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Risk of mortality in the setting of acute kidney injury (AKI) in cats and dogs remains unclear. To evaluate the incidence of mortality in cats and dogs with AKI based on etiology (i.e. infectious versus non-infectious; receiving dialysis versus conservative treatment). Ovid Medline, EMBASE, and LILACS were searched up to July 2016. Articles were deemed eligible if they were case series studies evaluating the incidence of all-cause mortality in cats and dogs with AKI, regardless of etiology or the nature of treatment. Eighteen case series involving 1,201animalsproved eligible. The pooled proportions for overall mortality were: cats53.1% [95% CI 0.475, 0.586; I2 = 11,9%, p = 0.3352]; dogs 45.0% [95% CI 0.33, 0.58; I2 = 91.5%, P < 0.0001]. A non-significant increase in overall mortality risk was found among dialysed animals relative to those managed with conservative treatment, independent of animal type and the etiology of their AKI. The pooled proportions for overall mortality according to etiology, regardless of treatment type, were: AKI due infectious etiology for cats and dogs, 19.2% [95% CI 0.134, 0.258; I2 = 37.7%, P = 0.0982]; AKI due non-infectious etiology for cats and dogs, 59.9% [95% CI 0.532, 0.663; I2 = 51.0%, P = 0.0211]. Our findings suggest higher rates of overall mortality in cats and dogs with AKI due to non-infectious etiologies relative to infectious etiologies, and showed non-significant differences in terms of higher rates associated with dialysis compared to conservative management. Further investigations regarding optimal time to initiate dialysis and the development of clinical models to prognosticate the course of disease and guide optimal treatment initiation for less severe cases of AKI in cats and dogs is warranted.

Peritonitis due to gram-negative bacilli (GNB), particularly nonfermenting GNB (NF-GNB), is a serious complication of peritoneal dialysis with a low resolution rate. Beyond the patient’s condition, microbiological properties such as antimicrobial resistance, biofilm production and other virulence factors can explain the poor outcomes. This study aimed to evaluate the influence of patient condition, microbiological characteristics, including biofilm production, and treatment on peritonitis outcome. We reviewed the records of 62 index episodes caused by NF-GNB that occurred between 1997 and 2015 in our center. The etiologies were species of Pseudomonas (51.6%), Acinetobacter (32.2%), and other NF-GNB (16.1%). There was a high (72.9%) proportion of biofilm producer lineages. The in vitro susceptibility rate of Pseudomonas spp. to amikacin, ciprofloxacin, and ceftazidime was significantly greater than that of Acinetobacter spp. and other species; however, there was a similar low resolution rate (< 45%) among the episodes attributable to them. Preexisting exit-site infection was independently associated with nonresolution. No other factor, including biofilm production, was associated with the outcome. The higher in vitro susceptibility of Pseudomonas compared to other NF-GNB that presented a similar resolution rate suggests that bacterial virulence factors such as biofilms can act in concert, thereby worsening the outcome.

Carbapenem-resistant Klebsiella pneumoniae (CRKP) are highly disseminated worldwide, and isolates co-resistant to other antimicrobial agents pose a threat to effective antimicrobial therapy. Therefore, evaluation of novel antimicrobial drugs is needed to identify potential treatments with better outcomes. We evaluated the in vitro activity of novel antimicrobial drugs/combinations against 97 KPC-producing Klebsiella pneumoniae isolates recovered from different hospitals in Brazil during 2021–2022. Clonality, resistance and virulence genes were detected by whole-genome sequencing. The majority of the isolates (54.6%) were classified as extensively drug resistant or multidrug resistant (44.3%); one isolate showed a pandrug resistance phenotype. The most active antimicrobial agents were meropenem-vaborbactam, cefiderocol, and ceftazidime-avibactam, with sensitivities higher than 90%; resistance to ceftazidime-avibactam was associated with KPC-33 or KPC-44 variants. Colistin and polymyxin B were active against 58.6% of the isolates. The 97 isolates were distributed into 17 different sequence types, with a predominance of ST11 (37.4%). Although high in vitro susceptibility rates were detected for meropenem-vaborbactam and cefiderocol, only ceftazidime-avibactam is currently available in Brazil. Our findings showed limited susceptibility to antimicrobial drugs employed for infection treatment of carbapenem-resistant K. pneumoniae , underscoring the urgent need for stringent policies for antimicrobial stewardship to preserve the activity of such drugs.

We tested if fatigue in incident Peritoneal Dialysis associated with an increased risk for mortality, independently from main confounders. We conducted a side-by-side study from two of incident PD patients in Brazil and the United States. We used the same code to independently analyze data in both countries during 2004 to 2011. We included data from adults who completed KDQOL-SF vitality subscale within 90 days after starting PD. Vitality score was categorized in four groups: >50 (high vitality), [greater than or equal to]40 to [less than or equal to]50 (moderate vitality), >35 to <40 (moderate fatigue), [less than or equal to]35 (high fatigue; reference group). In each country's cohort, we built four distinct models to estimate the associations between vitality (exposure) and all-cause mortality (outcome): (i) Cox regression model; (ii) competing risk model accounting for technique failure events; (iii) multilevel survival model of clinic-level clusters; (iv) multivariate regression model with smoothing splines treating vitality as a continuous measure. Analyses were adjusted for age, comorbidities, PD modality, hemoglobin, and albumin. A mixed-effects meta-analysis was used to pool hazard ratios (HRs) from both cohorts to model mortality risk for each 10-unit increase in vitality. We used data from 4,285 PD patients (Brazil n = 1,388 and United States n = 2,897). Model estimates showed lower vitality levels within 90 days of starting PD were associated with a higher risk of mortality, which was consistent in Brazil and the United States cohorts. In the multivariate survival model, each 10-unit increase in vitality score was associated with lower risk of all-cause mortality in both cohorts (Brazil HR = 0.79 [95%CI 0.70 to 0.90] and United States HR = 0.90 [95%CI 0.88 to 0.93], pooled HR = 0.86 [95%CI 0.75 to 0.98]). Results for all models provided consistent effect estimates. Among patients in Brazil and the United States, lower vitality score in the initial months of PD was independently associated with all-cause mortality.

Hypokalemia has been consistently associated with high mortality rate in peritoneal dialysis. However, studies investigating if hypokalemia is acting as a surrogate marker of comorbidities or has a direct effect in the risk for mortality have not been studied. Thus, the aim of this study was to analyze the effect of hypokalemia on overall and cause-specific mortality. This is an analysis of BRAZPD II, a nationwide prospective cohort study. All patients on PD for longer than 90 days with measured serum potassium levels were used to verify the association of hypokalemia with overall and cause-specific mortality using a propensity match score to reduce selection bias. In addition, competing risks were also taken into account for the analysis of cause-specific mortality. There was a U-shaped relationship between time-averaged serum potassium and all-cause mortality of PD patients. Cardiovascular disease was the main cause of death in the normokalemic group with 133 events (41.8%) followed by PD-non related infections, n=105 (33.0%). Hypokalemia was associated with a 49% increased risk for CV mortality after adjustments for covariates and the presence of competing risks (SHR 1.49; CI95% 1.01-2.21). In contrast, in the group of patients with K <3.5 mEq/L, PD-non related infections were the main cause of death with 43 events (44.3%) followed by cardiovascular disease (n=36; 37.1%). For PD-non related infections the SHR was 2.19 (CI95% 1.52-3.14) while for peritonitis was SHR 1.09 (CI95% 0.47-2.49). Hypokalemia had a significant impact on overall, cardiovascular and infectious mortality even after adjustments for competing risks. The causative nature of this association suggested by our study raises the need for intervention studies looking at the effect of potassium supplementation on clinical outcomes of PD patients.

Peritoneal dialysis (PD) modalities affect solute removal differently. However, the impacts of switching PD modalities on serum levels of biomarkers of different sizes are not known. Our objective was to analyze whether a change in the PD modality associates with the levels of two routine biochemical laboratories. In this multicentric prospective cohort study. we selected all patients who remained on a PD modality for at least 6 months and switched PD modality. Patients were also required to be treated with the same PD modality for at least 3 months before and after the modality change. The primary outcome was change in potassium and phosphate serum levels. We identified 737 eligible patients who switched their PD modality during the study. We found mean serum phosphate levels increased during the 3 months after switching from CAPD to APD and conversely decreased after switching to from APD to CAPD. In contrast, for potassium the difference in the mean serum levels was comparable between groups switching from CAPD to APD, and vice versa. In conclusion, CAPD seems to be as efficient as APD for the control of potassium serum levels, but more effective for the control of phosphate serum levels. The effect of a higher removal of middle size molecules as result of PD modalities in terms of clinical and patient-reported outcomes should be further explored.

Peritoneal dialysis (PD) modalities affect solute removal differently. However, the impacts of switching PD modalities on serum levels of biomarkers of different sizes are not known. Our objective was to analyze whether a change in the PD modality associates with the levels of two routine biochemical laboratories. In this multicentric prospective cohort study. we selected all patients who remained on a PD modality for at least 6 months and switched PD modality. Patients were also required to be treated with the same PD modality for at least 3 months before and after the modality change. The primary outcome was change in potassium and phosphate serum levels. We identified 737 eligible patients who switched their PD modality during the study. We found mean serum phosphate levels increased during the 3 months after switching from CAPD to APD and conversely decreased after switching to from APD to CAPD. In contrast, for potassium the difference in the mean serum levels was comparable between groups switching from CAPD to APD, and vice versa. In conclusion, CAPD seems to be as efficient as APD for the control of potassium serum levels, but more effective for the control of phosphate serum levels. The effect of a higher removal of middle size molecules as result of PD modalities in terms of clinical and patient-reported outcomes should be further explored.

Objective: The study aimed to evaluate the vancomycin and amikacin concentrations in serum and dialysate for automatic peritoneal dialysis (APD) patients . Methods: A total of 558 serum and dialysate samples of 12 episodes of gram-positive and 18 episodes of gram-negative peritonitis were included to investigate the relationship between vancomycin and amikacin concentrations in serum and dialysate on the first and third days of treatment. Samples were analysed 30, 120 min, and 48 h after intraperitoneal administration of vancomycin in peritonitis caused by gram-positive agents and 30, 120 min, and 24 h after intraperitoneal administration of amikacin in peritonitis caused by gram-negative agents. Vancomycin was administered every 72 h and amikacin once a day. The target therapeutic concentration of amikacin was 25–35 mg/l at the peak moment and 4–8 mg/l at the trough moment; and after 48 h for vancomycin, 15–20 mg/l at the trough moment. Results: For peritonitis caused by gram-negative agents, at the peak moment, therapeutic levels of amikacin were reached in dialysate in 80.7% of patients with evolution to cure and in 50% of patients evaluated as non-cure ( p = 0.05). At the trough moment, only 38% were in therapeutic concentrations in the dialysate in the cure group and 42.8% in the non-cure group ( p = 1). Peak plasma concentrations were subtherapeutic in 98.4% of the samples in the cure group and in 100% of the non-cure group. At the trough moment, therapeutic concentrations were present in 74.4% of the cure group and 71.4% of the non-cure group ( p = 1). Regarding vancomycin and among gram-positive agents, therapeutic levels were reached at the peak moment in 94% of the cure group and 6% of the non-cure group ( p = 0.007). After 48 h, 56.8% of the cure group had a therapeutic serum concentration whereas for the non-cure group it was only 33.3% ( p = 0.39). Conclusion: Despite a small sample size, we demonstrated peak dialysate amikacin level and peak serum vancomycin level correlates well with Gram-negative and Gram positve peritonitis cure, respectively. It is suggested to study the antibiotics pharmacodynamics for a better understanding of therapeutic success in a larger sample.

Purpose Peritonitis is a serious complication of peritoneal dialysis and coagulase-negative Staphylococcus (CNS) is the most frequent cause of peritoneal dialysis (PD)–infections in many centers. This study aimed to investigate the molecular epidemiology of CNS isolated from PD-peritonitis in a Brazilian single center, focusing on the genetic determinants conferring methicillin resistance. Methods Bacterial strains were isolated from peritoneal fluid of patients presenting PD-peritonitis, identified by phenotypic and molecular methods, and those identified as CNS were submitted to mecA detection, SCC mec , pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). Results Over the 18-year period of this study (1995–2011), a total of 878 peritonitis episodes were diagnosed in this unit, 115 were caused by coagulase-negative staphylococci of which 72 by Staphylococcus epidermidis . mecA gene was detected in 55 CNS (47.8%), more frequently on the more recent years. SCC mec type III was the most frequent cassette, followed by SCC mec type IV and SCC mec type II. A diverstity of pulsotypes was observed among the S. epidermidis isolates, but five clusters (based on the 80% cutoff) were identified. Diversified sequence types (ST02, ST05, ST06, ST09, ST23, ST59 and ST371) were detected. Conclusions Detection of SCC mec type III among coagulase-negative Staphylococcus underscores the role of hospital environments as potential source of methicillin-resistant Staphylococcus causing peritonitis in PD patients.

The impact of peritoneal dialysis modality on patient survival and peritonitis rates is not fully understood, and no large-scale randomized clinical trial (RCT) is available. In the absence of a RCT, the use of an advanced matching procedure to reduce selection bias in large cohort studies may be the best approach. The aim of this study is to compare automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) according to peritonitis risk, technique failure and patient survival in a large nation-wide PD cohort. This is a prospective cohort study that included all incident PD patients with at least 90 days of PD recruited in the BRAZPD study. All patients who were treated exclusively with either APD or CAPD were matched for 15 different covariates using a propensity score calculated with the nearest neighbor method. Clinical outcomes analyzed were overall mortality, technique failure and time to first peritonitis. For all analysis we also adjusted the curves for the presence of competing risks with the Fine and Gray analysis. After the matching procedure, 2,890 patients were included in the analysis (1,445 in each group). Baseline characteristics were similar for all covariates including: age, diabetes, BMI, Center-experience, coronary artery disease, cancer, literacy, hypertension, race, previous HD, gender, pre-dialysis care, family income, peripheral artery disease and year of starting PD. Mortality rate was higher in CAPD patients (SHR1.44 CI95%1.21-1.71) compared to APD, but no difference was observed for technique failure (SHR0.83 CI95%0.69-1.02) nor for time till the first peritonitis episode (SHR0.96 CI95%0.93-1.11). In the first large PD cohort study with groups balanced for several covariates using propensity score matching, PD modality was not associated with differences in neither time to first peritonitis nor in technique failure. Nevertheless, patient survival was significantly better in APD patients.