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Karlien François, Joanne M Bargman Division of Nephrology, University Health Network Toronto General Hospital, University of Toronto, Toronto, ON, Canada Abstract: Peritoneal dialysis (PD) is an effective renal replacement strategy for patients suffering from end-stage renal disease. PD offers patient survival comparable to or better than in-center hemodialysis while preserving residual kidney function, empowering patient autonomy, and reducing financial burden to payors. The majority of patients suffering from kidney failure are eligible for PD. In patients with cardiorenal syndrome and uncontrolled fluid status, PD is of particular benefit, decreasing hospitalization rates and duration. This review discusses the benefits of chronic PD, performed by the patient or a caregiver at home. Recognition of the benefits of PD is a cornerstone in stimulating the use of this treatment strategy. Keywords: peritoneal dialysis, survival, quality of life, cost, home dialysis

Inflammatory myofibroblastic tumor, or inflammatory pseudotumor, usually is a benign lesion composed of mixed inflammatory and fibroblastic elements. It has rarely been reported in the posttransplantation setting and never in association with a renal allograft. Although the pathogenesis of this lesion is unclear, exposure to immunosuppressive agents and various infections have been implicated in its development. We report the first case of inflammatory myofibroblastic tumor infiltrating a renal allograft and highlight the role immunosuppression may have in the development of this lesion. Copyright © 2009 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Increasing the dialysis dose has failed to have an impact on the mortality of dialysis patients. In contrast, residual kidney function (RKF) has consistently been a potent predictor of improved survival for both hemodialysis and peritoneal dialysis patients. The benefits of RKF preservation challenge historical concepts of dialysis adequacy that have focused principally on achieving small-solute clearance targets. In this review, we highlight the evidence supporting the impact of RKF on survival and quality of life of dialysis patients and provide a mechanistic framework for this relationship. Current strategies to preserve RKF also are reviewed, emphasizing those used in patients treated with peritoneal dialysis. Copyright © 2009 National Kidney Foundation, Inc. [ABSTRACT FROM AUTHOR]

Peritoneal dialysis (PD) was historically the initial kidney replacement modality of choice for patients admitted to the intensive care unit, and there are several advantages to maintaining critically ill PD patients on their usual dialysis therapy. However, in this patient population, there are two contentious questions: how are the respiratory dynamics of mechanical ventilation impacted by the presence of dialysate within the abdomen, and what can be done to mitigate these potential effects? This review discusses the theoretical impact of PD on intra-abdominal pressure (IAP) and evidence for the effect of IAP on respiratory mechanics in mechanically ventilated PD patients., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Effective treatment of infections is a growing challenge owing to antimicrobial resistance. Peritoneal dialysis (PD) patients experience more frequent hospitalisations than the general population and have greater exposure to antibiotics, making them particularly vulnerable to this threat. Over the last decade, we have noted a surge in cases of complicated peritoneal dialysis-associated peritonitis (PD peritonitis) caused by antimicrobial-resistant organisms, including extended-spectrum beta-lactamase (ESBL), AmpC beta-lactamase-producing Enterobacterales, Pseudomonas aeruginosa and fungi. Practitioners must be alert to these organisms, seek early recognition of these resistance patterns and make timely adjustments in order to avoid delay in treatment that may increase risk of PD catheter removal and technique failure. We present a case of successful treatment of ESBL peritonitis, highlight its challenges, while providing guidance on management of other unusual and complicated PD peritonitis., Competing Interests: Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JMB is speaker and consultant at Baxter Healthcare and DaVita Healthcare Partners. This paper only addresses PD peritonitis management in adults; the approach in children may differ.

Introduction: Many individuals start dialysis in an acute setting with suboptimal pre-dialysis education. These individuals are often treated with central venous catheter insertion and initiation of in-center hemodialysis and only a minority will transfer to a home-based therapy. The dialysis start unit is a program performing in-center hemodialysis in a separate space while providing support and education on chronic kidney disease and treatment options in the initial weeks of kidney replacement therapy. We aimed to assess the uptake of home dialysis therapies between 2013 and 2021 among patients who started acute inpatient hemodialysis at University Health Network, Toronto and underwent dialysis at the dialysis start unit., Methods: This is a retrospective observational cohort study based on prospectively collected data. Patients' demographics were obtained from electronic charts. In the dialysis start unit, all patients received dialysis modality education by a nurse educator, dedicated home dialysis nurses, and the allied health care team., Findings: During 2013-2021, 122 patients were dialyzed in the dialysis start unit and included in the study. Among those patients, 68 patients ultimately chose home dialysis (57 peritoneal dialysis and 11 home hemodialysis). Fifty-four patients continued in-center hemodialysis. Patients adopting home dialysis were less likely to have diabetes and hypertension as the etiology of kidney failure and more likely to have glomerulonephritis or vasculitis., Discussion: Dialysis modality education is implementable in advanced chronic kidney disease. Individualized education and care after unplanned start dialysis can potentially enhance home dialysis choice and utilization., (© 2024 International Society for Hemodialysis.)

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption., Competing Interests: A.C.N.F. received speaker honoraria by Baxter Healthcare and holds a FRQS scholarship. J.B. serves as consultant to and received speaker honoraria with both DaVita Healthcare Partners and Baxter Healthcare. C.C. holds the R Fraser Elliott Chair in Home Dialysis and serves as consultant to Medtronic, Quanta, and Dialco Inc. He received an investigator—initiated grant from Medtronic ERP program. He also serves as the President of the International Society for Hemodialysis. L.C.D. has no disclosures relevant to the current submission., (© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)

Abstract: Peritoneal dialysis (PD) is now commonly prescribed to achieve target clearances for urea or creatinine. The International Society for Peritoneal Dialysis has proposed however that such targets should no longer be imposed. The Society's new guidelines suggest rather that the PD prescription should be adjusted to achieve well-being in individual patients. The relaxation of treatment targets could allow increased use of PD. Measurement of solute levels in patients receiving dialysis individualized to relieve uremic symptoms could also help us identify the solutes responsible for those symptoms and then devise new means to limit their accumulation. This possibility has prompted us to review the extent to which different uremic solutes are removed by PD., (Copyright © 2023 by the American Society of Nephrology.)

Peritoneal dialysis (PD) patients have higher hospitalisation rates than the general population. The hospitalisations are not always related to dialysis issues, and physicians with little or no experience with PD may be responsible for the care of these hospitalised patients. Furthermore, the hospital may not be familiar with or equipped to manage these patients. This review highlights barriers, knowledge gaps and management strategies to guide the care of hospitalised PD patients.

As the global prevalence of peritoneal dialysis (PD) continues to grow, practitioners must be equipped with prescribing strategies that focus on the needs and preferences of patients. PD is an effective form of kidney replacement therapy that offers numerous benefits to patients, including more flexibility in schedules compared with in-center hemodialysis (HD). Additional benefits of PD include salt and water removal without significant changes in patient hemodynamics. This continuous yet gentle removal of solutes and fluid is associated with better-preserved residual kidney function. Unfortunately, sometimes these advantages are overlooked at the expense of an emphasis on achieving small solute clearance targets. A more patient-centered approach emphasizes the importance of individualized treatment, particularly when considering incremental PD and other prescriptions that align with lifestyle preferences. In shifting the focus from small solute clearance targets to patient needs and clinical goals, PD remains an attractive, patient-centered form of kidney replacement therapy., (Copyright © 2022 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: This retrospective cohort study investigated the characteristics and outcomes of the end-stage kidney disease (ESKD) patients treated with incremental peritoneal dialysis (PD) at a large academic centre., Methods: ESKD patients initiating PD with a dialysate volume ≤6 L/day were analysed., Results: One hundred and seventy-five patients were included and were followed up for 352.6 patient-years. The baseline residual kidney function (RKF) was 8.3 ± 3.4 mL/min/1.73 m 2 . The unadjusted 1- to 5-year patient survival rate was 89.6%, 80.4%, 65.4%, 62.7% and 48.8%, respectively, and the corresponding time on PD therapy rate was 95.1%, 89.1%, 89.1%, 82.4% and 77.6%. Greater initial PD dose (hazard ratio = 1.608, 95% confidence interval 1.089-2.375) was associated with death after adjusting for age, Charlson comorbidity index (CCI), haemodialysis prior to PD, assisted PD and baseline RKF, likely as a result of residual confounding. There was no association with PD discontinuation. The average peritonitis rate and hospitalisation rate were 0.122 and 0.645 episodes per patient-year, respectively. The dialysate volume increased from 4.5 (4.3-5.7) L/day to 8.0 (6.0-9.8) L/day at 5 years. Fifty-seven (32.6%) patients graduated to full-dose PD at a median time of 10.3 (6.2, 15.7) months. Male sex, greater body mass index and lower baseline serum albumin were risk factors for increasing PD dose to over 6 L/day within 1 year., Conclusions: Incremental PD is a safe approach to initiate dialysis, and it offers satisfactory outcomes. Close monitoring, comprehensive evaluation of clinical responses and prompt adjustment of the prescription as needed play a crucial role in this patient-centred treatment.

Home dialysis (peritoneal dialysis (PD) and home haemodialysis (HHD)) are ideal options for kidney replacement therapy (KRT). Occasionally, because of technique failure, patients are required to transition out of home dialysis, and the most common option tends to be to in-centre HD. There are few published studies on home-to-home transition (PD to HHD or HHD to PD) and dynamics during the transition period. We present a retrospective review of 28 patients who transitioned from a home-to-home dialysis modality at our centre over a 24-year period. We observed a total of 911 home dialysis patients with technique failure (826 PD patients and 85 HHD patients) with only 28 patients (3% of the total with technique failure) having successful home-to-home transition. During the transition period, 11 patients (39%) were hospitalized and 13 patients (46%) required variable periods of in-centre HD. After a median follow-up of 48 months following dialysis modality transition, four patients switched to in-centre HD permanently (home dialysis technique survival of 86% censored for death and kidney transplantation) and four patients died resulting in a patient survival of 86% (censored for switch to in-centre HD and transplantation). In our centre, home-to-home transition is a feasible strategy with comparable patient and technique survival. A significant proportion of patients switching from a home-to-home dialysis modality required variable intervals of hospitalization and in-centre HD during transitions. Future efforts should be directed towards assessment and home dialysis education during the entire process of dialysis transition.

The severe acute respiratory syndrome coronavirus (SARS-Cov-2) resulting in the coronavirus disease 2019 (COVID-19) is documented to have a negative psychosocial impact on patients. Home dialysis patients may be at risk of additional isolating factors affecting their mental health. The aim of this study is to describe levels of anxiety and quality of life during the COVID-19 pandemic among home dialysis patients. This is a single-centre survey of home dialysis patients in Toronto, Ontario. Surveys were sent to 98 home haemodialysis and 43 peritoneal dialysis patients. Validated instruments (Haemodialysis and Peritoneal Dialysis Treatment Satisfaction Questionnaire, Generalized Anxiety Disorder 7 Item [GAD7] Scale, Patient Health Questionnaire [PHQ-9], Illness Intrusiveness Ratings Scale, Family APGAR Questionnaire and The Self Perceived Burden Scale) assessing well-being were used. Forty of the 141 patients surveyed, participated in September 2020. The mean age was 53.1 ± 12.1 years, with 60% male, and 85% home haemodialysis, 80% of patients rated their satisfaction with dialysis at 8/10 or greater, 82% of respondents reported either "not at all" or "for several days" indicating frequency of anxiety and depressive symptoms, 79% said their illness minimally or moderately impacted their life, 76% of respondents were almost always satisfied with interactions with family members, 91% were never or sometimes worried about caregiver burden. Among our respondents, there was no indication of a negative psychosocial impact from the pandemic, despite the increased social isolation. Our data further supports the use of home dialysis as the optimal form of dialysis., (© 2021 Asian Pacific Society of Nephrology.)

The high prevalence of cardiovascular disease is caused by the traditional cardiovascular risk factors common among end-stage renal disease patients, and nontraditional risk factors attributed to underlying kidney disease, including chronic inflammation, anemia, bone mineral disease, and the dialysis procedure itself. Individualization of the treatment of cardiovascular disease in end-stage renal disease that could impact the underlying mechanisms of the cardiovascular diseases is important to improve outcomes. This article reviews and compares hemodialysis and peritoneal dialysis in association with different cardiovascular diseases affecting dialysis patients, including hypertension, coronary artery disease, myocardial stunning, cardiac arrhythmias, heart failure, and the cardiorenal syndrome., Competing Interests: Disclosure Dr J.M. Bargman has received honoraria and is a consultant for DaVita Healthcare Partners and Baxter Healthcare. Dr R.B. Albakr was funded through a scholarship from King Saud University, Riyadh, KSA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Home dialysis therapies are flexible kidney replacement strategies with documented clinical benefits. While the incidence of end-stage kidney disease continues to increase globally, the use of home dialysis remains low in most developed countries. Multiple barriers to providing home dialysis have been noted in the published literature. Among known challenges, gaps in clinician knowledge are potentially addressable with a focused education strategy. Recent national surveys in the United States and Australia have highlighted the need for enhanced home dialysis knowledge especially among nephrologists who have recently completed training. Traditional in-person continuing professional educational programmes have had modest success in promoting home dialysis and are limited by scale and the present global COVID-19 pandemic. We hypothesize that the use of a 'Hub and Spoke' model of virtual home dialysis mentorship for nephrologists based on project ECHO would support home dialysis growth. We review the home dialysis literature, known educational gaps and plausible educational interventions to address current limitations in physician education., (© 2021 Asian Pacific Society of Nephrology.)

Background: Inotropic dependence and diuretic resistance in patients with cardiorenal syndrome (CRS) lead to frequent hospitalizations and are associated with high mortality. Starting peritoneal dialysis (PD) acutely (within 2 weeks of a heart failure hospitalization) offers effective volume removal without hemodynamic compromise in this population. There is little data on this approach in the North American literature., Objective: To determine whether volume-overloaded patients with CRS on maximal doses of diuretic therapy had reduced hospitalization for heart failure following PD initiation., Design: Retrospective cohort study., Setting: Academic hospital network (University Health Network, Toronto, Ontario)., Patients: Patients with CRS receiving a bedside catheter and starting PD within 2 weeks of insertion at the University Health Network from January 1, 2013, to December 31, 2018., Methods and Measurements: Data for heart failure-related hospitalizations and length of stay 6 months before and after PD initiation were collected. Patients who died, switched to hemodialysis, or were transferred to another facility within 6 months of starting PD were excluded from the analysis., Results: We identified 31 patients with CRS who had a bedside PD catheter inserted. The average age of patients was 66.0 ± 13.0 years. There were 7 (22.6%) deaths and 4 (12.9%) transfers to other programs or hemodialysis within 6 months of catheter insertion. After exclusion, we analyzed hospitalization and length of stay data for 20 patients. The hospitalization rate 6 months before PD initiation was 6.9 admissions per 1000 patient-days. This decreased to 2.5 admissions per 1000 patient-days after PD initiation. In addition, there was also a significant reduction in the average length of stay per hospitalization (24.1-3.9 days; P = .001)., Limitations: Our study did not assess the severity of heart failure symptoms using a standardized functional classification system. We did not assess quality of life and illness intrusiveness scores before and after starting dialysis, nor did we capture non-heart-failure-related hospitalizations or external admissions at other hospital sites. We limited eligibility to clinically stable patients with no prior major abdominal surgical history in a single Canadian PD program using bedside ultrasound approach for catheter insertions by experienced nephrologists and included a small number of patients., Conclusions: Volume-overloaded patients with CRS receiving maximal diuretic therapy have lower hospitalization rates and shorter stays after initiation of PD. The development of a bedside PD catheter insertion program and close collaboration between nephrology and cardiology services may facilitate acute start dialysis in this population., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

Background: Peritonitis remains a major complication in peritoneal dialysis (PD). Abdominal imaging is often performed in the setting of peritonitis to evaluate for concomitant intra-abdominal processes. However, the usefulness of this procedure is unknown., Objective: The aim of this study was to assess the prevalence of abdominal imaging performed in the setting of PD peritonitis and to evaluate clinical parameters associated with abnormal imaging results to identify clinical situations in which radiographic examinations are informative., Design: This is a retrospective cohort study., Setting: The study was conducted at the Toronto General Hospital, Ontario, Canada., Patients: We studied 166 episodes of PD peritonitis in 114 patients between January 1, 2011, and June 30, 2016., Measurements: Baseline demographics, characteristics of PD peritonitis, and characteristics of abdominal imaging performed., Methods: The association between relevant clinical parameters and abnormal abdominal imaging was examined using a univariate and multivariate logistic regression model., Results: Abdominal imaging (computed tomography [CT] scan or ultrasound) was performed in 68 cases (41%). Patients were more likely to undergo imaging if they required hospitalization, were admitted to the intensive care unit (ICU), had polymicrobial or fungal organisms causing peritonitis, had relapsing/recurrent/refractory peritonitis, had an indication for hemodialysis or PD catheter removal, or presented with hypotension, tachycardia, or an elevated serum lactate. Of the imaging performed, abnormalities were found in 32 cases (47%). The most common findings were bowel obstruction, intra-abdominal collection, and biliary abnormalities. In the univariate analysis, ICU admission (43.3% vs 14.3%, P < .01) and need for temporary or permanent hemodialysis (62.5% vs 30.6%, P < .01) were associated with imaging abnormalities. Importantly, the peritonitis organism was not associated with abnormal imaging results. In a multivariate analysis, ICU admission was the only significant clinical parameter associated with imaging abnormalities with an odds ratio (OR) of 4.4 (95% confidence interval [CI]: 1.1-17.4, P = .04)., Limitations: Single-center study, small sample size, and lack of detailed information on the exact indications leading to abdominal imaging., Conclusions: Abdominal imaging is commonly performed in the setting of PD peritonitis. Abnormalities are not infrequent and are present in almost half of the cases, with need for ICU admission being the most significant clinical parameter associated with abnormal findings. Therefore, abdominal imaging should be performed in carefully selected patients with PD peritonitis, especially if there is evidence of hemodynamic instability. While the finding of fungal or polymicrobial peritonitis was a driver for abdominal imaging, the presence of these organisms did not predict radiologic abnormalities., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: E.T. receives speaking honoraria from Baxter Healthcare. J.M.B. is a speaker and consultant for Baxter Canada and for DaVita HealthCare Partners., (© The Author(s) 2020.)

Introduction: As interest for home dialysis is growing, knowledge of comparative clinical outcomes between peritoneal dialysis (PD) and home hemodialysis (HHD) would help to better inform shared decision making with patients and caregivers during modality discussion. This study aimed to assess differences in risk of mortality and technique failure in an incident home dialysis cohort and, specifically, to assess change in this association through eras., Methods: All adults patients initiating PD or HHD, in Canada (excluding Quebec), within 365 days after kidney replacement therapy (KRT) initiation between 2000 and 2013 were included (administrative censoring 31 December 2014). Mortality and treatment failure (transfer to another modality for >90 days or death) were assessed in a multivariable Cox proportional hazard model, with prespecified stratification based on the year of KRT initiation., Results: The study included 959 HHD and 15,469 PD patients. Compared with incident PD, incident HHD was associated with a lower risk of mortality (adjusted hazard ratio [aHR] = 0.64, 95% confidence interval [CI] = 0.53-0.78), and treatment failure (aHR = 0.52, 95% CI = 0.45-0.60). These lower risks of mortality with HHD were more pronounced for older cohorts (2000-2005: aHR = 0.47, 95% CI = 0.31-0.70; 2006-2010: aHR = 0.70, 95% CI = 0.54-0.89) and not significantly different in the most recent era (2011-2013: aHR = 0.86, 95% CI = 0.51-1.47)., Conclusion: In Canadian incident KRT patients, HHD was associated with appreciably lower risks of mortality and treatment failure compared to PD, although this association appeared to be attenuated in the most contemporary era., (© 2020 International Society of Nephrology. Published by Elsevier Inc.)

Peritonitis is a common complication of peritoneal dialysis that is associated with substantial morbidity and mortality. Peritonitis increases treatment costs and hospitalization events and is the most common reason for transfer to hemodialysis. Although there is much focus on preventing peritoneal dialysis-associated peritonitis, equally as important is appropriate management to minimize the morbidity of a peritonitis episode when it has occurred. Despite the presence of international guidelines on peritonitis treatment, the evidence base to support optimal peritonitis treatment practices is lacking, leaving the practitioner to rely on clinical experience and extrapolate from across other infection treatment practices. This article reviews common mistakes and misconceptions that we have observed in the management of peritonitis that may compromise treatment success. It also provides suggestions on common controversial aspects of peritonitis management based on the best available literature. Although the use of the word mistakes is somewhat controversial and subjective, we acknowledge that evidence is lacking and have based many of our suggestions on clinical judgment, experience, and available data., (© 2020 Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc.)

Introduction : Congestion is an integral component of heart failure (HF) pathophysiology and portends an adverse impact on outcome. Peritoneal dialysis (PD) is a home-based therapeutic modality that has been used in the setting of refractory congestive HF to help optimize volume status. Not only does PD allow for customized sodium and water removal, but it also provides the opportunity for the patients to fully benefit from guideline-directed medical therapy for HF that could have otherwise been challenging to use. Areas covered : Authors provide an overview of the pathophysiologic basis for the use of PD in HF, followed by a review of the findings of the main clinical trials such as the salutary impact on HF re-admissions and quality of life. Since the goals of therapy in this setting differ from those for patients with end-stage renal disease, pertinent practical considerations in the use of this modality are then discussed as well as potential barriers. Expert opinion : For patients with chronic refractory HF, PD represents an alternative to medical therapy alone. Identification of patients that would benefit most from this modality and detection of major enablers and obstacles for the implementation of this therapy should be the focus of future studies.

Competing Interests: Competing interests: None declared.

Background: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW., Methods: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient's care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied., Results: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0-2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29-3.62), while longer dialysis vintage was -associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95-0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist., Conclusion: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions., (© 2019 S. Karger AG, Basel.)

Introduction: The globally increasing prevalence of chronic kidney disease has resulted in an ever-growing demand for renal replacement therapy. Although programs are present around the world, there is a paucity of immersive educational programs that train clinicians and administrators to develop new home dialysis programs. Explore Home Dialysis (EHD) is a program created to fill this gap., Methods: We present the results of the evaluation of the EHD program. Our team interviewed 23 clinicians and administrators who participated in the EHD program. We also assessed country-specific needs and challenges associated with home dialysis., Results: The 4 main findings include (i) the evaluation of the effectiveness of the EHD program; (ii) the need for an educational program to train individuals on how to deploy home dialysis programs; (iii) evidence that such an educational program is beneficial to participants and for the establishment of new home dialysis programs; and (iv) the identification of barriers to the development of home dialysis programs in countries represented in this study. The data show an increased demand, with strong patient and provider interest in establishing new programs, interest in accessing resources to train clinical and administrative staff in how to run a home dialysis program, and positive feedback about the EHD program in general., Conclusions: The data from this study were used in the next iteration of the EHD program, to inform clinicians about challenges in the deployment of new home dialysis programs, and to present educational resources that need to be developed in the future.

Background: Lactate is the most commonly used buffer in peritoneal dialysis (PD) solutions. While previous studies have shown that serum lactate is normal in stable PD patients, the purpose of our study was to evaluate whether abnormal lactate values are more common in PD patients presenting to the emergency department (ED) and have the same significance as in the general population., Methods: This observational cohort study assessed the prevalence of elevated serum lactate in PD patients presenting to the ED and evaluated clinical factors associated with an abnormal lactate value., Results: We studied 172 patient visits in 89 PD patients to the ED at a major academic center between January 1, 2015, and December 31, 2015. An initial venous blood lactate value was performed in 91 visits (53%) and was found to be elevated (> 2 mmol/L) in 26 cases (29%). While an abnormal lactate was associated with signs of hemodynamic compromise such as intensive care unit (ICU) admission (26.9% vs 10.8%, p = 0.05) and tachycardia (46.2% vs 9.2%, p < 0.01), in half of the cases with elevated lactate, there was no evidence of hemodynamic instability at initial presentation. Moreover, an abnormal lactate value was also associated with a greater likelihood of undergoing an abdominal computed tomography (CT) scan (46.2% vs 18.5%, p < 0.01), but bowel ischemia was present in only 1 case., Conclusion: An abnormal lactate value is often seen in PD patients presenting to the ED, even in the absence of signs of hemodynamic instability, and very rarely indicates bowel ischemia. We postulate that in the setting of an acute intercurrent illness, there is a transient disruption in the metabolism of lactate absorbed from the PD fluid. This novel observation suggests that elevated serum lactate in the sick PD patient does not necessarily indicate tissue hypoperfusion or gut ischemia and may obviate unnecessary investigations., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Since the advent of maintenance dialysis therapy, our interpretation of what adequate dialysis really is has broadened and become more controversial. This is not only due to our changing and aging dialysis population but also to our evolving knowledge base. As nephrologists, we strive to achieve both quality and (often) quantity of life for our patients and we feel reassured when we have a quantifiable marker to show for our efforts. However, we suggest that adequate dialysis reaches far beyond the realms of attaining a particular biochemical result. Dialysis adequacy should encompass a more comprehensive assessment of patient well-being. This metric could comprise quality of life and patient-specified goals, sufficient small solute and middle molecule clearance, optimal blood pressure control, and effective bone-mineral balance, all in the context of minimizing mortality and morbidity, and a livable dialysis regimen for the patient., (© 2018 Wiley Periodicals, Inc.)

The outcome of lupus nephritis (LN) has changed since the introduction of glucocorticoids (GCs), which dramatically reduced the mortality related to one of the most severe complications of systemic lupus erythematosus (SLE). Since the 1950's, other immunosuppressants, including biologic drugs (i.e. rituximab) have aided in maintaining remission, preserving kidney function, but not preventing treatment-related toxicity. GCs still remain the cornerstone in the treatment of SLE, including LN, and they are widely used in clinical practice. However, GC administration represents a double-edged sword. Indeed, from one side they allow a fast and effective control of disease activity by dampening inflammation; from the other side, they have many and severe side effects leading to organ damage. In this paper, we will discuss pros and cons of the chronic use of GCs, especially focusing on LN., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Peritoneal dialysis (PD) is one of the corner stones of renal replacement therapy and should be strongly considered if preemptive kidney transplantation is not available., Summary: There are several initiatives that may help the growth in the use of PD around the world. First, PD is an underused and valuable option in patients with heart failure and the chronic cardiorenal syndrome, especially in those with frequent hospitalizations despite optimal medical therapy. To identify these patients, an interdisciplinary approach of nephrologists and cardiologists is needed. These patients and other CKD patients with significant residual kidney function may do well with a regimen employing fewer than the usual number of bag exchanges, referred to as "incremental" dialysis. Second, acute kidney injury (AKI) is a worldwide burden with high morbidity and mortality, especially in low income countries. To reach the goal of zero preventable deaths caused by AKI by 2025 endorsed by the International Society of Nephrology, PD is the therapy of choice for treatment in this setting. Third, although dextrose has served well as the osmotic agent in PD solutions, there has been a continuous search for alternative agents. Hyperbranched polyglycerol might be such an osmole. Finally, to obviate the need for production and delivery of bags of PD solution, the development of home-generated dialysate is of interest. Key Message: The future of PD lies not only in accruing experience from the past decades, but also in staying open to other uses., (© 2018 S. Karger AG, Basel.)

Background: In many dialysis programs, there is resistance to initiating peritoneal dialysis (PD) in liver transplant patients needing renal replacement therapy. This retrospective study reviews the outcome of PD in liver transplant patients at a major transplantation and dialysis center., Method: We performed a retrospective cohort study in patients who underwent liver transplants and received PD between 1991 and 2016. Patient demographics, laboratory parameters, and adverse events were collected from our electronic database., Results: Between 1991 and 2016, 14 patients underwent liver transplants and subsequently received PD. The mean age was 59.0 ± 7.1 years; 42.8% women; the mean time from transplant to PD initiation was 9.7 ± 2.8 years; average follow-up on PD was 31.3 months (range: 9 - 87 months). Hepatitis C was the main cause of liver failure necessitating the transplant (8 patients). Calcineurin inhibitor toxicity was the lead cause of end-stage renal disease (ESRD) (12 patients). The overall peritonitis rate was 39.8 patient-months (0.3 episodes per year at risk). There was 1 patient with relapsing peritonitis, and 1 patient had severe peritonitis and died. Mean survival was 58.9 ± 11.3 months, 4 patients died, 4 received a kidney transplant, 1 patient was transitioned to hemodialysis due to poor ultrafiltration, 1 patient was transferred to another program, 2 remained on PD and 2 patients recovered renal function. Eight patients underwent liver biopsies during their time on PD without complication., Conclusion: There appears to be no specific concern related to liver transplant patients undergoing PD. Peritonitis and mortality rates were no different from other solid organ recipients or even from the general PD population. The hepatic graft was never threatened, even during peritonitis. Therefore, these patients should not be denied the option of PD., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Background and Objectives: Residual kidney function contributes to the clearance of antibiotics excreted by the kidneys, lowering the antibiotic concentration, which may adversely affect the treatment of peritoneal dialysis-associated peritonitis. The objective of our study was to examine the relationship between residual kidneyfunction and peritonitis treatment outcomes., Design, Setting, Participants, & Measurements: Our study included 181 participants who experienced 339 episodes of Gram-positive, Gram-negative, and culture-negative peritoneal dialysis-associated peritonitis at a single centerfrom 2003 to 2010. Episodes were categorized according to participants' urinary creatinine clearance (0, >0-5, and >5 ml/min). The data were analyzed using generalized estimating equation models to determine the covariate-adjusted association between urinary creatinine clearance and treatment failure (defined as relapse or recurrent peritonitis episodes, peritoneal catheter removal, or death from any cause during peritonitis treatment)., Results: Among episodes of peritonitis due to Gram-positive organisms or culture-negative infections, those experienced by participants with urinary creatinine clearance >5 ml/min had significantly higher odds of treatment failure than episodes experienced by anuric participants (27 of 80 versus 20 of 119 episodes resulting in treatment failure for creatinine clearance >5 versus 0 ml/min; odds ratio, 6.80; 95% confidence interval, 2.37 to 19.6). Episodes experienced by participants with creatinine clearance >0-5 ml/min also had significantly higher odds of treatment failure than episodes experienced by anuric participants (14 of 64 episodes resulting in treatment failure for creatinine clearance >0-5 ml/min; odds ratio, 2.87; 95% confidence interval, 1.12 to 7.35). The odds of relapse and recurrent peritonitis among participants with creatinine clearance >5 ml/min was also significantly higher compared with in anuric participants (17 of 80 versus 12 of 119 episodes resulting in relapse and recurrence for creatinine clearance >5 versus 0 ml/min; odds ratio, 6.76; 95% confidence interval, 1.90 to 23.8). Among participants with Gram-negative peritonitis, creatinine clearance was significantly associated with neither treatment failure nor relapse and recurrent peritonitis., Conclusions: Residual kidney function as measured by greater urinary creatinine clearance was associated with treatment failure among participants with Gram-positive and culture-negative peritonitis., (Copyright © 2017 by the American Society of Nephrology.)

We present a peritoneal dialysis (PD) patient who had a renal biopsy performed during an episode of urosepsis and subsequently presented with a renal abscess at the biopsy site along with concurrent peritonitis. Microbiology from the PD effluent and from the renal abscess were both positive for Klebsiella pneumoniae We propose that the PD peritonitis was the result of seeding of the peritoneal cavity with bacteria from the renal abscess. Successful treatment was achieved through drainage of the abscess and intraperitoneal antibiotics., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Asymptomatic hyperuricemia is increasing in prevalence. There is a growing body of literature suggesting that uric acid has deleterious effects on vascular health and renal histological integrity. Several trials, reviewed herein, suggest that lowering the serum uric acid level is associated with a slowing in the rate of renal deterioration in those with chronic kidney disease. Given that there is little available in the general armamentarium to slow the rate of kidney deterioration, strong consideration could be given to the administration of agents or lifestyle changes that decrease uric acid production in hyperuricemic patients with deteriorating kidney function.

Background: Readmissions following hospital discharge among maintenance dialysis patients are common, potentially modifiable, and costly. Compared with patients receiving in-center hemodialysis (HD), patients receiving peritoneal dialysis (PD) have fewer routine dialysis clinic encounters and as a result may be more susceptible to a hospital readmission following discharge., Study Design: Population-based retrospective-cohort observational study., Settings & Participants: Patients treated with maintenance dialysis who were discharged following an acute-care hospitalization during January 1, 2003, to December 31, 2013, across 164 acute-care hospitals in Ontario, Canada. For those with multiple hospitalizations, we randomly selected a single hospitalization as the index hospitalization., Predictor: Dialysis modality PD or in-center HD. Propensity scores were used to match each patient on PD therapy to 2 patients on in-center HD therapy to ensure that baseline indicators of health were similar between the 2 groups., Outcome: All-cause 30-day readmission following the index hospital discharge., Results: 28,026 dialysis patients were included in the study. 4,013 PD patients were matched to 8,026 in-center HD patients. Among the matched cohort, 30-day readmission rates were 7.1 (95% CI, 6.6-7.6) per 1,000 person-days for patients on PD therapy and 6.0 (95% CI, 5.7-6.3) per 1,000 person-days for patients on in-center HD therapy. The risk for a 30-day readmission among patients on PD therapy was higher compared with those on in-center HD therapy (adjusted HR, 1.19; 95% CI, 1.08-1.31). The primary results were consistent across several key prespecified subgroups., Limitations: Lack of information for the frequency of nephrology physician encounters following discharge from the hospital in both the PD and in-center HD cohorts. Limited validation of International Classification of Diseases, Tenth Revision codes., Conclusions: The risk for 30-day readmission is higher for patients on home-based PD compared to in-center HD therapy. Interventions to improve transitions in care between the inpatient and outpatient settings are needed, particularly for patients on PD therapy., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/V urea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to ( 1 ) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and ( 2 ) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive clinical and dialysis-related measures., (Copyright © 2017 by the American Society of Nephrology.)

Treatment for end-stage kidney disease is a major economic challenge and a public health concern worldwide. Renal-replacement therapy poses several practical and ethical dilemmas of global relevance for patients, clinicians, and policy makers. These include how to: promote patients' best interests; increase access to dialysis while maintaining procedural and distributive justice; minimise the influence of financial incentives and competing interests; ensure quality of care in service delivery and access to non-dialytic supportive care when needed; minimise the financial burden on patients and health-care system; and protect the interests of vulnerable groups during crisis situations. These issues have received comparatively little attention, and there is scant ethical analysis and guidance available to decision makers. In this Health Policy, we provide an overview of the major ethical issues related to dialysis provision worldwide, identify priorities for further investigation and management, and present preliminary recommendations to guide practice and policy., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Preapproval clinical trials examining the safety and efficacy of rosuvastatin demonstrated an increased incidence of proteinuria, hematuria, rhabdomyolysis, and other acute kidney injury of unknown cause at high doses. The latter cases manifested with urine sediment findings and in some cases, renal histology, indicating renal tubular injury in the absence of rhabdomyolysis. Despite these provocative findings, there have been very few reports in the literature regarding non-rhabdomyolysis-mediated acute kidney injury associated with high-dose rosuvastatin since its widespread introduction more than a decade ago, suggesting that it is either a rare entity or systematically underdiagnosed and under-reported. We present a case of renal tubular toxicity attributable to the initiation of rosuvastatin treatment at a dose of 40mg in a patient with no prior evidence of kidney disease. Tubular toxicity should be considered in cases of unexplained kidney injury in the setting of exposure to a potent statin such as rosuvastatin, particularly at high dose. The limited evidence suggests a good kidney prognosis following withdrawal of the agent in these cases., (Copyright © 2016 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)