been described using large databases. A prior retrospective cohort study of prevalent PD patients in the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry found a time-dependent association between the most common causes of technique failure (defined as transfer to HD for ≥30 days) and mortality risk. The risk was highest in the first 2 years after technique failure.6Chen J.H.C. Johnson D.W. Hawley C. Boudville N. Lim W.H. Association between causes of peritoneal dialysis technique failure and all-cause mortality.Sci Rep. 2018; 8: 3980Crossref PubMed Scopus (19) Google Scholar In this current issue, the study by Nadeau-Fredette et al.7Nadeau-Fredette A.-C. Sukul N. Lambie M. et al.Mortality trends after transfer from peritoneal dialysis to hemodialysis.Kidney Int Rep. 2022; 7: 1062-1073Abstract Full Text Full Text PDF Scopus (2) Google Scholar analyzes multinational registry data between 2000 and 2014 to assess mortality rates and risk factors when transfer from PD to HD is required. Patient data were sourced from the following 4 large registries representing 15 countries: ANZDATA Registry, Canadian Organ Replacement Register, European Renal Association Registry, and USRDS. Of the included patients, 70% were from the US. Patients with ESKD using PD as initial modality were included if there was recorded use of subsequent HD for ≥1 day during the specified time period. These patients were followed until the primary end point (all-cause mortality) censored for transplantation, loss to follow-up, or study end date. This group was further divided into cohorts 2000 to 2004, 2005 to 2009, and 2010 to 2014, representing 3 eras of dialysis initiation (early, medium, and late, respectively). A subset of patients transferred back to PD and were included (16%–19% of all patients who transferred to HD, data not available for USRDS). Patients with preceding kidney transplants were excluded. In total, 114,563 patients were included in the study, representing 20% to 25% of all incident PD patients across the 4 registries. The median time on PD before transfer to HD was between 1.1 and 1.3 years. Approximately 20% to 25% of incident PD patients transferred to HD. The authors evaluated risk of death after transfer to HD by age, sex, cohort year, and PD duration in each of the 4 registries. Cause of death was available for 3 of the registries but not the USRDS. Risk of death was high on HD in the first 30 days after transfer, but it was much higher in the Canadian and the ANZDATA (approximately 68 and 48 deaths per 100 patient-years, respectively) compared with approximately 32 to 35 deaths per 100 patient-years in the US and Europe. When evaluated, deaths over time during the first 30 days showed a peak at approximately 15 days (more than 90 deaths per 100 patient-years) in Canada and at approximately 10 days (approximately 80 deaths per 100 patient-years) in ANZDATA, whereas in the US and Europe, the rate of death gradually rose during the first 2 weeks and then plateaued, never reaching the heights of the Canadian or Australian cohorts. These findings were particularly striking for patients 60 years and older. More recent PD vintage attenuated the effect to some extent. Overall, mortality rates were lower in the late cohort (2010–2014) compared with the early cohort (2000–2004); this is consistent with findings from previous studies showing improved mortality over time.8Elsayed M.E. Morris A.D. Li X. et al.Propensity score matched mortality comparisons of peritoneal and in-centre haemodialysis: systematic review and meta-analysis.Nephrol Dial Transplant. 2020; 35: 2172-2182https://doi.org/10.1093/ndt/gfz278Crossref PubMed Google Scholar This improvement in early mortality was particularly striking in ANZDATA and Canadian Organ Replacement Register data. The study also delineated other risk factors for death after transfer to HD. Not surprisingly, those with diabetic nephropathy uniformly had a higher risk of death after transfer across all time periods and all registries. Men had a lower risk of death than women during the first 90 days after transfer (hazard ratio = 0.80; CI: 0.67–0.96, P = 0.01), but higher risk of death after 180 days, although in the adjusted model this later risk disappeared. Those patients on PD 3 years or more were more likely to die after transfer to HD (again, with risk highest in the first 90 days, hazard ratio = 1.91, CI: 1.47–2.49, P < 0.001, in adjusted model) than those on PD < 6 months. Only the ANZDATA registry contained information on cause of technique failure. Within this registry, those transferring for infectious reasons had higher early mortality than those who transferred for inadequate dialysis or mechanical causes. If the cause of transfer was social, then risk of death was particularly high between 90 and 180 days after transfer. What take-home messages can we glean from this paper? The study raises several important questions. First, can we do more to reduce mortality after transfer from PD to HD by more preparation and planning? We do not have data on access with the transfer from PD to HD, but it seems likely that most occur with HD catheters, which are known to be high risk for infection and increased mortality risk. Although placing an arteriovenous fistula/graft at the start of PD has been shown to be frequently futile, later placement of such access while the patient is still on PD, if adequacy becomes an issue, might be worth exploring further. Second, in some cases, where the risk of early death after transfer from PD to HD is particularly high, patients should be made aware so patient-centered goals of care discussions are held before hazardous transitions. The mortality of older patients in the first 90 days is particularly high. It seems probable that older patients are more likely to withdraw from dialysis after transfer to HD. This might explain some of the variation in mortality trends in the first 30 days among the 4 registries although from the data presented this is unclear. Perhaps, in such cases, an in-depth conversation about outcomes is warranted, particularly in older frail patients, instead of a knee jerk transfer to HD, when PD cannot be continued. In addition to the abovementioned mortality risk, Weinhandl9Weinhandl ED. Hidden costs associated with conversion from peritoneal dialysis to hemodialysis. Kidney360. Published online March 3, 2022. https://doi.org/10.34067/KID.0007692021Google Scholar has recently reported an increased rate of acute care encounters and health care expenditures during the period immediately before and after transitions from PD to HD. Although not addressed by Nadeau-Fredette et al.,7Nadeau-Fredette A.-C. Sukul N. Lambie M. et al.Mortality trends after transfer from peritoneal dialysis to hemodialysis.Kidney Int Rep. 2022; 7: 1062-1073Abstract Full Text Full Text PDF Scopus (2) Google Scholar further information on this period in the timeline of ESKD is very much needed to minimize hospitalizations, which may exacerbate risk in this group. A strength of this paper is the inclusion of all patients who started on PD and then transferred to HD regardless of time on PD. The USRDS has historically only counted deaths on dialysis occurring after 90 days on therapy, thereby excluding a period of very high risk for mortality on HD (as shown again in this paper). Most registries require 30 to 90 days of any new modality in definition of technique failure and furthermore attribute a death within 30 days of transfer to the first modality. This clearly skews the results and gives a false picture of what is really happening. The current paper attempted to avoid early ascertainment bias by using transfer definition as ≥1 day on HD. Further investigation into the first month on HD is warranted. What specifically about HD is so inherently risky in that early time period? Is it infection, bacteremia, or HD catheter related, cardiovascular events, or frequent hospitalizations leading to death? Regardless, the trend/risk is now apparent whether a patient is initiating HD or transferring to HD from PD. Although the utilization of multinational data is one strength of the study, the analyses were limited to covariates that were available in the registries. In the largest registry (USRDS), the cause of death was often missing. In addition, race was not an analyzed covariate for risk of death. Because the USRDS constituted most of the patients and African Americans constitute a good percentage of US patients on dialysis, the impact of race would be of interest. Furthermore, regional differences exist in how variables were defined and how data were captured. For example, the study was unable to identify specific cause of the early variability in mortality between ANZDATA and Canadian Organ Replacement Register compared with European Renal Association and USRDS groups. It may be that practice variations resulted in more regionally accepted recommendations to withdrawal from dialysis. Other limitations include the inability to delve into sex-specific mortality risk and the inclusion of those transferring from PD to home HD (although this assuredly is a small number). This study provides important insights into mortality trends during the period after transition from PD to HD. It particularly highlights the very high mortality risk for elderly patients who have been on PD for longer periods of time before transfer, raising the issue of futility. More research is needed to understand the mortality risk associated with transition from PD to HD. It is likely that individualized management plans considering patient-specific factors may be one way to lessen the risks and improve patient outcomes (Figure 1). Better planning may reduce the risk for some subsets of patients. As always, the patient's goals need to be carefully discussed using real data to inform the patient of risks during necessary transitions. All the authors declared no competing interests. Mortality Trends After Transfer From Peritoneal Dialysis to HemodialysisKidney International ReportsVol. 7Issue 5PreviewTransition to hemodialysis (HD) is a common outcome in peritoneal dialysis (PD), but the associated mortality risk is poorly understood. This study sought to identify rates of and risk factors for mortality after transitioning from PD to HD. Full-Text PDF Open Access

Intraperitoneal vancomycin is the first-line therapy in the management of peritoneal dialysis (PD)-related peritonitis. However, due to the paucity of data, vancomycin dosing for peritonitis in patients on automated peritoneal dialysis (APD) is empiric and based on clinical experience rather than evidence. Studies in continuous ambulatory peritoneal dialysis (CAPD) patients have been used to provide guidelines for dosing and are often extrapolated for APD use, but it is unclear whether this is appropriate. This review summarizes the available pharmacokinetic data used to inform optimal dosing in patients on CAPD or APD. The determinants of vancomycin disposition and pharmacodynamic effects are critically summarized, knowledge gaps explored, and a vancomycin dosing algorithm in PD patients is proposed.

Peritoneal dialysis (PD)-associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.

Preparation for home dialysis begins with a robust modality education program because patients cannot make a decision regarding the type of dialysis if they are not provided adequate information. This requires infrastructure that some programs do not have, as well as nephrologists who are welcoming and receptive to their patients' choice of home dialysis. Unfortunately, many dialysis patients in the US do not recall receiving much information about peritoneal dialysis (PD), indicating that the process is often inadequate. This is one barrier to PD. Another is the nephrologist. The nephrologist is the most important influence regarding the decision for PD, so it is critically important that the nephrologist be trained in PD sufficiently to eliminate biases. The program must have the infrastructure to provide robust and comprehensive modality education to patients and their support persons. This includes a one-on-one session with an educator (often a nurse), videos, visits to a home program, peer-to-peer discussion with a PD patient, and follow-up with the nephrologist. Because many patients with advanced chronic kidney disease present urgently with signs and symptoms that require rapid dialysis implementation, an in-house education program is desirable but requires an investment in a nurse educator on site. Once the decision is made to start PD, arrangements are made for PD catheter placement. In most centers, scheduling this procedure can be delayed, so careful planning is necessary. Some innovative programs incorporate interventional nephrologists or radiologists in the program who can place PD catheters and thus ensure that rapid start PD is available. These approaches have been shown to greatly increase PD program size and allow a higher proportion of patients to choose PD at the outset. Use of the buried catheter technique is another approach that may facilitate timely PD start. The home dialysis program must be supported by the dialysis provider or hospital or institution, as appropriate. Adequate staffing is critical to the success of the program, allowing time for training (which is usually one on one), and for meeting the regulations in place for home programs. Space for the home program is also essential, with room for private training and for clinic visits.

Peritoneal dialysis (PD)–associated peritonitis is the leading cause of permanent transition to hemodialysis among patients receiving PD. Peritonitis is associated with higher mortality risk and added treatment costs and limits more widespread PD utilization. Optimizing the prevention of peritonitis in the United States will first require standardization of peritonitis definitions, key data elements, and outcomes in an effort to facilitate nationwide reporting. Standardized reporting can also help describe the variability in peritonitis rates and outcomes across facilities in the United States in an effort to identify potential peritonitis prevention strategies and engage with stakeholders to develop strategies for their implementation. Here, we will highlight considerations and challenges in developing standardized definitions and implementation of national reporting of peritonitis rates by PD facilities. We will describe existing peritonitis prevention evidence gaps, highlight successful infection-reporting initiatives among patients receiving in-center hemodialysis or PD, and provide an overview of nationwide quality improvement initiatives, both in the United States and elsewhere, that have translated into a reduction in peritonitis incidence. We will discuss opportunities for collaboration and expansion of the Nephrologists Transforming Dialysis Safety (NTDS) initiative to develop knowledge translation pathways that will lead to dissemination of best practices in an effort to reduce peritonitis incidence.