Chronic Ambulatory Peritoneal Dialysis Patients Research Articles

Pharmacokinetics of intravenous piperacillin/tazobactam among patients with peritoneal dialysis-associated peritonitis.

Currently, pharmacokinetic information on intravenous (IV) piperacillin/tazobactam in patients with peritoneal dialysis-associated peritonitis (PD peritonitis) is limited. This study employed a prospective single-dose pharmacokinetic design to assess the pharmacokinetics of IV piperacillin/tazobactam in these patients. Four patients with PD peritonitis who received an IV loading dose of 4000 mg/500 mg piperacillin/tazobactam were enrolled in this study. The concentrations of piperacillin and tazobactam in plasma, peritoneal dialysis fluid (PDF) and urine were determined by high-performance liquid chromatography. Non-compartmental methods were used for pharmacokinetic analysis. During a 6-h dwell time for chronic ambulatory peritoneal dialysis (CAPD), 9.23 ± 4.01% of the piperacillin was recovered in the PDF. This result is greater than that observed in patients without peritonitis in prior research. Piperacillin's PD clearance (CLPD), steady-state volume of distribution (Vss) and terminal half-life (t 1/2) were 5.79 ± 2.55 mL/min, 24.35 ± 11.26 L and 5.74 ± 1.53 h, respectively. These values are also higher than those of patients without peritonitis in a prior study. Eight hours following the loading dosage, the plasma and PDF piperacillin concentrations of all patients (98.25 ± 26.03 and 52.70 ± 22.99 mg/L, respectively) surpassed the Pseudomonas aeruginosa and Enterobacterales Clinical and Laboratory Standards Institute susceptible breakpoints. In summary, the CLPD, Vss and t 1/2 for piperacillin were found to be greater in patients with PD peritonitis than in CAPD patients without peritonitis when compared with the results of a previous study. The IV loading dose of 4000 mg/500 mg piperacillin/tazobactam is sufficient to treat peritonitis caused by susceptible P. aeruginosa and Enterobacterales. The multiple-dose pharmacokinetics of IV piperacillin and tazobactam in this specific patient group should be further investigated.

Opinion: Peritoneal Dialysis In Pakistan: An Insider’s View. State of Affairs and Planning?

Pakistan has an estimated population of 212 million while the incidence of end stage renal disease in Pakistan is 100 patients per million; hence approximately 22,000 patients require maintenance dialysis to sustain life in our country. Remarkably peritoneal dialysis (PD) as a form of maintenance renal replacement is utilized in less than one per cent of these patients. In the absence of a formal dialysis registry, we place the total number of chronic ambulatory peritoneal dialysis patients (CAPD) in Pakistan at approximately 76 excluding holiday patients who are visiting from abroad (*This figure was estimated by enquiring the total number of patients each PD units care in Pakistan. This figure was corroborated with the sole distributor of CAPD fluids in Pakistan.).

Home-based training using neuromuscular electrical stimulation in patients on continuous ambulatory peritoneal dialysis: A pilot study.

There is ample evidence that maintenance of basic physical fitness through exercise training is crucial for patients with chronic renal insufficiency. Rehabilitation based on neuromuscular electrical stimulation (NMES) of thigh muscles has been shown to have many beneficial effects in patients with chronic diseases. It is likely that NMES could have beneficial effects also in patients on chronic ambulatory peritoneal dialysis (CAPD). NMES was applied for 20weeks to 14 patients on CAPD, mean age 61.9 (8.7) years, using battery-powered stimulators (CEFAR-REHAB X2; Sweden) and self-adhesive electrodes 80×130 mm (PALS Platinum; Denmark). Stimulation characteristics: biphasic current, pulse width 400μs, 8seconds contraction-12seconds relaxation, frequency modulation 40-60Hz, and maximal intensity 60mA. NMES was home-based and applied simultaneously to quadriceps muscles of both legs (2 × 30min/day). Functional performance, muscle power (Fmax ), arterial stiffness (assessed by cardio-ankle vascular index-CAVI), and quality of life by KDQOL-SF evaluation was done at baseline and at the end of program. Home NMES improved significantly the main functional parameters: VO2peak /kg increased by +2.2 (1.6) mL O2 /kg/min (P<0.002), peak workload by +0.1 (0.1) W/kg (P<0.005), and distance walked in 6MWT by +44.7 (58.4) m (P<0.008). Only insignificant changes were observed in CAVI and Fmax . KDQOL-SF analysis showed significant improvement in seven parameters of QoL (P<0.012-0.049). This pilot study is the first clinical report dealing with the use of NMES in patients on CAPD. The results demonstrate that an improvement of exercise capacity and QoL can be achieved by home-based NMES in CAPD patients.

Peritoneal Dialysis Access Associated Infections.

Infection is a significant driver of morbidity and mortality in patients with end-stage renal disease undergoing maintenance dialysis. In the United States, septicemia and other infections account for 8% deaths in patients undergoing dialysis. In patients undergoing peritoneal dialysis (PD), PD-related peritonitis remains the most frequent treatment-related infection and is the greatest contributor to infection-related morbidity, including risk for hospitalization, and temporary or permanent transfer to hemodialysis. In the 4 decades since the introduction of ambulatory PD in clinical practice, a large number of treatment innovations have been shown to be effective in reducing the risk for exit site infection and PD-related peritonitis. Notwithstanding the evidence for efficacy of these innovations and the numerous adverse health consequences with PD-related peritonitis, the uptake of these interventions in clinical practice around the world remains inconsistent. This article reviews current knowledge with regards to prevention of PD-associated infections, and the diagnosis and management of exit site infections and peritonitis.

Complications of continuous ambulatory peritoneal dialysis: An early experience in tertiary hospital of Western region of Nepal

Background and Aims: Chronic ambulatory peritoneal dialysis (CAPD) has been established form of therapy in adults patients with end stage kidney diseases and has emerged as a feasible modality of renal replacement therapy. The aim of the study was to evaluate the complications of CAPD and its contributing factor in order to improve the patient survival and reduce morbidity and mortality.Methods: A hospital based retrospective study of 35 patients who opted for CAPD at Manipal teaching hospital, Pokhara from 1st June 2015 to 31st May 2016 was carried out.Results: Total 35 CAPD patients were included in study. The mean age of the patients was 45.78±16.34 years. Nineteen (54%) patients were male. The total follow up was 533 patients months with mean follow up of 15.22 ±5.02 months. There were 41 episodes of different complications that occurred during the study period with rate of 0.9 episodes/patient years. There were 18 (43%) episodes of peritonitis including 5 recurrence of peritonitis in 5 patients, 6 (15%) exit site infections, 6 (15%) failure of drainage, 2 (5%) pericatheter leakage, 2 (5%) catheter displacement , 2 (5%) omental wrapping, 2 (5%) catheter removal, 2 (5%) mortality. The commonest pathogen for peritonitis was staphylococcus aureus in 5 (22%) episodes.Conclusion: Overall complications rate was comparable to other studies. Peritonitis rate has been declined in our study. The majority of non-infectious complications are treatable and do not interfere with the catheter survival. CAPD is a safe and viable mode of renal replacement therapy alternative to hemodialysis.Journal of Advances in Internal Medicine Vol.5(2) 2016: 34-37

Comparing the Effect of Dressing Versus No-dressing on Exit Site Infection and Peritonitis in Chronic Ambulatory Peritoneal Dialysis Patients.

Bachground:Peritonitis and exit site (ES) infection are two main complications of peritoneal dialysis. There are some controversies regard to preventive strategies for ES care. In this study we compared peritonitis and ES infection rates in patients with and without dressing.Materials and Methods:This historical cohort study carried out on 72 patients under continuous ambulatory peritoneal dialysis treatment, 54 with dressing versus 18 patients without dressing, followed from October 1, 2010 to March 31, 2011 for peritonitis and ES infection.Results:A total of 17 episodes of ES infection occurred in 12 patients in dressing group, but no case was seen in no-dressing group (P = 0.02). Twenty-one episodes of peritonitis occurred in 15 patients in both groups (one episode every 20.6 patient-months). In no-dressing group two episodes occurred in only one patient (one episode every 54 patient-months), and in dressing group, 19 episode in 14 patients (one episode every 17.1 patient-months) (P = 0.03). Peritonitis was significantly more frequent in male versus female in overall patients (38% vs. 14%, P = 0.025) and in dressing group (52% vs. 15%, P = 0.003). In dressing group, peritonitis was more frequent in diabetics versus non-diabetics (48% vs. 11%, P = 0.01). Odds ratio for developing peritonitis was 9.4 in dressing group (95% confidence interval [CI] =1.05 − 84.4; P = 0.045), and 4.4 in men (95% CI = 1.26 − 15.19; P = 0.02).Conclusion:In this study, chronic ES care without dressing was associated with lower risk of peritonitis and ES infection.

A Case Report of Neisseria mucosa Peritonitis in a Chronic Ambulatory Peritoneal Dialysis Patient

Peritonitis is a leading complication of chronic ambulatory peritoneal dialysis. However, very rarely does Neisseria mucosa cause peritonitis. We describe an unusual case of N. mucosa peritonitis in a chronic ambulatory peritoneal dialysis patient. A 28-year-old Hispanic male presents with diffuse abdominal pain exacerbated during draining of the peritoneal fluid. Peritoneal fluid examination was remarkable for leukocytosis and gramnegative diplococci. Bacterial cultures were positive for N. mucosa growth. The patient was treated with ciprofloxacin with preservation of the dialysis catheter. This case highlights the rarity and importance of Neisseria mucosa causing peritonitis in chronic ambulatory peritoneal dialysis patients’. There seems to be a unique association between N. mucosa peritonitis and chronic ambulatory peritoneal dialysis patients’. The patient was successfully managed with ciprofloxacin along with salvaging of the dialysis catheter.

Falsely Elevated Glucose Concentrations in Peritoneal Dialysis Patients Using Icodextrin.

Peritoneal dialysis (PD) is used as an alternative to hemodialysis in end-stage renal disease (ESRD). Icodextrin has been used as a hyperosmotic agent in PD. The aim of the study was to assess two different point-of-care testing (POCT) glucose strips, affected and not affected by icodextrin, with serum glucose concentrations of the patients using and not using icodextrin. Fifty-two chronic ambulatory peritoneal dialysis (CAPD) patients using icodextrin (Extraneal®) and 20 CAPD patients using another hyperosmotic fluid (Dianeal®) were included in the study. Duplicate capillary and serum glucose concentrations were measured with two different POCT glucose strips and central laboratory hexokinase method. Assay principles of glucose strips were based on glucose dehydrogenase-pyrroloquinoline quinone (GDH-PQQ) and a mutant variant of GDH (Mut Q-GDH). The results of both strips were compared with those of hexokinase method. Regression equations between POCT and hexokinase methods in icodextrin group were y = 2.55x + 1.12 mmol/l and y = 1.057x + 0.16 mmol/l for the GDH-PQQ and Mut Q-GDH methods, respectively. The mean difference between the results of hexokinase and those of GDH-PQQ and Mut Q-GDH in icodextrin group was 3.41 ± 1.56 and 0.72 ± 0.64 mmol/l, respectively. However, the mean differences were found much lower in the control group; 0.64 mmol/l for GDH-PQQ and 0.52 mmol/l for Mut Q-GDH. Compared to GDH-PQQ, glucose strips of Mut Q-GDH correlated better with hexokinase method in PD patients using icodextrin.

Effect of omega-3 supplementation on inflammatory parameters in patients on chronic ambulatory peritoneal dialysis.

Background:End stage renal disease (ESRD) is a state of micro inflammation that attenuates patient's life span and quality of life. Inflammatory markers like interlukin 6 (IL-6) and C- reactive protein (CRP) can predict inflammatory state in ESRD patients. Dietary limitations are risk factors for omega-3 deficiency in these patients. Omega-3 supplementation is an attractive material that proposed in inflammation modulation. The aim of this study is evaluation of effect of omega-3 supplementation on IL-6 and CRP level in chronic ambulatory peritoneal dialysis (CAPD) patients.Materials and Methods:This randomized controlled double-blind clinical trial is performed in 40 CAPD patients in two academic hospitals in Isfahan, Iran. One group received 1000 mg omega-3 capsule (each capsule contains 180 mg Eicosapentanoic and 120 mg Dosahexanoic acid) three times a day orally for 8 weeks (n = 20) and the other matched group by placebo (n = 20). Serum level of IL-6 and quantitative CRP (Q-CRP) were measured in beginning and the end of the study. Finally all data were analyzed by SPSS version 18.Results:Mean age of patients was 53 years old in omega-3 group patients and 54 years old in placebo group. There were not any differences in CRP and IL-6 level in the beginning and the end of study between two groups (P: 0.81 and 0.10 for CRP and 0.26 and 0.23 for IL-6, respectively).Conclusion:Omega-3 supplementation did not effect on inflammatory markers (Q-CRP and IL-6) in CAPD patients after 8 weeks.

Utility of cystatin C-derived equations for evaluation of residual renal function in peritoneal dialysis patients

Background: Residual renal function (RRF) plays a key role in the follow-up of the patients undergoing chronic ambulatory peritoneal dialysis (CAPD). Available methods for measurement of RRF are cumbersome and rarely used, and alternatively, cystatin C-derived equations have been proposed. Methods: Seventy-six adult CAPD patients were recruited. RRF was measured using the 24-hour urea–creatinine clearance method. Serum concentrations of cystatin C were determined. Glomerular filtration rate (GFR) was estimated using the two published equations of Hoek and colleagues, and Yang and colleagues. GFR was also estimated from serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Results: Patients (age range 18–86 years) were on CAPD for a median of 24 months. Average serum concentrations of cystatin C was 5 ± 1.2 mg/L. Average RRF was 0.7 ± 1.6 mL/min/1.73 m2. All three methods significantly overestimated the measured RRF values (Hoek: 4 ± 1.4; Yang: 4.5 ± 1.5; 7.4 ± 4 mL/min/1.73 m2). Based on Bland–Altman plots, all three methods yielded poor agreement with RRF (p < 0.001 for all tests), with Hoek’s equation providing the narrowest limits of agreement [mean difference (limits of agreement): 3.4 (2.9–3.9)] and CKD-EPI the widest [6.7 (5.9–7.5)]. Although the Hoek’s method outperformed CKD-EPI, the within 30 and 50% accuracy rates were unsatisfactory (10.5 and19.7 %, respectively). Conclusions: Cystatin C-derived equations outperform the CKD-EPI formula in approximating the RRF values. Yet, these methods still significantly overestimate the measured RRF and their routine application in clinical practice is not advised.

The effect of omega-3 fatty acid supplementation on oxidative stress in continuous ambulatory peritoneal dialysis patients.

Background:End stage renal disease (ESRD) is a condition that inflammation and oxidative stress plays an important role in damaging to tissues, especially, in the vascular system. The effect of omega-3 fatty acids is well-documented in some inflammatory diseases via eicosapentanoic acid and docosahexanoic acid components of fish oil. The aim of this study was to investigate the effects of dietary omega-3 fatty acid supplementation on levels of lipid peroxidation and oxidative sttress in ESRD patients.Materials and Methods:This randomized controlled double-blind clinical trial consisted of 90 patients on chronic ambulatory peritoneal dialysis (CAPD). One group was treated orally with 3000 mg omega-3, per day for 8 weeks (n = 45) and the other matched group by placebo (n = 45). Serum levels of lipids, iron, ferritin, Protrombin Time, Partial thromboplastin time, superoxide dismutase (SOD), and reduced glutathione (GH) were measured at the beginning and at 8 weeks.Results:Our results showed that SOD and reduced GH were not significantly changed in omega-3 group where lipid profile showed no significant changes too. Erythropoietin requirements also had no significant differences.Conclusion:Incorporation of omega-3 fatty acids to CAPD patients had no beneficial effects on oxidative stress but should evaluate more.

Correlation between iron stores and QTc dispersion in chronic ambulatory peritoneal dialysis patients

Aim: We aimed to investigate the QT dispersion and corrected QT (QTc) dispersion which are suggested as the signals of ventricular arrhythmias, in patients on maintenance CAPD and to evaluate the correlation between iron stores and these electrocardiographic parameters. Materials and method: Fifty-eight patients on maintenance CAPD and 19 healthy age- and sex-matched adults without cardiac disease were included. The PD patients were divided into two groups according to whether their computerized measurements of QTc dispersion were longer than 65 ms. Results: Although QT interval was statistically significantly shorter in control group (34 ± 28 vs. 43 ± 34 ms; p < 0.05), there was no significant difference in regards to the QTc, QT dispersion and QTc dispersion between two groups. PD patients with QTc dispersion longer than 65 ms had higher levels of serum ferritin (p = 0.038) and transferrin saturation (TSAT; p = 0.022) than the others. QTc dispersion were positively correlated with ferritin (r = 0.469, p < 0.01) and TSAT (r = 0.430, p < 0.01) in CAPD patients. Conclusion: Although prolonged QTc, QT dispersion and QTc dispersion were suggested as the markers of ventricular arrhythmias we did not find any significant difference in regards to these parameters between control patients and CAPD patients. But the high body iron stores in these patients increase the risk of increased QT dispersion. The concern over iron overload in dialysis patients is not only because of its oxidative toxicity, but also its precipitation of arrhythmias, which may be measured by the surrogate marker of QTc dispersion.

Coenzyme Q10 and its Relation with Oxidant and Antioxidant System Markers in Patients with End-Stage Renal Disease

Rationale and objectives: Oxidative stress is increased in chronic kidney disease (CKD) patients and end-stage renal disease (ESRD) patients undergoing dialysis treatment. Coenzyme Q10 (CoQ10) is a ubiquitous and strong antioxidant. Role of CoQ10 is not fully evaluated in renal patients. We aimed to investigate the relationship of CoQ10 with oxidant and antioxidant system markers in patients with renal disease. Material and methods: Forty patients with CKD (stages 3–5) who were managed conservatively without dialysis treatment, 40 hemodialysis, and 60 chronic ambulatory peritoneal dialysis (CAPD) patients were included in the study. Biochemical and whole blood analyses were done using hospital auto-analyzers from stored samples. Serum CoQ10, malondialdehyde (MDA), superoxide dismutase (SOD), and antioxidant activity (AOA) levels were determined. Main findings: There was no difference among the groups in terms of serum CoQ10 levels. However, other components of antioxidant system, namely, SOD and AOA were significantly higher in CAPD patients when compared to CKD patients. MDA levels were not significantly different among the groups. Principal conclusion(s): The results of this study showed no difference among CKD, CAPD, and hemodialysis patients in terms of serum CoQ10 levels.

Review article: Hepatitis B and dialysis

The incidence of hepatitis B virus (HBV) infection in dialysis populations has declined over recent decades, largely because of improvements in infection control and widespread implementation of HBV vaccination. Regardless, outbreaks of infection continue to occur in dialysis units, and prevalence rates remain unacceptably high. For a variety of reasons, dialysis patients are at increased risk of acquiring HBV. They also demonstrate different disease manifestations compared with healthy individuals and are more likely to progress to chronic carriage. This paper will review the epidemiology, modes of transmission and diagnosis of HBV in this population. Prevention and treatment will be discussed, with a specific focus on strategies to improve vaccination response, new therapeutic options and selection of patients for therapy.

Pharmacokinetics of single-dose rosiglitazone in chronic ambulatory peritoneal dialysis patients

End-stage renal disease (ESRD) is associated with marked alterations in the pharmacokinetics of many drugs, not only from reduction in renal clearance but also from changes in metabolic activity, bioavailability, volume of distribution and plasma protein binding. To study the pharmacokinetics of a single 8-mg oral dose of rosiglitazone in patients with ESRD and requiring long-term chronic ambulatory peritoneal dialysis (CAPD). The medication was administered just before the first exchange of peritoneal dialysis fluid on the day that blood and peritoneal dialysate collection was performed. In our CAPD patients the mean (+/-SD) T(max) and T(1/2) of rosiglitazone were 1.20 +/- 0.26 and 21.38 +/- 21.96 h respectively. These values were different to those reported for healthy volunteers reported in previous studies. The mean area under the concentration-time curve (AUC((0-infinity))) and an average maximum observed plasma concentration (C(max)) of rosiglitazone in our CAPD patients were 4203.56 +/- 2916.97 ng h/mL and 409.67 +/- 148.89 ng/mL respectively. These appear no different from those reported in healthy volunteers . The apparently significant difference in T(1/2) of rosiglitazone in CAPD patients compared with healthy volunteers suggest that dose adjustment may be necessary in order to avoid toxicity.

Serotyping of DutchStaphylococcus aureusstrains from carriage and infection

International epidemiological studies have shown that clinical isolates of Staphylococcus aureus are usually capsulated with either type 5 or 8 capsular polysaccharides (CPs). Because all noncapsulated strains were found to be cross-reactive with polysaccharide 336 (336PS) antibodies, the noncapsulated strains were denoted as type 336PS. The capsular types of 162 Dutch methicillin-susceptible S. aureus strains derived from individuals living in the Rotterdam area were determined. The serotype distribution was 28.4% serotype 5, 53.7% type 8, and 17.9% type 336PS. Serotyping was in agreement with genotyping by amplified fragment length polymorphism (AFLP) and multi locus sequence typing (MLST). Among 49 nasal carriage isolates from healthy children 24.5% belonged to serotype 5, 67.3% were type 8 and 8.2% were type 336PS. For 28 adult patients on chronic ambulatory peritoneal dialysis (CAPD) the serotype incidences among carriage isolates obtained from the nose, catheter exit-site, and abdominal skin were 45.1%, 41.2% and 13.7%, respectively. Among S. aureus strains deriving from blood cultures, the serotype incidences were 17.7% serotype 5, 53.2% type 8, and 29.0% type 336PS. Apparently, type 336PS strains are more prevalent (P=0.017) among bacteraemia isolates as compared with the nasal carriage isolates obtained from healthy children and CAPD patients. In conclusion, all Dutch S. aureus isolates belonged to types 5, 8, or 336PS, which is in agreement with data from other countries. Thus, addition of the 336PS conjugate to a type 5- and type 8-CP protein conjugate vaccine would significantly extend the vaccine coverage.

Effect of Peritoneal Dialysis Solution Type on Serum Lipid Levels in End-Stage Renal Disease

Among the different cardiovascular risk factors, lipid abnormalities dominate the high mortality in chronic ambulatory peritoneal dialysis patients. So far, no data comparing the effect of standard glucose-containing, amino acid-containing, and icodextrin-containing peritoneal dialysis solutions on serum lipid concentrations in a chronic ambulatory peritoneal dialysis population are available. To determine the effect of peritoneal dialysis solutions on parameters of lipid metabolism, 67 subjects who had continued their usual dialysis for the last six months were enrolled in the study. Group A consisted of 18 patients who were receiving only glucose-based peritoneal dialysis solutions, group B consisted of 18 patients who were receiving glucose and amino acid-based peritoneal dialysis solutions, and group C consisted of 31 patients who were receiving glucose and icodextrin-based peritoneal dialysis solutions. Serum lipid parameters including total cholesterol, low-density lipoprotein, high-density lipoprotein, triglyceride, and lipoprotein (a) were determined in all groups. No significant difference in serum lipid parameters was found between groups A, B, and C. These results demonstrate the lack of the effect of amino acid or icodextrin-based peritoneal solutions on dyslipidemia of CAPD patients.

Pantoea peritonitis in a patient receiving chronic ambulatory peritoneal dialysis (Case Report)

Pantoea agglomerans is usually the most common organism transmitted through plant thorn injuries. This report is of a female patient maintained on chronic ambulatory peritoneal dialysis (CAPD) who developed peritonitis attributed to P. agglomerans. Peritonitis is an uncommon complication of P. agglomerans and there is no previous report of peritonitis associated with this organism in a CAPD patient. The source of infection was thought to be due to rose-thorn injury. Antibiotic therapy with ceftazidime and amikacin i.p. led to a clinical improvement, with disappearance of the organism in the peritoneal fluid.

Rapid Removal of Free Light Chains from Serum by Hemodialysis for Patients with Myeloma Kidney.

Introduction. Acute renal failure (ARF) develops in 10–15% of patients with multiple myeloma (MM). Typically, complexes of serum free light chains (sFLC) and Tamm-Horsfall protein form casts in the distal tubules that block urine flow. Many patients, subsequently, require long-term hemodialysis (HD) and may have reduced survival. In an attempt to minimise renal damage, plasma exchange (PE) has been used to reduce the pre-renal load of sFLC. Zucchelli et al., (Kidney Int 1988; 33:1175–1180) showed that PE reduced HD requirements but subsequent controlled trials showed no benefit (Johnson WJ et al., Arch Intern Med 1990; 150:863–869: Clarke WF et al., Haematologica 2005; 90(s1) p117). The availability of sFLC immunoassays now allows an informed evaluation of the role of PE and/or HD in treating these patients.Methods. sFLC were measured in 1: 100 patients with chronic renal failure (CRF), GFR< 15ml/min and not on dialysis; 2: 38 at the beginning and end of HD (dialyzer A) and 3: 25 on chronic ambulatory peritoneal dialysis (CAPD). sFLC hemofiltration efficiency was assessed, in-vitro, for three different dialyzers, using standard pump pressures and flow rates. Sera containing approximately 1,000 mg/L of monoclonal kappa (κ ) (NR < 20mg/L) and lambda (λ ) FLC (NR < 27mg/L) were recycled for ~45 minutes through the dialyzers and clearance rates assessed. A two-compartment, mathematical model was constructed to assess sFLC removal by HD and PE from hypothetical patients. The following parameters were considered:- sFLC concentrations in MM at clinical presentation; monomeric κ or dimeric λ clearance differences; partition of sFLC between vascular and extravascular compartments; flow of FLC between compartments; half-life of sFLC in ARF; sFLC production and tumour killing rates with chemotherapy. The model was interrogated for various dialysis times, different dialyzers and a PE protocol of 3L, x6 over 2 weeks.Results. Mean sFLC concentrations in severe CRF were: κ 93 mg/L (range 43–207); λ 64 mg/L (range 43–134). Mean sFLC before and after HD: κ 130 mg/L (range 40–567) to 49 (range 20–234); λ 100 mg/L (range 31–225) to 61 (range 24–159). Mean sFLC in CAPD patients: κ 118 mg/L (range 31–266); λ 114 mg/L (range 36–263). Clearances of sFLC by the 3 dialyzers were: A: BBraun high flux polyethersulfone 1.8sqm (HI PeS) (the dialyzer in routine use); κ 46%: λ 39%, B: Idmesa high flux polyethersulphone 2.0sqm (200MHP); κ 67%: λ 59%, C: Asahi high flux polysulphone 2.1sqm (APS 1050); κ 71%: λ 65%. Model calculations showed that sFLC reduced from a starting value of 14g/L (typical of light chain MM) to less than 0.5g/L in 14 days using PE. Membrane A, used for four hours, x3/week, was approximately 20% more efficient than PE and reduced κ sFLC approximately 50% faster than the natural clearance rate of patients in ARF. Dialyzers B and C were approximately twice as efficient. Performing initial, 16-hour dialyses daily for 3 days, with dialyzer C reduced sFLC to less than 0.5g/L in 2–3 days with ~95% of the sFLC being removed. Dimeric λ sFLC were removed ~50% more slowly.Conclusion. PE was less efficient at removing sFLC than routine HD. Prolonged HD with high-flux dialyzers removed monoclonal sFLC quickly and should be assessed in a clinical trial for patients with acute myeloma kidney. CAPD was inefficient at removing sFLC.

Platelet surface receptor activation in patients with chronic renal failure on hemodialysis, peritoneal dialysis and those with successful kidney transplantation

Hemostatic disorders associated with chronic renal failure (CRF) include hemorrhagic and/or thrombotic manifestations, which were ascribed, in part, to uremic platelet dysfunction including abnormalities of expression of platelet glycoprotein receptors. There is, however, still no general agreement on the exact characterization of these platelet abnormalities. This study aims at characterizing the platelet glycoprotein abnormalities associated with CRF, by recording the effect of the three renal replacement therapies, hemodialysis (HD), chronic ambulatory peritoneal dialysis (CAPD), and renal transplantation, on these receptors. The study, which was mainly cross-sectional, included two groups: (i) Patient groups (n = 50): HD patients (n = 20), CAPD patients (n = 10) and successful renal transplant patients (n = 20); (ii) Healthy Controls (n = 34): 23 were men and 11 were women who were age- and sex-matched with the patients. Flow cytometric quantitation of CD41, CD42a, CD42b and CD61 was carried out using a Becton-Dickinson FACScan. The expression of CD41 levels showed a highly significant increase in HD and CAPD patients when compared with the normal control levels. However, levels in transplant patients were comparable to the normal control levels. On the other hand, the expression of CD42a, CD42b, and CD61 showed no significant change in HD and CAPD patients when compared with normal control levels, but there was a significant decrease in transplant patients when compared to the normal control levels. In conclusion, there was evidence of increased expression of one glycoprotein receptor (GpIIb–IIIa) pre-dialysis whether HD or CAPD. In transplant patients, no evidence of platelet activation could be demonstrated.