Cohort Of Peritoneal Dialysis Patients Research Articles

Impact of patient training patterns on peritonitis rates in a large national cohort study.

Ideal training methods that could ensure best peritoneal dialysis (PD) outcome have not been defined in previous reports. The aim of the present study was to evaluate the impact of training characteristics on peritonitis rates in a large Brazilian cohort. Incident patients with valid data on training recruited in the Brazilian Peritoneal Dialysis Multicenter Study (BRAZPD II) from January 2008 to January 2011 were included. Peritonitis was diagnosed according to International Society for Peritoneal Dialysis guidelines; incidence rate of peritonitis (episodes/patient-months) and time to the first peritonitis were used as end points. Two thousand two hundred and forty-three adult patients were included in the analysis: 59 ± 16 years old, 51.8% female, 64.7% with ≤4 years of education. The median training time was 15 h (IQI 10-20 h). Patients were followed for a median of 11.2 months (range 3-36.5). The overall peritonitis rate was 0.29 per year at risk (1 episode/41 patient-months). The mean number of hours of training per day was 1.8 ± 2.4. Less than 1 h of training/day was associated with higher incidence rate when compared with the intervals of 1-2 h/day (P = 0.03) and >2 h/day (P = 0.02). Patients who received a cumulative training of >15 h had significantly lower incidence of peritonitis compared with <15 h (0.26 per year at risk versus 0.32 per year at risk, P = 0.01). The presence of a caregiver and the number of people trained were not significantly associated with peritonitis incidence rate. Training in the immediate 10 days after implantation of the catheter was associated with the highest peritonitis rate (0.32 per year), compared with training prior to catheter implantation (0.28 per year) or >10 days after implantation (0.23 per year). More experienced centers had a lower risk for the first peritonitis (P = 0.003). This is the first study to analyze the association between training characteristics and outcomes in a large cohort of PD patients. Low training time (particularly <15 h), smaller center size and the timing of training in relation to catheter implantation were associated with a higher incidence of peritonitis. These results support the recommendation of a minimum amount of training hours to reduce peritonitis incidence regardless of the number of hours trained per day.

A multicentric, international matched pair analysis of body composition in peritoneal dialysis versus haemodialysis patients

Volume status, lean and fat tissue are gaining interest as prognostic predictors in patients on dialysis. Comparative data in peritoneal dialysis (PD) versus haemodialysis (HD) patients are lacking. In a cohort of PD (EuroBCM) and HD (Euclid database) patients, matched for country, gender, age and dialysis vintage, body composition was assessed by bioimpedance spectroscopy (BCM, Fresenius Medical Care). Time-averaged volume overload (TAVO) was defined as the mean of pre- and post-dialysis volume overload (VO), and relative (%) (TA)VO as (TA)VO/ECV. Four hundred and ninety-one matched pairs (55.2% males, median age 60.0 years) were included. The body mass index (BMI, PD = 26.5 ± 4.7 versus HD = 25.9 ± 4.6 kg/m(2), P = 0.18 in males and 27.4 ± 5.8 versus 27.5 ± 6.6 kg/m(2), P = 0.75 in females) and fat tissue index (males: 11.5 ± 5.3 versus 11.4 ± 5.4 kg/m(2), P = 0.90, females: 14.8 ± 6.7 versus 15.4 ± 7.2 kg/m(2), P = 0.30) were not different in PD versus HD patients, whereas the lean tissue index (LTI) was higher in PD versus HD patients (males: 14.5 ± 3.4 versus 13.7 ± 3.1 kg/m(2), P = 0.001, females: 12.6 ± 3.3 versus 11.5 ± 2.6 kg/m(2), P < 0.0001). VO/extracellular water (ECW) was not different between PD versus just before the HD treatment (males: 10.8 ± 12.1 versus 9.2 ± 10.2%, P = 0.09; females: 6.5 ± 10.8 versus 7.7 ± 9.4%, P = 0.19). The relative TAVO was higher in PD versus HD (10.8 ± 12.1% versus 3.2 ± 11.2%, and 6.5 ± 10.8% versus 1.2 ± 10.9%, both P < 0.0001). The LTI was impaired, and this was more in males versus females, but was better preserved on PD versus HD, whereas fat tissue index (FTI) was increased, but not different between PD and HD. Volume overload was more present in PD versus HD when TAVO, but not when predialysis volume status, was used as a reference.

Increased risk of fatal infections in women starting peritoneal dialysis.

Although cardiovascular disease (CVD) is an important cause of morbidity and mortality in patients with end-stage renal disease, non-CVD causes account for more than 50% of total deaths. We previously showed that, compared with men, women starting dialysis-- both hemodialysis and peritoneal dialysis (PD)--have higher non-CVD mortality rates. Here, we evaluate sex-specific outcomes in a large cohort of incident PD patients. Incident de novo PD patients from the Andalusian SICATA Registry for 1999 - 2010, with follow-up until 31 December 2010 or up to 5 years, were investigated for fatal outcomes. Causes of death were extracted from medical records. The analysis used traditional and competing-risk Cox models for all-cause and cause-specific mortality in men and women, correcting in the competing-risk models for the events of kidney transplantation and transfer to hemodialysis. A total of 1458 patients (57% men; mean overall age: 55.3 ± 17.0 years) initiated PD in Andalusia during the study period. During follow-up, 350 deaths, 355 renal transplantation procedures, and 331 transfers to hemodialysis were recorded. Vascular disease and diabetic nephropathy were the most frequent causes of kidney failure in men; other causes were more common in women. In the traditional Cox model, both sexes showed a similar all-cause mortality risk [crude hazard ratio (HR): 0.90; 95% confidence interval (CI): 0.72 to 1.12]. However, with respect to specific causes of death, women showed a borderline lower risk of both CVD (crude HR: 0.71; 95% CI: 0.50 to 0.99) and non-CVD mortality from other than infection (crude HR: 0.81; 95% CI: 0.57 to 1.15). In contrast, the risk of death from infection was almost doubled in women compared with men (crude HR: 1.92; 95% CI: 1.15 to 3.20), a finding that held true after multivariate adjustment for age, primary renal disease, period of inclusion, and initial PD modality (adjusted HR: 1.76; 95% CI: 1.03 to 3.01). This result was confirmed even taking into consideration the competing events of kidney transplantation and transfer to hemodialysis. Compared with men starting PD, women starting PD are at higher risk of mortality from infection. More stringent screening measures and corrective efforts in women might be indicated.

Peritoneal dialysis outcomes in a modern cohort of overweight patients

The incidence of obesity is increasing both in the general population and in incident dialysis patients. While there is evidence that being overweight is associated with good outcomes in hemodialysis, the evidence in peritoneal dialysis (PD) patients is not very clear. We studied a modern cohort of PD patients to examine outcomes in large patients. Forty-three patients who started PD, who weighed more than 90 kg at dialysis initiation, between January/2000 and June/2010 were matched with 43 control patients who weighed less than 90 kg. Detailed review of the charts was undertaken. The mean weight and body mass index of the wt < 90 kg group were 69.3 ± 11.3 kg and 25.0 ± 3.9 kg/m(2). The number of peritonitis episodes per year was 0.33 ± 0.6 (wt < 90 kg) and 0.82 ± 1.7 (wt ≥ 90 kg) (p = 0.26). The median time to first peritonitis showed a trend toward earlier peritonitis in larger patients [9.5 (4.3, 27) months in wt ≥ 90 kg, 19.1(7.9, 30.8) months in wt < 90 kg] but did not reach statistical significance (p = 0.12). Surprisingly, hernias and leaks were more common in the weight <90 kg group (44 vs. 18.6 % p = 0.02). There was no difference in total number of hospitalizations or the number of days hospitalized. Kaplan-Meier analysis of survival on PD showed no differences between the two groups (logrank p = 0.99). Cox regression analysis using age, race, cause of ESRD due to diabetes and Charlson comorbidity index as the covariates did not show weight to be associated with survival on PD. Large patients tend to do just as well on PD, with survival on PD being no different compared to individuals with lower weight and body mass index.

Paricalcitol reduces proteinuria but does not modify peritoneal protein loss in patients on peritoneal dialysis.

Paricalcitol, a selective activator of Vitamin D receptors, is successfully used as a treatment of hyperparathyroidism secondary to chronic kidney disease (CKD). In addition, it has been proposed for reducing proteinuria in patients with CKD. Nonetheless, little is known about its effect on peritoneal protein loss in patients on peritoneal dialysis (PD). To analyse the efficiency of oral paricalcitol in secondary hyperparathyroidism control in PD patients and to verify its effect on urinary and peritoneal effluent protein loss. Prospective study with a 12-month follow-up on a cohort of PD patients. Invention consisted of the introduction of paricalcitol for the treatment of secondary hyperparathyroidism. Paricalcitol was dosed according to parathyroid hormone (PTH): 1mg/day for patients with PTH < 500 pg/ml, and 2mg/day for those with higher PTH levels. Epidemiological, clinical and analytical data were analysed. 38 patients (56 ± 19 years, 55% women, 16% diabetics, technique time (14 ± 10 months) were included in the study. Thirty-three of them received 1mg/day of paricalcitol; the rest received 2mg/day. The use of paricalcitol was associated with a PTH decrease of 30.7 ± 6.8% (P<.001) after 12 months of treatment with no changes in calcium (8.82 ± 0.96 vs. 9.02 ± 0.91; P = .153) and phosphate levels (4.78 ± 0.63 vs. 4.93 ± 0.77; P = .693). Patients did not modify treatment concurrent with phosphate binders over the study period, nor did they change the cinacalcet dosage. However, fewer patients needed it by the end of the study. The PTH baseline levels were independent indicators of its decrease (b = 0.689, P = .018), and the rest of the analysed parameters were not affected. Over the study period there was a proteinuria decrease (0.79 ± 0.41 vs. 0.64 ± 0.36 g/day, P = .034) with no changes in renal function (7.2 ± 1.1 vs. 6.3 ± 0.9 ml/min, P =.104). Similarly, no differences were found in in the percentages of patients taking renin-angiotensin system inhibitors (71 vs. 68 %, P = .472) or the doses needed. There was no significant change in peritoneal protein loss (5.8 ± 1.9 vs. 6.0 ± 2.2g/24h, P = .731) nor in serum albumin levels (3.7 ± 1.1 vs. 3.7 ± 1.2g/dl, P = .697). The use of oral paricalcitol reduces PTH levels safely and substantially in patients on PD. Their use is associated with a proteinuria decrease and is not linked to a decrease of glomerular filtration rate or changes in the medication that could modify it. We have found no modification in the amount of peritoneal protein loss.

"Ico-Alone" single nocturnal exchange to initiate peritoneal dialysis in patients with residual renal function-Five year, single centre experience

We analyzed the outcome of incremental dialysis with single nocturnal icodextrin exchange peritoneal dialysis (PD) as the initial treatment for end-stage kidney failure in patients who have significant residual renal function. All adult patients opting for PD as renal replacement therapy, having residual renal function, and urinary KT/V of 1.0 were offered incremental dialysis with single nocturnal icodextrin exchange as initial treatment. Adequacy of dialysis was calculated at 1, 3, and 6 months and then 6 monthly. Patients were shifted to conventional PD if short of adequacy or if clinically indicated. Median period on “Ico-alone,” peritonitis, exit site infection rates, and patient survival, while on this protocol, were calculated. These outcomes were compared with the cohort of contemporary patients on conventional PD. Thirteen patients were initiated on “Ico-alone” dialysis between October 2006 and October 2011. The baseline characteristics were similar when compared with cohort of conventional PD patients, except urine volume, which was more in “Ico-alone” group (1265 ± 316 vs. 551 ± 504, P = 0.000). Total KT/V at 3 months (1.63 ± 0.6 vs. 1.7 ± 0.2, P = 0.6) and at 1 year (1.64 ± 0.5 vs. 1.53 ± 0.3, P = 0.6) was similar to the cohort of conventional PD patients. Median period on “Ico-alone” was 9.6 months. Peritonitis rate was 1 episode in 56.22 vs 25.29 patient-months and exit site infection was 1 episode in 56.2 vs 189.71 patient-months in “Ico-alone” and conventional group, respectively. Patient survival was 42.84 months in “Ico-alone” vs 25.29 months in conventional dialysis (P = 0.01). In conclusion, single icodextrin exchange offers adequate dialysis in patients with residual renal function (KT/V = 1) for a median period of 9 months.

Residual renal function in peritoneal dialysis with failed allograft and minimum immunosuppression

Immunosuppression (IS) is often withdrawn in patients with end stage renal disease secondary to a failed renal allograft, and this can lead to an accelerated loss of residual renal function (RRF). As maintenance of RRF appears to provide a survival benefit to peritoneal dialysis (PD) patients, it is not clear whether this benefit of maintaining RRF in failed allograft patients returning to PD outweigh the risks of maintaining IS. A 49 year-old Caucasian male developed progressive allograft failure nine years after living-donor renal transplantation. Hemodialysis was initiated via tunneled dialysis catheter (TDC) and IS was gradually withdrawn. Two weeks after IS withdrawal he developed a febrile illness, which necessitate removal of the TDC and conversion to PD. He was maintained on small dose of tacrolimus (1 mg/d) and prednisone (5 mg/d). Currently (1 year later) he is doing exceedingly well on cycler-assisted PD. Residual urine output ranges between 600-1200 mL/d. Total weekly Kt/V achieved 1.82. RRF remained well preserved in this patient with failed renal allograft with minimal immunosuppressive therapy. This strategy will need further study in well-defined cohorts of PD patients with failed allografts and residual RRF to determine efficacy and safety.

Malnutrition Inflammation Score Is Comparable To Subjective Global Assessment As A Nutritional Assessment Tool For Peritoneal Dialysis Patients

Malnutrition is highly prevalent in dialysis patients. Appropriate assessment tools are key for its prevention and treatment. This study aimed to provide information regarding the Malnutrition Inflammation score (MIS) as a nutritional assessment tool in Peritoneal Dialysis (PD) patients by analysing relationships with other standard measures of nutritional status, and comparing them with the Subjective Global Assessment (SGA). The study also aimed to provide information regarding the nutritional status of a cohort of Australian PD patients, which is lacking in current literature. Ninety stable PD patients received a nutritional assessment over a period of 6 months. Nutritional status was assessed by MIS, SGA, serum albumin, c-reactive protein (CRP), body mass index (BMI), mid arm muscle circumference (MAMC), and a 24-hour recall to measure energy and protein intake. Estimated glucose absorption from the dialysate was also included. Correlations between MIS, SGA and the other measures of nutritional status were analysed (using Spearman’s analysis, SPSS, v 17.0) and compared. Thirty seven percent of the study group was considered to be malnourished according to SGA score. The median MIS score was 5.0 (2.5–7.5). MIS and SGA were both inversely correlated with energy intake (p=0.002, p=0.001 respectively), serum albumin (p

NUTRITION AND QUALITY OF LIFE OUTCOMES IN PERITONEAL DIALYSIS – A COMPARISON BETWEEN AUTOMATED AND CONTINUOUS AMBULATORYPERITONEAL DIALYSIS

Automated Peritoneal Dialysis (APD) has become the most popular form of peritoneal dialysis (PD) in Australia; however few studies on nutritional status in PD patients have separated APD from CAPD. Therefore the purpose was to assess the nutritional status, oral intake and self rated Quality of Life (QoL) in PD patients and compare between CAPD and APD. 10 adult CAPD and 37 APD patients on home-based peritoneal dialysis for ≥ 3 months had anthropometry measured, nutritional intake calculated from three day food diaries, and Patient Generated Subjective Global Assessment (PG-SGA) completed. QoL was assessed using the Medical Outcomes Study Short Form (SF-36) questionnaire. Overall 48.9% (n=23) were classified as well nourished, 44.7% (n=21) were mild or moderately undernourished, and 6.4% (n=3) were severely undernourished. The proportion of PD patients with energy and protein intake below evidence based guideline targets was 90.2% (n=37) and 70.7% (n=29), respectively. 25.5% (n=12) of patients lost weight and 59.6% (n=28) gained weight from initiation of therapy until date of assessment. Average quality of life score was 50.4±18.7. QoL was correlated with PG-SGA (R2=0.298, p<0.01) with adjustment for age, gender, and length of time on PD. No significant differences were seen between CAPD and APD for PG-SGA mean numerical score, PG-SGA category, or for energy, protein, phosphate and potassium intakes. QoL was not statistically significant between modalities for any of the eight dimensions or total score. In Conclusion, under-nutrition was highly prevalent in this small cohort of PD patients. Energy and protein intakes were below the current Australian recommendation for the majority of the sample. Nutritional status, dietary intakes and QoL outcomes did not differ between stable CAPD and APD patients.

The -174G/C variant of IL6 as risk factor for mortality and technique failure in a large cohort of peritoneal dialysis patients

Functional variants in the IL6 gene, in particular the -174G/C polymorphism (rs1800795), affect the mortality risk in dialysis patients. Peritoneal dialysis (PD) patients harbouring the C allele of the -174G/C polymorphism of IL6 showed faster peritoneal transport. The aim of this study was to investigate this IL6 variant as risk factor for mortality and technique failure in a large cohort of Caucasian PD patients. A Dutch multicentre cohort of 398 incident PD patients (NECOSAD) was analysed. Survival analysis was performed for death and technique failure with a maximum follow-up of 5 years. A combined PD cohort from Amsterdam (Academic Medical Center, N = 71) and Brussels (Université catholique de Louvain Medical School, N = 102) was used for independent replication. In NECOSAD, 105 patients died on dialysis [incidence rate 10.3/100 person-years (py)], and 138 patients experienced technique failure (16.2/100 py), with peritonitis as important cause. Patients with the C/C genotype had a 71% increased mortality risk compared to patients with the G/G genotype (95% confidence interval 0.98-2.98); this effect was mainly a long-term effect: a 2.7-fold increased mortality risk was found in patients having survived 2 years since the start on dialysis, and a 1.7-fold increased risk for the combined end point (mortality or technique failure). In the combined replication cohort, no increased risks were found in patients with the C/C genotype. The C/C genotype of the -174G/C polymorphism was associated with an increased mortality risk in 398 Dutch incident PD patients. The existence of substantial differences between the two academic replication cohorts and the discovery cohort from NECOSAD and the limited power of these cohorts prevented an independent replication of the NECOSAD findings.

Changes in Patient and Technique Survival over Time among Incident Peritoneal Dialysis Patients in Canada

In the last 15 years in Canada, there have been less stringent guidelines for peritoneal dialysis (PD) adequacy, availability of novel PD solutions, and lower PD-related peritonitis rates. Effects of these changes on outcomes of incident patients treated with PD during this period are unknown. Risk of PD technique failure and mortality were compared among three incident cohorts of PD patients who initiated dialysis during the following periods: 1995-2000, 2001-2005, and 2006-2009. A multivariable model was used to evaluate time to PD technique failure using inverse probability of treatment and censoring weights accounting for changing survival and transplantation rates. Between 1995 and 2009,13,120 incident adult PD patients were identified from the Canadian Organ Replacement Register. Compared with the 1995-2000 cohort (n=5183), the risk of PD technique failure was lower among patients between 2001 and 2005 (n=4316) but similar among incident patients between 2006 and 2009 (n=3621). Cause-specific PD technique failure revealed no difference in PD peritonitis-related technique failure over time. PD technique failure due to inadequate PD was initially higher in the 2001-2005 cohort but lower in the 2006-2009 cohort compared with the 1995-2000 cohort. Relative to incident patients between 1995 and 2000, adjusted mortality was lower among incident patients between 2001 and 2005 and 2006 and 2009. Survival on PD continues to improve with only modest changes in PD technique failure. Peritonitis remains an ongoing and modifiable source of PD technique failure.

Relationship of body size and initial dialysis modality on subsequent transplantation, mortality and weight gain of ESRD patients

Whether peritoneal dialysis (PD) treatment leads to greater weight gain than with hemodialysis (HD) and if this limits access of obese end-stage renal disease patients to renal transplantation has not been examined. We undertook this study to determine the interrelationship between body size and initial dialysis modality on transplantation, mortality and weight gain. Time to transplantation, time to death and weight gain were estimated in a 1:1 propensity score-matched cohort of incident HD and PD patients treated in facilities owned by DaVita Inc. between 1 July 2001 through 30 June 2006 followed through 30 June 2007 (4008 pairs) in four strata of body mass index (BMI) (<18.5, 18.5-24.99, 25.00-29.99 and ≥ 30 kg/m(2)). Transplantation was significantly more likely in PD patients [adjusted hazards ratio (aHR) 1.48, 95% confidence interval (95% CI) 1.29-1.70]; the probability of receiving a kidney transplant was significantly higher in each strata of BMI >18.5 kg/m(2), including with BMI ≥ 30 kg/m(2) (aHR 1.45, 95% CI 1.11-1.89). PD patients had significantly lower all-cause mortality for patients with BMI 18.50-29.99 kg/m(2). Both these findings were confirmed on analyses of the entire unmatched incident cohort (PD 4008; HD 58 471). The effect of dialysis modality on weight gain was tested in 687 propensity score-matched pairs; the odds of >2, >5 or >10% weight gain were significantly lower in PD patients. Treatment with PD is less likely to be associated with a significant weight gain and does not limit the access of obese patients to renal transplantation.

High Rates of Mortality and Technique Failure in Peritoneal Dialysis Patients after Critical Illness

Little is known regarding the causes and outcomes of peritoneal dialysis (PD) patients admitted to the intensive care unit (ICU). We explored the outcomes of technique failure and mortality in a cohort of PD patients admitted to the ICU. Using a provincial database of 990 incident PD patients followed from January 1997 to June 2009, we identified 90 (9%) who were admitted to the ICU. Parametric and nonparametric tests were used as appropriate to determine differences in baseline characteristics. The Cox proportional hazards and competing risk methods were used to investigate associations. Compared with other patients, those admitted to the ICU had been on PD longer (p < 0.0001) and were more often on continuous ambulatory PD (74.2% vs 25.8%, p = 0.016). Cardiac problems were the most common admitting diagnosis (50%), followed by sepsis (23%), with peritonitis accounting for 69% of the sepsis admissions. The 1-year mortality was 53.3%, with 12% alive and converted to hemodialysis, and one third remaining alive on PD. In multivariate Cox modeling, age [hazard ratio (HR): 1.01; 95% confidence interval (CI): 0.99 to 1.03], white blood cell count (HR: 1.02; 95% CI: 1.00 to 1.04), temperature (HR: 0.75; 95% CI: 0.61 to 0.92), and peritonitis (1.64; 95% CI: 1.21 to 2.22) at admission to the ICU were associated with the composite outcome of technique failure or death. In a competing risk analysis, the risk for death was 30%, and for technique failure, 36% at 1 year. Patients on PD have high rates of death and technique failure after admission to the ICU.

Glycemic control and survival in peritoneal dialysis patients with diabetes mellitus.

The optimal target for glycemic control has not been established for diabetic peritoneal dialysis (PD) patients. We examined mortality-predictability of hemoglobin A1c random serum glucose in a contemporary cohort of diabetic PD patients treated in DaVita dialysis clinics July 2001 through June 2006 with follow-up through June 2007. We identified 2798 diabetic PD patients with A1c data. Serum glucose correlated with A1C (r=0.51). Adjusted all-cause death hazard ratio and 95% confidence interval for baseline A1c increments of 7.0 to 7.9%, 8.0 to 8.9%, 9.0 to 9.9%, and ≥10%, compared with 6.0 to 6.9% (reference), were 1.13 (0.97 to 1.32), 1.05 (0.88 to 1.27), 1.06 (0.84 to 1.34), and 1.48 (1.18 to 1.86); and for time-averaged A1c values were 1.10 (0.96 to 1.27), 1.28 (1.07 to 1.53), 1.34 (1.05 to 1.70), and 1.81 (1.33 to 2.46), respectively. The A1c-mortality association was modified by hemoglobin level such that higher all-cause mortality was evident only in nonanemic patients. Similar but non-significant trends in cardiovascular death risk was found across A1c increments. Adjusted all-cause death HR for time-averaged blood glucose 150 to 199, 200 to 249, 250 to 299, and ≥300 mg/dl, compared with 60 to 99 mg/dl (reference), were 1.02 (0.70 to 1.47), 1.12 (0.77 to 1.63), 1.45 (0.97 to 2.18), and 2.10 (1.37 to 3.20), respectively. Poor glycemic control appears associated incrementally with higher mortality in PD patients. Moderate to severe hyperglycemia is associated with higher death risk especially in certain subgroups.

CD4+CD28null cells are expanded and exhibit a cytolytic profile in end-stage renal disease patients on peritoneal dialysis

End-stage renal failure patients, including those on peritoneal dialysis (PD), exhibit several nontraditional cardiovascular (CV) risk factors. A role of CD4(+)CD28(null) T lymphocytes in the genesis of coronary artery disease (CAD) has been proposed. We investigated this cell population and examined its phenotype in a cohort of PD patients without CV disease. The frequency of the peripheral blood CD4(+)CD28(null) T-cell compartment and cytotoxic characteristic of these cells (as assessed by perforin and granzyme B expressions) were determined in 33 PD patients without CAD and 20 healthy subjects by two- and three-color flowcytometry. High-sensitivity C-reactive protein (hs-CRP) was determined by enzyme-linked immunosorbent assay. We investigated whether there was a correlation between these cells and traditional CV risk factors. Compared to healthy controls, CD4(+)CD28(null) T cells were significantly expanded in PD patients (10.30 ± 2.03% versus 3.55 ± 0.67%, mean ± SE, P = 0.0007). Perforin and granzyme B expressions were restricted to CD4(+)CD28(null) T cells compared to CD4(+)CD28(+) T cells (<0.0001). A greater proportion of CD4(+)CD28(null) T cells in PD patients expressed these molecules (P = 0.007 and 0.04). hs-CRP level was increased in PD patients (P < 0.0001) but did not correlate with the CD4(+)CD28(null) T-cell frequency. Increasing age correlated with the CD4(+)CD28(null) cells. PD patients exhibit a substantially increased number of circulating CD4(+)CD28(null) T cells that show a cytolytic profile before the onset of clinically significant CAD. Their significance as a nontraditional CV risk factor needs further studies.

Predictive Value of Malnutrition Markers for Mortality in Peritoneal Dialysis Patients

Alterations in nutritional status have been described as important predictors of mortality in patients with chronic kidney disease (CKD). However, the association between multiple markers for nutritional status and the mortality rates of patients with CKD on peritoneal dialysis (PD) has not yet been illustrated in previously published data, particularly by using the new definition of protein energy wasting (PEW). To evaluate the predictive value of malnutrition markers for mortality rates, on the basis of the PEW definition, of PD patients. At the start of PD treatment, the nutritional status of 199 patients (mean age, 56 ± 13.3 years; 53% females) was evaluated. Body mass index (BMI), arm circumference, mid-arm muscle circumference, protein and caloric intake (by using a 3-day food record), and serum albumin were all recorded, as well as a subjective global assessment (SGA) and presence of PEW. Cut-off points were defined on the basis of the consensus of the International Society for Renal Nutrition and Metabolism (albumin, <3.8 g/dL; BMI, <23 kg/m(2); mid-arm muscle circumference, >10% in comparison with the 50th percentile for the reference population; protein intake, <0.8 g/kg/daily; caloric intake, <25 kcal/kg/daily). The data were obtained retrospectively between the years 2001 and 2008 on the basis of routine nutritional evaluation. Patients were monitored for fatal events from all possible causes. The mean BMI for the population was 26.6 ± 5.0 kg/m(2). A median protein intake of 0.94 (0.18 to 4.57) g/kg/daily was reported and 60.3% of the patients reported a protein intake of <0.8 g/kg/daily. With respect to caloric intake, 38.7% of the patients consumed <25 kcal/kg/daily. A median of 3.5 (1.4 to 5.3) g/dL for serum albumin was observed and 29.3% of the patients presented values of <3.8 g/dL. PEW was diagnosed in 17.5% of patients. In the univariate model, being of age >65 years (P = .002), cardiovascular disease (P < .001), diabetes mellitus (P = .02), SGA (P = .02), and albumin (P = .002), were all significant markers for mortality. The presence of patients aged >65 years (P = .02), with diabetes mellitus (P = .057), cardiovascular disease (P = .005), and albumin were considered as independent factors for mortality in this study. SGA, albumin, and PEW were the only nutritional markers found to be associated with mortality in this cohort of PD patients. In the multivariate analysis, after adjusting for classic mortality risk factors, only patients with hypoalbuminemia were found to be at a high risk for mortality at follow-up. These results may be limited by the number of observations and a necessity for confirmation in larger prospective studies.

Time-Dependent Reasons for Peritoneal Dialysis Technique Failure and Mortality

Peritoneal dialysis (PD) technique failure is high compared to hemodialysis (HD). There is a lack of data on the impact of duration of PD treatment on technique survival and on whether there is a difference in risk factors with respect to early and late failure. The aim of this study was to clarify these issues by performing a time-dependent analysis of PD technique and patient survival in a large cohort of incident PD patients. We analyzed 709 incident PD patients participating in the Netherlands Cooperative Study on the Adequacy of Dialysis (NECOSAD), who started their treatment between 1997 and 2007. We compared technique and patient survival on PD in 4 periods of follow-up: within the first 3 months, and after 3 - 12 months, 12 - 24 months, and 24 - 36 months of treatment. Cox proportional hazards model was used to analyze survival on PD and technique failure. Risk factors were also identified by comparing patients that were transferred to HD with those that remained on PD. Incidence rates for every cause of dropout for each period of follow-up were calculated to establish their trends with respect to PD treatment duration. There was a significant increase in transplantation rate after the first year of treatment. The rate of switching to HD was highest during the first 3 months and decreased afterward. One-, 2- and 3-year technique survival was 87%, 76%, and 66%, respectively. Age, diabetes, and cardiovascular disease appeared to be risk factors for death on PD or switch to HD: a 1-year increase in age was associated with a relative risk (RR) of PD failure of 1.04 [95% confidence interval (CI) 1.003 - 1.06]; for diabetes, RR of stopping PD after 3 months of treatment increased from 1.8 (95% CI 1.1 - 3) during the first year to 2.2 (95% CI 1.3 - 4) after the second year; cardiovascular disease had a major impact in the earliest period (RR 2.5, 95% CI 1.2 - 5) and had a stable influence further on (RR 2, 95% CI 1.1 - 3.5). Loss of 1 mL/minute residual glomerular filtration rate (rGFR) appeared to be a significant predictor of PD failure after 3 months of treatment, but within the first 2 years, RR was 1.1 (95% CI 1.04 - 1.25). In The Netherlands, transplantation is a main reason to stop PD treatment. The incidence of PD technique failure is at its highest during the earliest months after treatment initiation and decreases later due to fewer catheter and abdominal complications as well as less influence of psychosocial factors. Risk factors for PD discontinuation are those responsible for patient survival: age, cardiovascular disease, diabetes, and rGFR.

Colonic Diverticulosis as a Risk Factor for Peritonitis in Chinese Peritoneal Dialysis Patients

The risk of development of enteric peritonitis in Chinese peritoneal dialysis (PD) patients with colonic diverticulosis is not known. There have been no reports on whether colonic diverticulosis may affect peritonitis outcomes. The objectives of this study were to examine whether colonic diverticulosis is a risk factor for the development of enteric peritonitis and to study its influence on the outcome of enteric peritonitis. All continuous ambulatory PD patients that had barium enema and colonoscopic examinations performed between January 1994 and January 2006 were included. They were divided into 2 groups: patients with diverticulosis and patients without diverticulosis. Their demographic and clinical characteristics, colonic examination findings, and peritonitis data were compared and analyzed. 104 Chinese patients received 110 colonoscopies and 51 barium enema examinations. 25 patients (24.0%) had colonic diverticulosis. Patients with diverticulosis were older (65.4 +/- 14.7 vs 58.4 +/- 14.0 years, p = 0.033). The most common site of involvement of diverticulosis was the ascending colon (56%). 128 episodes of enteric peritonitis were recorded in 49 patients. Compared with patients without enteric peritonitis, more patients in the enteric peritonitis group had diverticulosis (38.8% vs 10.9%, p = 0.001) and diverticulosis most often involved the ascending colon (20.4% vs 7.3%, p = 0.082). Multivariate logistic regression analysis showed that the presence of diverticulosis (hazard ratio 5.17, 95% confidence interval 1.86 - 14.40; p = 0.002) and diverticulosis involving the ascending colon (hazard ratio 6.89, 95% confidence interval 1.43 - 33.32, p = 0.016) were independent risk factors for the development of enteric peritonitis. Enteric peritonitis in patients with diverticulosis had a higher but nonsignificant treatment failure rate (26.9% vs 18.4%, p = 0.282). In this selected cohort of PD patients with indications of colonic examinations, diverticulosis, especially involving the ascending colon, may be a risk factor for the development of enteric peritonitis. Colonic diverticulosis does not appear to affect the outcome of enteric peritonitis. Further studies are warranted to determine ways to prevent enteric peritonitis in PD patients with diverticulosis.

Arterial Pulse Wave Velocity and Peritoneal Transport Characteristics Independently Predict Hospitalization in Chinese Peritoneal Dialysis Patients

Cardiovascular disease (CVD) is the most common cause of mortality in chronic peritoneal dialysis (PD) patients. Increased arterial stiffness may be related to a high peritoneal permeability resulting in fluid overload in PD patients. We studied the relations between arterial stiffness, peritoneal transport, and radiographic parameters of systemic fluid overload in a cohort of Chinese PD patients. Prospective cohort study. University referral center. We studied 107 PD patients. Vascular pedicle width and cardiothoracic ratio were measured from a plain postero-anterior chest radiograph. Pulse wave velocity (PWV) was determined at carotid-femoral (C-F) and carotid-radial sites. Peritoneal transport was determined by the dialysate-to-plasma ratio (D/P) of creatinine at 4 hours of dwell. Patients were followed for 9.4 +/- 4.6 months. Duration of hospitalization; actuarial and technique survival. There were no relationships between radiographic measures, arterial PWV, and D/P creatinine. However, both C-F PWV and D/P creatinine were independent predictors of the number of hospitalizations for CVD. None of the parameters correlated with mortality in this study. There were no relationships between radiological parameters of fluid overload, peritoneal transport characteristics, and arterial PWV. Both C-F PWV and D/P creatinine were independent predictors of the number of hospitalizations for CVD. Our result suggests that arterial stiffness and high peritoneal transport each contribute to the development of CVD in this group of patients.

Technique Failure and Center Size in a Large Cohort of Peritoneal Dialysis Patients in a Defined Geographic Area

Hemodialysis (HD) and peritoneal dialysis (PD) are both viable options for renal replacement therapy. Technique failure has been shown to be a major problem in PD therapy. To examine the relationship between center size and PD technique failure. ESRD Network #1 (NW1). Retrospective review of NW1 database. 5003 incident PD patients between 2001 and 2005 in 105 PD units were included. Patients were grouped into 2 based on center size: group A, patients in units with <or=25 patients, and group B, patients in units with >25 patients. Outcome measures were analyzed for the first and second years of PD therapy. Patients were censored at transplantation, transfer to HD, or death. Technique failure and mortality reported as death in Standard Information Management Systems (SIMS) database (NW1 data system). Technique failure rates were significantly higher in group A for year 1 (odds ratio: 1.36, p = 0.005) and for year 2 (odds ratio: 1.35, p = 0.03). Mortality rates were not statistically different between the 2 groups. Technique failure was higher in units with <or=25 patients than in units with >25 patients. There was no difference in mortality between the 2 groups. The majority of patients in NW1 receive care in small units.