BACKGROUND:Venous excess ultrasound score (VExUS) is an emerging point-of-care ultrasound tool to evaluate venous congestion using inferior vena cava (IVC) diameter and hepatic vein pulse-wave Doppler. The utility of VExUS to detect changes in intravascular volume is not well established. OBJECTIVES:The objective of the study was to investigate the ability of a standardized point-of-care ultrasound exam to capture dynamic changes in volume status. METHODS:This was a prospective observational study of inpatients with end-stage renal disease. Patients underwent VExUS exams before and after hemodialysis (HD). Patient with an IVC diameter <2 cm had a VExUS score of 0. For patients with an IVC diameter >2 cm, the scores of the component were totaled for a composite score. The primary outcome was change in composite VExUS score. A univariate linear regression analysis was used to evaluate for a linear relationship between the volume of fluid removed and change in composite VExUS score. RESULTS:Forty-six patients (92 paired ultrasound exams) were included. The median volume of fluid removed with HD was 2,000 mL (IQR: 985-2,500 mL). Wilcoxon signed-rank test of pre-HD and post-HD VExUS scores revealed a median score decrease of 1.5 (95% CI: 1-2; P < 0.001) on a VExUS scale ranging from 0 to 4. There was not a significant linear relationship between volume removed and change in VExUS score. CONCLUSIONS:Fluid removal with HD was associated with changes in the VExUS score, highlighting the utility of VExUS to capture dynamic shifts in intravascular volume in patients with end-stage renal disease.

Twenty-five percent of peritoneal dialysis (PD) patients who discontinue PD do so because of membrane dysfunction-problems with ultrafiltration or solute clearance. This review will briefly summarize the physiology and pathophysiology of the peritoneal membrane and then discuss strategies for the preservation of its function. Inhibition of the renin-angiotensin-aldosterone system is the only currently available maneuver with proven efficacy to prospectively benefit peritoneal membrane function. The evidence in favor of neutral pH fluids low in glucose degradation products is equivocal, and the potential benefits of icodextrin, steady-state glucose concentration, or incremental PD are unknown. Resting the peritoneal membrane after the development of ultrafiltration failure does seem to be beneficial. There are several promising potential strategies for preservation of peritoneal membrane function currently under investigation. These include the use of alanyl-glutamine as an additive to PD fluid, the systemic administration of a sodium-glucose transport 2 inhibitor to decrease glucose absorption, and the use of a combination of xylitol and carnitine as an alternative to glucose-based PD fluid. Each of these is discussed in detail in this review.

BackgroundThe impact of incremental peritoneal dialysis (PD) on outcomes is poorly understood, and there is a paucity of evidence informing best practices regarding the dialysis dose at the commencement of PD. This international prospective cohort study aimed to compare PD prescription practices at dialysis commencement and their subsequent association with clinical outcomes.MethodsAdult patients who started PD for less than three months at the time of enrolment in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) between 1 January 2014 and 31 December 2017 were included. Patients were defined as initiating incremental PD if prescribed a total of <4 exchanges/day for continuous ambulatory peritoneal dialysis (CAPD) or, with dry days or having PD less than seven days per week for automated peritoneal dialysis (APD). All other prescriptions were considered standard PD. The primary outcome was the transfer to haemodialysis (HD). Secondary outcomes included peritonitis rate, time to first peritonitis and mortality. Logistic regression analysed PD uptake and the Cox proportional hazards regression model analysed HD transfer, peritonitis and patient survival.ResultsOverall, 1365 PD patients from 128 facilities across seven countries were included. Fewer individuals started on incremental PD than standard PD (37% vs 63%, p < 0.001). Higher incremental PD uptake was associated with receiving treatment in Japan (odds ratio [OR] 2.35, 95% CI 1.05-5.26, p = 0.04; ref: Canada), age >75 years (OR 1.51, 95% CI 1.02-2.24, p = 0.04), icodextrin use (OR 8.54, 95% CI 6.26-11.64, p < 0.001), lower serum creatinine concentration at PD start (OR 1.01, 95% CI 1.01-1.01, p = 0.007) and higher number of PD patients at a facility (OR 1.01, 95% CI 1.00-1.01, p = 0.02). Crude HD transfer rates for the incremental and standard PD groups were 0.14 (95% CI, 0.12-0.16) and 0.15 (95% CI, 0.13-0.17) per patient-year of follow-up, respectively (incidence rate ratio [IRR], 0.93; 95% CI, 0.75-1.15; p = 0.49). There was no significant difference in the hazard of HD transfer between the incremental and standard PD groups (hazard ratio [HR] 0.87, 95% CI 0.68-1.12, p = 0.29). There were also no differences between the two groups concerning peritonitis and mortality.ConclusionsIncremental PD start was prescribed in approximately one-third of patients and, in low certainty evidence, was associated with comparable risks of HD transfer, peritonitis and death.

Icodextrin (ICO) is widely used in peritoneal dialysis (PD). Hyperosmolar hyponatremia (hypoNa) has been reported as an adverse event of ICO, but it is unknown whether there is a dose effect relationship between the two. We present a case demonstrating this relationship. A 61-year-old woman with end-stage kidney disease (ESKD) and no history of diabetes, began PD with a single daily dwell of 1L of ICO. Her serum Na during the previous 6 months (n = 16) was 138.9 (mmol/L) ± 2.2 (SD). Within days of starting PD, the Na fell to 132 and over the ensuing 9 months (n = 27) it averaged 133.6 ± 2.1. As her PD prescription (Rx) was changed throughout two hospital admissions and subsequent outpatient management, she maintained normonatremia when using dextrose exchanges and became hyponatremic with ICO exchanges. With increasing daily doses of ICO, her hyponatremia became more severe (nadir of Na 121 with 3L of daily ICO use). She ultimately returned to exclusively dextrose cycles for two years and remained normonatremic. Years later a single 2L ICO dwell was started, and she developed hypoNa again (Na 131). ICO was stopped and Na normalized. We plotted serum Na vs total daily ICO dose and showed a strong correlation (R 2 = 0.737). HypoNa is a risk factor for ESKD patients that lead to increased morbidity and mortality. This report demonstrates that the severity of ICO-induced hyponatremia is directly proportional to the amount of ICO used. For patients developing hyponatremia, instead of discontinuing ICO, practitioners might consider reducing the dose.

RATIONALE & OBJECTIVE:The clinical consequences of hyponatremia among patients receiving peritoneal dialysis (PD) are poorly understood. This study sought to evaluate the association of variations in serum sodium with peritoneal dialysis-associated peritonitis and death. STUDY DESIGN:Multicenter observational cohort study. SETTINGS & PARTICIPANTS:23,707 participants in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) in 8 countries between 2014 and 2022 with a serum sodium measure available at study enrollment. PREDICTOR:Serum sodium categories (<135, 135-137, 138-139, 140-141, ≥142 mEq/L) at study enrollment. OUTCOME:Time to first peritonitis episode and all-cause mortality. ANALYTICAL APPROACH:Cause-specific hazards models adjusted for demographic, comorbidity, and treatment characteristics. Secondary analyses using average serum sodium levels over time and evaluation of modification of the association between serum sodium and study outcomes by use of icodextrin as well as patient characteristics and PD modality. RESULTS:Compared to a serum sodium of 140-141 mEq/L (n=5,065), those with a sodium of<135 mEq/L (n=3,601) had longer dialysis vintage and were more likely to have diabetes and use icodextrin. Across serum sodium categories, there were no differences in the adjusted peritonitis risks. Compared to individuals with a sodium of 140-141 mEq/L, those with a sodium of<135 mEq/L (adjusted hazard ratio [AHR], 1.45 [95% CI, 1.29-1.63]), a sodium of 135-137 mEq/L (AHR, 1.26 [95% CI, 1.13-1.42]), and a sodium≥142 mEq/L (AHR, 1.16 [95% CI, 1.03-1.30]) were all associated with higher mortality. Associations between serum sodium and mortality were similar across all patient characteristic and PD modality subgroups. Peritonitis risk was not detectably different across serum sodium categories regardless of treatment with icodextrin. LIMITATIONS:Lack of standardization/validation of serum sodium measures across sites; icodextrin use was limited to a subset of patients. CONCLUSIONS:Variations in serum sodium were associated with death but not peritonitis risk. Future studies are needed to understand the mechanisms underpinning these associations and whether modification of serum sodium would improve outcomes among those receiving PD.

For some patients, peritoneal dialysis (PD) has several advantages over center-based hemodialysis. PD-related infections such as peritonitis and PD catheter exit site and tunnel infections are a significant source of morbidity. Peritonitis leads to increased mortality, and it is the leading cause of transfer off PD. Infection prevention practices may vary widely across dialysis centers, resulting in significant differences in infection rates. To address these issues and improve patient outcomes, the American Society of Nephrology facilitated the development of core interventions aimed at reducing PD-related infections across US dialysis facilities. The core interventions focus on six key strategies: ( 1 ) regular surveillance and feedback on infection rates, ( 2 ) standardized staff training and competency assessments, ( 3 ) standardized patient and care partner/caregiver education, ( 4 ) routine infection prevention assessments, ( 5 ) antimicrobial prophylaxis for PD catheter exit sites, and ( 6 ) prophylactic antimicrobials for certain procedures and events. These strategies, on the basis of evidence and international guidelines, emphasize consistency in implementation and monitoring at the facility level. The workgroup followed an iterative process, incorporating expert review and feedback to inform and refine these interventions. Effective implementation requires coordinated efforts among dialysis teams, patients, and support networks, with ongoing evaluation through surveillance and quality improvement initiatives. Although the interventions are grounded in current evidence, additional research is necessary to refine practices and address emerging challenges. The goal is to reduce infection risks, improve the quality of life for patients on PD, and support national efforts to expand home dialysis use.

Introduction: Patients with acute kidney injury (AKI) or end stage kidney disease (ESKD) may require continuous renal replacement therapy (CRRT) as a supportive intervention. While CRRT is effective at achieving solute control and fluid balance, the indiscriminate nature of this procedure raises the possibility that beneficial substances may similarly be removed. Hepcidin, an antimicrobial peptide with pivotal roles in iron homeostasis and pathogen clearance, has biochemical properties amenable to direct removal via CRRT. We hypothesized that serum hepcidin levels would significantly decrease after initiation of CRRT. Methods: In this prospective, observational trial, we enrolled 13 patients who required CRRT: 11 due to stage 3 AKI, and 2 due to critical illness in the setting of ESKD. Plasma was collected at the time of enrollment, and then plasma and effluent were collected at 10:00 a.m. on the following 3 days. Plasma samples were also collected from healthy controls, and we compared hepcidin concentrations in those with renal disease compared to normal controls, evaluated trends in hepcidin levels over time, and calculated the hepcidin sieving coefficient. Results: Plasma hepcidin levels were significantly higher in patients initiating CRRT than in normal controls (158 ± 60 vs. 17 ± 3 ng/mL respectively, p < 0.001). Hepcidin levels were highest prior to CRRT initiation (158 ± 60 ng/mL), and were significantly lower on day 1 (102 ± 24 ng/mL, p < 0.001) and day 2 (56 ± 14 ng/mL, p < 0.001) before leveling out on day 3 (51 ± 11 ng/mL). The median sieving coefficient was consistent at 0.82–0.83 for each of 3 days. Conclusions: CRRT initiation is associated with significant decreases in plasma hepcidin levels over the first 2 days of treatment regardless of indication for CRRT, or presence of underlying ESKD. Since reduced hepcidin levels are associated with increased mortality and our data implicate CRRT in hepcidin removal, larger clinical studies evaluating relevant clinical outcomes based on hepcidin trends in this population should be pursued.

BACKGROUND Peritonitis is a complication associated with peritoneal dialysis (PD), which carries a significant morbidity and mortality risk. Empiric therapy must include coverage of gram-positive organisms; vancomycin is a recommended treatment option, particularly when MRSA infection is a risk. Vancomycin is cumbersome for patients, requiring therapeutic drug monitoring and re-administration by a healthcare provider. Dalbavancin, administered as a one-time intravenous dose, is a convenient potential treatment option for PD patients to cover gram-positive organisms without the need for routine drug monitoring. CASE REPORT We present 2 patients effectively treated with dalbavancin for infectious peritonitis. The first patient, a 73-year-old woman with end-stage renal disease (ESRD) on PD, presented to the hospital with fever, elevated white blood cells (WBCs), and cloudy peritoneal fluid with elevated nucleated cell counts (88% neutrophils). This patient was given 1 dose of 1500 mg IV dalbavancin. Within 3 days, her fever resolved, WBCs returned to normal, and peritoneal fluid results improved. The second patient was a 36-year-old woman presenting to an outpatient clinic with abdominal pain and cloudy peritoneal fluid with elevated nucleated cell counts (53% neutrophils) treated with dalbavancin 1500 mg IV once. Within 4 days, this patient's pain had resolved, and peritoneal fluid results returned to baseline. No adverse effects were noted for either patient. CONCLUSIONS These cases illustrate the potential of dalbavancin as a convenient option for patients with PD-associated peritonitis. Both patients demonstrated rapid and complete response to a single dose of dalbavancin without complications. Further prospective studies are needed to establish dalbavancin as an option for peritonitis.

1Division of Nephrology, St. Michael's Hospital, Unity Health, University of Toronto, Toronto, Ontario, Canada 2Division of Kidney Diseases and Hypertension, Department of Medicine, School of Medicine, University of Colorado Hospital, Aurora, Colorado 3Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada Correspondence: Dr. Jeffrey Perl, Division of Nephrology, St. Michael's Hospital, Unity Health, University of Toronto, 61 Queen Street East, 9-128, Toronto, ON M5C 2T2, Canada. Email: [email protected] Published online ahead of print. Publication date available at www.jasn.org. See related article, “Peritoneal Dialysis Catheter Complications after Insertion by Surgeons, Radiologists, or Nephrologists,” on pages 85–93.

Background:The evaluation of volume status is essential to clinical decision-making, yet multiple studies have shown that physical exam does not reliably estimate a patient's intravascular volume. Venous excess ultrasound score (VExUS) is an emerging volume assessment tool that utilizes inferior vena cava (IVC) diameter and pulse-wave Doppler waveforms of the portal, hepatic and renal veins to evaluate venous congestion. A point-of-care ultrasound exam initially developed by Beaubein-Souligny et al., VExUS represents a reproducible, non-invasive and accurate means of assessing intravascular congestion. VExUS has recently been validated against RHC-the gold-standard of hemodynamic evaluation for volume assessment. While VExUS scores were shown to correlate with elevated cardiac filling pressures (i.e., right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP)) at a static point in time, the ability of VExUS to capture dynamic changes in volume status has yet to be elucidated. We hypothesized that paired VExUS examinations performed before and after hemodialysis (HD) would reflect changes in venous congestion in a diverse patient population. Methods:Inpatients with end-stage renal disease undergoing intermittent HD were evaluated with transabdominal VExUS and lung ultrasonography before and following HD. Paired t-tests were conducted to assess differences between pre-HD and post-HD VExUS scores, B-line scores and dyspnea scores. Results:Fifty-six patients were screened for inclusion in this study. Ten were excluded due to insufficient image quality or incomplete exams, and forty-six patients (ninety-two paired ultrasound exams) were included in the final analysis. Paired t-test analysis of pre-HD and post-HD VExUS scores revealed a mean VExUS grade change of 0.82 (p<0.001) on a VExUS scale ranging from 0 to 4. The mean difference in B-line score following HD was 0.8 (p=0.001). There was no statistically significant difference in subjective dyspnea score (p=0.41). Conclusions:Large-volume fluid removal with HD was represented by changes in VExUS score, highlighting the utility of the VExUS exam to capture dynamic shifts in intravascular volume status. Future studies should evaluate change in VExUS grade with intravenous fluid or diuretic administration, with the ultimate goal of evaluating the capacity of a standardized bedside ultrasound protocol to guide inpatient volume optimization.

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.