Duration Of Peritoneal Dialysis Treatment Research Articles

PATIENT TRANSFER FROM HEMODIALYSIS TO PERITONEAL DIALYSIS: A SINGLE CENTER EXPERIENCE

INTRODUCTION Peritoneal dialysis and hemodialysis are complementary ways of treating end-stage renal failure. Changing the dialysis modality from hemodialysis to peritoneal dialysis is a rare and poorly studied phenomenon. MATERIALS AND METHODS Retrospective cohort study conducted on the population of adult patients with end-stage chronic renal failure who were treated at the Nephrology Clinic of the Clinical Center of the University of Sarajevo in the period from 2006 to 2023. A total of 109 adult patients, whose medical documentation was complete and who were in the peritoneal dialysis program at the Nephrology Clinic of the Clinical Center of the University of Sarajevo during the observed period, were included in this study. One group started the treatment with peritoneal dialysis, and the other with hemodialysis. Demographic data were collected for each patient: age, gender, underlying kidney disease, comorbidities (heart disease and diabetes), duration of treatment modality, data on modality change, complications and treatment outcomes. Data from physical and electronic patient histories were used. RESULTS Total of 109 adult patients were included in this study. They are divided into two groups. Group 1 (n=99) in which peritoneal dialysis was the first treatment modality and Group 2 (n=10) in which haemodialysis was the first treatment modality, but in which patients, after a certain time, were transferred to peritoneal dialysis. The median age of patients in Group 1 was 60 (-/-14.07) years and 54 (-/+12.23) years for Group 2. Within Group 1 the most common cause of terminal renal failure was diabetic nephropathy (n=40, 40.4%) and nephroangiosclerosis (n=24, 24.24%). The mean age of onset of peritoneal dialysis was 60 (-/-14.07) years, while the mean age of cessation of peritoneal dialysis was 63 (±13.69) years. The average duration of peritoneal dialysis treatment was 38.36(±34.14) months. During the stay at peritoneal dialysis, death was recorded in 63 patients (62.38%). The number of patients who replaced peritoneal dialysis treatment with hemodialysis was 26. The most common reason for switching to haemodialysis was insufficiency of peritoneal dialysis (n=13, 14%). After switching to haemodialysis, the average length of staying on it was 10.22 months. The reason for discontinuation of haemodialysis was death (n=17, ) or transplantation (n=1, 3.7%). Kaplan-Meier test shown worse outcome in patients with haemodialyis first than peritoneal dialysis first. CONCLUSION Changing the dialysis modality carries with it a high risk of mortality, especially in the first month. Changing the way of active treatment with dialysis speaks in favor of severe comorbidities.

Dialysis Duration and Glucose Exposure Amount Do Not Increase Mortality Risk in Peritoneal Dialysis Patients: A Population-Based Cohort Study From 2004 to 2012.

BackgroundAlthough the bio-incompatibility of glucose-based peritoneal dialysis (PD) solution is well documented, it is used worldwide. How PD duration and the amount of dialyzate glucose exposure affect survival in patients with end-stage renal disease remain inconclusive due to improper study designs in the extant literature.MethodsAll incident patients with PD from 2004 to 2007 who were older than 18 years in Taiwan were included. Patients were censored when they received a transplant or at the end of 2012. Glucose exposure through PD solution was calculated by the mean glucose contained per liter when receiving PD. For those who had already shifted to hemodialysis (HD) and survived longer than 2, 3, and 4 years (the index dates), the cause-specific Cox regression model was used to make the survival comparison by PD duration and mean glucose concentration in these three cohorts, respectively. The model was adjusted by demographics, case-mix, time cohort (2004–2005 vs. 2006–2007), peritonitis episode (none vs. ≥once), and mean PD solution glucose exposure (tertile).ResultsA total of 3,226 patients were included, with a mean age of 53.4 ± 15.2 years, 44.6% being male, and 34.2% having diabetes mellitus. The 1, 2, 3, and 4-year survival rates were 94, 87, 80, and 74%, while technical survival rates were 86, 70, 56, and 45%, respectively. The overall transplant events were 309 (9.6%) only. There were 389, 495, and 553 incident patients with PD shifting to HD included in 2-, 3-, and 4-year cohort, respectively. The population with moderate glucose concentration exposure had the highest mortality, and the high glucose concentration exposure had non-significant lower mortality in each cohort. In various fixed time-window cohorts, the duration of PD treatment did not increase mortality risk after adjustments. In addition, glucose exposure did not affect the mortality rate.ConclusionFor incident PD patients with PD duration no longer than 4 years, neither PD duration nor glucose exposure amount increases the long-term mortality risk.

Changes in aortic pulse wave velocity in peritoneal dialysis do not mirror changes in extracellular water measured by bioimpedance.

Pulse wave velocity is a measurement of arterial stiffness and associated with increased cardiovascular mortality. Previous reports in peritoneal dialysis have linked increased pulse wave velocity with an expansion in extracellular water. As cardiovascular mortality is increased in peritoneal dialysis patient, we wished to determine whether changes in pulse wave velocity mirrored changes in extracellular water. We repeated aortic pulse wave velocity and bioimpedance-derived extracellular water measurements in peritoneal dialysis patients attending for assessment of peritoneal membrane function. Sixty-six patients, 41 males (62.1%), mean age of 66.2 ± 13.9 years, median duration of peritoneal dialysis treatment (14.3 (3.1-31.9) months) had repeated measurement 6.4 (5.8-10.2) months apart, with no significant change in aortic pulse wave velocity (10.1 ± 3.2 to 9.9 ± 2.8 m/s). In univariate analysis, the initial aortic pulse wave velocity was associated with extracellular water (r = 0.26, p = 0.034) and serum N-terminal pro brain-type natriuretic peptide (r = 0.25, p = 0.04), and on follow-up, aortic pulse wave velocity with N-terminal pro brain-type natriuretic peptide (r = 0.31, p = 0.01). Aortic pulse wave velocity increased in 50% of patients, and these patients had greater serum C-reactive protein 3(2-10) versus 2(1-4) mg/L, and ferritin (778(444-1099) versus 585(313-811), p < 0.05), but there were no differences in either absolute or adjusted extracellular water. Both log C-reactive protein (odds ratio 4.7 (95% confidence limits 1.3-17.1), p = 0.019) and prescription of calcium channel blockers (odds ratio 4.9 (95% confidence limits 1.2-19.1), p = 0.024) were independently associated with an increase in aortic pulse wave velocity. We did not find an independent association between a change in aortic pulse wave velocity and extracellular water, suggesting that changes in aortic stiffness in peritoneal dialysis patients are more complex than simply following changes in extracellular water.

Relationship between plasminogen activator inhibitor-1 gene alterations and fibrosis in peritoneal dialysis patients.

Peritoneal fibrosis (PF) is a pathological change that occurs mostly long-term peritoneal dialysis (PD) patients, as a result of triggering the inflammatory response. Plasminogen activator inhibitor-1 (PAI-1) is an important molecule featured in the development of fibrosis. It has been shown in literature that PAI-1 gene alterations are associated with fibrosis in many tissues and organs. However, PAI-1 gene alterations in long-term PD patients have not yet been investigated. In this study, PAI-1 4G/5G polymorphism was examined by reverse hybridization, and all coding exons of the PAI-1 gene were examined by sequence analysis to provide treatment modification in patients with predisposition before fibrosis develops. The patients were divided into two groups according to ultrafiltration failure test and duration of PD treatment: those with suspected PF or a high probability of developing PF (36%) and those with a low probability of developing PF (64%). There was no significant difference between the two groups in findings such as peritoneal equilibration test (PET), Kt/V, the content of the PD solution used, peritonitis, and PAI-1 4G/5G polymorphism (P > .05). A total of eight gene alterations (rs2227660, rs2227668, rs2854233, rs41281004, rs61553169, rs368413856, rs2227684) were detected by sequence analysis, one of which was exonic (rs6092). When the genotype distributions of these variants were examined, no significant difference was found between the two groups. PAI-1 gene changes were not detected in patients with the probability of developing PF. There is a need for further studies involving other molecules responsible for predisposing to PF with larger patient populations in patients undergoing long-term PD treatment.

Surgical Complications of Peritoneal Dialysis.

Peritoneal dialysis (PD) is a method of renal function replacement which has a series of advantages like greater autonomy of the patient with fewer hospital visits and better preservation of residual renal function, but it has also disadvantages. The main disadvantages are a limited life-time due to peritoneal membrane failure and the risk of infections. The main complication of PD remains peritonitis, which is responsible for the most cases of method failure. There are also other complications which incorrect treated may lead to failure of the method: mechanical complications, abdominal wall defects, exit site and tunnel infections. Encapsulating peritoneal sclerosis is a rare entity found in PD patients but with high morbidity and mortality. We have retrospectively analyzed the patients with end stage renal disease under peritoneal dialysis which were admitted to Surgical Clinic "I. Juvara" of the Clinical Hospital "Dr. I. Cantacuzino" between 2007 and 2017 for surgical complications related to PD. The patients were assigned in two groups: with non-infectious and infectious complications. We have found 109 patients which have had 126 surgical interventions related to peritoneal dialysis. Out of these, 30 interventions consisted in catheter removal for loss of ultrafiltration capacity, so these were excluded from analysis. The lot resulted consisted in 80 patients with 91 complications: 42 non-infectious and 49 infectious. Mean age was 60.5 (+-12.3) years. Sex distribution was 2.75/1 male/female. Diabetes mellitus was present at 45 (56,25 %) patients. Comparing the patients with non-infectious with those with infectious complications we found significant association between type of complications and the length of PD in the sense that infectious complications tend to appear later than the non-infectious. Also, the loss of peritoneal dialysis is strongly associated with infectious complications. Looking inside groups we found that abdominal wall defects are associated with the history of previous abdominal surgery (p 0,001). Regarding the morbidity and mortality only infectious complications had associated mortality in our study, there were no significant differences in morbidity rate between groups. Between all these patients we have also identified 16 with encapsultating peritoneal sclerosis. In most cases the diagnosis was established during the intervention for another complication. We have registered a 20% morality rate at these patients. Conclusions: Noninfectious surgical complications are not raising problems for diagnosis or surgical treatment, but an incorrect treatment may lead to failure of the PD. Infectious complications and especially peritonitis remains the main cause of method failure. These are generating the highest rates of morbidity and mortality from peritoneal dialysis complications. Even if the immediate surgical intervention for peritonitis related to peritoneal dialysis is usually unnecessary, surgical observation is absolutely mandatory in every case. The absence of a response to the proper medical treatment is an indication for peritoneal cavity exploration inclusive by laparoscopy/laparotomy. Any delay in diagnosis and definitive treatment can lead to loss of peritoneal membrane function and even death of the patient. Encapsulated peritoneal sclerosis is a rare but serious complication of PD. The risk for developing EPS increases with the duration of PD treatment. No predictive and reliable screening tests especially in the early stages of EPS were found. So, it is important not to underestimate the clinical symptoms, diagnosis being based on a high index of suspicion. The only established basic treatment of EPS is enterolysis of peritoneal adhesions, and time should not be unnecessarily wasted on conservative treatment.

DYSLIPIDEMIA AS A FACTOR FOR PROGRESSION OF RENAL OSTEODYSTROPHY AND CORONARY HEART DISEASE IN PATIENTS WITH CHRONIC KIDNEY DISEASE ON PERITONEAL DIALYSIS

Numerous studies of the last years focused on various links of pathogenesis and factors for progression of coronary heart disease (CHD) and chronic kidney disease (CKD) allowed to find intersection, such as progression of atherosclerosis or phosphorus and calcium and lipid imbalance, which lead to vascular calcareous infiltration, development of renal osteodystrophy and rising of cardiac risks.&#x0D; Purpose of the research: To define indicators of lipid exchange in patients on peritoneal dialysis which can be factors for progression of renal osteodystrophy and ischemic heart disease.&#x0D; Materials and methods. Indicators of lipid exchange, various types of renal osteodystrophy and clinical types of ischemic heart disease in 114 patients receiving peritoneal dialysis therapy in the Regional Clinical Center of Urology and Nephrology of V.I.Shapoval were analysed.&#x0D; Results. Having analysed changes in blood lipid profile of patients on peritoneal dialysis (PD), we found out a reliable growth of high-density lipoproteins (HDL) in a group of patients without signs of ischemic heart disease and in a group of patients having stable angina, whose primary types of renal osteodystrophy were osteoporosis and fibrous ostitis. Reliable differences had also very-low-density lipoproteins (VLDL) which also were the highest in a group of patients having stable angina without signs of cardiac decompensation. The average duration of PD treatment of patients of this group was 12,3 months.&#x0D; Conclusion. The results of the research confirmed that calcareous infiltration of vessels and heart valves on early stages of PD therapy is mainly caused by dyslipidemia and atherosclerotic changes and less by phosphorus and calcium imbalance which importance increases with duration of PD treatment.

THE ASSOCIATION OF DYSLIPIDEMIA WITH INTRAPERITONEAL INFLAMMATION AND PERITONEAL DIALYSIS TECHNIQUE SURVIVAL

The aim of the study was to determine the relationship between the dyslipidemia, intraperitoneal inflammation and peritoneal dialysis (PD) survival.&#x0D; Patients and methods. A total of 40patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis (PD) have been included in a prospective, observational study (average age was 49.3 ± 12.7). All patients were determined the blood lipid spectrum and IL-10, TNF-a, MCP-1 levels in peritoneal dialysis effluent (PDE). PD adequacy indicators evaluated by determining the concentration of urea and creatinine in plasma, urine and dialysate, calculated weekly creatinine clearance (CrCl), dialysis (Kt/ Vd), renal (Kt/ Vr) and total weekly urea clearance (Kt/ V).&#x0D; Results. Dyslipidemia defined as increase of atherogenic lipoprotein fractions and inhibition ofHDL cholesterol was identified in 70% of the PD-patients. LDL cholesterol level and, accordingly, an atherogenic index (AI) were significantly dependent on the duration of PD treatment (R2 = 2.18 ± 0.15 (95% CI 1.87, 2.5), p &lt; 0,0001 and R2 = 2.77 ± 0.27(95% CI 2.2, 3.3), p &lt; 0,0001). The blood levels of total cholesterol, LDL-C and TG in the patients with diabetes were significantly higher compared with the diabetes-free patients (p = 0.007, p = 0.001 andp = 0.02, respectively).&#x0D; Reducing the HDL cholesterol level was associated with high intraperitoneal production of pro-inflammatory mediators TNF-a (r = - 0.53;p = 0.001) and anti-inflammatory IL-10 (r = - 0.783;p &lt;0.0001), whereas hypertriglyceridemia and high VLDL cholesterol are associated with an increase of MCP-1 (r = 0.6;p = 0.0003 and r = 0.55;p = 0.002, respectively).&#x0D; The Cox proportional hazards regression analysis demonstrated the significant effect of VLDL cholesterol, LDL cholesterol and AI on the survival of PD technique survival (x2 = 24.8; p &lt; 0.0001). The results of the Kaplan–Meier analysis and log-rank test also identified that there was a significant difference in the cumulative technical survival rate between the patients with AI level &lt; 3.5 and &gt; 3.5 (log-rank test: x2 = 19.8, P = 0.001.&#x0D; Conclusions. Our results can be considered dyslipidemia in PD-patients not only as a traditional risk factor for CVD, but also as a predictor of chronic intraperitoneal inflammation and decrease of PD technical survival.

Gastrointestinal Non-Infectious Complications in Patients on Peritoneal Dialysis

Abstract Gastrointestinal complications are common among patients on peritoneal dialysis. Risk factors for the development of gastrointestinal complications in this patient population include: toxic effects of uremic toxins, frequent use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, angiodysplasia, increased intra-abdominal pressure, use of bioincompatible solution for peritoneal dialysis, increased glucose in solutions for peritoneal dialysis, secondary hyperparathyroidism (hypercalcemia), a disorder of lipid metabolism (hypertriglyceridemia), and the duration of peritoneal dialysis treatment. The most important non-infectious gastrointestinal complications in patients on peritoneal dialysis are: gastrointestinal bleeding, herniation and leaking of the dialysate from the abdomen (increased intra-abdominal pressure), impaired lung function (intra-abdominal hypertension), acute pancreatitis, and encapsulating sclerosis of the peritoneum. Intra-abdominal hypertension is defined as IAP ≥ 12 mmHg. Pouring the peritoneal dialysis solution leads to increased intra-abdominal pressure, which results in the development of hernias, pleuro-peritoneal dialysate leakage (hydrothorax), and restrictive pulmonary dysfunction. Risk factors for the development of acute pancreatitis in this patient population include: uraemia, secondary hyperparathyroidism with hypercalcemia, hypertriglyceridemia, features of the peritoneal dialysis solution (osmolarity, acidity, glucose, chemical irritation, and calcium in the solution for peritoneal dialysis lead to “local hypercalcemia”), toxic substances from the dialysate, the bags and tubing, and peritonitis and treatment of peritonitis with antibiotics and anticoagulants. Encapsulating sclerosis of the peritoneum is rare and is the most serious complication of long-term peritoneal dialysis. It is characterized by thickening of the peritoneum, including cancer, and signs and symptoms of obstructive ileus. Diagnosis is based on clinical, laboratory and radiological parameters. Encapsulating sclerosis of the peritoneum can be indicated by an AR-CA-125 concentration of less than 33 U/min and a concentration of AR-IL-6 greater than 350 pg/min in the effluent of patients with ultrafiltration weakness. Treatment consists of stopping peritoneal dialysis, using anti-inflammatory (corticosteroids) and anticicatricial drugs (tamoxifen), while surgical treatment includes enterolysis and adhesiolysis.

Clinical efficacy of combined therapy with peritoneal dialysis and hemodialysis

Combined therapy with peritoneal dialysis (PD) and hemodialysis (HD) represents a treatment option for PD patients who cannot maintain adequate solute and fluid removal. It has rapidly gained popularity in Japan, and 15 years of accumulated experiences is available. Serum creatinine, serum β2 microglobulin (β2m), body weight, and blood pressure decreased, whereas hemoglobin increased after initiating combined therapy. These results indicated that both adequacy of dialysis and hydration status were significantly improved. In addition, dialysate-to-plasma ratio of creatinine (D/P Cr) as obtained from peritoneal equilibration test (PET) was decreased, probably due to the functional and histological improvements of the peritoneal membrane. Combined therapy may have a good impact on the prevention of cardiovascular disease through reduction of blood pressure, correction of fluid overload, and improvement of left ventricular hypertrophy. Quality of life may improve as a result of decreases in uremic symptomatology and freedom from bag exchanges. On the other hand, combined therapy with PD and HD has some concerns. A reduction in urine volume during combined therapy indicates a decline in residual renal function, and may have potential negative impacts on life expectancy. Furthermore, induction of combined therapy would increase the overall duration of PD treatment and susceptibility to peritonitis. We have to pay attention to the development of encapsulating peritoneal sclerosis, as the most serious complication of PD, because both prolonged PD duration and increased number of peritonitis episodes are independent risk factors. Here, we propose criteria for the indication and discontinuation of combined therapy. Under these criteria, Kt/V, serum β2m, and uremic symptoms including nutritional status, erythropoiesis-stimulating agent-hyporesponsive anemia, and restless legs syndrome were used as markers of dialysis adequacy. On the other hand, higher blood pressure, heart enlargement or pleural effusion on chest X-ray, and persistent peripheral edema were used as markers of hydration status. Further studies, particularly prospective cohort studies with a large group of cases, are needed to confirm the clinical efficacy of combined therapy with PD and HD.

Association of Adiponectin with High-Sensitivity C-Reactive Protein and Clinical Outcomes in Peritoneal Dialysis Patients: A 3.5-Year Follow-Up Study.

IntroductionAdiponectin (ADPN), one of most abundant fat-derived biologically active substances, plays an important role in anti-atherosclerotic process. There are conflicting results about the impact of ADPN on cardiovascular (CV) outcomes and mortality, particularly in patients undergoing peritoneal dialysis (PD). Moreover, the relationship between ADPN and inflammatory mediators has been seldom explored in this population. Therefore, we examined the relationship between ADPN and longitudinal high-sensitivity C-reactive protein (hs-CRP) changes and investigated whether ADPN or hs-CRP levels could predict CV outcomes and mortality in prevalent PD patients after comprehensive adjustment of possible confounders.MethodsIn this prospective cohort study, 78 PD patients were enrolled and followed from February 2009 to August 2012. During follow-up, CV events and all-cause mortality were recorded.ResultsThe mean baseline ADPN value was 29.46±18.01 μg/ml and duration of PD treatment was 37.76±36.96 months. In multiple linear regression analysis, plasma ADPN levels positively correlated with high-density lipoprotein and negatively associated with hs-CRP, body mass index, D4/D0 glucose, triglyceride, and duration of PD treatment. After stratified by genders, the inverse association between baseline ADPN and hs-CRP was more significant in the female group. The hs-CRP levels were followed up annually and remained significantly lower in the high ADPN group in the first 2 years. Patients were then stratified into two groups according to the median ADPN value (23.8 μg/ml). The results of Kaplan-Meier survival analysis demonstrated less CV events and better survival in high ADPN group. On multivariate Cox regression analysis, only ADPN level (HR: 0.93, 95% CI: 0.88–0.98, p = 0.02), age and history of CV diseases were independent risk factors for future CV events. Furthermore, hs-CRP (HR: 1.11, 95% CI:1.001–1.22, p = 0.04) was identified as independent predictor of all-cause mortality.ConclusionsSerum hs-CRP levels were consistently lower in the high ADPN group during 2-year follow-up. We also demonstrated the importance of ADPN and hs-CRP in predicting CV events and all-cause mortality in PD population during 3.5-year follow-up.

Cell‐Free Plasma DNA during Peritoneal Dialysis and Hemodialysis and in Patients with Chronic Kidney Disease

The mechanisms of clearance of circulating plasma DNA are not fully understood, and so we aimed to examine it in patients with impaired renal function compared with healthy individuals. We also assessed the effect of peritoneal dialysis and hemodialysis on circulating plasma cell-free DNA (cfDNA) in our treated patients. Overall, 20 healthy volunteers, 20 patients with chronic kidney disease (CKD), 18 patients undergoing peritoneal dialysis (PD), and 17 patients on hemodialysis (HD; high-flux polysulfone membrane) were examined. Cell-free DNA levels were determined using real-time GADPH gene sequence amplification. The levels of cfDNA in all groups of our patients did not differ significantly from those of healthy volunteers. In HD patients, cfDNA levels were significantly increased compared with those of CKD patients (P < 0.05) and PD-treated patients (P < 0.01). In PD-treated patients, cfDNA was detectable in overnight effluent, with its levels correlating inversely with the duration of PD treatment (r=-0.619, Spearman's coefficient, P= 0.008). Factors contributing to these differences may include changes in the quality and quantity of the cell population of the peritoneum, highlighting the need for additional studies clarifying the dynamics of cfDNA during PD. The plasma levels of cfDNA do not seem to be dramatically altered even in CKD patients or those on PD or HD (as long as they are measured prior to the procedure in the latter two). Our data suggest renal elimination is not the main mechanism of circulating cfDNA clearance.

Posttransplant Encapsulating Peritoneal Sclerosis: A Worrying New Trend?

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication in patients on peritoneal dialysis (PD). We describe a cluster of 13 EPS cases occurring in 2 university hospitals in The Netherlands. Most of these cases were diagnosed after recent kidney transplantation, when the patients developed severe symptoms of bowel obstruction. This accumulation raised the question as to whether other than known risk factors, such as duration of PD treatment, could be involved in the development or course of EPS after transplantation. According to various publications, EPS has been diagnosed often after withdrawal from PD, suggesting that cessation in itself may be a risk factor. In addition, transplantation-related management should be considered to play a role, including the use of the profibrotic calcineurin inhibitors and the trend to reduce the load of corticosteroids in treatment regimes. To identify risk factors, further multicenter studies are required, paying special attention to alterations in immunosuppressive treatment regimens as well as PD prescriptions, including PD fluid characteristics. Transfer from PD to hemodialysis should be under serious consideration in patients eligible for kidney transplantation as soon as there are indications of ultrafiltration failure.

Does a history of peritoneal dialysis result in an impaired gastrointestinal life quality?

Peritoneal dialysis (PD) invariably induces sclerotic changes in the peritoneal membrane. The impact of these changes on the well-being of PD patients has not been studied sufficiently. In a matched-pair analysis, the gastrointestinal life quality of patients with a history of PD was compared with end-stage renal disease patients who never performed PD, using a standardized questionnaire (gastrointestinal life-quality index [GLQI]). We identified all patients in our dialysis unit who underwent PD between 1989 and 2001 and who were alive in October 2001 (PD patients; n=53). Patients who were treated by hemodialysis (HD patients) were recruited as pairs. Hemodialysis and PD patients did not differ in gastrointestinal life quality (GLQI: HD 106.0+/-16.4 points; PD 104.0+/-16.7 points; p=0.70). Gastrointestinal life quality was neither correlated with the number of peritonitis episodes, nor with the duration of PD treatment. Peritoneal dialysis treatment is not associated with a long-term impairment of gastrointestinal life quality.

Peritoneal sclerosis—aetiology, diagnosis, treatment and prevention

Peritoneal selerosis (PS) is a rare, but potentially life-threatening complication in peritoneal dialysis (PD). The annual incidence increases with the duration of PD treatment and the mortality rate is high. Aetiology of PS is probably multifactorial and in most cases not exactly known. One import factor of PS is the bioincompatibility of the glucose-based PD solutions. Diagnosis is mainly based on clinical suspicion and radiological findings. Early detection is important to institute preventive strategies and development of therapeutic strategies has reduced mortality.

Effectiveness of peritonaeal dialysis

In the last few years, an increasing number of patients suffering from terminal renal disease of various leading causes was treated with renal replacement therapy. Peritonaeal dialysis involves an exchange of water and solutes between blood in the peritonaeal capillaries and dialysate in the peritonaeal cavum throughout the peritonaeum. Effective dialysis treatment should provide good quality of life, decrease the number of physical complaints, and bring the incidence of morbidity and mortality closer to the incidence of morbidity and mortality in the healthy population. The aim of this study was the evaluation of peritonaeal transport characteristics and dialysis effectiveness in 58 patients affected by terminal renal disease who underwent peritonaeal dialysis treatment during August 2003 at the Clinic of Nephrology of the Clinical Centre of Serbia. We examined 30 male and 28 female patients, with an average age of 52 years (range 26 to 78 years). The average duration of peritoneal dialysis treatment was 20 months (ranging from 2 to 66 months), and the end-stage renal failure was caused by different leading disease in our patients. We applied different dialysis modalities: continuous ambulatory peritonaeal dialysis (CAPD) with three to five 2- or 3-litre exchanges daily, cyclic peritonaeal dialysis (CCPD), intermittent peritonaeal dialysis (IPD), or automatic peritonaeal dialysis (APD), according to the transport characteristics of the peritonaeal membrane, the residual renal function (RRF), and the clinical status of the patients, in order to perform adequate depuration as suggested by the new international criteria. A peritonaeal equilibrium test (PET) was performed according to the new international advice; urea and creatinine clearances (Kt/V and Ccr) as well as RRF were calculated using the internationally suggested formulas. Most of our patients received effective dialysis treatment, thanks to the modulation of number, volume, and timing of exchanges. Adequate dialysis improved blood count, nutritional status, and quality of life in our patients, while reducing the incidence of infection to a significant degree.

Association of Hypertriglyceridemia and Insulin Resistance in UREMIC Patients Undergoing CAPD

Hyperlipidemia is frequently encountered in uremic patients and may be worsened by continuous ambulatory peritoneal dialysis (CAPD) treatment. The lipid abnormalities in these patients may be multifactorial. Insulin resistance (or its compensatory hyperinsulinemia) is commonly observed in uremic patients, but its association with hyperlipidemia in these patients has not been studied. Lipid profiles of 35 nondiabetic nonobese patients undergoing CAPD for more than 1 year (mean 52.3 months) were studied. Current laboratory data and parameters related to peritoneal dialysis (PD) within the previous 3 months were recorded. After overnight fasting and interruption of PD, an oral 75-g glucose tolerance test (OGTT) was examined. After CAPD treatment for more than 12 months, these patients had higher serum triglyceride (TG) (p = 0.001) and total cholesterol (p = 0.0058) levels than their values before commencing CAPD. Twelve of 14 patients with serum TG higher than 200 mg/dL (high-TG) were diagnosed de novo, in contrast with only 1 patient diagnosed of de novo hypercholesterolemia (total cholesterol > 240 mg/dL). There was no difference in age, gender, body mass index (BMI), duration of PD treatment, serum albumin, hematocrit, intact serum parathyroid hormone (iPTH), peritoneal glucose load, solute transport, or weekly Kt/V urea between normal-TG and high-TG patients. After adjusting for age, gender, BMI, weekly Kt/V urea, and iPTH, the high-TG patients had higher levels of area under the curve for glucose (AUC(Glu)), area under the curve for insulin (AUC(Ins)), and AUC(Ins)/AUC(Glu) ratios (F = 10.63, 10.14, and 8.65; p = 0.0029, 0.0035, and 0.0065, respectively), indicating that the high-TG patients were more insulin resistant. There were 24 patients with normal glucose tolerance (NGT), and 11 patients with impaired glucose tolerance (IGT). The IGT group had higher serum TG (F = 10.43, p = 0.003) and total cholesterol (F = 8.05, p = 0.009) than the NGT group, after adjusting for BMI, duration of CAPD treatment, peritoneal glucose load, solute transport, serum albumin, and lipid levels before PD treatment. TheTG levels after CAPD treatment were positively correlated with AUC(Glu), AUC(Ins), and AUC(Ins)/AUC(Glu) ratio (r = 0.48, 0.53, and 0.49; p = 0.0037, 0.001, and 0.0028, respectively). These results indicate that insulin resistance is an important factor in the development of hypertriglyceridemia in CAPD patients.

Vascular endothelial growth factor in peritoneal dialysis: A longitudinal follow-up

In a previous study, vascular endothelial growth factor (VEGF) was found to be locally produced in the peritoneal tissue of patients undergoing peritoneal dialysis (PD) who were being treated with glucose-containing PD solutions. Locally produced VEGF (LVEGF) was positively related to the mass transfer area coefficient (MTAC) of creatinine and to glucose absorption, both of which are representative of the peritoneal vascular surface area. It was therefore hypothesized that VEGF is involved in the peritoneal neoangiogenesis found in long-term PD. The aim of the present study was to investigate the time course of peritoneal VEGF levels in PD patients treated with glucose-based PD solutions during longitudinal follow-up. We also studied the effect of the switch to glucose-free PD treatment on VEGF production. Forty standard peritoneal permeability analyses (SPAs) with 3.86% glucose-containing dialysis solution were investigated. The SPAs were performed in 10 PD patients with a median number of three SPAs per patient during a follow-up of 23 months. Duration of PD treatment at the last SPA was 74 months. All patients were initially treated with glucose-containing dialysis solutions. Four patients switched after 114 months of glucose-based PD to glucose-free PD and were followed for 7 months. A PD regimen of icodextrin, glycerol, and amino acid–based dialysis solutions was applied in these patients. Four SPAs were performed per patient in this period. To predict the VEGF dialysate-to-serum ratio (D/S), when diffusion would be the only explanation for the VEGF dialysate concentration, we calculated the power relationship between D/S ratios of serum proteins that are only transported across the peritoneum and the molecular weights of those proteins. The measured VEGF D/S ratio was higher than expected (P <.001) in each observation, pointing to local production of VEGF. LVEGF increased with duration of glucose PD, 11.7 ng/L to 23.45 ng/L (P <.03). LVEGF decreased in all 4 patients undergoing glucose-free PD, from 57.35 ng/L to 23.10 ng/L. A correlation (r = 0.83, P <.001) was found be-tween the differences in MTAC creatinine between the first and last SPA during glucose-based PD and the difference in LVEGF between these observations. A similar correlation was present between the difference in glucose absorption and the difference in LVEGF (r = 0.85, P <.001). This supports a pathogenetic role of high glucose dialysate concentrations in the development of changes in the peritoneum that are found in long-term PD. Treatment with non-glucose-based PD solutions may inhibit further development of these alterations. (J Lab Clin Med 2001;137:125-32)

Immunoglobulins in chronic renal failure of childhood: Effects of dialysis modalities

It is not clear whether low serum levels of IgG (subclasses), previously demonstrated in children on peritoneal dialysis (PD), are related to the PD procedure or to factors associated with chronic renal failure (CRF). The aim of our study was to analyze the effect of PD on serum and PD effluent (PDE) IgG and subclass levels in children with end-stage renal failure. We measured albumin, IgG, IgA, IgM, and IgG subclasses in serum and PDE from children on PD (N = 40) and compared the serum values with those of children treated with hemodialysis (HD, N = 23) or presenting with CRF but not yet dialyzed (CRF; N = 63), and with a group of healthy controls (HCs; N = 67). Sixteen PD children could be followed sequentially from before starting PD and eight during a peritonitis episode. Forty percent of the PD children showed reduced serum IgG2 levels (P = 0.0003) compared with 35% in HD (P = 0.006), 33% in CRF (P = 0.001), and 9% in HC children. IgG1 deficiencies were observed in 25% of PD patients (P < 0.0001), 4% of HD (P = NS), 16% of CRF (P = 0.0005), and 0% of HC children. IgG3 and IgG4 deficiencies were observed less frequently. Peritoneal clearances were similar for total IgG, IgG1, IgG2, and IgG4, but were lower for IgG3 (P < 0.05). No relationships were found between clearances and age or duration of PD treatment. Total IgG (P = 0. 003) and IgG1 (P = 0.002) levels declined just after starting PD. Peritonitis was associated with temporarily increased peritoneal loss of Ig, while the serum concentrations were unaffected. No significant relationship was found between the peritonitis incidence and reduced IgG or subclasses. However, all children with two or more peritonitis episodes per year had a reduced Ig level. Although the mean serum concentrations of immunoglobulins were normal in all studied groups, a deficiency of one or more IgG subclasses was present in all groups with renal failure, suggesting inhibition of their synthesis by the uremic state. Ig deficiencies were more frequently found in PD, likely caused by protein loss in PDE. A high peritonitis incidence was associated with reduced serum Ig levels.

Dyslipidemia in Peritoneal Dialysis — Relation to Dialytic Variables

To investigate whether the specific lipoprotein (LP) abnormalities of peritoneal dialysis (PD) are associated with functional variables of this mode of dialysis. A survey of the LP profile in relation to peritoneal dialysis capacity (PDC) variables. The LP profile was compared to that of a group of age- and sex-matched controls. The Peritoneal Dialysis Unit at Sahlgrenska University Hospital in Gothenburg, Sweden. Twenty-two nondiabetic PD patients (5 women, 17 men) who had been on PD for at least 6 months. The LP profile included plasma lipids, apolipoproteins (Apo), and individual ApoA- and ApoB-containing LP. The PDC measurement determined peritoneal glucose uptake, protein losses, effective peritoneal surface area, and total weekly creatinine clearance. The patients had been on PD for 6 to 48 months (mean 15.3 months) and had a total weekly creatinine clearance of 69.7+/-13.3 L/1.73 m2 body surface area, an average peritoneal glucose uptake corresponding to 446+/-162 kcal/24 hour, and a protein loss of 8.1+/-2.5 g/24 hr. The patients had significantly higher total cholesterol (7.1 mmol/L),VLDL-cholesterol (1.0 mmol/L), LDL-cholesterol (4.7 mmol/L), and triglyceride levels (2.5 mmol/L); whereas the HDL-cholesterol level (1.2 mmol/L) was significantly lower than in controls. The PD patients had increased levels of ApoB-containing LPs, both of the cholesterol-rich LP-B and of the triglyceride-rich LP-B complex, reflected in higher plasma concentrations of ApoB, ApoC-III, and ApoE. Furthermore, they had significantly lower levels of LP-A-I:A-II, as well as of ApoA-I and ApoA-II. The LP-A-I:A-II and ApoA-II levels correlated inversely with the duration of PD treatment (r = 0.54, p < 0.01 and r = 0.52, p < 0.05, respectively). The ApoA-II level was inversely correlated with the peritoneal surface area (r = 0.53, p < 0.05). There were no other correlations between LP variables and PDC variables, nor did any of the LP variables correlate with peritoneal glucose uptake or protein losses. The proatherogenic lipoprotein profile of patients on PD is characterized by increased concentrations of cholesterol-rich and triglyceride-rich ApoB-containing LPs. While the duration of treatment appears to have some influence on the development of this type of dyslipidemia, the pathophysiological links to the dialysis mode must be further explored.

Trough serum vancomycin levels predict the relapse of gram-positive peritonitis in peritoneal dialysis patients

We reviewed 31 episodes of gram-positive peritonitis that occurred in our peritoneal dialysis population between 1990 and 1993 in an attempt to identify the risk factor(s) for peritonitis relapse. All patients were treated with 4 weekly doses of intravenous vancomycin. Vancomycin doses no. 1 and 2 were based on body weight (15 mg/kg with a 1-g minimum); vancomycin doses no. 3 and 4 were adjusted in an attempt to maintain the trough serum vancomycin level at greater than 12 mg/L. Nine peritonitis episodes complicated by a relapse were identified. Peritonitis episodes preceding a relapse were similar to relapse-free episodes with respect to patient age, diabetes, peritoneal dialysis modality, duration of peritoneal dialysis treatment, residual urea clearance, peritoneal fluid cell count, causative organism, and weekly vancomycin dose. However, cumulative 4-week mean trough vancomycin levels were consistently lower during peritonitis episodes preceding a relapse (7.8 ± 0.6 mg/L during relapse-prone episodes v 13.7 ± 0.9 mg/L during relapse-free episodes; P = 0.0004). Furthermore, relapses developed during nine of 14 peritonitis episodes demonstrating a 4-week mean trough vancomycin level less than 12 mg/L compared with zero of 17 episodes with a 4-week trough level greater than 12 mg/L ( P < 0.05). The detection of a low initial 7-day trough vancomycin level also was a useful marker for subsequent peritonitis relapse. In 13 peritonitis episodes associated with an initial trough level less than 9 mg/L, nine were complicated by a relapse. The mean trough vancomycin level persisted below 9 mg/L over the final 3 weeks of therapy in all nine relapse-prone episodes as opposed to only one of four relapse-free episodes. All peritonitis relapses were treated successfully with 4 weeks of intravenous vancomycin therapy. This coincided with a significantly higher 4-week mean trough vancomycin level during treatment of the relapses (14.7 ± 0.7 mg/L during the relapse v 7.8 ± 0.6 mg/L immediately preceding the relapse; P < 0.05) despite similar mean weekly vancomycin dosages during both periods (19.4 ± 1.0 mg/kg during the relapse v 17.8 ± 1.2 mg/kg prior to the relapse; P = NS). In patients with uncomplicated peritoneal dialysis-related gram-positive peritonitis treated with weekly intravenous vancomycin, we conclude that (1) a suboptimal trough serum vancomycin level (cumulative 4-week trough serum vancomycin level <12 mg/L or an initial 7-day trough serum level <9 mg/L) is the only clinical parameter that identified peritonitis episodes at risk for relapse, and that (2) on detection of a suboptimal initial trough level (<9 mg/L), prevention of a subsequent peritonitis relapse may be possible if adequate trough vancomycin levels (>9 mg/L and preferably >12 mg/L) can be maintained for the remainder of therapy.