Abstract
Management of Calciphylaxis in Peritoneal Dialysis Patients
Background: Calciphylaxis, also referred to as calcific uremic arteriolopathy, is a syndrome associated with end-stage renal disease and causes necrotic skin ulcers, often leading to a fatal outcome. Hyperbaric oxygen (HBO) therapy has been used to enhance wound healing, but its role in the treatment of calciphylaxis is unclear.
Methods: We undertook a retrospective study of patients on peritoneal dialysis (PD) with biopsy-proven calciphylaxis who were treated with HBO between March 2003 and February 2008.
Results: Six patients were treated with HBO. All patients were on continuous ambulatory PD (CAPD). None of the patients had uncontrolled hyperparathyroidism and none underwent parathyroidectomy. The patients each received 25–35 treatments of HBO2 at 2.5 atmospheres for 90 min per treatment. Four of these patients had complete resolution of extensive necrotic skin ulcers, with no adverse effects of HBO therapy. In the other 2 patients receiving HBO, the skin lesions did not resolve; 1 patient received amputation and the other died due to sepsis.
Conclusions: The data support a role for HBO in the treatment of CAPD patients with calciphylaxis.
Hypoalbuminemia Caused Severe Calciphylaxis in a Peritoneal Dialysis (PD) Patient by Calcium Overload
Objective: Calciphylaxis is a rare but higher mortality disorder characterized by microcalcification of small- and medium-sized blood vessels causing cutaneous and soft tissue necrosis. Disorders implicated in the pathogenesis of calciphylaxis include chronic renal failure, hypercalcemia, hyperphosphatemia, elevated calcium–phosphate product, and secondary hyperparathyroidism. We examined the relationship between corrected Ca and calciphylaxis through 1 case report who showed severe calciphylaxis.
Methods: We examined 14 patients (pts; mean age 56 years, duration of PD 7 years, Kt/V 2.16, nPCR 0.87 g/kg/day, protein excretion from urine and dialysate 5.97 g/day) undergoing CAPD. Serum Ca, phosphorus, iPTH, and albumin levels were examined for 5 consecutive years (2004-2008) by chart review. Case Report: 43-year-old male reached end-stage renal disease by malignant hypertension. He started PD in Dec. 2007. After start of PD, hypoalbuminemia persisted (serum albumin 1.9 g/dL by unknown reason) with stable dialysis dose (Kt/V 1.83). In Feb. 2008, he suffered from myelodysplastic syndrome requiring frequent blood transfusion. He started to notice painful skin lesion at a thigh when bacterial peritonitis happened in July 2008. After peritonitis was treated, skin lesion extended to ulceration with MRSA infection. He finally showed intestinal necrosis, resulting in intestinal resection. Although various efforts to treat severe septicemia, he died by multiple organ failure. Resected intestinal tissue also showed severe calciphylaxis. Higher corrected Ca by hypoalbuminemia (> 10 mg/dL), hyperphosphatemia (> 8 mg/dL), and hypoparathyroidism (iPTH 66 pg/mL) were the reason for calciphylaxis in this case.
Results: Retrospective Analysis: All 14 pts were almost anuric but well being state. While Ca, phosphorus, and iPTH remained stable, corrected Ca level increased over time (from 9 to 10 mg/dL, p = 0.008) mainly due to progressive hypoalbuminemia (from 3.6 to 3.4 g/dL, p = 0.0007) in these PD pts.
Conclusion: We concluded that the risk of calciphylaxis may increase in PD pts especially in those pts with hypoalbuminemia. 24-hour continuous Ca load from dialysate also contributes to this disorder.
Characteristics of Long-Term Survivors on Peritoneal Dialysis; a Single-Center Experience from India
Aims and Objectives: To study the characteristics of peritoneal dialysis (PD) patients who survive for more than 5 years and compare with patients who did not complete 5 years of PD.
Materials and Methods: A prospective observational study from January 2000 to December 2008. All PD patients under the care of a single nephrologist were studied. Data were collected for demographics, comorbidities, and biochemical and hematological parameters for all these patients. The PD-related parameters that were studied included transport status, urine output, residual renal function, and peritonitis rates. Patients who did not complete 6 months of PD, were withdrawn, or shifted to another modality of renal replacement therapy (hemodialysis, transplantation) were excluded in the final analyses. Data were analyzed using statistical software SPSS® version 12.
Results: A total of 93 patients were enrolled for PD during the study period, of which 74 were available for final analysis. 17 patients survived more than 5 years of PD (survivors) and 29 died (nonsurvivors). 28 patients are continuing PD but have not completed 5 years on PD. There was no significant difference in mean age and gender composition between survivors and nonsurvivors. Also the incidence of diabetes mellitus was not significantly different between the groups. Biochemically the survivors had a higher serum albumin levels (p = 0.002). The survivor group had lesser number of high transport status patients (p = 0.038), higher urine output (p = 0.036), higher eGFR (p = 0.002), and lesser peritonitis rates overall and in first year (p = 0.000).
Conclusions: The characteristics of long-term survivors on PD in India are mostly related to PD. Except for transport status, all other factors can be modified (peritonitis rates, maintenance of residual renal function, malnutrition, etc.). Hence proper PD management can improve long-term survival in India.
Fasting Serum Adiponectin Level Correlates Inversely with Body Mass Index in Peritoneal Dialysis Patients
Objective: Adiponectin is an adipocyte-derived hormone that has been found to be an inverse predictor of cardiovascular outcomes among peritoneal dialysis (PD) patients. Body mass index (BMI) was negatively correlated with that for adiponectin level in general population. The aim of this study was to investigate the relationships of fasting serum adiponectin levels and the anthropometric components among PD patients.
Methods: Fasting blood samples were obtained from 40 PD patients and 40 subjects at an outpatient department who were enrolled as control group. Anthropometric analysis included body weight, height, body mass index (BMI), body fat mass, triceps skinfold (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), mid-arm muscle area (MAMA), and mid-arm fat area (MAFA). Fasting adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit.
Results: PD patients had lower serum albumin (p < 0.001) and higher serum adiponectin (p < 0.001), (hs-CRP; p = 0.030), and Cre (p < 0.001) levels than the controls. Univariate linear regression analysis showed that body weight (r = –0.451; p = 0.003), waist circumference (r = –0.351; p = 0.026), BMI (r = –0.547; p < 0.001), body fat mass (r = –0.370; p = 0.019), white blood cell count (WBC; r = –0.584; p < 0.001), triglyceride (TG; r = –0.550; p < 0.001), fasting glucose (r = –0.349; p < 0.027), hs-CRP (r = –0.340; p = 0.032), TSF (r = –0.427; p = 0.006), MAC (r = –0.335; p = 0.034), and MAFA (r = –0.446; p < 0.001) were negatively correlated with fasting serum adiponectin levels, whereas HDL (r = 0.607; p < 0.001) was positively correlated with the fasting serum adiponectin levels in the PD patients. Multivariate forward stepwise linear regression analysis of the significant variables showed that the HDL (R2 change =0.368, p = 0.005) and BMI (R2 change =0.159, p = 0.001) were independent predictors of fasting serum adiponectin levels and explained 52.7% of the variance. Using BMI cutoff points (underweight, normal, overweight, and obesity) also noted inversely associated with serum adiponectin levels in PD patients (p = 0.001).
Conclusions: We observed that fasting adiponectin level was inversely associated with BMI in PD patients.
Icodextrin Increases Serum Adiponectin Level in Peritoneal Dialysis Patients during a Six-Month Follow-up Period
Objective: Adiponectin is a recently discovered adipocyte-derived plasma protein having anti-atherogenic properties. Low plasma adiponectin levels have a high risk of cardiovascular death in uremia patients (pts). The aim of this study was to elucidate the effects of icodextrin-based dialysis solution on serum adiponectin metabolism.
Methods: Fasting blood samples were obtained from 30 peritoneal dialysis (PD) pts in June 2008 and December 2008. 12 pts had been on one bag of icodextrin-based dialysis solution per day. Fasting adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit.
Results: There was no significant difference in baseline characteristics of PD pts using (ICO group) or not using (non-ICO group) icodextrin-based dialysis solution. After a 6-month follow-up period, there was no significant difference in clinical variables among 30 PD pts. Fasting glucose (p = 0.025), white blood cell count (WBC; p = 0.010), body weight (p = 0.014), waist circumference (p < 0.001), body fat mass (p = 0.001), and body mass index (BMI; p < 0.001) were higher in baseline ICO group compared with non-ICO group. After a 6-month follow-up period, WBC (p = 0.026), body weight (p = 0.048), waist circumference (p = 0.001), body fat mass (p = 0.010), and BMI (p = 0.002) were still higher in baseline ICO group compared with non-ICO group. The changes in serum adiponectin level in PD pts 6 months later were higher in the ICO group compared with non-ICO group (p = 0.035) and no significant difference in the changes of fasting glucose (p = 0.626), WBC (p = 0.631), body weight (p = 0.090), waist circumference (p = 0.100), body fat mass (p = 0.057), and BMI (p = 0.230) in the ICO group compared with non-ICO group.
Conclusions: We observed that fasting adiponectin level was increased in ICO group compared to the non-ICO group in a 6-month follow-up period in our PD pts.
Outcome of Peritoneal Dialysis in Military Personnel with End-Stage Renal Disease
Background: The quality of military personnel is one of the determinants of the militarys combat capabilities. Results of military personnel with end stage renal disease (ESRD) undergoing peritoneal dialysis (PD) are limited.
Methods: A retrospective study was performed in military personnel with ESRD undergoing PD followed up at our hospital, Tri-Service Gen. Hosp., the only one military medical center in Taiwan.
Results: The total number of military personnel with ESRD undergoing PD was 15 (male and female, 14 and 1, respectively), mean age at initiation of PD 36.3 years old (range 22–59 years). Among them, soldier is 20%, sergeants 26.7% and officers 53.3%. The main causes of ESRD were chronic glomerulonephritis (33%), chronic interstitial nephritis (13%), diabetic mellitus (6.7%), hypertension (6.7%), gouty arthritis (6.7%), systemic lupus erythematosus (6.7%), polycystic kidney disease (6.7%), and unknown cause (20%). The most frequent symptoms were nausea (40%), vomiting (33.3%), malaise (26.7%) and dyspnea (20%). The main reasons for withdrawal of PD were renal transplantation (53%), death (13%), and inadequate peritoneal clearance (6.7%). The main causes of death were cardiovascular events (1 patient) and infectious complications (1 patient). Five-year patient survival rate were 86.7%. Eight patients received renal transplant after 25.5 ± 10.1 months PD therapy. A low frequency of peritonitis one episode/159 patient-months compared with one episode/67 patient-months in controls was found. The hospitalization rate was also lower (3.4%/100 patient-months in military personnel, 7.1%/100 patient-months in controls). Biochemistries and life qualities got much improvement after initiation of PD. All the patients could fulfill military build-up and combat missions smoothly.
Conclusion: All the military ESRD personnel receiving timely and appropriate PD have good prognosis, low mortality, morbidity and hospitalization rate. It is suggested that PD is the choice of treatment in military personnel with ESRD.
Outcomes and Complications of Peritoneal Dialysis (PD) as a Dialysis Method for End-Stage Renal Disease Patients with Acute Intracranial Hemorrhage
Objective: PD can provide more stable hemodynamics for end-stage renal disease (ESRD) patients (pts) who have intracranial hemorrhage (ICH) and need dialysis therapy. The outcomes and prognostic factors of ESRD pts with ICH and receiving PD therapy have not been widely studied yet. The aims of this study were to compare the outcomes of ESRD pts who received PD with those on hemodialysis (HD) therapy after ICH, and to investigate the prognostic factors for ICH pts with ESRD and receiving PD therapy.
Methods: From 2005 to 2008, the ICH pts who had ESRD requiring dialysis were included in this study. We retrospectively reviewed their charts for the dialysis history, comorbidities, pre-ICH and post-ICH dialysis modes, and the serial brain images changes. Using ICH score, the severity of ICH was measured. We compared the outcomes (30-day mortality rate) between the pts receiving PD and HD after ICH. In the pts receiving PD as a dialysis method, the prognostic factors and complications were analyzed.
Results: 32 pts were included in this study; 19 were receiving HD and 13 were receiving PD. The pts who died within 30 days had higher ICH score (3.1 ± 0.3 vs 1.0 ± 0.2, p < 0.001). There was a similar 30-day mortality rate between PD and HD pts (30.8% vs 26.3%, p > 0.05). In the pts receiving PD, systolic blood pressure (BP) and Glasgow Coma Scale (GCS) at presentation were significantly associated with mortality. Seven pts (54%) had suffered from PD-related complications, including catheter malfunction (n = 5), peritonitis (n = 1), and dialysate leakage (n = 1) but PD-related complications were not associated with mortality.
Conclusion: The outcome of PD as a dialysis method for ESRD pts with acute ICH is similar to HD. In ICH pts on PD, systolic BP and GCS at presentation were associated with mortality. PD-related complications frequently occurred but they were not associated with mortality.
Can Blood Eosinophilia be an Ominous Sign of Eosinophilic Peritonitis? a Strange Experience
Dialysis patients are frequently exposed to chemical or artificial allergens. It is well known that intermittent blood eosinophilia is no rare phenomenon in patients undergoing peritoneal dialysis (PD). Apart from this, peritoneal eosinophilia is often accompanied by blood eosinophilia. There are some hypotheses that the PD system itself may be suspected as the cause. We experienced an interesting case of eosinophilic peritonitis (EP). The patient was a 79-year-old female. She had received hemodialysis over 4 years and was suffering from vascular access failure despite the fact that she had had AVG implants. She also had lasting eosinophilia (> 450 eosinophils/mL3) of unknown etiology for 6 months. She was recommended to switch to CAPD and accepted peritoneal access catheter surgery on 20 May 2008. We noticed that the eosinophilia became worse temporarily after installing an indwelling PD catheter. A cloudy effluent appeared 18 days after commencing CAPD. Analysis of the dialysate effluent did reveal EP on solid substrate. The maximum count of peripheral blood eosinophils reached 813/mL3 in the course of her peritonitis. After this, the cloudy effluent spontaneously cleared 3 weeks later. Her blood eosinophil count returned to within the normal range at the cessation of peritonitis. Serum IgE concentration did not exceed the upper limit. The present case not only suggests that peripheral blood eosinophils may be influenced by a PD catheter in situ but also showed that EP occurred in the worst part of her blood eosinophilia episode for many days, which is a noteworthy phenomenon. Such a case report does not examine a kind else. We believe that lasting blood eosinophilia may trigger EP, that is, the occurrence of oozing-out and migration of eosinophils into the peritoneal cavity. This may have been the underlying cause. Why the blood eosinophilia disappeared simultaneously with the cessation of EP in this case is still an unanswered question. This cannot be interpreted solely by the resolution of peritonitis. Although the etiology of her blood eosinophilia has not been identified, the fact is that her blood eosinophil count has remained within the normal range for a whole year since then.
Survival Analysis of Elderly Patients Undergoing Continuous Ambulatory Peritoneal Dialysis (CAPD)
Purpose: The increased prevalence and incidence of end-stage renal disease (ESRD) in the elderly is a worldwide phenomenon. New cases of ESRD are growing faster among people older than 70 years. CAPD offers many advantages to elderly patients (pts), including hemodynamic stability, steady-state chemistries, and no need for vascular access. However, few data are available in the literature documenting the use of CAPD in elderly pts. To evaluate the efficacy of CAPD in elderly pts, we retrospectively reviewed the survival rate, cause of death, and the predictors of death in pts starting CAPD at age >70 years.
Methods: We analyzed 47 pts who started CAPD as initial renal replacement therapy for ESRD in Kangnung Asan Hospital from January 2004 to December 2008. Demographic and clinical characteristics and laboratory findings at the starting CAPD were analyzed retrospectively. The survival rate was calculated by Kaplan-Meier method. To determine prognostic factors of death, we used Cox proportional hazard model.
Results: Median age of the pts was 75.26 years and sex ratio was 1.35:1 (F:M). The most common cause of ESRD was hypertension (53.2%); diabetes was the second (31.9%). During follow-up, 19 pts died and 3 were transferred to hemodialysis due to peritonitis. Mean follow-up period was 20.2 months and cardiovascular problems were major problem of death (47.4%); infection was the second (26.3%). Median survival time was 29.7 months. The survival rate was 90.3%, 66.7%, and 34.1% at 1, 2, and 3 years. The technical survival rate was 89.1% at 1 year and 30.2% at 3 years. The peritonitis rate was 0.56 episodes/patient-year. Multivariate analysis showed that age was associated with pt survival (p = 0.043). Gender, the presence of diabetes, and serum albumin, cholesterol, and C-reactive protein levels were not associated with pt survival.
Conclusion: Elderly ESRD pts with CAPD have a relatively good outcome. The most significant prognostic factor affecting pt survival was patient age. Measures to improve quality of life of elderly PD pts may favorably influence their survival.
Reasons Why Patients Choose Peritoneal Dialysis (PD)—a SingleCenter Experience
Background: Patients (pts) choose PD for various reasons. In recent years, there has been an increase in the age of the end-stage renal disease population and the number of comorbidities in these pts. Many of these pts are also functionally dependent in activities of daily living (ADL) and/or diabetic. It is possible these factors may have influenced the choice of PD as a therapy. Therefore, we conducted a survey to study the reasons for the choice of PD by pts starting on PD to evaluate the influence of ADL and diabetic status on this choice.
Methods: All pts who started CAPD at the National University Hosp. 1 January 2008 to 31 May 2009 were interviewed by phone using a structured questionnaire. The pts were asked to choose what they felt were the 3 most important reasons (from a list of 7 reasons) for them choosing PD. The options were (1) cost of therapy, (2) home-based therapy, (3) fear of needling/blood, (4) flexibility of therapy time and/or travel, (5) medically unfit for hemodialysis, (6) ability to travel, and (7) others—to be specified by pt. The pts were then asked to rank these 3 reasons 1–3 (1=most important, 3=least important). The demographics and diabetic and ADL status (dependent/independent) were also recorded.
Results: 70 pts were interviewed. 29/70 (41.4%) were male. Median age was 67 (range 26–86) years. Ethnic distribution was 58.6% Chinese, 34.3% Malays, and 7.1% Indians. 38 of 70 pts (54.3%) were ADL dependent. 80% (56/70) were diabetics. Home-based therapy was the most frequently cited reason (61/70 pts; 87%). Of these pts, 34/61 (55.8%) considered it the most important reason. 43 of 70 (61%) pts cited cost of therapy as a reason but only 3% ranked it as most important. Fear of needles and flexibility of therapy time were cited by 34/70 (48.5%) and 19/70 (12.8%) respectively. ADL status, diabetic status, and ethnicity were not significantly associated with the choice of reasons.
Conclusions: This study clearly shows that being a home-based therapy was the most frequent and most important reason for choosing PD as a therapy. ADL dependency and diabetes, although affecting the majority of pts, did not affect the reasons for choosing PD.
Continuous Ambulatory Peritoneal Dialysis (PD) in Hepatorenal Syndrome
Objectives: In older reports, the use of PD in patients (pts) with hepatorenal syndrome (HRS) is limited. In Vietnam, the first case of PD for HRS pt was April 2006. We examined the role of PD in HRS.
Methods and Patient: A 62-year-old male electrical technician had hepatitis B since 1984 and liver cirrhosis since 2000. His son had also hepatitis B. He was admitted March 2006 for oliguria. Liver disease: fatigue, legs edema, right hypochondria pain, important ascites, collateral circular, no hemorrhage digestion. Serum SGOT 41, SGPT 54 U/L, bilirubin 24, protein 45 g/L, albumin 22 g/L; prothrombin 35%. Ultrasound: cirrhosis image: port vein 1.3 cm. Kidney disease: oliguria: < 300 mL/24 hours; serum urea 43 mmo/L, creatinine 987 μmol/L, sodium 128 mmol/L, potassium 5.6 mmo/L. Urine: natriuria: 7 mmo/L; proteinuria 0.2 g/24 hours; without blood cell in urine. Ultrasound: no dilatation or stone. Anemia: Hb 67 g/L, Hct 27%; Plq 126 G/L.
Results: After 6 months of follow-up, urea and creatinine decreased in the 1st month and stable to 17 mmol/L and 380 μmol/L at the 6th month. But Kt/V was 1.32, showing inadequate dialysis. Ionogramme was normal. Peritoneal ultrafiltration was 700 mL/24 hr and 1500 mL urine. Edema disappeared without diuretic drugs. SGOT 19, SGPT 24, bilirubin 9.8; prothrombin 50% at 6th month meaning liver disease was stable. He did not have a peritonitis, fever, or hemorrhage digestion. Protein loss into peritoneal cavity was 1.7 g, 2.19 g, 2.15 g at 1st, 3rd, 6th month. This is not different from the other PD pts. Osteoarthritis of right femoral and knee joint appeared at 3rd month. Umbilical hernia happened at 1st month caused by hyper intraperitoneal pressure and operated by Vicryl 3.0; 5 months later he was re-operated on due to recurred hernia; perlon use to prevent it was proposed.
Conclusion: We conclude that, in pts with kidney failure suffering from liver disease, PD can be considered a good treatment option.
Icodextrin 7.5% Does Not Improve Fluid Status in Continuous Ambulatory Peritoneal Dialysis (CAPD): Results of a Randomized Controlled Trial (RCT)
Background: Subclinical overhydration is prevalent in PD, correlates with LVH, and contributes to cardiovascular risk. Studies suggest that icodextrin (ICO) may improve fluid status. This 3-month RCT compared efficacy of ICO 7.5% with dextrose (DEX) 2.5% (long dwell) for the same.
Methods: Total body water (TBW) was assessed using single frequency (50 kHz at 800 uA) whole body bioelectric impedance analysis at study entry, 1, and 3 months. Subjects fulfilling following criteria were randomized: CAPD duration ≥ 3 months, no peritonitis in previous 30 days, tolerance of 2.5% DEX for long dwell (8 hours), high/high-average transporter status, urine volume, 140/90 mmHg. Additionally, clinical assessment of fluid status, antihypertensive therapy, subjective assessment of clinical response, and adverse events were documented.
Results: 41 subjects were randomized to ICO [n = 20; 12 males, age 50.7 ± 13.3, DM = 8, CAPD duration 15 months (IQR 38)] or 2.5% DEX [n = 21,16 males, age 54.4 ± 12.1, DM = 7, CAPD duration=16 months (IQR 38)]. Ultrafiltration (UF; long dwell and total 24-hr respectively) improved from 169 ± 132 to 588 ± 187 mL and from 1183 ± 443 to 1418 ± 365 mL with ICO; no improvement with 2.5% DEX: from 311 ± 213 to 306 ± 158 mL and from 1279 ± 522 to 1379 ± 453 mL noted. No significant differences observed in TBW and extracellular water at study entry, 1, and 3 months: ICO 35.66 ± 7.64 L, 36.07 ± 3.85 L, 36.78 ± 8.85 L, p = 0.81; 2.5% DEX 34.74 ± 4.89 L, 35.63 ± 4.39 L, 35.01 ± 4.89 L, p = 0.60. Mean number of antihypertensive medications remained unchanged with ICO (3 ± 1.3 to 2.47 ± 1.5, p = 0.12). No improvement noted in either clinicians or patient's Subjective Global Assessment. 8 major adverse events in ICO arm (1 septicemia, 1 peritonitis, 3 digital gangrene, 1 branch retinal vein occlusion, 1 hypoglycemia, 1 rash) versus 3 in 2.5% DEX arm (3 peritonitis), p = 0.053.
Conclusions: Failure of ICO to improve fluid status despite better UF suggests importance of other factors (residual renal function, thirst, salt intake) on fluid status.
Catheter Insertion by SMAP Preserves Renal Function
Objective: SMAP [stepwise initiation of peritoneal dialysis (PD) using Moncrief and Popovich technique] is used about 25% of the time for the initiation of PD in Japan, and the advantages of this method are now recognized. There are several case reports of a slower decline of renal function after catheter insertion by SMAP. In this study, we investigated whether catheter insertion by SAMP preserves renal function.
Methods: 18 patients (8 males; 10 females) who had catheter insertion by SMAP were followed up for at least 3 months. We compared the values of serum Cr and BUN, the changes in serum Cr and BUN at 1 month before catheter insertion, at catheter insertion and 1, 2, and 3 months after catheter insertion. All statistical analyses were performed by ANONA.
Results: Significantly slowing of the increase in serum Cr and BUN were observed after catheter insertion.
Conclusion: In this study, catheter insertion by SMAP influences in slowing of the decline in renal function. We believe that management of renal failure, especially diet, was improved after catheter insertion. Further investigation is needed.
A Retrospective Analysis of Short-Term and Long-Term Clinical Benefits of Using Icodextrin in Peritoneal Dialysis (PD) Patients in a Local Hospital
Background: Icodextrin (ICO) is a starch-derived, high molecular weight glucose polymer that provides sustains ultrafiltration (UF). The aim of this study was to evaluate the clinical benefits and patient (pt) and technique survivals after using ICO in Chinese pts.
Method: All pts using ICO due to persistent fluid overload 1 January 2002 to 30 June 2008 were identified. The primary outcome was change in UF after commencement of ICO; secondary outcomes were changes in biochemical parameters and hospitalization rate. Pt and technique survivals were analyzed, with subgroup analysis on pt's diabetic (DM) and PET status and history of peritonitis.
Results: 133 pts using ICO were identified: mean age 57.98 ± 12.33, 63 (47%) males, 78 pts (59%) had DM, mean dialysis duration 2.14 ± 2.88 years. 55 pts (41%) had high PET; 55 pts (41%) had high-average (HA) PET. There was significant increase in UF volume at 1 month (p = 0.0000); the effect was sustained at 1 year. Systolic and diastolic blood pressures were decreased with significant reduction in antihypertensive medications at 1 year (p = 0.0096). There were no significant changes in glycemic or lipid profile. Hospitalization rates due to fluid overload and PD-related problems were significantly reduced (p = 0.0003 and p = 0.0023 respectively). Median pt survival was 6.7 years; technique survival (death not censored) was 7.9 years. Pts with DM or high/HA PET status had significantly worse pt survival (p = 0.0007 and p = 0.0001 respectively) and technique survival (p = 0.0029 and p = 0.0266 respectively). There was no difference in pt survival in pts with/without history of peritonitis within 6 months prior using ICO (p = 0.5584). Compared with pts using dextrose-based dialysate, there was no significant difference in pt survival (p = 0.5187) or technique survival (p = 0.1159) although significantly more pts had DM (p = 0.0030) and high/HA PET status (p = 0.0003) in ICO group.
Conclusion: This study suggests that ICO produces significantly increased UF volume, especially in pts with DM and high/HA PET status. The hospitalization rates due to fluid overload and PD-related problems were significantly reduced. Early change to ICO in high-risk pts might improve pt survival and technique survival.
Fasting Glucose Level Predicts Two-Year Survival Rate for Nondiabetic Patients Undergoing Peritoneal Dialysis (PD)
Objectives: Whether fasting glucose level (FGL) is associated with increased mortality of nondiabetic (non-D) PD patients (pts) had not been fully elucidated. In the current study, we evaluated the FGL and prognosis of non-D PD pts over a 2-year period and also investigated the association of FGL with other clinical parameters.
Methods: We enrolled 473 uremic pts who newly initiated PD at a single hospital in Taiwan. We recorded FGL measured 3 months after stabilization on PD and also reviewed clinical factors might affect the prognosis or FGL. Cox regression was used to analysis the association of FGL with all-cause mortality. Linear regression was used to evaluate the relationship between FGL and other clinical parameters.
Results: There were 244 non-D pts with normal FGL (<100 mg/dL), 110 non-D pts with elevated FGL (100–200 mg/dL), and 119 diabetic pts. Non-D pts with elevated FGL had more clinical features similar to metabolic syndromes than those with normal FGL. The 2-year survival rate was 95.3% for non-D pts with normal FGL, 86.3% for non-D pts with elevated FGL, and 70.7% for diabetic pts. Kaplan-Meier survival analysis indicated non-D PD pts with elevated FGL had significantly worse 2-year survival than non-D PD pts with normal FGL (log rank test, p = 0.001) and significantly better 2-year survival than diabetic PD pts (log rank test, p = 0.023). Cox regression multivariate analysis demonstrated FGL is an independent predictor for survival in non-D PD pts (relative risk: 1.027; 95% confidence interval: 1.012–1.043; p = 0.001). Multiple linear regression analysis indicated that FGL was independently and positively correlated with pulse pressure (p = 0.001) in these pts.
Conclusions: Among uremic pts who do not have diabetes and were stabilized for 3 months on PD, elevation of FGL was associated with higher pulse pressure and independently predicted worse 2-year survival rate.
The Automated Peritoneal Dialysis Experience in Brunei Darussalam
Background: Continuous ambulatory peritoneal dialysis (CAPD) has been in used in Brunei since 1999. We started using automated peritoneal dialysis (APD) on a trial basis from May 2008 because of the recent availability of government resources to fund this dialysis modality. Here, we share our 1-year experience with APD in our unique population, which is mainly derived from a pool of patients with high socio-economic status, but poor disease perception.
Methods: In this prospective clinical trial, patients previously on CAPD were enrolled into the APD program and followed for 1 year. Data on serum hemoglobin, phosphate, albumen, creatinine, peritonitis rates, erythropoietin usage, and urea clearance for these patients were collected at 0, 6, and 12 months following the initiation of APD. A quality-of-life survey was also conducted at 12 months.
Results: A total of 8 patients participated in the trial. The mean and median age of these patients were 42 years and 45.5 ± 12.73 years respectively. Serum hemoglobin (n = 7) and albumin (n = 6) improved to 12.26 ± 1.82 and 33.63 ± 6.89 from 10.56 ± 1.95 and 27.88 ± 7.71 respectively (p < 0.05 in both instances). There was no statistically significant improvement in serum phosphate, serum creatinine, or urea clearance. Erythropoietin usage declined in 6 patients, with 3 patients coming off erythropoietin completely. No peritonitis incidents occurred. All 8 patients reported improved quality of life, with better sleep, appetite, and general well being.
Conclusions: All our patients did extremely well on APD, with a subjective improvement in quality of life as well as improvements in quantitative markers such as serum hemoglobin and albumin. There was a marked reduction in erythropoietin usage not previously observed in other studies in the literature. Based on these findings, we will actively encourage and promote use of APD as opposed to CAPD in our population because of its potential cost savings and life-improving implications. More studies are needed to examine the relationship between hemoglobin and use of APD.
Outcome of Assisted Compared to Self-Care Peritoneal Dialysis
Background: The inability of a patient to perform self-care peritoneal dialysis (PD) is a common reason for ineligibility to enter the PD program and this is one factor that leads to PD underutilization. Expanding eligibility by offering assisted PD (aPD) has allowed incapable patient to overcome this problem. In Malaysia, aPD is mainly performed by family members.
Objective: To investigate the outcome of assisted versus self-care PD patients in our center.
Methods: Prospective data were collected on 335 consecutive PD patients from 1 January 2006 to 31 December 2008. All patients more than 18 years old and on PD for at least 3 months were included into the study. There were 305 continuous ambulatory peritoneal dialysis (CAPD) and 30 automated peritoneal dialysis (APD) patients. Baseline demographics, comorbidity (Stoke comorbidity score), treatment information, and detailed information on peritonitis were documented. Reasons for requiring assistance and type of assistance were also identified.
Results: There were 70 (20.9%) aPD and 265 (79.1%) self-care PD patients. The aPD patients were older (median age 61 vs 53.6 years, p<0.05, in aPD vs self-care respectively). Majority of the aPD patients (81.4%) were diabetic compared to 51.3% in the self-care group. aPD patients had a higher comorbidity score compared to self-care patients (45.8% vs 24.7% with comorbidity score of ≥ 2, respectively). In the aPD patients, 56.5% were being assisted by their spouse and 37%, 4.8%, and 3.2% were assisted by their children, domestic helper, and parents, respectively. Reasons for requiring assistance were poor dexterity (67.7%), blindness (29%), and cerebrovascular disease (3.2%). 125 episodes of peritonitis in 71 self-care patients vs 27 episodes in 19 aPD patients were documented. Pseudomonas and E. coli were the predominant organisms cultured in the aPD group. There were no differences in peritonitis episodes between aPD and self-care patients (1/38.4 vs 1/37.7 infections/patient-month respectively). aPD patients had poorer technique survival (p < 0.02) after 16 months with a median technique survival of 57.9 vs 102.5 months in aPD vs self-care respectively. There was no difference between the 2 groups in patient survival within the first 2 years but it starts to diverge with poorer survival after 26 months in the aPD group (p = 0.29) with median 59.7 vs 108.3 months in aPD vs self-care respectively.
Conclusions: Older age and comorbidities is associated with aPD. There was no difference in peritonitis episodes between aPD and self-care. Technique survival was poor in the aPD group after 1 year but no difference in patient survival in both groups within the first 2 years on PD.
Peritoneal–Retroperitoneal–Scrotal Leakage Complication of Peritoneal Dialysis
Background: When patients are undergoing peritoneal dialysis (PD), it is possible for dialysate to leak out of the peritoneal cavity due to the increased intra-abdominal pressure. Extraperitoneal leaks usually occur in the exit site, the pleura, or the patent processus vaginalis. However, it is uncommon for dialysate to leak into the retroperitoneum and extend to the scrotum. This is a report on a case of retroperitoneal and scrotal fluid accumulation resulting from peritoneal–retroperitoneal communication in a patient on PD.
Case: The patient was a 33-year-old male diagnosed with chronic renal failure due to IgA nephropathy. He had received continuous ambulatory PD for 5 years and changed to automated PD for the last 2 years. From 4 days before admission, ultrafiltration volume was reduced and the right side of the abdominal wall was edematous. One day before admission, the right scrotum was enlarged. CT scans were performed. Initial unenhanced CT scan showed scanty fluid density and strands in the right retroperitoneal space. To evaluate details of the lesion, CT peritoneography was performed 1 hour and 4 hours after the intraperitoneal infusion of a dialysis solution (2-L bag) containing 100 mL of nonionic contrast. CT peritoneography demonstrated retroperitoneal leakage into the right posterior pararenal space, right anterior pararenal space, right anterior extraperitoneal space of abdominal wall, and right paravesical space. Extension to the right scrotum going along the spermatic cord was also noted. After the peritoneal–retroperitoneal leak was confirmed by the CT peritoneography, PD was halted and the patient was transferred to hemodialysis to allow the retroperitoneal defect to heal. One month after transfer to hemodialysis, PD was resumed. There were no signs of extraperitoneal leakage in the latest follow-up examination (5 months after the onset).
Prognostic Factors Associated with Patient and Technique Survival in Patients on Long-Term Peritoneal Dialysis — a Single-Center Experience
Objectives: This retrospective observational study was performed to investigate the prognostic factors of patient and technique survival in patients on long-term peritoneal dialysis (PD) in a single center in North Taiwan.
Methods: All incident PD patients from a medical center in North Taiwan who began PD between January 1996 and December 2005 were enrolled and followed until December 2008. Patient-specific data such as demographics, dialysis prescription and adequacy, peritoneal transport status, residual renal function, and relevant laboratory parameters were recorded at the time of enrollment. Kaplan-Meier survival analysis was used to determine patient survival and actuarial PD technique survival. Multivariate Cox regression model was used to identify independent prognostic factors associated with PD outcome.
Results: 370 patients were included in this study. During an average follow-up period of 44.7 months, 88 (23.8%) deaths and 104 (28.1%) non-death technique failures occurred. 1-, 2-, and 5-year patient survival rates were 93.8%, 86.4%, and 73.3%. Actuarial PD technique survival rates were 88.2%, 75.4%, and 49.4%, respectively. Multivariate Cox regression model revealed that old age, low baseline residual renal function (RRF), diabetes, and having coronary artery disease (CAD) were independent prognostic factors associated with worse patient survival and actuarial PD technique survival.
Conclusions: Our study demonstrated that nearly half of patients can maintain PD as their modality of renal replacement therapy after 5 years on dialysis. The results also indicated that age, diabetes, CAD, and baseline RRF are major factors associated with all-cause mortality and technique failure in patients on long-term PD.
A Reference Equation for Adjusting Appropriate Dialysate Volume for Adult Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objectives: Fluid overload-induced cardiovascular diseases are the leading cause of mortality in dialysis patients (pts). Few studies mention how to adjust dwell volume objectively in adult CAPD pts to obtain more ultrafiltration (UF). We proposed a reference equation composed of parameters from the peritoneal equilibrium test (PET) and basic demographic data for modifying daily dialysate dwell volume.
Method: Use body mass index (BMI), waist circumference (WC), and other parameters from the PET to determine a reference formula for predicting appropriate infill volume. 88 PD pts in 1 center with laboratory data during PET evaluation were enrolled. Instilled dialysate was 2.57% glucose PD fluid, either 1500 mL or 2000 mL in volume. We applied statistical multivariate techniques of discrimination analysis and logistic regression to verify the most feasible and optimal formula to determine infill volumes for pts.
Results: We determined a reference formula for calculating daily dialysate dwell volume Z [Z=(0.523 × WC) + (0.852 × BMI)] derived from rotating axes to obtain an accurate prediction rate of 80.68% using the multivariate approach. Using 2 variables of BMI and WC, with cutoff points of 21.5 and 68.5 cm respectively, for deciding dwell volume with 1500 mL or 2000 mL by physician and pts themselves can be simple and unbiased during the early phase of treatment. Only 2 choices of dwell volume (1500 or 2000 mL) would not be sufficient for clinical practice in individual pts. After performing clustering analysis, we further suggested that the cutoff threshold values of 57, 65, and 74 of raw scores calculated from reference equation could provide 4 types of dwell volume for individual pts with 1500 mL, 1700 mL, 1850 mL, and 2000 mL, respectively.
Conclusion: The reference formula composed objective parameters for adjusting appropriate dwell volume of PD pts with maximal UF and reduced subjective abdominal discomfort.
Against All Odds—a Successful Peritoneal Dialysis (PD) Program in a Developing Country
Objective: PD is a relatively new therapy in the developing countries of Asia. PD faces bias in the form of lack of awareness among physicians and patients (pts) alike, unhelpful government policies, lack of structured reimbursement plans for physicians, and misinformation from vested interests. We started our journey in 2003 and have evolved into one of the largest PD units in India. Passion for PD and attention to detail, with the pt central to all endeavors, has made us achieve most of our goals. We decided to evaluate the performance of our Unit over the 6 years since its inception.
Methods: We retrospectively analyzed our data from May 2003 to May 2009. Demographic characteristics, duration on PD, technique failure rates, peritonitis rates, and technique and pt survival were recorded. Data were analyzed using SPSS® version 12 software for statistical analysis.
Results: 252 (69% male, 31% female) pts were initiated on PD to date. Mean age was 52±12.4 years. Cumulative follow-up was 4296 pt-months. Diabetic nephropathy was the most common cause of ESRD (39%). We had a low technique failure rate of 22.2%. 94 (37.3%) pts remain active on PD. The longest surviving pt has completed 5.8 years on PD. Technique survival at 6 years was 77.1%. Pt survival at 6 years was 37.3%. The most common cause of mortality was coronary artery disease (38%). We managed to achieve consistently low peritonitis rates through diligent efforts at pt education and training. We had peritonitis rates of 1 episode/36.5 pt-months.
Conclusion: With consistent and focused team efforts, we have managed to achieve good results in our pts on PD. Technique failure and peritonitis rates are consistently low and comparable to reported literature. We believe that, despite the odds, it is possible to run a quality PD program in the developing world and hope our experience will inspire similar efforts across the developing world.
Rural–Urban Divide in Continuous Ambulatory Peritoneal Dialysis (CAPD)—Myth or Reality? a Comparison of Outcomes on CAPD in Rural and Urban Populations
Objectives: It is believed that patients (pts) of urban (U) settings, with more access to healthcare facilities than their rural (R) counterparts, would perform better on CAPD and have generally better outcomes. This would all the more be true in a developing country, where the R populations have limited access to education and healthcare. There is a paucity of data regarding R-based pts and their outcomes on CAPD. We aimed to study the outcomes on CAPD in our pts from U and R backgrounds, and compare their performance on CAPD.
Methods: We retrospectively analyzed our pts’ dialysis records from May 2003 to May 2009. Data on pts’ demographic characteristics, diagnosis, initiation on CAPD, technique and pt survival, and peritonitis rates were recorded. Data were analyzed using SPSS® v12 software.
Results: 115 pts were in R group and 131 in U group. Mean follow-up was 4296 pt-months. Mean age was 51.49 ± 12.8 in R group versus 52.32 ± 12.59 in U group. Diabetic nephropathy was the most common cause of ESRD in either group (39.3% vs 36.4%). Technique failure rates were 25.3% in R group and 20.6% in U group (difference not statistically significant, p > 0.05). Pt survival at 5 years was 42.6% in R group vs 29.8% in U group (p < 0.01, difference statistically significant). Peritonitis rates were 1 episode/40.3 pt-mths in R group vs 1 epi/34.8 pt-mths in U group (p > 0.05). 18% of pts were lost to follow-up in R group vs 6.1% in U group (p < 0.05, statistically significant).
Conclusions: Results were comparable on most parameters studied between U and R pts. Significantly higher number of pts in R group were lost to follow-up, the reasons for which were not apparent and could probably reflect difficulty in access to the parent unit. Overall, our R CAPD pts performed well with low technique failure rates and low peritonitis rates. We also noted a statistically significant difference in survival rates between the groups, with R pts having better survival rates, confirmed by a Kaplan-Meier analysis. This is contrary to what would normally be expected.
Good Outcomes for Elderly Patients on CAPD—a Single-Center Experience
Objectives: The number of elderly patients (pts) requiring renal replacement therapy is on the rise. Several factors unique to this population are thought to be likely adverse factors for successful CAPD. As a result, elderly pts may end up being denied the benefits of CAPD. We analyzed our data to determine the performance of our elderly pts (age>55 years) on CAPD.
Methods: Our CAPD records for May 2003 through May 2009 were retrospectively analyzed. Pts’ demographic data, technique and patient survival rates, technique failure rates, and peritonitis rates were recorded. This was compared with the data for our pts younger than 55 years. We used SPSS® v12 software for data analysis.
Results: 116 elderly pts underwent CAPD initiation on our center over the study period. 89 (76.7%) were male; mean age was 62.14 ± 6.08 years. Diabetic nephropathy was the most common cause of ESRD (40.6%). We had a technique survival rate of 77.1% in these pts, which was similar to our non-elderly pts (78.6%). 26 pts had to shift to hemodialysis due to peritonitis/ultrafiltration failure/compliance issues/lack of support/stroke (technique failure rate 22.4%). Technique failure rate was 26% in the non-elderly group. 15 pts in the elderly group were lost to follow-up and 2 received a deceased donor renal transplant. Peritonitis rate was 1 episode/30.4 pt-months, which was not significantly different from our baseline peritonitis rate of 1 episode/36.5 pt-months. Pt survival at 5 years was 28.8% compared to 37.3% in the non-elderly pts.
Conclusion: Elderly pts seem to perform well on CAPD. We did not see any significant increase in technique failure rates or mortality in these pts. Excellent technique survival rates were obtained. Peritonitis rates were low and not significantly higher than our baseline rates. We believe that elderly pts should not be denied the benefits of CAPD.
The Elderly Patient on Continuous Ambulatory Peritoneal Dialysis (CAPD)—Is Diabetic Status Really an Indicator of Poor Outcome
Objectives: Elderly patients on CAPD pose unique challenges to the nephrologist. Some studies have indicated that diabetes mellitus is an added risk factor for mortality in this patient population on CAPD. Available data are not conclusive in this regard. We decided to compare the outcomes of our elderly diabetic patients to that of our nondiabetic elderly patients.
Methods: We retrospectively analyzed patient records from May 2003 to May 2009. Elderly patients were defined as those aged 55 years and above. We divided these patients into the diabetic and nondiabetic groups and compared data regarding demographic characteristics, outcomes, patient and technique survival, and peritonitis rates. We used SPSS® v12 software for our statistical analyses.
Results: The elderly diabetic group had 55 patients (85% male, 15% female); mean age 62.56 ± 6.37. The elderly nondiabetic group had 61 patients (69% male, 31% female); mean age 61.75 ± 5.83. Peritonitis rate was 1 episode/34.3 patient-months for the diabetic group versus 1 episode/38.7 patient-months for the nondiabetic group (p > 0.05). 5year technique survival rates were 78.2% in the diabetic group and 77.1% in the nondiabetic group (p>0.05). 5-year patient survival for diabetics was 29.1% vs 36.1% in the nondiabetic group. Technique failure rates were similar in both groups (21.8% in diabetics and 23% in nondiabetics).
Conclusions: Elderly diabetics seemed to perform well on CAPD in this large patient series. Diabetic status did not seem to confer any added risk of mortality, technique failure, or peritonitis. 5-year survival was comparable in both groups. We believe that diabetic elderly patients do as well as their nondiabetic counterparts on CAPD.
A Comparison of Long-Term Continuous Ambulatory Peritoneal Dialysis (CAPD) Outcomes in Patients with Diabetic Nephropathy versus Chronic Interstitial Nephritis
Objectives: Diabetic nephropathy and chronic interstitial nephritis (CIN) are leading causes of ESRD. Diabetes mellitus, with its multisystem insults, is thought to portend a worse outcome than other causes of ESRD. In this large series of CAPD patients with long-term data, we aimed to determine if there was any difference in outcomes between patients of ESRD secondary to diabetes mellitus or CIN.
Methods: We retrospectively analyzed data of our CAPD center, over a period from May 2003 to May 2009. We compared patients with diabetic nephropathy and patients with CIN with respect to demographic characteristics, technique and patient survival, technique failure, and peritonitis rates.
Results: The diabetic group had 98 patients (79% male, 21% female) and there were 95 patients (66% male, 34% female) in CIN group. Mean age was 55.54 ± 10.31 for diabetics and 48.82 ± 13.39 in CIN group. Peritonitis rates were comparable in either group (1/34.4 patient-months for diabetics and 1/30.8 patient-months for CIN, p > 0.05). Technique failure rates were 25.5% for diabetics and 19% for CIN (p > 0.05). There was a trend for lower technique failure rates in CIN group. Technique survival rates were 74.5% for diabetics and 81% for CIN (p > 0.05). 5-year survival rates were 49.3% for diabetics and 54.5% for CIN (p > 0.05).
Results: Outcomes for patients with CIN and diabetic nephropathy were found to be similar in this large patient cohort. There was a trend towards lower technique failure in CIN group but it did not reach statistical significance. Technique survival, peritonitis rates, and 5-year patient survival (as estimated by Kaplan-Meier analysis) were similar in both groups.
Short-Term Outcome of Continuous Ambulatory Peritoneal Dialysis (PD) under PD-First Policy in Patients with Severe Cardiac Disease
Our hospital has been a leading cardiology hospital in Japan; over 10,000 patients undergo cardiac catheterization and percutaneous coronary intervention every year. 120 ESRD patients were started dialysis therapy last year and many of them also suffered severe ischemic heart disease and valvular heart disease. Recently, residual renal function in dialysis patients was regarded as a significant predictor of patient prognosis. PD therapy has the advantage that it preserves residual renal function better than hemodialysis. After we proposed PD-first policy in April 2008, our PD program has rapidly expanded. 87 patients (67%) were selected PD as a first-line therapy and underwent catheter insertion. This PD selection rate is much greater than overall PD selection rate in Japan. All but 2 catheters were inserted by nephrologist under local anesthesia. 70 patients (M:F 60:27, average age 66 years) started PD therapy. SMAP method was adopted 32 patients. Two patients developed catheter trouble by catheter captured by omentum, which was resolved by minor surgery under local anesthesia. Six patients died in this year and their causes of death were old age, severe peritonitis, sepsis after peripheral vascular bypass graft implantation, and sudden death. All the remaining patients preserve their residual renal function very well and there is no case of ultrafiltration failure. We did not observe any proven case of death from cardiovascular disease.
Conclusion: PD first policy drastically changed our program for dialysis therapy. Dialysis patients with severe cardiac disease are apparently suitable for PD than hemodialysis at least 1 year follow-up.
Chronic Inflammatory Demyelinating Polyneuropathy Should be Considered in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients Developing Disabling Motor-Sensory Neuropathy
Although Toepfer et al. reported a causal relationship between CAPD and chronic inflammatory demyelinating polyneuropathy (CIPD) in 1998 (PDI 1998; 18:172–6), there are no reports that CIDP is more common in PD patients (pts) compared to general populations. CIDP is rare and has similar manifestations to those of uremic neuropathy and diabetic nephropathy, which are commonly observed in PD pts. It is easily misdiagnosed as these in PD pts or diabetic PD pts. We report a case of a PD pt who developed the inability to walk and recovered with immunosuppressive treatment. A 36-year-old Japanese woman slowly developed progressive trouble with walking and balance and fell over easily 6 weeks after starting CAPD treatment 3 years ago. At first, uremic neuropathy was diagnosed and an additional 1.5-L bag exchange was prescribed. She was unable to rise from a sitting position or bed without help 4 weeks later. Upon examination, it was noted that she had decreased motor strength, fatigue, tingling or tight sensation in both lower limbs, and was hyporeflexic. No upper motor neuron signs were presented. Cranial and spinal CT scans showed no abnormal findings. Weekly Kt/V urea was 1.86 and laboratory data as follows: serum UN 46.1 mg/dL, creatinine 9.45 mg/dL, albumin 3.9 g/dL, sodium 141 mEq/L, potassium 3.9 mEq/L, creatine kinase 68 U/L (nl: 59–220), LDH 177 U/L; and hemoglobin 11.6 g/dL. Electrophysiological findings showed decreased sensory and motor response in distal lower limbs, slowing nerve conduction velocities. CIDP was most suspected and treatment with intravenous immune globulin of 17.5 given for 5 successive days and repeated 2 months later. After that she could walk with a walker. The 3rd treatment significantly improved the neuropathy. She can walk alone with a stick 12 months later. In pts on CAPD developing disabling motor-sensory neuropathies, CIDP should be considered as should the use of potentially beneficial immunosuppressive treatment.
Itami N., Nakashima T., Takada J., Hamada H. Kidney Centre, Nikko Memorial Hospital, Muroran, Japan.
Exacerbation of Hypertriglyceridemia in the Diabetic and Uremic Patient with Chronic Hepatitis C during Interferon Therapy
A 66-year-old male diabetic uremic patient had received CAPD for 1 year. Positive anti-HCV was noted 7 years ago. Interferon-alfa had been prescribed for hepatitis C and elevated liver function tests since 3 months ago. Exacerbation of hypertriglyceridemia more than 1500 mg/dL even on gemfibrozil (1200 mg/day) was found after interferon treatment for 2 months. After stopping interferon treatment, the triglyceride level decreased to previous level. Another 65-year-old male nondiabetic uremic patient with CAPD had received complete interferon-alfa treatment for HCV but his triglyceride level had no apparent change.
Conclusion: In patients with chronic hepatitis C, interferon-alpha therapy is associated with an increase in triglyceride level. The development of severe hypertriglyceridemia in some cases makes mandatory a close monitoring of triglycerides during interferon-alfa therapy, particularly among diabetic patients with increased triglycerides at baseline and receiving CAPD for renal replacement therapy.
Liu Y.C., Lin C.H. Yuan's General Hospital, Kaohsiung, Taiwan.
Assisted Peritoneal Dialysis (PD)—Experience in a Taipei Renal Department
Objectives: PD at home is an appropriate method of management for frail elderly end-stage renal disease (ESRD) patients (pts). However, barriers to PD therapy are also more common in elderly persons. In Taiwan, families are allowed to hire foreign caregivers if the sick family members need 24-hour care. Assistance provided by foreign caregivers may help to overcome barriers to self-care and expand the use of PD. We described our experience with assisted PD provided by foreign caregivers in a Taipei renal department.
Methods: This was a retrospective study of 368 ESRD pts who started dialysis in our department between September 2006 and December 2008. All new dialysis pts were educated about the different dialysis modalities with an experienced PD nurse. If a pt chose PD but homecare assistance was required, a program of assisted PD was started, including rigorous training in PD technique for the family members or the foreign caregivers and providing them with supervision and support.
Results: Of these 368 pts, 214 were treated with hemodialysis (HD) and 154 with PD during the study period. Among the PD pts, 77 were treated with assisted PD (28/77 by foreign caregivers and 49/77 by family members) and 77 with self-care PD. Although PD pts assisted by foreign caregivers were significantly older (76 ± 9 years) than those assisted by family members (65 ± 13 years; p < 0.01) and self-care PD pts (55 ± 11 years; p < 0.01), they had a significantly lower peritonitis rate (1/91.8 pt-months) compared to those with family member assistance (1/45.1 pt-months; p < 0.01) and those with self-care (1/63.2 pt-months; p < 0.01). Pt survival was 82.1% at 6 months for PD pts with foreign caregiver assistance. Only 1 pt transferred to HD due to hydrothorax at 6 months.
Conclusions: Assisted PD by foreign caregivers had very low peritonitis rate and high technique success. The availability of homecare assistance from foreign caregivers may increase the proportion of elderly pts who are eligible for PD.
Lu J.H., Juling Huang J. Renal Department, Buddhist Tzu Chi Taipei General Hospital, Taiwan.
A Comparison of Dialysis-Related Peritoneal Membrane (PM) Changes between Continuous Ambulatory Peritoneal Dialysis (CAPD) and Automated PD (APD) Patients
Background: APD becomes the first option for PD, overtaking CAPD in many countries. The comparative incidence of PM changes in patients (pts) treated with CAPD and APD is controversial. We therefore compared the incidence of PM changes in pts undergoing CAPD only using the “flush before fill” technique and APD in 4 different centers during a half-year period.
Methods: Using a multivariate approach, clinical course, peritoneal mass, and changes of peritoneal function in 36 CAPD and 25 APD pts with 287 pt-months were compared. Peritoneal function was assessed using modified peritoneal equilibrium test (PET) with 4.25% dextrose solution. CA125 and overnight exfoliated mesothelial cells (MC) in the spent effluents representing MC mass were simultaneously evaluated at the beginning and after 6 months of follow-up. Intention-to-treat and as-treated models were used to test the difference between groups.
Results: CA125 and exfoliative MC showed significant changes in CAPD group compared with APD group (3.9 ± 17.8% vs –46.1 ± 38.1%, p = 0.005; 44.3 ± 252.7% vs 302.0 ± 981.0%, p = 0.02) while D/P creatinine, D/D0 glucose, sodium dip, and dialysate protein loss showed no significant changes between the 2 groups. After adjustment the baseline demographics, the changes in MC mass, including number of exfoliated cells and CA125, were not different between pts undergoing CAPD or APD. Results were similar after stratification; the changes of MC mass were not different for pts who had the highest propensity of being initially treated with APD. There were no significant differences in adequacy, serum albumin, nutritional status, and residual renal function at 6 months between groups. Three pts died (2 in APD, 1 in CAPD) and another 3 pts had peritonitis during the follow-up period. None died related to peritoneal treatment (1 from cancer, 2 from septicemia). After 6-month treatment, there were no changes in blood pressure, fasting blood sugar, and lipid profiles in both groups.
Conclusion: Change in PM in pts undergoing PD does not depend on the dialysis type and prescription. These findings warrant further evaluation to confirm whether long-term difference exists.
Continuous Ambulatory Peritoneal Dialysis (CAPD) in the Elderly—a Single-Center Experience in South India
In India the prevalence of end-stage renal disease (ESRD) is 785/million; the population is >1000 million. There is a huge burden of diabetes in India, resulting in increased prevalence of chronic kidney disease in elderly people. Renal replacement therapy, either as hemodialysis or CAPD, is available only to a few ESRD patients (pts; 3.5%), much less to elderly ESRD pts. Viability and outcome of CAPD in older pts is not well known. This is a retrospective analysis of ESRD pts >55 years old initiated on CAPD in a secondary-care urban center. We present here the socioeconomic and clinical perspectives of CAPD in pts >55 years old. Of 48 pts initiated on CAPD in this center, 35 (73%) were above the age of 55 years; male:female 24 (69%):11 (31%); 22 (63%) were 55–65 years old and 13 37% were >65 years old. In 89% (31 pts) diabetic nephropathy is the underlying cause; HT in 6%, GN in 3%, and others 3%. The comorbidities are cardiac (54%), HT (72%), vision related (62%), PVD with minor amputations (20%), depression (20%). PET was done in 28 pts: high-average in 75%, high in 7%, low-average in 19%. Incidence of peritonitis was 37% (13 pts) and resulted in catheter removal in 3 pts. Dialysis was done by spouse in 62%, children in 8.5%, daughter-in-law and others in 17%. Self-dialysis was done by 4 pts (11%). Median survival was 24 months. Follow-up was over a period of 5 years: 25 pts (71%) died, average survival 21.67 mths; 64% died due to cardiac causes, 20% due to infection. Two patients had transplantation. Funding is by self and family in 54%, employer in 34%, and insurance in 12%. CAPD in elderly is viable but could be applied to <1% of our ESRD pts due mainly to funding constraints, which has to be managed by self and family. Infections, comorbidities, CAD, blindness, disability due to neuropathy, dependence on family and others, and depression make this procedure not preferred by the elderly ESRD pts.
Declining Ability to Retain Knowledge/Skill in Doing Peritoneal Dialysis (PD) in Thai Continuous Ambulatory PD (CAPD) Patients
Background: In 2002, the Thai government launched a healthcare scheme in Thailand called “universal coverage (UC)” healthcare. Thai government officially announced a “PD-first” policy for end-stage renal disease people in Oct 2007 and set it effective since 1 Jan 2008. At present over 3000 new PD patients (pts) have received the treatment. Data from 23 CAPD hospitals called “Phase I CAPD hospitals,” which had experience on PD before the policy, were studied.
Objectives: To demonstrate that after first training, pts’ and caregivers’ knowledge/skill in doing PD will decline and need retraining from PD centers.
Methods: Cross-sectional descriptive study. The data taken from all pts were categorized into 2 parts: general assessment of pt's knowledge by paper tests and home visit scorecard. The scores from paper test and home visit scorecard will be summarized; score < 80% is the cutoff point to determine that the result is too low to accept.
Results: 152 pts participated in the study: 118 from Banphaeo (Prommitr) Hosp, 17 from Banphaeo Hosp (Public org), 17 from Chaoprayayomraj Hosp. The score from paper tests divided into 2 parts: (1) nutrition: average score 8.7 ± 1.017 from 10 and 9.4% of pts scored < 80%; (2) exchange procedure and exit-site care: average score 9 ± 1.011 from 10 and 10.9% of pts scored < 80%. On home visit scorecard, average score of housing environment is 227 ± 22.44 from 250 and 7.9% of pts scored < 80%. Average score of exchange procedure is 232.7 ± 25.85 from 250 and 5.9% of pts scored < 80%. Average duration after 1st training is 249 (range 15–1221) days. Comparing groups of pts in which duration after 1st training is < 365 days and > 365 days, demonstrate that the average score of both parts of paper tests is 9.1/8.7 in 1st group of patients and 8.8/8.5 in 2nd group. Regarding home visit scorecard, average score of both parts in the 1st group is 229.2/234.9, and 221.6/224.3 in the 2nd group.
Conclusions: After 1st training, pts and caregivers knowledge/skill in doing PD will decline in all areas. PD centers need to set process to detect this event. Early detection can prevent many PD complications.
Preliminary Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients under the PD-First Policy in Thailand
Background: In 2008 PD-first policy, that provides CAPD treatment free of charge for end-stage renal disease patients under universal health coverage by health security project, launched in Thailand. Number of patients has surprisingly increased very fast. Up to now there have been 23 experienced hospitals and 62 new to CAPD hospitals joining the policy.
Objectives: To analyze outcome of CAPD treatment under the policy.
Method: We reviewed 19-month data from the 23 hospitals that recruited the patients during a pilot period (Oct–Dec 2007) and Jan 2008–April 2009.
Results: Number of the enrolled patients was 1320 cases (approx. 40% of the whole policy). Female-to-male ratio was 1:1.3, average age 48.3 years. Diabetes mellitus was an underlying disease in 29% cases. Catheter was implanted by surgical technique in 86.2%; the rest done by bedside technique. Average cost of the implantation was about $133; 90% of cases needed the implantation only once. Cost of 2000-mL double-bag PD solution was US$2.71, regular regime was 4 cycles/day. Peritonitis developed only once in 40 months, average cost to treat the condition was about US$202. Rate of exit-site infection was 0.11 episode/case/year. Dropout rate was 17%: death in 9.5%, receiving kidney transplant in 1%, shift to hemodialysis 5.1%, others 0.4%.
Conclusion: The preliminary outcomes are good. The success of Thai PD-first policy is a combination of strong policy, systematic manipulation, and good attitude to the treatment. Commitment on the part of nephrologists and nursing staff to patient education is also a key of success.
Tuberculosis: A Bane for Patients on Chronic Peritoneal Dialysis (PD) in India
Objectives: Patients (pts) receiving dialysis therapy are known to be at increased risk of tuberculosis (TB). The aim of this study was to determine prevalence, course, and outcome of TB in pts undergoing continuous ambulatory PD (CAPD) at a tertiary-care hospital in India.
Methods: Retrospective study of pts initiated on chronic PD since November 2002 at Indira Gandhi Medical College Hospital, Shimla, and who survived and/or had more than 6 months’ follow-up on this treatment with last follow-up until 30 June 2009.
Results: Of 63 patients, 45 were included in the analysis. Mean age of the pts was 60.2 ± 9.6 years. 23 (51%) pts were male. Causes of ESRD were diabetic nephropathy 19 (42.2%), CIN 13 (28.9.9%), hypertension 10 (22.2%), CGN 2 (4.4%) pt each, and ADPKD 1 (2.2%) pt. 25 (55.6%) pts were alive and 20 (44.4%) pts had died. Total follow-up was 1098 pt-months; mean follow-up 24.4 ± 17.7 (6-80) months. Over this period, 9 (20%) pts were diagnosed to have TB. Extrapulmonary TB was more frequent (66.6%) than pulmonary TB (33.3%). Two pts had lymph nodal TB, 3 pts had pulmonary TB, and 4 pts TB peritonitis. Mean time between initiation of dialysis to TB diagnosis was 14 ± 14.9 months. Microbiological and/or histological diagnosis was achieved in 7 pts and in 2 pts diagnosis of TB was made on clinical grounds. In 1 pt the culture report was received postmortem, and in all the other 8 pts anti-TB therapy was started. In pts with TB peritonitis, catheter removal and switch to hemodialysis were needed in 2 pts due to persistent peritonitis with cloudy bags; 1 pt remained on CAPD. Four pts who completed the treatment recovered and the other 5 pts died.
Conclusions: There is a high incidence (20%) of TB among pts on chronic PD in India which results in high morbidity and mortality. Extrapulmonary TB is more frequent and a high index of suspicion for early diagnosis and treatment is required.
Effects of Educational Information about Renal Replacement Therapy for End-Stage Renal Disease Patients and Family on Modality Selection
Background: In 2002 Thai government launched a healthcare scheme in Thailand started to included 48 million people who are not government related and not private employee. This scheme is called “universal coverage (UC)” healthcare. Thai government has officially announced a “PD-first” policy for end-stage renal disease (ESRD) people in October 2007 and set it effective since 1 January 2008. At present over 3000 new PD patients have received the treatment. Data from 23 CAPD hospitals in Thailand, of which have had experience on PD before the policy, were studied.
Objectives: To describe a model of educational information for ESRD patients and family in renal replacement therapy (RRT) and to evaluate modality selection and knowledge of the patients before and after using the educational media.
Methods: A descriptive and comparative study was conducted on a process using educational media to educate ESRD patients and family about RRT including choices, cost, policy, and complications. The media include (1) face-to-face communication, (2) flip charts, (3) brochures, (4) self-questionnaires, and (5) flow charts. We evaluated modality selection and knowledge of these patients before and after they used the education process.
Results: 80 ESRD patients and family were included. These patients had gain knowledge about RRT. The patients who chose CAPD as their RRT increased from 50.67% to 59.60%. We also found that incidence of hemodialysis before PD running was decreased.
Conclusions: We demonstrated a model of educational information for ESRD patients and family about RRT. Providing adequate information can influence patient's modality selection.
Ten-Year Retrospective Study of Peritoneal Dialysis in Dalian
Objective: To improve peritoneal dialysis (PD) care status and meet the clinical requirements of PD, we analyzed CAPD data in our hospital for the last 10 years.
Methods: Clinical data of 76 PD patients who underwent CAPD for more than 3 month in our hospital from 1999 to 2008, including age, etiology, course, causes of hospitalization, causes of death were collected.
Results: (1) Age 47.1 ± 18.3 years; the average age of diabetes patients is older than that of non-diabetes patients: 65.6 ± 9.3 versus 50.6 ± 15.1. (2) Etiology: diabetes 29/76, chronic glomerulonephritis 19/76, hypertension 10/76, chronic tubulointerstitial nephritis 7/76. (3) Time of ending PD: 20.3 ± 11.9 months. (4) Causes of hospitalization: peritonitis 42.3%, respiratory inflammation 23.5%, peritonitis 15%, heart failure 10%. (5) Causes of death: peritonitis 21.3%, heart failure 16%, asthenia universalis 20.9%, other inflammation 44.1%. (6) Education and management of CAPD patients: there was no special doctor and nurse for PD patients and education was very limited. The patients lacked self-management knowledge, instruction from medical staff, and follow-up system. Acute care model was used in PD care.
Conclusion: (1) Diabetes is the leading etiology of CAPD. (2) Problems in managing PD patients such as lack of follow-up system, lack of adequate education for staffs, lack of patient self-management education brought on inadequacy of treatment and high risk of complications.
Clinical Analysis of Peritoneal Dialysis (PD) of Twenty Years
Objective: To analyze 213 patients (pts) with continuous ambulatory PD (CAPD) during 20 years.
Methods: Cross-section investigation on status of 213 pts treated with CAPD for > 3 months from December 1988 to December 2008. Pts were divided according to: (1) dialysis time: group A (Dec 1998–Dec 1988); group B (Dec 2008–Dec 1998); (2) age at start of dialysis: ≥65 years group and <65 years group; (3) etiology: diabetes (D) group and non-diabetes (n-D) group.
Results: (1) Compared with group A, pts in group B were older (61.8 ± 16.0 vs 49.4 ± 17.7 years, p < 0.001), had lower serum creatinine level (701.2 ± 325.8 vs 914.0 ± 315.6 μmol/L, p < 0.001), and higher hemoglobin level (84.7 ± 18.8 vs 63.4 ± 17.9 g/L, p < 0.001). (2) The proportion of D in group B was higher than group A [59/125 (47.2%) vs 17/88 (19.3%),p < 0.005] but the proportion of chronic nephritis was notably reduced [19/125 (15.2%) vs 49/88 (55.7%),p < 0.01]. Compared with < 65 years group, the proportions of D and hypertensive benign glomerular sclerosis in ≥ 65 years group were notably increased [44/83 (53.0%) vs 32/130 (24.6%),p < 0.005; 19/83 (22.9%) vs 6/130 (4.6%),p < 0.005] but the proportion of chronic nephritis was notably reduced [5/83 (6.0%) vs 63/130 (48.4%),p < 0.005]. (3) Mortality of group B was less than group A [53/125 (42.4%) vs 50/88 (56.8%),p < 0.05]. Mortality of D group was higher than n-D group [44/75 (58.7%) vs 59/138 (42.8%),p < 0.05]. (4) Mortality of peritonitis in group B was less than group A [13/50 (26.0%) vs 5/53(9.4%),p < 0.05]. Principal causes of death in group A were ordered as follows: peritonitis > cerebral hemorrhage > heart failure/whole body failure; while in group B it was heart failure/whole body failure > myocardial infarction > infection. Mortality of cardiovascular diseases (CVD) in the ≥ 65 years group was notably higher than the < 65 years group [7/46 (15.2%) vs 2/57 (3.5%),p < 0.05]. Mortality of CVD in the D group was notably higher than the n-D group [7/44 (15.9%) vs 2/59 (3.4%),p < 0.05].
Conclusion: The key point of our work should focus on age and D, while CVD and infection still are the major factors affecting the prognosis of pts with CAPD.
Fourteen Cases of Hemorrhagic Fever with Renal Syndrome Treated with Peritoneal Dialysis
Objective: To explore the effect of peritoneal dialysis on hemorrhagic fever with renal syndrome (HFRS) patients with acute renal failure (ARF).
Methods: Peritoneal dialysis was carried out on 14 cases of HFRS patients with ARF. Insert Tenckhoff single-cuff straight catheter to rectouterine pouch or rectovesical pouch. Continuous ambulatory peritoneal dialysis (CAPD) was done with 2000 mL Baxter standard peritoneal dialysis fluid 5 times a day and changed to twice a day when the serum creatinine became normal. The treatment of CAPD was stopped if the patient's renal function became stable for 2 days. Meanwhile, the patients were also treated with antiviral and symptomatic treatments.
Results: Renal function and urine volume became normal after dialysis. The digestive symptoms were improved obviously. No incision infection, leakage, peritonitis, or other complications occurred. Cure rate is 100%.
Conclusion: Peritoneal dialysis is effective for HFRS patients with ARF.
Clinical Observation of Peritoneal Dialysis on Severe Acute Pancreatitis
Objective: To explore the treatment effects and feasibility of peritoneal dialysis on severe acute pancreatitis.
Methods: 26 severe acute pancreatitis patients were enrolled into this study and divided into 2 groups: treatment group and control group. The treatment group was treated with peritoneal dialysis within 48 hours together with routine comprehensive treatment (n = 12). Peritoneal dialysis was carried out 3–4 times a day with 2000 mL dialysate. The control group just accepted routine comprehensive treatment (n = 14). Then we observed the curative rate and fatality rate.
Results: After catheter insertion, 200–1000 mL brown necrotic transudate was discharged immediately. The treatment group's symptoms relieved much earlier than the control groups. The curative rate of the treatment group is 100%; the fatality rate is 0%. The curative rate of the control group is 64.2%; the fatality rate is 35.8%.
Conclusion: Peritoneal dialysis could increase curative rate, decrease fatality rate, and improve prognosis of severe acute pancreatitis. It is worth for popularization and application.
Restrictions on Water and Salt in Patients with Intractable Hypertension Treated with Peritoneal Dialysis
Objective: To observe the patients undergoing peritoneal dialysis and with resistant hypertension, antihypertensive treatment in addition to formal restrictions on water and salt intake on hypertension.
Methods: Select 20 patients undergoing peritoneal dialysis and with resistant hypertension, once blood pressure ≥160/90 mmHg, except for heart failure, cerebrovascular accident, acute pulmonary edema, and other complications. Make sure that they treated with peritoneal dialysis regularly, and the ultrafiltration volume >600 mSv L/day and take felodipine 10 mg/day, metoprolol 25 mg 3 times/day, losartan potassium 100 mg/day, furosemide 100 mg/day. One group of 10 patients did not limit the water and salt, the other group of 10 patients had sodium intake of 2–3 g/day, water intake <400 mL/day. We monitored all the patients’ blood pressure 4 times a day.
Results: The group which had restriction of water and salt intake had a better blood pressure control and more stable blood pressure throughout a day. The group which did not have restriction of water and salt intake had a poor blood pressure control.
Conclusion: Patients undergoing peritoneal dialysis and with resistant hypertension should be strictly limited to water and salt intake, in addition to reasonable use of antihypertensive drugs in order to achieve the antihypertensive effect.
Clinical Analysis of Continuous Ambulatory Peritoneal Dialysis-Related Peritonitis
Objective: Peritonitis is a common complication in continuous ambulatory peritoneal dialysis (CAPD). This study is to analyze CAPD-related peritonitis in our department.
Methods: 36 CAPD patients with peritonitis between February 2005 and March 2009 in our department were enrolled into this study. Their data were analyzed retrospectively to conclude the causes of peritonitis, bacterial type, and the time of occurrence and the impact of nursing measures on them.
Results: The most common organisms in early postoperative (<1 months) dialysis-related peritonitis was coccal bacteria, and gram-negative bacillus was popular in late postoperative (>1 months) dialysis-related peritonitis. There are 8 patients of 36 occurred peritonitis and coccal bacteria accounted for 60%. After retraining, refractory peritonitis never occurred again.
Conclusion: Early postoperative dialysis-related peritonitis may be associated with imperfect practices in early stage and bowel disorder may predispose the late postoperative dialysis-related peritonitis. The CAPD patients need more training in the early stage and retraining, accommodation of the intestinal tract in the late stage.
Hypokalemia is an Independent Risk Factor of Poor Clinical Outcome in Patients with Continuous Ambulatory Peritoneal Dialysis (CAPD)
Objective: To investigate the prevalence and the clinical outcome of hypokalemia in patients (pts) with CAPD.
Methods: 283 CAPD pts who had hypokalemia in the 6-month period without edema or active infection were retrospectively recruited in this study. Hypokalemia was defined as a serum potassium level <3.5 mmol/L. Correlation between hypokalemia and several clinical parameters, including the nutrition status, residual renal function (RRF), dialysis adequacy, and diuretics was analyzed. The effect of hypokalemia on clinical outcome was assessed.
Results: Pts’ average age was 49.30 ± 0.90 years. There were 133 females and 66 (22.3%) diabetics. Mean dialysis duration was 12.83 ± 12.02 months. The K level was 3.68 ± 0.65 mmol/L and 110 pts (37.2%) had hypokalemia. The incidence of hypokalemia was significantly higher in female pts with old age and diabetic nephropathy (p < 0.05). Hypokalemia was also associated with lower levels of body mass index (BMI), skeletal muscle volume, intracellular fluid; serum albumin, prealbumin, BUN, phosphorus, and iPTH; and more serious comorbid conditions (p < 0.05). Hypokalemic pts had higher levels of hs-CRP, fasting blood glucose, total Kt/V, total clearance of creatinine, and peritoneal Kt/V. There was no correlation between the serum K level, peritoneal membrane transport status, daily PD exchange volume, daily ultrafiltration volume, and RRF. The prevalence of peritonitis, cardiovascular events, and hospitalization was not significantly different in pts with or without hypokalemia. However, compared with normokalemic pts, hypokalemic pts had a higher mortality (p < 0.05).
Conclusions: Hypokalemia is a common complication in CAPD pts. Old age, female, and diabetic nephropathy were significantly associated with hypokalemia. CAPD pts with hypokalemia had a poor nutritional status and higher mortality.
The Clinical Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients in a Rapidly Developing PD Center in South China
Objective: To explore the clinical outcomes of incident patients (pts) undergoing CAPD in a rapidly developing PD center in South China.
Methods: A single center, prospective, observational cohort study. Between 2006 and 2007, all incident CAPD pts in our center were recruited for the study. Pts were followed up until death or 31 December 2008, at which point data were censored. Data collected consisted of demographic details, socioeconomic status, information about primary renal disease, and anthropometric data at dialysis initiation. Pt survival, technique survival, and time to first peritonitis (P) episode were examined using standard survival methodology.
Results: 335 incident CAPD pts (mean age 48.6 ± 16.4, range 14 to 82 years; male/female 188/147) were studied over total observation period of 6472.7 pt-months (539.4 pt-years). Mean follow-up period was 19.3 ± 8.3 (3.6–35.9) mths. Diabetic subjects comprised 23.3% (n = 78) of all pts. By the end of the study, 50 (14.9%) pts had died, 52 (15.5%) had received a renal transplant, 14 (4.2%) were transferred to hemodialysis, 2 (0.6%) pts discontinued PD treatment by personal decision, and 2 (0.6%) pts were lost to follow-up. At the end of 1, 2, and 3 years, actuarial pt survival rates were 92%, 82%, and 78%. Cumulative technique survival (death censored) at the end of 1, 2, and 3 years was 97%, 95%, and 93%. In multivariate Cox proportional hazards analysis, higher age, diabetes, and lower hemoglobin at initiation were independent predictors of overall mortality. During the observation period, most pts (81.5%, n = 273) had no P. A total 104 episodes of P were observed in 62 pts. Overall P rate was 62.2 pt-months 0.193/pt-years). By the end of the observation period, estimated median P-free time was 34.3 months. Among the pathogens for the 1st episode of P, 35.5% (n = 22) were gram-positive organism, 32.3% (n = 22) were gram-negative organism, 6.5% (n = 4) were fungi, 22.6% (n = 14) were culture negative, and 3.2% (n = 2) had no culture.
Conclusion: Our study revealed excellent short-term pt and technique survival and low rate of P episodes in our rapidly developing center. This reflects the collective efforts of our nephrologists, nurses, and pts.
Effect of Bailing Capsule and Niaoduqing Granule on Vascular Endothelial Growth Factor (VEGF) in Peritoneal Dialysis Patients: A Clinical Randomized Control Study
Objective: Bailing capsule and Niaoduqing granule are widely applied in clinic. This study is to investigate the effect on serum and dialysate VEGF in continuous ambulatory PD (CAPD) patients (pts) after Bailing capsule or Niaoduqing granule treatment by a clinical randomized control trial.
Methods: 60 pts treated with CAPD for at least 1 month in our department were enrolled into this study and divided into 3 groups: group A: taking Bailing capsule, 5# t.i.d.; group B: taking Niaoduqing granule, 5 g t.i.d.; and group C (control group): taking neither Bailing capsule nor Niaoduqing granule. Serum and dialysate VEGF were measured before and after the 1-month treatment by a sensitive enzyme-linked immunosorbent assay (ELISA). Serum C-reactive protein (CRP), white blood cell (WBC), hemoglobin, blood urea nitrogen (BUN), creatinine (Cr), and albumin (Alb) concentrations were also tested.
Results: Both serum and dialysate VEGF levels were significantly lower after Bailing capsule or Niaoduqing granule treatment (p < 0.01); there was no significant difference in group C (p > 0.05). Both serum and dialysate VEGF levels in groups A and B after medication were significantly lower compared with group C (p < 0.05). There was no significant difference between groups A and B in serum and dialysate VEGF after medication (p > 0.05). Serum CRP level was lower in groups A and B after medication compared to pretreatment (p < 0.05). There was no significant difference in WBC, Hb, BUN, Cr, and Alb concentration before and after treatment in all groups. There was no correlation between serum VEGF level and WBC, Hb, BUN, Cr, Alb concentration, and dialysate VEGF level (p > 0.05).
Conclusions: Both Bailing capsule and Niaoduqing granule can decrease serum and dialysate VEGF levels in CAPD pts. After Bailing capsule or Niaoduqing granule treatment for 1 month, CRP level is decreased, thus the microinflammatory situation of the pts may improve.
A Correlative Analysis of Dropout in Forty Patients with Peritoneal Dialysis (PD) in Hospital
Objective: To analyze cause of death and conversion to hemodialysis (HD) and correlative factors in PD patients (pts) in West China Hospital.
Methods: Between May 2003 and October 2008, 40 pts on PD in our unit were enrolled into the study, 14 pts died and 26 converted to HD. Complete case history of the pts was reviewed, evaluating cause of death and conversion to HD, infection-associated pathogenic micro-organism, nutritional status, etc.
Results: The main causes of death were pulmonary infection complicating cardiac-cerebral diseases (29%, 4/14), pulmonary infection complicating gastrointestinal bleeding (29%, 4/14); the secondary causes were pulmonary infection complicating septicemia (14%, 2/14) and pulmonary infection complicating PD-related peritonitis (P; 14%, 2/14). The proportion of bacteria and fungus was matched approximately (10/9) in pulmonary infection pathogenic micro-organism. The dead PD pts who suffered from malnutrition (Hb <90 g/L, albumin <30 g/L) accounted for 64.3% (9/14); those who suffered from Ca and phosphate metabolism disturbance accounted for 71.4% (10/14). The first cause of conversion HD therapy was PD-related P (50%, 13/26), the secondary cause was dialysis fluid inadequate drainage (42%, 11/26). The positive rate of pathogenic micro-organism in P was 46% (6/13); fungi were the major pathogenic micro-organism, which occupied 31% (4/13), accounting for 66.7% (4/6) in positive pathogenic micro-organism. Pts with P had Hb <90 g/L accounted for 84.6% (11/13); those with Alb <30 g/L occupied 92.3% (12/13). PD pts with dialysis fluid inadequate drainage average age was (34.5 ± 7.0) years, the rate of pts with dialysis <30 days occupied 90.9%, 72.7% (8/11) of whom were diagnosed catheter shift by image method, 27.3% (3/11) of whom were validated net membrane wall up catheter by pull pipe operation.
Conclusions: Pulmonary infection with multiple organ diseases syndrome which mostly incorporates cardiac-cerebral diseases and digestive system were major death causes in PD pts, as well as correlated with malnutrition and Ca and phosphate metabolism disturbance. PD-related P was still the main cause of conversion to HD in PD pts; the positive rate of pathogenic bacteria was low in pts with P, fungus was major in positive pathogenic micro-organism; P was correlated with malnutrition inducing poor immunity incurring infection. Dialysis fluid inadequate drainage, the cause of which were catheter shift and net membrane wall up catheter, was the secondary cause inducing conversion to HD after operation, the PD pts who were young were mostly encountered within 1 month.
Analysis of Etiology, Complications, and Outcome of Peritoneal Dialysis (PD) in Tibet
Objective: To explore the etiology, complications, and outcome of PD patients (pts) with chronic renal failure (CRF) in Tibetan Autonomous Region.
Methods: Complete clinical data of 36 cases that received CAPD from October 2004 to November 2008 in our department were collected to analyze the etiology, complications, and outcome retrospectively.
Results: All 36 pts (male/female: 19/17) were Tibetans; mean age 46.36 ± 14.88 (18.8–73) years. Etiology distribution: Chronic glomerulonephritis (CGN) in 24, 66.67%; diabetic nephropathy (DN) in 5, 13.89%; obstructive nephropathy (ON) in 4, 11.11%, including 3 pts of benign prostatic hyperplasia and 1 pt of urinary stone; lupus nephritis in 1, 2.78%; hypertensive nephropathy in 1, 2.78%; and genitourinary tuberculosis in 1, 2.78%. Complications: bacterial peritonitis (15 pts, 39 times), cannula-related tunnelitis (1 pt, 2 times); peritoneal dialysate leakage (5 pts); cannula drifting (3 pts). Outcome: Death in 12, 33.33%, including 5 pts with of unknown reasons (died in home, 41.67%) and 2 pts who gave up dialysis (16.67%), the 2 reasons take up 58.34% of death; 5 pts had peritoneal failure because of cerebral hemorrhage, cardiac failure, respiratory failure, multiple organ failure, and infection, respectively (8.33% each). 11 pts survived (30.56%), including 4 who stopped dialysis because of improvement of renal function (36.36%), 7 maintained dialysis (63.63%); 8 pts lost to follow-up (22.22%), 3 pts received renal transplantation (8.33%); 2 pts underwent hemodialysis (5.56%).
Conclusions: The major etiology of PD pts with CRF is CGN, as in the inland. The 2nd is ON and DN. The most common complication is infection of abdominal cavity. Refer to an outcome: 33.33% of pts died, of which 58.33% did not come to a hosp and gave up. Survivors were 30.56%, and 22.22% pts were lost. It suggests that it is better for the outcome of the pts to take CAPD in a hosp, and the outcome related to the compliance of the pts after discharged. The study shows that education and training of PD in Tibetan Autonomous Region should be enhanced.
Analysis of Influencing Factors Associated with Mortality of Peritoneal Dialysis (PD) Patients
Objective: To analyze the risk factors that influence mortality of ESRD patients (pts) receiving continuous ambulatory PD (CAPD).
Methods: Pts who began dialysis from January 2005 to December 2008 in our PD center were included in the study. We investigated pts’ demographic characteristics, clinical data, payment scheme, and causes of death at the end of 2008.
Results: 160 pts were included in this study. Among them, 49 died and 111 survived. Pts were divided into 2 groups according to death and survival. In death group, 29 (59.2%) pts died from cardiovascular diseases (CVD), 8 (16.3%) from severe malnutrition, 3 (6.1%) from peritonitis, 3 (6.1%) from severe pulmonary infection, 2 (4.1%) from cancer, and 4 (8.2%) from others. Compared with survival pts, mean blood pressure (BP; 97.9 ± 18.1 vs 115.3 ± 19.7 mmHg) was significantly higher; serum albumin (33.7 ± 5.2 vs 23.2 ± 7.1 g/L) and hemoglobin level (89.1 ± 15.2 vs 72.3 ± 11.1 g/L) were significantly lower in death groups (p < 0.05). There were no significant differences in age, gender, initial creatinine clearance rate, dialysate doses, total fluid removed between 2 groups, whereas the death group had higher fluid overload than survival (67.9% vs 41.7%, p < 0.05). According to payment scheme, pts were divided into higher payment group (HPG; 50%–70% of the total cost by government) and lower payment group (LPG; totally self-paid). There were 108 pts in HPG (23 died, 85 survived) and 52 pts in LPG (26 died, 26 survived). Compared with HPG, there was significantly higher mortality (21.3% vs 50%, p < 0.001) in LPG.
Conclusions: Our results suggest that CVD was the major cause of CAPD pts’ death. These pts had high BP and were more fluid overloaded compared to survival pts. This indicates that maintaining fluid balance and controlling BP are very important. Otherwise, pts’ economic status is a significant problem affecting outcome of CAPD pts.
Comparison of Survival in Patients on Hemodialysis (HD) and Peritoneal Dialysis (PD)
Objective: To investigate the basic characteristics of HD and PD patients (pts), evaluate and compare survival in pts on HD and PD, and to explore the main risk factors affecting survival of dialysis.
Methods: The demographic and clinical data of incident pts on HD and PD in Zhong Shan Hospital, Fudan Univ, from 1 January 2005 to 31 December 2008 were retrospectively analyzed. All pts were followed up through 31 March 2009. Survival analysis was performed using Kaplan-Meier method, log-rank test, and Cox regression model. The methods of intention-to-treat analysis (ITTA) and as-treated analysis (ATA) were both performed in this study.
Results: 460 pts were enrolled. 247 pts received HD initially and others received PD. There was no significant difference in age, BMI, duration of renal insufficiency before dialysis, eGFR, albumin, MAP, urine volume, cerebrovascular accident (CVA), cardiovascular accident, CHF, and CCI between pts on HD and PD at the beginning of dialysis (p > 0.05). Results of ITTA: Kaplan-Meier survival curve revealed that overall mortality was similar in the first 1 year (p = 0.14, log-rank test). In the period over 1 year, there was a significantly higher mortality among those treated with PD initially. When adjusted by age and DM, survival was better on HD (p < 0.05, log-rank test) in the non-DM pts >65 years old. In the group of non-DM pts <65 years and DM pts, there was no significant difference of survival between HD and PD pts (p > 0.05, log-rank test). Multivariate Cox regression model indicated that there was no significant difference of survival between HD and PD pts when adjusted by case-mix differences [HR (HD:PD) = 0.778,95%CI (0.483–1.254),p < 0.303] and age (HR = 1.051, 95%CI 1.030–1.073, p < 0.01), CVA (HR = 2.032, 95%CI 1.125–3.670, p < 0.05), CCI ≥ 5 (HR = 2.592, 95%CI 1.230–5.465, p < 0.05), prealbumin (HR = 0.022, 95%CI 0.001–0.768, p < 0.05) were the main risk factors to survival of dialysis. Results of dialysis was constant with those of ITTA except for prealbumin which was no longer the main risk factors to survival of dialysis in ATA.
Conclusions: Survival was similar between HD and PD pts in the first 1 year of dialysis. In the period beyond 1 year, there may be a significantly higher mortality among those treated with PD. Survival was better on HD in non-DM pts >65 years old. Age, CVA, and CCI ≥ 5 were the main risk factors to survival of dialysis.
Lv W.L, Teng J., Ji J., Zou J.Z.,
Contrast Observation of the Effect of Continuous Ambulatory Peritoneal Dialysis (CAPD) and High-Flux Hemodialysis (HD) on Clearance of Plasma FGF23 in Uremic Patients
Objective: Fibroblast growth factor 23 (FGF23) has a considerable effect on the renal reabsorption of phosphonium and metabolism of 1,25-dihydroxy vitamin D3 [1,25(OH)2D3]. Plasma FGF23 levels of uremic patients (pts) elevates obviously, which is the important cause to elevate blood phosphorus and leads to high morbidity of cardiovascular complication in uremic pts. The research is to compare the elimination effect on plasma FGF23 between HD and CAPD in uremic pts. Methods: 80 cases of end-stage renal disease (ESRD) pts were enrolled then randomly divided into the HD group (n = 55) and the CAPD group (n = 25). HD group was treated with 3×4 h/W for more than 6 months, average dialysis time was (19.5 ± 10.3) months. The speed of blood flow was 300 mL/min and the speed of dialysate was 500 mL/min. Xuhuacheng strainer and Sweden gold AK-100 dialysis machine are used. In the CAPD group, American Baxter Corporation's PD pipeline and the dialysis fluid are used. After catheter insertion, pts get interrupted PD (IPD) and then change to CAPD with exchanges of 6000–8000 mL fluid per day. Pts received CAPD treatment >6 months, average dialysis time was 16.5 ± 11.7 months. Venous blood before and after treatment of the 2 groups was collected. Serum phosphorus, Ca, urea nitrogen (BUN), and creatinine levels were examined by the completely automatic biochemistry meter (Japan). Plasma parathyroid hormone (iPTH) and FGF23 level are tested by ELISA. Plasma 1, 25(OH)2D3 level is measured by emission and immunity testing method. Results: Before treatment, serum P, Ca, BUN, creatinine, iPTH, FGF23, and 1,25(OH)2D3 of the 2 groups were not significantly different (p > 0.05). There were no significant differences (p > 0.05) in HD group between before and after treatment with serum P (2.95 ± 0.78 and 2.83 ± 0.92 mmol/L), Ca (1.88 ± 0.62 and 1.75 ± 0.74 mmol/L), iPTH (381.2 ± 102.7 and 376.6 ± 113.6 pg/mL), FGF23 (472.9 ± 141.2 and 458.8 ± 182.1 pg/mL), and 1,25(OH)2D3 (285 ± 83 and 247 ± 75 pg/mL). But BUN (33.7 ± 11.2 and 12.3 ± 5.5 mmol/L) and creatinine (793.1 ± 169.3 and 356.6 ± 150.7 μmol/L) levels decreased significantly (p < 0.001). There was no significant decrease (p > 0.05) of Ca (1.86 ± 0.78 and 1.71 ± 0.82 mmol/L) and 1,25(OH)2D3 (311 ± 127 and 292 ± 86 pg/mL) in CAPD group before and after treatment, but P (2.79 ± 0.82 and 1.85 ± 0.90 mmol/L), iPTH (377.0 ± 125.8 and 258.9 ± 96.7 pg/mL), FGF23 (487.4 ± 251.9 and 172.6 ± 77.1 pg/mL), BUN (32.2 ± 19.4 and 19.5 ± 9.7 mmol/L), and creatinine (945.6 ± 182.8 and 672.6 ± 205.3 μmol/L) were significantly lower (p < 0.001). After treatment, P, iPTH, and FGF23 of the CAPD group were significantly lower than the HD group. The difference was statistically significant (p < 0.01). Conclusion: CAPD treatment is superior to hemodialysis on the effect of reducing serum P, iPTH, and FGF23 expression levels in uremic pts, which may play a role in the prevention of cardiovascular disease in uremic pts.
Effects of Combination of Aspirin® with Probucol on Oxidative Stress and Inflammatory Status in Nondiabetic Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: To investigate the effects of combination of Aspirin® and probucol on oxidative stress, inflammatory status, and vascular lesions in nondiabetic patients (pts) undergoing CAPD.
Methods: A placebo controlled, double blind, randomized study carried out on 36 nondiabetic CAPD pts: 28 had chronic glomerular disease, 2 had chronic interstitial nephritis, 3 had lupus nephritis, and 3 unknown; 4 pts had normal blood pressure and 32 had hypertension (HTN). CCB or α– and β–receptor antagonist combination with RAS blocker was used to control HTN. All pts were treated with regular chalybeate, calcium, active vitamin D3, and erythropoietin. They were divided into oryzanol + vitamin B6 group [placebo/control group (CG),n = 15, mean age 46 ± 21 years], and Aspirin® + probucol group [treatment group (TG),n = 21, mean age 50 ± 15 years]. Pts were assigned to 12 months of treatment with placebo or Aspirin® (100 mg/d) + prubucol (0.5 g/d). Oxidized LDL (OX-LDL), serum Cu/Zn superoxide dismutase (Cu/Zn SOD), high-sensitivity C-reactive protein (hs-CRP), complete blood count, hepatic function, lipid profile, serum Ca, P, and iPTH were analyzed at 0, 6, and 12 months. The internal carotid atherosclerosis plaque and carotid intima media thickness (IMT) were also examined using color Doppler ultrasonography at 0 and 12 months. Adverse events and safety parameters were monitored throughout the study.
Results: There is no significant difference of basal clinical characteristics in 2 groups. At 6 months, the level of Cu/Zn SOD elevated significantly (p < 0.01) and the levels of OX-LDL and hs-CRP decreased obviously (p < 0.01) in TG compared with CG (p < 0.01). The level of total cholesterol was lower than in CG (p < 0.05) and the level of high-density lipoprotein (HDL) appeared to increase (p > 0.05). No differences were observed in levels of serum albumin, total protein, hepatic function, hemoglobin, Ca, P, and iPTH between 2 groups (p > 0.05). The levels of Cu/Zn SOD, OX-LDL, hs-CRP, total cholesterol, and HDL exhibited no obvious changes at 12 months compared with 6 months of treatment (p > 0.05) but were significantly lower than in CG (p < 0.05). The incidence of increment of carotid IMT and new-onset of plaque was significantly lower in TG than in CG (p < 0.05). There were no differences in clinically relevant adverse events between 2 groups including digestive tract symptoms, i.e., nausea and upper abdominal discomfort, alimentary tract, and subhyaloid hemorrhage.
Conclusion: A combination of Aspirin® and probucol significantly inhibited the oxidative stress and inflammatory status in nondiabetic pts on CAPD and alleviated cardiovascular lesion.
Effects of Short-Term Recombinant Human Growth Hormone (rhGH) Therapy on Nutrition, Inflammatory Status, and Quality of Life in Elderly Nondiabetic Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: To evaluate the effects of short-term rhGH treatment on nutritional and inflammatory status, as well as quality of life in elderly nondiabetic patients undergoing CAPD.
Methods: A total of 23 elderly nondiabetic patients (mean age 68 ± 7 years) on CAPD and with serum albumin levels ≤ 30 g/L were enrolled in this study. 11 patients were administered rhGH (4 IU, 3/Ws.c.; Aubonne, Switzerland) for 6 months, the other 12 patients were administered vitamin B1 (100 mg, 3/W, im) as placebo. Changes in lean body mass (LBM), serum albumin levels, health-related quality of life, hs-CRP, lipid profile, and safety parameters were monitored.
Results: LBM was increased significantly in rhGH treatment group compared with that of placebo group (p < 0.05). Serum albumin, transferrin, and HDL increased (p < 0.05) and hs-CRP was reduced significantly (p < 0.05). The Role Physical SF-36® quality-of-life subscale was significantly improved in rhGH treatment group. There were no differences in clinically relevant adverse events between groups.
Conclusion: rhGH treatment improved nutritional and inflammatory status and health-related quality of life in elderly nondiabetic patients undergoing CAPD.
Hemodiafiltration Improves Pruritus Symptoms in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: Pruritus in dialytic patients (pts) is common. Persistent pruritus is regarded as distressing and severely affects quality of life. The pathophysiology of uremic pruritus (UP) is unclear. Although many factors were related to UP, there was no definite conclusion drawn as to the pathogenesis of this symptom. Treatment of pruritus is nonspecific and ineffective. Several methods of controlling pruritus are considered, including pharmacologic and non-pharmacologic options, but their efficacy is still unsatisfactory. Our aim is to determine whether hemodiafiltration (HDF) would improve cutaneous symptoms and sleep quality.
Methods: Eight severe and generalized pruritus pts on maintenance CAPD (age 58 ± 11 years, vintage 57 ± 46 months) were enrolled. No ultrafiltration failure was found in these pts. No pt could sleep without interruption because of itching before the study. They received 1× weekly HDF for 2 months following 3 weeks of 3× weekly HDF in addition to routine PD. The dialyzers utilized for this study are Gambro Polyflux®–17R. All patients had a weekly creatinine clearance (CCr) of at least 60 L/1.73 m2 (range 60–89 L/1.73 m2) and Kt/V at least 1.7 (range 1.72–2.34).
Results: HDF was well tolerated in these 8 pts. All pts reported improvement at 1st to 3rd session of treatment. 7 pts could sleep without interruption with 3 weeks of treatment. Compared to before study, serum PTH, calcium, and phosphorus levels decreased after the study (p < 0.05): PTH from 37.0 ± 21.0 to 44.0 ± 22.5 pmol/L, Ca 2.03 ± 0.23 to 2.17 ± 0.22 mmol/L, and P 1.56 ± 0.26 to 1.75 ± 0.23 mmol/L. Hemoglobin improved from 95.9 ± 11.8 to 100.5 ± 5.94 g/L (p < 0.05).
Conclusions: Addition of HDF therapy is effective to relieve pruritus and to improve quality of sleep in CAPD pts. The mechanism of UP is unclear and believed to be from metabolic disequilibrium, increased release of pruritogenic mediators, and altered balance between the opioid receptors. The beneficial effect of HDF may be owing to more sufficient solute clearance, which includes more sufficient pruritogenic mediators clearance, more sufficient larger toxic molecules (such as PTH) and P clearance, and more effective to correct metabolic disequilibrium (e.g., acidosis). However, this study is only a small observation. Further study is needed to evaluate the effectiveness and long-term effect of HDF on CAPD pts.
Zhong H., Sa Z.H., Tang X.H., Yuan H.H., Qin M., Zeng D.C.,
Peritoneal Dialysis for Crush Injury Child with Acute Renal Failure (ARF) in Wenchuan Earthquake: A Case Report
Objective: The choice between peritoneal dialysis (PD) or hemodialysis (HD) has always been a difficult and key step for ARF patients (pts) having crush injury. Generally, for crush syndrome pts, we choose HD especially CRRT as priority selection. However, there are still contraindications for HD, especially when the pt cannot bear blood pressure variation, is too young and too light in weight, and holding less muscle volume. Under these conditions, PD plays vital role for helping them going through danger. We have cured a child pt in crush injury to discuss the feasibility of PD and the way and dialysis intensity as dialysis fluid volume and suitable time.
Methods: A male pt, 3 years old, admitted with chief complaint of general crush injury for 1 day. He developed severe right forearm and right shank edema and received fasciotome. His 24-hour urine output was < 250 mL/d in the 2nd day after admission, with complaining of abdominal distention. Laboratory findings showed BUN 17.84 mmol/L, serum creatinine 298 μmol/L, serum potassium 5.95 mmol/L, serum calcium 1.65 mmol/L, CO2 17 mmol/L, GOT 1554 IU/L, ALT 535 IU/L, CK 11209 IU/L, and myoglobin 1200 μg/L, according to which, he developed ARF and hyperkalemia. HD was not indicated for him because of his low body weight (15 kg), consequently, PD was performed. PD tube was placed by a surgeon and 1.5% peritoneal dialysate was used. within 3 hours, the exchange volume was 500 mL kept in the peritoneal cavity, up to 4 L every day with an ultrafiltrate of 450 mL/d.
Results: After 3 days’ treatment, his 24-hour urine output increased to 1000 mL/d and renal function and serum electrolytes became normal. He achieved to get through ARF.
Conclusion: PD is an alternative renal replacement therapy in crush syndrome pts with ARF, especially in children with low weight and low muscle volume.
Potassium Loss is Positively Correlated to Dialysis Dose in Peritoneal Dialysis (PD) Patients: A Dynamics Study
Objective: Hypokalemia is common in PD patients (pts). Dialysis (Ds) dose is 1 of the main factors related to hypokalemia. There have been no studies of quantitative relationship between potassium loss and Ds dose so far, which is important for how to administer K dose. To expose theoretically the quantitative relationship between K loss and Ds dose.
Method: Mathematical model of K transport was established according to Ds dynamics and the 3-pore theory model.
Equation was established between K loss and Ds dose: ΔmK+ = CDK+(t)·V D(t) = CPK+·D/P K+(t)·(VD0 + Q). Here C represents the concentrations of solutes (mmol/L); the subscripts D, P, and represent, respectively, dialysate, plasma, and solutes that can induce osmosis including glucose, Na and its anions, K, et al. CD0, CD(t), CP represent the initial, instant concentration of solutes in dialysate and plasma (mmol/L), respectively. VD0, VD(t) represent the initial and instant volume of dialysate in peritoneal cavity (mL), respectively. PS, LpS, s, σ, represent mass transport area coefficient (mL/min), hydraulic conductance (mL “min–1“mmHg–1), sieving coefficient, osmotic reflection coefficient and ultrafiltration (UF) fraction, respectively. Q, Qu, Qa, L represent net UF, UF, and reabsorption (mL/min), respectively. During calculation Q is supposed to 200 mL according to clinical practice and L 0.3 mL according to Rippe et al. Δπ pro is the colloid osmotic pressure difference caused by the plasma albumin (mmHg). ΔP is the mean hydrostatic pressure difference prevailing between the blood capillaries and peritoneal cavity (mmHg). D/P K+ is concentration ratio of K between dialysate and plasma. The peritoneal parameters were from Rippe et al. (KI 1991; 40:315). All simulations and figure drawing were performed with MATLAB® 6.5 (The MathWorks™, Inc).
Results: K equilibration between blood and dialysate could be gained after 4-5 hours of dwell time no matter what the dialysate glucose concentration was. D/P K could generally reach 90%-95% at that time. The clearance of K also reached the utmost. There was positive linear relationship between K loss and Ds dose. About 9 mmol K (0.67 g chloride potassium) could be cleared by 2 L dialysate.
Conclusions: K loss is positively related to Ds dose in PD patients. The latter can be regarded as one of references of administering K dose.
Shan Y.S.,1,2 Xu F.F.,2 Mao R.Y.,2 Ji J.,1
Safety and Efficiency of Two Different Methods of Intravenous (IV) Iron Supplementation in Peritoneal Dialysis (PD) Patients
Objective: To explore the safety and efficiency of 2 different methods of IV iron supplementation in PD patients (pts). Methods: 24 pts undergoing continuous ambulatory PD (CAPD) from our hospital were selected. The inclusion criteria were (1) duration of CAPD >3 months; (2) serum ferritin (SF) <500 μg/L, or transferrin saturation (TS) <30%; (3) anemia: hemoglobin <90 g/L or hematocrit <0.27. All pts were divided into Group A (GA) and B (GB), and both were given IV iron dextran. The pts in GA were treated with all drug at one time, and the total iron volume = weight (kg) × (120 – actual value of Hb) × 0.24 + 500 mg but the maximum volume should not exceed 1000 mg. The total amount of iron was diluted in 500 mL sodium chloride injection, which should be dripped over 4 hours. Blood pressure and heart rate were measured at the 1st, 2nd, 3rd, and 4th hour after dripping. The pts in GB were treated with the drug 2×/week (100 mg/time), the total iron volume of which was the same as that of GA. The pts in both groups were given Epiao 10000 U by subcutaneous injection once/wk. Drug dosages were unchanged throughout the course of the study. We got the data of Hb, Hct, SF, and TS before the treatment and in the 4th and 8th wks after the treatment, recorded side effect, and then evaluated whether there was a relationship between the side effect and the drug. Results: (1) General information: 1 pt with drug-related skin itching was found in GA, and the symptom disappeared after drug withdrawal without any treatment. One pt with drug-related gastrointestinal reaction was found in GB, whose symptom was remission after symptomatic treatment, and he did not withdraw from the experiment. 23 pts completed the study and their vital signs were stable throughout the experiment. (2) Changed makers: in GA, Hb was 75.23 ± 6.78, 82.85 ± 7.42, and 95.57 ± 7.82 g/L at the beginning of treatment, the 4th wk, the 8th wk, respectively. There was significant difference between Hb level at the beginning of treatment and that at the 8th wk (p < 0. 05). In GB, Hb was 74.97 ± 6.85, 83.15 ± 7.24, and 96.07 ± 8.12 g/L at the beginning of treatment, the 4th wk, the 8th wk, respectively. There was significant difference between Hb at the beginning of treatment and that at the 8th wk (p < 0. 05). Comparing GA with GB, there was no significant difference in Hb level at the 4th wk (p > 0.05) and the 8th wk (p > 0.05). At the 8th wk after treatment, the efficiency of 2 groups was 72.3% and 75% respectively and there was no significant difference between them (p > 0. 05). Iron reserves: in GA, SF was 158 ± 63.27, 484.45 ± 77.32, and 535.53 ± 67.52 μg/L at the beginning of treatment, the 4th wk, the 8th wk, respectively. There was significant difference in Hb level between at the beginning of treatment and the 8th wk (p < 0. 01). In GB, SF was 157.89 ± 68.55, 543.15 ± 76.64, and 536.07 ± 68.12 μg/L at the beginning of treatment, the 4th wk, the 8th wk, respectively. There was significant difference in Hb level between the beginning of treatment and the 8th wk (p < 0. 01) Comparing GA with GB, the increase of SF was significant in the 4th wk (p < 0.05) but not in the 8th wk (p > 0.05). Conclusions: IV iron supplementation is safe and effective for PD pts which increases the levels of Hb and Hct as well as SF and TS in 4 wks. The method of one-time and high-dose supplementation is superior to the other method in the 4th wk. But the efficacy of the 2 kinds of methods are similar at 8 wks. In conclusion, the one-time and high-dose supplementation is effective, inexpensive, and safe in PD pts.
Augmentation Index (AI) and Its Influencing Factors in Patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)
Objective: To examine AI changes in patients (pts) who received CAPD therapy, and analyze the influencing factors of AI.
Methods: We chose 46 pts on CAPD (>3 months’ dialysis) in the PD Center of Nephrology Department in the First Affiliated Hospital of Dalian Medical University. 42 pts with normal blood pressure (BP; 90–139/60–89 mmHg), normal kidney function, no diabetes, and no cardiovascular and or cerebrovascular diseases were chosen as control group. Body height, body weight, BP, and serum BUN, Cre, UA, Ca, P, PTH, TG, chol, Fib, HDL, LDL, glucose were measured in routine methods. AI was detected by radial artery pressure wave analyzer (OMRON HEM-9000AI). We then compared the AI of 2 groups and analyzed its affecters. Statistics was done by SPSS® v11.5 software. Correlation analysis used linear correlation and rank correlation of simple correlation; Multivariate analysis used multiple linear regression, taking AI as dependent variable, gender, age, height, weight, weight index, systolic BP, diastolic BP, pulse pressure (PP), central aortic pressure (CAP), and blood indicators as variable. Backward method was used to select variable to enter the multivariate analysis. A p < 0.05 was viewed as statistically significant.
Results: Systolic BP, diastolic BP, PP, CAP, and AIp75 (when pulse is presented as AI value of 75/min) of PD pts were significantly higher than control group (p < 0.01). In PD pts, when grouped by gender, no statistical difference was seen between males and females in age, dialysis months, systolic BP, diastolic BP, PP, and CAP (p > 0.05). However, AIp75 was significantly higher in females than in males (p < 0.05). The result of simple correlation showed a positive relationship of age, systolic BP, diastolic BP, PP, and CAP with AI; and a negative relationship of height, weight and weight index with IA; while there is no relationship of BUN, Cre, UA, Ca, P, PTH, TG, chol, Fib, HDL, LDL, glucose, dialysis year with AI. Multiple linear regression analysis evidenced that age, height, diastolic BP, and CAP of PD pts are important factors that affect AI.
Conclusions: AI in pts on CAPD is significantly higher than that of normal subjects implied decreased artery elasticity and increased stiffness. AI of CAPD pts has tight correlation with age, height, diastolic BP and CAP, and it may be as a noninvasive factor that perhaps partially reflects the arterial elasticity.
Efficacy of Intraperitoneal (IP) Administration of Insulin on Diabetic Patients on Peritoneal Dialysis
Objective: To investigate the efficacy and safety of IP administration of insulin on refractory hyperglycemia in diabetic patients (pts) on peritoneal dialysis (PD).
Methods: 17 pts with type 2 diabetes on continuous ambulatory PD (CAPD), who required at least 60 IU/d subcutaneous (SC) insulin to control blood glucose, were randomly assigned to 2 groups. All patients received dialysate containing glucose of 2 L x 4/d. Fasting blood glucose (FBG) and blood glucose at 1 hour after meals were measured. The blood glucose targets were 4.48–10.08 mmol/L for FBG and 6.72–10.08 mmol/L for those at 1 hour after meals. IP group (n = 10) received IP insulin for 3 months. The initial dosage of insulin in 2 L dialysate equal to previous daily dosage of SC insulin multiply 1/4 plus add dosage, which was 2 IU, 4 IU, and 6 IU for 1.5%, 2.5%, and 4.25% glucose solution, respectively. The IP insulin dose was adjusted every day according to the blood glucose levels until reaching targeted values. Control group (n = 7) received standard CAPD and routine SC insulin, with the same dosage of insulin added into dialysis solution when necessary. Scr, BUN, lipids, HbA1C, and ultrafiltration volume, were assayed at baseline and at the end of month 3.
Results: No significant differences were found in sCr, BUN, ultrafiltration volume between IP and control group before and after treatment. The HbA1c in IP group was (9.63% ± 1.44%) at baseline, and (8.19% ± 1.31%) at month 3 (p < 0.01), comparing with that in control group of (9.76% ± 1.34%) at baseline, and (9.31% ± 1.72%) at month 3 (p < 0.05), with no differences between 2 groups before and after treatment (p > 0.05). No changes of blood lipids were found during the treatment in both groups, and no differences were found between the groups. Blood glucose in 9 cases in IP group reached the targeted values, while 5 cases in control group. Daily dosage of insulin was 51.70 ± 14.05 IU in IP group and 58.86 ± 12.21 in control group with no difference. Two hypoglycemic reactions were recorded in control group, while none in IP group. No peritonitis, cardiovascular affairs, and death were found in both groups.
Conclusion: IP insulin could effectively and safely control the blood glucose and HbA1c in CAPD patients with type 2 diabetes, with less hypoglycemic reactions, no adverse effects on blood lipid, cardiovascular outcome, and prognosis.
Analysis of Outcome in Lupus Nephritis Patients Undergoing Peritoneal Dialysis (PD)
Objective: To analyze the outcome of end-stage renal disease (ESRD) lupus nephritis (LN) patients (pts) treated with PD.
Methods: LN pts on maintenance PD in Renji Hosp from 1995 to 2008 were retrospectively analyzed. Pts’ clinical data were recorded; mortality and morbidity during dialysis follow-up period were investigated.
Results: 25 ESRD LN pts were enrolled: 6 (24%) males, 19 (76%) females; age 41.8 ± 14.5 years. 7 pts (28%) were switched to hemodialysis because of severe peritonitis, median duration was 12 (8, 30) months on PD. Compared with predialysis, hemoglobin at 1, 6, 12, 18, and 24 months after PD was higher (88.5 ± 18.8, 86.9 ± 12.1, 89.6 ± 16.7, 87.3 ± 15.1, and 91.5 ± 27.6, respectively, vs 68.5 ± 14.3 g/L at baseline, all p < 0.05). There was no difference in serum albumin level (32.5 ± 2.9, 32.7 ± 4.4, 33.0 ± 3.8, 35.3 ± 4.1, and 33.6 ± 4.8 vs 31.6 ± 7.2 g/L, all p > 0.05). In pts with urine volume > 400 mL/d predialysis, urine output volume was stable during the 1st and 2nd year postdialysis compared with predialysis (1045.5 ± 711.1 and 1010.7 ± 620.4 vs 857.1 ± 629.4 mL/d, both p > 0.05). In addition, Kt/V at 1, 6, 12, 18, and 24 months after dialysis kept stable (2.12 ± 0.23, 1.84 ± 0.31, 2.08 ± 0.28, and 2.03 ± 0.19 vs 2.17 ± 0.26, all p > 0.05). During the median follow-up of 22 (12, 35) months, 8 (32%) of these pts died, 6 of them died due to cardio- and cerebrovascular disease, 1 pt died of septic shock and the other unknown. Median survival time is 1.9 years (1.6, 2.2) after dialysis initiation. One-, 2-, and 3-year pt survival rates were 100%, 69%, and 57%, respectively. During the 1st year on dialysis, 25 episodes of various infections (including 9 cases of peritonitis) occurred; 6 pts had extrarenal SLE relapse. At the 2nd year, 8 pts complicated with infections (including 7 cases of peritonitis) and 2 with SLE relapse.
Conclusions: The mortality of LN pts with PD remains high during the first 2 years. CVD is a major cause of death. Residual renal function remains stable during the first 2 years. Peritonitis is a common complication and major reason of technology failure at the early stage of PD.
Prevalence and Management of Hernias in Peritoneal Dialysis (PD) Patients
Objective: Patients (pts) on continuous ambulatory PD (CAPD) are prone to develop hernias (H) because of increased intra-abdominal pressure. Most of the H need surgical repair. In this study, we observed the prevalence and management of H in these pts. We also investigated whether there were differences in hospitalization days, peritonitis rates, and H recurrence between postoperative pts treated with automated PD (APD) and those treated with temporary hemodialysis (HD).
Methods: We included all pts who initiated CAPD between January 1995 and December 2008 in our center. Pts were followed up until cessation of PD, loss of follow-up, or the end of study (31 December 2008). Data of pt demographics, incidence and kinds of H, days of hospitalization, were collected and analyzed. Peritonitis episodes and H recurrence were recorded.
Results: 285 pts were evaluated. Among them, 35 pts (12.2%) developed H at median PD duration of 10.6 months (2.6–33.0 months). These pts were 52.9 ± 12.3 years old and 19 were males. Inguinal H were the most common H in CAPD pts (48.6%), followed by umbilical (37.1%), incision (8.6%), and multiple H (5.7%). 14 males developed inguinal H; 10 females developed umbilical H. More inguinal H occurred in male pts (73.6% vs 18.7%, p = 0.001); more umbilical H occurred in females (62.5% vs 15.7%, p = 0.004). 19 pts (54.2%) developed H within 1 year after PD initiation. 19 pts with H received surgical repair. Postoperatively, 8 pts were put on APD and 10 on HD for 2 weeks before return to CAPD. There were no differences of hospitalization days, peritonitis rates, and H recurrence in postoperative pts between temporary APD and HD.
Conclusions: Hernia is a common noninfectious complication of PD. Most H are developed within 1 year after PD initiation. Umbilical H is more common in females while inguinal H occurs more in males. Temporary APD is as effective as HD in treating PD pts after H repair and can be chosen in clinical practice.
Value of Computed Tomography Peritoneography (CTP) in Diagnosis Complications of Continuous Ambulatory Peritoneal Dialysis (CAPD) without Infection
Objective: The purpose of this study is to assess the diagnostic value of CTP in complications of CAPD.
Methods: CTP of 14 patients [pts; 4 females, 10 males; median age 46.5 (16-75) years] with end-stage renal disease receiving CAPD were investigated. CTP was performed with a suspicion of CAPD-related complications who were admitted to dialysis unit with various complaints. Images were obtained from the level of the dome of the diaphragm to the pelvis before and after intraperitoneal contrast injection before performing CTP, dialysate was completely drained. Take plain CT of abdomen. Then 50 mL iopamidol was mixed with 1000 mL of dialysate and infused into peritoneal cavity. These procedures were performed by PD nurse as strict adherence to an aseptic technique is mandatory. Then pts were encouraged to ambulate for 30 min to achieve good distribution of the contrast material and dialysate mixture. Then repeat CTP. Images were reviewed for evidence of peritoneal leaks, hernias, localized fluid collections, and adhesions.
Results: Abnormal findings were identified by CTP in 12 (85.7%) (9 males, 3 females) of 14 pts that constituted the study group. Inguinal hernias were detected in 4 pts (28.6%), showing a side of hernia contained a quantity of dialysate mixed with contrast medium, compared with peritoneal CT scan obtained before. Umbilical hernias were detected incidentally in 3 pts (21.4%). Abdominal wall leaks were discovered in 2 (14.3%) of the 14 pts; in these 2 pts, fluid collections were found at the site of peritoneal catheter insertion. Both pts presented with localized abdominal swelling and extravasation of dialysate at the catheter exit site. Hydrocele was found in 2 pts (14.3%), showing contrast medium in 1 or 2 sides of scrotum. Peritoneal adhesions were detected in another 2 pts (14.3%), showing contrast medium restricted in only a part of the abdominal cavity. The abnormal findings were confirmed and corrected by surgical in several pts.
Conclusion: CTP is useful for the evaluation of PD-related noninfectious complications, and it offers excellent tissue contrast and multiplane imaging for assessment of complications.
Clinical Analysis of Causes and Risk Factors for Death in Peritoneal Dialysis (PD) Patients
Objectives: To identify the causes and risk factors for death in PD patients (pts). Methods: We retrospectively reviewed the clinical data of PD pts in our hospital between Aug 2001 and Dec 2008 and who died in the follow-up period. Univariate analysis was used for detecting the influences of age, gender, primary diseases of ESRD on pts’ survival. Risk factors for deaths were analyzed by Cox regression model. Results: 132 PD pts died and were enrolled in our study (66 males, 66 females). Average age when they started PD was 71.99 ± 10.49 years. Among them 87.9% of pts were >60 years old. The most common primary disease was diabetic nephropathy (DN), accounting for 27.3% of all the pts. Chronic glomerulonephritis (CGN) (20.5%) and hypertension (HTN)-related renal diseases (18.9%) were also common primary diseases in these pts. 84.8% of the pts had the complication of HTN before they began PD. DM (37.1%) and arteriosclerosis (28.8%) were also common complications. 22.7% of pts had suffered from cerebral accident more than once before PD. 10 pts accepted hemodialysis (HD) before and transferred to PD because of complications during HD. The median MDRD-eGFR was 6.22 mL/min (2.00–13.93 mL/min) when they began PD treatment. Residual urine was 722.3 ± 402.8 mL/d. Average Hb was 82.20 ± 18.78 g/L and average albumin 27.94 ± 6.45g/L. The univariate analysis revealed that the survival rates were significantly different among pts with different primary disease (p = 0.007). Median survival time was shorter in pts with renal amyloidosis/myeloma (5 months) and systemic vasculitis (7 months). Median survival time was longer in pts with ADPKD (42 months). The most common cause for death was infection in these pts (34.1%), followed by cardiovascular (CV) complications (18.9%) and cerebral accidents (12.9%). More pts died of CV complications in PD pts with DN than in pts with other primary diseases (p = 0.002). Infection was also the most common cause for death in pts >80 years old. In pts 70–79 years, pts 60–69 years, and pts <60 years, the most common causes for death were infection (31.2%), CV complications (31.8%), and infection (31.2%), respectively. Median survival time was longer in pts 60–69 years old compared with pts >80 years old (23 vs 13 months, p = 0.033). Cox regression model indicated: pts with primary diseases of renal amyloidosis/MM (HR = 5.631, p = 0.002), vasculitis (HR = 2.425, p = 0.089), elderly (HR = 1.033, p = 0.004), complicated with DM (HR = 2.247, p = 0.004), arteriosclerosis (HR = 2.109, p = 0.022), gout (HR = 1.988, p = 0.017), or gastrointestinal hemorrhage (HR = 6.46, p = 0.021) were risk factors for deaths in PD pts. Conclusion: Elderly PD pts have a relatively short survival time. Infection is the most common cause for death among these pts. PD pts with DN are more likely to die of CV complications than other pts. Pts with primary diseases of renal amyloidosis/MM, vasculitis, elder, complicated with DM, arteriosclerosis, gout, or gastrointestinal hemorrhage are risk factors for deaths in these PD pts.
Clinical Analysis on the Outcomes of Peritoneal Dialysis (PD) Patients with Diabetes and End-Stage Renal Diseases (ESRD)
Objectives: The number of patients (pts) with diabetes (D) and ESRD is increasing. Dialysis is required in these pts. Here we retrospectively analyzed the clinical manifestations and outcomes of PD pts with D and ESRD.
Methods: Between Jan 2003 and Dec 2008, 85 PD pts with D and ESRD were enrolled in our study. Average age when they began with PD treatment was 57.4 ± 15.8 years. All the pts had accepted PD treatment for more than 90 days. According to the different clinical outcomes including continued with PD, accepted renal transplantation, transferred to hemodialysis (HD), and died, all the pts were divided into 4 groups. The recent nutrition conditions (serum albumin in the latest half year), adequacy of dialysis (Kt/V, Ccr), and residual renal function (RRF) were compared. The 4-year mortality of the deceased group was calculated and the causes for death were analyzed.
Results: The 85 pts included 46 males and 39 females. 28 pts continue with PD treatment. 2 pts accepted renal transplantation during the follow-up period. 6 pts transferred to HD. 4 pts lost to follow-up. Kt/V, Ccr, serum albumin, and RRF showed no difference among the former 3 groups. 45 pts died during follow-up. 1-, 2-, 3-, and 4-year mortality was 17.6%, 25.8%, 36.4%, and 52.9%. Mortality increased obviously during the 3rd and 4th year of PD and was over 50% during the 4th year. In pts >65 years old, the 4-year mortality was as high as 62.2%. The major causes of death were infection (35.6%), including peritoneal infection and pulmonary infection. 28 (62.2%) pts that died were >65 years. The Kt/V, Ccr, serum albumin, and RRF were significantly lower in deceased group than other 3 groups (p < 0.01).
Conclusions: Mortality of PD pts with D and ESRD is obviously increased after 2 years of PD treatment. The high mortality might relate to more incidences of glucose and lipid metabolism disturbances, obvious decrease of serum albumin, more incidence of malnutrition, the characters of PD techniques and advanced age. PD inadequacy is an important cause of death in long-term PD pts. Further evidence should be collected by abundant strict clinical controlled studies to determine whether PD is a superior dialysis mode in D and ESRD pts especially in elderly pts.
Pulmonary Arterial Hypertension in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objectives: To investigate the prevalence of pulmonary arterial hypertension (PAH) and the possible risk factors for PA H in patients (pts) receiving CAPD.
Methods: The study retrospectively collected the clinical profile, echocardiographic (ECHO) findings, and biochemical data for 140 PD pts for which ECHO findings were available and initiated treatment between 2004.1 and 2007.1. The pts were followed up for a maximum of 3 years. We compared characteristics between pts with and without PAH. PAH was defined as systolic pulmonary artery pressure (PAP) > 35 mmHg at rest.
Results: Prevalence of PAH was 31.4%. Mean age of pts with and without PAH was 67.2 ± 12.7 and 64.0 ± 14.7 years respectively (p = 0.22). Pts with PAH had a higher left atrial dimension (LAD; 44.7 ± 6.7 vs 40.7 ± 6.0 mm, p = 0. 000), left ventricular end-systolic dimension (LVDs; 37.3 ± 8.4 vs 33.5 ± 5.2 mm, p = 0.007), and LV mass index (LVMI; 139.4 ± 40.8 vs 125.4 ± 34.4 g/m2, p = 0.043) than pts without PAH. In PAH pts, ejection fraction (EF; 58.2% ± 12.5% vs 62.9% ± 7.7%, p = 0.025), serum iron (SFe; 8.9 ± 4.7 vs 12.5 ± 7.5 μmol/L, p = 0.009), hemoglobin (73.6 ± 15.2 vs 85.4 ± 24.4 g/L, p = 0.004), and albumin (28.4 ± 5.7 vs 30.5 ± 6.0 g/L, p = 0.046) were significantly lower. The survival rate at 1, 2, and 3 years for PAH pts was 73.2%, 62.5%, and 53.8%, respectively, and for pts without PAH, 89.4%, 66.7%, and 51.1%, respectively. The survival with pts without PAH was better in the 1st year of treatment compared with PAH pts (p = 0.01), with subsequently no difference up to 3 years. PAP correlated with LVMI (r = 0.170, p = 0.045), LAD (r = 0.296, p = 0.000), and LVDs (r = 0.240, p = 0.004). It inversely correlated with Alb level (r = –0.175, p = 0.039), Hb level (r = –0.250, p = 0.003), EF (r = –0.192, p = 0.023), and SFe (r = –0.238, p = 0.009). Serum calcium phosphate product (Ca×P), uric acid, cholesterol, triglyceride, LAD, and systolic blood pressure (SBP) were found in multivariate analysis to be independent risk factors for PAH.
Conclusion: PAH is a frequent cardiovascular complication in CAPD pts. PAH increase the mortality of CAPD pts in the initial stage of the treatment. Serum Ca×P, uric acid, cholesterol, triglyceride, LAD, and SBP are major risk factors for PAH. Therefore, strategies for treatment of these problems should be enhanced to prevent the development of PAH in CAPD pts.
Clinical Analysis on the Relations between Postoperative Start Time of Peritoneal Dialysis (PD) and Long-Term Complications Induced by Dialysis Catheters
Objective: To study the relations between the incidences of complications induced by PD and the postoperative start time of PD, and find an ideal time interval to start PD treatment suitable for domestic medical conditions.
Methods: From 1997, 154 patients (pts) treated with implantation of the PD catheter in our department and long-term follow-up data were retrospectively studied. These pts were divided into 3 groups according to the different time intervals from PD catheter implantation time to the start time of PD treatment: <7 days group (time <7 days), >7 days group (7–14 days), and 14 days group (time 14 days). The underlying diseases, preoperative levels of the serum albumin and creatinine, incidences of leakage of the dialysis fluid, drifting of the dialysis catheter, and encapsulated omentum were recorded and the case times of catheter re-implantations and nonoperative treatments among the 3 groups were analyzed. The advantages and disadvantages of the 3 groups were analyzed.
Results: Chronic glomerulonephritis (59.8%) was the most common underlying disease; the next was diabetic nephropathy (13.7%), followed by hypertensive nephropathy (13%). There was no statistical difference in the distribution of diseases among the 3 groups (p > 0.05). No statistical difference in the preoperative levels of serum albumin and creatinine was detected in the 3 groups (p > 0.05), and the incidence of leakage of the dialysis fluid, drifting of the dialysis catheter, and encapsulated omentum in <7 days group was higher than that of the other 2 groups (p < 0.05), and the incidences of the other 2 groups were comparable (p > 0.05). The incidence of surgical treatment was significantly higher in the <7 days group (p < 0.05).
Conclusion: Long-term complications induced by dialysis catheters in pts started the dialysis from 7 to 14 days postoperatively were as good as the pts started the treatment as guideline, which may due to the difference of underlying disease spectrum and ethnic groups in China.
Analysis of Therapy Outcome in Peritoneal Dialysis Patients Transferred from Hemodialysis
Objective: Analysis of patient and technique survival in peritoneal dialysis (PD) patients transferred from hemodialysis (HD) due to vascular access problems, cardiac disease, and so on.
Methods: We have analyzed retrospectively a cohort of 177 patients treated with PD in our center during 2000–2008. Patient characteristics, therapy measures, and outcome of patients were compared between patients for whom PD was the initial method of renal replacement therapy (group 1, n = 131) and those transferred to PD from HD due to complications (group 2, n = 46).
Results: Baseline Kt/V was significantly higher in the primary PD therapy group (2.26 ± 0.46 vs 1.95 ± 0.39, p < 0.001), due to lower residual renal function in patients transferred from HD. Group 2 had also significantly higher peritonitis rate (0.78 vs 0.64 episode/year, p < 0.05). No significant differences were observed in unadjusted patient survival, but technique survival was significantly lower in group 2 (p < 0.05). In the Cox multiple regression model, diabetes status, age, and albumin level significantly influenced survival. Relative risk of death was not increased significantly in patients transferred from HD.
Conclusions: Our data suggest that therapy outcome of patients transferred from HD is similar to that of patients in whom PD is the first choice therapy. Thus, this option should be strongly considered in patients experiencing complications on HD, mainly vascular access problems, heart failure, or intradialytic hypotension.
Efficacy of Automated Peritoneal Dialysis in Uremic Patients with Cardiac and Pulmonary Failure
Objective: To assess the efficacy of automated peritoneal dialysis (APD) in uremic patients with cardiac and pulmonary failure.
Methods: A total of 18 uremic patients with cardiac and pulmonary failure (10 male, and 8 female; mean age: 66 ± 7 years, age range 41–75 years) received the APD therapy with a HomeChoice® system. 12 uremic patients with cardiac failure were enrolled, including 2 patients with cardiac permanent pacing, while 6 uremic patients with both cardiac failure and pulmonary failure were enrolled. All the patients had previously been on continuous ambulatory peritoneal dialysis (CAPD) or intermittent peritoneal dialysis (IPD). The glucose concentration of dialysate was 2.5%. Dialysis exchange frequency was 8–10 times per day, and the volume of each exchange was 800–1000 mL. Clinical manifestation, daily intake and outtake, ultrafiltration volume, creatinine, urea nitrogen, electrolyte before and after treatment were recorded and evaluated.
Results: Mean APD therapy duration of the patients was 15.6 ± 7.3 days. Clinical manifestation and biochemical indexes were significantly improved after APD therapy, which indicated that APD therapy could remove uremic toxins effectively, and rebalance water electrolyte and acid–base disorders rapidly.
Conclusion: APD is an effective and safe alternative renal replacement therapy in uremic patients with cardiac and pulmonary failure, which could ensure the adequacy of peritoneal dialysis, and improve the survival rate.
A Clinical Research into Calculation of Peritoneal Dialysis (PD) Volume of PD Patients Based on the Status of Residual Renal Function (RRF)
Objective: To observe retrospectively the correlation among the PD volume (PDV), RRF, and body surface area (BSA) in PD patients (pts) who have different dialysis efficiencies and summarize a method for calculating PDV in conformity with the physiological and disease characteristics of Chinese pts.
Methods: Measurements have been made 1650 times in 414 pts who have taken medium-position dialysis for 14.8 (6-161) months and been divided into 3 groups: adequacy, critical, and inadequacy according to the 2006 NKF-K/DOQI standard. The changes of urea Kt/V, creatinine clearance rate (CCR), protein expression rate (nPNA), plasma albumin (ALB), residual glomerular filtration rate (rGFR), PDV, and PDV per unit BSA (PDV/BSA) of each group of pts and the relationship among such factors were observed.
Results: With measurements for 1650 times, the majority of pts have been dialyzed adequately; only 391 have been dialyzed inadequately, covering 23.7%. As indicated by the analysis, there were significant differences (p < 0.0001 and p < 0.001) in urine volume (UV) and rGFR, as well as in PDV and PDV/BSA in such 3 groups of pts. According to the research, it has also been discovered that rGFR of the pts of adequate dialysis was remarkably higher than that of other groups (p < 0.0001), while their PDV/BSA was obviously less than that of other groups (p < 0.0001). As indicated by the observation of rGFR in different groups, PDV required for different RRF was significantly different (F 189.3, p < 0.0001). Therefore, it suggests that choosing PDV according to rGFR status is of great clinical importance. The correlation between rGFR and PV/BSA was further discussed, the correlation coefficient between them is capable of being formulated as follows: PDV/BSA = 4277.0 – 123.7 × rGFR, r = –0.58, p < 0.001. Therefore, the formula for calculating individual PDV of PD pts was got as follows: PDV (L/d) = (4.4 – 0.15 × rGFR) × BSA.
Conclusion: PDV for all PD pts should be calculated according to RRF and BSA status. Such individual dialysis scheme is capable of not only exerting the advantages of RRF in PD to the maximum, but also saving dialysate dosage and reducing economic expenses of the pts.
Clinical Analysis of Peritoneal Dialysis (PD) Treatment in Patients with Severe Lupus Nephritis (LN)
Background: Systemic lupus erythematosus (SLE) is a multisystem disease characterized by an autoimmune reaction. SLE most often harms the heart, joints, skin, lungs, blood vessels, liver, kidney, and nervous system. Approximately, 10% of patients (pts) with lupus nephritis develop end-stage renal disease. In some cases with a rapidly progressive course, treatment may result in partial recovery of renal function.
Objective: To evaluate the clinical efficacy of continuous ambulatory PD (CAPD) in pts with severe LN complicated with acute or chronic renal failure (A/CRF).
Methods: 18 severe LN pts (12 females, 6 males; 18–54 years old) had been undergoing CAPD for at least 4 months in our department. The pts’ clinical features were as follows: hypercatabolism occurred after methylprednisolone pulse treatment during lupus active stage; renal function aggravated progressively which resulted in immunosuppressive agent taboo; low protein diet could not be applied because of severe malnutrition state; common treatment could not be carried on owing to complications such as severe edema, cardiac insufficiency, and severe azotemia. The total pts were followed up for 4–18 months. The parameters of renal function, SLE disease activity index (SLE-DAI), immunologic exanimation, clinical outcome, lupus activities, biochemical parameters, hemoglobin level, and infective complications were reviewed.
Results: A total patients’ general state of health, heart function, spirit, and physical strength were improved obviously. Prednisone and other immunosuppressive agent were applied in 16 patients after PD treatment. Among the whole cases, 8 cases’ renal functions were recovered, 5 cases received complete remission, and 2 cases obtained partial remission. The titers of ANA, anti-dsDNA, and the SLE-DAI of the pts were significantly declined after PD treatment. Peritonitis occurred in 3 cases during PD treatment. One of the 3 was induced by cholecystitis.
Conclusion: PD treatment can relieve the symptoms of edema, heart failure, and azotemia in severe LN pts obviously. PD treatment plays an important role in preserving residual renal function and improving nutritional state. PD combined with immunosuppressive treatment is in favor of the activity of protopathy control. Severe LN pts complicated with A/CRF should undertake PD promptly.
Combination Treatment of Peritoneal Dialysis (PD), Lamivudine, Methylprednisolone, and Anticoagulation in Patients with Nephrotic Syndrome (NS) and Acute Renal Failure (ARF) Caused by Hepatitis B Virus (HBV)-Associated Glomerulonephritis (GN)
Objective: The NS and ARF caused by HBV-associated GN is uncommon. This paper is to investigate the use of PD in patients (pts) with NS and ARF caused by HBV-GN.
Methods: Three pts with NS and ARF caused by HBV-GN were treated with PD, lamivudine (100 mg/d), methylprednisolone (Methyl-P; 40 mg/d), and anticoagulation (low molecular heparin and urokinase). Among those pts, mycophenolate (1.5 g/d) was given in 2 pts and traditional Chinese medicine in 1 pt. During follow-up, ACEI (benazepril 10 mg/d) or angiotensin II receptor-1 (telmisartan 80 mg/d) were administrated. The dose of Methyl-P and mycophenolate were decreased according to the status of pts. Data of complications, serum creatinine, HBV-DNA in serum and renal tissue, renal pathology, and therapeutic regime were collected.
Results: 3 pts (2 males, 1 female; 17–34 years old) were diagnosed as HBV-GN by renal biopsy. The course of disease was 3 days to 5 months. All the pts underwent nephritic syndrome, ARF with oliguria, ascites, and hyponatremia, whose HbsAg, HbcAb, HbeAg or HBeAb were positive in serum. The level of serum creatinine was 210–860 μmol/L. The amounts of HBV-DNA in serum and renal tissue were no less than 1.0 × 105 copy/mL and 5.0 x 104 copy/mL respectively. Mesangial proliferative nephritis was confirmed in 2 cases and membranoproliferative GN (MPGN) in 1 case. Dose of PD was 2–6 L/d with effluent 1000–1600 mL/d. Duration of PD was 15 days, 33 days, and 10 months, respectively. Pneumonia and brain edema appeared in 2 pts respectively. Maintenance PD was employed until the level of serum creatinine of pts declined to 140, 164, and 230 μmol/L, respectively. Complete remission was observed in 2 pts after 6 months and partial remission in 1 pt. The PD catheter was explanted at 19 months, 31 months, and 38 months. During 3 years of follow-up, persistent complete remission was observed in 2 pts; the pt with MPGN was aggravated (Ccr 54 mL/min).
Conclusion: Combination treatment of PD, lamivudine, Methyl-P, and anticoagulation is efficacious for pts with NS and ARF caused by HBV-GN. PD is helpful to relieve the loading of water and natrium, drainage of ascites, and edema of kidney.
Early Impact of Incremental Peritoneal Dialysis
Objective: To investigate the early impact of incremental peritoneal dialysis (PD) and to provide a method of controlling the symptoms in uremia patients in early period.
Methods: 109 new PD patients treated with incremental PD were included in the present study, including 61 males and 48 females. Mean age was 57.5 ± 16.1 years. The dialyzed dose and frequency of the incremental PD were different according to the patient's symptoms, physical signs, urinary volume, and remaining renal function. 4000–6000 mL PD solution with 1.5% glucose was administered every day. In order to maintain the sum of the ultrafiltration and urinary volume between 1000–1200 mL every day, the 4000–6000 mL dose was distributed 3 times in 24 hours and each dose may be changed between 1000–2000 mL. Clinical data, dialysis adequacy, and nutritional status were evaluated at the initiation of dialysis and at 3 months after PD.
Results: The PD patients achieved good results in the dialysis adequacy and nutrition at the end of the 3rd month. The total amount of fluid eliminated was 1113 ± 286 mL at the end of the 3rd month, and the total Kt/V is 1.82 ± 0.78. The patient's comorbidities such as cardiac insufficiency and dropsy were reduced significantly (p < 0.05). Systolic BP was reduced from 148 ± 21.6 to 137 ± 19.7 mmHg (p < 0.05). Diastolic BP was reduced from 88.7 ± 17.2 to 82.3 ± 11.2 mmHg (p < 0.05). Hemoglobin levels rose from 92.0 ± 18.4 to 118 ± 28.8 g/L (p < 0.05).
Conclusion: Our results suggest that incremental PD improves patients’ clinical status even at the early stage of dialysis. The incremental PD is a good method of therapy for uremia patients.
The Application of Peritoneal Dialysis (PD) in Patients with Severe Renal Diseases
Objective: Hemodialysis (HD) is not available for some patients (pts) with special severe renal diseases (RD), such as complicated large ascites, severe lupus nephritis (LN), or hepatorenal syndrome (HRS). This study is aimed to investigate effect of PD on these pts. Methods: 30 pts with severe RD were enrolled in this study. Data including primary disease, pathology, therapeutic regimen, and outcome were collected. Some pts with idiopathic acute renal failure (iARF) were also treated with a large dose of methylprednisolone, anticoagulation, and statins. All pts were treated with PD. Renal failure caused by severe LN was treated by prednisone and pulse of cyclophosphamide according to the acute activity and chronic index in renal pathologic change on the base of PD. Anticoagulation control of hypertension and administration of antibiotic and immunoglobulin were also considered. Pts with HRS were treated by protection of liver function. Severe acute tubulointerstitial nephritis (SATIN) was treated with middle or small dose prednisone. Dose of PD was determined individually (IPD or CAPD, 2–12 L/d). Results: Primary diseases of the 30 pts with refractory RD included severe iARF due to primary nephrotic syndrome (PNS) (8 pts), renal failure due to severe LN (12 pts), HRS (3 pts), maintenance HD with large ascites (3 pts), congenital heart disease with ARF (2 pts), and SATIN (2 pts). Dropsy of multi-serious cavity (large amount of ascites in 25 pts), insufficient effective circulatory blood volume, severe electrolyte disturbances (18 pts with serve hyponatremia), and/or multiple organ dysfunction syndromes was observed. Diuretics were not effective in all of them. Among the pts with iARF due to PNS, there were 4 with focal segmental mesangial proliferative nephritis (MPN), 3 with diffuse MPN, and 1 with minimal change disease, respectively. All 12 pts with LN were confirmed to be type IV LN. Maintenance PD was not necessary in 8 iARF pts caused by PNS whose remission rate was 75%. Only 50% of LN pts needed to undergo maintenance PD and the other LN pts did not profit from the combination treatment. Maintenance PD was not necessary in 22 pts (73%). The large ascites disappeared or decrease obviously. Repeat renal biopsy revealed the decreased acute activity index and unaltered chronic index in 4 pts with LN. Complete remission was obtained by 4 ptss with iARF caused by PNS (4/8) and partial remission was obtained in 2 pts. All pts were followed up for 15–96 months and 2 of them succumbed to ineffectiveness or died respectively. Conclusion: HD is not available for these severe RD with severe pathophysiological features. PD is thought to be a kind new therapy for the severe RD. PD is effective in decreasing dropsy of multi-serious cavity and larger ascites accepted as well as cooperating with immunosuppressive therapy, especially in pts with iARF, PNS, or HRS.
Analysis of Death-Related Factors in Peritoneal Dialysis (PD) Patients
Objective: Relatively little is known of the predictors of death in PD populations. We aimed to identify the risk factors of death among PD subjects in order to extend the survival time of patients (pts) with an appropriate strategy.
Methods: 29 deaths in pts (18 males, 11 females; mean age 58.6 ± 16.6 years; dialysis duration 4–90 months) undergoing PD for more than 6 months with complete information in our hospital PD center were analyzed. The primary disease consisted of diabetic nephropathy (DN) (11), chronic glomerular nephritis (16), purpura nephritis (1), and chronic pyelonephritis (1). Retrospective analysis was used to analyze the causes of death in PD pts and cross-sectional analysis was employed to analyze the roles of serum albumin as well as residual renal function, dialysis adequacy, and age as risk factors in the 18 deaths undergoing PD for more than 12 months (10 males, 8 females; mean age 56.1 ± 17.6 years).
Results: 11 pts (37.9%) underwent DN, 15 pts (51.7%) were elderly (>60 years old), 6 pts (20.9%) complicated by infection-related multiorgan failure, 20.9% of them underwent cardiac complications such as acute myocardial infarction (1) and heart failure (5). The other complications consisted of tumor (3), cerebrovascular complications (3), and severe malnutrition (4). Three pts finally abandoned treatment due to shortage of money. There were no significant differences between diabetic and nondiabetic death cases for Kt/V and the level of serum albumin (1.44 ± 0.21 vs 1.13 ± 0.43, p = 0.13; 31.38 ± 4.98 vs 31.54 ± 5.09, respectively, p = 0.95). Plasma albumin levels and residual renal function were confirmed no significant difference in pts >60 years of age and <60 years of age (30.33 ± 5.57 vs 31.95 ± 4.31 respectively, p = 0.51; 8.20 ± 8.93 vs 8.81 ± 5.68 respectively, p = 0.87).
Conclusion: Advanced age and DN are the main risk factors for death of pts undergoing PD, which are seldom responsible for dialysis adequacy and nutritional status. It should be emphasized that poverty maybe a factor in quitting PD.
Analysis of the Reasons for Withdrawing from Peritoneal Dialysis (PD) in 292 End-Stage Renal Disease (ESRD) Patients in 2008
Objective: PD is one of the renal replacement therapies widely applied in our country. This study was designed to investigate the reasons for withdrawing from PD in ESRD patients in 2008.
Methods: 292 of 654 ESRD patients withdrawing from PD in 2008 were enrolled in the study. The reason for each patient withdrawing from PD was analyzed. The volumes of ultrafiltration and urine were calculated.
Results: 132 (45.2%) of the ESRD patients who were undergoing PD turned to get the treatment of hemodialysis (HD), 99 (33.9%) ESRD patients died, 35 (11.9%) of whom received renal transplantation, 17 (5.8%) abandoned treatment for any reason, and 9(3%) transferred to other hospitals for treatment. The reasons that the ESRD patients undergoing PD turned to HD were insufficiency PD (56, 42%), ultrafiltration failure (13, 10%), inadequate drainage 19, 14%; hernia 2, 2%; leakage 3, 2%; damage of catheter 6, 5%; and others (1, 1%). The reasons of death for the ESRD patients undergoing PD were congestive heart failure (46, 47%), infection (15, 15%), cerebral hemorrhage (11, 11%), neoplasm (7, 7%), cerebral thrombosis (4, 4%), acute myocardial infarction (7, 7%), malnutrition (6, 6%), hyperkalemia (3, 3%). The mean daily ultrafiltration volume of 654 patients with ESRD was 723.6 ± 113.4 mL and the mean daily urine volume of these patients was 607.1 ± 143.2 mL. The frequency of PD daily was 3.6 ± 1.2 for all the 654 patients.
Conclusions: HD and death were the main cause for the ESRD patients withdrawing from PD and the leading cause for the PD patients changed to get HD treatment was insufficiency of PD. Moreover, the main cause of death for the PD patients was congestive heart failure. Daily ultrafiltration volume and the frequency of PD daily should be improved to reduce the number of ESRD patients withdrawing from PD.
Impacts of Puerarin on Oxidative Stress in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients
Objective: Oxidative stress is commonly responsible for cardiovascular events and peritoneal fibrosis. Puerarin is regarded as an inhibitor of oxidative stress. The effect of puerarin on peritoneal oxidative stress is unclear. This study is aimed to investigate the impact of puerarin on oxidative stress in continuous ambulatory peritoneal dialysis (CAPD) patients.
Methods: A total of 38 stable CAPD patients were involved in this study and divided into 2 equal groups randomly. The experimental group patients (n = 19) were dialyzed with traditional 1.5% PD fluid containing puerarin (50 mg/2 L), while control group (n = 19) were dialyzed only with the traditional 1.5% PD fluid. The serum and effluent levels of oxidative stress marks such as glutathione (GSH), total-superoxide dismutase (T-SOD), and malondialdehyde (MDA) were evaluated both at the beginning and the end of 2-week observation period.
Results: The serum and effluent levels of GSH, T-SOD, and MDA were not significantly different between experimental group and control group at the beginning of the observation. Two weeks later, higher levels of serum and effluent GSH and T-SOD were found in experimental group compared with control group (p < 0.05, 0.05 respectively). Effluent MDA in experiment group was lower than in control group (p < 0.05). Both serum and effluent levels of GSH and T-SOD in experimental group, but not in control group, increased significantly after 2 weeks as compared with those at the beginning (p < 0.05 and 0.05 respectively). Significantly decreased concentration of effluent MDA was observed in experimental group (p < 0.05).
Conclusion: Short-term supplementation of puerarin into PD fluid can ameliorate oxidative stress in CAPD patients.
Oxidative Stress Induced by Intravenous Iron and the Effect of Lipoic Acid on Peritoneal Dialysis (PD) Patients
Objective: Anemia is one of the most common clinical manifestations and complications of chronic kidney disease. Intravenous (IV) iron is an important supplementary drug for correcting renal anemia. Some studies showed that application of IV iron would result in oxidative stress (OxS), which would increase the incidence of atherosclerosis and cardiovascular disease in ESRD patients. In this study, we observed the acute OxS response induced by IV iron in PD patients, and the effects of antioxidant lipoic acid (LipA) on the OxS induced by IV iron in PD patients.
Methods: 40 patients on continuous ambulatory PD (CAPD) were enrolled into this study. They all received the same treatment. First, the patients got the iron treatment (Fe group: IV low molecular dextran 100 mg) and then got the LipA preventive treatment (LipA + Fe group: LipA 450 mg + low molecular dextran 100 mg). Patients’ blood was collected before IV iron, the 1st, 2nd, and 4th hour after the treatment. Serum superoxide dismutase (SOD), serum glutathione peroxidase (GSH-POx), and malondialdehyde (MDA) were detected.
Results: After IV iron therapy, serum SOD and GSH-POx began to decrease, reaching its valley value in 1 hour, there was significantly statistical difference (p < 0.05). Serum MDA level was significantly increased and reached its peak value in 1 hour and the levels of 1, 2, and 3 hours were significantly higher than 0 hour (p < 0.01). In the patients given preventive treatment of LipA before IV iron therapy, serum SOD level was significantly decreased in 1 and 2 hours (p < 0.01) and reached its valley value in 1 hour but serum SOD level was higher than Fe group at each time point (p < 0.05). In the LipA + Fe group, serum GSH-POx level was significantly decreased in 1 hour (p < 0.01) but serum GSH-POx level was higher than Fe group at each time point (p < 0.01). In the LipA + Fe group, serum MDA levels in 1, 2, and 3 hours were higher than 0 hour (p < 0.01) and reached its peak value in 1 hour but serum MDA level was lower than Fe group at each time point (p < 0.05).
Conclusion: Application of IV iron therapy would intensify OxS acutely in short time in CAPD patients, and IV LipA before IV iron therapy could relieve the OxS injury to some degree.
A Prospective Clinical Research of Valsartan Benefit to Residual Renal Function (RRF) in Peritoneal Dialysis (PD)
Objective: RRF is an independent predictor of survival rate in continuous ambulatory PD (CAPD) patients (pts). This study is aimed to prospectively research the effects of angiotensin receptor blocker (ARB) valsartan on RRF in CAPD pts.
Methods: 50 pts (26 males, 24 females; mean age 53.4 ± 8.54 years) undergoing CAPD were recruited in our hospital. All the pts were randomly divided into 2 groups: the valsartan treatment (VT) group and the control (C) group. The PD solution was produced by Baxter® company, the period of PD was 27.2 ± 13.8 months. VT group was administered routine treatment and valsartan 80 – 160 mg/d, while the C group were only administered routine treatment. Pts undergoing peritonitis, severe heart failure, active liver disease, malignant tumors, and other related complications in the latest 3 months were excluded. Comparison of age, gender, and morbidity state in the 2 groups was similar (p > 0.05). Residual glomerular filtration rate (eGFR) was determined every 3 months. Creatinine clearance rate (Ccr) and Kt/V were determined weekly pre- and post study respectively. Urea clearance rate, RRF, and levels of hemoglobin and serum potassium, sodium, chloride, and albumin were determined pre- and post study respectively too. 24-hour urine volume and blood pressure were recorded.
Results: RRF declined in both groups. RRF could be protected in the VT group with the certain total Ccr and total Kt/V. The eGFR in VT group was 25.17 ± 8.43 and 21.88 ± 6.97 mL/min/1.73 m2 pre- and post study respectively, and in C group 24.91 ± 7.82 and 16.35 ± 7.13 mL/min per 1.73 m2 pre- and post-study respectively. There was significant difference in RRF regression in the 2 groups (p < 0.01). 24-hour urine volume of the 2 groups was reduced, especially in the C group (p < 0.05). Hb level in VT group was higher than in C group (p < 0.05).
Conclusion: These results suggest that valsartan protects RRF of long-term PD pts effectively.
Factors Affecting Survival Rate in Peritoneal Dialysis Patients
Objective: To analyze factors impacting the survival rate in continuous ambulatory peritoneal dialysis (CAPD) patients.
Methods: From January 2002 to June 2008, 335 patients receiving CAPD therapy more than 3 months were recruited in this study. Sex, age, primary disease, outcome of disease, long-term survival rate, and the factors impacting survival rate were analyzed.
Results: Men and women accounted for 61.6% and 38.4% respectively (male:female ratio 1.61:1). The age of starting peritoneal dialysis was 15–85 years, mean 43.7 ± 11.4 years. The duration of dialysis was 3–64 months, average 25.1 ± 12.8 months. The primary diseases included primary glomerulopathy (172 patients, 57.3%), secondary glomerulopathy (76 patients, 22.9%), interstitial nephritis (29 patients, 8.7%), congenital genetic disease (23 patients, 6.9%), and other reasons (35 patients, 10.4%). IgA nephropathy was the most common primary glomerulopathy which lead to ESRD, and the etiopathogenesis of secondary glomerulopathy was diabetic mellitus (27 patients, 40.9%), hypertensive (22 patients, 33.3%), lupus (6 patients, 9.1%). During the follow-up, 31 patients (9.0%) transferred kidney transplantation and 65 patients transferred to hemodialysis. In 123 CAPD patients, death accounted for 24.1%. Cox regression showed that malnutrition (RR = 3.63, p < 0.01), cardiovascular disease (RR = 1.63, p < 0.05), age increased by 10 years (RR = 1.85, p < 0.05), and dialysis insufficiency (RR = 4.13, p < 0.001) were the independent risk factors.
Conclusions: The overall survival rate after 1, 2, 3 and 5 years was 88.9%, 72.6%, 61.4%, and 45.2%. Malnutrition, cardiovascular disease, age, and dialysis insufficiency are the independent risk factors.
Clinical Characteristics of Elderly Patients Undergoing Peritoneal Dialysis (PD)
Objective: To study the clinical characteristics of elderly patients undergoing PD.
Methods: We retrospectively reviewed 118 uremic patients on PD for more than 3 months in our center. The average duration for PD was 32.5 months. They were divided into elderly group (>60 years old) and non-elderly group (<60 years old). All patients used 1.5%–2.5% peritoneal dialysate 4–8 L/d. The etiology, clinical characteristics, and biochemical markers before PD, complications during PD, causes for quitting, death, and survival rate were compared between 2 groups.
Results: Diabetic mellitus (23.26% vs 10.81%, p < 0.01) and hypertensive renal damage (11.64% vs 5.13%, p < 0.01) were main etiology in elderly group. There were no significant differences in serum biochemical markers, renal function, adiponectin levels, hemoglobin, creatinine, calcium, phosphorus, Kt/V, residual renal function, between the 2 groups. In elderly group, serum album (35.25 ± 4.19 vs 30.75 ± 5.24 g/L, p < 0.01) was markedly decreased. The prevalence of cardiovascular events (22/48, 45.83% vs 27/70, 38.57%; p < 0.01) and malnutrition (19/48, 39.58% vs 18/70, 25.71%, p < 0.01) was higher than non-elderly group. The causes of quitting showed that peritonitis (4/48, 8.33% vs 3/70, 4.29%, p < 0.01) was notably higher in the elderly patients. The elderly group had higher mortality in cardiovascular events (50.51% vs 46.43%, p < 0.05), malignant tumor (17.81% vs 0, p < 0.01), infections (14.73% vs 6.43%, p < 0.01), and malnutrition (19/48, 39.58% vs 18/70, 25.71%, p < 0.01). No difference in 1-, 2-, 3-year survival rates (95.83% vs 96.14%, 64.37% vs 61.35%, 44.37% vs 42.45%, p > 0.05) was observed between the 2 groups.
Conclusions: PD was feasible renal replacement therapy for the elderly patients. Clinicians and administrators should pay more attention to prevent the occurrence of cardiovascular complications and malnutrition, thereby improve the life quality of patients.
Relationship between the Survival Rate of Patients on Continuous Peritoneal Dialysis and Their Primary Diseases
Background: To analyze the relationship between the survival rate of peritoneal dialysis (PD) patients and primary diseases as well as the factor of age, and to study the effects of the primary diseases and age on the survival time of PD patients.
Methods: 65 PD patients of the Nephrology Department of General Navy Hospital were enrolled in this study. Male-to-female ratio was 1:1.55 (22/34). Age was 32–79 years at the initiation of PD. The data of primary disease and PD duration were collected and analyzed.
Results: The primary diseases included diabetic nephropathy (n = 33, 64.0%), chronic glomerulonephritis (n = 11, 19.6%), hypertensive nephropathy (n = 5, 0.94%), interstitial nephritis (n = 2, 0.36%), rheumatoid disease (n = 3, 0.54%), and other diseases (n = 4, 0.71%). Upon Cox model regression analysis, actuarial patient survival rates were 89.2%, 75.5%, 60.7%, and 51.2% respectively at the end of 1, 2, 3, and 4 years. The regression analysis of single-factor Cox model revealed that both the patients over 65 years old and the diabetic nephropathy patients’ anticipated survival rate decreased (p < 0.05). The regression analysis of the multivariate Cox model shows that diabetes and age were the independent risk factors of uremic patients undergoing PD. The relative risk of the death in diabetic patients was 3.32 times than that of nondiabetic patients (95% CI 1.62–5.38; p < 0.0001). The relative risk increased 0.32 with 10-year age intervals (p = 0.037).
Conclusion: Advanced age and primary diseases are predictors of survival rate of PD patients.
Comparison of Continuous Ambulatory Peritoneal Dialysis Patients on Different Doses of Peritoneal Dialysis (PD) Fluid
Objective: To explore the suitable dose of PD fluid for Chinese CAPD patients (pts) to obtain adequate dialysis.
Method: 52 CAPD pts who have accepted PD for over 3 months were enrolled. Among of them, 32 received daily dialysis dose of 6 L and 20 received daily dialysis dose of 8 L. All pts were free from peritonitis within 1 month. The parameters of blood pressure, hemoglobin, creatinine, urea nitrogen, calcium, phosphorus, sodium, potassium, albumin, and blood carbonate were examined. Urine volume (UV) and ultrafiltration volume (UFV) of the pts were recorded. According to data of parameters, Kt/V of residual renal function was calculated. On the basis of nitrogen balance, the urea dynamics model was used to compare the various decisive indices of dialysis adequacy with the daily dialysis amount of 6 L and 8 L.
Results: The pts with 6 L daily dialysis dose had DPI of 0.92 ± 0.44 g/kg/d and nPCR of 0.84 ± 0.26 g/kg/d. They were in the status of nitrogen balance. There was no obvious difference between actual Kt/V and theoretical Kt/V. For the pts with 8 L daily dialysis dose, DPI was 0.74 ± 0.31 g/kg/d and nPCR was 0.88 ± 0.12 g/kg/d; they were also in the status of negative nitrogen balance and actual Kt/V was higher than theoretical Kt/V. The pts with 6 L daily dialysis had more UV than that with 8 L daily dialysis (735 ± 461 vs 342 ± 265 mL/d) and less UFV (447 ± 452 vs 856 ± 545 mL/d, p < 0.01) but there was no obvious difference in the outlet amount of body fluid (1182 ± 541 vs 1153 ± 5812 mL/d). There were also no obvious differences in hypertension, anemia, Ca and P metabolic disturbance, and the correction of the acidosis and the nutrition conditions between the 2 groups.
Conclusions: There is no obvious difference in clearance of water and solute in CAPD pts with daily PD doses of 6 L or 8 L. While the dialysis dose of 6 L is similar to the theoretical dose and the dialysis dose of 8 L is obviously higher than the theoretical dose.
Immunosuppressant Therapy: How Far Can We Go in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients with Anti-Neutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis?
Background: The management of immunosuppressants (IS) drugs in dialysis patients (pts) is a difficult matter, but pts with certain autoimmune insufficiency like ANCA-associated vasculitis (AAV) still need to continue the IS treatment for the illness that caused their renal failure. There is a paucity of evidence and literature indicating the optimal therapy of AAV pts requiring dialysis, especially with PD treatment. Little is known regarding a continuation of IS being beneficial following PD commencement, and question of how strong should the strategy be.
Methods: From 2006 to 2008, 9 AAV pts with IS therapy received CAPD treatment. Serum tests identified that all samples were positive for anti-MPO-ANCA. Clinical records of pts were retrospectively reviewed and analyzed.
Results: All 9 AAV pts were dialysis dependent; mean age at start of dialysis was 67.9 ± 12.3 years. Pts continued to receive IS treatment with pulse IV cyclophosphamide and prednisolone. Among them, 4 pts died of multiorgan failure due to uncontrolled pulmonary infection as well as active vasculitic lesions and stopped performing PD. Five AAV pts were on chronic CAPD therapy, with mean follow-up of 27.8 months (range 4–76). Survival rates for 5 chronic CAPD pts with AAV were 60% at 1 year and 20% at 5 years. There was no statistically significant difference in peritonitis (P) rates between AAV and non-AAV pts on chronic PD. Infection relevant to pulmonary involvement of active vasculitis accounted for the major causes of death. Poor nutritional status with hypoalbuminemia and severe anemia might indicate a worse prognosis.
Conclusion: IS therapy has been described as an additional risk factor for P in CAPD pts, leading to an impaired outcome, while our investigation stated evidence that P associated with IS treatment was not the most common cause of death in CAPD pts with AAV, same as AAV pts without dialysis. Pulmonary infection is the major cause of death in CAPD pts. Pts under suitable treatment with IS drugs during CAPD therapy should be taken into consideration and be tailored to meet individual requirements. Long-term monitoring of IS in AAV pts on CAPD requires further evaluation.
Combining Peritoneal Dialysis (PD) with Hemodialysis (HD) to Treat Chronic Renal Failure Patients
Objective: PD and HD are regarded as common renal replacement therapies. Each has its own characteristics and advantages. This study is to discuss the indications and values of clinical application combining PD with HD (PD+HD) to treat patients (pts) with chronic renal failure (CRF).
Methods: There were 7 pts with CRF treated by the combination PD+HD in our hospital. We analyzed the reasons of the combination of PD+HD, dialysis adequacy, and pts’ quality of life.
Results: There were 7 pts in the study (2 men, 5 women; average age 48.4 ± 12.1 years). The primary diseases of renal failure were as follows: chronic nephritis (4 pts), diabetic nephropathy (1), polycystic kidney (1), and hypertensive renal disease (1). Five pts preferred PD and 2 preferred HD. The latter 2 changed HDto PD about 1 year later because of refractory hypotension and their closed fistulas. For such reasons as peritoneal cavity infection (2 pts), ultrafiltration failure on PD (3), and secondary congestive heart failure of pulmonary infection (2), total Kt/V of the 7 pts was 1.46 ± 0.21 per week after they were treated by PD for 1–1.5 years. The doctor made them stop PD temporarily and change it to HD (3 times/week for 2 weeks) then gradually resumed PD, 8 L/day. Meanwhile, they needed to reduce HD to twice weekly for 1 week, CAPD for 5 days + 1 HD/week finally. Until now, the average dialysis time of adopting combination of PD+HD is 4.5 months and total Kt/V is 2.04 ± 0.16 per week. The pts’ dry weight is stable and their conditions of renal anemia and blood pressure are under good control.
Conclusion: When pts have some relevant complications or the single dialysis is not sufficient and so on, combining the 2 modalities and applying them alternately can help pts who need dialysis get through these special phases, enhance dialysis adequacy, improve the pts’ life quality, and lengthen their life.
Associations of Inflammation Status and EPO Resistance in Patients on Peritoneal Dialysis (PD)
Objective: Patients (pts) undergoing PD frequently exhibit subclinical inflammation and erythropoietin (EPO) resistance. The present study was aimed at investigating the associations of inflammation status and EPO resistance in pts on PD compared with those on hemodialysis (HD).
Methods: We studied 24 pts with end-stage renal disease on PD and 125 pts on HD for more than 6 months and receiving EPO 1 MIU/week and vitamin B12 0.5 mg/week. We expressed EPO resistance index (ERI) as weekly EPO dose per hematocrit per body weight. The satisfactory dose of EPO was defined to maintain a target Hct level of 33%–36% and hemoglobin >110 g/L. Subclinical inflammation statuses were expressed by serum levels of C-reactive protein (CRP) and interleukin (IL)-6. Various factors in those 2 groups were investigated that might predict EPO resistance using correlation and linear regression analysis. The difference between the 2 groups was compared.
Results: (1) 29.2% (7/24) of pts in the PD group were EPO >150 U/kg/week versus 28% (35/125) of pts in the HD group; there was no difference between the 2 groups. (2) It seemed that Hb levels in PD group were higher than in HD group but did not reach significant difference (79 ± 12 vs 75 ± 13 g/L, p = 0.31). The level of serum albumin (sAlb) had the same results (34.2 ± 15.6 vs 33.9 ± 15.2 g/L, p = 0.25). When infection appeared, Hb and sAlb decreased rapidly and recovered slowly when the infection was controlled. (3) In PD group there was a lower CRP level compared to the HD group (11.5 ± 4.9 vs 13.2 ± 5.8 mg/L, p < 0.05). (4) The EPO >150 U/kg/week patients had a lower sAlb level and a higher CRP. Correlation analysis showed that the ERI had statistically significant correlations with CRP (r = 0.285), IL-6 (r = 0.331), and sAlb (r = –0.30). These results show that CRP, sAlb, and IL-6 are factors related to EPO resistance. Multiple stepwise linear regression analysis showed that CRP was the most important independent predictor of EPO resistance.
Conclusion: CRP, sAlb, and IL-6 relate to EPO resistance. Inflammation contributes significantly to EPO resistance. PD pts may be in a low inflammation status compared to HD pts.
A Comparison between Diabetic and Nondiabetic Patients on Peritoneal Dialysis in a Single Center in China
Objective: To analyze the morbidity and mortality between diabetic (DN) and nondiabetic patients on peritoneal dialysis.
Methods: 230 patients on peritoneal dialysis were included in this study from November 2001 to May 2009, of them 42 patients’ underlying disease was DN (29 males, 13 females); 188 were nondiabetic (126 males, 62 females). Mean follow-up time was 24.6 months (range 6–81 months).
Results: The overall median survival time was 48 patient-months. Median survival time of DN (34.5 patient-months) was significantly inferior to nondiabetic patients (59 patient-months, p = 0.001). The overall patient survival rate at 1, 2, 3, 4, and 5 years was 76.1%, 42.2%, 23.0%, 10.9%, and 4.8%, respectively. Survival rates of diabetic versus nondiabetic at 1, 2, 3, 4, and 5 years was 64.3% versus 78.7%, 38.1% vs 43.1%, 26.2% vs 22.3%, 9.5% vs 11.2%, and 0 vs 3.7%, respectively. Albumin (33.0 ± 4.7 g/L vs 36.9 ± 5.7 g/L, p < 0.05), C-reactive protein (CRP; 48.9 ± 49.4 vs 26.3 ± 43.5, p < 0.05) had statistical difference between DN patients and nondiabetics on peritoneal dialysis.
Conclusion: The majority of ESRD in China is primary glomerular disease. The mortality of DN on peritoneal dialysis is higher than in nondiabetics. The major cause of dropout was cardiovascular complications for DN on peritoneal dialysis and peritonitis for nondiabetics.
High-Dose Peritoneal Dialysis in Acute Kidney Injury
Objectives: Continuous replacement renal therapy (CRRT) has become the most commonly used dialysis method for acute kidney injury (AKI) around the world. However, the optimal dialysis modality for the treatment of AKI is controversial, and CRRT requires dedicated machines that most hospitals in developing countries may not have. In this prospective observational trial, we compared the effect of high-dose peritoneal dialysis (HPD) with CRRT on AKI patient survival and renal recovery.
Methods: AKI was defined according to the acute dialysis quality initiative RIFLE criteria. Estimated glomerular filtration rate (eGFR) was calculated from the Cockcroft-Gault equation. 46 patients with AKI were assigned to HPD or CRRT in our hospital, 22 were treated with HPD and 24 with CRRT: HPD patients exchange 16–20 L/d; CRRT patients with mean effluent flow of 30–45 mL/kg/h. The end points were hospital survival rate and renal function recovery.
Results: The HPD and CRRT groups were similar in age (54.2 ± 16.8 vs 52.5 ± 17.2 years), gender (male: 64% vs 58%), sepsis (68% vs 66%), hemodynamic instability (64% vs 63%), predialysis creatinine (432.4 ± 136.8 vs 468.2 ± 168.4 μmol/L), BUN (26.4 ± 13.4 vs 32.6 ± 16.8 mmol/L), and eGFR (11.2 ± 4.6 vs 12.4 ± 6.6 mL/min). Weekly delivered Kt/V was 3.4 ± 0.8 in HPD group and 4.3 ± 0.9 in CRRT group. Mortality (55% vs 58%) and renal function recovery (36% vs 41%) were similar in both groups. Time to the recovery of renal function was 123.2 ± 50.4 hours and 143.2 ± 56.4 hours in patients of the 2 groups respectively.
Conclusion: With careful selection of techniques to meet the individual demands of the patient, PD can be considered an appropriate modality of RRT in AKI.
Proton Pump Inhibitor for Gastroesophageal Reflux Symptom in Continuous Ambulatory Peritoneal Dialysis Patients
Objective: To evaluate the gastroesophageal reflux symptom in continuous ambulatory peritoneal dialysis (CAPD) patients and observe the effect of proton pump inhibitor (PPI).
Methods: 58 clinically stable and adequately dialyzed CAPD patients were inquired about their gastroesophageal reflux symptoms by the same doctor using reflux disease questionnaire (RDQ). Of the 58 patients, 17 (29.31%) had a RDQ score >6. For patients with RDQ ≥6 (group 1), we prescribed esomeprazole magnesium enteric-coated tablets 20 mg once daily, and for patients with RDQ ≥12 (group 2), we prescribed esomeprazole magnesium enteric-coated tablets 20 mg twice daily. After 4 weeks of therapy, RDQ scores were reevaluated to assess the effects.
Results: Mean age of the 17 patients (7 males and 10 females) enrolled in the study was 62.47 ± 14.87 years and mean dialysis duration was 29.19 ± 26.22 months. The range of total daily dialysate volume was 8–10 L. Before treatment, the most frequent symptom was reflux (11/17, 64.70%), followed by acid reflux (9/17, 52.90%) and epigastric pain (8/17, 47.10%). Mean RDQ scores were 8.12 ± 1.64 in group 1 and 15.44 ± 4.39 in group 2. After 4 weeks of therapy, mean RDQ scores were 5.87 ± 1.45 in group 1 and 11.77 ± 4.26 in group 2. RDQ scores decreased significantly in both groups but there was no significant difference on the therapy effects between the 2 groups.
Conclusion: PPI can release the gastroesophageal reflux symptom in CAPD patients. A larger clinical trial is needed to evaluate the course and effect of treatment.
Prevalence of Gastroesophageal Reflux Disease in Senile Continuous Ambulatory Peritoneal Dialysis Patients and Analysis of Associated Factors
Objective: To evaluate the prevalence of gastroesophageal reflux disease (GERD) in old continuous ambulatory peritoneal dialysis (CAPD) patients and analyze the associated factors.
Methods: 56 clinically stable and adequately dialyzed CAPD patients were inquired about their gastroesophageal reflux symptoms by the same doctor by using reflux disease questionnaire (RDQ). Group senile included those patients with age ≥60 years and group non-senile included those patients with age <60 years. We compared the baseline characteristics, peritoneal dialysis-related factors, nutritional indices, inflammatory index, and RDQ score between 2 groups and evaluated the relationship between RDQ score and other factors.
Results: Mean age of the 56 PD patients enrolled in the study was 60.34 ± 14.22 years, mean body mass index was 24.24 ± 4.31 kg/m2, and median dialysis duration was 20.0 (10.0–33.0) months. Of the 56 patients, there were 27 patients in senile group and 29 in non-senile group. Five (18.52%) in senile group and 4 (13.79%) in non-senile group were diagnosed as GERD by RDQ. Mean RDQ scores were 4.07 ± 5.27 (range 0–14) in senile group and 3.90 ± 6.74 (range 0–25) in non-senile group. There were no significant differences in Ccr and prevalence of GERD between 2 groups, but group senile seemed to have a higher prevalence of GERD and RDQ score than group non-senile. RDQ score was highly correlated to dialysate volume per day (r = 0.349, p = 0.009).
Conclusions: Senile CAPD patients seem to have a higher RDQ score and GERD prevalence. RDQ score is highly correlated to daily dialysate volume.
Clinical Observation and Nursing of Peritoneal Dialysis Patients with Different Residual Renal Function
Objective: To compare the clinical characteristics of peritoneal dialysis (PD) patients with different residual renal function (RRF) to decide the optimal therapy and nursing regimen.
Methods: We included 32 patients maintaining PD. 16 patients had residual creatinine clearance rate (CCR) <3 mL/min were in low-RRF group and the other 16 patients with residual CCR ≥3 mL/min were in high-RRF group. The clinical characteristics concerning the PD dose, nutrition, and RRF were collected.
Results: Mean age of these patients was 49 (13-78) years; 20 males and 12 females. The time under PD was 737 (318-2183) days. Average follow-up time was 432 (203-772) days. There were no significant differences in above characteristics between groups. The urine output in low-RRF group (71.2 ± 108.1 mL) was significantly less than that in high-RRF group (940.3 ± 454.4 mL, p < 0.05), and the serum creatinine level in low-RRF group was higher than that in high-RRF group (1193.8 ± 249.7 vs 900.6 ± 285.2 μmol/L, p < 0.05). There were no significant differences in serum albumin level, nPCR, and nDPI between 2 groups. The peritoneal Kt/V in low-RRF group was 1.76 ± 0.33 with 3.9 ± 0.7 bags/day, higher than that in high-RRF group: 1.30 ± 0.36 with 3.3 ± 0.6 bags/day (p < 0.05). The total CCR in low-RRF group was 41.94 ± 5.33 mL/min, lower than that in high-RRF group (64.77 ± 15.01 mL/min, p < 0.05), but the total Kt/V level in low-RRF group was 1.78 ± 0.34, with no significant difference compared to that in high-RRF group (1.87 ± 0.38, p > 0.05).
Conclusion: The PD patients with low RRF could maintain dialysis adequacy and nutritional status by increasing the PD dose.
Glucose Control in Peritoneal Dialysis Patients is Related to Predialysis Diabetic Control
Objective: Glucose control is an important part in managing diabetic peritoneal dialysis patients. Many studies have shown that glucose control in this patient population may not be optimal. In the present study, we investigated the possible causes of inadequate glucose control in peritoneal dialysis patients.
Methods: We retrospectively analyzed glucose control in 102 diabetic peritoneal dialysis patients in our program and compared the glucose control at sixth month after peritoneal dialysis and the glucose control before peritoneal dialysis. All patients were divided into 2 groups based on their hemoglobin A1C (HbA1C) values at sixth month after dialysis: <7% in group 1 and ≥7% in group 2.
Results: HbA1C before peritoneal dialysis was 6.14% ± 0.82% in group 1 and 7.30% ± 1.42% in group 2 (p < 0.01). The proportion of adequate HbA1C control before peritoneal dialysis accounted for 89.8% in group 1 and 31.4% in group 2 (p < 0.01). In addition, there were significant differences in the duration of diabetes as well as the frequency of glucose monitoring before peritoneal dialysis between these 2 groups, with group 1 significantly better than group 2.
Conclusion: Glucose control after peritoneal dialysis is related to glucose control before dialysis, indicating poor glucose control in peritoneal dialysis patients may not be a simple medical issue but more of a cultural issue.
A Novel Overhydration Marker Predicts Cardiac Structure and Remodeling in Peritoneal Dialysis Patients
Objective: Fluid overload is common in peritoneal dialysis (PD) patients. However, it has been difficult to assess volume status and dry weight in this patient population. In the present study, we investigated the relationship between a new index of overhydration (OH) derived from body composition monitor (BCM) and cardiac status.
Methods: 80 PD patients in our program from March to June 2009 were included in the present study. Patients’ volume status was measured by BCM and the cardiac status, such as cardiac hemodynamics and cardiac structure, were assessed by echocardiography. Patients were grouped according to the OH values: OH <2 L in group 1 and OH ≥2 L in group 2. Comparisons were made between these 2 groups on baseline information, cardiac function, cardiac structure, and hemodynamics and left ventricular remodeling.
Results: There were significant correlations between OH values and cardiac status such as left ventricular end diastolic volume (EDV), left ventricular end systolic volume (ESV), left ventricular end diastolic diameter (LVEDD), left atrial (LA), left ventricular mass (LVM), and left ventricular mass index (LVMI-BSA, LVMI-height) (all p < 0.01). There were no significant differences in gender, age, height, weight, body mass index (BMI), dialysis vintage, and total Kt/V between the 2 groups. Blood pressure including systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure (PP) and mean arterial pressure (MAP) were all higher in group 2 compared to group 1. Cardiac structure and remodeling were all significantly altered in group 2 compared to group 1.
Conclusion: OH values correlate significantly with cardiac structure, indicating OH might be used as a novel noninvasive quantitative indicator of fluid status in PD patients.
Predialysis Cardiac Function Predicts Volume Control after Initiation of Peritoneal Dialysis Treatment
Objective: It has been recently reported that patients with predialysis congestive heart failure had high mortality on dialysis, especially on peritoneal dialysis. However, the mechanism was not clear. We postulated that this patient population may be more prone to be volume overloaded after dialysis. In the present study, we investigated the association between cardiac function before dialysis therapy and volume control after peritoneal dialysis.
Methods: In a cross-sectional study, 143 prevalent peritoneal dialysis patients treated in our hospital from September 2008 to February 2009 were investigated. We checked their volume status and retrospectively reviewed their cardiac function before dialysis therapy, fluid removal, diabetic status, and volume status.
Results: Among the patients studied, patients with resistant volume overload had significantly higher percentage of congestive heart failure before dialysis compared to those with normal volume status (63.6% vs 40.9%, p < 0.01). Furthermore, male diabetic patients were more likely to be volume overloaded compared to their respective counterparts. However, there were no significant differences in fluid removal between the patients with resistant volume overload and patients with normal volume status.
Conclusions: Previous cardiac function may predict the volume control after initiation of peritoneal dialysis therapy. The nonsignificant differences in fluid removal between the groups indicate there must be differences in their fluid intake.
Relationship between Traditional Chinese Medicine Syndromes and C-Reactive Protein in Peritoneal Dialysis Patients
Objective: The state of microinflammation is a common clinical manifestation in patients. In the present study, we tried to find clinical characteristics using Chinese medicine syndromes in patients with elevated C-reactive protein (CRP) without apparent infection.
Method: A questionnaire based on the critera made by the Nephrology Branch of the Chinese Medical Association in 2006 was used in peritoneal dialysis patients and their Chinese medicine syndromes were identified. The asthenia syndromes include spleen and kidney Qi deficiency, liver and kidney Yin deficiency, spleen and kidney Yang deficiency, both Qi and Yin deficiency, and both Yin and Yang deficiency. The excess syndromes consist of none syndrome, turbid damp syndrome, damp-heat syndrome, heat-toxicity syndrome, and blood stasis syndrome. The relationship between CRP and these syndromes was analyzed.
Results: The mean values of all the asthenia syndromes were higher than the normal levels but there were no significant differences among the different asthenia syndromes. However, in the excess syndromes, the CRP in patients with damp-heat syndrome was significantly higher than that of any other syndrome (p < 0.05).
Conclusions: Elevated CRP level in patients without apparent infection is associated with damp-heat syndrome, indicating traditional Chinese medicine may be a novel way to decreased serum CRP level in dialysis patients.
Volume Control in Peritoneal Dialysis Patients Guided by Bioimpedance Assessment: A Randomized Controlled Trial
Objective: Volume overload is a common problem in peritoneal dialysis (PD) patients and may have contributed to the high cardiac mortality in this patient population. Controlling volume status has been difficult due to the lack of appropriate assessment of dry weight. This randomized controlled trial was conducted to test if the recent use of overhydration (OH) value would help to control OH.
Methods: 169 PD patients were included in this study. All the patients were randomly divided into 2 groups: in group 1 the patients and their primary nurses were informed of the OH values; in group 2 the values were not told. Fluid status was evaluated by means of repeated bioimpedance analysis and clinical assessment. Blood pressure and antihypertensive medication were all recorded.
Results: There were no differences in gender, age, height, weight, hydration status, and diabetic status between the 2 groups at the baseline. In group 1, OH (p < 0.01), extracellular (ECW) volume (p < 0.05), and the extracellular volume to intracellular volume (E/I) ratio (p < 0.05) decreased steadily during the 3-month follow-up. On the contrary, all the 3 parameters increased significantly in group 2. Systolic blood pressure decreased significantly in group 1 but increased significantly in group 2.
Conclusion: The use of OH value may facilitate volume control in peritoneal dialysis patients.
Gender Difference in Volume Control in Continuous Ambulatory Peritoneal Dialysis Patients
Objective: Volume overload is common in continuous ambulatory peritoneal dialysis (CAPD) patients and is commonly related to patients’ lifestyle, which may differ very much between different genders. In the present study we investigated the impact of gender on volume control in CAPD patients.
Methods: Clinically stable CAPD patients (n = 251; 113 males, 138 females) in a single center were included. Multiple-frequency bioelectrical impedance analysis was used to evaluate the volume status of the patients and the values of volume overload (OH) were analyzed. Blood biochemistry was determined with standard methods.
Results: There was significant difference in the OH value and total fluid removal between male and female peritoneal dialysis patients: OH values were 3.05 ± 2.15 L in males and 1.86 ± 1.52 L in females (p < 0.01). The total sodium removal was 118.13 ± 50.26 mmol/d in males and 96.47 ± 57.34 mmol/d in females (p < 0.01) and total fluid removal was 1112.54 ± 598.62 mL in males and 1042.56 ± 501.98 mL in females (p < 0.05).
Conclusion: Male CAPD patients are more volume overloaded compared to female CAPD patients despite the fact that female patients remove less sodium and fluid compared to male patients, indicating that female CAPD patients must have restricted salt and fluid intake more vigorously than male patients.
Clinical Research of Trocar for Placement of Peritoneal Dialysis Catheter
Background: Continuous ambulatory peritoneal dialysis (CAPD) is commonly used in uremia patients and its outcome highly depends on a well functional PD catheter. The placement of the catheter is frequently limited by the cooperation of surgeons. A less costly, safer, and more effective method is needed. We aimed to evaluate the use of a novel Trocar with less blade exposure in the abdominal cavity, and a unique self-retaining stability sleeve for placement of PD catheter.
Methods: 40 uremic patients were enrolled and randomly assigned to Trocar group (n = 20) and traditional operation group (Trad group, n = 20). The time of operation and out-of-bed activity were recorded, and the complications of operation and catheter related were observed.
Results: The time of operation and out-of-bed activity in the Trocar group was remarkably shorter than that in the Trad group (p < 0.001). Abdominal pain, impairment of organs in abdominal cavity, and hematoma were not found in both groups. Migrated catheter (n = 1), non-patent catheter (n = 4), and bloody ascites (n = 1) were found in the Trocar group, while migrated catheter (n = 1), non-patent catheter (n = 3), and peritonitis (n = 1) were found in the Trad group. Leak was not found at operative incision and tunnel in both groups.
Conclusions: Using Trocar for placement of PD catheter can decrease the operation time, and patients would recover quickly. Peritoneal dialysis 2 weeks after operation is safe and feasible.
Complications of Peritoneal Catheter Insertion: Comparison of Painless Operation with Others Using Local Anesthesia
Objective: To investigate complications from painless peritoneal dialysis catheter surgery and the incidence of nonfunctioning catheter.
Methods: To find a way to make patients feel painless during the operation, we applied a variety of anesthesia manners to those patients who need peritoneal dialysis catheter insertion as of November 2007, of which there were 75 cases through the use of local anesthesia and intravenous anesthesia, 3 cases with abdominal wall nerve block, 2 cases of abdominal wall nerve block and intravenous anesthesia plus local anesthesia, 5 cases utilizing epidural anesthesia. Besides complications of the surgery, the incidence of nonfunctioning catheter was compared between the above group and those who received the same operations by local anesthesia prior to November 2007. All patients were inserted with straight catheters, Quinton™ 41 cm.
Results: Intraoperative complications were found as follows: high blood pressure was found in 2 cases in painless anesthesia group, 78 cases in local anesthesia group; blood pressure decreased significantly.
Conclusions: The peritoneal dialysis catheter painless operation can not only alleviate the suffering of patients, also can reduce the incidence of elevated blood pressure, reduce the risk of surgery. Besides no difference between the 2 groups was found in regard to catheter function, peritoneal dialysis catheter painless operation is worth promoting. However, due to the vague awareness in patients of intravenous anesthesia and failure of determination of exact catheter position, experienced doctors are highly recommended for this kind of surgery.
Therapy in Twenty Cases of Peritoneal Dialysis-Related Staphylococcal Peritonitis
Objective: To investigate the therapeutic strategy in continuous ambulatory peritoneal dialysis (CAPD)-related staphylococcal peritonitis.
Methods: 20 cases of staphylococcal peritonitis in CAPD patients were analyzed from January 2007 to March 2009.
Results: During the study period, 61 cases of peritonitis developed. 54 cases of infections presented positive (88.5%) in terms of pathogenic culture, including 48 cases of bacterial infections and 6 cases of fungal infections. Among these bacterial peritonitis, 38 cases were gram positive, 11 cases were gram negative. 17 cases of coagulase-negative staphylococci and 3 Staphylococcus aureus were responsible for staphylococci infections. Empirical treatment was intraperitoneal administration of cefazolin, levofloxacin, or amikacin. Vancomycin was administered intraperitoneally in patients with S. aureus peritonitis. 15 cases of staphylococcal peritonitis were cured while the other 5 cases relapsed, with no signs of infection in subcutaneous tunnel or at the exit. The pathogens of the relapsed peritonitis were S. epidermidis (2 cases), S. haemolyticus (1 case), S. cohnii (1 case), and S. aureus (1 case). The 2 relapsed cases of S. epidermidis infection were cured after vancomycin treatment. The 1 relapsed case of S. haemolyticus sensitive to vancomycin in culture was treated by cefazolin and ceftazidime intraperitoneally for 2 weeks, then teicoplanin and sulperazon for another 2 weeks. This case was cured by intraperitoneal administration of linezolid eventually. Catheters were removed in 2 relapsed cases caused by S. aureus and S. cohnii.
Conclusions: The relapse of coagulase-negative staphylococci peritonitis is not rare and can be cured with vancomycin usually. In exceptional cases, removing the catheter or administering specific antibiotics of vancomycin-resistant bacteria is preferred.
Clinical Investigation of Patients Surviving on Continuous Ambulatory Peritoneal Dialysis (CAPD) Longer than Three Years
Objective: To investigate the clinical features of patients (pts) receiving CAPD with over 3-year survival. Methods: Retrospective analysis was performed on the pts receiving CAPD for >3 years in our hospital from April 1999 to May 2006, to investigate the clinical features of pts with long-term CAPD. 24 pts receiving CAPD were recruited [14 males, 10 females; mean age 57.04 ± 11.62 (23-73) years; mean dialysis duration 4.28 ± 0.83 (3-6) years]. Primary diseases were chronic glomerulonephritis (in 13), benign arteriolar nephrosclerosis (4), diabetic nephropathy (4), obstructive nephropathy (1), lupus nephritis (1), and gouty nephropathy (1). All pts received CAPD. Residual renal Ccr and urinary volume (UV) at the beginning of CAPD were recorded and telephone follow-up was performed every month. Dialysis adequacy, frequency and cause of hospitalization, hemoglobin, blood pressure (BP), and serum albumin, creatinine, calcium, phosphate, and blood lipids were determined and recorded. Results: Residual Renal Function: At the beginning of CAPD, residual renal Ccr was 7.82 ± 2.74 mL/min, 24-hour UV 537 ± 367 mL; after 3 years, 24-hour UV 286 ± 277 mL, 6 of 24 pts 24-hour UV >400 mL/d (using furosemide), 7 of 24 >100 mL/d. Dialysis Adequacy: Dialysis dosage 6000–8000 mL/d, Kt/V >1.7, range 1.77–2.85, average 2.21 ± 0.36. Nutrition Condition: 24 pts Alb 36.63 ± 3.93 g/L, 3 of 24 <30 g/L, 9 of 24 Alb 30–34 g/L, 12 of 24 >35 g/L. BP: 10 of 24 systolic BP <140 mmHg, 15 of 24 diastolic BP <90 mmHg, 6 of 24 pts taking 2–4 antihypertensive drugs at the beginning of dialysis and stopped using antihypertensive drugs at present. The pts reduced the dosage and categories of antihypertensive drugs, the BP normalized. Blood Lipids: 16 of 24 with normal blood lipid, 8 of 24 with abnormal blood lipid level. Hemoglobin: 24 pts with Hb 85.18 ± 10.93 g/dL, only 3 Hb >100 g/dL, the reason for abnormal Hb was the irregular use of EPO. Calcium and Phosphate: 2 patients with high phosphate and low Ca, 11 with high PTH. Composition of Dialysis Solution: Mainly using low glucose dialysis solution: 1.5% dialysis solution accounted for 66%, 2.5% dialysis solution for 33%, 4.25% dialysis solution for 1%. Hospitalization Condition: 8 pts with >3 times, 3 pts >2 times, and 5 pts once. The primary reason for hospitalization was peritonitis, the secondary was cerebral infarction and cardiac insufficiency caused by volume overload. Cause of Death: 7 pts died at 3–6 years after CAPD. The cause of death was cerebral apoplexy in 3, peritonitis in 3, and myocardial infarct in 1. Conclusion: After 3 years on PD, majority pts could maintain certain residual renal function and have good small solute clearance and ultrafiltration. With only mild malnutrition and anemia, BP and lipids were under control; some pts had disturbance of Ca and P metabolism. The high mortality of this group of pts was related to multiple system organ failure caused by replication and refractory peritonitis.
Quitting Treatment or Hospitalization: Cause Analysis for Patients with Peritoneal Dialysis (PD)
Objective: To analyze the cause for patients (pts) with PD to quit treatment or to be hospitalized (Hos), therefore to elucidate the factors influencing the pts with PD to maintain treatment.
Methods: 62 pts receiving PD in our hospital from April 1999 to February 2006 were recruited [36 males, 26 females; average age 60.8 ± 17.0 (23-89) years; dialysis duration 18.6 ± 12.9 (3-67) months]. The primary diseases to cause chronic renal failure included chronic glomerulonephritis in 30 pts, benign arteriolar nephrosclerosis in 11, diabetic nephropathy in 10, gouty nephropathy in 4, and other diseases in 7. Kidney function when receiving dialysis: BUN 26.1 ± 7.7 mmol/L, Cr 832.2 ± 299.6 μmol/L, CCr 4.5 ± 2.3 mL/min. All pts received CAPD. To investigate the Hos condition after receiving PD, including the date, duration, cause of Hos, dialysis adequacy, and residual renal function were determined; serum albumin, prealbumin, transferrin, and creatinine were evaluated; serum C-reactive protein, blood pressure, heart function, record history of the cardio- cerebrovascular diseases, and history of peritonitis were investigated. All pts were traced until Feb. 2006. If the pt quit within the tracing duration, the quit date would be the ending date of tracing. The Hos condition and the reason to quit treatment were recorded.
Results: Among the 62 pts, 38 maintained to the end date of tracing; 24 quit treatment. Dialysis duration for the pts quitting treatment was 3 ± 45 (18.5–12.8) months; age at time of quitting was 63.3 ± 17.9 years. Among the 24 pts quitting treatment, 20 died, 4 transferred to hemodialysis. The primary cause for the 24 pts was cardiovascular diseases, accounting for 62.5%; the second cause was peritonitis, 20.8%; lung infection and malnutrition were also important causes for these pts. To the ending date of tracing, 27 pts had Hos record, accounting for 43.5%; Hos occurred once for 11 patients, 40.7%; twice 12 pts, 44.4%; three times for 4 pts, 14.8%. The causes of 47 Hos's of the 27 pts were as follows: PD-related infection was the primary cause, 42.6%; second was cardio- cerebrovascular diseases, 25.5%; lung infection, 14.9%.
Conclusions: Cardio- cerebrovascular diseases and infection were important factors for pts to quit treatment or Hos, and peritonitis is one of the most frequent factors affecting quitting or Hos.
Prevalence of Hepatitis B and C Virus Infection in Uremia Patients Undergoing Peritoneal Dialysis (PD)
Objective: To investigate the prevalence and causes of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in chronic PD patients (pts) during the long-term therapy and try to find the clue of preventing from HBV and HCV infection.
Methods: The investigation was performed in March 2009. 123 PD pts who had received PD therapy for more than 6 months were screened for HBV markers (HBV-M) and HCV antibody and blood transfusion were collected. Data were compared with those collected before their entrance of PD. In the meantime, PD pts were also compared with hemodialysis (HD) pts to research the characteristic of HBV and HCV infection in uremia pts undergoing PD therapy.
Results: The 123 PD pts included 75 males and 48 females, average age 63.1 years, 37 months of follow-up, and no blood transfusion. Before maintenance PD, 47 were identified HBsAg negative with HBV antibody positive and 66 were all HBV-M(–). The rest 10 were HbsAg(+). In March 2009 there was no change in HBV-M in both group of HBsAg(–) with HBV antibody(+) and HbsAg(+). But, among 66 all HBV-M(–) pts, 44 kept negative and 21 showed HBsAg(–) with HBV antibody(+). Two pts had their HBsAg turned into positive. At the same time 174 HD pts were recruited as control with 39 months follow-up. 11 kept HBsAg(+) and 96 had HBsAg(–) with HBV antibody(+) persistently. One of 67 pts with all HBV-M(–) first turned into HbsAg(+) while 24 had HBsAg(–) with HBV antibody(+). There was no significant difference between PD and HD pts (p > 0.05). Before entrance of PD only 1 pt showed anti-HCV(+) and there was no increasing case of anti-HCV(+) in the end. Among HD pts, 1 of 174 pts was positive with anti-HCV at first, while in March 2009 other 36 pts were positive too. It showed significant difference between PD and HD pts (p < 0.01).
Conclusion: Uremia pts undergoing PD and HD have a high risk of infecting HBV with poor immunity but HBV infection is not associated with dialysis type. HD pts have higher rate of HCV infection than PD pts.