Continuous Cycling Peritoneal Dialysis Patients Research Articles

Daptomycin Pharmacokinetics in Adolescents Undergoing Hemodialysis and Peritoneal Dialysis: A Case Series With Pharmacokinetic Modeling.

Children who undergo hemodialysis (HD) and peritoneal dialysis are at increased risk of infection. Daptomcyin is used to treat resistant infections; however, the pharmacokinetics of daptomycin in pediatric and adolescent dialysis patients remain unknown. We report the safety and pharmacokinetics of a single intravenous 5 mg/kg dose of daptomycin for 6 individuals age 12 to 17 years old who underwent HD or continuous cycling peritoneal dialysis (CCPD). Daptomycin concentrations from all samples were determined by high-performance liquid chromatography. A non-compartmental analysis was performed to compare the pharmacokinetic parameters among HD and CCPD patients. A population pharmacokinetic model was developed to describe the concentration-time profiles of daptomycin in plasma, urine, and dialysis effluent. Monte Carlo simulations were performed to assess the pharmacodynamic outcomes. All subjects tolerated the single dose of daptomycin. During HD, significant drug removal was observed, compared with CCPD (26% vs 5% of total dose). A low daptomycin renal clearance (<12% of total clearance) with moderate variability (40.5%) was observed among subjects with residual renal function. An anuric and obese subject who received CCPD treatment appeared to have >80% higher daptomycin area under the plasma concentration-time curve than the other CCPD subjects. Dosing regimens that achieved predefined pharmacodynamic targets were reported. Daptomycin clearance was faster in 12- to 17-year-old patients receiving HD than CCPD. Administration of daptomycin immediately after HD reduces drug loss. The CCPD treatment, anuria, and obesity may increase the risk for drug accumulation. Our pharmacokinetic model can be further used to optimize dosing regimens of daptomycin in this population.

Steady-State Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis Patients: Brief Report.

Steady-state pharmacokinetics of oral ciprofloxacin in 3 continuous cycling peritoneal dialysis (CCPD) outpatients given ciprofloxacin 750 mg b.i.d. for 5 doses was determined. Mean steady-state maximum serum concentration and half-life were 4.4 ± 1.5 mg/L and 10.3 ± 2.6 hours, respectively. Mean maximum dialysate concentration in the daytime long dwell and overnight continuous cycling dwell were 7.4 ± 1.2 mg/L and 3.3 ± 1.2 mg/L, respectively. Oral ciprofloxacin 750 mg b.i.d. may be reasonable for bloodstream and peritoneal infections caused by susceptible bacteria in CCPD patients.

Comparison of Peritoneal Low-Molecular-Weight-Protein-Removal in CCPD and CAPD Patients Based on C-Terminal Agrin Fragment Clearance

Background/Aims: This study compares the peritoneal elimination of the low-molecular-weight-protein (LMWP) C-terminal agrin fragment (tCAF, size 22 kDa), a promising biomarker for kidney function, in continuous cycling peritoneal dialysis (CCPD) and continuous ambulatory peritoneal dialysis (CAPD). Methods: 103 sets of serum, 24h-urine and dialysate samples were obtained in 15 CCPD (63 sets) and 11 CAPD (40 sets) patients. Total, renal and peritoneal substrate removals/clearances were measured/calculated for tCAF, creatinine, blood-urea-nitrogen (BUN), cystatin C and albumin and correlated with the peritoneal transport type. Results: Serum und urine concentrations of all biomarkers did not differ between both groups, urinary substrate removal was higher in CAPD patients for all biomarkers due to better residual renal function. Peritoneal substrate removal of tCAF and albumin were significantly higher in CAPD (tCAF: 35.3 vs. 19.3 µg/d, p<0.001; albumin: 4.3 vs. 3.7 g/d, p=0.001), whereas cystatin C and creatinine did not differ between CAPD and CCPD (cystatin: 7.7 vs. 6.1 mg/d, p=0.08, creatinine: 423.9 vs. 456.7 mg/d, p=0.241). BUN was better removed by CCPD (4846.6 vs. 3393.4 mg/d, p<0.001). CAPD patients with high-transporter characteristics had a higher peritoneal tCAF removal compared to high-average-transporters (49.8 vs. 28.4 µg/d, p<0.001), no differences could be detected in CCPD patients between these groups. CAPD patients using icodextrin twice/day had higher peritoneal clearance of tCAF compared to once daily (4.4 vs. 2.8 l/wk/1.73 m2 body-surface-area, p<0.001). Conclusions: CAPD was superior to CCPD concerning peritoneal tCAF removal. This finding was pronounced in high-transporters and CAPD patients using icodextrin twice daily.

Effect of Peritoneal Dialysis Modality on the 1-Year Rate of Decline of Residual Renal Function

PurposeThe effect of different peritoneal dialysis (PD) modalities on the decline in residual renal function (RRF) is unclear due to inconsistencies among studies. In particular, the effect of automated peritoneal dialysis (APD) modalities [continuous cyclic peritoneal dialysis (CCPD) and nightly intermittent peritoneal dialysis (NIPD)] on RRF has not been examined in a large cohort.Materials and MethodsWe conducted a single-center retrospective study to investigate the association between PD modalities and decline in RRF in 142 incident PD patients [34 on CCPD, 36 on NIPD, and 72 on continuous ambulatory peritoneal dialysis (CAPD)]. RRF was measured within 2 months from PD start and at 1 year after PD initiation.ResultsThe RRF at 1 year after PD initiation was 1.98±2.20 mL/min/1.73 m2 in CCPD patients and 3.63±3.67 mL/min/1.73 m2 in NIPD patients, which were moderately lower than 4.23±3.51 mL/min/1.73 m2 in CAPD patients (p=0.064). Moreover, there was no significant difference in the 1-year rate of decline of RRF between CCPD and NIPD patients, although APD patients had a faster 1-year RRF decline rate than CAPD patients (CCPD and NIPD vs. CAPD: -45.68 and -36.69 vs. 1.17%/year, p=0.045). APD was associated with a more rapid decline in RRF in patients with end-stage renal disease undergoing PD, although multivariate analysis attenuated the significance of this finding (β=-31.50; 95% CI, -63.61 to 0.62; p=0.052).ConclusionOur results suggest that CAPD might be more helpful than APD for preserving RRF during the first year of dialysis therapy, although there was no significant difference in the 1-year rate of decline of RRF between the two APD modalities.

Metabolic parameters of CAPD and CCPD in diabetics with terminal renal insufficiency

The effects of continuous ambulant (CAPD) and continuous cyclic peritoneal dialysis (CCPD) on a series of laboratory parameters in the blood and dialysate were assessed in two groups of nine juvenile diabetics each, suffering from terminal renal failure. The CCPD patients showed higher urea and creatinine levels in serum and, as a result of lower protein loss via the dialysate, also higher total protein and transferrin concentrations than the CAPD patients. The glucose absorption of the CCPD patients was about 50% lower than of the CAPD patients. Control of diabetes was equally successful with both procedures, the HbA1 values were less than 10%. The triglycerides were lowered by both CAPD and CCPD on the condition that the absorbed glucose amounts were included in the calculation of the dietary adjustment. Cholesterol and HDL-cholesterol remained unchanged. Thus CCPD appears to have advantages over CAPD, especially with respect to the lowering of the glucose absorption and the protein loss. The wider application of both methods will be, however, less influenced by the metabolic parameters than by other factors such as reduction of the risk of peritonitis.

Intra-Peritoneal Administration of Potassium and Magnesium: A Practical Method to Supplement These Electrolytes in Peritoneal Dialysis Patients

Background. Malnutrition and gastrointestinal (GI) losses are frequently encountered in peritoneal dialysis patients, leading to hypokalemia and hypomagnesemia. Oral supplementation is limited by patients' compliance, as well as GI side effects. Methods. Among the 27 patients on continuous cyclic peritoneal dialysis (CCPD) in whom we had one-year data, 15 (55%) were on oral potassium (K) supplements and 10 (37%) were on oral magnesium (Mg) supplements. Hypokalemia and hypomagnesemia persisted in 3 (11%) patients despite oral supplementation. We examined the efficacy and tolerability of intra-peritoneal (IP) K and Mg administration. Four grams of magnesium sulfate (MgSO4) and/or 60–80 mEq of potassium chloride (KCl) were added to a 2 liter, 2.5% peritoneal dialysis solution bag, and it was used as the last dwell in five CCPD patients. We serially measured serum K and Mg concentrations at 2, 4, and 6–8 hour intervals, drained the fluid, and measured serum concentrations at 20–24 hours. Results. Mean serum K concentration increased from a baseline of 3.2 mEq/L to 4.1, 4.2, 4.1, and 4.2 mEq/L at 2, 4, 6–8, and 20–24 hours post IP administration of KCl, respectively. Similarly, mean serum Mg concentration increased from a baseline of 1.5 mg/dL to 2.5, 2.9, 2.6, and 2 mg/dL at 2, 4, 6–8, and 20–24 hours post-IP administration of MgSO4, respectively. Patients tolerated IP replacement very well, and there were no adverse events. Serum K and Mg concentrations normalized in all patients. Conclusion. IP administration is a safe, practical, and effective method to supplement K and Mg in peritoneal dialysis patients.

A comparison of peritonitis rates from the United States Renal Data System database: CAPD versus continuous cycling peritoneal dialysis patients

Previous comparisons of peritonitis rates between continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) have produced varying results. Using United States Renal Data System data, the authors evaluated peritonitis rates in 1994 through 1997 incident CAPD (n = 9,190) and CCPD (n = 2,785) Medicare patients. Patients were characterized during a 6-month entry period (months 4 through 9) and followed for a maximum of 2 years (months 10 through 33). Medicare claims data provided the date of the first peritonitis episode during the follow-up period. The time to first peritonitis after 9 months of PD was compared by the log-rank test, and then by Cox regression with adjustment for peritoneal dialysis modality, age, sex, race, primary end-stage renal disease (ESRD) diagnosis, number of entry-period hospital days, peritonitis during the entry period, hematocrit value, and congestive heart failure. For CAPD and CCPD, the adjusted average months to first peritonitis after 9 months of PD were 17.1 and 16.1, respectively. The probabilities of remaining without a peritonitis episode after 1 year of follow-up were 0.53 and 0.50, respectively ( P = 0.008). The risk of peritonitis was lower for CAPD than for CCPD (relative risk, 0.939; 95% confidence interval, 0.883 to 0.998). Other significant risk factors included age <or=44 years, black race, diabetes as primary ESRD diagnosis, peritonitis during the entry period, greater than 4 entry-period hospital days, and congestive heart failure. Patients treated with recombinant human erythropoietin with a hematocrit value of >or=36% had lower risk of peritonitis. Compared with CCPD, CAPD is associated with a slightly but significantly lower risk for development of a first peritonitis episode after 9 months of peritoneal dialysis therapy.

How strong are patients’ preferences in choices between dialysis modalities and doses?

Background: How dialysis patients feel about their treatment may influence how they respond to information suggesting that survival is better with a higher dose or different treatment modality. We assessed the strength of dialysis patients’ preferences for their current treatment modality versus other modalities, how differences in survival between modalities and doses could influence preferences, and whether preferences differ by patient characteristics. Methods: We measured preference values for current health on dialysis therapy and for standardized descriptions of dialysis modalities and doses by using a sample of dialysis patients in Maryland and Massachusetts and a time trade-off technique scaled between 0 (death) and 1 (perfect health). Results: We interviewed 109 patients on hemodialysis therapy, 57 patients on continuous ambulatory peritoneal dialysis (CAPD), and 22 patients on continuous cycling peritoneal dialysis (CCPD). Hemodialysis, CAPD, and CCPD patients had similar preference values for current health (mean, 0.69, 0.74, and 0.70, respectively; P > 0.1) and lower preference values for alternative modalities (eg, mean of 0.55 assigned to CAPD by hemodialysis patients). More than 75% of patients would choose a high dose over a lower dose of dialysis if it increased length of survival by 20%, but more than 30% would not switch modality, even if it increased survival by 100%. The only characteristic associated with a difference in preference values was depression, with weaker preferences among those with mild to moderate depressive mood. Conclusion: Dialysis patients have strong preferences for their current modality and are more likely to accept a higher dose of dialysis than switch modality to increase survival. Physicians should talk with patients about the modality and dose they prefer because preferences cannot be predicted by patient characteristics. Background: How dialysis patients feel about their treatment may influence how they respond to information suggesting that survival is better with a higher dose or different treatment modality. We assessed the strength of dialysis patients’ preferences for their current treatment modality versus other modalities, how differences in survival between modalities and doses could influence preferences, and whether preferences differ by patient characteristics. Methods: We measured preference values for current health on dialysis therapy and for standardized descriptions of dialysis modalities and doses by using a sample of dialysis patients in Maryland and Massachusetts and a time trade-off technique scaled between 0 (death) and 1 (perfect health). Results: We interviewed 109 patients on hemodialysis therapy, 57 patients on continuous ambulatory peritoneal dialysis (CAPD), and 22 patients on continuous cycling peritoneal dialysis (CCPD). Hemodialysis, CAPD, and CCPD patients had similar preference values for current health (mean, 0.69, 0.74, and 0.70, respectively; P > 0.1) and lower preference values for alternative modalities (eg, mean of 0.55 assigned to CAPD by hemodialysis patients). More than 75% of patients would choose a high dose over a lower dose of dialysis if it increased length of survival by 20%, but more than 30% would not switch modality, even if it increased survival by 100%. The only characteristic associated with a difference in preference values was depression, with weaker preferences among those with mild to moderate depressive mood. Conclusion: Dialysis patients have strong preferences for their current modality and are more likely to accept a higher dose of dialysis than switch modality to increase survival. Physicians should talk with patients about the modality and dose they prefer because preferences cannot be predicted by patient characteristics.

How strong are patients’ preferences in choices between dialysis modalities and doses?

How dialysis patients feel about their treatment may influence how they respond to information suggesting that survival is better with a higher dose or different treatment modality. We assessed the strength of dialysis patients' preferences for their current treatment modality versus other modalities, how differences in survival between modalities and doses could influence preferences, and whether preferences differ by patient characteristics. We measured preference values for current health on dialysis therapy and for standardized descriptions of dialysis modalities and doses by using a sample of dialysis patients in Maryland and Massachusetts and a time trade-off technique scaled between 0 (death) and 1 (perfect health). We interviewed 109 patients on hemodialysis therapy, 57 patients on continuous ambulatory peritoneal dialysis (CAPD), and 22 patients on continuous cycling peritoneal dialysis (CCPD). Hemodialysis, CAPD, and CCPD patients had similar preference values for current health (mean, 0.69, 0.74, and 0.70, respectively; P > 0.1) and lower preference values for alternative modalities (eg, mean of 0.55 assigned to CAPD by hemodialysis patients). More than 75% of patients would choose a high dose over a lower dose of dialysis if it increased length of survival by 20%, but more than 30% would not switch modality, even if it increased survival by 100%. The only characteristic associated with a difference in preference values was depression, with weaker preferences among those with mild to moderate depressive mood. Dialysis patients have strong preferences for their current modality and are more likely to accept a higher dose of dialysis than switch modality to increase survival. Physicians should talk with patients about the modality and dose they prefer because preferences cannot be predicted by patient characteristics.

Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis

In order to avoid aminoglycosides, the International Society for Peritoneal Dialysis recommends cefazolin and ceftazidime for empirical treatment of peritonitis. Ciprofloxacin covers relevant gram-negative pathogens without the resistance associated with ceftazidime. However, ciprofloxacin pharmacokinetic data in patients on continuous cycling peritoneal dialysis (CCPD) are lacking. (1) To determine the pharmacokinetics of oral ciprofloxacin in CCPD patients, (2) to compare serum and dialysate ciprofloxacin concentrations with minimum inhibitory concentrations (MIC) of the gram-negative bacteria associated with peritonitis, and (3) to establish oral ciprofloxacin dosing guidelines for the empirical treatment of peritonitis in patients receiving CCPD. Eligible CCPD patients received 2 doses of ciprofloxacin: 750 mg orally every 12 hours. Serial blood and end-of-dwell dialysate samples were collected during the first 12-hour interval; an end-of-dwell dialysate sample from the overnight dwell and a final blood sample were collected at the end of the second 12-hour interval. Ciprofloxacin concentrations were determined using a liquid chromatographic (HPLC)-fluorescence method. Pharmacokinetic calculations were completed assuming a one-compartment model. Eight patients completed the study. The pharmacokinetic parameters determined for ciprofloxacin were (mean +/- SEM) serum half-life 10.1 +/- 1.2 hours, maximum serum concentration 2.7 +/- 0.5 mg/L, time to maximum serum concentration 1.6 +/- 0.1 hours after the first dose, and peritoneal clearance 1.2% +/- 0.1% of the mean calculated total body clearance. While all patients achieved serum area under the concentration-time curve:MIC > 125 for Escherichia coli and Klebsiella species after the first dose, only 2 patients achieved this goal for Pseudomonas aeruginosa. End-of-dwell dialysate concentrations were above the MIC for E. coli, Klebsiella spp, and P. aeruginosa after the second dose. Ciprofloxacin 750 mg orally every 12 hours in CCPD patients may be useful for empirical gram-negative coverage of CCPD peritonitis and for treatment of documented peritonitis caused by sensitive E. coli or Klebsiella species. While ceftazidime may be required for documented pseudomonal peritonitis, the oral ciprofloxacin regimen achieved adequate serum concentrations to treat systemic gram-negative infections caused by sensitive E. coli or Klebsiella species.

Amadori Albumin and Advanced Glycation End-Product Formation in Peritoneal Dialysis using Icodextrin

To study the influence of peritoneal dialysis (PD) solutions on the formation of early glycated products and advanced glycation end-products (AGEs). The formation of both Amadori albumin and AGEs in glucose- and icodextrin-based PD fluids was analyzed in vitro and in peritoneal effluents of continuous cyclic peritoneal dialysis (CCPD) patients. Albumin incubated with glucose-based PD fluids showed a time- and glucose concentration-dependent formation of Amadori albumin and AGEs. Aminoguanidine completely inhibited AGE but not Amadori albumin formation. Albumin incubated in icodextrin resulted in the lowest levels of Amadori albumin and AGE. Amadori albumin levels in effluents of 24 CCPD patients (12 glucose and 12 icodextrin for their daytime dwells) were similar. Dialysate samples collected during a mass transfer area coefficient test in 16 CCPD patients (8 glucose, 8 icodextrin) showed an increase in Amadori albumin formation from baseline (p < 0.0001), without a difference between the groups. In the total group, there was a positive relationship between duration on PD and dialysate Amadori albumin concentration at 240 minutes (p = 0.03). The Amadori albumin dialysate-to-plasma (D/P) ratio at 240 minutes was 0.82+/-0.11, and its clearance amounted to 7.71+/-1.14 mL/min, while the albumin D/P ratio was 0.010+/-0.003 and its clearance was 0.089+/-0.017 mL/min. In a peritoneal biopsy of a CCPD patient, Amadori albumin was observed in the mesothelial layer and the endothelium of the peritoneum. Using icodextrin-based instead of glucose-based PD fluids can largely reduce the formation of Amadori albumin and AGEs. However, CCPD patients using icodextrin during daytime dwells do not have lower effluent levels of Amadori albumin and AGEs, probably due to the exposure to glucose during their nighttime exchanges. Kinetic studies suggest washout of locally produced Amadori albumin.

Blood Pressure and Left Ventricular Hypertrophy in Patients on Different Peritoneal Dialysis Regimens

To examine the relation between the results of ambulatory 24-hour blood pressure monitoring (ABPM) and left ventricular mass index (LVMI), then to find the independent determinant for left ventricular hypertrophy (LVH) in peritoneal dialysis (PD) patients. Finally, to evaluate the differences in the clinical and cardiovascular characteristics between patients on continuous ambulatory PD (CAPD) and continuous cyclic PD (CCPD). An open, nonrandomized, cross-sectional study. Divisions of nephrology and cardiology in a medical center. Thirty-two uremic patients on maintenance PD therapy (22 patients on CAPD, and 10 on CCPD) without anatomical heart disease or history of receiving long-term hemodialysis. Home blood pressure (BP) and office BP were measured using the Korotkoff sound technique by sphygmomanometer. ABPM was employed for continuous measurement of BP. Echocardiography was performed for measurement of cardiac parameters and calculation of LVMI. Multivariate logistic regression analysis was performed for independent determinant of LVH in PD patients. The differences in clinical and cardiovascular characteristics between CAPD and CCPD patients were compared. Simple regression analysis showed positive correlations between LVMI and the duration of hypertension, ambulatory nighttime BP/BP load/BP load > 30%, serum phosphate, calcium-phosphate product, ultrafiltration (UF) volume, and percentage of UF volume during the nighttime. A negative correlation was noted between LVMI and dipping. In multiple regression analysis, the duration of hypertension was the only variable linked to LVMI. In multivariate logistic regression analysis, only ambulatory nighttime systolic BP load > 30% had an independent association with LVH. There were correlations between office/home BP and ambulatory 24-hour BP. In addition, CCPD patients had higher LVMI, UF volume during the nighttime, and percentage of UF volume during the nighttime than those of CAPD patients. In this study, ambulatory nighttime systolic BP load > 30% had an independent association with LVH. Office and home BP measurements were correlated with ABPM in PD patients. The result that CCPD patients had a higher LVMI than CAPD patients may be due to a relative volume overload during the daytime in CCPD patients.

Assessment of the Effectiveness, Safety, and Biocompatibility of Icodextrin in Automated Peritoneal Dialysis

ObjectiveOur study assessed the efficacy, safety, and biocompatibility of icodextrin (I) solution compared to glucose (G) solution as the daytime dwell in continuous cycling peritoneal dialysis (CCPD).DesignIn a randomized, open, prospective, parallel group study of two years’ duration, either I or G was used for the long daytime dwell in CCPD patients.MethodThe study was carried out in a university hospital and teaching hospital. Established CCPD patients and patients new to the modality were both included. Clinic visits were made at three-month intervals. In all patients, clinical data were gathered; ultrafiltration (UF) was recorded; and serum, urine, and dialysate samples and effluents were collected. Peritoneal defense characteristics and mesothelial markers were determined. Every six months, peritoneal kinetics studies were performed, and serum samples for icodextrin metabolites were taken.ResultsThirty-eight patients (19 G, 19 I) started the study. The median follow-up was 16 months and 17 months respectively (range: 0.5 – 26 months and 3 – 26 months, respectively). Daytime UF volumes increased significantly (p &lt; 0.001), and 24-hour UF tended to increase from baseline in the I group. Dialysate creatinine clearance increased non significantly in both groups over time. In I patients, serum disaccharides (maltose) concentration increased from 0.05 ± 0.01 mg/mL [mean ± standard error of mean (SEM)] at baseline, to an average concentration in the follow-up visits of 1.15 ± 0.04 mg/mL (p &lt; 0.001). At the same time, serum sodium levels decreased from 138.1 ± 0.7 mmol/L to an average concentration in the follow-up visits of 135.9 ± 0.8 mmol/L (p &lt; 0.05). At 12 months, the serum sodium concentration increased to a non significant difference from baseline. Serum osmolality increased, but did not differ significantly from G users at any visit. During peritonitis (P), daytime dwell UF decreased significantly compared to non peritonitis (NP) episodes in G patients (p &lt; 0.001), but remained stable in I patients. Total 24-hour UF also decreased in G patients (p &lt; 0.001), but not in I patients. In these I patients, serum disaccharides increased from 0.05 ± 0.01 mg/mL to 1.26 ± 0.2 mg/mL during follow-up. During peritonitis, serum disaccharides concentration did not increase further (1.47 ± 0.2 mg/mL, p = 0.56). Thirty P episodes occurred during follow-up: 16 in G patients and 14 in I patients (1 per 17.6 months and 1 per 21.9 months, respectively). After one year, absolute number and percentage of effluent peritoneal macrophages (PMΦs) were significantly higher in I patients than in G patients. The difference in percentage persisted after two years. The phagocytic capacity of PMΦs decreased over time, resulting in a borderline significant difference for coagulase-negative staphylococci phagocytosis (p = 0.05) and a significant difference for E. coli phagocytosis (p &lt; 0.05) in favor of I patients. PMΦ oxidative metabolism, PMΦ cytokine production, and effluent opsonic capacity remained stable over time with no difference between the groups. Mass transfer area coefficients (MTACs) and clearances were stable and appeared unaffected by G or I treatment. Effluent cancer antigen 125 (CA125) was stable in G users and tended to decrease in I users. Effluent interleukin-8 (IL-8), carboxy-terminal propeptide of type I procollagen (PICP), and amino-terminal propeptide of type III procollagen (PIIINP) did not change over time and did not differ between the groups.ConclusionsThe use of I for the long daytime dwell in CCPD led to an increase in total UF of at least 261 mL per day, which was maintained over at least 24 months. During I treatment, serum I metabolites increased significantly and serum sodium concentrations decreased initially. As a result, serum osmolality increased slightly. Clinical adverse effects did not accompany these findings. The UF gain in the I patients was even higher during P, without a further increase in serum I metabolites. CCPD patients using I did equally well as G-treated patients with regard to clinical infections and most peritoneal defense characteristics. However, in a few peritoneal defense tests, I-treated patients did better. Peritoneal transport variables did not change over time. Peritoneal membrane markers did not change throughout the study and did not differ between the groups.

Peritoneal Defense Using Icodextrin Or Glucose for Daytime Dwell in Ccpd Patients

To investigate peritoneal defense during icodextrin use in continuous cyclic peritoneal dialysis (CCPD). In an open, prospective, 2-year follow-up study, CCPD patients were randomized to either glucose (Glu) or icodextrin (Ico) for their long daytime dwell. University hospital and teaching hospital. Both established and patients new to CCPD were included. A life expectancy of more than 2 years, a stable clinical condition, and written informed consent were necessary before entry. Patients aged under 18 years, those who had peritonitis in the previous month, and women of childbearing potential, unless taking adequate contraceptive precautions, were excluded. Thirty-eight patients (19 Glu, 19 Ico) started the study. The median follow-up was 16 and 17 months for Glu and Ico respectively (range 0.5-25 months and 5-25 months, respectively). Peritoneal defense characteristics and peritoneal dialysis-related infections were recorded every 3 months. Total peritoneal white cell count tended to decrease over time in both groups. After 1 year, absolute numbers and percentages of effluent peritoneal macrophages (PMphis) were significantly higher in Ico than in Glu patients; this difference in the percentage persisted after 2 years. Percentage of mesothelial cells increased overtime in Ico patients. The phagocytic capacity of PMphis decreased over time, resulting in a borderline significant difference for coagulase-negative staphylococci (p = 0.05) and a significant difference for Escherichia coli (p < 0.05) phagocytosis in favor of Ico patients. PMphi oxidative metabolism remained stable over time without a difference between the groups. PMphi cytokine production and effluent opsonic capacity also remained stable over time. Finally, 16 peritonitis episodes in Glu and 14 in Ico patients occurred. Glucose patients had 37 and Ico patients 32 exit-site infections during the study. CCPD patients using Ico did equally as well as Glu-treated patients with respect to clinical infections and most peritoneal defense characteristics. However, in a few peritoneal defense tests, Ico-treated patients did better.

Induction of 1,2-Dicarbonyl Compounds, Intermediates in the Formation of Advanced Glycation End-Products, during Heat-Sterilization of Glucose-Based Peritoneal Dialysis Fluids

To study the presence of 1,2-dicarbonyl compounds in peritoneal dialysis (PD) fluids, their concentration in effluents with increasing dwell time, and their role in the formation of advanced glycation end-products (AGEs). Dicarbonyl compounds in heat- and filter-sterilized PD fluids were quantified by reverse-phase high performance liquid chromatography (HPLC) after derivatization to dimethoxyquinoxaline derivatives. Kinetics of the in vitro formation of AGEs upon incubation of 1,2-dicarbonyl compounds or PD fluids with albumin, with or without aminoguanidine, were measured by AGE fluorescence (excitation/emission wavelengths of 350 nm/430 nm). AGEs and dicarbonyl compounds were measured in effluents collected from standardized 4-hour dwells from 8 continuous cycling peritoneal dialysis patients. In PD fluids, 3-deoxyglucosone (3-DG) has been identified as the major dicarbonyl compound formed during the process of heat sterilization. The process also formed glyoxal (GO) and methylglyoxal (MGO), with the amount of 3-DG being approximately 25-60 times higher than GO and MGO. When incubated with albumin, the identified 1,2-dicarbonyl compounds rapidly formed AGEs. The formation of AGEs was more pronounced in conventional heat-sterilized PD fluids compared with filter-sterilized PD fluids, and was completely inhibited by aminoguanidine. In effluents, the concentration of MGO, GO, and 3-DG decreased with increasing dwell time, with a concomitant increase in AGE fluorescence. The dicarbonyl compounds 3-DG, MGO, and GO are potent promoters of AGE formation. The presence of these and possibly other dicarbonyl compounds formed during heat sterilization of glucose-based PD fluids is, to a large extent, responsible for the in vitroAGE formation by these fluids, as evidenced by the speed of AGE formation in PD fluids and the complete inhibition by aminoguanidine. Because 3-DG, MGO, and GO are rapidly cleared from PD fluids during dialysis, these compounds may contribute to the in vivo AGE formation in PD patients.

Biochemical Parameters, Nutritional Status and Efficiency of Dialysis in CAPD and CCPD Patients

Background/Aims: Several studies indicate that small solute transport is influenced by peritoneal dialysate volume and dwell time. This study focuses on the clinical impact of peritoneal dialysis modality, continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD). Methods: We studied 18 patients on CAPD and 11 on CCPD for 18 months and assessed biochemical parameters, nutritional status and efficiency of dialysis at 6-month intervals. Results: Four-hour D/P urea and creatinine ratios were similar in both CAPD and CCPD patients. However, 24-hour D/P urea and creatinine ratios were significantly higher in CAPD than in CCPD patients (0.9 ± 0.1 vs. 0.8 ± 0.2 and 0.8 ± 0.1 vs. 0.6 ± 0.2, p < 0.05 and p < 0.01, respectively). The dialysate urea nitrogen concentration was significantly different between the two groups (65 ± 14 mg/dl in CAPD, 48 ± 13 mg/dl in CCPD; p < 0.05). Total weekly Kt/V and total weekly creatinine clearance were not significantly different between CAPD and CCPD patients at 18 months (1.6 ± 0.4 vs. 1.7 ± 0.3 and 52 ± 21 vs. 50 ± 12 liters, respectively). Two-way ANOVA with a post-hoc Bonferroni-Dunn test showed serum potassium concentration was significantly lower in CCPD patients at 18 months (3.8 ± 0.5 mEq/l, p < 0.05), and significant increases in triglyceride levels in the CAPD groups by 18 months (301 ± 286 mg/dl, p < 0.05). Conclusion: This study demonstrates that the mean serum triglyceride level increases in CAPD patients over time, and the mean serum potassium concentration decreases in CCPD patients at 18 months. Dialysis adequacy and nutritional status are not significantly different between the two peritoneal dialysis modalities, CAPD and CCPD. We suggest the peritoneal dialysis prescription for CAPD or CCPD with respect to volume and frequency of exchanges be individualized to achieve adequate of therapy.

Outbreak of sterile peritonitis among continuous cycling peritoneal dialysis patients

Approximately 30,000 patients receive peritoneal dialysis in the United States. In August 1996, several dialysis centers from different states reported sterile peritonitis among CCPD patients using sterile peritoneal dialysis solution (PDS) from a single manufacturer. The manufacturer recalled 53 lots of PDS that had passed established industry guidelines and Food and Drug Administration (FDA) approved quality control tests [including endotoxin levels <0.5 endotoxin units (EU)/ml], but had pre-sterilization bacterial colony counts >1 cfu/ml. At one outpatient dialysis center, Hospital of the University of Pennsylvania (HUP), we conducted a retrospective cohort study of all CCPD patients treated during July 15 to August 30, 1996. A case-patient was defined as any HUP patient with culture-negative peritoneal fluid with a white blood cell count >100/mm3, cloudy peritoneal fluid, and/or abdominal pain. PDS and tubing were cultured for bacteria and assayed for endotoxin. Overall, 14 of 28 patients had sterile peritonitis. The only risk factor identified was exposure to > or =1 lot of recalled PDS (14 of 22 vs. 0/6, P = 0.02); the more recalled lots received, the higher the attack rate (P = 0.0001). Five of 47 PDS bags had detectable endotoxin; recalled lots were more likely to have measurable endotoxin than nonrecalled lots (5/19 vs. 0/17, P = 0.05). When case-patients resumed CCPD using PDS from non-recalled lots, no further cases were reported. Our results suggest that this outbreak was caused by intrinsic PDS contamination with endotoxin. Pre-sterilization colony counts may be an important quality control indicator for CCPD fluids in conjunction with endotoxin levels.

A Survey of Home Visits at Peritoneal Dialysis Centers in the United States

Objective To determine the frequency and characteristics of home visits in centers that provide training for peritoneal dialysis (PD). Design Mail survey sent to all dialysis centers in the United States providing home PD, using the Health Care Federal Administration (HCFA) Renal Provider list. Results Surveys were mailed to 1247 centers; 13 were undeliverable, resulting in 1234 surveys successfully delivered; 670 (54%) of those surveyed responded. Of those responding, 525 (78.4%) reported home visits were part of the care of home PD patients: 11% made a single home visit, 52% made an initial home visit with at least one followup visit, and 16% made visits only as needed. No home visits were made by 21% of responding centers. A registered nurse (RN) alone made the home visit in 61% of the centers, while a multidisciplinary team accompanied the RN in 35% of centers; 3% of visits were made by a licensed practical nurse, and 1% by the physician. Half of the visits required 0.5 -1 hour, while 41% required 1 -2 hours. Travel time was most often an hour or less one way. Staff were reimbursed for travel expenses by 90% of the centers. The 525 centers making home visits were not different than the 145 centers not making home visits in number of patients per center, number of RNs, rural or urban location, or affiliation with a university. Interpretation of the HCFA regulations concerning home visits was the most important factor influencing centers making home visits. Conclusions Home visits to continuous ambulatory PD and continuous cycling PD patients in the United States are common. Nearly 80% of centers responding to the survey include home visits in the care of their home peritoneal dialysis patients.

A Survey of Home Visits at Peritoneal Dialysis Centers in the United States

To determine the frequency and characteristics of home visits in centers that provide training for peritoneal dialysis (PD). Mail survey sent to all dialysis centers in the United States providing home PD, using the Health Care Federal Administration (HCFA) Renal Provider list. Surveys were mailed to 1247 centers; 13 were undeliverable, resulting in 1234 surveys successfully delivered; 670 (54%) of those surveyed responded. Of those responding, 525 (78.4%) reported home visits were part of the care of home PD patients: 11% made a single home visit, 52% made an initial home visit with at least one follow-up visit, and 16% made visits only as needed. No home visits were made by 21% of responding centers. A registered nurse (RN) alone made the home visit in 61% of the centers, while a multidisciplinary team accompanied the RN in 35% of centers; 3% of visits were made by a licensed practical nurse, and 1% by the physician. Half of the visits required 0.5-1 hour, while 41% required 1-2 hours. Travel time was most often an hour or less one way. Staff were reimbursed for travel expenses by 90% of the centers. The 525 centers making home visits were not different than the 145 centers not making home visits in number of patients per center, number of RNs, rural or urban location, or affiliation with a university. Interpretation of the HCFA regulations concerning home visits was the most important factor influencing centers making home visits. Home visits to continuous ambulatory PD and continuous cycling PD patients in the United States are common. Nearly 80% of centers responding to the survey include home visits in the care of their home peritoneal dialysis patients.

Reducing a peritoneal dialysis program's cost by changing from a vendor- provided to a program-provided system for general medical supplies: Significant savings in CCPD

An examination of the costs associated with outpatient chronic peritoneal dialysis prompted us to investigate the charges for general medical supplies used by patients on continuous ambulatory peritoneal dialysis (CAPD) and continuous cycling peritoneal dialysis (CCPD) in our hospital-owned, not-for-profit peritoneal dialysis program. The items used by patients to perform their dialysis exchanges and daily exit site care included 4 x 3 and 2 x 2 sterile gauze pads, antibacterial soap, masks, tape, and betadine swabsticks. The charges for these supplies when purchased from the dialysis vendor were compared with charges for the same items if purchased directly from hospital stores by the peritoneal dialysis program and then distributed to the patients. This initial analysis suggested a considerable savings if the peritoneal dialysis program provided the supplies. Based on this estimated savings, in July 1995, the peritoneal dialysis program changed from a vendor-provided to a program-provided system for general supplies used by CAPD and CCPD patients. This study examined the differences in charges expressed as $/patient-month for two periods: July 1994 to June 1995 (when all general medical supplies were provided by dialysis vendors directly to the CAPD and CCPD patients) and July 1995 to May 1996 (when the peritoneal dialysis program purchased general medical supplies from hospital stores and distributed these supplies directly to the patients). The median vendor charges for CAPD patients (n = 21 during 1994 to 1995 and n = 18 during 1995 to 1996) were not significantly different between the two periods. In fact, the charges were slightly higher during the 1995 to 1996 period ($1,264/patient-month v $1,193/patient-month during the vendor-provided period of July 1994 to June 1995, P = 0.67). The median vendor charges for patients on CCPD were significantly lower during the 1995 to 1996 period when the peritoneal dialysis program provided the general medical supplies used for CCPD ($1,110/patient-month v $1,389/patient- month during 1994 to 1995, P = 0.003). There were 30 CCPD patients during the 1994 to 1995 period and 27 patients on CCPD during 1995 to 1996. The total charges for CAPD and CCPD patients combined included dialysis vendor charges (dialysis solution, tubing, cycler rental) and charges from hospital stores. These total charges were lower in the July 1995 to May 1996 period when general medical supplies were purchased directly from hospital stores rather than from the dialysis vendors: $1,201/patient-month versus $1,360/patient-month (P = 0.03). The median hospital store charges rose slightly during the July 1995 to May 1996 period when supplies were purchased by the peritoneal dialysis program from hospital stores ($31/patient-month v $21/patient-month, P = 0.37, during the July 1994 to June 1995 period when general medical supplies were purchased directly from dialysis vendors). However, despite the rise in charges from hospital stores, an overall savings of $149/patient-month was achieved when the peritoneal dialysis program purchased and provided general medical supplies used by the peritoneal dialysis patients. This $149/patient-month equals $1,788 savings per dialysis year for each patient on peritoneal dialysis for that year. Significant savings in the cost of a chronic peritoneal dialysis program may therefore occur if less expensive sources for the general medical supplies used by CAPD and, especially, CCPD patients are found. (Am J Kidney Dis 1998 Apr;31(4):662-5)