bluuebunny/crossref_metadata_2025 huggingface dataset:
Take Care in how you Store Your PD Fluids: Actual Temperature Determines the Balance between Reactive and Non-Reactive GDPs
Authors: Erixon Martin , Wieslander Anders , Lindén Torbjörn , Carlsson Ola , Forsbäck Gunita , Svensson Eva , Jönsson Jan Åke , Kjellstrand Per
Published: February 2020

Objective

During heat sterilization and during prolonged storage, glucose in peritoneal dialysis fluids (PDF) degrades to carbonyl compounds commonly known as glucose degradation products (GDPs). Of these, 3,4-dideoxyglucosone-3-ene (3,4-DGE) is the most cytotoxic. It is an intermediate in degradation between 3-deoxyglucosone (3-DG) and 5-hydroxymethyl-2-furaldehyde (5-HMF). We have earlier reported that there seems to be equilibrium between these GDPs in PDF. The aim of the present study was to investigate details of this equilibrium.

Methods

Aqueous solutions of pure 3-DG, 3,4-DGE, and 5-HMF were incubated at 40°C for 40 days. Conventional and low-GDP fluids were incubated at various temperatures for up to 3 weeks. Formaldehyde, acetaldehyde, glyoxal, methylglyoxal, 3-DG, 3,4-DGE, and 5-HMF were analyzed using high performance liquid chromatography.

Results

Incubation of 100 μmol/L 3,4-DGE resulted in the production of 36 μmol/L 3-DG, 4 μmol/L 5-HMF, and 40 μmol/L unidentified substances. With the same incubation, 200 μmol/L 3-DG was converted to 9 μmol/L 3,4-DGE, 6 μmol/L 5-HMF, and 14 μmol/L unidentified substances. By contrast, 100 μmol/L 5-HMF was uninfluenced by incubation. In a conventional PDF incubated at 60°C for 1 day, the 3,4-DGE concentration increased from 14 to a maximum of 49 μmol/L. When the fluids were returned to room temperature, the concentration decreased but did not reach original values until after 40 days. In a low GDP fluid, 3,4-DGE increased and decreased in the same manner as in the conventional fluid but reached a maximum of only 0.8 μmol/L.

Conclusions

Considerable amounts of 3,4-DGE may be recruited by increases in temperature in conventional PDFs. Lowering the temperature will again reduce the concentration but much more time will be needed. Precursors for 3,4-DGE recruitment are most probably 3-DG and the enol 3-deoxyaldose-2-ene, but not 5-HMF. Considering the ease at which 3,4-DGE is recruited from its pool of precursors and the difficulty of getting rid of it again, one should be extremely careful with the temperatures conventional PDFs are exposed to.
Influence of Icodextrin on Plasma and Dialysate Levels of N∊-(Carboxymethyl)Lysine and N∊-(Carboxyethyl)Lysine
Authors: Konings Constantijn J. , Schalkwijk Casper G. , van der Sande Frank M. , Leunissen Karel M. , Kooman Jeroen P.
Published: February 2020

Rationale

Standard peritoneal glucose solutions may induce the formation of advanced glycation end products (AGEs). Preliminary data suggest that AGE formation may be less with the use of polyglucose solutions (icodextrin). Therefore, we investigated whether the use of icodextrin for the long dwell would result in a reduction in plasma and dialysate levels of the AGE products N∊-(carboxymethyl) lysine (CML) and N∊-(carboxyethyl)lysine (CEL).

Patients and Methods

40 patients were randomized to treatment with standard glucose solutions (1.36%) and icodextrin for the long dwell during a 4-month study period; 32 patients completed the study. CML was assessed by stable isotope dilution/tandem mass spectrometry.

Results

CML levels in plasma increased significantly in patients treated with icodextrin (0.146 ± 0.056 at start vs 0.188 ± 0.069 μmol/mmol Lys at the end of the study, p < 0.0001) but did not change in the control group (0.183 ± 0.090 vs 0.188 ± 0.085 μmol/mmol Lys). The same held true for CML levels in dialysate (0.28 ± 0.09 at start vs 0.33 ± 0.11 μmol/mmol Lys at the end of the study, p < 0.025). No change was observed in patients treated with the control solutions (0.31 ± 0.11 at start vs 0.31 ± 0.07 μmol/mmol Lys).

Conclusion

Contrary to the hypothesis, plasma and dialysate levels of CML increased in patients treated using icodextrin for the long dwell.
The Effect of Low Glucose Degradation Product Dialysis Solution on Epithelial-To-Mesenchymal Transition in Continuous Ambulatory Peritoneal Dialysis Patients
Authors: Do Jun-Young , Kim Yong-Lim , Park Jong-Won , Cho Kyu-Hyang , Kim Tae-Woo , Yoon Kyung-Woo , Kim Chan-Duck , Park Sun-Hee , Han Jin-Hyun , Song In-Han
Published: February 2020

♦ Background

Human peritoneal mesothelial cells (HPMCs) undergo a transition from an epithelial phenotype to a mesenchymal phenotype (EMT) during peritoneal dialysis (PD). That transition may be directly related to failure of peritoneal membrane function.

♦ Objective

In a randomized prospective controlled study, we investigated the effect of low glucose degradation product (GDP) dialysis solution on the transition of HPMCs.

♦ Methods

Among new continuous ambulatory PD patients, 60 patients completed a 12-month protocol (low-GDP solution group, n = 32; high-GDP solution group, n = 28). At the 1st, 6th, and 12th months, HPMCs drained from overnight effluent were cultured on T25. When they had nearly reached confluence, cell scores were measured blindly by the same person (score 1 = cobblestone-shaped HPMCs, score 2 = mixed, score 3 = fibroblast dominant). Cell scores and clinical indices, including peritoneal markers, were compared between the low-GDP and high-GDP groups at the 1st, 6th, and 12th months. The factors associated with EMT were analyzed with generalized estimating equations using STATA 7.0 (STATA Corp., College Station, Texas, USA). In addition, vimentin and cytokeratin 8/18 stains were used to verify EMT in cultured cells and peritoneal specimens in some patients.

♦ Results

( 1 ) The low-GDP group showed higher dialysate cancer antigen 125 levels from the 1st to 12th months (55.4 ± 24.8 vs 8.8 ± 1.7, 56.7 ± 28.1 vs 22.1 ± 11.3, and 54.2 ± 28.2 vs 24.6 ± 16.5 U/mL, at the 1st, 6th, and 12th months, respectively; all p = 0.000). ( 2 ) The low-GDP group showed lower cell scores at the 1st, 6th, and 12th months (1.22, 1.22, and 1.56 vs 1.61, 1.75, and 2.14; p < 0.05, p < 0.01, and p < 0.01, respectively). ( 3 ) At the 12th month, the number of fibroblast-dominant cultures (score 3) was significantly lower in the low-GDP group [4/32 (12.5%) patients vs 14/28 (50%), p < 0.05]. ( 4 ) Both cobblestone-shaped HPMCs and fibroblastoid cells were positively stained with cytokeratin and vimentin. ( 5 ) There were many cytokeratin- and vimentin-positive cells in the submesothelial area in the peritoneal biopsy specimens. (6) The consistent factor associated with EMT was only high-GDP solution (60 patients, n = 178, beta coefficient 0.312, p = 0.000; 46 patients, n = 137, beta coef: 0.228, p = 0.000) and not numbers of peritonitis episodes, duration of angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker medication, or diabetes.

♦ Conclusion

Low-GDP solution showed beneficial effects such as rapid remesothelialization and less EMT in the peritoneum with time on PD.
A Ward-Based Procedure for Assessment of Fluid Status in Peritoneal Dialysis Patients Using Bioimpedance Spectroscopy
Authors: Lindley Elizabeth , Devine Yvette , Hall Lisa , Cullen Mary , Cuthbert Suzanne , Woodrow Graham , Lopot František
Published: February 2020

♦ Objective

This study was carried out to evaluate a procedure for converting bioimpedance spectroscopy (BIS) data to a clinically useful measure of fluid status that is easily interpreted by nursing staff and patients.

♦ Design

The ratio of extracellular water (ECW) to total body water (TBW) in a cohort of peritoneal dialysis (PD) patients was compared with the distribution for normal control subjects. The result was expressed as the difference between the measured ECW/TBW ratio and the mean ratio for age- and sex-matched controls divided by the standard deviation for the controls (the “hydration score”). Where possible, interventions were made to reduce the target weight in patients with a hydration score greater than +2.0.

♦ Setting

This clinical study was carried out in the nurseled outpatient PD unit at St. James's University Hospital. BIS measurements were carried out during routine clinic visits. The data for the control subjects were obtained in a range of settings in the UK and the Czech Republic.

♦ Patients

31 PD patients (21 M, 10 F; aged 19 – 78 years) who came to the PD unit for routine procedures during the study participated.

♦ Results

The mean hydration score for PD patients was significantly higher than for the control subjects (+1.3 vs 0.0, p < 0.0001). 11 (35%) patients had a hydration score greater than +2.0, compared with only 2.5% of the controls; systolic blood pressure was greater than 130 mmHg in only two of these patients. After a 3-month follow-up, a weight reduction of 3.6 ± 2.3 kg had been achieved in 7 patients through modality change and implementation of prescription changes, with no adverse effects.

♦ Conclusions

Although this was a small study, all the data collected indicated that the hydration score provides a reliable indication of fluid status in PD patients. BIS measurements are now carried out at 6-month intervals and are used to monitor the effect of interventions.
Assisted Automated Peritoneal Dialysis (Aapd) for the Functionally Dependent and Elderly Patient
Authors: Povlsen Johan V. , Ivarsen Per
Published: February 2020

♦ Objective

To describe basic demographics and clinical outcomes among elderly end-stage renal disease (ESRD) patients physically dependent on a caregiver and maintained on an assisted automated peritoneal dialysis (AAPD) program.

♦ Design

Retrospective single-center study based on patient records and data files.

♦ Setting

University Hospital.

♦ Patients

64 physically dependent AAPD patients followed for 1.012 treatment months. Assistance and care was delivered by 52 briefly trained teams of visiting nurses or nursing home staff.

♦ Result

Crude 1-year survival was 58% and 2-year survival was 48%. Crude 1- and 2-year survivals, excluding deaths within 90 days, were 66% and 54% respectively. We found no significant effect on survival by main causes of ESRD, gender, age, late referral, need for acute start, social isolation, physical dependency on help at inclusion, or residence in a nursing home. 10% of patient-days on AAPD were spent in hospital. 13 (20%) of the patients were converted permanently to hemodialysis due to PD technique failure. The incidence of peritonitis was 1 in every 25.3 treatment-months.

♦ Conclusions

AAPD may be a feasible and safe option for renal replacement therapy for frail, elderly, and physically dependent patients with ESRD. Despite the special patient selection for this AAPD program, we achieved results of international standards for patient survival, PD technique survival, and incidence of acute peritonitis. These results do not justify withholding dialysis from this group of patients.
Improving Salt Balance in Peritoneal Dialysis Patients
Authors: Van Biesen Wim , Vanholder Raymond , Veys Nic , Lameire Norbert
Published: February 2020

Volume homeostasis is an important predictor of outcome in peritoneal dialysis. Because volume retention is driven by salt retention, maintenance of salt balance should be a concern to all nephrologists. An important factor in this is dietary salt restriction. This has long been neglected in peritoneal dialysis patients, where it was considered that the continuous nature of the therapy and residual renal function would be sufficient to remove any extra salt load. In patients with preserved renal function, diuresis and salt excretion can be enhanced by the application of high doses of loop diuretics. This practice seems not to have an impact on the further deterioration of renal function. Peritoneal salt removal can be enhanced using polyglucose. Also, the use of low sodium-containing dialysate can be efficient. These solutions are, however, not commercially available, and they need higher concentrations of glucose to obtain an efficient osmolarity. It should always be considered that, due to sodium sieving over the ultrasmall pores, fluid and salt removal are not always concordant.
Peritoneal Dialysis Prescription for Diabetic Patients
Authors: Yao Qiang , Lindholm Bengt , Heimbürger Olof
Published: February 2020

The number of end-stage renal disease (ESRD) patients with diabetes mellitus has increased dramatically during the past few years and, in many countries, diabetes has become the most important cause of ESRD in patients admitted to dialysis. Furthermore, compared to nondiabetic patients, diabetic patients continue to suffer from more frequent and severe comorbidity and complications, including cardiovascular disease, poor fluid balance, worse quality of life, as well as high morbidity and mortality after initiation of dialysis. These systemic problems in diabetic patients should influence the dialysis prescription. In addition, the structure and transport properties of the peritoneal membrane may deteriorate as a consequence of diabetes. Thus, both the systemic and the peritoneal consequences of diabetes influence the dialysis prescription in diabetic patients. In this brief review, we discuss the care of diabetic ESRD patients on peritoneal dialysis — which, compared with hemodialysis, has both advantages and disadvantages in this group of patients — focusing on the special needs for intense and integrated care involving individualized dialysis prescription as well as care of diabetic complications and comorbidity in this diseased patient group.
Impact of Peritoneal Dialysis Dose Guidelines on Clinical Outcomes
Authors: Churchill David N.
Published: February 2020

The objective was to review the rationale for the Kidney Disease Outcomes Quality Initiative (K/DOQI) recommendations for adequacy of peritoneal dialysis and to evaluate the impact of these recommendations on clinical practice and patient survival. The K/DOQI recommendations were based on large observational studies; the target weekly Kt/V value of 2.0 assumed equivalence of peritoneal and renal clearances. This assumption is no longer considered correct. The impact on clinical practice was evaluated by an examination of temporal trends before and after publication of the guidelines in 1997. In the United States and The Netherlands, there had been a trend toward increased delivered total Kt/V prior to 1997, and there was no acceleration in this trend after 1997. Two randomized clinical trials have implemented these guidelines with increased peritoneal Kt/V (or creatinine clearance) used to achieve the K/DOQI target in the intervention group. This was not associated with improved survival, compared to a lower Kt/V, in either of the randomized clinical trials. Among the explanations for the failure to improve outcome are potential adverse effects of increasing the dialysis dose. These include increased intraperitoneal pressure associated with increased exchange volume, failure to increase clearance of middle molecules, and increased exposure to glucose. Strategies that increase peritoneal clearance without exposure to these potential adverse effects include more-frequent exchanges rather than increased exchange volume, and decreased exposure to glucose and glucose degradation products. Pending such studies, current K/DOQI guidelines should be updated in a timely manner.
Access and Continuous Flow Peritoneal Dialysis
Authors: Diaz-Buxo Jose A.
Published: February 2020

Continuous flow peritoneal dialysis (CFPD) presents many potential advantages over any conventional peritoneal dialysis modality. Foremost are the impressive clearances achieved by CFPD in clinical studies, approaching those of quotidian hemodialysis. The principal limitation of CFPD is its inability to provide adequate and consistent ultrafiltration in clinical practice, contrary to the high ultrafiltration predicted by theoretical models. There is a good possibility that this discrepancy is due to poor mixing, streaming, and recirculation of dialysate related to inadequate peritoneal access. Novel access designs are encouraging but await longitudinal clinical testing to prove their superiority.
Prevention and Treatment of Peritoneal Dialysis-Associated Peritonitis in Pediatric Patients
Authors: Klaus Günter
Published: February 2020

Peritoneal dialysis (PD) is the preferred dialysis modality in children and adolescents aged less than 15 years. Peritoneal dialysis-associated peritonitis remains a major cause of morbidity and reason for dropout from the PD program, although the incidence of peritonitis seems to have decreased during the past few years. Improved patient care, more frequent use of automated peritoneal dialysis (APD), use of PD catheters with downward facing exit sites, and Staphylococcus aureus prophylaxis account for this decline in infectious complications. With respect to the isolated micro-organism in PD-associated peritonitis, a predominance of gram-positive germs is found in children. Recent registry data suggest a decrease in coagulase-negative staphylococci, with a relative increase in gram-negative peritonitis episodes. The empiric antibiotic treatment regimen using a first-generation cephalosporin or a glycopeptide in combination with a third-generation cephalosporin in a risk-stratified manner was suggested in the pediatric peritonitis treatment guidelines. This regimen is currently being evaluated in the International Pediatric Peritonitis Registry.
Cardiovascular Morbidity and Mortality in Children with Chronic Kidney Disease in North America: Lessons from the Usrds and Naprtcs Databases
Authors: Mitsnefes Mark M.
Published: February 2020

Cardiovascular (CV) disease mortality has not changed in the past three decades, remaining the second most common cause of death in children with end-stage renal disease (ESRD). This article reviews pediatric data pertaining to CV disease obtained from the two largest renal databases in North America. The data indicate high incidence and prevalence of CV complications and cardiac risk factors in children with ESRD, accounting for high cardiac mortality in this patient population. Early identification and intervention to treat modifiable risk factors and asymptomatic cardiac disease might lead to prevention of cardiac disease and to a decrease in CV morbidity and mortality in young adults who developed chronic kidney disease during childhood.
How to Increase Adequacy of Peritoneal Dialysis in Children?
Authors: Schröder Cornelis H.
Published: February 2020

Since children on dialysis are treated most often with nightly intermittent peritoneal dialysis, adequacy of dialysis is determined by the number and duration of cycles, the volume of the dialysis fluid applied, and the choice of dialysis solution. The number and duration of cycles are dependent on the maximal acceptable duration of night rest and the permeability properties of the peritoneal membrane. The latter can be established by performance of a peritoneal equilibration test. The volume used should be about 1200 mL/m2 body surface area, and intraperitoneal pressure should be between 5 and 15 cm H2O. The dialysis solution administered should have a glucose concentration as low as possible, and an icodextrin daytime dwell may be considered.
Peritoneal Dialysis Training: A Multisensory Approach
Authors: Neville Alison , Jenkins Jean , Williams John D. , Craig Kathrine J.
Published: February 2020

Undertaking peritoneal dialysis (PD) therapy poses a challenge to all patients with renal failure. The potentially high risk of infection makes it essential that patients undertaking PD have adequate training and ongoing support. Over recent years, increasing numbers of elderly patients, patients with significant learning disabilities, and patients with marked comorbidities have been accepted onto renal replacement therapy programs. For those undertaking PD in particular, this has posed new educational challenges.

The Community Dialysis Team recognized an area of weakness in their current training program for these patient groups. The degree of literacy skills as well as the volume of written material and the amount of medical terminology used did not result in a user-friendly training program. A collaborative approach involving various members of the multidisciplinary team designed an appropriate training program for patients with learning disabilities. The new program included ( 1 ) a photographic bag-exchange procedure; ( 2 ) the provision of simple, step-by-step instructions on audiotape; ( 3 ) a new assessment sheet where words were replaced with symbols; ( 4 ) a redesigned daily record sheet (used to monitor clinical parameters); and ( 5 ) a simple contact card.

The quality of the new training program was assessed by a small pilot study evaluation. The reduction of training times and the satisfactory peritonitis rates suggest that the new multisensory training program could be successfully implemented. The use of pictorial aids and more symbols, with less focus on the written word, made PD training a viable option for many individuals, including elderly patients and those with learning disabilities. The increased use of pictorial aids and symbols may also be helpful in training patients where there is a language barrier as well as the pediatric population.
A Historical Review of Encapsulating Peritoneal Sclerosis
Authors: Kawaguchi Yoshindo , Tranæus Anders
Published: February 2020

Publications providing insights into the pathophysiology of, and therapeutic strategies for, EPS are the focus of the present review. Referenced publications are limited to those written in English.
Peritoneal Dialysis in Japan: The Issue of Encapsulating Peritoneal Sclerosis and Future Challenges
Authors: Saito Akira
Published: February 2020

Encapsulating peritoneal sclerosis (EPS) is a life-threatening complication of peritoneal dialysis (PD). The overall prevalence of EPS in Japanese PD patients is 2.3%. Among patients on PD for less than 5 years, the rate is 0.9%; among patients on PD for 5 – 10 years, the rate is 3.8%; and among patients on PD for >10 years, it is 11.5%. Thus, the longer the treatment duration, the higher the prevalence of EPS.

Encapsulating peritoneal sclerosis does not result solely from the natural progression of peritoneal sclerosis. A “second hit” event, such as bacterial peritonitis, abdominal bleeding, or abdominal surgery may be needed to trigger the onset of EPS in the face of advanced peritoneal sclerosis.

To prevent development of EPS, PD treatment is replaced by other treatments when patients reached high-transport status. Peritoneal lavage and prednisolone administration have been reported to be effective in preventing or stopping the progress of EPS. When bowel obstruction has occurred, total enterolysis to remove the fibrous capsule from the bowel is indicated.

To maximize overall quality of life, patients with end-stage renal disease (ESRD) should have the choice to make use of all the treatment modalities available: PD, hemodialysis (HD), and transplantation. Furthermore, the development of truly biocompatible PD equipment—including peritoneal catheters, solutions, and systems—are desirable to extend PD treatment for the long term. The cost of individual products could decrease significantly if PD use were to increase to 30% from 10% among ESRD patients worldwide. As practitioners, we have to further improve the technical survival rate and functional duration of PD treatment so that adequate peritoneal function can be maintained for 10 years in at least 40% of PD patients. The goal is to place PD on par with HD using high-flux dialysis membranes and ultrapure dialysis solution.
The Effect of Proinflammatory Cytokine Gene and Angiotensin-Converting Enzyme Polymorphisms on Erythropoietin Requirements in Patients on Continuous Ambulatory Peritoneal Dialysis
Authors: Sharples Edward J. , Varagunam Mira , Sinnott Paul J. , McCloskey Daniel J. , Raftery Martin J. , Yaqoob Mohammad M.
Published: February 2020

Background

The correction of anemia by recombinant human erythropoietin (rHuEPO) improves quality of life and prolongs life in end-stage renal failure. rHuEPO requirements for an individual are determined by a range of factors, including iron deficiency and inflammation. Single nucleotide polymorphisms in the promoter sequence of several proinflammatory cytokines have been shown, in different fields of medicine, to influence the cytokine response to different stimuli, with effects on clinical outcome.

Methods

The angiotensin-converting enzyme (ACE) insertion/deletion polymorphism and polymorphisms in the promoter regions of the genes for tumor necrosis factor alpha (-308 A/G), interleukin-6 (-174 G/C), and interferon gamma were examined for their association with rHuEPO requirements in 112 patients on continuous ambulatory peritoneal dialysis (CAPD). Genomic DNA was extracted from peripheral blood leukocytes and genotyping performed with ARMS-PCR methodology, with sequence-specific primers. We examined rHuEPO requirements and C-reactive protein at baseline and during a 6-month study period.

Results

We found no significant effect of proinflammatory cytokine polymorphisms on rHuEPO responsiveness. However, throughout the study, we observed that there was a significantly higher rHuEPO requirement in the II and ID ACE genotypes compared with the DD group, which remained an independent association following multivariate analysis.

Conclusions

ACE insertion/deletion polymorphism may determine rHuEPO responsiveness in CAPD patients and should be considered in relative rHuEPO resistance.
Percutaneous Endoscopic Gastrostomy in Children on Peritoneal Dialysis
Authors: von Schnakenburg Christian , Feneberg Reinhard , Plank Christian , Zimmering Miriam , Arbeiter Klaus , Bald Martin , Fehrenbach Henry , Griebel Martin , Licht Christoph , Konrad Martin , Timmermann Kirsten , Kemper Markus J.
Published: February 2020

Objective

Insertion of percutaneous endoscopic gastrostomies (PEG) in patients on chronic peritoneal dialysis (PD) has been reported to be contraindicated due to an increased risk of morbidity and mortality. However, no systematic survey on this topic has yet been published.

Design

Retrospective multicenter study.

Setting

23 pediatric dialysis units associated with the working group Arbeitsgemeinschaft für Pädiatrische Nephrologie (APN).

Data Source

A structured questionnaire on clinical details of PD patients who had undergone PEG insertion or open gastrostomy (OG) since 1994 was distributed to all pediatric dialysis units of the APN.

Results

27 PD patients (20 males) from 12 centers in whom PEG insertion was performed after Tenckhoff catheter introduction were evaluated. Age at intervention ranged from 0.25 to 10.9 years (median 1.3 years). Most patients were malnourished, with standard deviation score (SDS) for body weight between –4.2 and –0.6 (median -2.2). Major complications were early peritonitis <7 days after PEG in 10/27 (37%) patients, episodes of fungal peritonitis in 7/27 (26%) patients, 4 cessations of PD and change to hemodialysis, and 2 associated deaths. However, in 14 patients, no such problems were encountered and, in 4 patients, early peritonitis effectively treated with intraperitoneal antibiotics was the only major complication. Thus, in 18/27 (67%) patients, PD was successfully reinitiated shortly after PEG insertion. Among all participating centers, only two OG procedures were reported during the study period, illustrating a clear preference for the PEG over the OG procedure among members of the APN.

Conclusion

PEG insertion following PD initiation carries a high risk for fungal peritonitis and potential PD failure; however, complication rates in this largest reported series were lower than previously described. Antibiotic and anti-fungal prophylaxis, withholding PD for 2 – 3 days, and gastrostomy placement by an experienced endoscopy team are suggested precautions for lowering the risk of associated complications. When gastrostomy placement does not occur prior to or at the time of initiating PD, the risks and benefits of percutaneous versus open placement must be carefully weighed.
Serum Markers of Low-Turnover Bone Disease in Mexican Children with Chronic Kidney Disease Undergoing Dialysis
Authors: Ávila-Díaz Marcela , Matos Mario , García-López Elvia , Prado María-del-Carmen , Castro-Vázquez Florencia , Ventura María-de-Jesús , Dante Amato Elia González , Paniagua Ramón
Published: February 2020

Background

The frequency of low-turnover bone disease (LTBD) in patients with chronic kidney disease (CKD) has increased in past years. This change is important because LTBD is associated with bone pain, growth delay, and higher risk for bone fractures and extraosseous calcifications. LTBD is a histological diagnosis. However, serum markers such as parathyroid hormone (PTH) and calcium levels offer a noninvasive alternative for diagnosing these patients.

Objective

To describe the prevalence of LTBD in pediatric patients with renal failure undergoing some form of renal replacement therapy, using serum calcium and intact PTH levels as serum markers.

Methods

In this cross-sectional study, 41 children with CKD undergoing dialysis treatment (31 on continuous ambulatory peritoneal dialysis and 10 on hemodialysis) were included. There were no inclusion restrictions with respect to gender, cause of CKD, or dialysis modality. The children were studied as outpatients. The demographic data, CKD course, time on dialysis, phosphate-binding agents, and calcitriol prescription were registered, as well as weight, height, Z-score for height, linear growth rate, and Z-score for body mass index. Serum calcium, phosphorus, aluminum, PTH, alkaline phosphatase, osteocalcin, glucose, creatinine, urea, cholesterol, and triglycerides were measured.

Results

There were 20 (48.8%) children with both PTH <150 pg/mL and corrected total calcium >10 mg/dL who were classified as having LTBD[(+)]; the remaining 21 (51.2%) children were classified as having no LTBD[(–)]. The LTBD(+) patients were younger (11.2 ± 2.7 vs 13.2 ± 2.4 years, p < 0.01) but they had no differences regarding Z-scores for height. Linear growth in 6 months was less than expected in both groups (-0.15 ± 0.23 cm/month), but the difference between expected and observed growth was higher in the LTBD(+) group (-0.24 ± 0.14 vs –0.07 ± 0.28 cm/mo, p < 0.03). LTBD(+) patients also had lower serum creatinine (8.69± 2.75 vs 11.19 ± 3.17 mg/dL, p < 0.01), higher serum aluminum levels [median (range) 38.4 (9 – 106) vs 28.1 (9 – 62) μg/L, p < 0.05], and lower systolic blood pressure (112.0 ± 10.3 vs 125.0 ±12.9 mmHg, p < 0.015) and diastolic blood pressure (76.0 ± 9.7 vs 84.5 ± 8.2 mmHg, p < 0.017). A significant correlation was found between PTH and alkaline phosphatase ( r = 0.68, p < 0.001), but not between PTH and aluminum.

Conclusion

The LTBD(+) biochemical profile was found in 48.8% of the children and was associated with impaired linear growth. Aluminum contamination, evidenced by higher serum aluminum levels, may have had a pathogenic role in these disorders. Higher systolic and diastolic blood pressure levels may be related to higher serum PTH levels.
Volume Control Associated with Better Cardiac Function in Long-Term Peritoneal Dialysis Patients
Authors: Aşci Gulay , Özkahya Mehmet , Duman Soner , Toz Huseyin , Erten Sinan , Ok Ercan
Published: February 2020

Background

This study was undertaken to investigate the effect of long-term blood pressure (BP) reduction, achieved with salt restriction and strict volume control, on frequency and regression of left ventricular hypertrophy (LVH) in long-term peritoneal dialysis (PD) patients.

Methods

56 patients who had been treated for more than 2 years under our care were enrolled. After echocardiographic (Echo) evaluation, 46 patients were included in the follow-up study. In our unit, we aim to keep patients’ BP below 130/85 mmHg and cardiothoracic index below 0.50. To reach these targets, moderate salt restriction is advised, and if necessary, hypertonic PD solutions are used. Echo was performed at the beginning of the study (after a mean period of 36 months on PD) and at the end of the prospective follow-up period (24 months later).

Results

At the time of the first Echo, LVH was detected in only 8 (21%) patients. Residual urine volume was significantly decreased compared to data taken when they first started PD (658 ± 795 vs 236 ± 307 mL/day). Mean left ventricular mass index (LVMI) was 107 ± 26.5 g/m2. LVMI was significantly decreased at the end of the follow-up in patients who had LVH at baseline. No LVH developed in patients who had normal LVMI at baseline.

Conclusion

Our results indicate that control of hypertension is possible when extracellular fluid volume is kept under control using hypertonic PD solutions in case of recruitment in addition to salt restriction in long-term PD patients. Sustained normovolemia is associated with low incidence and regression of LVH.
Negotiated Care Improves Fluid Status in Diabetic Peritoneal Dialysis Patients
Authors: Quan Lei , Xu Ying , Luo Shu-ping , Wang Lan , LeBlanc Denise , Wang Tao
Published: February 2020

Background

Volume overload is common in diabetic patients on continuous ambulatory peritoneal dialysis (PD), especially when the patient's residual renal function decreases with time on PD. Due to the higher dietary salt and fluid intake, diabetic PD patients tend to use more hyper-tonic glucose solution to remove excess fluid, which in turn may lead to increased membrane permeability. In the present study, we investigated the effect of negotiated care on fluid status in diabetic PD patients.

Methods

All diabetic PD patients who had been on PD for at least 3 months by the end of year 2002 in the First Hospital of Peking University were included in the present study. A primary nurse was assigned to each patient and intensive patient education was implemented, focusing on the importance of dietary salt and fluid restriction, the detrimental effect of using more hypertonic glucose solution, and the consequence of fluid overload. Decisions on dialysis prescriptions were made after extensive discussion among the primary nurse, nephrologists, patients, and patients’ families. A patient support group was also involved when it was necessary. All the patients were followed for 1 year and fluid status, compliance to dietary restriction, and dialysis prescription were evaluated before the start and at the end of the study.

Results

There were 30 diabetic PD patients (age 65.4 ± 10.3 years; on PD for 24.5 ± 19.9 months, range 3 – 66 months) included in the study when it was started. During the 1 year of follow-up, 4 patients died of diabetic complications, 3 patients were transferred to hemodialysis due to resistant peritonitis, and 2 patients were transplanted. By the end of follow-up, 21 patients remained on PD, among whom 15 had improved fluid status, 4 did not change, and 2 had worsened fluid status as assessed by clinical and bio-impedance evaluation. Patient compliance to dietary salt and fluid restriction had increased from 19.5% to 76.2%. During the follow-up, 8 patients were anuric at the beginning of the study and the remaining 22 patients had declining residual renal function. Only 4 patients increased their use of hypertonic solution including 2.5% (3 patients) and 4.25% (1 patient) glucose, whereas 5 patients decreased their use of 2.5% dialysis solution. By the end of follow-up, only 1 of the 21 patients was using 4.25% glucose solution and all the patients had good blood glucose control.

Conclusions

Our results suggest that negotiated care can be successfully used in diabetic PD patients. It helps to minimize the use of hypertonic glucose solution and improves patient compliance to dietary restriction of salt and fluid intake, and thus improves their fluid status.
Prevalence and Management of Hernias in Peritoneal Dialysis Patients
Authors: García-Ureña Miguel Ángel , Rodríguez César Remón , Ruiz Vicente Vega , Hernández Francisco Javier Carnero , Fernández-Ruiz Evaristo , Gallego Jose Manuel Vazquez , García Miguel Velasco
Published: February 2020

Objectives

The aim of this study was to assess the prevalence of hernias before and after the start of continuous ambulatory peritoneal dialysis (CAPD) in patients with end-stage renal disease, and to evaluate the result of a proposed surgical treatment.

Design

Prospective observational study.

Setting

University hospital.

Patients

122 patients who started CAPD from 1994 to 2000; 26 hernias were diagnosed in 21 (17.2%) patients.

Main Outcome Measures

Finding of hernias; morbidity associated with catheter insertion and hernia repair; recurrence of hernias.

Results

19 hernias were detected in 15 patients (12.3%) before they began CAPD; only 7 hernias were observed while on CAPD. Umbilical (61.5%) and inguinal (26.9%) hernias were the most common. Multiple hernias were detected in 4 patients. Simultaneous repair of hernia and catheter insertion was performed in patients with preexisting hernias. Under local anesthesia, most patients were operated on with surgical techniques of tension-free hernioplasty using a polypropylene mesh. Only mild postoperative complications were recorded: 3 seromas and 1 hematoma. No fluid leakage was found in our series. There were no long-term complications (infection or recurrence) related to the mesh.

Conclusions

73% of hernias in peritoneal dialysis patients occur before starting dialysis. Hernia problems in these high-risk patients can be safely solved using a careful technique with application of tension-free hernioplasty. Most may be repaired under local anesthesia with simultaneous catheter insertion.
Four Consecutive Cases of Peritoneal Dialysis-Related Encapsulating Peritoneal Sclerosis Treated Successfully with Tamoxifen
Authors: Eltoum Mohmed A. , Wright Sue , Atchley Julian , Mason Juan C.
Published: February 2020

Sclerosing peritonitis is a rare complication of peritoneal dialysis (PD). In encapsulating peritoneal sclerosis (EPS), the most severe form of the disease, the intestine is entrapped in a fibrous tissue, causing intestinal obstruction. Patients are typically seriously ill, with evidence of infection and requirement for parenteral nutrition. A mortality rate of 73% has been reported. There is no established medical treatment and surgery has offered variable results.

Our unit provides renal replacement therapy for a population of about 2 million. The prevalent population of PD patients averages 110. The cumulative PD population since January 1993 is 643, with an EPS prevalence of 0.6%.

Influenced by the first case reported by Allaria in 1999 suggesting benefit of tamoxifen in treating EPS, we have treated with tamoxifen the four consecutive cases of EPS that have presented since 1999. All 4 patients have survived and recovered intestinal function. All showed prior evidence of peritoneal dysfunction with ultrafiltration failure and were characterized by long duration of PD therapy rather than multiple episodes of peritonitis.

We conclude that tamoxifen is a highly promising therapy in EPS, hitherto a usually fatal condition. This description of its efficacy in acutely ill patients with EPS complements its possible prophylactic use in patients with the earlier and milder disease, sclerosing peritonitis. A high index of clinical suspicion for sclerosing peritonitis is desirable, perhaps facilitated by routine screening of at-risk patients.
Relationship between Serum Magnesium, Parathyroid Hormone, and Vascular Calcification in Patients on Dialysis: A Literature Review
Authors: Wei Mingxin , Esbaei Khaled , Bargman Joanne , Oreopoulos Dimitrios G.
Published: February 2020

Secondary hyperparathyroidism is present in most patients with end-stage renal disease and has been linked to uremic bone disease, vascular calcification, and mortality. Current literature suggests an association between hypomagnesemia and cardiovascular disease in the general population. We reviewed all published studies on the relationship between serum magnesium and parathyroid hormone and the relationship between serum Mg and vascular calcification in dialysis patients. Of these, 10 of 12 studies of patients on hemodialysis and 4 of 5 studies of patients on peritoneal dialysis showed a significant inverse relationship between serum Mg and serum intact parathyroid hormone. Hyperparathyroidism develops in peritoneal dialysis patients dialyzed with a solution containing normal calcium (1.25 mmol/L) and low Mg (0.25 mmol/L), even though serum calcium is maintained at a normal level. Four of the hemodialysis studies and one of the peritoneal dialysis studies indicated that there is an inverse relationship between serum Mg and vascular calcification in these patients. Potential benefits have been attributed to magnesium carbonate as a phosphate binder and it may possibly be an effective, less toxic, less expensive phosphate binder. We believe that the role of Mg in secondary hyperparathyroidism and vascular calcification merits further investigation.
Laparoscopic Findings of Peritoneal Dialysis Catheter Malfunction and Management Outcomes
Authors: Yilmazlar Tuncay , Kirdak Turkay , Bilgin Serpil , Yavuz Mahmut , Yurtkuran Mustafa
Published: February 2020

Objective

Peritoneal dialysis catheter malfunction is a common complication forcing conversion to hemodialysis. The purpose of this study was to evaluate laparoscopic findings of catheter malfunction and to establish a relationship between those findings and the outcomes of procedures performed.

Design

Retrospective study.

Setting

A tertiary referral center.

Patients

40 consecutive patients with stage 5 chronic kidney disease underwent 46 laparoscopic correction procedures for the treatment of peritoneal dialysis catheter malfunction between November 1994 and August 2004.

Main Outcome Measures

Laparoscopic findings of catheter malfunction, procedures performed, catheter survival, and recurrent cases were evaluated.

Results

There were 28 tip migrations in 40 patients; 16 were without adhesions and 10 were associated with omental adhesions. Reposition and adhesiolysis were the most frequent procedures performed. Malfunction recurred in 12 patients and 5 of them underwent 6 secondary laparoscopic procedures. Estimated mean catheter survival was 19.9 ± 3.32 months (%95 confidence interval 13.43 – 26.46).

Conclusions

The most frequent laparoscopic finding was catheter tip migration, with or without adhesions. Laparoscopic repositioning and adhesiolysis without omentectomy are simple and effective procedures that can prolong catheter survival, even in recurrent malfunctions.
Correlation between Fractional Reabsorption of Sodium and Erythropoietin dose in Peritoneal Dialysis Patients
Authors: Ossareh Shahrzad , Moupas Iloise , Thodis Elias , Oreopoulos Dimitrios G. , Donnelly Sandra
Published: February 2020

Background

Erythropoietin (EPO) deficiency of chronic renal failure (CRF) may be a functional consequence of decreased glomerular filtration rate and fractional reabsorption of sodium (FRNa). Decreased FRNa reduces renal oxygen consumption and increases tissue oxygen pressure, resulting in less EPO production. We hypothesized that, in CRF patients, there is a positive relationship between EPO production and FRNa and that, in such patients receiving EPO, a negative correlation is expected between FRNa and EPO dose.

Methods

Creatinine clearance, FRNa, serum iron, transferrin, transferrin saturation, ferritin, and intact parathyroid hormone (iPTH) levels were measured in 91 peritoneal dialysis patients. The correlation between EPO dose and FRNa was studied.

Results

Mean EPO dose was 7076 ± 4821 units/week and mean FRNa was 93.40% ± 6.14%. A negative correlation was found between EPO dose and FRNa ( r = -0.28, p < 0.01), and a positive correlation was found between both ferritin and iPTH and EPO dose ( r = 0.39, p < 0.001 and r = 0.35, p < 0.002 respectively). After adjusting for the effect of creatinine clearance, ferritin, and iPTH, there was still a significant correlation between EPO dose and FRNa ( p < 0.05).

Conclusion

In CRF patients there is a negative correlation between FRNa and EPO dose, which supports the hypothesis that EPO deficiency may be related to the decreased renal oxygen-consuming work of sodium reabsorption.
No Significant Differences in Peritoneal Fluid Handling in Children Using pH-Neutral or Acidic Solutions
Authors: Nourse Peter , van de Kar Nicole C. A. J. , Willems Hans L. , Schröder Cornelis H.
Published: February 2020

Objectives

Differences in peritoneal fluid handling in the acute setting can be expected if children are converted to pH-neutral dialysis solutions because conventional acidic solutions exert toxic effects on peritoneal mesothelial cells and microcirculation. Peritoneal fluid kinetics was therefore investigated with both types of solutions in a group of children.

Design

Peritoneal equilibration tests (PETs) were performed in 12 patients [mean age 70 months, mean time on peritoneal dialysis (PD) 18 months] using a pH-neutral PD fluid (Physioneal 3.86%; Baxter Ltd, Castlebar, Ireland) and dextran 70 as a volume marker. The results of these PETs were compared to those of a historic group of 12 children (mean age 75 months, mean time on PD 17 months).

Setting

Pediatric dialysis unit in a tertiary institute.

Patients

Stable pediatric PD patients.

Main Outcome Measures

Transcapillary ultrafiltration (TCUF) and marker clearance, dialysate-to-plasma (D/P) ratios for urea and creatinine, and Dt/D0 ratio for glucose.

Results

TCUF and lymphatic absorption were not different between the two groups. There was also no significant difference in small solute clearance measured by D/P ratio for urea and creatinine and Dt/D0 ratio for glucose.

Conclusion

Peritoneal fluid kinetics is not significantly altered if pH-neutral dialysis solutions are applied compared to acidic solutions. An altered TCUF, as is hypothetically possible using an acidic solution, was not established.
Gene Transfer Using Nonviral Delivery Systems
Authors: Miyazaki Masanobu , Obata Yoko , Abe Katsushige , Furusu Akira , Koji Takehiko , Tabata Yasuhiko , Kohno Shigeru
Published: February 2020

In peritoneal dialysis, loss of peritoneal function is a major factor in treatment failure. The alterations in peritoneal function are related to structural changes in the peritoneal membrane, including peritoneal sclerosis with increased extracellular matrix. Although peritoneal sclerosis is considered reversible to some extent through peritoneal rest, which improves peritoneal function and facilitates morphological changes, there has been no therapeutic intervention and no drug against the development and progression of peritoneal sclerosis. Using recent biotechnological advances in genetic engineering, a strategy based on genetic modification of the peritoneal membrane could be a potential therapeutic maneuver against peritoneal sclerosis and peritoneal membrane failure. Before this gene therapy may be applied clinically, a safe and effective gene delivery system as well as the selection of a gene therapy method must be established. There are presently two kinds of gene transfer vectors: viral and nonviral. Viral vectors are used mainly as a gene delivery system in the field of continuous ambulatory peritoneal dialysis research; however, they have several problems such as immunogenicity and toxicity. On the other hand, nonviral vectors have several advantages over viral vectors. We review here gene transfer using nonviral vector systems in the peritoneum: electroporation, liposomes, and cationized gelatin microspheres. In the field of peritoneal dialysis, gene therapy research using nonviral vectors is presently limited. Improvement in delivery methods together with an intelligent design of targeted genes has brought about large degrees of enhancement in the efficiency, specificity, and temporal control of nonviral vectors.