bluuebunny/crossref_metadata_2025 huggingface dataset:
Automated Peritoneal Dialysis Has Significant Effects on Systemic Hemodynamics
Authors: Selby Nicholas M. , Fonseca Sally , Hulme Lisa , Fluck Richard J. , Taal Maarten W. , McIntyre Christopher W.
Published: February 2020

Objectives

Maintenance of residual renal function (RRF) is an important determinant of outcome in peritoneal dialysis patients. It remains contentious as to whether automated peritoneal dialysis (APD) leads to an increased rate of decline of RRF compared with continuous ambulatory peritoneal dialysis (CAPD). We studied whether APD was associated with significant systemic hemodynamic changes that may play a role in the accelerated loss of RRF.

Methods

As a follow-on from a previous study, 8 well-established CAPD patients underwent a 4-hour APD treatment consisting of 3 drain/fill cycles using 2 x 2.5 L 1.36% glucose and 1 x 3.86% glucose dialysate. Each dwell phase lasted 76 minutes. Blood pressure (BP) and a full range of hemodynamic variables, including pulse (HR), stroke volume (SV), cardiac output (CO), and total peripheral resistance (TPR), were measured noninvasively using continuous arterial pulse wave analysis.

Results

BP fell during 2 of the 3 drain/fill periods when dialysate was drained from the peritoneal cavity, but then rose upon instillation of dialysate fluid. The fall in BP was associated with a fall in TPR, matched by an inadequate rise in SV and CO. Over the entire study period, TPR progressively rose to +53.4% above baseline ( p = 0.032). Both SV and CO fell over the same period, to -21.1% ( p = 0.060) and -22.4% from baseline ( p = 0.037) respectively. This did not result in any significant difference between start and end BP.

Conclusions

This study demonstrates that APD is associated with significant systemic hemodynamic effects. The increased number of drain/fill cycles compared to CAPD, or the progressive rise in TPR and reduction in CO (possibly due to a cooling effect), may potentially be factors that adversely affect RRF in APD patients.
T Lymphocytes: The “Cellular” Arm of Acquired Immunity in the Peritoneum
Authors: Glik Amir , Douvdevani Amos
Published: February 2020

T cells are an important part of the acquired immune response and target specific antigen with their T cell receptor. The peritoneum is a special milieu within which T cells react. We describe briefly the anatomy important for T cell function. T cell biology including antigen presentation, T cell activation, and the different T cell subpopulations are reviewed. We also define innate and acquired immunity and describe the role of polymorphonuclear cells and peritoneal mesothelial cells in the regulation of leukocyte population recruitment during peritonitis. We focus particularly on peritoneal lymphocytes and compare them to the regular lymphocyte populations in the circulation. We illustrate the role of PMCs in antigen presentation and discuss the changes of CD4+ helper T cell subtypes (Th1 and Th2) during peritoneal dialysis. The role of CD8+ cytotoxic T lymphocytes and their possible destructive role for the peritoneal membrane modified by advanced glycation end products are discussed. Polymorphonuclear cells play an important role in the regulation of inflammation and immunity. We describe their possible role in supporting T cells and particularly for generating memory CD8+ T cells by secretion of interleukin-15, a potent T cell growth factor. Light is shed on γδ T cells, a special T cell population that is able to recognize antigens without the restriction of antigen presentation. We end our review with a description of regulatory T cells. This cell population is extremely important in preventing autoimmunity and in the regulation of acquired immunity.
Barriers to Utilization of Chronic Peritoneal Dialysis in Network #1, New England
Authors: Troidle Laura , Kliger Alan , Finkelstein Fredric
Published: February 2020

Objective

The percentage of prevalent end-stage renal disease (ESRD) patients maintained on chronic peritoneal dialysis (CPD) therapy in the United States declined from 15% in 1991 to 8.1% in 2002. Previous studies indicate that nephrologists in the United States feel 32.6% of prevalent ESRD patients should be on CPD therapy. The present study was designed to better understand the reasons for the discrepancy in actual versus desired prevalence of CPD utilization.

Methods

The medical directors of all dialysis centers in New England were mailed a questionnaire about the nephrologists’ opinions concerning the percentage of patients that should be maintained on CPD therapy, reasons that limited patients’ selection of CPD as initial therapy, and concerns about the current status of CPD therapy. The nephrologists were also invited to free text any other comments or concerns.

Results

A total of 117 questionnaires were sent; 59 (50.4%) were returned. These medical directors cared for a median of 10 (range 1 – 100) patients on CPD therapy, meaning 15% of dialysis patients in New England are maintained on CPD therapy. The medical directors felt that 29% (range 10% – 50%) of prevalent ESRD patients should be maintained on CPD therapy. The most common reasons cited by the nephrologists as barriers to CPD therapy included patient preference (54%), contraindications to performing CPD therapy (32%), poor social support (31%), significant comorbid disease (20%), late referrals and acute hospital starts (19%), problems with education re chronic kidney disease (12%), and problems with the structure and organization of CPD facilities (12%). These same medical directors stated that concerns about technique failure (25%), long-term viability of CPD therapy (25%), and mortality rates of CPD patients (17%) impacted on their use of CPD therapy as renal replacement therapy for patients with ESRD.

Conclusion

Nephrologists in New England felt that 29% of prevalent ESRD patients should be maintained on CPD therapy, yet the actual incidence of CPD utilization in New England is 15%. A variety of factors were cited by the nephrologists as important reasons limiting CPD utilization. These nephrologists were also concerned about technique failure and long-term viability of CPD therapy. It is necessary that we look closely at each domain cited by the nephrologists if CPD therapy is to remain a viable option for patients with ESRD in the United States.
International Survey of Peritoneal Dialysis Training Programs
Authors: Bernardini Judith , Price Valerie , Figueiredo Ana , Riemann Aase , Leung Dora
Published: February 2020

Objective

To survey nurses around the world about current practices for peritoneal dialysis (PD) home training programs.

Design

Random sampling of nurses to complete a written survey from the International Society for Peritoneal Dialysis Nursing Liaison Committee.

Settings

United States, Canada, South America (Brazil, Columbia), The Netherlands, Hong Kong.

Methods

Surveys and responses were sent by fax whenever possible, or by regular mail, or hand carried, or conducted by telephone. Results were stratified by geographic areas as well as by cumulative responses and were expressed as medians with ranges. Kruskal–Wallis was used to evaluate differences in responses. Associations between variables were tested with Pearson correlation. Univariate regression analysis was used to evaluate the impact of variables on peritonitis rates. Variables with p < 0.10 were included in a multivariate analysis.

Results

A total of 317 nurses responded: 88 in the United States, 46 in Canada, 58 in South America, 58 in Hong Kong, and 67 in The Netherlands. This represented 37% of all surveys distributed. Respondents had a median of 12 years’ experience in nephrology (range 1 – 35 years), but only 31% had a formal background in adult education. Nearly half received their guidance to patient training from a nurse colleague, 11% were guided by a corporate colleague, and 8% were simply self-taught. Clinics responding had a median of 30 PD patients (range 1 – 400) and reported they trained a median of 8 patients per year (range 0 – 86). Reported peritonitis rates were a median 0.46 per year or 1 episode every 26 months. Peritonitis rates, however, were not known by 53% of respondents. Total training time per patient had a very wide range of hours, from 6 to 96. There was no correlation between training time and peritonitis rates among the study respondents ( p = 0.38), nor with any other variables.

Conclusions

There is wide variation in practices for PD patient training programs within countries and around the world. Training time did not appear to be related to peritonitis rates. Randomized trials of training practices are needed to determine which approaches produce the best outcomes for patients.
Prospective Comparison of Downward and Lateral Peritoneal Dialysis Catheter Tunnel-Tract and Exit-Site Directions
Authors: Crabtree John H. , Burchette Raoul J.
Published: February 2020

Objective

Guidelines for optimal peritoneal dialysis access support both downward and lateral exit-site directions. Numerous clinical reports support the superiority of downward exit sites but none substantiate lateral configurations.

Methods

This prospective study compared infectious and mechanical complications between 85 catheters with a preformed arcuate bend to produce a downward exit site and 93 catheters with a straight intercuff segment configured to create a lateral exit site.

Results

Kaplan–Meier survivals were not different for time to first exit-site infection ( p = 0.62), tunnel infection ( p = 0.89), or peritonitis ( p = 0.38) for downward and lateral exit-site directions. Poisson regression showed no differences in rates (episodes/patient-year) of exit-site infection (0.26 vs 0.27, p = 0.86), tunnel infection (0.02 vs 0.03, p = 0.79), peritonitis (0.42 vs 0.43, p = 0.87), or catheter loss (0.06 vs 0.09, p = 0.29) for downward and lateral exit sites. Kaplan–Meier analyses of antibiotic-free intervals for exit-site ( p = 0.94) and peritonitis infections ( p = 0.72) were not different for the two groups. There was one case of catheter tip displacement with flow dysfunction in each group. There were no pericatheter hernias or spontaneous cuff extrusions. Catheter survival between groups was not different ( p = 0.20).

Conclusions

Catheter types employing downward and lateral tunnel-tract and exit-site configurations produce equivalent outcomes for infectious and mechanical complications.
The Continuum of Chronic Kidney Disease and End-Stage Renal Disease: Challenges and Opportunities for Chronic Peritoneal Dialysis in the United States
Authors: Mehrotra Rajnish
Published: February 2020

End-stage renal disease (ESRD) patients undergoing renal replacement therapy have a high mortality rate and suffer from considerable morbidity. Degree of nutritional decline, disordered mineral metabolism, and vascular calcification are some of the abnormalities that predict an adverse outcome for ESRD patients. All these abnormalities begin early during the course of chronic kidney disease (CKD), long before the need for maintenance dialysis. Thus, CKD represents a continuum of metabolic and vascular abnormalities. Treatment of these abnormalities early during the course of CKD and a timely initiation of dialysis have the potential of improving patient outcomes. However, the thesis that successful management of these abnormalities will favorably modify the outcomes of dialysis patients remains untested.

The proportion of incident USA ESRD patients starting chronic peritoneal dialysis (CPD) has historically been low. Limited physician training and inadequate predialysis patient education appear to underlie the low CPD take-on in the USA. Furthermore, two key changes have occurred in the USA: steep decline in CPD take-on and progressive increase in the use of automated peritoneal dialysis. The decline in CPD take-on has afflicted virtually every subgroup examined and has occurred, paradoxically, when the CPD outcomes in the country have improved. Understanding the reasons for historically low CPD take-on and recent steep declines in utilization may allow the development of plans to reverse these trends.
ACE Inhibitor and At1-Receptor Blocker Attenuate the Production of Vegf in Mesothelial Cells
Authors: Sauter Matthias , Cohen Clemens D. , Wörnle Markus , Mussack Thomas , Ladurner Roland , Sitter Thomas
Published: February 2020

Objective

Human mesothelial cells (HMC) are a major source of intraperitoneal vascular endothelial growth factor (VEGF) and by that are presumably involved in complications of long-term peritoneal dialysis (PD), such as ultrafiltration failure. This prompted us to look for agents that reduce basic mesothelial VEGF production and abrogate VEGF-overproduction induced by proinflammatory cytokines such as tumor necrosis factor alpha (TNF-α) and interleukin-1α (IL-1α). Angiotensin-converting enzyme (ACE) inhibition was found to preserve peritoneal function and ameliorate morphologic changes in a rat PD model. The present in vitro study was designed to investigate the effect of the ACE inhibitors captopril and enalapril, and the angiotensin II type 1-receptor (AT1) antagonist losartan on mesothelial VEGF synthesis.

Methods

HMC were isolated from omental tissue and taken into culture. VEGF antigen concentrations were measured in the cell supernatant by ELISA. VEGF mRNA levels were determined by real-time polymerase chain reaction.

Results

Incubation of HMC with captopril (100 - 1000 μmol/L) resulted in a concentration-dependent attenuation of VEGF synthesis. Incubation with captopril (500 - 1000 – μmol/L), enalapril (100 - 1000 μmol/L), and losartan (1 100 μmol/L) significantly decreased inflammatory mediator (TNF-α, IL-1α)-induced mesothelial VEGF overproduction.

Conclusion

The results indicate that ACE inhibitors and AT1-receptor blockers are capable of effectively attenuating the overproduction of VEGF due to proinflammatory cytokine stimuli. These data suggest that locally produced angiotensin II in the peritoneal cavity may be a potential therapeutic target in ultrafiltration failure during long-term PD.
Predictors of Renal Recovery in Australian and New Zealand end-Stage Renal Failure Patients Treated with Peritoneal Dialysis
Authors: Craven Ann-Maree S. , Hawley Carmel M. , McDonald Stephen P. , Rosman Johan B. , Brown Fiona G. , Johnson David W.
Published: February 2020

Objectives

The aim of this study was to investigate the factors affecting recovery and durability of dialysis-independent renal function following commencement of peritoneal dialysis (PD).

Design

Retrospective, observational cohort study of the Australian and New Zealand PD patient population.

Setting

Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry.

Participants

The study reviewed all patients in Australia and New Zealand who commenced PD for treatment of end-stage renal failure between 15 May 1963 and 31 December 2004.

Main Outcome Measures

The primary outcomes examined were recovery of dialysis-independent renal function and time from PD commencement to recovery of renal function. A secondary outcome measure was time to renal death (patient death or recommencement of renal replacement therapy) following recovery of dialysis-independent renal function.

Results

24663 patients commenced PD during the study period. Of these, 253 (1%) recovered dialysis-independent renal function. An increased likelihood of recovery was predicted by autoimmune renal disease, hemolytic-uremic syndrome, paraproteinemia, cortical necrosis, renovascular disease, and treatment in New Zealand. A reduced likelihood of recovery was associated with polycystic kidney disease and indigenous race. Analysis of a contemporary subset of 14743 patients in whom complete data were available for body mass index, smoking, and comorbidities yielded comparable results, except that increasing age was additionally associated with a decreased likelihood of recovery. Of the 253 patients who recovered renal function, 151 (60%) recommenced renal replacement therapy and 49 (19%) died within a median period of 226 days (interquartile range 110 – 581 days). The only significant predictors of continued renal survival after renal recovery were autoimmune renal disease and cortical necrosis.

Conclusions

Recovery of renal function in patients treated with PD is rare and determined mainly by renal disease type and race. In the majority of cases, recovery is short term. The apparently high rate of early patient death or return to dialysis after recovery of renal function on PD raises questions about the appropriateness of discontinuing PD therapy under such circumstances.
High Volume Peritoneal Dialysis for Acute Renal Failure
Authors: Gabriel Daniela Ponce , Nascimento Ginivaldo Victor Ribeiro do , Caramori Jacqueline Teixeira , Martim Luís Cuadrado , Barretti Pasqual , Balbi André Luís
Published: February 2020

Background

Peritoneal dialysis (PD) is still widely used for acute renal failure (ARF) in developing countries despite concerns about its inadequacy. Continuous PD has been evaluated in ARF by analyzing the resolution of metabolic abnormality and normalization of plasma pH, bicarbonate, and potassium.

Methodology

A prospective study was performed on 30 ARF patients who were assigned to high-dose continuous PD (Kt/V = 0.65 per session) via a flexible catheter (Tenckhoff) and automated PD with a cycler. Fluid removal, pH and metabolic control, protein loss, and patient outcome were evaluated.

Results

Patients received 236 continuous PD sessions; 76% were admitted to ICUs. APACHE II score was 32.2 ± 8.65. BUN concentrations stabilized after 3 sessions, creatinine after 4, and bicarbonate and pH after 2. Fluid removal was 2.1 ± 0.62 L/day. Creatinine and urea clearances were 15.8 ± 4.16 and 17.3 ± 5.01 mL/minute respectively. Normalized creatinine clearance and urea Kt/V values were 110.6 ± 22.5 L/week/1.73 m2 body surface area and 3.8 ± 0.6 respectively. Solute reduction index was 41% ± 6.5% per session. Serum albumin values remained stable in spite of considerable protein losses (median 21.7 g/day, interquartile range 9.1 – 29.8 g/day). Regarding ARF outcome, 23% of patients presented renal function recovery, 13% remained on dialysis after 30 days of follow-up, and 57% died.

Conclusion

High-dose continuous PD by flexible catheter and cycler was an effective treatment for ARF. It provided high solute removal, allowing appropriate metabolic and pH control, and adequate dialysis dose and fluid removal. Continuous PD can therefore be considered an alternative to other forms of renal replacement therapy in ARF.
Acute Hydrothorax Complicating Peritoneal Dialysis
Authors: Krishnan Rajesh G. , Ognjanovic Milos V. , Crosier Jean , Coulthard Malcolm G.
Published: February 2020

Aim

To determine whether gradually increasing the peritoneal dialysate fill volume from 10 to 40 mL/kg over 6 days, rather than commencing at 40 mL/kg, prevents hydrothorax in children and reverses it if present.

Methods

A review of children peritoneally dialyzed in a single center.

Results

During the 20 years beginning June 1985, 416 children were peritoneally dialyzed, of which 327 (79%) had acute and 89 had end-stage renal failure. Among 253 children who had gradually increasing fill volumes, none developed acute hydrothoraces, but 13/163 (8%) who began with 40 mL/kg cycles did ( p < 0.000, Fisher's exact test). These were diagnosed after a median (range) of 48 (6 – 72) hours and were predominantly right sided. Initially, we readily abandoned peritoneal dialysis; 2 were changed to hemodialysis. Subsequently, we found that peritoneal dialysis could be continued by using small volumes with the patients sitting up; cycle volumes were then gradually increased again. One pre-term baby died soon after developing an acute hydrothorax. One patient on chronic peritoneal dialysis developed an acute hydrothorax after forceful vomiting, but recovered after being dialyzed sitting up with low fills.

Conclusion

Acute hydrothorax can be prevented and treated using graduated cycle volumes, and is not a contraindication for peritoneal dialysis.
Inflammation in Peritoneal Dialysis: A Latin-American Perspective
Authors: Cueto-Manzano Alfonso M. , González-Espinoza Liliana , del Campo Fabiola Martin , Fortes Paulo C. , Pecoits-Filho Roberto
Published: February 2020

Peritoneal dialysis (PD) patients present an extremely high mortality rate, but the mechanisms mediating the increased risk of mortality observed in this group of patients are still largely unknown, which limits the perspective of effective therapeutic strategies. The leading hypothesis that tries to explain this high mortality risk is that PD patients are exposed to a number of traditional risk factors for cardiovascular disease (CVD) already at the onset of their chronic kidney disease (CKD), since many of these risk factors are common to both CVD and CKD. Of particular importance, chronic inflammation recently emerged as an important novel risk factor related to multiple complications of CKD. There are many stimuli of the inflammatory response in CKD patients, such as fluid overload, decreased cytokine clearance, presence of uremia-modified proteins, presence of chronic infections, metabolic disturbances (including hyperglycemia), obesity. Many of these factors are related to PD. Latin America has made some progress in economic issues; however, a large portion of the population is still living in poverty, in poor sanitary conditions, and with many health-related issues, such as an increasing elderly population, low birth weights, and increasingly high energy intake in the adult population, which, in combination with changes in lifestyle, has provoked an increase in the prevalence of obesity, diabetes, and CVD. Therefore, in Latin America, there seems to be a peculiar situation combining high prevalence of low education level, poor sanitary conditions, and poverty with increases in obesity, diabetes, and sedentary lifestyle. Since inflammation and mortality risk are intimately related to both sides of those health issues, in this review we aim to analyze the peculiarities of inflammation and mortality risk in the Latin-American PD population.
A Simple Method to Prevent Peritoneal Dialysis Catheter Tip Migration
Authors: Chen Wen-Ming , Cheng Chen-Li
Published: February 2020

Background

We report here a one-stitch fixation method that prevents catheter tip migration during implantation of the double-cuffed straight Tenckhoff catheter.

Methods

From July 2003 to September 2005, 38 patients with end-stage renal disease underwent implantation of the double-cuff straight Tenckhoff catheter for peritoneal dialysis by this method.

Results

No patient had catheter tip migration out of the true pelvis. No patient had pericatheter dialysate leakage or developed incisional hernia. Two patients (5.3%) experienced exit-site infection during the 2- and 5-month follow-up and they recovered well after wound care. Three patients (7.9%) developed peritonitis during the 3-day and 2- and 6-month follow-up; the conditions were controlled after antibiotic care. One patient (2.6%) experienced mechanical catheter obstruction during the 10-day follow-up due to omental wrapping; surgical revision was necessitated.

Conclusions

We believe that the method is an easy, safe, and effective technique for preventing catheter tip migration.
Posttransplant Encapsulating Peritoneal Sclerosis: A Worrying New Trend?
Authors: Fieren Marien W.J.A. , Betjes Michiel G.H. , Korte Mario R. , Boer Walther H.
Published: February 2020

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication in patients on peritoneal dialysis (PD). We describe a cluster of 13 EPS cases occurring in 2 university hospitals in The Netherlands. Most of these cases were diagnosed after recent kidney transplantation, when the patients developed severe symptoms of bowel obstruction. This accumulation raised the question as to whether other than known risk factors, such as duration of PD treatment, could be involved in the development or course of EPS after transplantation. According to various publications, EPS has been diagnosed often after withdrawal from PD, suggesting that cessation in itself may be a risk factor. In addition, transplantation-related management should be considered to play a role, including the use of the profibrotic calcineurin inhibitors and the trend to reduce the load of corticosteroids in treatment regimes. To identify risk factors, further multicenter studies are required, paying special attention to alterations in immunosuppressive treatment regimens as well as PD prescriptions, including PD fluid characteristics. Transfer from PD to hemodialysis should be under serious consideration in patients eligible for kidney transplantation as soon as there are indications of ultrafiltration failure.
Primary Malfunction of a Peritoneal Dialysis Catheter Due to Encasement in an Encapsulating Sheath
Authors: Kazory Amir , Cendan Juan C. , Hollen Tracy L. , Ross Edward A.
Published: February 2020

Obstruction of the catheter is one of the potentially serious complications of peritoneal dialysis. Dislocation of the tip of the catheter, intraluminal fibrin formation, and omental wrapping are among the most common etiologies of peritoneal dialysis catheter malfunction that necessitate correction. Here we present a rare case of primary malfunction of a newly placed catheter in which multiple attempts to restore the patency by minimally invasive procedures were unsuccessful. Laparoscopy revealed a thick encapsulating sheath around the entire length of the catheter as the etiology of complete obstruction, without involvement of other intra-abdominal structures. The sheath was opened and the catheter was pulled out in its entirety. There was no intraluminal or orifice obstruction and it subsequently functioned perfectly.
Endothelial Glycocalyx and the Peritoneal Barrier
Authors: Flessner Michael F.
Published: February 2020

Recent advances in the study of the microcirculation have demonstrated the critical role of the endothelial glycocalyx in transcapillary transport from the plasma to the tissue interstitium. Since the capillary wall represents the initial resistance to solute transfer from the plasma through the tissue to the dialysate, the glycocalyx is potentially of major importance to peritoneal dialysis. Inadvertently removed in early histological studies, this thin, delicate layer of glycosaminoglycans and proteoglycans is now recognized as a primary barrier in transendothelial solute and water transport. Subperitoneal endothelia are exposed to inflammation, angiogenesis, and hyperglycemia, which have been shown to affect the layer by increasing permeability. This entity permits new hypotheses concerning the factors that influence the transport characteristics of peritoneal dialysis patients and provides new avenues of basic research into the fundamental mechanisms of alteration of the peritoneal barrier.
Severe Hyponatremia, Hyperglycemia, and Hyperlactatemia Are Associated with Intraoperative Hyperthermic Intraperitoneal Chemoperfusion with Oxaliplatin
Authors: Somer Filip De , Ceelen Wim , Delanghe Joris , Smet Dirk De , Vanackere Martin , Pattyn Piet , Mortier Eric
Published: February 2020

Background

Since the introduction of surgical debulking in combination with intraoperative hyperthermic intra-peritoneal chemoperfusion (HIPEC) with oxaliplatin in our institution, severe hyponatremia (sodium: 126.5 ± 3.8 mmol/L), hyperglycemia (glucose: 22.37 ± 4.89 mmol/L), and hyperlactatemia (lactate: 3.17 ± 1.8 mmol/L) have been observed post HIPEC. This metabolic disorder was not observed in patients in whom cisplatin or mitomycin C was used as a chemotherapeutic drug.

Methods

In order to understand the pathophysiology of this finding, an analysis of our data was made. In a first analysis, plasma sodium was corrected for hyperglycemia based on the formula of Hillier. In a second analysis, the influence of total exchangeable sodium, total exchangeable potassium, and total body water on plasma sodium concentration was modeled.

Results

Analysis of our data revealed a double mechanism for the observed metabolic disorder: hyperglycemia caused by dextrose 5%, which is used as a carrier for the oxaliplatin, and major loss of sodium into the dialysate (256.7 ± 68.7 mmol).

Conclusion

Better control of hyperglycemia and intravenous compensation of sodium loss into the dialysate can attenuate the reported biochemical disturbance.
A Randomized Controlled Trial Comparing Mupirocin versus Polysporin Triple for the Prevention of Catheter-Related Infections in Peritoneal Dialysis Patients (The MP3 Study)
Authors: Jassal Sarbjit V. , Lok Charmaine E.
Published: February 2020

Background

Peritonitis remains the most serious complication of peritoneal dialysis (PD). Gram-positive organisms are among the most common causes of PD peritonitis; however, recent trends show increasing rates of gram-negative and fungal infections. Strategies to prevent peritonitis include the use of prophylactic topical mupirocin at the site where the PD catheter exits from the abdominal wall; however, mupirocin does not afford protection against gram-negative or fungal infections. The aim of this study is to determine if the incidence of catheter-related infections (exit-site infection, tunnel infection, or peritonitis) is significantly reduced by the routine application of Polysporin Triple antibiotic ointment (Pfizer Canada, Markham, Ontario, Canada) in comparison to mupirocin ointment.

Methods and Design

The Mupirocin Versus Polysporin Triple Study (MP3) is a multicenter, randomized, double-blinded controlled study comparing Polysporin Triple (P3) against the current standard of care. The aim of the study is to recruit 200 patients being treated with or starting on PD and randomize them to receive either mupirocin or P3 at the catheter exit site. Patients will be followed for 18 months or until death or transfer from PD to an alternate treatment modality. The primary outcome will be the time to first catheter-related infection. Catheter-related infections will be strictly defined using current guidelines and categorized into exit-site infections, infective peritonitis, or tunnel infections. The primary analysis will be an intention-to-treat analysis.

Discussion

The results of this study will help determine if the use of P3 is superior to mupirocin ointment in the prevention of catheter-related infections and will help guide evidence-based best practices.
Early Initiation of Dialysis and Late Implantation of Catheters Adversely Affect Outcomes of Patients on Chronic Peritoneal Dialysis
Authors: Shiao Chih-Chung , Huang Jenq-Wen , Chien Kuo-Liong , Chuang Hsueh-Fang , Chen Yung-Ming , Wu Kwan-Dun
Published: February 2020

Objectives

Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD).

Design

Retrospective cohort.

Setting and Participants

275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (≥ 6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) ≥ 5 or <5 mL/minute/1.73 m2].

Main Outcome Measures

All-cause mortality and hospitalization.

Results

During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization.

Conclusions

Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.
High Peritoneal Permeability is Not Associated with Higher Mortality or Technique Failure in Patients on Automated Peritoneal Dialysis
Authors: Yang Xiao , Fang Wei , Bargman Joanne M. , Oreopoulos Dimitrios G.
Published: February 2020

Background

Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality.

Objective

To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin.

Design

Retrospective observational cohort study.

Setting

A single PD unit.

Patients and Methods

193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined.

Results

Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (≥ 30 kg/m2) were independent predictors of death.

Conclusion

This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.
Peritoneal Dialysis in the Comprehensive Management of End-Stage Renal Disease Patients with Liver Cirrhosis and Ascites: Practical Aspects and Review of the Literature
Authors: Selgas Rafael , Bajo M.-Auxiliadora , Peso Gloria Del , Sánchez-Villanueva Rafael , Gonzalez Elena , Romero Sara , Olivas Elena , Hevia Covadonga
Published: February 2020

The treatment of cirrhotic patients with ascites and end-stage renal disease is complex, due mainly to decreased effective arterial volume and hemodynamic instability. Peritoneal dialysis as a continuous therapy represents an alternative to hemodialysis-related intolerance. We report on our experience and that of others with cirrhotic patients with ascites treated by peritoneal dialysis. Hemodynamic tolerance was excellent in all patients and solute and water peritoneal transport increased to above the normal range in almost all cases. Morbidity and mortality were related principally to liver disease and other comorbidities. Peritoneal protein losses, initially high, decreased over time, maintaining serum albumin within the low normal range. The incidence of peritonitis was similar or slightly higher than usual in these patients, with peculiar etiology. The experiences with peritoneal dialysis suggest consideration of this treatment as the first choice for cirrhotic patients with ascites and that need to start dialysis.
In Vivo Peritoneal Surface Area Measurement in Rats by Micro-Computed Tomography (μCT)
Authors: Breton Elodie , Choquet Philippe , Bergua Laure , Barthelmebs Mariette , Haraldsson Börje , Helwig Jean-Jacques , Constantinesco André , Fischbach Michel
Published: February 2020

Peritoneal dialysis (PD) uses the dynamic dialysis properties of the peritoneal membrane. The fraction of the anatomic peritoneal surface area (PSA) recruited is of importance for maximizing exchanges and is potentially impacted by parameters such as fill volume.

We describe an in vivo assessment of the contact surface area by micro-computed tomography (μCT) using an iodinated contrast medium added to the PD fluid, a contrast agent presumed without surfactant property. In the isotropic volume (reconstructed voxel size 186 μm x 186 μm x 186 μm), the iodinated PD fluid is automatically selected, thanks to its contrast difference with soft tissues, and its surface area is computed. The method was first tested on phantoms showing the ability to select the PD fluid volume and to measure its surface area. In vivo experiments in rat consisted of μCT acquisition of rat abdomen directly after intraperitoneal administration (10 mL/100 g rat body weight) of a dialysis fluid containing 10% by volume iodinated contrast agent. Fluorescein isothiocyanate albumin was used as dilution marker.

We found a strong linear relationship ( R2 = 0.98) between recruited PSA (cm2) and rat weight (g) in the range of 235 to 435 g: recruited PSA = (1.61 weight + 40.5) cm2. Applying μCT with a fill volume of 10 mL/100 g rat body weight, the in vivo measured PSA was in the order of magnitude of the ex vivo anatomic PSA as determined by Kuzlan's formula, considered in most instances as the maximal surface area that can be recruited by PD fluid.

This new methodology was the first to give an in vivo high-resolution isotropic three-dimensional (3-D) determination of the PSA in contact with dialysate. Its sensitivity allows us to take into account the recruitment of fine 3-D structures of the PSA membrane that were not accessible to previous 2-D-based imaging methodologies. Its in vivo application also integrates the physiological natural tensile stress of tissues.
Rate of Synthetic Oligosaccharide Degradation as a Novel Measure of Amylase Activity in Peritoneal Dialysis Patients
Authors: García–López Elvia , Werynski Andrzej , Heimbürger Olof , Filho José C. Divino , Lindholm Bengt , Anderstam Björn
Published: February 2020

Background

Plasma α–amylase activity is elevated in uremic patients but lower in peritoneal dialysis (PD) patients using icodextrin in comparison to healthy controls. We studied the rate by which an exogenous oligosaccharide (maltoheptaose; G7) is degraded ex vivo by amylase in plasma from PD patients treated with glucose or icodextrin PD solutions.

Methods

Plasma amylase (pancreatic and total) activity and concentration were measured in 11 controls and in PD patients treated with glucose ( n = 11) and icodextrin ( n = 19). The plasma was spiked with G7 and/or synthetic amylase and the metabolites formed were measured by HPLC following incubation at 37°C for 4 hours.

Results

The relationship between amylase activity and amylase concentration was similar in all patients and controls. The G7 degradation rate was slower in plasma from icodextrin patients but it was also reduced in patients using glucose compared with the controls, in spite of the higher amylase activity in the glucose group. Normalization (by spiking) of patient plasma with porcine amylase increased but did not normalize the speed of G7 degradation. At a given endogenous amylase activity level, the efficiency of G7 degradation was similar for both patient groups.

Conclusions

An ex vivo model to study the relationship between amylase activity and the actual rate of carbohydrate (represented by G7) breakdown was developed and showed that PD patients using glucose and icodextrin degrade G7 at a slower speed than controls. This suggests that amylase-mediated carbohydrate metabolism is reduced in PD patients. Further clinical studies are needed to confirm if these findings hold true also in other groups of uremic patients with varying degrees of kidney failure, as well as in patients undergoing hemodialysis.
Impact of Early Nephrology Referral on Mortality and Hospitalization in Peritoneal Dialysis Patients
Authors: Chow Kai Ming , Szeto Cheuk Chun , Law Man Ching , Kwan Bonnie Ching-Ha , Leung Chi Bon , Li Philip Kam-Tao
Published: February 2020

Objectives

Several studies have examined the possible association between late referral to a nephrologist and mortality on maintenance hemodialysis. However, we lack information on the benefit of early nephrologist referral in patients receiving peritoneal dialysis (PD).

Patients and Methods

In an inception cohort of 102 consecutive PD patients identified in a single center between 2003 and 2004, we sought to determine whether late nephrologist referral was associated with poor outcomes. The primary end point was all-cause mortality. The effects of early referral to a multidisciplinary low clearance clinic on cardiovascular mortality and length of hospitalization were also evaluated.

Results

Of 102 incident PD patients, 61 subjects (59.8%) were referred early to the nephrologist (more than 3 months) before dialysis initiation. During the study period of 284.9 patient-years (median follow-up period 36.8 months), 25 patients died, 12 due to cardiovascular causes. Both cardiovascular and all-cause mortality were significantly increased among PD patients with late referral, but the relationship between late referral and all-cause mortality was mitigated substantially by adjusting for relevant factors. In univariate analysis, late nephrology referral was associated with increased cardiovascular mortality, with a hazard ratio of 5.43 (95% confidence interval 1.46 – 20.21, p = 0.012). Annual adjusted days of hospitalization were similar between the early and late nephrology referral groups.

Conclusions

A comprehensive analysis of incident PD subjects confirmed the significant relationship between late nephrology referral and all-cause and cardiovascular mortality. A causal relationship remains to be established and validated.
A Comparison of Outcomes between Diabetic and Nondiabetic Capd Patients in India
Authors: Prasad Narayan , Gupta Amit , Sinha Archana , Singh Anurag , Sharma Raj Kumar , Kumar Alok , Kaul Anupama
Published: February 2020

Background

Continuous ambulatory peritoneal dialysis (CAPD) has been an established modality of renal replacement therapy in India for a decade, but there is a paucity of published data on the outcome of CAPD patients in India. We analyzed our data to determine the overall predictors of survival and compared patient survival between diabetic and nondiabetic end-stage renal disease patients on CAPD.

Methods

Of 373 patients, 197 were diabetic (165 males, 32 females) and 176 nondiabetic (104 males, 72 females). Patients were followed for 22 ± 14 patient-months. Patients were prospectively followed until the study end point or death.

Results

Overall median survival was 48 patient-months. Median survival of diabetics (34.5 patient-months) was significantly inferior to nondiabetic patients (59 patient-months) p = 0.001. Overall patient survival at 1, 2, 3, 4, and 5 years was 90%, 72%, 60%, 49%, and 39%, respectively. Patient survival of diabetics versus nondiabetics at 1, 2, 3, 4, and 5 years was 85% versus 96%, 62% vs 82%, 48% vs 72%, 39% vs 62%, and 34% vs 42%, respectively. The relative risk of mortality in nondiabetics (34/176) was less than that in diabetic patients (71/197): odds ratio (OR) 0.43, 95% confidence interval (CI) 0.26 – 0.68; p = 0.001. On Cox regression analysis, diabetes (OR 1.95, 95% CI 1.23 – 3.07; p = 0.004), comorbidities (OR 0.39, 95% CI 0.25 – 0.61; p = 0.001), peritonitis (OR 1.79, 95% CI 1.19 – 2.68; p = 0.005), malnutrition (OR 0.52, 95% CI 0.29 – 0.94; p = 0.03), and residual glomerular filtration rate at initiation of CAPD (OR 0.87, 95% CI 0.81 – 0.93; p = 0.001) were significant predictors of overall mortality. Age (OR 0.68, 95% CI 0.45 – 1.03; p = 0.07), gender (OR 0.66, 95% CI 0.42 – 1.03; p = 0.06), and albumin level at initiation of CAPD (OR 0.92, 95% CI 0.64 – 1.33; p = 0.68) were not predictors of mortality. Age (56 ± 10 vs 46 ± 15 years, p = 0.001), comorbidities (51/197 vs 16/176, p = 0.001), peritonitis rate (0.68 vs 0.50 episodes/patient-year, p = 0.056), and severe malnutrition (27/197 vs 10/176, p = 0.002) were higher in diabetic than in nondiabetic patients.

Conclusion

In India the majority of CAPD patients are diabetic. Patient survival was inferior in diabetic compared to nondiabetic patients on CAPD, but survival was statistically similar after adjustment for comorbidities. Diabetes, comorbidities, residual glomerular filtration rate, peritonitis, and severe malnutrition are predictors of mortality in CAPD patients.
Peripheral Resistance Modulates the Response to Volume Overload in Peritoneal Dialysis Patients
Authors: Tian Jun-Ping , Du Feng-He , Cheng Li-Tao , Tian Xin-Kui , Axelsson Jonas , Wang Tao
Published: February 2020

Background

Volume overload is thought to be the most important cause of hypertension in peritoneal dialysis (PD) patients. However, there is also evidence that normalization of volume overload is not always accompanied by a drop in blood pressure (BP). In the present study, we hypothesized that dysregulation of peripheral resistance due to endothelial dysfunction would constitute an important determinant of BP response in overhydrated PD patients.

Methods

We performed an observational, prospective cohort study including all prevalent PD patients at the Peking University Third Hospital between 1 June 2006 and 30 November 2006. After baseline measurements, including echocardiography and bioelectrical impedance analysis, patients fulfilling inclusion criteria were reevaluated after 2 months of follow-up. All patients that exhibited significant changes in BP and extracellular water (ECW) between 2 visits were asked to undergo a second ultrasound. These patients were then divided into group A (parallel change between BP and ECW; n = 12) and group B (paradoxical change between BP and ECW; n = 10).

Results

The cohort included 22 patients (13 males) with a mean age of 59 ± 13 years, on dialysis for 23.3 ± 32.6 months. There were no baseline differences between groups A and B. However, while patients in group A significantly increased their cardiac output, total peripheral resistance remained stable. In group B, cardiac output did not change significantly but total peripheral resistance decreased significantly.

Conclusion

In PD patients, a significant increase in fluid volume is not necessarily linked to a significant increase in BP. Rather, the change in total peripheral resistance was found to be the most important determinant of the extent to which increased fluid volume affected BP.
Interrelationships between B-Type Natriuretic Peptides and Vitamin D in Patients on Maintenance Peritoneal Dialysis
Authors: Obineche Enyioma N. , Saadi Hussain , Benedict Sheela , Pathan Javed Y. , Frampton Christopher M. , Nicholls M. Gary
Published: February 2020

Objective

Experimental evidence suggests that vitamin D deficiency impairs cardiac structure and function. Our objective was to observe relationships between circulating levels of the cardiac natriuretic peptides and vitamin D levels in patients on chronic peritoneal dialysis.

Method

Measurements were made of circulating levels of 25-hydroxyvitamin D [25(OH)D] and plasma B-type natriuretic peptide (BNP) levels in patients receiving chronic peritoneal dialysis.

Results

Both BNP and the 1–76 amino-terminal fragment of pro-BNP correlated inversely with 25(OH)D levels ( rs = –0.60, p = 0.007, and rs = –0.64, p = 0.003, respectively) in patients on peritoneal dialysis.

Conclusions

Vitamin D deficiency in chronic renal failure may impair cardiac function, as manifested by elevated levels of B-type cardiac natriuretic peptides.