Kamal Sud

Background: The Chronic Kidney Disease Screening and Quality Use of Medicines trial aimed to improve chronic kidney disease (CKD) detection and optimise medication use in Australia. This analysis evaluates the feasibility of pharmacy‐based screening for identifying individuals at risk of CKD and reports participant baseline characteristics. Methods: Eligible participants for the trial were aged 35–74 years and had ≥1 CKD risk factor. The intervention group received a QKidney® risk assessment, point‐of‐care test (POCT) and medication reviews, while the control group received the risk assessment only. QKidney® scores and blood pressure (BP) classified 5‐year CKD risk as low, moderate or high. Intervention participants at moderate‐to‐high risk underwent POCT of serum creatinine to estimate estimated glomerular filtration rate (eGFR). Reduced kidney function was defined as eGFR < 60 mL/min/1.73 m ² and prevalence was compared with Australian National Health Measures Survey 2022–2024 estimates. Data were analysed in Statistical Package for Social Sciences (version 31) using descriptive statistics. Results: Of the 1486 participants recruited between March 2023 and December 2024, 1189 were included in this analysis (550 (46%) intervention, 639 (54%) control). Risk assessment was completed in 99.9% of participants using QKidney® and in 100% using BP. A POCT was performed for 84% of intervention participants at moderate to high risk. Of those fulfilling pre‐defined general practice referral criteria, 73% were referred. Overall, 68% of trial participants were at moderate to high CKD risk (59% identified by QKidney® and 30% by BP). Additionally, 21% had reduced kidney function based on POCT results – substantially higher than the national estimates (5.2%). Conclusions: Pharmacy‐based targeted screening was feasible for identifying individuals at risk of developing CKD and could strengthen early detection efforts in Australia.

Background: Effective infection control practices are recommended to prevent peritoneal dialysis-associated peritonitis (PD peritonitis). Effects of the coronavirus 2019 (COVID-19) pandemic and preventive measures on PD peritonitis outcomes are unclear. Methods: Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry data, we assessed PD peritonitis rates and outcomes in Australia before and after COVID-19 pandemic onset, defined using the World Health Organisation pandemic date (11/03/2020), between 01/01/2015 and 31/12/2022. PD peritonitis rates, trends (using interrupted time series and joinpoint regression analysis) and outcomes were analysed in prevalent patients on PD. Incident and prevalent patient characteristics commencing PD were analysed. Results: In prevalent PD patients ( n = 11,499), peritonitis rates were lower post-COVID-19 (0.30 episodes per patient-year, 95% confidence interval [CI]: 0.29–0.31) than in the pre-COVID-19 period (0.35, 95% CI: 0.34–0.36, p < 0.001). PD peritonitis rates were declining prior to COVID-19 (incident rate ratio [IRR] per half-year = 0.97, 95% CI 0.96–0.98, p < 0.001), with a relative increase after COVID-19 onset (IRR = 1.05; 95% CI: 1.00–1.09, p = 0.049). There were increases in odds of PD peritonitis relapse (adjusted odds ratio (aOR): 1.41, 95% CI: 1.14–1.76) and recurrence (aOR: 1.45, 95% CI: 1.13–1.86) post-COVID-19. A total of 8999 incident patients started PD during the study period, 5763 pre-COVID-19 and 3236 post-COVID-19. Patient characteristics were similar between groups, other than rates of smoking, cerebrovascular disease and PD modality. Conclusions: PD peritonitis rates have been declining in Australia, with a modest relative increase in peritonitis rates post-COVID-19 onset. Odds of PD peritonitis relapse and recurrence were higher post-COVID-19, highlighting the need for further research regarding PD practices post-pandemic.

Centre-related factors, in addition to patient-related factors, are known to influence the outcomes of patients on peritoneal dialysis (PD). It is unclear if the nursing staff-to-patient ratios at different PD centres affect peritonitis outcomes. Our study aimed to examine whether full-time equivalent (FTE) PD nurse-patient ratios in individual PD centres were associated with centre-level outcomes of patients on PD. We used a cross-sectional survey of nursing leads of PD units across Australia and multi-centre registry data linkage. Of the 38 PD units in Australia, 28 (73.7%) nursing leads responded to the survey. The overall FTE PD nurse-patient ratio was 1 nurse to 12.7 patients (median; interquartile range 9.8-16.5), with substantial variability between PD units. There was no significant association between the FTE PD nurse-patient ratios and unit-specific peritonitis rates, overnight hospitalisation rates for peritonitis, mortality rates within 30 days of infection, or haemodialysis (HD) transfer rates. However, there was a moderate positive correlation between nurse FTE and transfer to HD rates (r = 0.476, p < 0.01). While our study revealed large variability in FTE PD nurse-patient ratios between PD units across the country, it was not associated with clinically significant PD outcomes between centres. Therefore, PD nurse-patient ratios may not be an important centre-related factor to explain variability in clinically meaningful PD outcomes between centres.

Aim: Chronic kidney disease‐associated pruritus is a common and distressing symptom in people with chronic kidney disease and is linked to increased mortality. Home haemodialysis is associated with a number of benefits compared to centre‐based haemodialysis. However, the impact of chronic kidney disease‐associated pruritus in patients receiving home haemodialysis on patient‐reported outcomes such as symptom burden, quality of life, anxiety and depression and sleep disorders is not well understood. In this cross‐sectional study on 59 patients on home haemodialysis, we aimed to determine the prevalence of chronic kidney disease‐associated pruritus and its impact on patient‐reported outcomes. Methods: The 5‐D itch scale and EQ‐5D were used to measure itch severity and quality of life, respectively. Results: The prevalence of chronic kidney disease‐associated pruritus was 31% ( n = 18). Patients with chronic kidney disease‐associated pruritus reported poorer quality of life compared to the non‐pruritus group (0.760 vs. 1.00, p = 0.042). However, there was no significant association between pruritus severity and patient‐reported outcomes, including quality of life. Conclusion: These findings highlight the complex relationship between pruritus and quality of life in patients on home haemodialysis and underscored the need for more extensive, longitudinal studies to better explore correlations between pruritus severity and patient‐reported outcomes, with the view to improving pruritus management and enhancing clinical outcomes.

Aim: People with kidney failure are at increased risk of gout‐related hospitalisations and mortality. Whilst dialysis enhances urate removal and reduces circulating oxypurinol (allopurinol's active metabolite), its effect on achieving target serum urate concentrations (< 0.36 mmol/L) and implications for gout management remain unclear. This study aimed to evaluate serum urate concentrations and allopurinol dosing following commencement of dialysis. Methods: We conducted a retrospective chart review of adults prescribed allopurinol at a dialysis Centre in New South Wales, Australia, between 01/06/2019 and 30/06/2024. Eligible patients had at least one serum urate concentration recorded after commencing dialysis. Data collected included patient demographics, dialysis modality, allopurinol dosing, and serum urate concentrations, spanning from pre‐dialysis to up to 5 years post‐commencing dialysis. Results: Forty‐five patients (18 haemodialysis [HD], 27 peritoneal dialysis [PD]) were included. Most HD patients (61%) received thrice‐weekly haemodiafiltration with high‐flux dialysers; 59% of PD patients used automated PD. Allopurinol doses (100–300 mg daily, mostly 100 mg) remained unchanged from pre‐dialysis in 93% (42/45). At 4 (0.25–38) months post‐dialysis, median serum urate concentrations declined compared to pre‐commencing dialysis (HD: 0.31 vs. 0.51 mmol/L, p = 0.031; PD: 0.33 vs. 0.53 mmol/L, p < 0.001). Target serum urate concentrations were reached at least once in 60% of HD and 78% of PD patients. Conclusion: Serum urate concentrations declined after starting dialysis with unchanged allopurinol dosing, suggesting dialysis independently contributes to urate reduction. These findings support re‐evaluating allopurinol dose in patients after commencing dialysis, including de‐prescribing allopurinol in those who consistently achieve target urate concentrations.

Background and Objectives: Renin-angiotensin system inhibitors (RASIs) are recommended to preserve residual kidney function (RKF) in patients on peritoneal dialysis (PD); however, evidence of benefit is inconsistent. This study evaluated the effect of RASI on RKF decline among patients undergoing PD. Materials and Methods: We conducted a retrospective cohort study among PD patients at a large metropolitan dialysis centre in Australia. RKF was assessed using residual Kt/V and urine volume from PD adequacy tests. Time zero was PD initiation. RASI exposure was modelled as a time-dependent variable to avoid immortal-time bias. Linear mixed-effects models were fitted for each outcome, including random intercepts and slopes for time (years since PD start) with unstructured covariance. Fixed effects included time, RASI(t), time × RASI(t), age, sex, baseline RKF, PD modality, PD infection episodes, loop diuretic use, and comorbidities. Results: Of 307 PD patients, 231 met the inclusion criteria; 111 (48.1%) received RASI. RASI users were younger than non-users [65 years (IQR 56–74) vs. 72 years (IQR 61–77); p = 0.014]. Residual Kt/V declined by 0.26 units/year; RASI exposure showed no significant effect on urine volume trajectory and a borderline slower Kt/V decline (interaction β = +0.038, p = 0.069). Hospitalisation and PD-related infection rates were similar between groups. Conclusions: RASI therapy was not associated with meaningful RKF preservation in PD patients in this cohort. While earlier studies suggested renoprotective effects of RASI while on PD, our findings align with recent evidence of mixed efficacy. Larger prospective trials are needed to clarify the role of RASI in maintaining RKF and improving long-term outcomes in PD.

Introduction: Incremental peritoneal dialysis (PD) may confer environmental benefits compared to full-dose PD due to reduced resource use. We aimed to quantify and compare carbon emissions, water consumption, and waste generation between incremental and full-dose PD in a cohort of incident PD patients. Methods: We compared environmental metrics, including carbon emissions, water consumption, and waste generation between incremental and full-dose PD, using prospectively collected data between June 2019 and May 2024 at the Western Renal Service, Sydney, Australia. Carbon emissions were quantified using standardized coefficients from a published life-cycle analysis, while water and waste volumes were estimated using literature-based assumptions. Group comparisons were conducted using the Mann–Whitney U test, with a two-sided p -value p < 0.001). Incremental PD yielded estimated savings of 201,087 kg carbon dioxide equivalent emissions, over 5 million liters of blue water, 1.8 million liters of gray water, 27,223 kg of landfill waste, and 16,219 kg of recyclable materials. Conclusion: Incremental PD was associated with a lower environmental impact than full-dose PD, highlighting its potential contribution to environmentally sustainable dialysis care.

Peritoneal dialysis (PD) is a preferred dialysis modality in many patients and healthcare settings, as it enables patient independence, reduces hospital visits, and health costs when compared to center-based hemodialysis (HD). However, PD technique failure due to loss of residual kidney function and/or loss of peritoneal membrane function may require patients to transition to HD, where hybrid dialysis (combining PD and HD) may be a viable alternative to thrice-weekly HD, while also promoting patient-centered care. However, hybrid dialysis is not advocated in current clinical practice guidelines, potentially due to a lack of clinician experience or high certainty evidence on the benefits, safety, and cost of combining PD and HD. In this narrative review, we summarize the existing data on health and economic outcomes in patients transitioning from PD alone to combined PD and HD, which may inform patient selection, dialysis prescription, and evaluation of dialysis quality for clinicians and patients considering hybrid dialysis.

Introduction: Therapy alerts during automated peritoneal dialysis (APD) can cause significant disruptions to patients’ sleep and quality of life and may portend poorer outcomes. Understanding the relationship between alert frequency during this early period and longer-term PD outcomes is important. Methods: Following the probabilistic linkage of Vantive's Sharesource database to the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the relationship between alert frequency in the first 30 days of APD and PD discontinuation. We included adult patients in Australia and New Zealand who commenced APD with the Vantive Homechoice Claria cycler over 2019–2023 and continued for at least 30 days. The average alerts per treatment in the first 30 days were divided into quartiles and time to PD discontinuation (inclusive of HD transfer and death), HD transfer only, and infective and non-infective HD transfer were modelled as outcomes. Results: The cohort was 1880 patients, 65% male, and median age at PD commencement of 58 years. Overall PD continuation at 1,2, and 3 years was 78%, 56% and 41%, with HD transfer rates at 14%, 23% and 27%. Higher rates of HD transfer in the first 12 months were seen in the groups with a higher average alert number. Within 12 months, there was a progressive risk of non-infective HD transfer with increasing 30-day alert quartile. Conclusion: Alert burden in the first 30 days is a risk factor for HD transfer in the first 12 months, and resolving underlying issues early may help to improve PD continuation.