Infection is the Achilles heel of peritoneal dialysis. Exit site mupirocin prevents Staphylococcus aureus peritoneal dialysis (PD) infections but does not reduce Pseudomonas aeruginosa or other Gram-negative infections, which are associated with considerable morbidity and sometimes death. Patients from three centers (53% incident to PD and 47% prevalent) were randomized in a double-blinded manner to daily mupirocin or gentamicin cream to the catheter exit site. Infections were tracked prospectively by organism and expressed as episodes per dialysis-year at risk. A total of 133 patients were randomized, 67 to gentamicin and 66 to mupirocin cream. Catheter infection rates were 0.23/yr with gentamicin cream versus 0.54/yr with mupirocin (P ‫؍‬ 0.005). Time to first catheter infection was longer using gentamicin (P ‫؍‬ 0.03). There were no P. aeruginosa catheter infections using gentamicin compared with 0.11/yr using mupirocin (P < 0.003). S. aureus exit site infections were infrequent in both groups (0.06 and 0.08/yr; P ‫؍‬ 0.44). Peritonitis rates were 0.34/yr versus 0.52/yr (P ‫؍‬ 0.03), with a striking decrease in Gram-negative peritonitis (0.02/yr versus 0.15/yr; P ‫؍‬ 0.003) using gentamicin compared with mupirocin cream, respectively. Gentamicin use was a significant predictor of lower peritonitis rates (relative risk, 0.52; 95% confidence interval, 0.29 to 0.93; P < 0.03), controlling for center and incident versus prevalent patients. Gentamicin cream applied daily to the peritoneal catheter exit site reduced P. aeruginosa and other Gram-negative catheter infections and reduced peritonitis by 35%, particularly Gram-negative organisms. Gentamicin cream was as effective as mupirocin in preventing S. aureus infections. Daily gentamicin cream at the exit site should be the prophylaxis of choice for PD patients.

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Peritoneal dialysis (PD) related infections continue to be a serious complication for PD patients. Peritonitis can be associated with pain, hospitalization and catheter loss as well as a risk of death. Peritonitis risk is not evenly spread across the PD population or programs. Very low rates of peritonitis in a program are possible if close attention is paid to the causes of peritonitis and protocols implemented to reduce the risk of infection. Protocols to decrease infection risk in PD patients include proper catheter placement, exit-site care that includes Staphylococcus aureus prophylaxis, careful training of patients with periodic retraining, treatment of contamination, and prevention of procedure-related and fungal peritonitis. Extensive data have been published on the use of antibiotic prophylaxis to prevent exit site infections. There are fewer data on training methods of patients to prevent infection risk. Quality improvement programs with continuous monitoring of infections, both of the catheter exit site and peritonitis, are important to decrease the PD related infections in PD programs. Continuous review of every episode of infection to determine the root cause of the event should be routine in PD programs. Further research is needed examining approaches to decrease infection risk.

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Urea seems effective and safe for the treatment of inpatient hyponatremia, and it is well tolerated.

Objectives To compare the small molecule clearances on tidal peritoneal dialysis (TPD) and intermittent peritoneal dialysis (IPD), controlling for dialysate flow rate. Design Alternating 8-hour treatments on IPD and TPD (2 of each in 6 patients), each treatment separated by 3 or more days [patients returning to continuous ambulatory peritoneal dialysis (CAPD) in the interim] were performed. IPD treatments consisted of 15 exchanges with 2 Llexchange for a total of 30 Lltreatment. TPD treatments consisted of 29 exchanges, with an initial fill volume of 2 L, followed by 1 L tidal volume for the subsequent exchanges (reserve volume of 1 L) for a total of 30 Lltreatment. Patients Six patients, with a mean dialysatelplasma (DIP) creatinine as determined by the peritoneal equilibration test (PET) of 0.64±0.1 0, were studied. Four had a low -average DIP creatinine, while 2 had a high-average DIP creatinine. Measurements Urea nitrogen, creatinine, phosphate, and potassium clearances on TPD and IPD were compared using the paired t-test. Results The dialysate flow rates were 3.7±0.1 Llhour for IPD and 3.8±0.2 Llhour for TPD. The mean dialysate dextrose was 1.9±0.5 gldL for both. The creatinine clearances were 9±2 versus 10±3 mLlminute, the urea nitrogen clearances 19±3 versus 20±3 mLlminute, and phosphate clearances 10±3 versus 11±3 mLlminute for IPD and TPD, respectively (all not different). The ultrafiltration rates were 2.9±0.9 mLlminute on IPD and 3.3±1.6 mLI minute on TPD (not different). On both IPD and TPD the clearances of urea nitrogen, creatinine, and phosphate for the 2 patients with high-average DIP creatinine were higher than for the 4 patients with low -average DIP creatinine. Conclusions When the dialysate flow rate is controlled and a TPD prescription of 1 L reserve and tidal volumes is used, the small molecule clearances on IPD are similar to those on TPD.

Technology-assisted cognitive-behavioral therapy (CBT) interventions have been conducted for symptoms including depression, pain, and fatigue in patients with chronic illnesses but not in end-stage renal disease (ESRD). The purpose of this study was to pilot the feasibility and acceptability of a technology-assisted CBT intervention in ESRD patients on hemodialysis (HD), share design and implementation lessons learned, and provide preliminary results on changes in select patient-reported symptoms. This was a single-center pilot feasibility study of adult ESRD patients on HD. Study eligibility required clinically elevated levels of at least one symptom (depression, pain, or fatigue). Patients met weekly with a CBT therapist for eight sessions, each 45–60 min, during HD sessions via a video-conferencing platform. Symptom questionnaires were completed at baseline and 3 months follow-up. Of 10 patients screened, 100% screened positive for at least one symptom, 100% of eligible patients consented, and eight (of 10) completed the intervention (mean age 59 years, 50% male, 50% African American). Patient adherence and satisfaction was high, and seven of the eight patients completed all eight prescribed sessions. Minimal interference with HD was reported. Preliminary results indicate no statistically significant changes in depression, fatigue, or pain at follow-up. However, there was small improvement in SF-36 Physical Component score [t(7) = −2.60, p = .035], and four of the six patients (67%) with clinically elevated pain at baseline reported improvement at follow-up. A technology-assisted CBT intervention for ESRD patients was feasible, well-accepted, and required minimal additional resources in the HD setting. Larger, adequately powered clinical trials are needed to evaluate the effect on ESRD patient-reported outcomes.

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