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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.

ISPD GUIDELINES/RECOMMENDATIONSBeing aware of controversies and lack of evidence in peritoneal dialysis (PD) training, the Nursing Liaison Committee of the International Society for Peritoneal Dialysis (ISPD) has undertaken a review of PD training programs around the world in order to develop a syllabus for PD training. This syllabus has been developed to help PD nurses train patients and caregivers based on a consensus of training program reviews, utilizing current theories and principles of adult education. It is designed as a 5-day program of about 3 hours per day, but both duration and content may be adjusted based on the learner. After completion of our proposed PD training syllabus, the PD nurse will have provided education to a patient and/or caregiver such that the patient/caregiver has the required knowledge, skills and abilities to perform PD at home safely and effectively. The course may also be modified to move some topics to additional training times in the early weeks after the initial sessions. Extra time may be needed to introduce other concepts, such as the renal diet or healthy lifestyle, or to arrange meetings with other healthcare professionals. The syllabus includes a checklist for PD patient assessment and another for PD training. Further research will be needed to evaluate the effect of training using this syllabus, based on patient and nurse satisfaction as well as on infection rates and longevity of PD as a treatment. . Based on the principles of adult learning, these guidelines established a broad description of a course and a set of proposals to aid the teacher/nurse (hereafter called the PD nurse). The committee currently believes that, while the recommendations are still relevant and agree with current teaching practices in PD clinics, there is a need for a more comprehensive course to guide PD nurses.The 2006 Guidelines tried to answer some questions that arise when talking about PD training: Who should be the trainer? Who is the learner? What should be taught? Where should the training occur? What should be the duration of training? How should the patient be taught? However, many of these questions remain unanswered. A search in PubMed using the words "training," "patient education," "peritoneal dialysis," and "peritonitis" found only 17 articles published in the last 5 years, and most of these were about infection prevention. Only 4 were published in the last 12 months. Of these 1 article was a narrative review of the literature of educational interventions in PD which concluded that the topic remained an under-studied aspect of PD (2); another looked at the impact of training hours on infection and suggested a minimum of 15 hours training, to be done before catheter implantation or more than 10 days after (3), and the remaining 2 looked at preventing PD infections (4,5). One further observational study, by Firanek et al., analyzing best practices for nurse-led PD training programs for patients on automated peritoneal dialysis (APD) in the United States, stated that best practices...

Patients with end-stage renal failure (ESRF) undergoing haemodialysis (HD) are repeatedly exposed to stress and pain from approximately 300 punctures per year to their arteriovenous fistula (AVF). Repeated AVF punctures lead to a considerable degree of pain, due to the calibre and length of the bevel of fistula needles. Pain is a sensitive, emotional and subjective experience. The objective of this study was to measure pain associated with AVF needling. The analogue visual scale (AVS) divided into 10 equal parts (0 indicating lack of pain, and 10 unbearable pain) was used. Patients(7) perceptions were measured in three different HD sessions. Pain was considered mild during AVF needling. The buttonhole technique caused a mean degree of pain of 2.4 (+/-1.7), compared to 3.1 (+/-2.3) using the conventional ropeladder technique. Although without reaching a statistically significant difference, diminished pain was associated with the buttonhole technique.

This is the first study to analyze the association between training characteristics and outcomes in a large cohort of PD patients. Low training time (particularly <15 h), smaller center size and the timing of training in relation to catheter implantation were associated with a higher incidence of peritonitis. These results support the recommendation of a minimum amount of training hours to reduce peritonitis incidence regardless of the number of hours trained per day.

Objective To survey nurses around the world about current practices for peritoneal dialysis (PD) home training programs. Design Random sampling of nurses to complete a written survey from the International Society for Peritoneal Dialysis Nursing Liaison Committee. Settings United States, Canada, South America (Brazil, Columbia), The Netherlands, Hong Kong. Methods Surveys and responses were sent by fax whenever possible, or by regular mail, or hand carried, or conducted by telephone. Results were stratified by geographic areas as well as by cumulative responses and were expressed as medians with ranges. Kruskal–Wallis was used to evaluate differences in responses. Associations between variables were tested with Pearson correlation. Univariate regression analysis was used to evaluate the impact of variables on peritonitis rates. Variables with p < 0.10 were included in a multivariate analysis. Results A total of 317 nurses responded: 88 in the United States, 46 in Canada, 58 in South America, 58 in Hong Kong, and 67 in The Netherlands. This represented 37% of all surveys distributed. Respondents had a median of 12 years’ experience in nephrology (range 1 – 35 years), but only 31% had a formal background in adult education. Nearly half received their guidance to patient training from a nurse colleague, 11% were guided by a corporate colleague, and 8% were simply self-taught. Clinics responding had a median of 30 PD patients (range 1 – 400) and reported they trained a median of 8 patients per year (range 0 – 86). Reported peritonitis rates were a median 0.46 per year or 1 episode every 26 months. Peritonitis rates, however, were not known by 53% of respondents. Total training time per patient had a very wide range of hours, from 6 to 96. There was no correlation between training time and peritonitis rates among the study respondents ( p = 0.38), nor with any other variables. Conclusions There is wide variation in practices for PD patient training programs within countries and around the world. Training time did not appear to be related to peritonitis rates. Randomized trials of training practices are needed to determine which approaches produce the best outcomes for patients.

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Intradialytic symptomatic hypotension and muscle cramps are frequent and disturbing adverse effects involving hemodialysis patients. The use of sodium profiling has been a proposed approach to preclude such events. The aim of the study was to compare the frequency of intradialytic adverse effects and changes in anthropometric and physiological variables without profiling and with two distinct sodium profiles. A prospective study randomized 22 stable hemodialysis patients to receive either a step (11 patients) or a linear (11 patients) dialysate sodium profile for 12 consecutive sessions, following a 12-session steady sodium control period. After a wash-out period of 12 sessions, the groups were crossed over for another 12-session period. Frequency of adverse effects, interdialytic weight gain, pre- and post-dialysis blood pressure were computed. The frequency of intradialytic adverse effects was significantly different between the control and either the step or linear periods (48.5%, 33.7%, and 36.0%, respectively; P < 0.001). No significant differences in interdialytic weight gain or pre-dialysis blood pressure were detected between treatment periods. The mean post-dialysis systolic blood pressure was lower in the linear period (128 +/- 21; 127 +/- 20; 123 +/- 22 mm Hg, for the control, step and linear periods, respectively; P = 0.014). Seven patients benefited from sodium profiling, yet two became more symptomatic. Overall, both sodium profiles were associated with fewer intradialytic adverse effects. Intradialytic symptomatic hypotension occurred less often with the step profile, while a tendency to fewer cramps was associated with the linear profile. However, sodium profiling may not benefit every dialysis patient and should be individually evaluated.