Peritoneal Dialysis Therapy Research Articles

Health Insurance and the Use of Peritoneal Dialysis in the United States

Many patients in the United States have limited or no health insurance at the time they develop end-stage renal disease (ESRD). We examined whether health insurance limitations affected the likelihood of peritoneal dialysis (PD) use. Retrospective cohort analysis of patients from the US Renal Data System initiating dialysis therapy in 2006 through2012. We identified socioeconomically similar groups of patients to examine the association between health insurance and PD use. Patients aged 60 to 64 years with "limited insurance" (defined as having Medicaid or no insurance) at ESRD onset were compared with patients aged66 to 70 years who were dually eligible for Medicare and Medicaid at ESRD onset. Type of insurance coverage at ESRD onset. The likelihoods of receiving PD before dialysis month 4, when all patients qualified for Medicare due to ESRD, and of switching to PD therapy following receipt of Medicare. After adjusting for observable patient and geographic differences, patients with limited insurance had an absolute 2.4% (95% CI, 1.1%-3.7%) lower probability of PD use by dialysismonth 4 compared with patients with Medicare at ESRD onset. The association between insurance and PD use reversed when patients became Medicare eligible; patients with limited insurance had a 3-fold higher rate of switching to PD therapy between months 4 and 12 of dialysis (HR, 2.9; 95% CI, 1.8-4.6) compared with patients with Medicare at ESRD onset. Because this study was observational, there is a potential for bias from unmeasured patient-level factors. Despite Medicare's policy of covering patients in the month that they initiate PD therapy, insurance limitations remain a barrier to PD use for many patients. Educating providers about Medicare reimbursement policy and expanding access to pre-ESRD education and training may help overcome these barriers.

MODERN VISION OF DEVELOPMENT FACTORS OF PROTEIN-ENERGY MALNUTRITION SYNDROME IN PATIENTS, RECEIVING PERITONEAL DIALYSIS

Patients who have end-stage chronic kidney disease (СKD) and who receive substitutive peritoneal dialysis (PD) therapy, often have complication such as protein-energy malnutrition syndrome (PEMS). Important prognostic value is given to nutritional disorders as they increase prior disease development, complicate its correction, influence survival rate of patients of this category.
 Purpose: to explore prevalence of protein-energy malnutrition syndrome in PD patients and define factors of its development.
 Materials and methods: 67 PD patients were examined. Evaluation of nutritional status in patients under investigation was made using development of complex methodology that includes 5 specifications – body mass index (BMI), triceps skinfold, arm circumference – biceps, floating albumin and seraalbumin, absolute number of lymphocyte.
 Results. PEMS was found in 35,8% of patients, 29,8% had mild case and 6% had moderate case with mixed form domination. 26,8% of PD patients had average high or high transport characteristics of abdominal membrane that provided increased protein loss through abdominal membrane on PD. It was determined that with the growth of С-reactive protein (CRP) level nutritional disorders increased. In our research chronic inflammation syndrome was found in 16,3% of cases. Besides, protein loss was growing fast after another dialysis peritonitis. Expressed deficit of daily consumption of protein was registered in 29,2% of patients.
 Conclusion. Our researches analysis allowed us to define that risk factors of formation of protein metabolism disorders in PD patients are low protein consumption, connection with nutritional deficiency syndrome, system inflammatory reaction, protein loss with dialysis fluid having high transport characteristics of abdominal membrane and repeated dialysis peritonitis.

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.
 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.
 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.
 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.
 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.

Longitudinal Weight Change During CKD Progression and Its Association With Subsequent Mortality

Few studies have investigated the changes in weight that may occur over time among adults with the progression of chronic kidney disease (CKD). Whether such weight changes are independently associated with death after the onset of end-stage renal disease has also not been rigorously examined. Prospective cohort study. We studied 3,933 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study, a longitudinal cohort of patients with CKD. We also performed similar analyses among 1,067 participants of the African American Study of Kidney Disease and Hypertension (AASK). Estimated glomerular filtration rate (eGFR) and weight change during CKD. Weight and all-cause mortality after dialysis therapy initiation. During a median follow-up of 5.7 years in CRIC, weight change was not linear. Weight was stable until cystatin C-based eGFR (eGFRcys) decreased to<35mL/min/1.73m2; thereafter, weight declined at a mean rate of 1.45 kg (95% CI, 1.19-1.70) for every 10 mL/min/1.73m2 decline in eGFRcys. Among the 770 CRIC participants who began hemodialysis or peritoneal dialysis therapy during follow-up, a >5% annualized weight loss after eGFR decreased to<35mL/min/1.73m2 was associated with a 54% higher risk for death after dialysis therapy initiation (95% CI, 1.17-2.03) compared with those with more stable weight (annualized weight changes within 5% of baseline) in adjusted analysis. Similar findings were observed in the AASK. Inclusion of research participants only; inability to distinguish intentional versus unintentional weight loss. Significant weight loss began relatively early during the course of CKD and was associated with a substantially higher risk for death after dialysis therapy initiation. Further studies are needed to determine whether interventions to optimize weight and nutritional status before the initiation of dialysis therapy will improve outcomes after end-stage renal disease.

Peritoneal dialysis for acute kidney injury.

Peritoneal dialysis (PD) has been suggested as an effective and safe dialysis modality in patients with acute kidney injury (AKI). However, whether PD is superior to extracorporeal therapy (e.g. haemodialysis) in terms of improving survival, recovery of kidney function, metabolic and clinical outcomes is still inconclusive. The aim of this review was to evaluate the benefits and harms of PD for patients with AKI compared with extracorporeal therapy or different PD modalities. We searched the Cochrane Kidney and Transplant Register of Studies to 29 May 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We also searched the China Biological Medicine Database. We included patients with AKI who were randomised to receive PD, extracorporeal therapy, or different PD modalities regardless of their age, sex, primary disease and clinical course. Screening, selection, data extraction and quality assessments for each retrieved article were carried out by two authors using standardised forms. Authors contacted when published data were incomplete. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI). Heterogeneity among studies was explored using the Cochran Q statistic and the I2 test. Outcomes of interest included all-cause mortality, recovery of kidney function, weekly delivered Kt/V, correction of acidosis, fluid removal, duration of dialysis, and infectious complications. Confidence in the evidence was assessing using GRADE. Six studies (484 participants) met our inclusion criteria. Five studies compared high volume PD with daily haemodialysis, extended daily haemodialysis, or continuous renal replacement therapy. One study focused on the intensity of PD. The overall risk of bias was low to unclear. Compared to extracorporeal therapy, PD probably made little or no difference to all-cause mortality (4 studies, 383 participants: RR 1.12, 95% CI 0.81 to 1.55; I2 = 69%; moderate certainty evidence), or kidney function recovery (3 studies, 333 participants: RR 0.95, 95% CI 0.68 to 1.35; I2 = 0%; moderate certainty evidence). PD probably slightly reduces the amount of fluid removal compared to extracorporeal therapy (3 studies, 313 participants: MD -0.59 L/d, 95% CI -1.19 to 0.01; I2 = 89%; low certainty evidence), and probably made little or no difference to infectious complications (2 studies, 263 participants: RR 1.03, 95% CI 0.60 to 1.78; I2 = 0%; low certainty evidence). It is uncertain whether PD compared to extracorporeal therapy has any effects on weekly delivered Kt/V (2 studies, 263 participants: MD -2.47, 95% CI -5.17 to 0.22; I2 = 99%; very low certainty evidence), correction of acidosis (2 studies, 89 participants: RR 1.32, 95% CI 0.13 to 13.60; I2 = 96%; very low certainty evidence), or duration of dialysis (2 studies, 170 participants: MD -1.01 hours, 95% CI -91.49 to 89.47; I2 = 98%; very low certainty evidence). Heterogeneity was high and this may be due to the different extracorporeal therapies used.One study (61 participants) reported little or no difference to all-cause mortality, kidney function recovery, or infection between low and high and intensity PD. Weekly delivered Kt/V and fluid removal was lower with low compared to high intensity PD. Based on moderate (mortality, recovery of kidney function), low (infectious complications), or very low certainty evidence (correction of acidosis) there is probably little or no difference between PD and extracorporeal therapy for treating AKI. Fluid removal (low certainty) and weekly delivered Kt/V (very low certainty) may be higher with extracorporeal therapy.

Total Bilirubin in Prognosis for Mortality in End-Stage Renal Disease Patients on Peritoneal Dialysis Therapy.

BackgroundEvidence regarding bilirubin's antioxidant properties and predictive roles is growing. However, it is unclear whether serum bilirubin would have a prognostic impact on survival of patients with regular peritoneal dialysis.Methods and ResultsWe used the Taiwan Renal Registry Data System utilizing its 2005‐2012 data set. Data from patients on regular peritoneal dialysis were retrieved. The primary end point of observation was 3‐year mortality. A total of 3704 patients (mean age 53.5 years, 44% male) were enrolled, and these patients were divided according to baseline serum total bilirubin levels (<0.3, 0.3‐0.4, 0.4‐0.5, 0.5‐0.6, >0.6 mg/dL). Serum total bilirubin level was linearly related to age, incidence of hypertension, and type 2 diabetes mellitus. At the end of the observation period with a mean follow‐up of 2.12±1.07 years, 1095 (30.6%) deaths were detected. Serum total bilirubin level and 3‐year mortality rate presented a U‐shaped relationship. Those with serum total bilirubin 0.5 to 0.6 mg/dL had the lowest 3‐year mortality rate (24%). After adjustment for age, sex, underlying systemic disorders, medications, and laboratory discrepancies, serum total bilirubin still played an independent role for predicting 3‐year mortality.ConclusionsBaseline serum total bilirubin level is significantly associated with 3‐year mortality among patients receiving regular peritoneal dialysis.

Risk factors for encapsulating peritoneal sclerosis: Analysis of a 36‐year experience in a University Hospital

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication that occurs in peritoneal dialysis (PD) therapy. The present study aimed to identify the risk factors, especially peritonitis and biocompatible PD fluid. The study included 703 patients who received PD between January 1980 and March 2015 at two centres. The patients were divided into two groups: those who had developed EPS (EPS group: n = 44) and those who had no documentary evidence of EPS (non-EPS group: n = 659). The independent risks of EPS were determined by univariate and multivariate logistic models. Encapsulating peritoneal sclerosis occurred in 44/703 (6.3%) patients between January 1980 and March 2015. In multivariate logistic models of risk factors correlated with EPS, dialysate to plasma creatinine ratio (D/P Cr) by peritoneal equilibration test (PET) and history of peritonitis were risk factors for EPS development (P < 0.01, respectively) in addition to PD duration. Especially, total duration of peritonitis, defined by period between onset and resolution of peritonitis, was an important risk factor for EPS development in patients with a history of peritonitis. Receiver operating characteristic (ROC) curve analysis revealed that cut-off point for EPS development was 36 days. Moreover, biocompatible PD fluid contributed to decreased EPS development. Both the longer duration of peritonitis and higher D/P Cr, as well as the longer PD duration, were risk factors for EPS development. Furthermore, use of biocompatible PD fluid contributed to the decrease in EPS development.

PD VS HD in Post-Economic Crisis Greece—Differences in Patient Characteristics and Estimation of Therapy Cost

The aim of this study was to investigate patient characteristics and make an estimation of the cost of peritoneal dialysis (PD) and hemodialysis (HD) to Greek society during the economic crisis. We recorded the characteristics and the total cost of dialysis treatment in 100 patients on PD and 100 on HD. Total costs included dialysis procedure, consumables, drugs, laboratory tests, food, and transportation fees (only HD), covered by patients' insurance. Also included were medical and administrative salaries, purchase and maintenance of equipment and sanitary material, all covered by the state hospital. The mean patient age was 64.5 ± 16.8 years (PD) and 62.8 ± 15.1 (HD) (p < 0,001). The most common cause of end-stage renal disease (ESRD) was diabetes (32% for PD and 24% for HD patients). A total of 35% of the PD patients were employed vs 4% of the HD patients (p < 0,001). The mean distance from home for PD patients was 41.6 ± 17.3 km, while for HD patients, it was 9.4 ± 1.5 km (p < 0,001). Mean monthly cost for PD and HD treatment per patient was €4,019.20 ± 1,126.30 and €3,254.30 ± 37.50, respectively, both fully covered by patients' insurance. Mean monthly cost for PD or HD dialysis unit maintenance was €11,660.80 and €56,270.50, respectively, also fully covered by the state. There is likely to be a considerable difference in terms of total cost of PD vs HD therapy, owing to the fact that the operational cost of a PD unit appears to be significantly lower than that of a HD unit.

Pharmacological inhibition of heparin-binding EGF-like growth factor promotes peritoneal angiogenesis in a peritoneal dialysis rat model.

Molecular mechanisms of peritoneal dialysis (PD) ultrafiltration failure, peritoneal neo-angiogenesis, and fibrosis remain to be determined. We aimed to determine the role of heparin-binding EGF-like growth factor (HB-EGF) inhibition on angiogenesis of peritoneal membrane in a PD rat model. 32 male Wistar rats were assigned into (1) control group; (2) uremic non-PD group: subtotal nephrectomy-induced uremic rats without PD; (3) uremic rats subjected to PD: uremic rats that were dialyzed with Dianeal® for 4weeks; (4) CRM 197 group: dialyzed uremic rats were supplemented with CRM197, a specific HB-EGF inhibitor. Peritoneal transport function was examined by peritoneal equilibration test. Expression of HB-EGF and EGFR in peritoneal samples were examined by real-time PCR, immunohistochemical staining, and western blot. Progressive angiogenesis and fibrosis were observed in uremic PD rats, and there were associated with decreased net ultrafiltration (nUF), increased permeability of peritoneal membrane, and reduced expression of HB-EGF and EGFR protein and mRNA in uremic PD rats compared to uremic non-PD or control groups (both p<0.05). CRM197 significantly induced peritoneal membrane permeability, decreased nUF, increased higher vessel density, and reduced pericyte count compared to that of uremic PD rats. The levels of HB-EGF and EGFR expression negatively correlated with vessel density in peritoneal membrane (both p<0.001). PD therapy was associated with peritoneal angiogenesis, functional deterioration, and downregulation of HB-EGF/EGFR. Pharmacological inhibition of HB-EGF promoted PD-induced peritoneal angiogenesis and fibrosis and ultrafiltration decline, suggesting that HB-EGF downregulation contributes to peritoneal functional deterioration in the uremic PD rat model.

Factores que influyen en la adherencia al tratamiento del paciente en diálisis peritoneal

Introducción: Actualmente, los profesionales de enfermería al implementar los cuidados para el paciente con enfermedad renal crónica mediante diálisis peritoneal, encuentran como principal dificultad la poca adherencia del mismo en las áreas correspondientes al dominio en la técnica, control de factores nutricionales, control hídrico y manejo farmacológico entre otros; los cuales conllevan un impacto negativo en la permanencia en la terapia así como en la supervivencia. Objetivo: Explorar los factores que influyen en la adherencia de los pacientes adultos a la terapia dialítica peritoneal y las consecuencias de la falta de ésta reportadas en la literatura. Material y Método: La búsqueda electrónica se realizó utilizando las bases de datos PUBMED, meta buscadores como google académico, Epistemonikos, Scielo, entre otros. Se consideraron estudios primarios realizados en pacientes adultos de 18 a 80 años, entre los años 2008-2015, en idioma inglés y español. Resultado: Los pacientes en DP presentan problemas de falta de adherencia en mayor proporción en los parámetros nutricionales, restricción de fluidos seguida del manejo correcto de la técnica y pautas farmacológicas indicadas por el profesional de la salud. Conclusión: La adherencia al tratamiento del paciente en diálisis peritoneal debe ser explorada por enfermería por su diversa complejidad mediante estudios fenomenológicos.

Assessment of Nutritional Status and Metabolic Syndrome in Peritoneal Dialysis Patients: A Pilot Study

Aim : Nutritional deficiencies and metabolic syndrome (MS) is challenge in chronic kidney disease patients with peritoneal dialysis(PD). This study was planned in order to assess the nutritional status and metabolic syndrome in PD patients. Methods: This study was performed on clinically stable patients that were undergoing PD therapy. Energy and nutrient intakes were determined with consequently three days dietary record. The statement of MS was identified according to MS criteria adopted for PD patients. Results: The prevalence of MS was found 64.3%. The mean duration of PD in with-MS(35.4±25.23mo.) was lower than without-MS(44.3±30.99mo.) (p>0.05). Patients with MS had significantly greater systolic/diastolic blood pressure and lower high-density-lypoprotein cholesterol levels (HDL-C) (p<0.05). According to the body mass index (BMI), the 83.3% of patients’ with-MS and 30% without-MS were found overweight and body fat mass was significant higher in patients with-MS(p<0.05). The mean daily protein intakes per kilograms of body weight determined lower with-MS patients (0.8±0.25g/kg) than without-MS (0.9±0.29 g/kg). Conclusion: The prevalence of MS is remarkably high. The daily dietary energy and protein intakes were found under the recommended levels. Inadequate energy and protein intake increase loss of muscle mass and also excessive energy intake leads to obesity. Monitoring of nutritional status of PD patients is important both in prevention and progression of MS.

Human Peritoneal Mesothelial Cell Death Induced by High-Glucose Hypertonic Solution Involves Ca2+ and Na+ Ions and Oxidative Stress with the Participation of PKC/NOX2 and PI3K/Akt Pathways.

Chronic peritoneal dialysis (PD) therapy is equally efficient as hemodialysis while providing greater patient comfort and mobility. Therefore, PD is the treatment of choice for several types of renal patients. During PD, a high-glucose hyperosmotic (HGH) solution is administered into the peritoneal cavity to generate an osmotic gradient that promotes water and solutes transport from peritoneal blood to the dialysis solution. Unfortunately, PD has been associated with a loss of peritoneal viability and function through the generation of a severe inflammatory state that induces human peritoneal mesothelial cell (HPMC) death. Despite this deleterious effect, the precise molecular mechanism of HPMC death as induced by HGH solutions is far from being understood. Therefore, the aim of this study was to explore the pathways involved in HGH solution-induced HPMC death. HGH-induced HPMC death included influxes of intracellular Ca2+ and Na+. Furthermore, HGH-induced HPMC death was inhibited by antioxidant and reducing agents. In line with this, HPMC death was induced solely by increased oxidative stress. In addition to this, the cPKC/NOX2 and PI3K/Akt intracellular signaling pathways also participated in HGH-induced HPMC death. The participation of PI3K/Akt intracellular is in agreement with previously shown in rat PMC apoptosis. These findings contribute toward fully elucidating the underlying molecular mechanism mediating peritoneal mesothelial cell death induced by high-glucose solutions during peritoneal dialysis.

Annual peritoneal dialysis report 2014, the peritoneal dialysis registry

BackgroundSince 2009, the peritoneal dialysis (PD) registry has been carried out as part of Japanese Society for Dialysis Therapy (JSDT) Renal Data Registry with the cooperation of Japanese Society for Peritoneal Dialysis. In this study, the current status of PD patients is reported on the basis of the results of the survey conducted at the end of 2014.MethodsThe subjects were PD patients who lived in Japan and participated in the 2014 survey. Descriptive analysis was performed for various items including the current status of the combined use of PD and another dialysis modalities such as hemodialysis or hemodiafiltration, the method of exchanging PD fluid, the use of an automated peritoneal dialysis machine, and the incidences of peritonitis and catheter exit-site infection.ResultsFrom the results of the facility survey in 2014, the number of PD patients was 9255, a decrease of 137 from that in 2013. Among the entire dialysis patient population, 2.9% were PD patients, a decrease of 0.1%. One thousand thirteen (21%) among them were on the combination therapy of PD and hemodialysis or hemodiafiltration. The mean incidence of peritonitis was 0.21 per patient per year in another expression as once per 57.1 patients per month. The mean incidence of catheter exit-site infection was 0.40 per patient per year in the other expression as once per 30.0 patients per month.ConclusionsThe number of PD patients has been stable around 9000~10,000 in these 10 years. High percentage of the combination therapy of PD and other dialysis modality and the lower PD dialysis dose was a unique point of the current PD in Japan. The patient’s and center’s peritonitis rates were very low as around 0.2 per patient-year. PD registry clearly showed the current trends in PD in Japan which were a little different from those in other many countries.Trial registrationJSDT renal data registry was approved by the ethical committee of JSDT and registered in “University hospital Medical Information Network (UMIN) Clinical Trials Registry” as an approved number of UMIN000018641 in 2015.

IL-6 promotes epithelial-to-mesenchymal transition of human peritoneal mesothelial cells possibly through the JAK2/STAT3 signaling pathway

Long-term peritoneal dialysis (PD) therapy results in functional and structural alteration of the peritoneal membrane, including epithelial-to-mesenchymal transition (EMT). Interleukin 6 (IL-6) is a local pleiotropic cytokine, hypothesized to play an important role in EMT. This study was designed to investigate the role of IL-6 in EMT and peritoneal membrane dysfunction in long-term PD patients by assessing the level of IL-6 in dialysate and exploring the relationship between IL-6, the related signaling pathway JAK2/STAT3, and EMT, using in vitro cellular and molecular techniques. Plasma and dialysate levels of IL-6 were significantly higher in PD ultrafiltration failure patients compared with patients without ultrafiltration failure and were negatively correlated with measures of PD adequacy. In vitro IL-6 treatment changed human peritoneal mesothelial cell phenotype from a typical cobblestone-like to a fibroblast-like appearance and increased cell viability. IL-6 treatment increased α-smooth muscle actin and vascular endothelial growth factor expression but decreased E-cadherin expression. IL-6 treatment activated the JAK/STAT signaling pathway. However, the JAK2/STAT3 inhibitor WP1066 prevented IL-6-induced activation of the JAK2/STAT3 pathway and EMT. We conclude that IL-6 promotes the EMT process, possibly by activating the JAK2/STAT3 signaling pathway. IL-6 may serve as a novel therapeutic target for preventing EMT, and preservation of the peritoneal membrane may arise from these studies.

Clinical Outcomes of Peritoneal Dialysis in End-Stage Renal Disease Patients with Liver Cirrhosis: A Propensity Score Matching Study.

♦ BACKGROUND: Clinical results of long-term peritoneal dialysis (PD) therapy in patients with liver cirrhosis (LC) and end-stage renal disease (ESRD) are controversial. This study evaluated the clinical outcomes of LC patients undergoing PD. ♦ METHODS: Clinical records were retrospectively collected from a single center between January 2007 and December 2014. An analysis of PD patients with LC and without liver disease was performed using propensity score matching. We further restricted matching by age, gender, and the presence of diabetes mellitus. Two cohorts of 33 patients each were selected. Early technical complications were defined as the presence of catheter-related complications, including malposition, leakage, omental wrapping, obstruction, and requiring a transfer to hemodialysis (HD) within 6 months of initiating PD. ♦ RESULTS: Mean PD duration was lower in LC patients (57.2 ± 46.1 months) than in controls (85.8 ± 64.2 months). Blood urea nitrogen, creatinine, and albumin levels were significantly lower in LC patients than in the control group. Cystatin C and cystatin C-based glomerular filtration rates were not significantly different in the LC group compared with those in the controls. We found that the risks for early technical complications, peritonitis, and long-term PD and patient survival were not higher in patients with LC than in those without LC. Ascites were easily controlled, and hepatic encephalopathy did not affect PD maintenance in LC patients. ♦ CONCLUSIONS: The clinical outcomes, including technical complications, peritonitis, and patients' survival, suggest that PD can be used as a renal replacement therapy in ESRD patients with LC.

Association of Pre-Transplant Dialysis Modality and Post-Transplant Outcomes: A Meta-Analysis.

♦ BACKGROUND: It remains unclear whether post-transplant outcomes differ according to the pre-transplant dialysis modality (peritoneal dialysis [PD] versus hemodialysis [HD]). We performed a meta-analysis of studies that assessed either post-transplant mortality, graft survival, or delayed graft function (DGF) in both PD and HD patients. ♦ METHODS: Two independent authors searched English-language literature from January 1, 1980, through August 31, 2014, national conference proceedings, and reference lists. We used combinations of terms related to dialysis (hemodialysis, peritoneal dialysis, or renal replacement therapy), kidney transplant, and outcomes. Studies were included if they measured any of the 3 post-transplant study outcomes in both pre-transplant HD and PD. ♦ RESULTS: A total of 16 studies were included in the final analysis. Of these, 6 studies reported adjusted hazard ratio for mortality, pooled adjusted risk ratio: 0.89 (95% confidence interval [CI] 0.82 - 0.97) in favor of PD (p = 0.006). The same 6 studies reported adjusted hazard ratio for graft survival, pooled adjusted risk ratio: 0.97 (95% CI 0.92 - 1.01, p = 0.16). A total of 13 studies reported unadjusted DGF. Pooled odds ratio: 0.5 (95% CI 0.41 - 0.63) in favor of PD (p < 0.005). Significant heterogeneity observed for all outcomes: I2 = 72.7%, I2 = 59.9%, and I2 = 66.8%, respectively. ♦ CONCLUSIONS: Based on these results, pre-transplant PD is associated with better post-transplant survival than HD. Pre-transplant PD was also associated with decreased risk for DGF compared with HD, although these results were unadjusted. There was no significant difference in graft survival between pre-transplant HD and PD. These results suggest that PD may be the preferred dialysis modality for patients expected to receive a transplant.

Urgent-Start Peritoneal Dialysis Complications: Prevalence and Risk Factors

Mechanical complications are of particular concern in urgent-start peritoneal dialysis (PD) because of the shorter break-in period. However, risk factors have been reported inconsistently and data in urgent-start PD populations are limited. Observational cohort study. All patients treated with urgent-start PD, defined as PD therapy initiated within 1 week after catheter insertion, January 2003 to May2013. Age, sex, abdominal surgery history, body mass index, hemoglobin level, albumin level, C-reactive protein level, break-in period (period between catheter insertion and PD therapy initiation), dialysate exchange volume, and use of overnight dwell. The presence of mechanical complications related to abdominal wall or catheter, including hernia, hydrothorax, hydrocele, subcutaneous leak, pericatheter leak, catheter malposition, omental wrap, and obstruction. 922 patients on urgent-start PD therapy were enrolled (mean age, 59.1±15.0 [SD] years). Prevalences of abdominal wall and catheter complications were 4.8% and 9.5%, respectively. The most common abdominal wall complication was hernia (55%), followed by hydrothorax (25%). On adjustment, male sex (HR, 5.41; 95% CI, 2.15-13.59; P<0.001) and history of abdominal surgery (HR, 2.34; 95% CI, 1.04-5.26; P=0.04) were independently associated with higher risk for developing abdominal wall complications. As a cohort study, comparisons could not be established between urgent-start PD and conventional PD. Urgent-start PD is a safe and practicable approach. Male sex and history of abdominal surgery could contribute to the development of abdominal wall complications.

"Biocompatible" Neutral pH Low-GDP Peritoneal Dialysis Solutions: Much Ado About Nothing?

Adverse outcomes in peritoneal dialysis (PD), including PD related infections, the loss of residual kidney function (RKF), and longitudinal, deleterious changes in peritoneal membrane function continue to limit the long-term success of PD therapy. The observation that these deleterious changes occur upon exposure to conventional glucose-based PD solutions fuels the search for a more biocompatible PD solution. The development of a novel PD solution with a neutral pH, and lower in glucose degradation products (GDPs) compared to its conventional predecessors has been labeled a "biocompatible" solution. While considerable evidence in support of these novel solutions' biocompatibility has emerged from cell culture and animal studies, the clinical benefits as compared to conventional PD solutions are less clear. Neutral pH low GDP (NpHLGDP) PD solutions appear to be effective in reducing infusion pain, but their effects on other clinical endpoints including peritoneal membrane function, preservation of RKF, PD-related infections, and technique and patient survival are less clear. The literature is limited by studies characterized by relatively few patients, short follow-up time, heterogeneity with regards to the novel PD solution type under study, and the different patient populations under study. Nonetheless, the search for a more biocompatible PD solution continues with emerging data on promising non glucose-based solutions.

Monitoring and complications during neonatal/pediatric ECMO run

Extracorporeal membrane oxygenation (ECMO) is a commonly used form of mechanical circulatory support in children with congenital or acquired heart disease, and cardiac failure refractory to conventional medical treatments.1 The cardiac output is partially or completely provided by the ECMO machine. To assess how much support is needed at any given time, a constant balance of oxygen delivery and oxygen consumption is required. Permanent monitoring of flow, hemoglobin, arterial, and mixed venous saturations are key elements to provide the needed understanding and continuous guidance of body requirements, aiming at controlling and maintaining optimal management of the ECMO patient. Although ECMO is lifesaving in many circumstances, it bares challenges and certain risks of complications. Despite bioline-coated circuits, anticoagulation is required. Measurement of activated clotting time (ACT) and activated partial thromboplastin time (APTT) are both used to guide anticoagulation, but it is unclear which method is the best, and constant monitoring of the hemoglobin level allows the early detection of internal and external bleeding.2 For children, sedation and analgesia, most often in combination with paralysis, is unavoidable for a smooth ECMO run. On the other hand, with such treatment on board, it is almost impossible to assess the neurological status of the patient on ECMO. Different monitoring tools, such as cerebral near infrared spectroscopy (NIRS) and serial brain ultrasound studies, are used to estimate brain integrity and function, but further research is needed to show which methods are the most practical and useful to achieve a favorable outcome.3 Nutrition in critically ill children is known to be crucial but debated how to achieve as the gut perfusion can be impaired and therefore the risk of necrotizing enterocolitis (NEC) is increased. It is discussed if somatic perfusion by NIRS monitoring can help to avoid NEC.4 The kidney function is often impaired in these critically ill children and careful monitoring of kidney function and urine output leads the decision when to start which type of renal replacement therapy for renal clearance and/or fluid removal. Techniques available include peritoneal dialysis or continuous renal replacement therapy (CRRT) incorporated with the ECMO circuit. Medication dosing is under discussion in many centers as the circulatory volume is higher than normal. Adjustment of medication dosing could consequently be of great importance. Close monitoring of medications where toxic levels can be reached is crucial to avoid further damage to the patient's organ functions.

Does Peritoneal Protein Transport Increase with Peritoneal Dialysis Therapy Duration and Lead to Extracellular Water Overload in Peritoneal Dialysis Patients?

Faster peritoneal transport status has been associated with adverse outcomes for peritoneal dialysis (PD) patients. Peritoneal protein clearance, through large pores, may be a surrogate marker of local inflammation. We wished to determine whether peritoneal protein transport increased with PD duration or was associated with extracellular water (ECW) expansion. We studied the relationships between 4 h Dialysate (D)/Serum (S) protein and ECW excess, using multifrequency bioelectrical impedance assessments, in 103 PD patients with up to 4 years of prospectively collected peritoneal equilibrium test (PET) results. 4 h PET D/S total protein and creatinine ratios were stable over time (K-W test, P = 0.063 and P = 0.3357, respectively). The initial PET 4 h D/S creatinine and D/S total protein correlated with ECW excess (r = 0.33, P = 0.003, and r = 0.27, P = 0.019, respectively), but thereafter there was no association. CRP and albumin did not correlate with 4 h D/S creatinine or total protein. Serial 4 h D/S total protein and 4 h D/S creatinine correlated all time points (P < 0.001). At the start of PD therapy, over-hydration (ECW excess) was observed with higher 4 h D/S creatinine and 4 h D/S total protein ratios, suggesting initial exposure to PD fluids causes faster transport. Thereafter changes in peritoneal creatinine and total protein transport mirrored each other suggesting that similar factors lead to changes in both small and large pore transport, and there was no sustained increase in larger pore transport with therapy time.