Intermittent Peritoneal Dialysis Patients Research Articles

Anemia in peritoneal dialysis patients

A normocytic normochromic anemia is one of the first signs of renal failure. Since anemia increases morbidity and mortality, its elimination is one of the essential objectives of the treatment. Human recombinant erythropoietin (rHuEPO) has changed the therapeutical approach to anemia. The aim of the present study was to compare efficacy of anemia correction in peritoneal dialysis patients depending on treatment and dialysis modality. The study is the retrospective analysis of 64 patients who presented to our Clinic in 2003. Eighteen (28.13%) patients were treated with rHuEPO, 14 (28%) underwent continuous ambulatory peritoneal dialysis (CAPD), 2 (100%)--automated peritoneal dialysis (APD) and 2 (33.3%)--intermittent peritoneal dialysis (IPD). Mean hemoglobin level was 98.6 +/- 17.82 g/l in patients treated with rHuEPO versus 98.81 +/- 15.14 g/l in patients without rHuEPO treatment. Erythropoietin requirements were 3392.85 +/- 1211.77 IU/week All patients received iron supplementation during rHuEPO therapy. Mean serum ferritin levels were 463.41 +/- 360 ug/l. Transferrin saturation (TSAT) was 0.35 +/- 0.16%. No difference of serum iron and TSAT levels was found between CAPD and IPD patients. The degree of anemia significantly differed between CAPD and IPD patients. A total of 17.11% of PD patients were given blood transfusions, most frequently during the first three months after the onset of dialysis. Our conclusion is that the number of patients receiving rHuEPO should be increased, as 50% of our patients should be substituted, while only 28% are being treated. As 50% of patients receiving rHuEPO failed to reach target Hgb levels, higher EPO doses should be considered. Iron stores should be continuously monitored, particularly in patients receiving rHuEPO, since iron deficiency is an important problem for patients undergoing peritoneal dialysis, especially during erythropoietin therapy. Oral iron supplementation is satisfactory in the majority of patients, and iron-gluconate is absorbed better than iron-sulphate. If required, intra-venous iron bolus is safe and efficient. Continuous peritoneal dialysis treatment improves blood count more effectively compared to intermittent procedures, as hemoglobin levels are significantly higher in patients with comparable iron stores. Peritoneal dialysis is particularly efficient in improving the blood count in diabetics, since no significant difference of anemia between patients affected by diabetes mellitus and the others could be found in our study.

Polymicrobial Outbreak of Intermittent Peritoneal Dialysis Peritonitis during External Wall Renovation at a Dialysis Center

To investigate an outbreak of peritonitis in intermittent peritoneal dialysis (IPD) patients. An outbreak investigation was performed to identify the etiology of the polymicrobial outbreak, and a retrospective case-control study was conducted to assess the risk factors for development of peritonitis. Renal dialysis center. Ten episodes of peritonitis occurred in 8 of 61 patients over a 6-month period in which 669 IPD procedures were analyzed. Field visit to renal dialysis center to examine the entire IPD procedure, inspect the hospital environment, and perform air bacterial count. The environmental factors and risk factors contributing to the polymicrobial peritonitis outbreak in IPD patients. The incidence of IPD peritonitis was determined before and after interventions. The causative organisms included Acinetobacter baumanii (6), Stenotrophomonas maltophilia (2), Pseudomonas aeruginosa (1), Candida albicans (1), C. tropicalis (1), Enterococcus (3), and Enterobacteriaceae (2). Four episodes of peritonitis involved infection by more than one organism. Air sampling of the environment detected a median of 110 colony forming units of bacteria per cubic meter of air, 10% of which were found to be Acinetobacter baumanii. The source of this polymicrobial outbreak was attributed to the bamboo scaffolding structure covering the external wall of the hospital during renovation. A retrospective case-control study indicated that the absence of the flush-before-fill step was a risk factor for development of peritonitis. In addition to invasive aspergillosis in transplant or oncology patients, Acinetobacter peritonitis in dialysis patients should be considered another microbial cause of outbreak associated with hospital renovation.

Epidemiologic and Demographic Aspects of Peritoneal Dialysis in Mexico

To assess some epidemiological and demographic aspects of peritoneal dialysis (PD) at the Instituto Mexicano del Seguro Social (IMSS), the major institution of social security in Mexico, that provides health care services for 57% of the Mexican population at the time of the study. A cross-sectional analysis of data about patients under peritoneal dialysis in 1992. A national survey containing demographic data, dialysis modality, type of catheter, peritonitis and death rates, and questions on costs, medical staff, and physical facilities for PD in all of the hospitals of the IMSS. All hospitals returned the information requested. Intermittent peritoneal dialysis (IPD) was performed in 19 hospitals, continuous ambulatory peritoneal dialysis (CAPD) in 11, and both modalities in 90. In 61 hospitals, a special area was designed for PD; in the rest of them, beds from general internal medicine departments were used. All hospitals had a head for the PD programs; overall, teams had 240 physicians and 765 nurses for IPD, and 182 physicians and 313 nurses for CAPD. CAPD prescription was four 2-L bags/day. For IPD, patients were hospitalized once a week and received 28 manually performed exchanges of 2-L bags; the mean time of hospitalization was 2.7 days, and 878 beds were used. The number of patients receiving PD was 7785, with a prevalence of 199.6 per million population. Of them, 4011 were on IPD and 3774 on CAPD; 54% of the patients were males. IPD patients' mean age was 49 +/- 17 yr, and that of CAPD patients' was 42 +/- 17 yr (NS). Diabetic nephropathy was the most frequent cause of ESRD (44%). Infection was the most important complication detected. Rates of peritonitis were 0.5/patient/yr on IPD and 0.8/patient/yr on CAPD. Annual mortality rates without stratification for specific causes were 34% in IPD and 17% in CAPD. Mortality rates may have been influenced by malnutrition and cardiovascular complications of diabetes, but specific causes of death were not investigated. All of the PD programs costs were covered by the institution. The cost per patient was not calculated, but IPD is known to be more expensive, due to its higher hospitalization rate. In spite of its higher cost and mortality, the institutions still use IPD, not so much on medical basis, but as the only alternative available for patients with adverse environmental, social, educational, and economic conditions for CAPD or HD.

A Comparison of Bone Scans in Uremic Patients Treated with Intermittent Peritoneal Dialysis Or Hemodialysis

The aim of the study was a comparative analysis of bone scans in uremic patients treated with intermittent peritoneal dialysis (IPD) or hemodialysis (HD). Bone scintigraphy was performed using technetium Tc 99m etidronate (EHDP) in 28 uremics (age 46.0 +/- 13.5 years, x +/- SD) on IPD for 3.1 +/- 3.0 months and 28 uremics (age 43.5 +/- 11.6 years) on HD for 47.3 +/- 33.9 months. Serum c terminal parathormone (cPTH) exceeded 5.3 +/- 3.3 and 6.8 +/- 3.5 times the upper normal limit of 1.4 ng/mL in IPD and HD patients, respectively. Despite significant differences in dialysis treatment duration in IPD and HD patients, an increased Tc 99m EHDP uptake in bones was shown with similar frequency, when all the groups were compared. However, in the group of patients with serum cPTH exceeding four times the upper normal limit (n = 30) or in the age group less than 45 years old (n = 26), a greater marker uptake was observed in HD patients. Significant differences (p < 0.05) were shown in the cranial vault: 33% of HD patients (n = 18) with higher cPTH and 47% of those less than 45 years old (n = 15) revealed an increased marker uptake, whereas it was not observed in any IPD patient. When scans of HD patients dialyzed less than (n = 11) and more than (n = 17) 30 months were compared, a significantly higher appearance of increased marker uptake was shown in cranial vault (41% vs 0%, p < 0.02) and in sacral bone (82% vs 36%, p < 0.02) in patients with longer dialysis. The latter group of HD patients also showed an increased marker uptake in cranial vault compared to the entire group of PD patients (41% vs 7%, p < 0.01). Our studies suggest that bone scan changes, indicating secondary hyperparathyroidism, progress significantly with prolongation of dialysis treatment, especially in patients with higher cPTH levels of younger age.

Influence of intraperitoneal gentamicin on peritoneal transport in IPD patients.

We have investigated the effect of intraperitoneal gentamicin on dialysis efficiency in 10 intermittent peritoneal dialysis (IPD) patients. The following parameters were measured: net ultrafiltration (UF); concentration ratios (D/P) of urea, creatinine, potassium; peritoneal clearances (ml/min) of urea, creatinine, potassium; mass transfer of sodium (MTNa); sodium sieving index (SCNa). It has been found that gentamicin significantly decreased D/P urea (p < 0.056) and D/P creatinine (p < 0.05). We found also a significant decrease of mean clearances of urea (p < 0.05) and creatinine (p < 0.05). The mean clearance of potassium did not significantly change. There was no significant change in UF, MTNa and SCNa. Our preliminary data suggest that gentamicin decreases the permeability of the peritoneum for certain low molecules in IPD patients, which may have a negative impact on dialysis efficiency.

Hematocrit Influence on Peritoneal Dialysis Effectiveness during Recombinant Human Erythropoietin Treatment in Patients with Chronic Renal Failure

Seven intermittent peritoneal dialysis (IPD) patients were investigated before and after correction of anemia with recombinant human erythropoietin (r-HuEPO). When hematocrit exceeded 30%, the peritoneal equilibration test was performed at 1, 2, 4, 8 hours. Correction of anemia was associated with a mean value increment in creatinine and phosphate clearance in 1- and 2-hour dwells. Differences in clearance of sodium, potassium, and urea in protein loss and glucose absorption before and after r-HuEPO therapy were not statistically significant. Increased creatinine and phosphate clearance during short dwells can be effected in IPD patients.

An outbreak of Candida tropicalis peritonitis in patients on intermittent peritoneal dialysis

An outbreak of Candida tropicalis peritonitis in intermittent peritoneal dialysis patients during a 6-week period is reported from a general hospital. Five patients were involved and there were three deaths. The strains recovered from affected patients were identical to those recovered from the water baths on the basis of biotyping, antimicrobial susceptibility pattern and chromosomal DNA fingerprints. No further cases were identified on subsequent surveillance after the prohibition of wet-warming of peritoneal dialysate in the hospital.

Effect of Peritoneal Macrophages from Intermittent Peritoneal Dialysis Patients on Lymphocytes in Culture

To investigate the biological activity of peritoneal macrophages, cells isolated from dialysate of 30 patients with end-stage kidney disease treated by intermittent peritoneal dialysis and from ascites of 6 patients with cardiac insufficiency (relative control group) were added to autologous, phytohemagglutinin (PHA)-stimulated lymphocyte cultures. Macrophages of dialyzed patients induced a dose-dependent increase in autologous lymphocyte proliferation, whereas macrophages obtained from control subjects exerted a suppressive effect on those cultures. The enhanced lymphocyte proliferation by macrophages from dialyzed patients was corroborated by the increased metabolic activity of macrophages as evaluated by the increased nitro blue tetrazolium (NBT) reduction test and increased functional expression of Fc receptors (FcR). The subpopulation of macrophages from patients with HLA-DR antigens as determined by HB55 monoclonal antibody, inhibited lymphoproliferation in vitro. We conclude that peritoneal macrophages from dialyzed patients represent a heterogenous population of cells with different phenotypic and functional characteristics.

Serum erythropoietin levels and hematocrit in end-stage renal disease: influence of the mode of dialysis.

Serum erythropoietin (Ep) levels were measured by radioimmunoassay in 70 patients with end-stage renal disease (ESRD) to evaluate the influence of the mode of dialysis on the relationship between serum Ep levels and the severity of anemia. Thirty-five patients were on hemodialysis (HD), seven were on intermittent peritoneal dialysis (IPD), and 28 were on continuous ambulatory peritoneal dialysis (CAPD). Compared to HD, CAPD patients had higher serum Ep (CAPD), 46.1 +/- 13.4 v HD, 16.9 +/- 2.2 mU/mL) and hematocrit (CAPD, 33.9 +/- 2.5 v HD, 24.8 +/- 1.4%; P less than 0.05). The Ep and Hct values for IPD patients were intermediate between the other two groups. Serum Ep levels were higher in CAPD patients in the first 4 weeks of initiation of CAPD (144 +/- 35 mU/mL, n = 6) than later (39 +/- 6.4 mU/mL, n = 24). A significant fluctuation in serum Ep and Hct values was noted in patients on all three modes of dialysis, when multiple samples were obtained at different time intervals. There was a weak correlation between serum Ep and Hct in the three groups of dialysis patients; r = 0.36, P less than 0.005. The data suggest that CAPD provides a better biochemical milieu for Ep production and responsiveness than HD treatment of ESRD.

Transcutaneous monitoring of blood gas tensions in patients on intermittent peritoneal dialysis.

A relative contraindication to intermittent peritoneal dialysis (IPD) is chronic lung disease. To evaluate whether the instillation of 2 L of fluid into the peritoneal cavity affects respiratory function, five IPD patients were studied in the supine position during the first 4 h of a routine IPD session. Blood gas tensions were monitored transcutaneously throughout the study period. At the onset of dialysis, mean transcutaneous blood oxygen tension (PtcO2) was 70.6 +/- 9.1 mm Hg. It decreased to 55 +/- 9.9 mm Hg (22% change from basal values) during the instillation of dialysate. Upon drainage, PtcO2 returned to baseline. This sequence of events repeated itself on subsequent exchanges, although with decreasing decrements of PtcO2 with each consecutive exchange (decrease to 58.6 +/- 7.05, 61 +/- 6.5, 63.8 +/- 5.2 mm Hg corresponding to 16%, 12.7%, and 9.6%, respectively, during the second to fourth exchanges). Transcutaneous blood carbon dioxide tension, PtcCO2, showed a very mild increase during the study (33 +/- 7.1 to 38 +/- 6.0 mm Hg). In two patients, the same study protocol was performed during the last 4 h of an IPD session. In these two patients, there was only a 5% variation of PtcO2 from baseline values. These results suggest that an adaptive response to the hypoxemia induced by dialysate instillation rapidly occurs in IPD patients.

Controlled comparison of hemodialysis and peritoneal dialysis: Veterans Administration multicenter study

We measured mortality and morbidity among 114 patients assigned randomly to home hemodialysis (HD) and home intermittent peritoneal dialysis (IPD). Data were collected during the time of home training and for 12 months after initiation of home dialysis. Training time was shorter for the IPD than for the HD patients (P less than 0.001) with median time 1.8 months for IPD and 3.9 months for HD. Switching to the alternative mode of treatment was more frequent for the IPD group (29/59 vs. 5/55, P less than 0.001). Survival time was not different, perhaps because of the modality change. More IPD patients were hospitalized in the first 6 months (20 for IPD vs. 9 for HD, P = 0.02), but they had fewer troublesome cardiovascular events in the first year (0 vs. 12, P less than 0.001). The HD patients maintained better nutritional status as reflected in body weight and arm muscle circumference and possibly in urea appearance rate. Thus, these data suggest that for most patients, IPD is a less satisfactory form of therapy than HD, but certain advantages of IPD did emerge. Applications of this information to the currently more popular mode of CAPD await further study.