No abstract

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.

It is not clear to what extent changes in blood pressure (BP) during hemodialysis affect or predict survival. Studying comparative outcomes of BP changes during hemodialysis can have major clinical implications including the impact on management strategies in hemodialysis patients. Here we undertook a retrospective cohort study of 113,255 hemodialysis patients over a 5 year period to evaluate an association between change in BP during hemodialysis and mortality. The change in BP was defined as post- minus pre-hemodialysis BP and mean of BP change values during the hemodialysis session was used as a mortality predictor. The patients averaged 61 years old and consisted of 45% women, 32% African-Americans and 58% diabetics. Over a median follow-up of 2.2 years, a total of 53,461 (47.2%) all-cause and 21,548 (25.7%) cardiovascular deaths occurred. In fully adjusted Cox regression model with restricted cubic splines, there was a U-shaped association between change systolic BP and all-cause mortality. Post-dialytic drops in systolic BP between −30 to 0 mmHg were associated with greater survival, but large decreases of systolic BP (more than −30 mmHg) and any increase in systolic BP (over 0 mmHg) were related to increased mortality. Peak survival was found at a change in systolic BP of −14 mmHg. The U-shaped association was also found for cardiovascular mortality. Thus, modest declines in BP after hemodialysis are associated with the greatest survival, whereas any rise or large decline in BP is associated with worsened survival.

Nafamostat mesilate (NM), a synthetic serine protease inhibitor, has been used increasingly as an anticoagulant during continuous renal replacement therapy (CRRT). However, there, are limited data from randomized studies on NM use in patients with a bleeding tendency. This prospective study evaluated the efficacy and safety of NM use during CRRT in patients with acute kidney injury (AKI) patients at high risk of bleeding.Patients with AKI at high risk of bleeding were randomized into the NM and no anticoagulant (NA) groups. The primary outcome was the treatment efficacy represented by the filter lifespan. Several parameters, including safety and patient survival rates at 30 and 90 days, were analyzed as secondary outcomes.Fifty-five patients were included in this study (NM group = 31, NA group = 24). The baseline characteristics did not significantly differ between the groups. The mean filter lifespan was significantly longer in the NM group than in the NA group (31.7 ± 24.1 versus 19.5 ± 14.9 hours; P = 0.035). The most common cause of filter failure was filter clotting, which was significantly more frequent in the NA group than in the NM group (59.6% versus 37.7%, P = 0.024). The Cox proportional hazards model showed a 42.2% longer filter lifespan in the NM group compared with the NA group (hazard ratio, 0.578; 95% confidence interval, 0.362–0.923; P = 0.022). There were no significant differences in the frequencies of transfusions and major bleeding between the groups. Patient survival rates at 30 and 90 days after CRRT initiation were comparable between the groups.Nafamostat mesilate is a safe and effective anticoagulant for CRRT and allows sufficient filter survival without increasing the risk of bleeding in critically ill patients with AKI and bleeding tendencies.