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The utilization of peritoneal dialysis (PD) has been increasing in the past decade owing to various government initiatives and recognition of benefits such as better preservation of residual renal function, quality of life, and lower cost. The Advancing American Kidney Health initiative aims to increase the utilization of home therapies such as PD and kidney transplantation to treat end stage kidney disease (ESKD). A natural consequence of this development is that more patients will receive PD, and many will eventually undergo kidney transplantation. Therefore, it is important to understand the effect of pretransplant PD on posttransplant outcomes such as delayed graft function (DGF), rejection, thrombosis, graft, and patient survival. Furthermore, some of these patients may develop DGF, which raises the question of the utility of PD during DGF and its risks. Although transplant is the best renal replacement therapy option, it is not everlasting, and many transplant recipients must go on dialysis after allograft failure. Can PD be a good option for these patients? This is another critical question. Furthermore, a significant proportion of nonrenal solid organ transplant recipients develop ESKD. Is PD feasible in this group? In this review, we try to address all of these questions in the light of available evidence.

Introduction Peritoneal dialysis (PD) has been used increasingly in past decade. Many of these patients undergo transplantation and may require dialysis for delayed graft function (DGF). The outcomes of DGF based on the post-transplantation dialysis modality are not well known. Methods We retrospectively reviewed all adult kidney transplant recipients (KTRs) from the University of Wisconsin School of Medicine and Public Health who developed DGF between November 2015 and April 2019. Patients were divided into those who received hemodialysis (HD) or PD during the DGF period. Immediate graft explant, DGF among living donor KTRs, or those requiring just a single dialysis treatment were excluded. Results Of 224 KTRs with DGF during the study period, 167 fulfilled our selection criteria. There were 16 patients in the PD and 151 in the HD group. Baseline characteristics were similar between the two groups, except diabetes was more prevalent in the HD group. Five of 16 PD patients had to be transitioned to HD. There was no difference in DGF duration, hospital length of stay, infectious or surgical complications, rejection at various time periods, graft function at last follow-up, or graft failure. In multivariate analysis, only rejection within the first year of transplantation (hazard ratio [HR]: 4.26; 95% confidence interval [CI]: 1.20–15.08; P = 0.02) and post-surgical complications (HR: 3.79; 95% CI: 1.03– 13.91; P = 0.04) were associated with death-censored graft failure (DCGF). The use of PD for treatment of DGF was not associated with DCGF. Conclusions In carefully selected patients, PD can be continued safely for DGF without any effect on short-term or long-term transplant outcomes., Graphical abstract

Background: Delay in care of suspected stenosis or thrombosis can increase the chance of losing a functioning hemodialysis access. Access to care and resources were restricted during the COVID-19 pandemic. To evaluate the impact of the pandemic on arteriovenous fistula (AVF) and arteriovenous graft (AVG) procedures we have assessed the number and success of thrombectomies done before and during the COVID-19 pandemic. Methods: We examined all AVF and AVG angiograms with and without interventions, including thrombectomies, performed at a single center during April 2017–March 2021 (pre-COVID-19 era) and April 2020–March 2021 (COVID-19 era). Results: The proportion of procedures that were thrombectomies was higher during the COVID-19 era compared to the pre-COVID-19 era (13.3% vs 8.7%, p = 0.009). The proportion of thrombectomy procedures was higher during COVID-19 for AVF (8.2% vs 3.0%, p < 0.001) but there was no difference for AVG (26.5% vs 27%, p = 0.99). There was a trend toward a higher likelihood of unsuccessful thrombectomy during COVID-19 (33.3% vs 20.4%, p = 0.08). Conclusions: More dialysis access thromboses and unsuccessful thrombectomies were noted during the COVID-19 pandemic. This difference could be due to a delay in patients getting procedures to maintain their dialysis accesses.

A mega fistula can be defined as generalized aneurysmal dilatation of arteriovenous fistula. Mega fistulae can lead to complications like high output cardiac failure, steal syndrome, skin ulceration and rupture. We describe a series of ten patients who were referred to our interventional nephrology practice for evaluation of mega fistula which had not been in use for a long time. Nine out of ten patients were post-transplant while one was pre dialysis. Five patients had Radiocephalic while four had Brachiocephalic and one had Brachial artery to Median Cubital vein fistula. All except one patient had severe outflow stenosis. The most common site of stenosis in Radiocepahlic and Brachiocepahlic fistula was cephalic vein at the elbow and cephalic arch respectively. Half of the patients had chronic total occlusion of the outflow vein. Successful angioplasty was done in only two patients. Seven patients underwent ligation while one had spontaneous thrombosis of the fistula. None of the patients had regular surveillance of their access for a long time as they were not on dialysis. Unrecognized and uncorrected outflow stenosis over a long time period can lead to creation of mega fistula. Once a mega fistula develops there are not many treatment options other than ligation. This leads to loss of the access which might be needed in future. Continuous access surveillance in patients who are not on dialysis is important to prevent complications like mega fistula.

Background: The effects of delayed graft function on long-term kidney allograft outcomes are poorly defined among simultaneous liver and kidney transplant recipients. Methods: We analyzed data of all simultaneous liver and kidney recipients transplanted at the University of Wisconsin between 2010 and 2017. Risk factors for the development of delayed graft function, kidney graft failure, and patient mortality were outcomes of interest. Results: There were a total of 60 simultaneous liver and kidney recipients; 28 (47%) had delayed graft function. After adjustment for multiple variables, we found that pretransplant dialysis >6 weeks (hazard ratio [HR] = 5.6, 95% CI: 1.23-25.59, P = .02), pretransplant albumin Conclusion: The incidence of delayed graft function was high in simultaneous liver and kidney recipients. However, with appropriate management, delayed graft function may not have a negative impact on patient or kidney allograft survival.

The cost and health burden of ESRD continues to increase globally. Total Medicare expenditure on dialysis has increased from 229 million USD in 1973 to 35.4 billion USD in 2016. Dialysis access can represent almost a tenth of these costs. Central venous catheters have been recognized as a significant factor driving costs and mortality in this population. Home dialysis, which includes peritoneal dialysis and home hemodialysis, is an effective way of reducing costs related to renal replacement therapy, reducing central venous catheter usage and in many cases improving the clinical and psychosocial aspects of patients' health. Addressing access-related issues for peritoneal dialysis, urgent-start peritoneal dialysis and home hemodialysis can have impact on the success of home dialysis. This article reviews issues related to dialysis access for home therapies.

Rationale & Objective Evidence is mixed regarding the optimal choice of the first permanent vascular access for elderly patients receiving hemodialysis (HD). Lacking data from randomized controlled trials, we used a target trial emulation approach to compare arteriovenous fistula (AVF) versus arteriovenous graft (AVG) creation among elderly patients receiving HD. Study Design Retrospective cohort study. Setting & Participants Elderly patients included in the US Renal Data System who initiated HD with a catheter and had an AVF or AVG created within 6 months of starting HD. Exposure Creation of an AVF versus an AVG as the incident arteriovenous access. Outcomes All-cause mortality, all-cause and cause-specific hospitalization, and sepsis. Analytical Approach Target trial emulation approach, high-dimensional propensity score and inverse probability of treatment weighting, and instrumental variable analysis using the proclivity of the operating physician to create a fistula as the instrumental variable. Results A total of 19,867 patients were included, with 80.1% receiving an AVF and 19.9% an AVG. In unweighted analysis, AVF creation was associated with significantly lower risks of mortality and hospitalization, especially within 6 months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of mortality and hospitalization within 6 months after creation (hazard ratios of 0.82 [95% CI, 0.75-0.91] and 0.82 [95% CI, 0.78-0.87] for mortality and all-cause hospitalization, respectively), but not between 6 months and 3 years after access creation. No association between AVF creation and mortality, sepsis, or all-cause, cardiovascular disease–related, or infection-related hospitalization was found in instrumental variable analyses. However, AVF creation was associated with a lower risk of access-related hospitalization not due to infection. Limitations Potential for unmeasured confounding, analyses limited to elderly patients, and absence of data on actual access use during follow-up. Conclusions Using observational data to emulate a target randomized controlled trial, the type of initial arteriovenous access created was not associated with the risks of mortality, sepsis, or all-cause, cardiovascular disease–related, or infection-related hospitalization among elderly patients who initiated HD with a catheter.

Vascular access is an important element in the overall care provided to kidney transplant recipients. The transplanted kidney is not indestructible, and chronic kidney disease after transplantation may result in needing another transplant or beginning dialysis. Commonly used vascular accesses, like peripheral and central lines, can preclude the creation of future, permanent dialysis access. Therefore, there is urgent need to preserve vessels for the future access needs for hemodialysis among kidney transplant recipients without functional vascular access for dialysis. Moreover, the proper care of functional vascular access among kidney transplant recipients is crucial. In this review article, we will address the common vascular access procedures and complications among kidney transplant recipients.

Vascular access dysfunction is a major cause of morbidity in patients with end-stage renal disease (ESRD) on chronic hemodialysis. The effects of abnormalities in mineral metabolism on vascular access are unclear. In this study, we evaluated the association of mineral metabolites, including 25-hydroxy vitamin D (25(OH)D) and fibroblast growth factor-23 (FGF-23), with vascular access complications.We included participants from the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study who were using an arteriovenous fistula (AVF; n = 103) or arteriovenous graft (AVG; n = 116). Serum levels of 25(OH)D, FGF-23, parathyroid hormone (PTH), calcium, phosphorus, C-reactive protein (CRP) and interleukin-6 (IL-6) were assessed from stored samples. Participants were followed for up to 1 year or until a vascular access intervention or replacement.A total of 24 participants using an AVF and 43 participants using an AVG experienced access intervention. Those with 25(OH)D level in the lowest tertile (11 ng/mL) had an increased risk of AVF intervention compared to those with higher 25(OH)D levels (adjusted relative hazard [aHR] = 3.28; 95% confidence interval [CI]: 1.31, 8.20). The highest tertile of FGF-23 (3750 RU/mL) was associated with greater risk of AVF intervention (aHR = 2.56; 95% CI: 1.06, 6.18). Higher PTH was associated with higher risk of AVF intervention (aHR = 1.64 per SD of log(PTH); 95% CI: 1.02, 2.62). These associations were not observed in participants using an AVG. None of the other analytes were significantly associated with AVF or AVG intervention.Low levels of 25(OH)D and high levels of FGF-23 and PTH are associated with increased risk of AVF intervention. Abnormalities in mineral metabolism are risk factors for vascular access dysfunction and potential therapeutic targets to improve outcomes.

Infection remains the leading complication of peritoneal dialysis (PD). Topical mupirocin and gentamicin are frequently used to prevent infections. Mupirocin ointment has been reported to cause damage to both polyurethane and silicone PD catheters. Gentamicin cream has not been associated with physical damage to catheters.A 64-year-old woman on PD developed relapsing peritonitis with Staphylococcus epidermidis. Because of a drainage problem and white discoloration at the exit site, which is known as " frosting," she underwent catheter exchange. The catheter was found to be fractured within the area of frosting. Four more patients with frosting of the catheter were identified. On further questioning, it was recognized that they were applying excessive amounts of gentamicin cream directly on the catheter surface rather than at the exit site. All patients in the program were educated about the correct method of topical antibiotic application. After the change in practice, no further cases of catheter frosting were identified.Polyurethane catheters can undergo oxidation, mineralization, and environmental stress cracking, leading to physical damage such frosting, ballooning, and fracture. Polyethylene glycol, a component of the mupirocin ointment base, is thought to cause plasticization of polyurethane, reducing its tensile strength. Similar damage has been observed in silicone catheters. Previous reports have not found gentamicin cream to cause that type of damage. We observed that excessive amounts of cream applied directly to the catheter surface can damage it. Damage did not recur once patients had been educated about the proper method of application.

BackgroundIt remains unclear whether post-transplant outcomes differ according to the pre-transplant dialysis modality (peritoneal dialysis [PD] versus hemodialysis [HD]). We performed a meta-analysis of studies that assessed either post-transplant mortality, graft survival, or delayed graft function (DGF) in both PD and HD patients.MethodsTwo independent authors searched English-language literature from January 1, 1980, through August 31, 2014, national conference proceedings, and reference lists. We used combinations of terms related to dialysis (hemodialysis, peritoneal dialysis, or renal replacement therapy), kidney transplant, and outcomes. Studies were included if they measured any of the 3 post-transplant study outcomes in both pre-transplant HD and PD.ResultsA total of 16 studies were included in the final analysis. Of these, 6 studies reported adjusted hazard ratio for mortality, pooled adjusted risk ratio: 0.89 (95% confidence interval [CI] 0.82 – 0.97) in favor of PD ( p = 0.006). The same 6 studies reported adjusted hazard ratio for graft survival, pooled adjusted risk ratio: 0.97 (95% CI 0.92 – 1.01, p = 0.16). A total of 13 studies reported unadjusted DGF. Pooled odds ratio: 0.5 (95% CI 0.41 – 0.63) in favor of PD ( p < 0.005). Significant heterogeneity observed for all outcomes: I2 = 72.7%, I2 = 59.9%, and I2 = 66.8%, respectively.ConclusionsBased on these results, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant.