[Show abstract][Hide abstract] ABSTRACT: Background: Daily gentamicin cream exit-site prophylaxis reduces peritoneal dialysis (PD)-related gram-negative infections. However, there is a concern about the potential for increasing gentamicin resistance with the long-term use of prophylactic gentamicin. This study evaluated the incidence of gentamicin-resistant PD-related infections over more than 2 decades. ♦ Methods: Study data on prevalent PD patients were retrieved from a prospectively maintained institutional review board (IRB)-approved PD registry at a single center from January 1, 1991, to December 31, 2000, and January 1, 2004, to December 31, 2013. The rates of gram-negative infections, fungal infections and those infections with organisms resistant to gentamicin were examined for the 2 periods. Period 1 from 1991 to 2000 when S. aureus prophylaxis consisted initially of oral rifampin to treat nasal carriage with S. aureus, and was then daily exit-site mupirocin ointment for all PD patients, was compared to the period from 2004 to 2013 when daily exit-site gentamicin cream was prescribed as prophylaxis (Period 2). ♦ Results: The study included a total of 444 PD patients (265 and 179 in Period 1 and Period 2, respectively). No significant difference was noted in demographics between the 2 periods except race. The gram-negative exit-site infection rates for Period 1 and Period 2 were 0.109 versus 0.027 (p < 0.0001). Gram-negative peritonitis rates were similar. There were 3 episodes of gentamicin-resistant infections in each period. Fungal infections remained consistently low. ♦ Conclusion: Despite a decade of exit-site gentamicin prophylaxis, gentamicin-resistant PD-related infections and fungal infections remained very low and similar to the prior period.
Full-text · Article · Dec 2015 · Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
[Show abstract][Hide abstract] ABSTRACT: Studies have shown that a single-item question might be useful in identifying patients with limited health literacy. However, the utility of the approach has not been studied in patients receiving maintenance peritoneal dialysis (PD). We assessed health literacy in a cohort of 31 PD patients by administering the Rapid Estimate of Adult Literacy in Medicine (REALM) and a single-item health literacy (SHL) screening question "How confident are you filling out medical forms by yourself?" (Extremely, Quite a bit, Somewhat, A little bit, or Not at all). To determine the accuracy of the single-item question for detecting limited health literacy, we performed sensitivity and specificity analyses of the SHL and plotted the area under the receiver operating characteristic (AUROC) curve using the REALM as a reference standard. Using a cut-off of "Somewhat" or less confident, the sensitivity of the SHL for detecting limited health literacy was 80%, and the specificity was 88%. The positive likelihood ratio was 6.9. The SHL had an AUROC of 0.79 (95% confidence interval: 0.52 to 1.00). Our results show that the SHL could be effective in detecting limited health literacy in PD patients.
No preview · Article · Oct 2014 · Advances in peritoneal dialysis. Conference on Peritoneal Dialysis
[Show abstract][Hide abstract] ABSTRACT: This review is focused on minimizing complications and avoiding harm in peritoneal dialysis (PD) patients. Issues related to planning for PD are covered first, with emphasis on PD versus hemodialysis outcomes. Catheter types and insertion techniques are described next, including relevant recommendations by the International Society for Peritoneal Dialysis. A brief review of both noninfectious and infectious complications follows, with emphasis on cardiovascular and metabolic complications. Finally, recommendations for preventing PD-related infections are provided. In conclusion, with proper catheter insertion technique, good training, and attention to detail during the tenure in PD, excellent outcomes can be obtained in a well-informed motivated patient.
No preview · Article · May 2012 · Advances in chronic kidney disease
[Show abstract][Hide abstract] ABSTRACT: Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis. Few data are available from the United States about the incidence of EPS over time. To examine that question, we retrospectively examined our PD registry, in existence for 30 years, to identify patients with EPS. All other data were collected prospectively. We asked a radiologist to review all computed tomography (CT) scans taken at the time of EPS diagnosis. Incidence of EPS in our 676 patients was 1.2%, but rose to 15% after 6 years, and 38% after 9 years on PD. Peritonitis rates were not high in patients that developed EPS. Scoring of CT scans confirmed the diagnosis of EPS in all patients. Treatment was variable, but in recent years, steroids and tamoxifen were generally used when EPS was recognized. Mortality related to EPS was 38%. Several years after diagnosis, 3 patients are still alive; none is on total parenteral nutrition. In summary, the risk of EPS is low early in the course of PD, but increases progressively at 6 years and beyond. Imaging by CT is useful for diagnosing EPS. Our preliminary results suggest that steroids and tamoxifen are beneficial. Multicenter studies on this serious problem are needed.
Full-text · Article · Jan 2010 · Advances in peritoneal dialysis. Conference on Peritoneal Dialysis
[Show abstract][Hide abstract] ABSTRACT: Home dialysis in the United States, both home hemodialysis and peritoneal dialysis, peaked in the early 1990s. Since then, there has been a striking increase in the numbers and proportion of patients on in-center home hemodialysis (HD). As of 2008, there were approximately 27,000 patients on peritoneal dialysis (PD) and 2,455 on home HD with over 300,000 on in-center HD. There are multiple barriers to home dialysis in the United States, including lack of adequate patient education on modalities prior to starting dialysis, physician competence with home dialysis, lack of infrastructure in many programs for home dialysis, and a misinterpretation of literature and research with selection bias that suggests higher mortality on PD versus in-center HD. These barriers to home dialysis can be overcome.
Full-text · Article · Jun 2009 · Advances in chronic kidney disease
[Show abstract][Hide abstract] ABSTRACT: The Kidney Disease Outcomes Quality Initiative guidelines for peritoneal dialysis (PD) emphasize the need for quality improvement interventions to improve outcomes in PD. Here, we report 17 years experience of initiatives focused on lowering peritonitis rates in a single PD program. This institutional review board-approved retrospective analysis used a PD registry containing prospectively collected data on patient demographics, initial Charlson comorbidity index (CCI), peritonitis, and clinical outcomes, including reasons for transfer to hemodialysis. Periods were analyzed based on quality initiatives: 1990 - 1991, baseline; 1992 - 1995, randomized controlled trial of exit-site infection prophylaxis comparing mupirocin cream applied daily to the exit site with oral cyclical (every 12 weeks) rifampin; 1996 - 1999, compact assist device introduced for spiking on the cycler; 2000 - 2004, randomized controlled trial comparing daily gentamicin cream with mupirocin as exit-site prophylaxis; and 2005 - 2007, gentamicin prophylaxis implemented as routine care (2005) and retraining of all patients (2006). Infection rates and technique failure rates in each period were compared with baseline rates using incident rate ratio analysis. A total of 382 PD patients were evaluated [median age: 50 years (range: 18 - 90 years); 54% women; 19% African American; 36% with diabetes; median CCI: 5 (range: 2 - 14)]. The peritonitis rate declined from 0.5 episodes per year at risk in 1990 - 1991 to 0.25 episodes per year at risk in 2005 - 2007 (p < 0.004). The exit-site infection rate declined from 0.72 episodes per year at risk to 0.1 episodes per year at risk over the same period (p < 0.0001). The percentage of patients transferring to hemodialysis did not change significantly over time (overall 14%, varying from 12% to 17% annually), nor did the mortality rate, which varied from 115 per 1000 years to 171 per 1000 years. We conclude that quality improvement initiatives can reduce infection rates in PD patients.
No preview · Article · Jan 2009 · Advances in peritoneal dialysis. Conference on Peritoneal Dialysis
[Show abstract][Hide abstract] ABSTRACT: In this Practice Point commentary, we discuss Wiggins et al.'s systematic review of the treatment of peritonitis, a serious problem in peritoneal dialysis patients. Wiggins and co-workers reported that most antibiotic classes were similarly effective for the treatment of peritonitis. Despite the limited data available, the investigators found that the intraperitoneal route was more effective than the intravenous route in preventing treatment failure, that intermittent dosing of various antibiotics was as effective as continuous administration of these drugs, and that glycopeptide-based regimens were more likely than first-generation cephalosporins to achieve a complete cure. Here, we discuss the importance of treating peritonitis and the lack of and limitations of existing data, and emphasize the urgent need for well-designed, large randomized trials in this area.
Full-text · Article · Aug 2008 · Nature Clinical Practice Nephrology