Peritoneal Dialysis Experience Research Articles

Difficult peritonitis cases in children undergoing chronic peritoneal dialysis: relapsing, repeat, recurrent and zoonotic episodes.

Despite technological improvements in dialysis connectology and dialysis technique, peritonitis remains the most common and most significant complication of peritoneal dialysis (PD) in children. Most children undergoing chronic PD experience none or only one peritonitis episode, while others have multiple episodes or episodes secondary to unusual organisms. Knowledge of potential risk factors and likely patient outcome is imperative if treatment is to be optimized. In this review we will, in turn, describe episodes of peritonitis that are characterized as either relapsing, recurrent, repeat or zoonosis-related to highlight the clinical issues that are commonly encountered by clinicians treating these infections.

Surgical treatment of persistent tertiary hyperparathyroidism induced by parathyroid adenomas in the aortopulmonary window

Background. Aortopulmonary window is a rare localization of ectopic parathyroid glands. This localization is the difficulty in diagnosis and surgical treatment, especially in conditions of the heavy somatic pathology that develops with prolonged of kidney replacement therapy. Persistence of tertiary hyperparathyroidism after cervical revision does not give in medical treatment, accompanied by the progression of bone and systemic symptoms of the disease, including death.Materials and Methods. Illustrates a case successful diagnosis and surgical treatment this rare disease. We discuss the treatment and diagnostic tactics. Female patient (age 66) had the experience of peritoneal dialysis for 6 years. She underwent cervical parathyroidectomy. Ectopic mediastinal paratiroma detected by gamma scintigraphy (from 99mTc-MIBI). Determination of the exact tumor location proved to be impossible before the surgery due to bad mental condition of the patient. Localization of adenomas was defined on the surgery after a sternotomy. Results. Operation efficiency proved decrease parathyroid hormone from 2095 pg / ml (before operation) to 10 pg / ml (1.5 months after surgery). After surgery, there was a mediastinal hematoma. The patient was discharged 21 days after surgery healed by.Conclusions. The use a sternotomy leads to the removal of the tumor. This access may be used when an unknown location. This access is a forced for tertiary hyperparathyroidism.

Seventeen Years’ Experience of Peritoneal Dialysis in Iran: First Official Report of the Iranian Peritoneal Dialysis Registry

To facilitate planning, national renal registries provide reliable and up-to-date information on numbers of patients with end-stage renal disease (ESRD), developing trends, treatment modalities, and outcomes. To that end, the present publication represents the first official report from Iranian Peritoneal Dialysis Registry. The prevalence, demographics, and clinical characteristics of patients on peritoneal dialysis (PD) were collected from all PD centers throughout the country. By the end of 2009, the prevalence of ESRD was 507 per million population in Iran. The most common renal replacement modality was hemodialysis (51.2%), followed by kidney transplantation (44.7%), and then PD (4.1%). The mean age of PD patients was 46 years, and the most common causes of ESRD were diabetes (33.5%), hypertension (24.4%), and glomerulonephritis (8.2%). Overall patient mortality was 25%, with cardiac events (46%), cerebral stroke (10%), and infection (8%) being the main causes of death. The 1-, 3-, and 5-year survivals were 89%, 64%, and 49% respectively. The most common cause of dropout was peritonitis (17.6%). Staphylococcus (coagulase-negative and S. aureus) was the most prevalent causative organism in peritonitis episodes; however, in more than 50% of episodes, a sterile culture was reported. Mean baseline serum hemoglobin and albumin were 10.7 g/dL and 3.6 g/dL respectively. Our registry results, representing the second largest report of PD in the Middle East, is almost comparable to available regional data. We hope that, in future, we can improve our shortcomings and lessen the gap with developed countries.

Can EPS Development be Avoided with Early Interventions? The Potential Role of Tamoxifen—A Single-Center Study

Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD). Identification of patients at high risk for EPS ("EPS-prone") and delivery of appropriate interventions might prevent its development. Our aim was to evaluate the clinical characteristics and outcomes of all EPS and EPS-prone patients diagnosed at our PD unit. For a 30-year period representing our entire PD experience, we retrospectively identified all patients with EPS (diagnosed according to International Society for Peritoneal Dialysis criteria) and all patients defined as EPS-prone because they met at least 2 established criteria (severe peritonitis, PD vintage greater than 3 years, severe hemoperitoneum, overexposure to glucose, and acquired ultrafiltration failure). Of 679 PD patients, we identified 20 with EPS, for an overall prevalence of 2.9%. Mean age at diagnosis was 50.2 ± 16.4 years, with a median PD time of 77.96 months (range: 44.36 - 102.7 months) and a median follow-up of 30.91 months (range: 4.6 - 68.75 months). Of patients with EPS, 10 (50%) received tamoxifen, 10 (50%) received parenteral nutrition, and 2 (10%) underwent adhesiolysis, with 25% mortality related to EPS. Another 14 patients were identified as EPS-prone. Median follow-up was 54.05 months (range: 11.9 - 87.04 months). All received tamoxifen, and 5 (36%) received corticosteroids; none progressed to full EPS. We observed no differences in baseline data between the groups, but the group with EPS had been on PD longer (84 ± 53 months vs 39 ± 20 months, p = 0.002) and had a higher cumulative number of days of peritoneal inflammation from peritonitis (17.2 ± 11.1 days vs 9.8 ± 7.9 days, p = 0.015). Overall mortality was similar in the groups. The incidence of EPS declined during our three decades of experience (5.6%, 3.9%, and 0.3%). Being a serious, life-threatening complication of PD, EPS requires high suspicion to allow for prompt diagnosis and treatment. Early detection of EPS-prone states and delivery of appropriate intervention might prevent EPS development. Tamoxifen seems to be a key strategy in prevention, but caution should be used in interpreting our results. Additional randomized controlled studies are needed.

Esiste un cutoff alla penetranza della dialisi peritoneale? Come superarlo?

Il centro di Brescia ha un'incidenza della DP del 35% e oltre 30 anni di esperienza. Nonostante ciò, ha un cutoff di prevalenza a 80 pazienti, che non riesce a superare. Questo breve scritto sintetizza alcune possibili soluzioni per incrementare l'utilizzo della DP.

Does penetration of peritoneal dialysis have a cutoff? How to overcome it?

At the dialysis center of Brescia, with experience in peritoneal dialysis (PD) of more than 30 years, the incidence of PD is 35%. Despite this, the prevalence of PD has an apparently fixed cutoff at about 80 patients. This short paper synthesizes some possible solutions to increase penetration of PD.

‘I am not defined by my illness’

Carla Phillips has been on dialysis twice in her life and has had two kidney transplants—the first lasted 15 years and the second was provided through the ‘paired donation’ scheme. She reflects on her experience of peritoneal dialysis and how it felt to receive a kidney from her loving husband.

Long-Term Peritoneal Dialysis Experience: Quality Control Supports the use of Fluconazole to Prevent Fungal Peritonitis

Fungal peritonitis (FP) is rare, but it is associated with high morbidity and mortality. A prospective study was conducted based on the peritonitis episodes registry to evaluate FP rate, possible risk factors, and outcomes. The impact of prophylactic intervention with oral fluconazole was evaluated. Over 24 years of experience, 417 patients underwent peritoneal dialysis (PD), followed for 956 patient-years. By the end of the study, the peritonitis rate reached 0.47 episodes per patient-year of treatment (ep/pt-y). FP was detected in 24 patients. The global rate of FP was 0.03 ep/pt-y (4.8%). Candida species accounted for 92% of the FP. Risk factors identified: recent use of antibiotics in 63% (13 episodes of bacterial peritonitis and 2 exit-site infections (ESI)) and immunosuppressive therapy in 8%. While rare, the FP proportion was still observed to increase from the beginning of the program, reaching 7.8% (0.05 ep/pt-y). A strategy of antifungal prophylaxis with oral fluconazole during peritonitis or ESI antibiotic therapy was adopted, which allowed thereafter a 4.0% falling FP proportion (by study end, rate of 0.01 ep/pt-y). Catheter removal occurred in all patients. The mortality rate was 12.5%. Reinsertion of dialysis catheter was attempted in 4 patients and PD was successfully resumed in 3 patients. FP was associated with high mortality and required early removal of the catheter in all patients. Recent use of antibiotics was a predisposing factor to PF. The quality control process determined a prophylactic strategy and reduction of PF after introduction of oral fluconazole was implemented.

Nonuremic Indication for Peritoneal Dialysis for Refractory Heart Failure in Cardiorenal Syndrome Type II: Review and Perspective

Cardiorenal syndrome (CRS) type II is a serious condition in which chronic cardiac abnormalities cause worsening kidney function, leading to permanent chronic kidney damage. Management of CRS type II coupled with diuretic-resistant congestive heart failure (CHF) has been an issue of dispute. However, since the early 1990s, reports indicating the clinical usefulness of peritoneal dialysis (PD) as maintenance therapy for intractable CHF in this population have been accumulating. The present manuscript reviews the mechanisms by which kidney dysfunction develops within CHF, and then examines recent experiences of PD as chronic supportive therapy for intractable CRS type II, reviews the contributing mechanisms, and discusses the rationale for using PD as a new therapeutic approach in the nonuremic setting of CHF.

Association of Modality with Mortality among Canadian Aboriginals

Previous studies have shown that Aboriginals and Caucasians experience similar outcome on dialysis in Canada. Using the Canadian Organ Replacement Registry, this study examined whether dialysis modality (peritoneal or hemodialysis) impacted mortality in Aboriginal patients. This study identified 31,576 adult patients (hemodialysis: Aboriginal=1839, Caucasian=21,430; peritoneal dialysis: Aboriginal=554, Caucasian=6769) who initiated dialysis between January of 2000 and December of 2009. Aboriginal status was identified by self-report. Dialysis modality was determined 90 days after dialysis initiation. Multivariate Cox proportional hazards and competing risk models were constructed to determine the association between race and mortality by dialysis modality. During the study period, 939 (51.1%) Aboriginals and 12,798 (53.3%) Caucasians initiating hemodialysis died, whereas 166 (30.0%) and 2037 (30.1%), respectively, initiating peritoneal dialysis died. Compared with Caucasians, Aboriginals on hemodialysis had a comparable risk of mortality (adjusted hazards ratio=1.04, 95% confidence interval=0.96-1.11, P=0.37). However, on peritoneal dialysis, Aboriginals experienced a higher risk of mortality (adjusted hazards ratio=1.36, 95% confidence interval=1.13-1.62, P=0.001) and technique failure (adjusted hazards ratio=1.29, 95% confidence interval=1.03-1.60, P=0.03) than Caucasians. The risk of technique failure varied by patient age, with younger Aboriginals (<50 years old) more likely to develop technique failure than Caucasians (adjusted hazards ratio=1.76, 95% confidence interval=1.23-2.52, P=0.002). Aboriginals on peritoneal dialysis experience higher mortality and technique failure relative to Caucasians. Reasons for this race disparity in peritoneal dialysis outcomes are unclear.

Encapsulating peritoneal sclerosis: a rare, serious but potentially curable complication of peritoneal dialysis–experience of a referral centre in Germany

Chronic peritoneal dialysis (PD) can be complicated by encapsulating peritoneal sclerosis (EPS), the most severe complication associated with long-term PD. In this study, we retrospectively analysed 49 EPS patients regarding clinical presentation, histopathological findings, treatment and long-term clinical outcome at our referral centre. Patients were divided into two clinical categories: severe and mild/moderate. All patients in the severe group and most patients in the mild/moderate group had symptoms consistent with EPS. The most common computed tomographic findings were peritoneal thickening in both groups. Small bowel dilatation was frequently present in the severe group. The time of onset of symptoms consistent with EPS to the surgical procedure was median 5 months with an inter-quartile range of 2-12 months in the severe group. To date, 25 of 31 patients in the severe group (follow-up 45.6 ± 39.0 months after surgery) are alive. In the mild/moderate group, 8 of 11 patients are alive (follow-up 41.6 ± 21.6 months). The histological features were consistent with EPS in all biopsies. The outcome of patients even with severe EPS is not worse. It is a precondition that these patients are treated in specialized referral centres. The time of first clinical symptoms consistent with EPS to requirement of surgery is very short. Earlier diagnosis of the disease is mandatory, even in asymptomatic patients.

Patients' experiences of peritoneal dialysis at home: a phenomenological approach

The aim of this study was to highlight the meaning of home dialysis as experienced by patients with chronic renal failure. The research design was influenced by Ricoeur's phenomenology. Nineteen patients from a Brazilian public hospital were interviewed, from May to September 2009. Interviews were guided by the question: "Tell me about your experiences lived undergoing PD". Findings unveiled the patients' perception of the drastic changes in their existence, consequent to disease and treatment; and the perception of themselves in that process. The feeling of anguish, physical pain and deprivations were part of living that condition. They foresee an uncertain future, depending on the expertise of health care providers and the demands on support of significant others. Findings suggest that individual aspects of patients' experiences must be considered if health care providers are to facilitate positive health outcomes.

Changes in Body Fat Mass in Patients after Starting Peritoneal Dialysis

Peritoneal dialysis (PD) is characterized by gain in fat mass. Visceral fat mass is associated with metabolic syndrome and atherosclerosis rather than subcutaneous fat mass. In addition, the change in visceral fat mass is a more reliable predictor of survival in PD patients. In this study, we prospectively examined serial changes in fat composition and nutritional status and analyzed factors associated with gain in fat mass in patients undergoing PD. Body composition was assessed by bioelectric impedance analysis (BIA) and computed tomogram (CT). Nutrition status was assessed by Subjective Global Assessment (SGA), protein equivalent of nitrogen appearance (nPNA), serum albumin, C-reactive protein (CRP), and lipid profile. All measurements except BIA were performed on the seventh day and at 6 and 12 months after the start of PD. 60 patients (30 men; mean age 55.0 ± 12.5 years) were enrolled. Increase in body weight continued during the 12 months but visceral and subcutaneous fat mass increased during the first 6 months and decreased during the second 6 months. While hematocrit and serum albumin decreased during the first 6 months, they did not change during the second 6 months. Serum creatinine, total cholesterol, and triglyceride increased similarly to the weight pattern. While nPNA decreased during the 12 months, Kt/V, SGA, and CRP did not change. Patients that had more visceral fat mass at the start of PD had less gain of visceral fat mass during the first 6 months (r = -0.821, p = 0.002). Patients that had more subcutaneous fat mass at the start of PD had less gain of subcutaneous fat mass (r = -0.709, p = 0.015). The change in weight was not associated with the change in visceral or subcutaneous fat during the first 6 months. Patients starting PD experience weight gain, including visceral and subcutaneous fat, during the first 6 months of PD. Patients with high baseline fat mass had less increase in fat mass than those with low baseline fat mass, regardless of visceral or subcutaneous fat mass.

Peritoneal dialysis - experiences

Peritoneal dialysis is the method of treatment of terminal-stage chronic kidney failure. Nowadays, this method is complementary to haemodialysis. It is based on the principles of the diffusion of solutes and ultrafiltration of fluids across the peritoneal membrane, which acts as a filter. The dialysate is introduced into the peritoneum via the previously positioned peritoneal catheter. The peritoneal dialysis is carried out on daily basis, at home by the patient, and the "exchange" is repeated 4-5 times during the 24 hours. The first steps in peritoneal dialysis at the Department for Haemodialysis of the Clinical Centre of Vojvodina date back to 1973. Until 1992, the patients were subjected to this program only sporadically. Since 1998 the peritoneal dialysis method has been performed at the Clinic for Nephrology and Clinical Immunology. In the period 1998-2008 ninety nine peritoneal catheters were placed. Chronic glomerulonephritis, nephroangiosclerosis and diabetes were identified as the most common causes of chronic renal failure. Two methods of catheter placement were applied: the standard open surgery method (majority of patients) and laparoscopy. Most of the patients were subjected to continuous ambulatory peritoneal dialysis, whereas four patients received automatic dialysis. Transplantation was performed in 10 patients, i.e. cadaveric transplantation and living-related donor transplantation, each in 5 patients. Peritoneal dialysis was available as a service outside our institution as well. A ten-year experience in peritoneal dialysis gained at our Centre has proved the advantages and qualities of this method, strongly supporting its wider application in the treatment of terminal-stage chronic kidney failure.

Computed Tomographic Findings Characteristic for Encapsulating Peritoneal Sclerosis: A Case-Control Study

Computed tomography (CT) is often used to confirm the diagnosis of encapsulating peritoneal sclerosis (EPS) but there is no consensus on specific CT abnormalities. To establish CT findings characteristic for EPS, we compared CT findings between EPS patients and long-term peritoneal dialysis (PD) patients without EPS. We included as cases all EPS patients in our center from 1996 to 2008 that underwent a CT scan at the time of diagnosis. Controls were all other long-term PD patients (PD duration > or = 4 years) without EPS that had a CT scan for different reasons. The CT scans were blindly and independently reviewed by 3 radiologists: 2 abdominal radiologists with PD knowledge (Observers 1 and 2) and 1 radiologist without PD experience (Observer 3). We included 15 EPS patients and 16 controls. Observer 1 found 6 CT findings that were significantly more often present in EPS than in controls (p < or = 0.05): peritoneal enhancement, thickening, and calcifications; adhesions of bowel loops; signs of obstruction; and fluid loculation/septation. Observer 2 scored almost identically but Observer 3 scored differently. The sensitivity and specificity of a combination of specific CT findings were, respectively, 100% and 94% for Observers 1 and 2, and 79% and 88% for Observer 3. CT scans showed characteristic abnormalities that were significantly more often present in EPS patients compared to long-term PD control patients. CT can be used to confirm the diagnosis of EPS when experienced radiologists apply a combination of specific CT findings.

Peritoneal Dialysis in Brazil: Twenty-Five Years of Experience in a Single Center

To evaluate patient and technique survival and to provide an analysis of peritoneal dialysis (PD)-related peritonitis in 25 years of experience in a single center. Retrospective study of incident patients on PD from July 1980 to July 2005. Single, university based, Brazilian dialysis program. 680 patients were analyzed in our study from July 1980 to July 2005, with a cumulative experience of 15 303 patient-months. All patients over 15 years of age entering the dialysis program were included in the study. Patients with less than 30 days of follow-up were excluded. Biochemical and demographic variables, peritonitis episodes, and patient and technique survival were analyzed. Mean age at start of PD was 53 +/- 16 years; diabetic nephropathy was the main cause of chronic kidney disease. Cardiovascular disease was the main cause of death (44%); peritonitis was responsible for 16% of fatal events. The predictors of death in our study were diabetes [relative risk (RR) 1.23, p < 0.01], advanced age (RR 1.58, p < 0.001), low serum albumin level (RR 1.25, p < 0.01), and low serum phosphate level (RR 1.39, p < 0.001) upon starting PD. There were 1048 cases of peritonitis over the 25-year period, with a significant reduction in incidence after the introduction of the double-bag system. The number of incident PD patients originating from hemodialysis increased threefold over the observation period (p < 0.001), with a similar increase in comorbidities over time. In the largest single-center report of PD experience in Latin America, we describe the overall rate and trends over time of peritonitis as well as patient and technique survival, which are similar to previous reports. Significant changes in peritonitis rates and causative organisms as well as a significant time-dependent increase in high-risk patients starting PD were observed.

The experience of uncertainty among patients having peritoneal dialysis

This paper is a report of a study conducted to examine factors (severity and duration of the disease, credible authority, social support, education) that may influence the level of uncertainty and stress in patients having peritoneal dialysis. Although home peritoneal dialysis improves the patient's quality of life, it has both physiological and psychosocial disadvantages. These disadvantages, along with the experience of chronic disease (end-stage renal disease), create strong feelings of stress and uncertainty. Few studies have examined the correlation between the peritoneal dialysis experience and this level of uncertainty. The sample comprised 71 patients having peritoneal dialysis. Their average age was 57 years (SD = 12.8), average number of years of education was 11.9 (SD = 3.25), and average time on peritoneal dialysis was 30.6 months (SD = 12.8). Data were collected from February to June 2004; the subjects answered a questionnaire comprising medical data, perception of the nurse and/or physician as epistemic authority, satisfaction with social support, level of uncertainty regarding the disease, its treatment and outcomes, and level of stress. Only patients' self-rated health and level of education, and doctors' epistemic authority contributed statistically significantly to explaining patients' uncertainty. Level of education was found to affect both uncertainty and stress. The factors that most influenced patients' uncertainty were related to their ability to process information. Familiarity with their disease was less influential. Peritoneal dialysis nurses should be aware of the fact that they can reduce their patients' uncertainty and stress by helping them to maintain hope and to view their health status positively.

Association of Peritoneal Dialysis Clinic Size with Clinical Outcomes

Very few studies have addressed the relationship between number of peritoneal dialysis (PD) patients treated at a clinic (PD clinic size) and clinical outcomes. In a national prospective cohort study of incident PD patients (n = 236, from 26 clinics), we examined whether being treated at a larger PD clinic [>50 PD patients (n = 3 clinics) vs <or=50 PD patients (n = 23 clinics)] was associated with better patient outcomes, including fewer switches to hemodialysis, fewer cardiovascular events, lower cardiovascular mortality, and lower all-cause mortality. Multivariable Cox models were used to assess relative hazards (RHs) for modality switches, cardiovascular events, cardiovascular deaths, and all-cause deaths by PD clinic size. All models were adjusted for demographics, comorbidities, laboratory values, and clinic years in operation. Being treated at a clinic with >50 patients was associated with fewer switches to hemodialysis (RH = 0.13, 95% CI 0.06 - 0.31) and fewer cardiovascular events (RH = 0.62, 95% CI 0.06 - 0.98). No associations of PD clinic size with cardiovascular or all-cause mortality were seen. PD patients treated at clinics with greater numbers of PD patients may have better outcomes in terms of technique failure and cardiovascular morbidity. PD clinic size may act as a proxy of greater PD experience, more focus on the modality, and better PD practices at the clinic, resulting in better outcomes.

Long-Term Peritoneal Dialysis Experience in Portugal

Peritoneal dialysis (PD) penetration varies widely. Since the beginning of this therapy, indications have changed and outcomes have improved. In Portugal, PD still remains clearly underutilized. The results of a 20 year PD programme were evaluated: 312 cumulative patients, 48+/-16 years, 27%>60 years old, 27% diabetic, 59% with prior hemodialysis (HD). The main reason for admission was vascular access failure (48.7%). Admission due to patient preference has increased significantly between first and second decades of the programme (33% vs 47% (P<0.001)); 98 patients (31.4%) were treated with automated PD but this prescription increased to 43% of the active patients.A total of 376 Tenckhoff catheters were surgically implanted, recently by the Popovich-Moncrief technique (77 catheters): the cumulative survival was 82%, 64% and 50% at 1, 3 and 5 years,respectively. A better catheter survival was found in the last decade (85.7%, 69.6%, 54.8% versus 77.3%, 55.5%, 40.2%, at 1, 3 and 5 years, respectively (P=0.007). The patient and technique cumulative survivals were 91, 74, 55% and 85, 67, 41%, at 1, 3, and 5 years, respectively. The main drop-out was to hemodialysis (35.8%), followed by death (23.7%), and transplantation (21.5%). Peritonitis and access-related infections caused 35% of the transfer to HD. Cardiovascular events caused 58% of deaths. The median PD retention was 35.5 months. The rate of peritonitis has decreased to one episode /30 patient months. Hospital admission has also decreased to 4.8 days/patient year. This is a first report on long-term PD experience in Portugal. It has been an effective modality of renal replacement therapy, reflected by the growing patient preference in our PD programme.Experience, knowledge and new technical solutions have improved the outcomes.

Peritoneal Inflammation and High Transport Status

Current US average annual growth of peritoneal dialysis (PD) is reported to be around 6 to 11% (1). There are wide variations in the utilization of PD in different countries. Similarly, there are wide variations in technique survival among various centers. If death and transplantation are excluded, infectious complications have been the most common reason for transfer out of PD. Over the past two decades, with improved technology and connectology systems, there has been a significant reduction in the rate of infectious complications. Centers with longer PD experience report PD-associated peritonitis rates on an average close to one episode for every six to seven patient years. In parallel, there has been increasing recognition of the importance of adequacy and ultrafiltration capacity. New adequacy guidelines now include, in addition to targets for solute clearances, ultrafiltration capacity recognition and BP control recommendations. There is now an acute awareness of the importance of peritoneal membrane transport characteristics in achieving favorable long-term morbidity and mortality. Factors that determine peritoneal membrane function in an individual are confounded by the coexistence of chronic inflammation due to uremia or other diseases, malnutrition, obesity, advanced cardiovascular diseases with hyperlipidemic state, diabetes, old age, ethnicity, and duration of PD. Recently, high peritoneal transport status in incident PD patients in particular has received increased attention due to poor outcome in some of them. It is as yet unclear what determines such a status in new patients starting PD. Interestingly, some of these high transporters have poor outcome and others do as well as other PD patients. Those with poor outcomes are recognized by the higher prevalence of markers of inflammation, malnourishment, and/or hypoalbuminemia. Studies to address these issues have been inconclusive and often are anecdotal experiences and based on small population studies. Peritoneal membrane permeability varies widely among individuals and …