8. Art. No.: CD013209. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.

Peritonitis is a serious and common complication of peritoneal dialysis (PD), representing the commonest cause of technique failure and a not infrequent cause of patient death. Early onset peritonitis, variously defined in the literature as peritonitis occurring within the first 3-20 months of PD, is increasingly being recognised as a discrete and important clinical problem with appreciably heightened risks of technique failure and death. The aim of this review is to provide a comprehensive up to date summary of current evidence surrounding early onset peritonitis and to discuss how to better manage the condition, including suggestions for future research directions.

Background: Commencing hemodialysis (HD) with an arteriovenous access is associated with superior patient outcomes compared to a catheter but the majority of patients in Australia and New Zealand (ANZ) initiate HD with a central venous catheter. This study examined patient and center factors associated with arteriovenous fistula/graft access use at HD commencement. Methods: All adult patients starting chronic HD in Australia and New Zealand between 2004 and 2015 were included. Access type at HD initiation was analyzed using logistic regression. Patient-level factors included sex, age, race, body mass index (BMI), smoking status, primary kidney disease, late nephrologist referral, comorbidities and prior kidney replacement therapy (KRT). Center-level factors included size, transplant capability, home HD proportion, incident peritoneal dialysis (average number of patients commencing KRT with peritoneal dialysis per year), mean weekly HD hours, average blood flow and achievement of phosphate, hemoglobin and weekly Kt/V targets. The study included 27,123 patients from 61 centers. Results: Arteriovenous access use at HD commencement varied 4-fold from 15% to 62% (median 39%) across centers. Incident arteriovenous access use was more likely in patients aged 51-72 years, males and patients with BMI >25kg/m2 and polycystic kidney disease but less likely in patients with BMI<18.5kg/m2, late nephrologist referral, diabetes mellitus, cardiovascular disease, chronic lung disease and prior KRT. Starting HD with an arteriovenous access was less likely in centers with the highest proportion of home HD and no center factor was associated with higher arteriovenous access use. Adjustment for center-level characteristics resulted in a 25% reduction in observed inter-center variability of arteriovenous access use at hemodialysis initiation compared to the model adjusted for only patient-level characteristics. Conclusions: This study identified several patient- and center-factors associated with incident hemodialysis access use, yet these factors did not fully explain the substantial variability in arteriovenous access use across centers.

Perioperative antibiotics for preventing post-surgical site infections in solid organ transplant recipients.

Peritoneal dialysis (PD)-related complications and outcomes have been shown to be influenced by both patient-and centre-level factors. There is a significant variability in outcomes across different centres, which is not explained by patient factors alone. This chapter aims to evaluate those modifiable centre-level factors that have been shown to impact PD outcomes, focussing specifically on peritonitis and technique failure, and the evidence that addressing these centre effects may lead to appreciable improvements in PD patient outcomes. Peritonitis rates have been shown to be related to a centre's degree of automated PD (APD) use, extent of icodextrin use, performance of home visits prior to PD commencement, the presence of a specialised PD nurse and duration of PD training. Better peritonitis outcomes have been shown to be associated with larger centre size, greater share of PD patients among dialysis cohorts and treatment of peritonitis with comprehensive empiric antimicrobial therapy. PD technique failure has been shown to be related to centre size and degree of PD experience. Although there is little evidence currently available to demonstrate that prospectively modifying centre factors improves PD outcomes, an Australian continuous quality improvement initiative has been associated with progressively improved peritonitis and technique failure outcomes.