PERITONITIS AS A RISK FACTOR FOR CARDIOVASCULAR EVENTS IN PERITONEAL DIALYSIS PATIENTS

K HEPBURN1, K LAMBERT2, J MULLAN2, B MCALISTER2, M LONERGAN1, H HASSAN1
1Department of Renal Medicine, Wollongong Hospital, Wollongong, Australia, 2Centre for Health Research Illawarra Shoalhaven Population (CHRISP), University of Wollongong, Wollongong, Australia

Aim: To examine peritonitis as a risk factor for cardiovascular events (CVE) in patients undertaking peritoneal dialysis (PD).
Background: Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in PD. There is a documented association between infection and an increase in CVE. However, no studies have examined the association between peritonitis and CVE in the PD population.
Methods: All adult patients undertaking PD for more than 3 months in one NSW health district from 2001-2015 were included in this retrospective cohort analysis. Patients, baseline characteristics and peritonitis events were obtained from the ANZDATA Registry. CVE data using ICD10 coding was obtained and data linkage was facilitated by the Centre for Health Research Illawarra Shoalhaven Population (CHRISP). Time-dependent covariate analysis using Cox-proportional models were used to determine hazard ratios.
Results: 212 patients were included; median age was 66 years (IQR 54.3-74.4) and 63.7% were male. Glomerulonephritis was the most common underlying renal disease (29.2%). 128 patients (60%) experienced peritonitis, and 64 (30.2%) experienced CVE. Risk factors for CVE were cerebrovascular disease (HR 2.74, 95%CI 1.37-5.51, p=0.005), diabetes (HR 2.29, 95%CI 1.39-3.77, p=0.001), CVD (HR 1.73, 95%CI 1.04-2.87, p=0.04) and age (HR 1.04, 95%CI 1.02-1.06, p=0.01). Risk of CVE from peritonitis was 1.33 (95%CI 0.79-2.25, p=0.28), even when accounting for covariates (HR 1.33, 95%CI 0.78-2.26, p=0.29).
Conclusions: This is the first study to quantify risk of CVE in PD patients who develop peritonitis. We found that peritonitis increases the risk of CVE by 33%. Statistical significance was not reached in this study, possibly due to a low event rate and relatively small sample size. Larger studies to explore this important association are warranted.


Biography:
Dr Kirsten Hepburn is a second year Nephrology Advanced Trainee in the East Coast Renal Network, Sydney, NSW. Her other degrees include BSc (Psych) and MPH.

DEVELOPING CONSENSUS-BASED OUTCOME DOMAINS FOR TRIALS IN PERITONEAL DIALYSIS: AN INTERNATIONAL DELPHI SURVEY

K MANERA1,2, A TONG1,2, J CRAIG1,2, J SHEN3, S JESUDASON4,5, Y CHO6,7,8, B SAUTENET1,2,9,M HOWELL1,2, A WANG10, E BROWN11, G BRUNIER12, J PERL13, J DONG14, M WILKIE15, R MEHROTRA16, R PECOITS-FILHO17, S NAICKER18, T DUNNING19, D JOHNSON6,7,8,20,21
1Sydney School of Public Health, The University Of Sydney, Sydney, Australia, 2Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia, 3Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrence, USA, 4Central and Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, Australia, 5School of Medicine, University of Adelaide, Adelaide, Australia, 6Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia, 7Australian Kidney Trials Network, University of Queensland, Brisbane, Australia, 8Translational Research Institute, Brisbane, Australia, 9Department of Nephrology and Clinical Immunology, , France, 10Department of Medicine, Queen Mary Hospital, University of Hong Kong, , Hong Kong, 11Imperial College Renal and Transplant Centre, Hammersmith Hospital, , United Kingdom, 12Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada, 13Division of Nephrology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, Canada, 14Renal Division, Department of Medicine, Peking University First Hospital, , China, 15Department of Nephrology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom, 16Kidney Research Institute and Harborview Medical Center, Division of Nephrology/Department of Medicine, University of Washington, Seattle, USA, 17School of Medicine, Pontifícia Universidade Católica do Paraná, Curitiba, Brazil, 18Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, , South Africa, 19South Bank TAFE, Brisbane, Austalia, 20Metro South and Ipswich Nephrology and Transplant Services (MINTS), Brisbane, Australia, 21Centre for Kidney Disease Research, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia

Background: Major inconsistencies in the reporting of outcomes, the omission of patient-reported outcomes, and frequent reporting of surrogate outcomes in trials impedes evidence-informed decision making by patients and their clinicians.
Aim: To generate a consensus-based prioritised list of outcome domains for trials in peritoneal dialysis (PD).
Methods: In an international online 3-round Delphi survey, patients/caregivers and health professionals rated the importance of outcomes using a 9-point Likert scale and provided comments. In rounds 2 and 3, participants re-rated the outcomes after reviewing the scores and comments of other respondents. For each outcome we calculated the mean, median, and proportion rating 7-9 (critically important).
Results: In total, 873 participants (207 [24%] patients/caregivers and 666 [76%] health professionals) from 68 countries completed round 1, and 530 (61%) completed round 3. The top outcomes based on a threshold (mean >8; median ≥8; proportion >85% in both groups) were PD-infection, membrane functioning, PD failure, cardiovascular disease, mortality, catheter complications, and ability to do usual activities. Compared with health professionals, patients/caregivers gave higher priority to 6 outcomes: blood pressure (mean difference of 0.4), fatigue (0.3), membrane functioning (0.3), impact on family/friends (0.1), peritoneal thickening [EPS] (0.1), and usual activities (0.1).
Conclusion: Clinical outcomes were highly prioritised by both stakeholder groups. Patients/caregivers gave higher priority to lifestyle-related outcomes than health professionals. This process will inform a core outcome set to improve the consistency and relevance of outcomes reported in trials in peritoneal dialysis.


Biography:
Karine Manera is a PhD candidate with The University of Sydney and research officer at the Centre for Kidney Research. She uses qualitative and quantitative research methods to generate evidence for improving shared decision-making in the area of peritoneal dialysis. She has applied this approach in global and multi-language studies.

 

OUTCOMES OF PERITONEAL DIALYSIS: DO THEY CORRELATE WITH TRAINING AND WELLBEING PRE-DIALYSIS FACTORS?

E VUJOVICH1, J CUENCA2, P MCLENNAN1, J HOLT2
1University of Wollongong, Wollongong, Australia, 2Illawarra Shoalhaven Local Health District, Wollongong, Australia

Aim: Examine the relationship between pre-treatment factors and peritoneal dialysis (PD) outcomes.
Background: Patients with end stage kidney disease requiring dialysis can choose from multiple modes of treatment depending on their personal needs. It is important for renal physicians to make informed decisions when recommending what modality may best suit a patient. Although many patients choose PD as a first option home therapy, current literature is limited regarding what pre-treatment factors may predict PD outcomes.
Methods: Retrospective study analysing data of patients from a major tertiary centre hospital in NSW who underwent education and assessment as part of their renal replacement therapy. Patients (n = 16) underwent a comprehensive pre-treatment assessment that includes measures of cognitive functioning (Montreal Cognitive Assessment), frailty (Frailty Phenotype Score) and mood (Patient Health Questionnaire 9).
Results: The results of Fisher’s exact test indicated that patients who took 6 or more days to complete their PD training had higher rates of peritonitis (p = .003). In addition, there were high rates of death or of being moved into a care home amongst those who developed peritonitis. A Mann-Whitney U test showed that older age was associated with higher rates of peritonitis (p = .03). There were no significant relationships between PD outcomes and patients’ pre-treatment scores of cognitive, frailty and depression measures.
Conclusions: Pre-treatment factors such as time taken to complete PD training and age may contribute to PD outcomes. Further research should be done with larger cohorts, investigating pre-treatment variables in PD and rates of peritonitis.


Biography:
Elicia Vujovich is a final year medical student at the University of Wollongong, Graduate Medicine. She has an Honours degree in Public Health, which she studied at Queens University in Canada. Prior to studying Graduate Medicine she worked for the Australian Red Cross, in Perth. This paper was part of the research component of her education, for the completion of her MD. She will be graduating in 2018 and commencing internship next year.

TWO CASES OF KOCURIA PERITONITIS NECESSITATING PERITONEAL DIALYSIS CATHETER REMOVAL.

V HERON1, A YOUNG1, S WILKINSON1, R BARTON1, A GUPTA1
1Darling Downs Hospital And Health Service, Toowoomba, Australia

Background: Peritonitis is a common and serious complication seen in peritoneal dialysis (PD) patients. Kocuria, a genus of gram-positive organisms, has been identified as commensal flora of the human skin and mucosa. It has a close microbiological resemblance to coagulase negative staphylococci and this has made its diagnosis difficult. New laboratory techniques have aided the identification of kocuria species. Sixteen cases of kocuria-associated peritonitis have been reported in the literature with two cases requiring removal of the PD catheter. We present a single centre experience of two cases of kocuria peritonitis necessitating catheter removal.
Case report: Two cases of kocuria peritonitis were treated by the Darling Downs Renal Service in 2017. Both cases occurred in patients treated with continuous ambulatory peritoneal dialysis (CAPD) and each presented with abdominal pain and cloudy dialysate. The first patient was treated with intraperitoneal vancomycin and despite his initial improvement, he developed worsening abdominal pain. His dialysate cell count rose and the catheter was removed on day eight of presentation. Intravenous cephazolin was continued for a further week. The second patient completed six days of intraperitoneal cephazolin before the peritoneal catheter was removed. A further two weeks of intravenous cephazolin was finished.
Conclusions: Kocuria peritonitis may be a previously under-recognised cause of PD peritonitis. It has predominately been reported in CAPD patients. Although it is a known commensal flora of the skin and mucosa, the requirement for peritoneal catheter removal in two cases of kocuria peritonitis suggests that it can be a clinically important pathogen in humans, including PD patients.


Biography:
Vanessa Heron is an advanced trainee in nephrology currently working at Toowoomba Hospital, Queensland.

PREDICTORS OF MORTALITY IN PERITONEAL DIALYSIS PATIENTS IN A TERTIARY CENTER

G LOW1, J KOH2, G LOW3, S PANG1,H HTAY1, M FOO1, T CHONG1, C TAN1
1Singapore General Hospital, Singapore, Singapore, 2Nanyang Technological University, Singapore, Singapore, 3National University of Singapore, Singapore, Singapore

Tenckhoff catheter longevity remains one of the leading challenges for long-term peritoneal dialysis. This study aims to report catheter outcomes and predictors of mortality within our center.

A single-center retrospective study was performed for patients who had Tenckhoff catheter inserted between January 2011 and January 2016, with patients followed up until 1st January 2017. Cox regression analysis was performed to investigate factors affecting patient survival and catheter survival. Catheter failure is defined as any catheter-related complication necessitating removal.

470 Tenckhoff catheters were inserted in total. Mean age of the study population was 61.6±14.3 years, 49.8% Male, 75.5% Chinese/18.9% Malay/4.9% Indian with median BMI of 24.0kg/m2. Diabetes Mellitus(DM)(58.5%), Hypertension(87.2%) and Ischemic Heart Disease(IHD)(41.1%) were the 3 most common patient comorbidities.

Median follow-up period was 29.2 months(IQR 16.7-49.7 months). All-cause mortality during follow-up was 37.0%(174/470), with only 18.4%(32/174) of deaths resulting from catheter failure. Significant associations with patient survival on multivariate analysis include age(HR=1.04, 95%CI 1.02-1.05), DM(HR=2.04, 95%CI 1.36-3.07), IHD(HR=1.80, 95%CI 1.28-2.52) and serum albumin before catheter insertion(HR=0.94, 95%CI 0.92-0.97). No significant association was observed between patient survival and gender, BMI, hypertensive status, previous cerebrovascular accident, PD modality, hemodialysis before catheter insertion or presence of infection during follow-up.

Catheter failure rate was 27.7%(130/470) during the follow-up period, with mean catheter survival of 50.1±1.4 months. The only significant association with catheter survival was presence of infection during follow-up(p<0.001, HR=3.51, 95%CI 2.16-5.71).

DM, IHD, older age and lower baseline serum albumin were associated with poorer survival and should be considerations when selecting patients within our population. Patients without any infectious episodes during follow-up experienced longer catheter survival in our study, suggesting infection prevention remains essential to prolonging catheter survival.


Biography:
Gerard Low is a Medical Student enrolled in Yong Loo Lin School of Medicine, National University of Singapore.

THE PREVALENCE AND UTILITY OF BACKUP ARTERIOVENOUS FISTULA IN PATIENTS UNDERGOING PERITONEAL DIALYSIS – A RURAL PERSPECTIVE

CW NG1, G HARRIS1, C HOLMES1
1Bendigo Health, Bendigo, Australia

Aim: To study the prevalence and utility of backup arteriovenous fistula (AVF) in patients undergoing peritoneal dialysis (PD) at a rural centre in Victoria.
Background: There are ongoing debates on the need for creating backup AVF in PD patients. The practice varies across renal centres and nephrologists. Previous studies demonstrated low utility of backup fistula, suggesting that benefit of such practice is questionable.
Methods: This is a retrospective cohort study of adult PD patients managed at Bendigo Health from 1st January 2017 till 30th April 2018. Primary outcomes were the prevalence of backup AVF and its subsequent utility.
Results: Bendigo Health managed 43 PD patients between 1st January 2017 and 30th April 2018. 28 remained on PD at end of study period. 62.8% of patients were male (n=27) and 93% were Caucasian (n=40). Mean PD commencement age was 62 years (range 19-86 years). Mean therapy time was 900 days (range 7-3042 days). 27.9% (n=12) patients had backup AVF, 5 of which were constructed simultaneously with Tenckhoff catheter insertion. 5 backup fistulae were accessed, either following conversion to haemodialysis (n=4) or perioperatively during transplantation (n=1). 7 backup fistulae were never used, 4 of which were non-functional. 4 patients without backup fistula required percutaneous vascular catheter insertion while converting to haemodialysis, due to peritonitis warranting Tenckhoff catheter removal (n=2), inadequate dialysis (n=1), or abdominal surgery (n=1).
Conclusions: A quarter of PD patients at Bendigo Health had backup AVF created, but less than half of those fistulae were ever accessed, and one third were non-functional for haemodialysis access. Larger studies are required to identify subgroups of PD patients who are more likely to benefit from backup AVF formation.


Biography:
Dr Chau Ng is the current Nephrology Advanced Trainee at Bendigo Health, Victoria.

PERITONEAL DIALYSIS CATHETER MALFUNCTION CAUSED BY A “PERITONEAL MOUSE”

D O’HARA1, K MURALI1, M WAYNE1
1Wollongong Hospital Renal Department, Wollongong, Australia

Background: Peritoneal loose bodies (PLB) or “peritoneal mice” are typically caused by fat necrosis of epiploic appendages with resultant auto-amputation and subsequent calcification. The rate of incidence is unknown and the condition usually causes few or non-specific symptoms. In patients undergoing peritoneal dialysis (PD), PLB have the potential to cause PD catheter outflow obstruction, but no such cases have been reported.
Case Report: A 70-year old male with end-stage kidney disease due to hypertensive nephrosclerosis commenced PD one year before the index presentation. He had no prior abdominal surgeries and never had PD peritonitis. He noticed intermittent PD catheter outflow obstruction over two weeks with preserved inflow. He experienced two episodes of total inability to drain PD fluid with resultant fluid absorption. He had daily bowel movements on aperients. An abdominal x-ray excluded constipation and catheter malposition. An alteplase lock was used, in hope of dislodging a presumed fibrin clot, but the catheter outflow didn’t improve. He was suspected to have omental wrapping of the PD catheter and a decision was made to proceed with surgical exploration for possible omentectomy and catheter replacement. When planning for surgery he was noted to have a flesh-coloured material sliding in the PD catheter lumen, which was carefully milked out. Histopathology revealed heavily calcified material with organising fat necrosis. After the material was squeezed out, the PD catheter function was perfectly restored with no further issues.
Conclusions: We report a case of PD catheter outflow obstruction caused by peritoneal loose body due to calcified organising fat necrosis. Awareness of this entity could prompt the clinician to recognise the condition, which may help to streamline management and avoid unnecessary surgery.


Biography:
Dr Daniel O’Hara is a second-year renal Advanced Trainee in the East Coast Renal Network. He has a keen interest in general nephrology, dialysis, obstetric medicine and global renal health.

TUBERCULOUS PERITONITIS IN PATIENTS ON PERITONEAL DIALYSIS

B CHOY, L KWAN, M MOK, T CHAN
1Department of Medicine, Queen Mary Hospital, Hong Kong, Hong Kong

Aim:To determine the incidence and outcome of tuberculous peritonitis among patients on peritoneal dialysis (PD)
Background:Mycobacterial infection is prevalent in Asia. Peritonitis caused by mycobacterium tuberculous may cause significant morbidity to patients on peritoneal dialysis.
Methods:We retrospective analyzed the 716 patients (Continuous Ambulatory PD 83.3%, Automated PD 16.7%) who had been followed up in our center between 2006 to December 2016.
Results:There were altogether 1624 episodes of peritonitis, among which 16 were due to mycobacterium tuberculous (TB) which accounted for 1% of peritonitis (gram positive 46.2%, gram negative 34.8%, fungal 3.5%, TB 1%, atypical TB 0.5%, no growth 14%). Mean age of patients with TB peritonitis was 71.4 ±11.7 years, 56% had diabetes mellitus . All patients presented with turbidity of peritoneal fluid (PDF), abdominal pain and persistent low grade elevation of PDF WBC count (232.6 ±120 /uL) not responding to first and second line antibiotic. Two patients also had fever and chest symptoms. The mean time from onset of symptoms to diagnosis was 26.2 ±16.6 days (all by culture). Two patients died of gastrointestinal bleeding before diagnosis and treatment. All others responded to anti-TB treatment (isoniazid, rifampicin, pyrazinamide and levofloxacin with reduction to 2 drugs after 3 months) for a total course of 9 to 12 months. Five patients needed Tenckhoff catheter (TC) removal. The TC removal rate was similar to peritonitis caused by other organisms (5/14 vs 279/1599, P=0.08) but only 1 patient was able to resume PD
Conclusions:Tuberculous peritonitis was uncommon among PD patients. However, diagnosis was often delayed resulting in significant morbidity. High index of suspicion and appropriate culture was needed for proper diagnosis and treatment.


Biography:
Dr. Choy is the nephrologist in-charge of the Renal Replacement Services of Queen Mary Hospital, Hong Kong. Dr. Choy graduated from the University of Hong Kong. She received her nephrology training in University Department of Medicine of Queen Mary Hospital in Hong Kong and Department of Nephrology of Royal Melbourne Hospital in Australia. Her clinical and research interest is in medical and infective complications of patients on dialysis and renal transplantation.

RETINAL CHANGES IN PERITONEAL DIALYSIS

S BEK1, N EREN1
1Kocaeli University Hospital, Kocaeli, Turkey

Aim: To compare retinal changes of peritoneal dialysis (PD) patients with healthy control group by using optical coherence tomography (OCT) and investigate the effects of age, gender and duration of PD on these parameters.
Background: OCT is a non-invasive ocular imaging technique widely used nowadays. There are limited studies focusing on the OCT findings in PD patients.
Methods: In this cross-sectional study right and left eyes of 32 patients were included. Detailed ophthalmological examinations with central fovea thickness (CFT), macular volume, retinal nerve fiber layer ( RNFL) thickness, and choroidal thickness (using EDI-OCT) were measured. The RNFL thickness was analysed in six different areas: temporal, inferotemporal, inferonasal, nasal, superonasal and superotemporal.
Results: Sixty-four eyes of 32 patients (18 males, 14 females; aged 20 to 60 years, mean 48.67±12.25 years) with a mean duration of PD of 46.80 months were included. There was a significant difference of retinal thickness in the nasal, inferior and superior quadrants between controls and PD patients (p < 0.05). Vitamin D supplementation was linked to increased retinal thickness in macula superior, nasal and inferior quadrants (p<0.05). There was a positive correlation between retinal thickness in macula central and temporal with residual renal function (p=0.006, p=0.019). Higher urea and total cholesterol levels were found to be linked to higher retinal thickness in central, nasal, temporal and macula central (p<0.05).
Conclusion: OCT revealed a significant reduction of retinal thickness in PD patients.


Biography:
I have been working as a nephrologist in Turkey and will be working in Sydney University for one year as ISN fellow. (June 2018-2019)

PROFILE OF CAPD PATIENTS IN SARDJITO GENERAL HOSPITAL YOGYAKARTA INDONESIA

WM WAYAN1
1Sarjito Hospital, Yogyakarta, Indonesia

Background. Currently Continuous Ambulatory Peritoneal Dialysis (CAPD) and hemodialysis (HD) are the two main modalities of renal replacement therapy in many Asian countries with varying proportions. In Indonesia, the percentage of CAPD patients 2% and HD patients 98% of total patients with CKD stage 5 dialysis. By 2016 the number of CAPD patients is increasing every year, but the dropout rate is still high.
Methods. We investigated bioclinical and patient-reported information from 73 the outpatient records of all CKD stage 5 patients treated with CAPD in Sardjito General Hospital. The assessed variable is age, sex, duration of CAPD and most common predisposing factors.
Results. A total of 73 CAPD patients at Sardjito General Hospital, 71,23 % were men, the median age of patients starting CAPD 36 (29- 44) years, average duration of CAPD 3 years. Most common predisposing factors are hypertension (32.97%), diabetes mellitus (15.39%), consumption of supplements / drugs (16.49%), urinary tract stones (6.59%), urinary tract infections (6, 59%), kidney cyst (4.39%), others (12.09%) and unknown (5.49%). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%), have cardiovascular disease (59% versus 42%) and had uncontrolled blood pressure ( 68 % vs 27 % ).  During the previous year, 60% of patients reported hospitalized caused by peritonitis (84% ) and cardiovascular disease (16% ).
Conclusion. The profile of CAPD patients in Sardjito General Hospital showed that the mean age of patients starting CAPD was 36 years, mean CAPD duration was 3 years, and the most common predisposing factor was hypertension (32.97%).
Keywords. Characteristic CAPD Patients, Continuous Ambulatory Peritoneal Dialysis, Chronic Kidney Disease


Biography:
Medical doctor 199
Internal medicine 2006
Fellow of nephrology 2016

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