Ambulatory Peritoneal Dialysis Patients Research Articles

A successful management of fungal peritonitis caused by Rhodotorula glutinis in CAPD patient, coincident with onychomycosis by Penicillium sp: Case report.

Rhodotorula glutinis is a rare cause of fungal peritonitis in peritoneal dialysis (PD) patients. The combination treatment between aggressive PD catheter replacement and adequate antifungal treatment is crucial in managing peritonitis due to fungal infection and onychomycosis. A 37-year-old man PD patient presented with cloudy effluent, abdominal pain, and black debris in the lumen of his PD catheter. Twelve days before admission, the patient traveled for 10 days to a high-temperature country, Saudi Arabia, for purpose of accomplishing haj. From the physical examinations, there was an onychomycosis in his right toenail. The result of the dialysate cell count confirmed the evidence of peritonitis (i.e., cell count of 187 cells per µL, however with polymorphonuclear 31%). The dialysate culture indicated R glutinis, with no growth of bacteria. Fungal culture of his toenail scrapings was obtained and the result was Penicillium sp. Based on the high clinical suspicion of fungal peritonitis, fluconazole intraperitoneal (IP) was immediately given on the first day in addition to empirical antibiotics, that is, cefazolin and gentamycin IP. His peritoneal catheter was simultaneously removed and reinserted on the 4th day of treatment. Since there was a sign of fluconazole resistance, fluconazole IP was switched into oral voriconazole, without any antimicrobial treatment intraperitoneally. After 21 days of voriconazole, oral itraconazole was given until 3 months for his onychomycosis. Clinical improvement was seen on the effluent where the leucocyte count falls below 100 cells after 21 days of giving voriconazole. This case report suggests the need for comprehensive evaluations of the risk for fungal infection in continuous ambulatory PD patients, especially those who live in a tropical country.

Single-cell sequencing reveals peritoneal environment and insights into fibrosis in CAPD patients

Long-term peritoneal dialysis (PD) is associated with the development of peritoneal fibrosis (PF). Understanding the changes of immune environments and peritoneal mesothelial cells (PMCs) may lead to the discovery of mechanisms of PF. Therefore, we used single-cell RNA sequencing to interrogate cell composition and transcriptome characteristics in dialysate of continuous ambulatory PD (CAPD) patients at different stages. Results showed that six major cell populations were identified in overnight effluent dialysate. Two subsets of macrophages (Macro-c2-SSP1 and Macro-c5-FCN1&SSP1) and PMCs (HSPA1A+ PMCs and RPL34+ PMCs) had the property of promoting fibrosis. Long-term patients had higher markers of cytotoxic CD8+T cells. Moreover, the expression levels of fibrosis-related genes were significantly increased and PMCs interacted closely with immune cells in the long-term group (p<0.05). These data reveal new phenotypes and functional characteristics of immune cells and PMCs in dialysate of CAPD patients with different stages, which provide potential mechanisms and therapeutic strategies for PF.

Patient-reported gastrointestinal symptoms in patients with peritoneal dialysis: the prevalence, influence factors and association with quality of life

BackgroundThe aims of this study were to investigate the prevalence and the influence factors of gastrointestinal symptoms, and its association with the quality of life (QOL) in peritoneal dialysis (PD) patients.MethodsContinuous ambulatory PD patients (CAPD) who followed up in our PD center between March 2016 and December 2017 were enrolled in this cross-sectional study. Gastrointestinal symptom rating scale (GSRS) was used to evaluate gastrointestinal symptoms. The related clinical data were also collected. Multiple linear regression analysis was test for the influence factors associated with score of GSRS and QOL.ResultsThis study included 471 CAPD patients. The mean age was 48.5±13.9 years, 53.9% were male and 15.1% with diabetic nephropathy. The median duration of PD was 37.3 (17.5~66.5) months. The median score of GSRS was 1.2(1.1~1.3) scores. Totally 82.2% (n=387) CAPD patients had at least one gastrointestinal symptom. Higher glycosylated hemoglobin, higher score of depression, lower diastolic blood pressure, urine output, score of instrumental activities of daily living scale and more amount of pills per day were independently associated with higher score of GSRS (all P<0.05). Score of dyspepsia and eating dysfunction were independently associated with worse score of QOL and physical health (all P<0.05).ConclusionsGastrointestinal symptoms were common but not serious in CAPD patients. Glycemic control, depression, blood pressure, urine output, activity of daily life and amount of pills were all associated with gastrointestinal symptoms. Moreover, gastrointestinal symptoms were correlated with QOL of PD patients.

Value of gamma interferon enzyme-linked immunospot assay in the diagnosis of peritoneal dialysis-associated tuberculous peritonitis

BackgroundTuberculous peritonitis is the most common form of extrapulmonary tuberculosis infection in peritoneal dialysis patients. However, diagnosing tuberculous peritonitis quickly and early has always been a challenge for nephrologists. Mycobacterium tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (IFN-γ ELISPOT) assay has been widely used in the clinical diagnosis of tuberculous pleurisy and peritonitis, but its use has not been reported for uremia.MethodsThis study mainly verified the feasibility of using the M. tuberculosis antigen-specific IFN-γ ELISPOT assay in the diagnosis of continuous ambulatory peritoneal dialysis (CAPD) patients with tuberculous peritonitis. Taking M. tuberculosis culture as the gold standard, the IFN-γ ELISPOT assay was used to analyze peripheral blood and peritoneal dialysis fluid of patients, and the receiver operating characteristic (ROC) curves in patients with tuberculous peritonitis (TBP) or non-tuberculous peritonitis (NTBP) were analyzed.ResultsThe area under the receiver operating characteristic curve (AUC) was 0.927 (95% CI 0.816–1.000, P = 0.001) for the ELISPOT assay with peritoneal fluid mononuclear cells (PFMC), which was higher than that for the ELISPOT assay with peripheral blood mononuclear cells (PBMC) (0.825, 95% CI 0.6490–1.000, P = 0.011). The cutoff value for the diagnosis of TBP was 40 spot-forming cells (SFCs)/2 × 105 for the ELISPOT with PBMC, with a sensitivity of 55.6%, a specificity of 92.3%, and a diagnostic efficiency of 77.3%. The cutoff value for the diagnosis of TBP was 100 SFCs/2 × 105 for the ELISPOT on PFMC, with a sensitivity, specificity, and diagnostic efficiency 77.8%, 84.6%, and 81.8%, respectively. Parallel and serial testing algorithms appeared more accurate than single ELISPOT assays with PBMC, but ELISPOT assays with PFMC.ConclusionsThe IFN-γ release test can be used for the early diagnosis of CAPD-related TBP; compared with peripheral blood, peritoneal fluid may be a more effective and accurate medium to diagnose CAPD complicated with tuberculous peritonitis.

Effluent Osteopontin levels reflect the peritoneal solute transport rate.

Long-term peritoneal dialysis (PD) is accompanied by low-grade intraperitoneal inflammation and may eventually lead to peritoneal membrane injury with a high solute transport rate and ultrafiltration failure. Osteopontin (OPN) is highly expressed through the stimulation of pro-inflammatory cytokines in many cell types. This study aimed to investigate the potential of OPN as a new indicator of peritoneal deterioration. One hundred nine continuous ambulatory PD patients were analyzed. The levels of OPN and IL-6 in peritoneal effluents or serum were analyzed by ELISA kits. The mean effluent OPN concentration was 2.39 ± 1.87 ng/mL. The OPN levels in drained dialysate were correlated with D/P Cr (p < 0.0001, R = 0.54) and D/D0 glucose (p < 0.0001, R = 0.39). Logistic regression analysis showed that the OPN levels in peritoneal effluents were an independent predictive factor for the increased peritoneal solute transport rate (PSTR) obtained by the peritoneal equilibration test (p < 0.001). The area under the receiver operating characteristic curve of OPN was 0.84 (95% CI: 0.75–0.92) in predicting the increased PSTR with a sensitivity of 86% and a specificity of 67%. The joint utilization of effluent OPN with age, effluent IL-6, and serum albumin further increased the specificity (81%). Thus, OPN may be a useful indicator of peritoneal deterioration in patients with PD.

Risk Factors and Clinical Outcomes of Cognitive Impairment in Diabetic Patients Undergoing Peritoneal Dialysis

Introduction: Cognitive impairment (CI) is common in patients with CKD or diabetes mellitus (DM). However, the relevance between DM and CI in diabetic patients undergoing peritoneal dialysis (PD) has not been clearly established. This study aimed to explore the role of DM in CI, the association of glycemic control with CI, and clinical outcomes of CI in diabetic PD patients. Methods: Continuous ambulatory PD (CAPD) patients followed up in our PD center between 2014 and 2016 were enrolled. The participants were followed until an endpoint was reached or December 2017. Demographic data and clinical characteristics were collected, and laboratory parameters were measured. The Montreal Cognitive Assessment (MoCA) was used to evaluate global cognitive function, and a score of <26 was considered to indicate CI. A propensity score matching according to age, gender, and mean arterial pressure was conducted between the DM and non-DM groups. Results: A total of 913 CAPD patients were enrolled, of whom 186 (20.4%) had diabetes. After appropriate matching, 175 patients in the DM group and 270 patients in the non-DM group were included. Patients with diabetes had a higher prevalence of CI and lower scores for visuospatial/executive function, naming, language, delayed recall, and orientation. Higher HbA1c (odds ratio [OR], 1.547; 95% confidence interval [95% CI], 1.013–2.362) and cardiovascular disease (CVD; OR, 2.926; 95% CI, 1.139–7.516) significantly correlated with a risk of CI in diabetic patients. During a median of 26.0 (interquartile range 13.5–35.6) months of follow-up, diabetic patients with CI demonstrated a significantly lower survival rate than those without CI, and CI was an independent risk factor for mortality after adjustment (hazard ratio, 7.224; 95% CI, 1.694–30.806). However, they did not show worse technique survival or higher peritonitis rate than patients without CI. Conclusions: HbA1c and CVD are independent risk factors for CI in diabetic patients undergoing CAPD, and CI is independently associated with a higher risk of mortality.

Elizabethkingia meningoseptica: An Uncommon Cause of Peritonitis In Continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature

Peritonitis is a major complication of peritoneal dialysis (PD) and due to its gravity, it remains the primary reason to switch from PD to hemodialysis. Elizabethkingia meningoseptica, a non-fermentative Gram-negative bacillus, is rarely encountered as a pathogen causing peritonitis in adults. We present here a case report of an acquired infection with this organism in adult on PD. To the best of our knowledge, this is the first report of infection with this organism in a continuous ambulatory PD patient in Tunisia.

COVID-19–Associated Acute Kidney Injury and Quantified Protein Catabolic Rate: A Likely Effect of Cytokine Storm on Muscle Protein Breakdown

Rationale & ObjectivesPreviously we reported a cohort of patients with coronavirus disease 2019 (COVID-19)–associated acute kidney injury (AKI) with striking biochemical evidence of tissue breakdown in the absence of apparent rhabdomyolysis. We sought to quantify the extent of tissue catabolism in similar patients.Study DesignDuring acute peritoneal dialysis (PD) in patients with COVID-19–associated AKI, we measured urea Kt/V adequacy and calculated the daily urea nitrogen generation rate while quantifying daily protein intake.Setting & PopulationWe did calculations in 8 patients with COVID-9–associated AKI undergoing acute PD at Mount Sinai Hospital in New York City. As a comparator, we obtained urea kinetic parameters from our database of ambulatory patients receiving maintenance PD.Exposure or Predictors8 patients with COVID-19–associated AKI undergoing acute PD.OutcomesUrea nitrogen generation rate in relation to daily protein intake.Analytical ApproachUrea nitrogen generation rate from urea kinetics was related to measured daily dietary protein intake in these patients and we compared it with this relationship in ambulatory maintenance PD patients for whom both parameters were calculated from urea kinetics.ResultsUrea nitrogen generation rate in patients with AKI was 10.2 ± 5 g/d, which is more than 2-fold higher than for stable outpatients receiving maintenance PD (4.7 ± 3 g/d) despite similar dietary protein intake (74.8 ± 11 vs 67.2 ± 29 g/d, respectively). This strongly suggests endogenous protein breakdown, probably from muscle. Urea nitrogen generation rate in these patients with AKI corresponds to 315 g/d of ongoing muscle breakdown and cumulative 2.5 kg of muscle breakdown during the early course of AKI.LimitationsSmall number of participants and assumptions in comparing urea nitrogen generation rate with protein intake.ConclusionsIn highly catabolic patients, an endogenous source of urea generation such as muscle protein breakdown seems to be the most likely explainable cause for our findings. This is the first study that we are aware of to quantify the degree of endogenous protein breakdown induced by COVID-19–related cytokine storm.

Overhydration and low serum prealbumin predict peritoneal dialysis-related peritonitis in continuous ambulatory peritoneal dialysis patients

BackgroundIn this study, we focused on the role of overhydration (OH) and low serum prealbumin concentration in predicting peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients over a 3-year period.MethodsWe measured serum prealbumin concentration and OH by body composition monitor in 278 CAPD patients (159 males and 119 females) with a mean age of 46 years and a median peritoneal dialysis (PD) duration of 21 months. Cases of PD-related peritonitis were collected over 3 years.ResultsAfter the 3-year follow-up, 44 patients were diagnosed with PD-related peritonitis (15.8%). Low education, serum glucose, prealbumin, and OH were independent risk factors for predicting peritonitis over 36 months in CAPD patients. Based on the ROC curve model and Kaplan-Meier analysis, we realized that low prealbumin and high OH were independent predictors of 3-year peritonitis in CAPD patients (Prealbumin: AUC = 0.838, cut-off value = 32.5 mg/dL, Se = 90.9%, Sp = 32.9%; OH: AUC = 0.851, cut-off value = 1.33 L, Se = 79.5%, Sp = 85.5%; and log-rank test p < 0.001, respectively).ConclusionOverhydration and low serum prealbumin were the independent predictors of PD-related peritonitis in CAPD patients.

Higher Eosinophils Predict Death-Censored Technique Failure in Peritoneal Dialysis Patients

Introduction: Eosinophilia (eosinophil fraction of leukocytes >5%), an indicative parameter for bioincompatibility in various circumstances, is well established in hemodialysis. However, change in eosinophil count (EOC) and its association with death-censored technique failure among peritoneal dialysis (PD) patients remain unclear. Methods: We compared eosinophils before and after PD initiation among 1,432 eligible continuous ambulatory PD patients regularly followed up in our PD center during 2007–2018. Risk factors of early-stage eosinophilia were examined by the logistic regression test. The relationship of early-stage eosinophilia and EOC with death-censored technique failure was examined using the Cox proportional hazards model for overall patients and for men and women separately. Results: After PD initiation, the EOC and percentage of patients with eosinophilia were significantly increased compared with baseline. Being male (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.55–3.31; p < 0.001) and higher EOC at baseline (100 cells/μL increase, OR: 1.62; 95% CI: 1.45–1.82; p < 0.001) were risk factors of early-stage eosinophilia after PD initiation. During follow-up, 204 death-censored technique failures were recorded. In fully adjusted models, each with 100 cells/μL increase in EOC, the adjusted hazard ratios (HRs) of technique failure were 1.11 (95% CI: 1.03–1.20; p = 0.009) in the whole cohort, 1.29 (95% CI: 1.10–1.51; p = 0.002) in women, and 1.07 (95% CI: 0.97–1.17; p = 0.196) in men. Eosinophilia was significantly associated with the risk of technique failure for women (HR: 2.24; 95% CI: 1.07–4.70; p = 0.033), which was especially significant for women aged <55 years (HR: 7.61; 95% CI: 1.88–30.90; p = 0.005). Conclusion: EOC was increased significantly after PD initiation, and increased numbers of eosinophils were associated with higher death-censored technique failure in PD patients, especially women.

P1217VALUE OF MYCOBACTERIUM TUBERCULOSIS SPECIFY ELISOPT IN THE DIAGNOSIS OF PERITONEAL DIALYSIS-ASSOCIATED TUBERCULOUS PERITONITIS PATIENTS

Abstract Background and Aims Patients with ESRD undergoing chronic dialysis are 6 to 25 times more likely to develop tuberculosis (TB) than the general population. Tuberculous peritonitis is the most common form of tuberculosis infection in peritoneal dialysis patients. However, diagnosing active TB infection can be challenging, early and rapid diagnosis of tuberculous peritonitis has always been a challenge for nephrologists. M.tuberculosis antigen-specific IFN-γ production by peripheral blood mononuclear cells (PBMC) was determined by using an in-house ELISPOT assay by Institute of Hepatology of Shenzhen Third Hospital.In this study, we evaluated diagnostic performance of an M.tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (ELISPOT) assay in continuous ambulatory peritoneal dialysis (CAPD) patients with tuberculous peritonitis. Method There were nine patients (1.29%) with tuberculous peritonitis among 700 CAPD patients. M. tuberculosis accounted for 2.84 % of all peritonitis.IFN-γ response in peripheral blood and peritoneal fluid were determined in 9 patients with tuberculous peritonitis(TBP),at the same time, 13 cases diagnosed with non-tuberculous peritonitis(NTBP) were enrolled.All patients were examined for tuberculosis-specific IFN-γ ELISPOT in peripheral blood and peritoneal dialysis fluid. Results 22 patients were recruited into this study, 9 were classified with confirmed tuberculosis peritonitis, 13 patients with bacterial or fungal peritonitis were enrolled as controls during the same period, in this patients, 3 were caused by Gram positive bacteria, 3 were caused by Gram negative bacteria, 3 were caused by fungus, 4 patients were negative athogenic bacteria culture .The AUC of ROC curve was 0.927 (95%CI:0.816–1.000,P=0.001) for ELISPOT on PFMC, which was higher than that of ELISPOT on PBMC (0.825,95%CI: 0.6490–1.000,P=0.011).When the cutoff value for the diagnosis of TBP was 40.5 SFCs/2 × 105 for ELISPOT on PBMC, with a sensitivity of 55.6%, a specificity of 92.3%,a diagnostic efficiency of 77.3%,The positive predictive value was83.3%, with negative predictive value of 75%,positive likelihood ratio of 7.2, and negative likelihood ratio of 0.48.The sensitivity, specificity,diagnostic efficiency,PPV, NPV, LR+, and LR- of the ELISPOT assay for the diagnosis of active TBP when performed on the PFMC were 77.8%, 84.6%, 81.8%, 77.8%, 84.6%, 5.05 and 0.26, respectively.Receiver operating characteristic(ROC) curves were used to estimate the diagnostic values of Elispot on PFMC and PBMC in 22 patients with confirmed TBP or NTBP. Conclusion IFN-γ release test can be used for early diagnosis of CAPD-related TBP; compared with peripheral blood, peritoneal dialysate may be a more effective and accurate way to diagnose CAPD complicated with tuberculous peritonitis.

High glucose contributes to the polarization of peritoneal macrophages to the M2 phenotype invivo and invitro.

Glucose is the primary osmotic medium used in most peritoneal dialysis (PD) solutions, and long-term exposure to high glucose is a major contributor to peritoneal fibrosis. Our previous study revealed that M2 macrophages participate in the development of PD-related fibrosis in a rat model. In the present study, the effects of high glucose on peritoneal macrophage polarization in vivo and in vitro were further evaluated. Continuous ambulatory PD (CAPD) patients with an overnight dwell of 1.5 or 2.5% glucose dialysate were recruited for this study. Overnight effluent samples from patients with CAPD (2,000 ml) were centrifuged to collect cells from the peritoneal cavity. J774A.1 cells (murine macrophages from ascites) were cultured in different concentrations of glucose. Macrophage phenotype markers were detected by flow cytometry. The levels of cytokines in PD effluent and the supernatant of murine macrophages were detected by enzyme-linked immunosorbent assays. The activity of arginase was determined by quantitative colorimetric analysis. In total, 107 CAPD subjects (92 patients using 1.5% glucose dialysate and 15 patients using 2.5% glucose dialysate) were recruited. The percentage of M1 macrophages (CD14- and CCr7-positive cells) in the 1.5 and 2.5% glucose dialysate groups was 23.0±13.3 and 24.9±12.0%, respectively. The difference was not significant (P>0.05). The percentage of M2 macrophages (CD14- and CD206-positive cells) in the 1.5% glucose dialysate group (36.2±11.4%) was significantly decreased compared to the 2.5% glucose dialysate group (43.2±7.4%) (P<0.05). Murine macrophages were cultured in a high-glucose in vitro environment, and the percentage of M1 macrophages in 138.8 mmol/l glucose medium significantly increased over time. The percentage of M2 macrophages increased in a glucose concentration-dependent and time-dependent manner. Arginase 1 in murine macrophages and the level of transforming growth factor β1 in the supernatant increased in a glucose concentration-dependent manner. In conclusion, high glucose contributed to the polarization of peritoneal macrophages to the M2 phenotype, which may play an important role in the pathogenesis of PD-related fibrosis.

The relationship between lymphocyte subsets, nutritional status and tuberculin reactivity in continuous ambulatory peritoneal dialysis and hemodialysis patients

AimSkin test anergy is common in patients with uremia and during maintenance hemodialysis treatment. However, up to date only one study concerning skin test in peritoneal dialysis patients has focused on the issue. Our cross-sectional controlled study was conducted to analyze the correlation of purified protein derivative (PPD) test response with demographical features, nutritional parameters and the distribution of peripheral blood lymphocyte subsets in peritoneal dialysis and hemodialysis patientsPatients and methodsStable 30 hemodialysis (HD) patients (16 men, 14 women) and 30 continuous ambulatory peritoneal dialysis (PD) patients (17 men, 13 women) were included. Thirty healthy cases (15 men, 15 women) with a mean age of 32.4 ± 9.4 constituted the control group.ResultsIn the HD group, 14 patients (46.6%) were PPD positive, and ın the PD group 16 patients (53.3%) were PPD positive. In the PPD-positive HD patients 64.2% (9/14), and in the PPD-positive PD patients 62.4% (10/16) had an induration of 10 mm or greater. In the control group, 21 of 30 patients (70%) were PPD positive. Comparison of both HD and PD groups with the control group showed significant differences in PPD reactivity (p < 0.01). Albumin levels were significantly high in the control groups (p < 0.01), and cholesterol levels were significantly high in the PD and the control groups (p < 0.05). Transferrin levels were significantly high in the PD (p < 0.01). The lymphocyte counts were significantly high in the control group compared to the HD patients (p < 0.05). The lymphocyte subset percentages CD19 were high in the control groups (p < 0.05), and CD16/56 was significantly high in the PD groups (p < 0.05). All the parameters were also similar between PPD-positive and -negative same groups.ConclusionThe prevalence of PPD positivity was lower in the PD and HD groups. The PPD test responses were not related to the peripheral lymphocyte counts, subsets and malnutrition parameters.

Sulodexide modulates the dialysate effect on the peritoneal mesothelium.

Peritoneal membrane damage during chronic peritoneal dialysis is the main cause of that treatment failure. Preservation of the mesothelial cells (MC) is important for the survival of the peritoneum. Evaluation of dialysates effect on the function of MC and potential modification of that effect by sulodexide (heparin 80% and dermatan sulfate 20%). Dialysate effluents, after the overnight exchange with dianeal 1.5% dextrose, were collected from 7 continuous ambulatory peritoneal dialysis (CAPD) patients, and their effect ± sulodexide 0.5 LRU/mL on genes expression, secretory activity and protein synthesis in MC was studied. Exposure of MC to the studied dialysates caused intracellular oxidative stress and significantly increased expression of the genes regulating the synthesis of interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), transforming growth factor-beta (TGF-β), vascular cell adhesion molecule 1 (VCAM-1) and vascular endothelial growth factor (VEGF). Secretion of the studied molecules from MC treated with dialysates was increased: by 96% for IL-6 (P < 0.01), 34% for MCP-1(P < 0.01), 24% for TGF-β (P < 0.01), 27% for VCAM-1 (P < 0.01), and by 15% for VEGF (P < 0.01). Sulodexide reduced the stimulatory effect of the dialysates on the intracellular generation of free radicals, genes expression and secretory activity of MC. These cells exposed to the dialysates showed increased synthesis of total protein (by 216%, P < 0.005) and collagen (by 264%, P < 0.005), as compared to standard culture medium. Supplementation of the dialysates with sulodexide resulted in weaker stimulation of collagen synthesis (-21% versus dialysate). We concluded that peritoneal dialysate changes the genes expression and phenotype of MC to a proinflammatory, profibrotic and proangiogenic one. Sulodexide reduces these negative effects of the dialysate.

Unusual organisms causing continuous ambulatory peritoneal dialysis peritonitis

Peritonitis is an important cause for morbidity and mortality in Continuous Ambulatory Peritoneal Dialysis (CAPD) patients. There is an emerging trend towards unusual organism causing CAPD peritonitis. We report our experience with unusual organisms and its impact on survival. We had 43 CAPD peritonitis episodes, out of which, six were due to unusual organisms. Although five patients responded to antibiotic therapy, one lost her CAPD access (catheter). Clinically, peritonitis caused by unusual organism is similar to that caused by other pathogens. Adherence to diligent hygienic practices while handling catheter and bag is most important in avoiding such peritonitis episodes.

Estimating total small solute clearance in patients treated with continuous ambulatory peritoneal dialysis without urine and dialysate collection.

International Society for Peritoneal Dialysis guidelines recommend to routinely monitor the total measured clearance (mCl) of small solutes such as creatinine; however, collection of 24-h urine and peritoneal dialysis (PD) fluid is burdensome to patients and prone to errors. We hypothesized that equations could be developed to estimate mCl (estimated clearance (eCl)) using endogenous filtration markers. In the Guangzhou PD Study (n = 980), we developed eCl equations using linear regression in two-third and validated them in the remaining one-third. Reference tests were mCl for urea nitrogen (UN) (mClUN, ml/min) and average mCl for UN and creatinine (mClUN-cr, ml/min/1.73 m2). Index tests were various eCl equations using UN, creatinine, low-molecular-weight proteins (LMWPs) (beta-trace protein (BTP), beta-2 microglobulin (B2M), and cystatin C), demographic variables, and body size. After reexpression of the equations in the combined data set, we analyzed accuracy (eCl within ± 2.0 units of mCl) and the predictive value of eCl to detect a weekly total standard Kt/V (weekly mClUN indexed for total body water) > 1.7 using receiver operating characteristic curve. Mean age of the cohort was 50 ± 15 years, 53% were male; mClUN was 6.9 ± 1.8 and mClUN-cr was 7.5 ± 2.8. Creatinine but not UN contributed to eCl for both mCl. LMWP did not improve accuracy for mClUN (range 88-89%). BTP and B2M improved the accuracy for mClUN-cr (82% vs. 80%); however, differences were small. The area under the curve for predicting a weekly Kt/V > 1.7 was similar for all equations (range 0.79-0.80). Total small solute clearance can be estimated moderately well in continuous ambulatory PD patients using serum creatinine and demographic variables without urine and dialysate collection.

Higher serum phosphorus predicts residual renal function loss in male but not female incident peritoneal dialysis patients.

Elevated serum phosphorus level is a risk factor for progression of chronic kidney disease in non-dialysis patients. However, the association of serum phosphorus level with residual renal function (RRF) loss among incident continuous ambulatory peritoneal dialysis (CAPD) patients remains unclear. We performed a retrospective analysis of prospectively collected cohort of 1245 incident CAPD patients from January 2006 to December 2015 and followed up until December 2017. Patients were stratified into tertiles according to baseline serum phosphorus levels. RRF loss was defined as residual glomerular filtration rate (mL/min/1.73m2) reaching zero or estimated urine output less than 200mL/day on two successive clinic visits. Propensity-score matched Cox's proportional hazards and competing risk models were performed to examine the association of serum phosphorus with RRF loss. A total of 421 (33.82%) patients had loss of RRF over a median follow-up of 26.23months. In the entire cohort, elevated serum phosphorus was associated with increased risk for RRF loss after adjustment. In the propensity-score matched cohort, patients in the 3rd tertile of serum phosphorus had a 51% higher risk of RRF loss than those in the combination of the 1st and 2nd tertiles. Furthermore, the association of serum phosphorus level with RRF loss differed by sex (interaction P = 0.018). The adjusted HRs per 1mg/dL increase in serum phosphorus level of RRF loss were 1.32 (95% CI 1.15-1.50, P < 0.001) for male and 1.03 (95% CI 0.87-1.21, P = 0.750) for female, respectively. These findings persisted in competing risk analysis. Higher serum phosphorus levels independently predicts RRF loss in men treated with CAPD.

Atherosclerotic vascular disease is more prevalent among black ESKD patients on long-term\xa0CAPD in South Africa

BackgroundOccurrence of cardiovascular disease (CVD) in the setting of chronic kidney disease (CKD) can be described as a “cruel alliance”, with CVD responsible for about half of all deaths among CKD patients. Chronic kidney disease patients are more likely to die from CVD than progress to end stage kidney disease (ESKD). Dyslipidaemia, a known traditional risk factor for CVD, is highly prevalent among CKD patients and with an even higher frequency among ESKD patients on dialytic therapies. Prolonged exposure of continuous ambulatory peritoneal dialysis (CAPD) patients to high glucose concentrations in CAPD fluid have been associated with increased risk of cardiovascular events. In this study, we investigated the relationship of atherosclerotic vascular disease (AsVD) to clinical and echocardiographic parameters among black South Africans with CKD (stage 3) and ESKD on CAPD and haemodialysis (HD).MethodsThis was a cross-sectional study of 40 adult (18–65 years) non-diabetic CKD patients (kidney disease outcome quality initiative [KDOQI] stage 3), 40 ESKD patients on CAPD, 40 ESKD patients on HD and 41 age and sex-matched healthy controls. An interviewer-administered questionnaire was used to obtain information on participants’ sociodemographic and cardiovascular risk factors. Anthropometric parameters were measured. Serum blood samples were analysed for creatinine, albumin and lipid profile; lipoprotein ratios, Framingham’s risk score and the 10-year risk of developing coronary heart disease (CHD) were calculated. Echocardiography was performed on all patients and carotid intima media thickness (CIMT) was measured in both right and left carotid arteries at 1 cm proximal to the carotid bulb. Spearman’s rank correlation and binary logistic regression were conducted to determine the relationship of AsVD to clinical and echocardiographic parameters.ResultsAtherosclerotic vascular disease was most prevalent among ESKD patients on CAPD (70%, n = 28/40). Chronic kidney disease and HD patients exhibited a similar prevalence (47.5%, n = 19/40), while the prevalence in controls was 17.1% (n = 7/41). Presence of AsVD was associated with significantly older age, higher waist hip ratio (WHR), left ventricular mass index (LVMI) and Framingham’s 10-year risk of developing CHD. Significant differences in clinical and echocardiographic parameters were observed when the study groups were compared. Age and LVH independently predicted AsVD.ConclusionAtherosclerotic vascular disease was more prevalent among CAPD patients compared to pre-dialysis CKD and HD patients. Among all lipoprotein ratios assessed, non-HDL-C showed the most consistent significant difference between the groups. Age (> 40 years) and presence of LVH were independent predictors of AsVD.

Metabolic Syndrome and Mortality in Continuous Ambulatory Peritoneal Dialysis Patients: A 5-Year Prospective Cohort Study

Background/Aims: Metabolic syndrome (MS) has been widely proved as a predictor of cardiovascular disease, all-cause, and cardiovascular mortality in general population. But its effects on mortality and technique failure have not been well illustrated in peritoneal dialysis (PD) patients. We aimed to investigate the association of MS and clinical outcomes in Chinese continuous ambulatory PD (CAPD) patients. Methods: A single-center, prospective, observational cohort study was conducted in CAPD patients enrolled from September 1 to December 31, 2011, and followed up until December 31, 2016. Demographic, clinical, biochemical and anthropological data were collected. The relationships between MS and mortality and technique failure were assessed using Kaplan-Meier and Cox Regression Survival Functions. Results: A total of 511 patients were enrolled. The baseline mean age was 48.4 ± 14.4 years, 282 patients (55.2%) were male, and 130 patients (25.4%) were diabetic. In total, 213 patients (41.7%) met the diagnostic criterion of MS. During a median of 4.4 years (interquartile range 2.3–5.3 years) follow-up period, 114 patients died, of whom, 65 patients (48%) died in MS group versus 49 patients (30%) in non-MS group. Patients who died tended to be older, higher in inflammation markers and with poorer nutritional state. Kaplan-Meier Survival Functions found patients with MS had a significant rising of all-cause mortality (log-rank test = 12.811, p < 0.001) and cardiovascular mortality (log-rank test = 14.529, p < 0.001) in all patients, and a significant rising of cardiovascular mortality (log-rank test = 4.486, p = 0.034) in non-diabetic patients. After adjusting for confounders, Cox Regression showed that MS was significantly associated with higher cardiovascular mortality in all patients (hazard ratio [HR] 2.21, 95% CI 1.12–4.36, p = 0.022) and in non-diabetic patients (HR 2.60, 95% CI 1.07–6.35, p = 0.036), but it has no significant effect on technique failure. Conclusion: In CAPD patients, MS predicted mortality, especially cardiovascular mortality. No relationship was found between MS and technique survival.

Alterations of peritoneal transport characteristics in dialysis patients with ultrafiltration failure: tissue and capillary components.

Ultrafiltration failure (UFF) in peritoneal dialysis (PD) patients is due to altered peritoneal transport properties leading to reduced capacity to remove excess water. Here, with the aim to establish the role of local alterations of the two major transport barriers, peritoneal tissue and capillary wall, we investigate changes in overall peritoneal transport characteristics in UFF patients in relation to corresponding local alterations of peritoneal tissue and capillary wall transport properties. Six-hour dwell studies using 3.86% glucose solutions and radioisotopically labelled serum albumin added to dialysate as a volume marker were analysed in 31 continuous ambulatory PD patients, 20 with normal ultrafiltration (NUF) and 11 with UFF. For each patient, the physiologically based parameters were evaluated for both transport barriers using the spatially distributed approach based on the individual intraperitoneal profiles of volume and concentrations of glucose, sodium, urea and creatinine. UFF patients as compared with NUF patients had increased solute diffusivity in both barriers, peritoneal tissue and capillary wall, decreased tissue hydraulic conductivity and increased local lymphatic absorption and functional decrease in the fraction of the ultra-small pores. This resulted in altered distribution of fluid and solutes in the peritoneal tissue, and decreased penetration depths of fluid and solutes into the tissue in UFF patients. Mathematical modelling using a spatially distributed approach for the description of clinical data suggests that alterations both in the capillary wall and in the tissue barrier contribute to UFF through their effect on transport and distribution of solutes and fluid within the tissue.