The 2010 University of Alabama – Birmingham (UAB) Peritoneal Dialysis Academy (PDA) is an annual seminar designed for nephrology fellows to become familiar and comfortable with peritoneal dialysis. In addition the latest data and news will also be presented. This year fellows, attendings and secondary providers came from all over including North Carolina, Minnesota, Puerto Rico, California, Alabama, Colorado, Florida, Tennessee, Georgia, Maryland, Wisconsin and other areas as well.

Dr. Sarath Kolluru of the Brody School of Medicine at East Carolina University has been selected as the physician-blogger for this year’s seminar. His blog is reported below.

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Day 1

Introduction
The introduction was given by the director of PDA, Dr. Zipporah Krishnasami of University of Alabama at Birmingham and Dr. John Moran, a consulting professor at Stanford University. Introduction included statistics of PD becoming less prevalent in the United States while it becomes more popular in foreign countries. In Hong Kong, the PD First Initiative was mentioned. Data was given showing the equivalent survival and morbidity of diabetic PD patients compared to that of HD patients. Many misconceptions of PD were addressed; including data showing that educational level did not matter in success of PD patients was quite interesting. Also slides showing the incidence of many infectious complications were higher if not the same between HD and PD patients. Granted we all know that blood stream infections were more common in HD, but also data was displayed showing pneumonia and cellulitis were more prevalent amongst HD patients.

One interesting note is the mention of a yet to be published study that has found using the Moncrief-Popovich peritoneal catheter buried until ready to use had no significant rise in infections or complications with the use of the catheter.



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Anatomy and Physiology of Peritoneal Dialysis
Lecture given by Dr. Isaac Teitelbaum of University of Colorado went over the models of transport, physiology, kinetics and middle molecules. Models of transport were reviewed including the three pore model, the pore-matrix model and the distributed model and how these helped with solute clearance and fluid removal. Kinetics and factors influencing ultrafiltration were also reviewed. This was good in understanding the slow versus rapid transporter practice, the science behind the Peritoneal Equilibrium Test (PET) and the Modified PET, and lymphatic reabsorption rate. The talk also covered icodextrin which many fellows had not had experience with yet. The controversies of middle molecules and their effect on long term complications of ESRD patients was explored in the final part of the talk, which basically states that long dwells are needed to clear these middle molecules.


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Ultrafiltration and Fluid Management
The lecture, presented by Dr. Teitelbaum, is a very good follow up to his previous lecture covering volume overload, ultrafiltration targets and evaluation of ultrafiltration failure (see below). The basics of why volume overload is detrimental to ESRD patients were explained due to increased cardiovascular events. Also regarding PD patients, how two different sets of data revealed volume overload led to significant numbers of transfers from PD to HD; 31% in 6 years in one study, 51% in 6 years in another study. Evidence was displayed showing increased peritoneal ultrafiltration decreased hypertension medication requirements. However evidence also was displayed showing increased peritoneal ultrafiltration reduced residual renal function. Then the data behind the benefits of residual renal function was explored. Data showing the different opinions was interesting and something to think about.

The biggest revelation for the fellows during this talk was all the data showing anuric ESRD patients could be treated with good success on PD. Sodium removal in PD patients was also explored showing data that increased total sodium removal improved survival rates. Middle molecules were again covered, showing data that increased clearance decreases mortality but it was unclear if this was due to more volume control or middle molecule clearance.

The last part of the talk dealt with ultrafiltration failure. An algorithm showing a systematic approach to the patient with ultrafiltration failure was given. This was especially good for clinicians. I personally thought this was very good for fellows who do not have much PD exposure.


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PD Adequacy
Dr. Moran did the adequacy lecture, reviewing the data from CANUSA and other trials afterwards finding how we have arrived at the clearance goals that are now in effect. Important to note the data showing peritoneal transport status was not different in diabetics. They then showed a PD prescription is made using the data at hand. An interesting study showing that many patients were tolerant of higher exchange volumes and increasing volumes to assist clearance was advocated. The problems and solutions to many PD prescriptions were offered. This was a strong session in it simplified the development of a patient’s PD prescription.


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Cases
The rest of the day was left for cases. Drs. Tolwani and Krishnasami of UAB lead sessions on problem solving cases involving PET and PD patients. This was helpful in putting all the information together. We were given a handout with two cases to do overnight before the next day.



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Dinner
Dinner was provided for by Baxter, where we had a representative of Baxter’s explained the CMS bundle and how it would be related to Peritoneal Dialysis. I thought this was a tough one for fellows to understand but the gist of the presentation was CMS is encouraging more home modalities including PD and will reimburse accordingly.


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Day 2

Adequacy/PD Cases
This session was run by Dr. Ashita Tolwani of UAB. We went over 5 cases given to us as homework from the night before. They were very good cases involving calculating the Kt/v and creatinine clearance. The cases were taken a step further as more clinical scenarios were given and the group had an open forum of how to solve these issues. This seemed to be a relaxed atmosphere with low to no pressure. It was definitely a good session for fellows not feeling comfortable with PD prescriptions, interpreting PET, and improving adequacy.



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Patient Selection
Patient selection, CKD education and the integrated care for ESRD was an excellent lecture done by Dr. Thomas Golper of Vanderbilt University. Patient selection statistics from across the globe showed that US patients are underrepresented in PD was again highlighted. Dr. Golper emphasized that selecting patients for renal replacement therapy is critical and should be the first decision made by the clinician, patient and patient’s family. The choice of home verse center should be second, and then only should one choose hemodialysis or peritoneal dialysis. Data was given showing ESRD patients with good planning for renal replacement improves outcomes along with predialysis education increases survival and decreased length of stay, temporary catheters, and hospitalizations. A very good synopsis on how to go about making decisions and informing patients about different modalities was presented. Data displaying showing patients survival statistics improved quality of life was an interesting slide. Then the data about patients initiating renal replacement therapy with PD compared to that of HD was looked at, along with patients who initiated with HD that were switched to PD and patients who were only on HD. The PD initiation patients did the best, HD to PD patients did well but not as well, and the HD only patient group preformed the poorest. Data discussing integrated dialysis was shown, implying that if a patient lives long enough, will need multiple modalities and that flexibility enhances survival. Data involving indications for transferring patients off PD and placing them on HD were viewed.


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PD Catheter Strategies, Care and Complications
The second lecture by Dr. Golper was about PD catheters. Introduction data showed the survival and number of complications were equal for AV fistula and PD catheters. Catheter design, prevention of tip migration, and choice of exit sites were reviewed. Advantages and disadvantages of different exit locations were examined including chest wall and back, new information to many in the room. Strong data about optimal results for PD catheters are laterally placed, down going exit site, swan neck design, being double cuffed and laparoscopic placement was presented. Perioperative management and strategies data was shown including how and why some catheter placements are suboptimal including prophylactic antibiotics data and incidence of peritonitis by different catheter placement techniques. Complications were then reviewed. The workup for poor outflow was evaluated including constipation, catheter tip migration, omental wrap, adhesions and fibrin clots. The strategies to prevent and treat these complications were reviewed including data about IR intervention have primary success rate of 86% in catheter migration. Leaks were covered and data was presented in how to locate, treat and prevent different types of leaks. Exit site care was then reviewed including examination and examples are variants of healthy and problematic exit sites. This was extremely helpful for those clinicians who are not used to looking at PD exit sites. The last part of the talk concentrated on prevention of peritonitis. Plenty of data for and against mucipirocin to prevent staph aureus peritonitis was reviewed. Topical antibiotics data was convincing to show reduced rates of peritonitis. Fungal peritonitis data was shown, including several studies showing that antifungal prophylaxis during bacterial peritonitis infection improves survival and outcomes.


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Infectious Complications of PD
This talk was given by Dr. Bargman of University of Toronto, which has a very robust PD population and program. Flushing the bag before filling data reviewed showing dramatic decrease in the rates of peritonitis. The incidence of peritonitis amongst PD patients was reviewed including the death rate of peritonitis and data showing the complications of peritonitis including adhesions, change to rapid transporters and pain. The lecture gave us several cases, the first involving cloudy peritoneal fluid and the differential diagnosis. Different cases illustrated abdominal pain and/or cloudy fluid do not define peritonitis and a thorough workup must be ensued. Data was given showing bloody peritoneal fluid is most likely not peritonitis and we reviewed causes of hemoperitoneum. Data showing why immediate antibiotics and choices of antibiotics were explained, some choices in antibiotics however were still controversial including holding aminoglycosides due to preservation of residual renal function. The presenter was fair in showing both points of view with data backing each claim. Indications for catheter removal were also presented. Fungal peritonitis was then analyzed including the increasing incidence and the etiology. The topic was elaborated on from the previous lecturers comments including much more data on prevention, treatment and prophylaxis. The last part detailed topical antibiotics on exit site infections. An excellent plus was ISPD guidelines were provided for this lecture.


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Non-infectious Complications of PD
The second lecture by Dr. Bargman was also case based addressing subjects of leaks, hydrothorax, hernias, encapsulating peritoneal sclerosis, and hemoperitoneum. The data of prevention, diagnosis and treatment of leaks was surprising on how few times a catheter needed to be removed, instead reducing intra abdominal pressure, quick surgical repairs and not withholding PD worked. Hernia dangers in PD patients were explained. Data showed that most patients had the abdominal wall hernia before initiating PD and repairing the hernia before had reduces complications. Dr. Bargman touted a study she was involved in showing that patients undergoing hernia repair did not to stop PD perioperatively and more importantly did not need HD. The rest of the lecture dealt with encapsulating peritoneal sclerosis (EPS) which is underdiagnosed and undertreated as per data given. Treatment options were for EPS include steroids, tamoxifen and surgery and then only switching to HD.


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Membrane Physiology and Novel PD Fluids
This lecture was conducted by Dr. Steven Guest formerly of Stanford University and now with Baxter Healthcare presented a lecture covering membrane physiology and new PD fluids. The beginning of his slides involved histology sections and how even just uremia causes peritoneal wall thickening. The basic science research causing such changes was reviewed. The data was very interesting with clinical relevance suggesting that the time duration of PD leads patients to becoming higher (rapid) transporters, ACE-I and ARBs seem to reduce peritoneal sclerosis and glucose exposure may affect peritoneal thickening. The second part of the lecture exposed the many new PD solutions that are available here, internationally and what is in development. Icodextrin was covered first which was taken with a grain of salt seeing Baxter makes Extraneal, the commercially available icodextrin. One slide showed the cost differential of placing a patient on Icodextrin compared to the cost of switching a patient from PD to HD. In all, it is a very good product for clearance of middle molecules and for long dwell ultrafiltration seeing the data reviewed. Other products in the pipeline for the US market were discussed, several were not made by Baxter. Popular regimens in Europe were looked at using these new products. Many products appear promising but data is still lacking.


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History of Peritoneal Dialysis
This was the second lecture by Dr. Guest. This was a very interesting perspective of how peritoneal dialysis came to be. For history buffs and those curious about how peritoneal dialysis developed, this was an excellent lecture. One could notice how much passion Dr. Guest had on this topic and how it relates to PD today. I personally enjoyed this lecture and found it very informative.


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Dinner
Dinner was held at an outside restaurant and a game of jeopardy was played to help review what was taught for the last two days. It was very fun in a relaxed atmosphere with a lot of important points reemphasized. If a point was not particularly understood by the fellow, it was again explained in a nonthreatening way. This was also good in getting to know many of the other fellows at the meeting.


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Day 3

Day three involved four different workshops on home dialysis modalities. This was held at the Davita Home Training Unit in Birmingham, right outside the Medical Campus of UAB. The first part was a lecture on exit site evaluations and care. This was very practical now that exit site care data was fresh in our heads. The other workshops included how nurses deal with CCPD, CAPD, Adequacy and home HD. These workshops were very nice and informal. It was nice to ask questions about much of the equipment and how they work, the protocols nurses use and why providers order things a certain way.

Overall this is an excellent conference to get more familiar and understand peritoneal dialysis and the topics surrounding it. I recommend any fellow or attending who wants to get more comfortable with PD to attend this conference. As a first year fellow, I thought it was very informative



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