03/20/2019. Thank you for the invitation to speak. I have no conflicts of interest
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1 Raj Munshi, MD Annual Dialysis Conference 2019 Thank you for the invitation to speak I have no conflicts of interest Expected remaining lifetime in years of prevalent patients by initial ESRD modality, 2015 Age group Dialysis patients Transplant patients General population Data Source: Special analyses, USRDS ESRD Database, USA SSA (Social Security Administration) Period Life Table Includes period prevalent ESRD dialysis and transplant patients in Abbreviation: ESRD, end stage renal disease Annual Data Report 1
2 2011 Annual Dialysis Report 2 main causes of death Cardiopulmonary: 21% Infectious: 20.5% Chesnaye N. Pediatric Nephrology 2014 ALL CAUSE HOSPITALIZATIONS 1 Year Hospitalization Associated With : Cardiovascular: 2.2% Infection: 29.2% USRDS
3 ACCESS: Fistula > Graft > Central Venous Access USRDS 2018 Annual Data Report Volume 2 ESRD, Chapter 7 8 HD patients with S. aureus bacteremia can develop Endocarditis 21-31% Osteomyelitis Infection costs $21,000 24,000 19% die within 12 weeks of infection 3
4 Estimated 37,000 CRBSI among HD patients in USA 3.2 per 100 patient-months Blood stream infection due to central venous catheter 8 times > than with fistula Central Venous Catheter Fistula/Graft Dialysis Needed >1 year <1 year PD AVF/AVG if >20 kg PD CVC 4
5 Buttonhole technique patient discomfort and non-infectious complications infectious complications Muir CA. CJASN 2014 HD machine Medication vials HD chairs, other surfaces Our hands Exogenous Contaminated environmental surfaces Contaminated water Endogenous Invasion of colonized bacteria Topical antimicrobial ointments & dressing Catheter securement Locking Solution & antimicrobial catheter hub device or needleless connectors Golestaneh L. Hemodialysis Int
6 Systemic antibiotics alone Addition of antibiotic locks Addition of Guide wire exchange Line holiday Kidney Disease Outcomes Quality Initiative Guidewire exchange of a tunneled HD catheter Am J Kidney Dis 48[Suppl 1]: S1 S322, 2006 European Renal Best Practice Guidewire exchange if removal and replacement of the catheter is not a feasible option Nephrol Dial Transplant Plus 3: , 2010 Infectious Diseases Society of America Removal/replacement as a first-line approach to CRBSI, although guidewire exchange can be used if no alternative access is available Clin Infect Dis 49: 1 45, 2009 ALL THREE SOCIETIES ENDORSE ANTIBIOTIC LOCK SOLUTION 6
7 30% HBeAg+ infectivity International prevalence 3.1% Hepatitis B Risk of Seroconversion Viruses International prevalence 13.5% Hepatitis C 1.8% 0.31% No documented pt pt transmission in USA HIV 45 outbreaks (adult unit) between with 335 unique patients demonstrated Nosocomial transmission confirmed in most cases Sharing contaminated machines & multi-dose vials responsible for 31% of the outbreaks Breaches in environmental cleaning & disinfection practices, failure of proper medication preparation responsible for 65% of outbreaks Fabrizi F. Int J Artif Organs 2015 Transmission: Patient patient Patient staff patient Blood exposure Shared hemodialysis machine Transmission documented via: Contaminated hands Gloves Other contaminated surfaces Needle stick injuries Contact with mucosal membranes Exposure to infected blood or body fluid 7
8 Immunization - CDC Surveillance CDC & KDIGO Infection control practices - CDC Hep B Vaccine less effective in ESRD Adults: seroconversion 34-88% after 3 doses & 73-91% after 4 doses Children similar issue, with <50% of previously unimmunized children demonstrating seroconversion after 3 doses Seroconversion increases if given a higher dose Children 75-97% conversion if given higher dose (off-label) 20 μg vs. 10 μg (Current CDC recommendation 10 μg) Menon S. Pediatr Nephrol 2018 Exit Site Infections Peritonitis 8
9 International Pediatric Peritoneal Dialysis Network (IPPN) Registry ~400 patients ~550 peritonitis episodes Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) Collaborative ~740 patients ~150 infants ~400 peritonitis episodes 207 ESI in 131 catheters (15% of all catheters) 0.25 ESI per year of peritoneal dialysis Swartz SJ. Pediatric Nephrology 2018 Both 8% Tunnel 23% ESI 69% ESI Tunnel Both Swartz SJ. Pediatric Nephrology
10 MSSA 35% Most common gram positive MRSA 6.5% Pseudomonas 18% Most common gram negative Swartz SJ. Pediatric Nephrology 2018 Peritonitis 6 Catheter Removal 12 Hospitalization 24 Resolved with Treatment 84 Swartz SJ. Pediatric Nephrology SCOPE IPPN Infants SCOPE Infants in Hospital SCOPE
11 0.46 SCOPE IPPN Infants SCOPE Infants in Hospital SCOPE 2018 Schaefer F. Kidney International 2007 Schaefer F. Kidney International 2007 ASIA 8 92 TURKEY 8 90 EASTERN EUROPE WESTERN EUROPE 5 90 MEXICO 8 88 ARGENTINA USA ALL 8 89 OUTCOME Technique Failure Full Recovery Schaefer F. Kidney International
12 IPPN Registry: 2453 patients from Characterization of 452 access revision by indication and time on peritoneal dialysis Borzych-Duzalka D. CJASN SCOPE IPPN Infants SCOPE Infants in Hospital SCOPE 2018 Sethna CB. CJASN 2016 Polymicrobial 10% Gram - 19% Fungal 8% Culture - 25% Gram + 38% Gram + Culture - Gram - Polymicrobial Fungal Sethna CB. CJASN
13 Age 2 Compliance with SCOPE Bundle Upward Exit Site Touch Contamination 0.62 episodes per patient year Rate ratio: 0.49 (95%: ) Rate ratio: 4.2 (95%: ) Rate ratio: 2.22 (95%: ) Sethna CB. CJASN 2016 Permanent Removal 12% Other 5% Temporary Removal 6% Resolution Temporary Removal Permanent Removal Other Resolution 77% Sethna CB. CJASN 2016 Sethna CB. CJASN
14 Munshi R. Pediatric Nephrology SCOPE IPPN 2007 Zaritsky JJ. Pediatric Nephrology Infants SCOPE Infants in Hospital SCOPE 2018 Zaritsky JJ. Pediatric Nephrology
15 Nephrectomy at or prior to PD Insertion Odds ratio: 5.93 (95%: ) G-tube insertion post PD insertion Odds ratio: 2.81 (95%: ) Zaritsky JJ. Pediatric Nephrology 2018 Age < 30 days at PD insertion Non- CAKUT as primary disease Pulmonary hypoplasia Nephrectomy & G-tube 29 vs. 9% P< vs. 61% P<0.05 P<0.05 As previous slide Zaritsky JJ. Pediatric Nephrology 2018 SURVIVAL % p<0.05 MEDIAN HOSPITALIZATION DAYS p<0.05 No Peritonitis Peritonitis Zaritsky JJ. Pediatric Nephrology
16 Median (IQR) cost of hospitalization for the treatment of peritonitis $13,655 ($7,871 - $28,434) SCOPE Collaborative Redpath-Mahon AC. Pediatric Nephrology 2019 Redpath-Mahon AC. Pediatric Nephrology 2019 Preinsertion Education Prevention Insertion ISPD Guidelines Pediatrics: 2012 Adult: 2017 Chronic Exit Site Care Early Exit Site Care 16
17 Thank you SCOPE & IPPN Reference Malnutrition Inhibition of phagocytosis & bacterial killing Horl WH, 1999 Fe overload of intracellular Ca Uremia CKD, Dialysis patients Defective phagocytosis, deactivation of neutrophils Cohen G 2012 Patruta SI 1998 Defective phagocytosis, cytokine production & reactive oxygen species apoptosis lymphopenia; abnormal function of antigen-presenting cells & B-lymphocytes impaired cell mediated immunity Dialysis patients response to immunization due to deficient T- lymphocyte dependent immune response Cohen G 2012 Vaziri ND 2012 Cohen G 2012 Girindt 2001 Cohen G
18 Water Purity Quality Allowable Bacterial Colony Forming Units Allowable Endotoxin Level Action Level CFU/ml Action Level EU/ml Pure <200 CFU/ml <2 EU/ml Ultrapure <0.1 CFU/ml <0.03 EU/ml AAMI Standards <100 CFU/ml <0.25 EU/ml >50 >.125 AAMI: Association for the Advancement of Medical Instrumentation DaVita Fresenius DaVita Fresenius Clear Guard vs. Curos Antimicrobial Cap 18
19 1. How To: 2. Benefits: Menon S. Pediatr Nephrol 2018 Clinical Scenario Hepatitis B susceptible (Including immunization nonresponder) Hepatitis B immunization Responder Initial immunization responder but with drop in titers to <10 miu/ml over time Supporting Treatment Serology* HBsAg negative or < Provide immunization if unimmunized 10mIU/mL 1-2 If received one series, repeat series months after the (consider using a higher dose of vaccine) series Anti-HBs > 10 None miu/ml Anti-HBs < 10 miu/ml Additional booster dose of Hepatitis B vaccine Surveillance Monthly HBsAg Yearly Anti-HBs Yearly Anti-HBs Natural Immunity Anti-HBsAb and None None Anti-HBcAb positive Acute Infection HBsAg positive + IgM Anti-HBcAb Follow CDC isolation guidelines Refer for treatment Follow treatment protocol *Serologic markers: HBsAg (hepatitis B surface antigen), Total Anti-HBcAb (total hepatitis B core antibody), IgM Anti-HBcAb (IgM hepatitis B core antibody), Anti-HBsAb (hepatitis B surface antibody). 19
20 Screen for HCV at: Initial evaluation for CKD Initiation of dialysis (in-center or home) As part of evaluation for kidney transplant In-center Hemodialysis patients Screening q6 months Report any positives to public health authority New HCV infection test all patients in center and increase frequency of testing 20
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