Impact of peritonitis on long-term survival of peritoneal dialysis patients
Impacto de las peritonitis en la supervivencia a largo plazo de los pacientes en diálisis peritoneal
Grupo Levante de diálisis peritoneal, E.. Muñoz de Bustillob, F.. Borrásc, C.. Gómez-Roldánd, F.J.. Pérez-Contrerase, J.. Olivarese, R.. Garcíaf, A.. Miguelf
b Servicio de Nefrología, Hospital Marina Baixa, Villajoyosa, Alicante,
c Departamento de Estadística, Matemáticas e Informática, Universidad Miguel Hernández, Elche, Alicante,
d Servicio de Nefrología, Hospital General Universitario de Albacete,
e Servicio de Nefrología, Hospital General Universitario de Alicante,
f Servicio de Nefrología, Hospital Clínico Universitario de Valencia,
Read
11792
Timeswas read the article
2712
Total PDF
9080
Total HTML
Share statistics
array:21 [ "pii" => "X201325141100017X" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2011.Oct.10987" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2011;31:723-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 6263 "formatos" => array:3 [ "EPUB" => 336 "HTML" => 5167 "PDF" => 760 ] ] "Traduccion" => array:1 [ "es" => array:17 [ "pii" => "X0211699511000172" "issn" => "02116995" "doi" => "10.3265/Nefrologia.pre2011.Oct.10987" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia. 2011;31:723-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9433 "formatos" => array:3 [ "EPUB" => 294 "HTML" => 8435 "PDF" => 704 ] ] "es" => array:12 [ "idiomaDefecto" => true "titulo" => "Impacto de las peritonitis en la supervivencia a largo plazo de los pacientes en diálisis peritoneal" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "723" "paginaFinal" => "732" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Impact of peritonitis on long-term survival of peritoneal dialysis patients" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_17809_es_10987_f1.jpg" "Alto" => 528 "Ancho" => 501 "Tamanyo" => 153212 ] ] "descripcion" => array:1 [ "es" => "Estimación de la supervivencia de los pacientes después de cada episodio de peritonitis en función del cultivo del efluente." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " Grupo Levante de diálisis peritoneal, E. Muñoz de Bustillo, F. Borrás, C. Gómez-Roldán, F.J. Pérez-Contreras, J. Olivares, R. García, A. Miguel" "autores" => array:8 [ 0 => array:1 [ "apellidos" => "Grupo Levante de diálisis peritoneal" ] 1 => array:2 [ "Iniciales" => "E." "apellidos" => "Muñoz de Bustillo" ] 2 => array:2 [ "Iniciales" => "F." "apellidos" => "Borrás" ] 3 => array:2 [ "Iniciales" => "C." "apellidos" => "Gómez-Roldán" ] 4 => array:2 [ "Iniciales" => "F.J." "apellidos" => "Pérez-Contreras" ] 5 => array:2 [ "Iniciales" => "J." "apellidos" => "Olivares" ] 6 => array:2 [ "Iniciales" => "R." "apellidos" => "García" ] 7 => array:2 [ "Iniciales" => "A." "apellidos" => "Miguel" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "X201325141100017X" "doi" => "10.3265/Nefrologia.pre2011.Oct.10987" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X201325141100017X?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699511000172?idApp=UINPBA000064" "url" => "/02116995/0000003100000006/v0_201502091400/X0211699511000172/v0_201502091401/es/main.assets" ] ] "itemSiguiente" => array:17 [ "pii" => "X2013251411000161" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2011.Sep.10927" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2011;31:733-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5904 "formatos" => array:3 [ "EPUB" => 305 "HTML" => 4922 "PDF" => 677 ] ] "en" => array:12 [ "idiomaDefecto" => true "titulo" => "Causes of unplanned hemodialysis initiation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "733" "paginaFinal" => "737" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Causas de inicio no programado del tratamiento renal sustitutivo con hemodiálisis" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10927_108_24074_en_10927t1.jpg" "Alto" => 263 "Ancho" => 600 "Tamanyo" => 150396 ] ] "descripcion" => array:1 [ "en" => "Baseline characteristics of each subgroup according to the conditions for starting haemodialysis treatment" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Gomis Couto, José Luis Teruel Briones, Milagros Fernández Lucas, Maite Rivera Gorrin, Nuria Rodríguez Mendiola, Sara Jiménez Álvaro, Carlos Quereda Rodríguez-Navarro" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Gomis Couto" ] 1 => array:2 [ "nombre" => "Antonio" "apellidos" => "Gomis Couto" ] 2 => array:2 [ "nombre" => "José Luis" "apellidos" => "Teruel Briones" ] 3 => array:2 [ "nombre" => "Milagros" "apellidos" => "Fernández Lucas" ] 4 => array:2 [ "nombre" => "Maite" "apellidos" => "Rivera Gorrin" ] 5 => array:2 [ "nombre" => "Nuria" "apellidos" => "Rodríguez Mendiola" ] 6 => array:2 [ "nombre" => "Sara" "apellidos" => "Jiménez Álvaro" ] 7 => array:2 [ "nombre" => "Carlos" "apellidos" => "Quereda Rodríguez-Navarro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699511000164" "doi" => "10.3265/Nefrologia.pre2011.Sep.10927" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699511000164?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411000161?idApp=UINPBA000064" "url" => "/20132514/0000003100000006/v0_201502091623/X2013251411000161/v0_201502091623/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "X2013251411000188" "issn" => "20132514" "doi" => "10.3265/Nefrologia.pre2011.Jul.10847" "estado" => "S300" "fechaPublicacion" => "2011-11-01" "documento" => "article" "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/" "subdocumento" => "fla" "cita" => "Nefrologia (English Version). 2011;31:716-22" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5363 "formatos" => array:3 [ "EPUB" => 303 "HTML" => 4258 "PDF" => 802 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Psychonephrology: psychological aspects in autosomal dominant polycistic kidney disease" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "716" "paginaFinal" => "722" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Psiconefrología: aspectos psicológicos en la poliquistosis renal autosómica dominante" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " en nombre del Grupo de Investigación HIRICARE, T.S. Pérez Domínguez, A. Rodríguez Pérez, N. Buset Ríos, F. Rodríguez Esparragón, M.A. García Bello, P. Pérez Borges, Y. Parodis López, J.C. Rodríguez Pérez" "autores" => array:10 [ 0 => array:1 [ "apellidos" => "en nombre del Grupo de Investigación HIRICARE" ] 1 => array:1 [ "apellidos" => "Grupo de Investigación HIRICARE" ] 2 => array:2 [ "Iniciales" => "T.S." "apellidos" => "Pérez Domínguez" ] 3 => array:2 [ "Iniciales" => "A." "apellidos" => "Rodríguez Pérez" ] 4 => array:2 [ "Iniciales" => "N." "apellidos" => "Buset Ríos" ] 5 => array:2 [ "Iniciales" => "F." "apellidos" => "Rodríguez Esparragón" ] 6 => array:2 [ "Iniciales" => "M.A." "apellidos" => "García Bello" ] 7 => array:2 [ "Iniciales" => "P." "apellidos" => "Pérez Borges" ] 8 => array:2 [ "Iniciales" => "Y." "apellidos" => "Parodis López" ] 9 => array:2 [ "Iniciales" => "J.C." "apellidos" => "Rodríguez Pérez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "X0211699511000180" "doi" => "10.3265/Nefrologia.pre2011.Jul.10847" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699511000180?idApp=UINPBA000064" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411000188?idApp=UINPBA000064" "url" => "/20132514/0000003100000006/v0_201502091623/X2013251411000188/v0_201502091623/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "titulo" => "Impact of peritonitis on long-term survival of peritoneal dialysis patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "723" "paginaFinal" => "732" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => " Grupo Levante de diálisis peritoneal, E. Muñoz de Bustillo, F. Borrás, C. Gómez-Roldán, F.J. Pérez-Contreras, J. Olivares, R. García, A. Miguel" "autores" => array:8 [ 0 => array:1 [ "apellidos" => "Grupo Levante de diálisis peritoneal" ] 1 => array:4 [ "Iniciales" => "E." "apellidos" => "Muñoz de Bustillo" "email" => array:1 [ 0 => "emunozd@senefro.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "F." "apellidos" => "Borrás" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "C." "apellidos" => "Gómez-Roldán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] ] ] 4 => array:3 [ "Iniciales" => "F.J." "apellidos" => "Pérez-Contreras" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] 5 => array:3 [ "Iniciales" => "J." "apellidos" => "Olivares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] ] ] 6 => array:3 [ "Iniciales" => "R." "apellidos" => "García" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] 7 => array:3 [ "Iniciales" => "A." "apellidos" => "Miguel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Marina Baixa, Villajoyosa, Alicante, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 1 => array:3 [ "entidad" => "Departamento de Estadística, Matemáticas e Informática, Universidad Miguel Hernández, Elche, Alicante, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] 2 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Universitario de Albacete, " "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "affd" ] 3 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital General Universitario de Alicante, " "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "affe" ] 4 => array:3 [ "entidad" => "Servicio de Nefrología, Hospital Clínico Universitario de Valencia, " "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "afff" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Impacto de las peritonitis en la supervivencia a largo plazo de los pacientes en diálisis peritoneal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25114_en_t1_10987.jpg" "Alto" => 384 "Ancho" => 600 "Tamanyo" => 208558 ] ] "descripcion" => array:1 [ "en" => "Characteristics of the 1515 incident patients on peritoneal dialysis and the sample of 1180 patients with information on peritoneal transport and adequacy included in the multivariate analysis" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Peritonitis currently constitutes one of the primary causes of death and technique failure in peritoneal dialysis (PD) patients, in spite of the continued decrease in the incidence rate of this complication.<span class="elsevierStyleSup">1-6</span> Fortunately, the direct mortality associated with episodes of peritonitis is low, below 4% according to most studies.<span class="elsevierStyleSup">5,6</span> This rate of lethality depends greatly on the causative micro-organism, and is highest for fungal peritonitis, followed by those due to gram-negative bacteria.<span class="elsevierStyleSup">6-10</span> The potential influence of episodes of peritonitis on the mortality of PD patients on a long-term basis is much less well understood. In fact, we only know one study in which this specific aspect has been analysed in detail.<span class="elsevierStyleSup">11</span> This study was published in 1996 when only 30% of patients used disconnect systems, a situation quite different from the current one.<span class="elsevierStyleSup">11</span> Additionally, until now, no study has been carried out in the survival of PD patients that has analysed the incidence of peritonitis as a time-dependent variable, with the previous literature on the subject limited to studies using the final rate of peritonitis as their study variable.<span class="elsevierStyleSup">11,12</span> As such, from a methodological point of view, no study has been able to estimate the increased risk of death or technique failure that each episode of peritonitis causes when these infections occur. We must keep in mind that in addition to the direct mortality attributable to peritonitis, each case also involves an inflammation state that will generate both a deleterious effect on the peritoneal membrane and a decrease in the PD patient’s general health and immunological and nutritional states. This could potentially affect the survival of the large majority of patients that overcome their episodes of peritonitis and remain on the dialysis technique.</p><p class="elsevierStylePara">Since 1991, the Levante registry has prospectively compiled an ample database of demographic and clinical information on all patients that start renal replacement therapy with PD in the public sector in the three provinces of the Community of Valencia (Alicante, Castellón, and Valencia), the community of Murcia, and the provinces of Albacete and Cuenca. In the present study, we analysed a large cohort of patients included in the Levante registry to estimate the long-term survival of PD patients after each case of peritonitis using analysis techniques for time-dependent variables. We also estimated the potential differences in long-term mortality based on the type of micro-organism causing the infection.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHOD</span></p><p class="elsevierStylePara">We performed a retrospective analysis of all episodes of peritonitis registered in a total of 1515 incident patients from the Levante registry that started PD using disconnect systems between 1 January 1993 and 31 December, 2005. In addition to the information provided on the episodes of peritonitis (date of diagnosis, culture from the dialysis effluent, and the need for hospitalisation), we used demographical and clinical data from all patients upon starting PD, and at least one analysis of peritoneal permeability and adequacy in a sample of 1180 patients (77.9% of the total). Some 2577 studies were performed during the follow-up period. We considered peritonitis to be any episode of turbid peritoneal effluent with a pathological cell count, defined as more than 100 leukocytes/mm<span class="elsevierStyleSup">3</span> with a polymorphonuclear neutrophil percentage greater than 50%.<span class="elsevierStyleSup">13</span> Comorbidity at the start of PD was estimated by calculating the Davies index<span class="elsevierStyleSup">14</span> for the 14 comorbidities compiled in the Levante registry.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Statistical analysis</span></p><p class="elsevierStylePara">We performed a descriptive analysis of the continuous variables of the sample using means and standard deviations, comparing between groups using the Mann-Whitney U test. Qualitative variables were analysed using chi-square tests. In all cases, the null hypothesis was rejected whenever its probability was less than 0.05 (<span class="elsevierStyleItalic">P</span><.05).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Survival analysis</span></p><p class="elsevierStylePara">We performed a survival analysis, considering only patient death. We estimated technique survival by considering only the event of switching to haemodialysis (HD). All other events in both cases were censored. We calculated mortality rate (deaths/100 patient-years) by dividing the total number of deaths registered in a period of time by the number of at-risk days for all patients within that period, dividing by 365.25 and multiplying by 100. The rate of technique failure within a given period was calculated in the same way, considering the number of patients that switched to HD during that time. Those patients that died during the first month after transferring to HD were considered to have died on PD. Direct mortality from peritonitis was defined as all deaths that occurred within 4 weeks of an episode of peritonitis, regardless of the immediate cause of death. For the univariate analysis of continuous variables, we performed a “dummy” transformation into categorical variables according to statistical and/or clinical criteria for later analysis using Kaplan-Meier curves, comparing between strata using log-rank tests. We analysed the impact of episodes of peritonitis as well as other time-dependent variables (PD technique used, use of icodextrin, and variables associated with peritoneal kinetics and adequacy) on survival, using Cox-regression models for time-dependent covariates. In this analysis, each event is related to the value of the previous variable, such that the resulting Cox model represents the instantaneous relative risk when comparing two different patients with the same follow-up time when one of them changes levels. In order to represent the univariate effect of the time-dependent variables, we used Kaplan-Meier curves with delayed-entry study. They represent survival as if a patient was in the same category of the study variables during the entire study period. The proportionality of risks that the Cox regression analysis requires was confirmed using Kaplan-Meier curves and a graphical representation of the log-transformed incidence rate by time according to each case. All fixed or time-dependent variables with a significant (<span class="elsevierStyleItalic">P</span><.05) or almost significant (<span class="elsevierStyleItalic">P</span>≤.1) value for survival in the univariate study were selected for a multivariate analysis using backwards stepwise conditional Cox regression. We developed two different multivariate models: the first was to estimate the risk of mortality associated with each episode of peritonitis, and the second was to analyse patient survival based on the causative micro-organism. In this last model, we decided to exclude episodes caused by mycobacteria (because of the small number: 7 cases) and those that produced a negative cell culture, since this was a heterogeneous group. Additionally, in accordance with previously existing literature on the subject, we decided to consider mixed infections as gram-negatives whenever a gram-negative bacteria was isolated, and fungal whenever at least one fungal species was isolated.<span class="elsevierStyleSup">11</span> We performed all statistical analyses using “R” statistical software, version 2.8.0 (The R Foundation for Statistical Computing) and SPSS version 13.0 (SPSS Inc., Chicago, Illinois, USA).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS</span></p><p class="elsevierStylePara">We analysed a total of 1515 incident patients with a cumulative time on PD of 3213.7 years. The primary characteristics of the cohort are compiled in Table 1. In a sample of 1180 patients (77.9%), we had access to at least one peritoneal transport and adequacy study. The characteristics of this sample and the differences with other patients appear summarised in Table 1. The baseline peritoneal transport and adequacy values were the following: weekly peritoneal Kt/V: 1.54±0.4; weekly renal Kt/V: 0.9±0.7; estimated glomerular filtration rate (average of urea and creatinine clearance rates): 5.08±4.08ml/min; nPCR: 1.08±0.3g/kg/day; D/P creatinine: 0.67±0.1. At the end of the study, 402 patients (26.5%) were still on PD, 386 (25.5%) had died, 367 (24.2%) received a kidney transplant, 308 (20.3%) were transferred to HD, and 52 (3.4%) were lost during the follow-up period. Mean patient survival was 63 months (95% confidence interval [CI]: 53.8-72.2), with a survival rate of 91%, 72%, 52%, and 23% at 1, 3, 5, and 10 years, respectively. Global mortality was 11.7 deaths per 100 patient-years. The cause of death was cardiovascular in 128 cases (33.2%), associated with peritonitis in 58 cases (15%), cachexia in 51 cases (13.2%), non-peritoneal infection in 47 cases (12.2%), miscellaneous in 30 cases (7.8%), and unknown in 72 cases (18.6%). Mean technique survival was 89.14 months (95% CI: 82.22-96.07), with a rate of 92%, 74%, 63%, and 37% at 1, 3, 5, and 10 years, respectively. The rate of transferral to HD was 9.4 cases per 100 patient-years on PD. Peritonitis was the primary cause of technique failure with 111 cases (36.4%).</p><p class="elsevierStylePara">During the follow-up period, we diagnosed 1609 episodes of peritonitis in 716 patients (47.2%); 339 patients (22.3%) developed one episode, 163 patients (10.7%) had two, 91 patients (6%) had three, and 123 patients (8.1%) had four or more episodes. The global rate of peritonitis was one episode per 24 patient-months (one episode for every 18.3, 24.5, and 29 patient-months for the periods of 1993-1995, 1996-2000, and 2001-2005, respectively). The lethality rate was 3.6%. Gram-positive bacteria were the most common causative micro-organisms with 902 cases of peritonitis (56% of the total), 129 of which were <span class="elsevierStyleItalic">Staphylococcus aureus</span> (8%). Gram-negative bacteria showed up in cultures in 339 episodes (21%), including 87 cases of <span class="elsevierStyleItalic">Pseudomonas spp</span>. (5.4%). In 63 cases, we observed a mixed culture of gram-positive and gram-negative bacteria (4.3%). The episode was caused by a fungus in 59 cases (3.6%), and mycobacteria were implicated in 7 cases (0.7%). The culture of the effluent was negative in 239 cases (14.8%). In 956 cases (59.4%), treatment was given in an outpatient setting, whereas 653 episodes (40.6%) required hospitalisation.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Patient survival</span></p><p class="elsevierStylePara">Univariate analysis</p><p class="elsevierStylePara">Mean patient survival with a rate of peritonitis equal to or greater than one episode every 24 months was 57 months (95% CI: 51.1-62.9), significantly lower than patients with a lower incidence of peritonitis (83 months; 95% CI: 74.9-91.1; <span class="elsevierStyleItalic">P</span><.001). The analysis of each case of peritonitis as a time-dependent variable confirmed that each episode was associated with a higher risk of death that increased progressively as episodes occurred to the same patient. Thus, the first episode was associated with a hazard ratio (HR) of 2.08 (95% CI: 1.59-2.72; <span class="elsevierStyleItalic">P</span><.001); the second had a HR of 2.72 (95% CI: 1.92-3.85; <span class="elsevierStyleItalic">P</span><.001), the third had a HR of 3.18 (95% CI: 2.07-4.88; <span class="elsevierStyleItalic">P</span><.001), the fourth had a HR of 4.76 (95% CI: 2.94-7.62; <span class="elsevierStyleItalic">P</span><.001), and the fifth and the following ones had a HR of 7.87 (95% CI: 5.16-12; <span class="elsevierStyleItalic">P</span><.001). This increased risk of mortality was greatest for patients with fungal infections (HR: 14.29; 95% CI: 7.97-25.65; <span class="elsevierStyleItalic">P</span><.001), followed by episodes caused by gram-negative bacteria (HR: 3.56; 95% CI: 2.62-4.83; <span class="elsevierStyleItalic">P</span><.001), with the lowest risk associated with episodes caused by gram-positive bacteria (HR: 2.23; 95% CI: 1.72-2.90; <span class="elsevierStyleItalic">P</span><.001) (Figure 1). The estimated long-term risk of mortality after an episode of peritonitis from <span class="elsevierStyleItalic">Staphylococcus aureus</span> (HR: 2.25; 95% CI: 1.37-3.70; <span class="elsevierStyleItalic">P=</span>.001) was similar to the rest of the gram-positive bacteria (HR: 2.23; 95% CI: 1.69-2.93; <span class="elsevierStyleItalic">P</span><.001). Additionally, the need for hospitalisation during the episode of peritonitis was also associated with increased long-term mortality (HR: 3.62; 95% CI: 2.78-4.72; <span class="elsevierStyleItalic">P</span><.001), although even those episodes treated in the outpatient setting were associated with a significantly lower long-term survival rate (HR: 1.99; 95% CI: 1.53-2.60; <span class="elsevierStyleItalic">P</span><.001) (Figure 2). In addition to the cases of peritonitis, the variables that showed a significant association in the univariate analysis with increased mortality were age (<span class="elsevierStyleItalic">P</span><.001), inclusion on PD before 2001 (<span class="elsevierStyleItalic">P</span><.001), previous time spent on HD (<span class="elsevierStyleItalic">P</span><.001), the absence of an adequate vascular access for HD as the reason for choosing PD (<span class="elsevierStyleItalic">P</span><.001), the cause of the CKD (<span class="elsevierStyleItalic">P</span>=.002), comorbidity as measured by the Davies index (<span class="elsevierStyleItalic">P</span><.001), the use of icodextrin (<span class="elsevierStyleItalic">P</span>=.035), a D/P creatinine index (D/P creat) greater than 0.65 (<span class="elsevierStyleItalic">P</span>=.002), a nPCR less than 1g/kg/day (<span class="elsevierStyleItalic">P</span><.001), and residual renal function (RRF) less than 3ml/min (<span class="elsevierStyleItalic">P</span><.001).</p><p class="elsevierStylePara">Multivariate analysis</p><p class="elsevierStylePara">In the first multivariate model, we confirmed that each case of peritonitis increases the long-term risk of mortality with an adjusted HR of 2.01 (95% CI: 1.53-2.64; <span class="elsevierStyleItalic">P</span><.001) (Table 2). The second multivariate model demonstrated how the risk of death appears after fungal peritonitis cases (adjusted HR: 5.71; 95% CI: 2.76-11.8; <span class="elsevierStyleItalic">P</span><.001), with lower rates associated with cases of gram-negative bacteria (adjusted HR: 2.43; 95% CI: 1.69-3.52; <span class="elsevierStyleItalic">P</span><.001) and gram-positive bacteria (adjusted HR: 1.73; 95% CI: 1.28-2.34; <span class="elsevierStyleItalic">P</span><.001) (Table 3). Other independent risk factors associated with reduced survival in both models were age, the absence of an adequate vascular access point for HD, comorbidity, and a low or non-existent RRF (Table 2 and Table 3).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Technique survival</span></p><p class="elsevierStylePara">Mean technique survival was significantly lower in patients with a higher incidence of peritonitis than the mean of one episode every 24 months (69.9 months; 95% CI: 61.8-78) as compared to patients with a lower incidence of peritonitis (101.2 months; 95% CI: 92.8-109.5; <span class="elsevierStyleItalic">P</span><.001). The univariate analysis also showed that the risk of technique failure increased in relation to the number of episodes of peritonitis experienced by the same patient, with an HR of 2.21 for the first episode (95% CI: 1.80-2.70; <span class="elsevierStyleItalic">P</span><.001), 3.35 for the second (95% CI: 2.60-4.31; <span class="elsevierStyleItalic">P</span><.001), 4.19 for the third (95% CI: 3.09-5.69; <span class="elsevierStyleItalic">P</span><.001), 4.46 for the fourth (95% CI: 3.02-6.59; <span class="elsevierStyleItalic">P</span><.001), and 8.50 from the fifth episode on (95% CI: 6.11-11.81; <span class="elsevierStyleItalic">P</span><.001). Additionally, the risk of transferring to HD was different for the episodes resulting from gram-positive bacteria (excluding <span class="elsevierStyleItalic">Staphylococcus</span><span class="elsevierStyleItalic">aureus</span>) (HR 2.09; 95% CI: 1.69-2.59; <span class="elsevierStyleItalic">P</span><.001), <span class="elsevierStyleItalic">Staphylococcus aureus </span>(HR: 2.34; 95% CI: 1.61-3.39; <span class="elsevierStyleItalic">P</span><.001) gram-negative bacteria (HR: 4.01; 95% CI: 3.20-5.03; <span class="elsevierStyleItalic">P</span><.001), and fungal infections (HR: 29.76; 95% CI: 21.31-41.58; <span class="elsevierStyleItalic">P</span><.001) (Figure 3). Other factors associated with technique failure in the univariate analysis were the cause of the chronic kidney disease (CKD) (<span class="elsevierStyleItalic">P</span>=.04), the use of automated peritoneal dialysis (APD) (<span class="elsevierStyleItalic">P</span>=.001), the use of icodextrin (<span class="elsevierStyleItalic">P</span>=.02), a D/P creatinine index greater than 0.65 (<span class="elsevierStyleItalic">P</span>=.002), an RRF less than 3ml/min (<span class="elsevierStyleItalic">P</span>=.001), and nPCR values less than 1g/kg/day (<span class="elsevierStyleItalic">P</span>=.04). The multivariate analysis confirmed that the episodes of peritonitis were the only factor independently associated with technique survival, with an adjusted HR of 1.29 (95% CI: 1.21-1.38; <span class="elsevierStyleItalic">P</span><.001), and this risk varied by the type of infectious micro-organism involved (Table 4).</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">The lack of a correct analysis of time-dependent variables is the cause of serious bias that can affect the results of many observational studies published even in upper-tier journals.<span class="elsevierStyleSup">15</span> In this study, we analysed episodes of peritonitis for the first time as a time-dependent variable with the objective of estimating the potential impact of this occurrence on mid-long-term technique failure and mortality in PD patients. Our results show that peritonitis does not only affect short-term patient survival, but also that it has long-term impact on the majority of patients that respond to treatment and overcome the original infection. Additionally, this increased risk of death and/or technique failure associated with peritonitis is independent of the presence of other well-known prognostic factors, such as advanced age, comorbidity, and absence of RRF.<span class="elsevierStyleSup">16-18 </span>Until now, very few studies have evaluated the impact of peritonitis on long-term survival of PD patients.<span class="elsevierStyleSup">11,12</span> Fried, et al studied the influence of peritonitis on mortality in 516 patients in a single PD unit, demonstrating lower survival rates in patients with more than one episode of peritonitis every 25 months.<span class="elsevierStyleSup">11</span> More recently, Sipahioglu et al published their experience with 423 patients, also from one single centre, demonstrating an increased risk of death in patients with a higher incidence of peritonitis (adjusted HR: 1.87 for each increase of one episode per year on PD).<span class="elsevierStyleSup">12</span> For the first time, and through the application of regression techniques for time-dependent variables, our study has been able to estimate the mean increase in risk of death that each episode of peritonitis accounts for, also adjusting for other significant variables (HR: 2.01; 95% CI: 1.53-2.64).<span class="elsevierStyleSup"> </span>Even more so, our results show that the several episodes of peritonitis in the same patient progressively increase the negative impact of this complication on survival. It is important to point out that even those episodes that are treated in the outpatient setting (because the patient has a good clinical situation with proper response to treatment) are later associated with a significant increase in mid-long-term mortality. The deleterious effect of peritonitis episodes on mid-long-term patient survival could be explained by their potential contribution to the development of malnutrition-inflammation-atherosclerosis syndrome (MIA).<span class="elsevierStyleSup">19</span> In this context, a recent study showed that each episode of peritonitis causes an increased inflammatory state in PD patients that lasts much longer than the clinical resolution of the peritonitis itself.<span class="elsevierStyleSup">20</span> This inflammation state, with the serological translation of increased PCR levels, is accompanied by nutritional deterioration that manifests itself in the form of decreased body mass index, which could also be caused by the concomitant increase in serum leptin levels because of the known anorectic activity of this compound.<span class="elsevierStyleSup">20</span> All of these alterations would still be present even six weeks after the complete clinical remission of the episode, with continued nutritional deterioration and prealbumin levels still below those from before the infectious event.<span class="elsevierStyleSup">20</span> Thus, each case of peritonitis would lead to a deteriorated nutritional state of the patient and would exacerbate the previous inflammatory state, enhancing the development of atherosclerosis and increasing cardiovascular risk.<span class="elsevierStyleSup">19</span> Precisely, the persistence of increased serum PCR levels following the resolution of the episode of peritonitis has be correlated with lower survival <span class="elsevierStyleItalic">a posteriori</span> both in the short and long term.<span class="elsevierStyleSup">20-22 </span>In this context, it is interesting to point out how even in studies that only analysed direct short-term mortality attributed to each episode of peritonitis a cardiovascular complication was the immediate cause of death in as many as 41.5% of cases.<span class="elsevierStyleSup">8</span> Finally, it has been suggested that the sustained inflammation and its exacerbations during episodes of peritonitis could contribute to the progressive loss of RRF, thus indirectly affecting patient survival.<span class="elsevierStyleSup">23,24</span> In any case, our study shows that the association between peritonitis and long-term patient survival is independent of the patient’s RRF at the time of the episode. Even more so, our study was able to detect significant differences in survival from each episode of peritonitis based on the causative micro-organism.<span class="elsevierStyleSup"> </span>Thus, fungal peritonitis episodes have the greatest impact on mortality, followed by episodes caused by gram-negative bacteria and finally gram-positive bacteria (Figure 3 and Table 3). Until now, only the study mentioned by Fried et al had analysed the impact of the causative micro-organism on long-term patient survival in PD patients, with similar conclusions.<span class="elsevierStyleSup">11</span> All other studies have focused on the immediate mortality rates associated with the episode or the rate of lethality,<span class="elsevierStyleSup">4,7,25</span> all of which resulted in greater mortality rates for cases of fungal peritonitis, followed by those caused by gram-negative bacteria. As such, an in accordance with the previously published studies and our own results, we can conclude that the different short-term profile of clinical aggressiveness of the different causative micro-organisms is maintained if we consider a more long-term evaluation of patient survival.</p><p class="elsevierStylePara">In our study, the episodes of peritonitis are the only variable that was independently associated with technique survival on PD. Although increased peritoneal transport and loss of RRF were significantly associated with technique survival in the univariate analysis, both factors lost this association in the multivariate analysis, which suggests that the use of APD could contribute to the treatment of high transporters and anuric patients to facilitate remaining on the technique under proper conditions.<span class="elsevierStyleSup">26,27</span> Additionally, if we take into consideration that the incidence of peritonitis was not included in the majority of previous studies on survival, it is plausible to consider that the association described in other studies between low RRF and technique failure could be explained at least in part by the lower incidence of peritonitis described in patients with a higher RRF,<span class="elsevierStyleSup">28</span> or even by the contribution that these episodes make to the loss of RRF.<span class="elsevierStyleSup">23,24</span> In a similar manner, the fact that the use of icodextrin solutions and APD is associated with lower technique survival in the univariate analysis, but not the multivariate analysis, suggests a probable selection bias of both therapeutic options for those patients with less favourable conditions for the long-term application of PD.</p><p class="elsevierStylePara">Given the important negative impact that peritonitis has on patient survival and PD technique failure, it is important to point out that our study observed a progressive decrease in peritonitis rates throughout the study period.</p><p class="elsevierStylePara">Our analysis of data from a registry had several limitations. Although all of the data used were compiled prospectively, the retrospective nature of our analysis and the fact that we did not have information regarding the adequacy of treatment and peritoneal transport in 335 patients (22.1%) may lead to a possible selection bias. However, the large sample analysed, the long follow-up period, and the fact that the sample analysed using the multivariate analysis had no significant differences in the primary variables associated with survival show that the results obtained were absolutely representative. On the other hand, we should also point out that although the models for time-dependent variables that we used allowed for estimating long-term risk of technique failure or death, the resulting indexes are also influenced by events that occur in the short-term, which should be taken into account in the interpretation of the results.</p><p class="elsevierStylePara">In summary, our study showed that each episode of peritonitis is independently associated with an increase in mortality and technique failure, both on the short and long term. As such, our results suggest that the incidence of peritonitis should be a key risk factor in all survival analyses in the field of PD. Finally, the importance of minimising the incidence of peritonitis in order to improve patient survival must be prioritised. </p><p class="elsevierStylePara"><a href="grande/10987_108_25114_en_t1_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25114_en_t1_10987.jpg" alt="Characteristics of the 1515 incident patients on peritoneal dialysis and the sample of 1180 patients with information on peritoneal transport and adequacy included in the multivariate analysis"></img></a></p><p class="elsevierStylePara">Table 1. Characteristics of the 1515 incident patients on peritoneal dialysis and the sample of 1180 patients with information on peritoneal transport and adequacy included in the multivariate analysis</p><p class="elsevierStylePara"><a href="grande/10987_108_25115_en_t2_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25115_en_t2_10987.jpg" alt="First multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis"></img></a></p><p class="elsevierStylePara">Table 2. First multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis</p><p class="elsevierStylePara"><a href="grande/10987_108_25116_en_t3_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25116_en_t3_10987.jpg" alt="Second multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis"></img></a></p><p class="elsevierStylePara">Table 3. Second multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis</p><p class="elsevierStylePara"><a href="grande/10987_108_25117_en_t4_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25117_en_t4_10987.jpg" alt="Cox multivariate regression analysis of the predictive factors for technique failure in 1180 incident patients on PD"></img></a></p><p class="elsevierStylePara">Table 4. Cox multivariate regression analysis of the predictive factors for technique failure in 1180 incident patients on PD</p><p class="elsevierStylePara"><a href="grande/10987_108_25118_en_f1_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25118_en_f1_10987.jpg" alt="Estimate of patient survival after each episode of peritonitis based on the result of the effluent culture"></img></a></p><p class="elsevierStylePara">Figure 1. Estimate of patient survival after each episode of peritonitis based on the result of the effluent culture</p><p class="elsevierStylePara"><a href="grande/10987_108_25119_en_f2_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25119_en_f2_10987.jpg" alt="Estimate of patient survival after each episode of peritonitis based on the need for hospitalisation."></img></a></p><p class="elsevierStylePara">Figure 2. Estimate of patient survival after each episode of peritonitis based on the need for hospitalisation.</p><p class="elsevierStylePara"><a href="grande/10987_108_25120_en_f3_10987.jpg" class="elsevierStyleCrossRefs"><img src="10987_108_25120_en_f3_10987.jpg" alt="Estimate of technique survival after each episode of peritonitis based on the result of the effluent culture."></img></a></p><p class="elsevierStylePara">Figure 3. Estimate of technique survival after each episode of peritonitis based on the result of the effluent culture.</p>" "pdfFichero" => "P1-E528-S3198-A10987-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439461" "palabras" => array:1 [ 0 => "Supervivencia técnica" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439463" "palabras" => array:1 [ 0 => "Supervivencia de los pacientes" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439465" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec439467" "palabras" => array:1 [ 0 => "Diálisis peritoneal" ] ] ] "en" => array:4 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439462" "palabras" => array:1 [ 0 => "Technique survival" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439464" "palabras" => array:1 [ 0 => "Survival analysis" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439466" "palabras" => array:1 [ 0 => "Peritonitis" ] ] 3 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec439468" "palabras" => array:1 [ 0 => "Peritoneal dialysis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Antecedentes:</span> El impacto de cada episodio de peritonitis sobre la supervivencia a largo plazo de los pacientes en diálisis peritoneal (DP) está por definir. <span class="elsevierStyleBold">Objetivos:</span> Establecer el riesgo que supone para la supervivencia de los pacientes y de la técnica de DP cada episodio de peritonitis. <span class="elsevierStyleBold">Pacientes:</span> 1.515 pacientes incluidos en el registro Levante desde el uno de enero de 1993 hasta el 31 de diciembre de 2005. <span class="elsevierStyleBold">Métodos:</span> Análisis retrospectivo de un registro multicéntrico mediante regresión de Cox para variables cambiantes en el tiempo. <span class="elsevierStyleBold">Resultados:</span> Se analizaron 1609 episodios de peritonitis en 716 pacientes (47,2%). En el análisis univariante cada peritonitis tratada ambulatoriamente se asoció a un aumento de la mortalidad (hazard ratio [HR] 1,99; p <0,001) que fue mayor para los episodios que requirieron hospitalización (HR 3,62; p <0,001). La mortalidad aumentó con cada episodio sucesivo en el mismo paciente. El análisis multivariante confirmó la asociación de cada peritonitis con una menor supervivencia a largo plazo (HR 2,01; p <0,001), con un riesgo diferente para episodios por gram`positivos, gramnegativos y hongos (HR 1,73, 2,43 y 5,71, respectivamente; p <0,001). Otras variables asociadas con la mortalidad fueron la edad, una función renal residual escasa, la ausencia de acceso vascular y la comorbilidad. Las peritonitis fueron la única variable independiente asociada al fracaso de la técnica (HR 1,29; p <0,001), con un riesgo diferente para episodios por grampositivos, gramnegativos y hongos (HR 1,25, 1,30 y 3,03, respectivamente) (p <0,001). <span class="elsevierStyleBold">Conclusiones:</span> Los episodios de peritonitis influyen de forma negativa en la supervivencia a largo plazo de los pacientes en DP.</p>" ] "en" => array:1 [ "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Background:</span> The impact of each episode of peritonitis on long-term survival of peritoneal dialysis (PD) patients has yet to be defined. <span class="elsevierStyleBold">Objectives:</span> To determine the risk that each episode of peritonitis poses for patient survival and for the PD technique. <span class="elsevierStyleBold">Patients:</span> 1515 patients included in the Levante registry from 1 January 1993 to 31 December 2005. <span class="elsevierStyleBold">Methods:</span> Retrospective analysis of a multicentre registry using Cox regression for time-dependent variables. <span class="elsevierStyleBold">Results:</span> We analysed 1609 episodes of peritonitis in 716 patients (47.2%). In the univariate analysis, each case of peritonitis treated in the outpatient unit was associated with an increase in mortality (hazard ratio [HR] 1.99, <span class="elsevierStyleItalic">P</span><.001), which was greater for episodes that required hospitalisation (HR 3.62, <span class="elsevierStyleItalic">P</span><.001). Mortality increased with each successive episode in the same patient. Multivariate analysis confirmed the association of each case of peritonitis with lower long-term survival (HR 2.01, <span class="elsevierStyleItalic">P</span><.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; <span class="elsevierStyleItalic">P</span><.001). Other variables associated with mortality were age, low residual renal function, absence of vascular access and comorbidity. Peritonitis was the only independent variable associated with technique failure (HR 1.29, <span class="elsevierStyleItalic">P</span><.001), with a different risk for episodes due to gram-positive and gram-negative bacteria and fungi (HR 1.73, 2.43 and 5.71, respectively; <span class="elsevierStyleItalic">P</span><.001). <span class="elsevierStyleBold">Conclusions:</span> Episodes of peritonitis negatively influence long-term survival of patients on PD.</p>" ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25114_en_t1_10987.jpg" "Alto" => 384 "Ancho" => 600 "Tamanyo" => 208558 ] ] "descripcion" => array:1 [ "en" => "Characteristics of the 1515 incident patients on peritoneal dialysis and the sample of 1180 patients with information on peritoneal transport and adequacy included in the multivariate analysis" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25115_en_t2_10987.jpg" "Alto" => 460 "Ancho" => 600 "Tamanyo" => 215896 ] ] "descripcion" => array:1 [ "en" => "First multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Tab. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25116_en_t3_10987.jpg" "Alto" => 511 "Ancho" => 600 "Tamanyo" => 237894 ] ] "descripcion" => array:1 [ "en" => "Second multivariate model using Cox regression with the predictive factors for mortality in 1180 incident patients on peritoneal dialysis" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Tab. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25117_en_t4_10987.jpg" "Alto" => 282 "Ancho" => 600 "Tamanyo" => 146909 ] ] "descripcion" => array:1 [ "en" => "Cox multivariate regression analysis of the predictive factors for technique failure in 1180 incident patients on PD" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25118_en_f1_10987.jpg" "Alto" => 531 "Ancho" => 600 "Tamanyo" => 105018 ] ] "descripcion" => array:1 [ "en" => "Estimate of patient survival after each episode of peritonitis based on the result of the effluent culture" ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25119_en_f2_10987.jpg" "Alto" => 875 "Ancho" => 974 "Tamanyo" => 177156 ] ] "descripcion" => array:1 [ "en" => "Estimate of patient survival after each episode of peritonitis based on the need for hospitalisation." ] ] 6 => array:8 [ "identificador" => "fig7" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10987_108_25120_en_f3_10987.jpg" "Alto" => 536 "Ancho" => 600 "Tamanyo" => 133937 ] ] "descripcion" => array:1 [ "en" => "Estimate of technique survival after each episode of peritonitis based on the result of the effluent culture." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mactier R. Peritonitis is still the achilles´s heel of peritoneal dialysis. Perit Dial Int 2009;29(3):262-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19458293" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pérez Contreras J, Miguel A, Sánchez J, Rivera F, Olivares J. A prospective multicenterP comparison of peritonitis in peritoneal dialysis patients aged above and below 65 years. Levante PD Multicenter Group. Adv Perit Dial 2000;16:267-70." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gil Cunquero JM, Marrón B. La realidad y la percepción de las infecciones en diálisis. Nefrologia 2010;1(Supl Ext 1):56-62." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mujais S, Story K. Peritoneal dialysis in the US: evaluation of outcomes in contemporary cohorts. Kidney Int 2006;70(Suppl 103):S21-S26." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davenport A. Peritonitis remains the main clinical complication of peritoneal dialysis: the London, UK, peritonitis audit 2002-2003. Perit Dial Int 2009;29(3):297-302." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Mujais S. Microbiology and outcomes of peritonitis in North America. Kidney Int 2006;70(Suppl 103):S55-S62." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bunke CM, Brier ME, Golper TA. Outcomes of single organism peritonitis in peritoneal dialysis: gram negatives versus gram positives in the Network 9 Peritonitis Study. Kidney Int 1997;52(2):524-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9264012" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Pérez Fontan M, Rodríguez-Carmona A, García-Naveiro R, Rosales M, Villaverde P, Valdés F. Peritonitis-related mortality in patients undergoing chronic peritoneal dialysis. Perit Dial Int 2005;25(3):274-84. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15981776" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kim DK, Yoo TH, Ryu DR. Changes in causative organisms and their antimicrobial susceptibilities in CAPD peritonitis: a single center´s experience over one decade. Perit Dial Int 2004;24(5):424-32. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15490981" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kavanagh D, Prescott GJ, Mactier RA. eritoneal dialysis-associated peritonitis in Scotland (1999-2002). Nephrol Dial Transplant 2004;19(10):2584-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15304559" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Fried LF, Bernardini J, Johnston JR, Piraino B. Peritonitis influences mortality in peritoneal dialysis patients. J Am Soc Nephrol 1996;7(10):2176-82. <a href="http://www.ncbi.nlm.nih.gov/pubmed/8915978" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Sipahioglu MH, Aybal A, Unal A, Tokgoz B, Oymak O, Utas C. Patient and technique survival and factors affecting mortality on peritoneal dialysis in Turkey: 12 years' experience in a single center. Perit Dial Int 2008;28(3):238-45. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18474915" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Keane WF, Bailie GR, Boeschoten E. International Society for Peritoneal Dialysis. Adult peritoneal dialysis-related peritonitis treatment recommendations: 2000 update. Perit Dial Int 2000;20(4):396-411. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11007371" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Davies SJ, Phillips L, Naish PF, Russell G. Quantifying comorbidity in peritoneal dialysis patients and its relationship to other predictors of survival. Nephrol Dial Transplant 2002;17(6):1085-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12032201" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Van Walraven C, Davis D, Forster AJ, Wells GA. Time-dependent bias was common in survival analyses published in leading clinical journals. J Clin Epidemiol 2004;57(7):672-82. <a href="http://www.ncbi.nlm.nih.gov/pubmed/15358395" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "16.\u{A0}Szeto CC,\u{A0}Wong TY,\u{A0}Chow KM,\u{A0}Leung CB,\u{A0}Law MC,\u{A0}Li PK. Independent effects of renal and peritoneal clearances on the mortality of peritoneal dialysis patients. Perit Dial Int 2004;24:58-64.\u{A0} <a href="http://www.ncbi.nlm.nih.gov/pubmed/15104337" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Miguel A, García R, Torregrosa I. Morbimortalidad en diálisis peritoneal continua ambulatoria (DPCA): Siete años de experiencia. Nefrologia 1997;17(3):233-40." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Coronel F, Cigarrán S, Herrero JA. Morbimortalidad en pacientes diabéticos en diálisis peritoneal. Experiencia de 25 años en un solo centro. Nefrologia 2010;30(6):626-32. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21113211" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Stenvinkel P, Chung SH, Heimbürger O, Lindholm B. Malnutrition, inflammation and atherosclerosis in peritoneal dialysis patients. Perit Dial Int 2001;21(Suppl 3):S157-162." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Lam MF, Leung JC, Lo WK. Hyperleptinemia and chronic inflammation after peritonitis predicts poor nutritional status and mortality in patients on peritoneal dialysis. Nephrol Dial Transplant 2007;22(5):1445-50. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17277343" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Zalunardo NY, Rose CL, Ma IW, Altmann P. Higher serum C-reactive protein predicts short and long term outcomes in peritoneal dialysis-associated peritonitis. Kidney Int 2007;71(7):687-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17299522" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Zalunardo N. Predicting outcome in peritoneal dialysis-related peritonitis: revisiting old themes and slowly moving forward. Perit Dial Int 2008;28(4):335-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18556372" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Liao CT, Chen YM, Shiao CC. Rate of decline of residual renal function is associated with all-cause mortality and technique failure in patients on long term peritoneal dialysis. Nephrol Dial Transplant 2009;24(9):2909-14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/19225016" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Coronel F, Pérez Flores I. Factores relacionados con la pérdida de diuresis residual en diálisis peritoneal. Nefrologia 2008;28(Supl 6):39-44. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18957011" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Yang X, Fang W, Bargman JM, Oreopoulos DG. High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis. Perit Dial Int 2008;28(1):82-92. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18178952" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Brown EA, Davies SJ, Rutherford P. Survival of functionally anuric patients on automated peritoneal dialysis: the European APD Outcome Study. J Am Soc Nephrol 2003;14(11):2948-57. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14569106" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Han SH, Lee SC, Ahn SV. Reduced residual renal function is a risk of peritonitis in continuous ambulatory peritoneal dialysis patients. Nephrol Dial Transplant 2007;22(9):2653-8. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17517797" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000006/v0_201502091623/X201325141100017X/v0_201502091623/en/main.assets" "Apartado" => array:4 [ "identificador" => "35441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003100000006/v0_201502091623/X201325141100017X/v0_201502091623/en/P1-E528-S3198-A10987-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X201325141100017X?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 6 | 15 |
| 2024 October | 68 | 49 | 117 |
| 2024 September | 67 | 37 | 104 |
| 2024 August | 87 | 72 | 159 |
| 2024 July | 79 | 46 | 125 |
| 2024 June | 92 | 60 | 152 |
| 2024 May | 90 | 60 | 150 |
| 2024 April | 77 | 40 | 117 |
| 2024 March | 60 | 32 | 92 |
| 2024 February | 61 | 43 | 104 |
| 2024 January | 50 | 31 | 81 |
| 2023 December | 58 | 22 | 80 |
| 2023 November | 102 | 40 | 142 |
| 2023 October | 81 | 40 | 121 |
| 2023 September | 51 | 31 | 82 |
| 2023 August | 67 | 30 | 97 |
| 2023 July | 72 | 37 | 109 |
| 2023 June | 93 | 25 | 118 |
| 2023 May | 93 | 32 | 125 |
| 2023 April | 49 | 14 | 63 |
| 2023 March | 64 | 28 | 92 |
| 2023 February | 61 | 25 | 86 |
| 2023 January | 61 | 27 | 88 |
| 2022 December | 79 | 40 | 119 |
| 2022 November | 79 | 35 | 114 |
| 2022 October | 93 | 47 | 140 |
| 2022 September | 82 | 28 | 110 |
| 2022 August | 75 | 54 | 129 |
| 2022 July | 61 | 48 | 109 |
| 2022 June | 75 | 48 | 123 |
| 2022 May | 99 | 31 | 130 |
| 2022 April | 60 | 55 | 115 |
| 2022 March | 66 | 49 | 115 |
| 2022 February | 85 | 40 | 125 |
| 2022 January | 87 | 26 | 113 |
| 2021 December | 48 | 39 | 87 |
| 2021 November | 45 | 38 | 83 |
| 2021 October | 59 | 43 | 102 |
| 2021 September | 47 | 47 | 94 |
| 2021 August | 43 | 42 | 85 |
| 2021 July | 67 | 37 | 104 |
| 2021 June | 63 | 34 | 97 |
| 2021 May | 82 | 40 | 122 |
| 2021 April | 107 | 49 | 156 |
| 2021 March | 86 | 45 | 131 |
| 2021 February | 80 | 25 | 105 |
| 2021 January | 71 | 22 | 93 |
| 2020 December | 59 | 19 | 78 |
| 2020 November | 67 | 16 | 83 |
| 2020 October | 62 | 11 | 73 |
| 2020 September | 30 | 9 | 39 |
| 2020 August | 49 | 17 | 66 |
| 2020 July | 60 | 10 | 70 |
| 2020 June | 45 | 25 | 70 |
| 2020 May | 64 | 8 | 72 |
| 2020 April | 44 | 20 | 64 |
| 2020 March | 76 | 20 | 96 |
| 2020 February | 53 | 19 | 72 |
| 2020 January | 56 | 32 | 88 |
| 2019 December | 66 | 30 | 96 |
| 2019 November | 72 | 29 | 101 |
| 2019 October | 41 | 14 | 55 |
| 2019 September | 46 | 23 | 69 |
| 2019 August | 51 | 15 | 66 |
| 2019 July | 45 | 25 | 70 |
| 2019 June | 61 | 24 | 85 |
| 2019 May | 75 | 20 | 95 |
| 2019 April | 119 | 35 | 154 |
| 2019 March | 59 | 21 | 80 |
| 2019 February | 41 | 23 | 64 |
| 2019 January | 54 | 28 | 82 |
| 2018 December | 141 | 43 | 184 |
| 2018 November | 126 | 16 | 142 |
| 2018 October | 145 | 30 | 175 |
| 2018 September | 99 | 15 | 114 |
| 2018 August | 86 | 12 | 98 |
| 2018 July | 74 | 19 | 93 |
| 2018 June | 46 | 14 | 60 |
| 2018 May | 78 | 13 | 91 |
| 2018 April | 82 | 11 | 93 |
| 2018 March | 56 | 14 | 70 |
| 2018 February | 76 | 9 | 85 |
| 2018 January | 51 | 9 | 60 |
| 2017 December | 74 | 16 | 90 |
| 2017 November | 63 | 12 | 75 |
| 2017 October | 43 | 8 | 51 |
| 2017 September | 45 | 9 | 54 |
| 2017 August | 29 | 15 | 44 |
| 2017 July | 51 | 9 | 60 |
| 2017 June | 53 | 30 | 83 |
| 2017 May | 91 | 11 | 102 |
| 2017 April | 363 | 19 | 382 |
| 2017 March | 88 | 8 | 96 |
| 2017 February | 76 | 23 | 99 |
| 2017 January | 33 | 12 | 45 |
| 2016 December | 62 | 9 | 71 |
| 2016 November | 60 | 8 | 68 |
| 2016 October | 105 | 9 | 114 |
| 2016 September | 216 | 3 | 219 |
| 2016 August | 278 | 15 | 293 |
| 2016 July | 187 | 9 | 196 |
| 2016 June | 151 | 0 | 151 |
| 2016 May | 132 | 0 | 132 |
| 2016 April | 127 | 0 | 127 |
| 2016 March | 86 | 0 | 86 |
| 2016 February | 108 | 0 | 108 |
| 2016 January | 98 | 0 | 98 |
| 2015 December | 120 | 0 | 120 |
| 2015 November | 95 | 0 | 95 |
| 2015 October | 100 | 0 | 100 |
| 2015 September | 91 | 0 | 91 |
| 2015 August | 87 | 0 | 87 |
| 2015 July | 87 | 0 | 87 |
| 2015 June | 34 | 0 | 34 |
| 2015 May | 53 | 0 | 53 |
| 2015 April | 8 | 0 | 8 |
Show all
