Diabetic Peritoneal Dialysis Patients Research Articles

Fasting blood glucose level and risk of all-cause and cause-specific mortality in peritoneal dialysis patients.

Glycemic control is crucial in peritoneal dialysis (PD) patients with diabetes. Although fasting blood glucose (FBG) is the most commonly used index to measure blood glucose levels, there is currently no evidence supporting the association between FBG level and mortality risk in PD patients. A total of 3548 diabetic PD patients between 2002 and 2018 were enrolled from the National Health Insurance Service database of Korea. We investigated the association between FBG levels and the risk of all-cause and cause-specific mortality. Patients with FBG levels 80-99 mg/dL exhibited the highest survival rates, whereas those with FBG levels ≥180 mg/dL had the lowest survival rates. Compared with FBG levels 80-99 mg/dL, the adjusted hazard ratios and 95% confidence interval for all-cause mortality significantly increased as follows: 1.02 (0.87-1.21), 1.41 (1.17-1.70), 1.44 (1.18-2.75), and 2.05 (1.73-2.42) for patients with FBG 100-124 mg/dL, FBG 125-149 mg/dL, FBG 150-179 mg/dL, and FBG ≥180 mg/dL, respectively. The risk for all-cause mortality also showed an increasing pattern in patients with FBG levels <80 mg/L. The risk of cardiovascular death significantly increased as FBG levels exceeded 125 mg/dL. However, the risk of infection-related and malignancy-related deaths did not show a significant increase with increasing FBG levels. There was an increase in the risk of all-cause mortality as FBG levels exceeded 125 mg/dL in PD patients with diabetes, and the risk of cardiovascular death showed a strong correlation with FBG levels compared with other causes of death.

SGLT-2 inhibitors in chronic peritoneal dialysis patients: a follow-up study

BackgroundSodium-glucose transporter-2 inhibitors (SGLT-2i) are recommended for use in patients with type 2 diabetes comorbid atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. Limited reports are currently available for their use in dialysis patients. In an observational, retrospective follow-up study, we reported the clinical characteristics of chronic peritoneal dialysis (PD) patients on SGLT-2i.MethodsWe enrolled 50 diabetic chronic PD patients, and 11 continued SGLT-2i after PD treatment. We reported the patients’ ultrafiltration, HbA1c, urinary tract infection episodes, and venous CO2 during follow-up and compared the differences in these factors between patients with and without SGLT-2i.ResultsThe mean age of the patients was 65 ± 15 years, and 16 (32%) patients were female. The age, gender, heart failure, and primary kidney disease were not different between patients with and without SGLT-2i at enrollment. In an average of 31 months follow-up, patients with SGLT-2i had higher ultrafiltration (1322 ± 200 ml/day vs. 985 ± 415 ml/day, p = 0.013), hemoglobin (11.2 ± 1.7 vs. 10.2 ± 1.7 g/dl), white blood cell count (9.2 ± 3.7 vs. 7.4 ± 2.1 109/L), and a lower venous CO2 (p = 0.036). The urine amount, the overall survival, the technical survival, and the chance of UTI were not different between patients with and without SGLT2i.ConclusionSGLT-2i may increase ultrafiltration volume and hemoglobin levels in chronic PD patients. SGLT-2i did not increase urinary tract infection but was linked to subclinical metabolic acidosis.What was knownThe effect of SGLT-2i in chronic PD patients is not clear?This study addsSGLT-2i is associated with increased ultrafiltration, hemoglobin, white blood cell counts, and a decreased CO2 in PD patient.Potential impactSGLT-2i may increase ultrafiltration in PD patients.

Status and trends in epidemiologic characteristics of diabetic end-stage renal disease: an analysis of the 2021 Korean Renal Data System.

Korean Renal Data System (KORDS) is a nationwide end-stage renal disease (ESRD) registry database operated by the Korean Society of Nephrology (KSN). Diabetes mellitus is currently the leading cause of ESRD in Korea; this article provides an update on the trends and characteristics of diabetic ESRD patients. The KORDS Committee of KSN collects data on dialysis centers and patients through an online registry program. Here, we analyzed the status and trends in characteristics of diabetic chronic kidney disease stage 5D (CKD 5D) patients using data from 2001 to 2021. In 2021, the dialysis adequacy of hemodialysis (HD) was lower in diabetic CKD 5D patients than in nondiabetic CKD 5D patients, while that of peritoneal dialysis (PD) was similar. Diabetic CKD 5D patients had a higher proportion of cardiac and vascular diseases and were more frequently admitted to hospitals than nondiabetic CKD 5D patients, and the leading cause of death was cardiac disease. From 2001 to 2020, diabetic CKD 5D patients had a higher mortality rate than nondiabetic CKD 5D patients, but in 2021 this trend was reversed. Diabetic PD patients had the highest mortality rate over 20 years. The mortality rate of diabetic HD patients was higher than that of nondiabetic HD patients until 2019 but became lower starting in 2020. There was a decreasing trend in mortality rate in diabetic CKD 5D patients, but cardiac and vascular diseases were still prevalent in diabetic CKD 5D patients with frequent admissions to hospitals. More specialized care is needed to improve the clinical outcomes of diabetic CKD 5D patients.

Visit-to-visit HbA1c variability is associated with poor prognosis in peritoneal dialysis patients with type 2 diabetes mellitus

BackgroundThe prognosis of diabetic peritoneal dialysis patients is poor. HbA1c serves as a crucial indicator for monitoring blood glucose control in patients with diabetes. Nevertheless, the relationship between visit-to-visit HbA1c variability and prognosis in peritoneal dialysis with diabetes remains unclear.MethodsAll participants were categorized into 3 groups based on the HbA1c variability score (HVS), which is the frequency of 0.5% (5.5 mmol/mol) alter in visit-to-visit HbA1c values. Then, the hazard ratio to HVS with all-cause mortality was analyzed using the Cox hazard model, followed by the Fine-Gray competing risk model for major adverse cardiovascular events. Subgroup and sensitivity analysis were conducted to ascertain the robustness of the findings.ResultsEight hundred twenty patients with type 2 diabetes were finally enrolled in this study from 2,855 participants with a mean age of 56.9 ± 14.6 years and a median follow-up time of 44 months [IQR: 27–70], death occurred in 496 (60.2%) individuals. Compared with the lowest category (HVS < 1/3) after being adjusted by potential confounding factors, the hazard ratio for all-cause mortality was 4.59 (3.74–5.64) and the sub-distribution hazard ratio for major adverse cardiovascular events was 1.91 (1.46–2.51) of the highest category (HVS ≥ 2/3). Subgroup interaction and sensitivity analysis, including the adjustment for variables such as time-weighted average HbA1c, HbA1c measurement times and expansion, confirmed the reliability of the results.ConclusionThe HVS is related to the risk of poor prognosis in peritoneal dialysis with type 2 diabetes mellitus, independently of clinical multiple variables, and is a novel indicator with clinical guidance.

Sex Modulates Cardiovascular Effects of Icodextrin-Based Peritoneal Dialysis Solutions.

Background/Aims: Some previous observations have noted that after six months of peritoneal dialysis (PD) treatment with icodextrin solutions, blood pressure (BP) and NT-proBNP tend to return to baseline values. This may be due to accumulation of icodextrin products that exert a colloid osmotic effect, which drives water into the bloodstream, causing the rise in blood pressure. Since icodextrin is metabolized by α-Amylase and its gene copies are lower in females than in males, we hypothesized icodextrin metabolites reach higher concentrations in females and that cardiovascular effects of icodextrin are influenced by sex. Methods: Secondary analysis of a RCT comparing factors influencing fluid balance control in diabetic PD patients with high or high average peritoneal transport receiving icodextrin (n = 30) or glucose (n = 29) PD solutions. Serum icodextrin metabolites, osmolality, body composition and Inferior Vena Cava (IVC) diameter were measured at baseline, and at 6 and 12 months of follow-up. Results: After six months of treatment, icodextrin metabolites showed higher levels in females than in males, particularly G5-7 and >G7, serum osmolality was lower in females. In spite of reduction in total and extracellular body water, ultrafiltration (UF) was lower and IVC diameter and BP increased in females, suggesting increment of blood volume. Conclusion: Females undergoing PD present with higher levels of icodextrin metabolites in serum that may exert an increased colloid-osmotic pressure followed by less UF volumes and increment in blood volume and blood pressure. Whether this could be due to the lesser number of α-Amylase gene copies described in diabetic females deserves further investigation.

The impact of multidisciplinary pre-dialysis care on the outcomes of incident peritoneal dialysis patients

BackgroundThis study aims to evaluate the impact of multidisciplinary pre-dialysis care (MDPC) on the risks of peritonitis, technique failure and mortality in peritoneal dialysis (PD) patients.MethodsIncident end-stage kidney disease patients who received peritoneal dialysis (PD) for more than 90 days were recruited in this study from 1 January 1, 2007 to December 31, 2018. Patients were classified into two groups, the MDPC group and the control group, that received the usual care by nephrologists. Risks of the first episode of peritonitis, technique failure and mortality were compared between the two groups.ResultsThere were 126 patients under the usual care and 546 patients under the MDPC. Patients in the MDPC group initiated dialysis earlier than those in the non-MDPC group. There was no significant difference between these two groups in time to the first episode of peritonitis. Compared to the non-MDPC group, the MDPC group was at similar risks of technique failure (adjusted HR = 0.85, 95% CI = 0.64–1.15) and mortality (adjusted HR = 0.66, 95% CI = 0.42–1.02). Among patients with diabetes, the risk of mortality was significantly reduced in the MDPC group with an adjusted HR of 0.45 (95% CI = 0.25–0.80).ConclusionsThere was no significant difference in time to develop the first episode of peritonitis, and risks of technique failure and mortality between these two groups. Diabetic PD patients under MDPC had a lower risk of mortality than those under the usual care.

Propensity-matched comparison of mortality between peritoneal dialysis and hemodialysis in patients with type 2 diabetes.

The optimal choice of dialysis modality for diabetic patients remains controversial. This study aimed to compare mortality between peritoneal dialysis (PD) and hemodialysis (HD) in end-stage renal disease (ESRD) patients with type 2 diabetes (T2D). Our observational, longitudinal cohort consisted of all incident ESRD patients with T2D who received either PD or HD in our center from January 2012 to December 2017 and were followed until December 2019. Propensity scores were used to select a 1:1 matched cohort. Mortality was compared between dialysis modalities using Kaplan-Meier survival analysis, and risk factors for mortality were estimated using multivariate Cox regression analyses. The median follow-up times were 35.5months in the PD group (n = 134) and 41.6months in the HD group (n = 134, p = 0.0381). The 1-, 2-, 3-, 5-, and 7-year patient survival rates were 98%, 91%, 77%, 61%, and 35% for diabetic PD patients and 96%, 88%, 81%, 60%, and 57% for diabetic HD patients. Kaplan-Meier survival analysis showed that overall mortality did not significantly differ between modalities (log-rank = 0.9473, p = 0.6575). Using a multivariate Cox regression model, advanced age and increased cholesterol at the initiation of PD treatment were independent risk factors associated with mortality, whereas under HD therapy, the risk factors associated with mortality were lower BMI and higher HbA1c. These results suggest that in patients with T2D, mortality is comparable between PD and HD irrespectiveof whether there arethe first 2yearsorover the 2-year period, and that different mortality predictor patterns exist between patients treated with PD versus HD.

Impact of assistance on peritonitis due to breach in aseptic procedure in diabetic patients: A cohort study with the RDPLF data.

Diabetic patients often have physical impairment that could lead to manipulation errors in peritoneal dialysis (PD) and touch contamination. Nurse assistance in diabetic PD patients is known to help prevent peritonitis. We made the hypothesis that this lower risk of peritonitis was observed thanks to prevention of breach in aseptic procedure. We evaluated the impact of nurse-assisted PD on specific causes of peritonitis, especially on peritonitis due to a breach in aseptic procedure. This was a retrospective observational study of the data from the French Language Peritoneal Dialysis Registry. All diabetic patients older than age 18 years starting PD in France between 1 January 2012 and 31 December 2015 were included in the study. The event of interest was the first peritonitis event due to a breach in aseptic procedure. Death, kidney transplantation and peritonitis due to another mechanism were considered as competing events. We examined the association of the covariates with all the possible outcomes using a subdistribution hazard model developed for survival analysis in the presence of competing risks. Four thousand one hundred one diabetic patients incident in PD were included in the study. At least one peritonitis event occurred in 1611 patients over the study period. A breach in aseptic procedure was reported in 441/1611 cases (27.3%): 209/575 (36.3%) in the self-care PD group, 56/217 (25.8%) in the family-assisted PD group and 176/819 (21.5%) in the nurse-assisted PD group. Both nurse and family assistance were associated with a lower risk of peritonitis due to breach in aseptic procedure in bivariate analysis. After adjustment on age, modified Charlson index, sex and diabetic nephropathy, patients treated by nurse-assisted PD (subdistribution hazard ratio (sd-HR) 0.52, 95% confidence interval (CI) 0.40-0.67) and those treated by family-assisted PD (sd-HR 0.70, 95% CI 0.51-0.95) had a lower likelihood of peritonitis due to a connection error compared to self-care PD in multivariate analysis. The modality of assistance was not associated with other causes of peritonitis in the multivariate analysis. While both nurse-assisted PD and family-assisted PD were associated with lower risk of peritonitis due to a breach in aseptic procedure compared to self-care PD in our study, the protective effect was greater with nurse assistance.

The change in the prevalence of obesity and new-onset diabetes in Chinese peritoneal dialysis patients over 25 years.

ABSTRACTBackgroundThe global prevalence of both obesity and end-stage kidney diseases (ESKDs) has increased in recent decades. Given the complicated interaction between obesity and ESKD, we examined the change in the prevalence of obesity in incident Chinese peritoneal dialysis (PD) patients over the past 25 years.MethodsWe reviewed the anthropometric measures of incident PD patients in a single Hong Kong center from 1995 to 2019. The results are reported in five 5-year periods. Patients with and without diabetes were analyzed separately, and the incidence of new-onset diabetes after PD was explored.ResultsWe reviewed 1681 patients. Their mean age was 58.4 ± 12.5 years; 931 patients (55.4%) had pre-existing diabetes. From 1995–99 to 2015–19, the prevalence of obesity or overweight at the initiation of PD increased progressively for every 5-year period (from 21.9% to 26.2, 37.9, 42.7 and 47.3%, P < 0.001 for linearity). The increase in the prevalence of obesity or overweight was more pronounced in diabetic patients (from 33.7% to 59.6%) than non-diabetic ones (from 13.2% to 32.3%). Among nondiabetics patients, the incidence of new-onset diabetes after started on PD showed an insignificant rising trend during that period (from 18.0, 19.7, 17.8 and 22.4% to 23.3%, P = 0.106). The incidence of new-onset impaired fasting glucose or diabetes was significantly higher in obese or overweight patients than the others (56.9% versus 51.4%, P < 0.001).ConclusionsThe prevalence of obesity has increased substantially in both diabetic and nondiabetic new PD patients in Hong Kong over the past 25 years. The incidence of new-onset diabetes was significantly higher in new PD patients with pre-existing obesity or overweight than those without obesity. The prognostic implication and impacts on the healthcare system deserve further studies.

POS-548 THE INCIDENTS OF BASELINE OBESITY AND ACQUIRED GLUCOSE INTOLERANCE IN NEW CHINESE PERITONEAL DIALYSIS PATIENTS

Acquired glucose intolerance is common and adversely affects the prognosis of new peritoneal dialysis (PD) patients. Since the prevalence of obesity increased in the general population worldwide over the past decades, we examined the change in the incidence of obesity and new-onset glucose intolerance in incident Chinese PD patients over the past 25 years. We reviewed the body built and fasting plasma glucose of incident PD patients in a single Hong Kong center from 1995 to 2019. The results are reported in five 5-year periods. We reviewed 1681 incident PD patients. Their mean age was 58.4 ± 12.5 years; 931 patients (55.4%) had pre-existing diabetes. From 1995-1999 to 2015-2019, the prevalence of obesity or overweight at the initiation of PD increased progressively for every 5-year period (from 21.9%, 26.2%, 37.9%, 42.7%, to 47.3%, p <0.001 for linearity). The increase in the prevalence of obesity or overweight was more pronounced in diabetic patients (33.7% to 59.6%) than non-diabetic ones (13.2% to 32.3%). Among non-diabetics, the incidence of new-onset impaired fasting glucose after initiation of PD gradually increased from 1995 to 2019 (from 29.2%, 35.2%, 32.2%, 33.6%, to 34.4% for every 5-year period), and the incidence of new-onset diabetes similarly increased during that period (from 18%, 19.7%, 17.8%, 22.4%, to 23.3%). The incidence of acquired impaired fasting glucose or diabetes was significantly higher in obese or overweight patients than those without overweight (56.9% vs. 51.4%, p <0.001), but the incidence remained substantial in the latter group. The incidents of obesity and overweight increase significantly in both diabetic and non-diabetic new PD patients in Hong Kong over the past 25 years. The incident of new-onset glucose intolerance or diabetes also increased during this period in non-diabetic PD patients, especially amongst obese or overweight ones. The prognostic implication and impacts on the healthcare system deserve further studies.

Dipeptidyl peptidase 4 promotes peritoneal fibrosis and its inhibitions prevent failure of peritoneal dialysis

Peritoneal dialysis (PD) possesses multiple advantages for end stage renal disease. However, long-term PD triggers peritoneal fibrosis (PF). From the nationwide analysis of diabetic PD patients (n = 19,828), we identified the incidence of PD failure was significantly lower in diabetic patients treated with dipeptidyl peptidase 4 (DPP4) inhibitors. Experimental study further showed high concentration of glucose remarkably enhanced DPP4 to promote epithelial-mesenchymal transition (EMT) in the mesothelial cells. In chlorhexidine gluconate (CG)-induced PF model of rats, DPP4 expression was enriched at thickening peritoneum. Moreover, as to CG-induced PF model, DPP4 deficiency (F344/DuCrlCrlj strain), sitagliptin and exendin-4 treatments significantly inhibited DPP4 to reverse the EMT process, angiogenesis, oxidative stress, and inflammation, resulting in the protection from PF, preservation of peritoneum and the corresponding functional integrity. Furthermore, DPP4 activity was significantly correlated with peritoneal dysfunction. Taken together, DPP4 caused peritoneal dysfunction/PF, whereas inhibition of DPP4 protected the PD patients against PD failure.

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

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

Comparison of peritoneal dialysis with hemodialysis on survival of diabetic patients with end-stage kidney disease: a meta-analysis of cohort studies

Aim: Renal replacement therapy was primary treatment for end stage kidney (ESRD) patients. Numbers of studies comparing peritoneal dialysis (PD) and hemodialysis (HD) yielded inconsistent results. The aim of this study was to assess the mortality risk between diabetic PD patients and those in HD.Methods: We included cohort studies comparing the risk of death among diabetic ESRD patients who receiving peritoneal dialysis or hemodialysis by searching Medline and Embase. Overall estimates were calculated using the random-effects model.Results: Seventeen studies were included in the meta-analyses. Mortality comparison between PD and HD in the diabetic ESRD patients showed PD significantly increased mortality rate (hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.10–1.30; I2 = 89.1%). The overall HR using an intention-to-treat analysis was 1.23 with 95% CI (1.13 to 1.34). Meta-regression demonstrated PD patients from Asian country were associated with increase in mortality risk (coefficient = 0.270, SE = 0.112, p = .033).Limitation: The high heterogeneity in our meta-analyses undermined the robustness of the findings.Conclusion: ESRD patients with diabetes may benefit more from HD than PD.

Long-term clinical outcomes of peritoneal dialysis patients: 10-year experience of a single unit from Tunisia.

Published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of PD in Tunisia is poor. The purpose of this study is to report long-term clinical outcomes of PD patients through a 10-year experience at a single unit. This is a retrospective review of the medical records of 182 PD patients who were followed up from January 2006 to June 2016. All patients were followed till death, renal transplant, switch over to hemodialysis (HD) or the end of the study in June 2016. The mean age of the incident patients was 43.93 ± 16.95 years. Nineteen (10.4%) were aged >65 years and 59.3% were male. The average duration of follow-up was 27.75 ± 26.18 months. The mean duration of PD treatment was 27.75 ± 26.18 months. There were 186 episodes of peritonitis that occurred over the total study period (54 episodes during the 1st year). The overall incidence of peritonitis during the 10-year study period was 1 per 27.25 patient months. Mechanical complications were noted in 31.2% of cases. Thirty- two (17.6%) patients had catheter displacement. Only 26 cases of hemoperitoneum (14.3%) were recorded. Death occurred in 23.1% of cases. Twenty-two patients (27.5%) were transplanted; 56 patients (70%) were transferred to HD, one patient had renal recovery and one case had voluntarily interrupted PD. In Kaplan-Meier curves of residual renal function (RRF) loss, there was a significant difference between peritonitis group and peritonitis-free group (P = 0.01). Technique and patient survival were associated with diabetes with a significant difference. The main cause of technique failure was peritonitis (61.4%). Moreover, the main repertoried causes of death were cardiovascular and septic causes. The mortality of diabetic and elderly PD patients was higher than mortality in nondiabetic and nonelderly groups, respectively, in our study. Peritonitis was associated with loss of RRF and technique failure.

Clinical outcome of incident peritoneal dialysis patients with diabetic kidney disease.

Although peritoneal dialysis (PD) is becoming more widespread, PD among diabetic patients carries some concerns, such as worsened glycemic control due to constant exposure to glucose and operational errors due to diabetic complications. However, several technical advances could overcome these disadvantages. We, therefore, aimed to compare technical and patient survival between diabetic and non-diabetic PD patients. We conducted a historical cohort study of 103 patients (mean age, 57 ± 16 years; 75 males, 32 diabetic patients) who started PD between January 2011 and January 2016. Kaplan-Meier survival analysis was used to compare technical and patient survivals between diabetic and non-diabetic patients. Multivariate Cox regression analysis was used to estimate the effects of the presence of diabetes on these outcomes. Technical and patient survivals did not differ significantly between groups (P = 0.62, P = 0.34, respectively). In addition, presence of diabetes affected neither technical nor patient survival in multivariate analysis (hazard ratio [HR], 1.31; 95% confidence interval [CI], 0.58-2.82 and HR 0.80; 95% CI 0.22-2.68, respectively). Technical and patient survivals of diabetic PD patients were not inferior to those of non-diabetic PD patients. These results suggest that no hesitation is warranted in initiating PD for diabetic patients with end-stage renal disease.

Icodextrin reduces the risk of congestive heart failure in peritoneal dialysis patients.

Icodextrin can enhance ultrafiltration and consequently improve fluid balance and can control blood pressure and reduce left ventricular mass for peritoneal dialysis (PD) patients. This study investigated whether icodextrin use could reduce the risk of congestive heart failure (CHF) for PD patients. From the Taiwan National Health Insurance database, we identified 5462 newly diagnosed end-stage renal disease patients undergoing PD from 2005 to 2010. Incidence rates and hazard ratio of CHF were estimated for patients with and without icodextrin treatment by the end of 2011. Among PD patients, icodextrin users had an overall 26% lower incidence of CHF than non-users (13.7 vs 18.6 per 1000 person-years). Relatively, the adjusted hazard ratio was 0.67 (95% CI=0.52-0.87) for users compared with non-users. Among PD patients with diabetes, the incident CHF in icodextrin users was 37.5% lower than that in non-users (17.8 vs 28.5 per 1000 person-years). Among PD patients without diabetes, the incident CHF in icodextrin users was 30.4% lower than that in non-users (11.0 vs 15.8 per 1000 person-years). Icodextrin solution could reduce the risk of new-onset CHF, particularly effective when diabetic PD patients use it.

Comparison of survival between hemodialysis and peritoneal dialysis patients with end-stage renal disease in the era of icodextrin treatment

BackgroundIcodextrin could reduce the risk of technique failure and improve patient survival in peritoneal dialysis (PD) patients. This study compared the survival between incident hemodialysis (HD) and PD patients, with and without diabetes, in the era of icodextrin treatment. MethodsFrom the Taiwan health insurance database, 53,103 incident end-stage renal disease patients undergoing dialysis were identified from 2005 to 2010. The mortality risks among HD and PD patients with or without icodextrin treatment were compared. The follow-up period started from the date of dialysis initiation to December 31, 2011. The competing-risks regression model was used to estimate the subhazard ratio (SHR) of death with considering renal transplantation as a competing event. ResultsCompared with the corresponding HD patients, mortality risks were higher in diabetic PD patients with icodextrin treatment (Bonferroni adjusted SHR=1.16, 98.3% CI=1.04–1.30) and without the treatment (Bonferroni adjusted SHR=1.35, 98.3% CI=1.16–1.57), particularly for elderly patients. Mortality risks for patients without diabetes were not different among the three cohorts. The time-dependent competing-risks model showed that PD patients with icodextrin treatment exhibited a reduced risk of death for diabetic patients, compared with those without icodextrin treatment (adjusted SHR=0.84, 95% CI=0.72–0.97). ConclusionsIcodextrin could attenuate the survival disadvantage for PD relative to HD in diabetic patients, particularly for the elderly patients.

An association of cognitive impairment with diabetes and retinopathy in end stage renal disease patients under peritoneal dialysis.

BackgroundDiabetes and retinopathy have been considered as risk factors of cognitive impairment (CI) in previous studies. We investigated both of these two factors and their relationship with global and specific cognitive functions in end stage renal disease patients under peritoneal dialysis (PD).MethodsIn this multicenter cross-sectional study, 424 clinically stable patients were enrolled from 5 PD units, who performed PD for at least three months and completed fundoscopy examination if they had diabetes. Global cognitive function was measured using the Modified Mini-Mental State Examination (3MS), Trail-Making Test forms A and B for executive function, and subtests of the Battery for the Assessment of Neuropsychological Status for immediate and delayed memory, visuospatial skills, and language ability.ResultsPD Patients with DM and Retinopathy had significantly higher prevalence of CI, executive dysfunction, impaired immediate memory and visuospatial skill, compared with patients in non-DM group. By multivariate logistic regression analyses, DM and retinopathy rather than DM only were significantly associated with increased risk for CI, executive dysfunction, impaired immediate memory and visuospatial skill, odds ratios(ORs) and 95% confidence intervals were 2.09[1.11,3.92], 2.89[1.55,5.37], 2.16 [1.15,4.06] and 2.37[1.32,4.22], respectively (all P < 0.05).ConclusionsDiabetic PD patients with retinopathy were at two times risk for overall cognitive impairment, executive dysfunction, impaired immediate memory and visuospatial skill as compared to non-diabetic PD patients.

Peritoneal Water Transport Characteristics of Diabetic Patients Undergoing Peritoneal Dialysis: A Longitudinal Study

Background: Volume overload is frequent in diabetics undergoing peritoneal dialysis (PD), and may play a significant role in the excess mortality observed in these patients. The characteristics of peritoneal water transport in this population have not been studied sufficiently. Method: Following a prospective, single-center design we made cross-sectional and longitudinal comparisons of peritoneal water transport in 2 relatively large samples of diabetic and nondiabetic PD patients. We used 3.86/4.25% glucose-based peritoneal equilibration tests (PET) with complete drainage at 60 min, for these purposes. Main Results: We scrutinized 59 diabetic and 120 nondiabetic PD patients. Both samples showed relatively similar characteristics, although diabetics were significantly more overhydrated than nondiabetics. The baseline PET disclosed lower ultrafiltration (mean 439 mL diabetics vs. 532 mL nondiabetics, p = 0.033) and sodium removal (41 vs. 53 m<smlcap>M</smlcap>, p = 0.014) rates in diabetics. One hundred and nine patients (36 diabetics) underwent a second PET after 12 months, and 45 (14 diabetics) underwent a third one after 24 months. Longitudinal analyses disclosed an essential stability of water transport in both groups, although nondiabetic patients showed a trend where an increase in free water transport (p = 0.033) was observed, which was not the case in diabetics. Conclusions: Diabetic patients undergoing PD present lower capacities of ultrafiltration and sodium removal than their nondiabetic counterparts. Longitudinal analyses disclose an essential stability of water transport capacities, both in diabetics and nondiabetics. The clinical significance of these differences deserves further analysis.

The Role of Residual Renal Function in Diabetic Peritoneal Dialysis Patients

Peritoneal dialysis (PD) is a treatment method used in home renal replacement therapy. Recently, there has been greater focus on residual renal function (RRF) in PD patients. RRF in PD patients is clinically significant, as it contributes to survival of the treatment, as well as patient mortality rates. Not only does decreased RRF cause poor management of water removal, but also increases risk of mortality as well as PD withdrawal due to over hydration. Diabetic patients are at higher risk of mortality/comorbidities and loss of RRF than patients with other diseases. Loss of RRF is the main cause of over hydration, poor quality of life (QOL), withdrawal of PD, and high mortality rate in dialysis patients; therefore, it is clinically important to maintain RRF. Control of blood pressure, inhibition of the renin-angiotensin system, decreased proteinuria, dietary intervention, avoidance of nephrotoxins, and glucose control should be considered for maintaining RRF in dialysis patients. Additionally, sarcopenia and frailty are issues of significant importance, especially in patients with end-stage renal disease (ESRD). As metabolic acidosis can be a complication of ESRD, anemia, uremia, and appetite loss are side effects; loss of appetite and inflammation are also associated with mortality. To ensure good QOL, PD survival, and low mortality risk, it is imperative to maintain RRF. Aside from the use of icodextrin or large amounts of diuretics, tolvaptan—often used at initiation of PD in patients with over hydration-may also be beneficial in maintaining RRF. RRF that is positively maintained aids in enhancing the appetite and improving malnutrition and inflammation, both of which contribute to loss of RRF. Moreover, enhanced appetite may improve QOL and prevent the possibility of sarcopenia and frailty in PD patients. In hemodialysis patients, tolvaptan also may be useful in the preservation of RRF and decreased mortality rate, as well as improved QOL.