Stable Continuous Ambulatory Peritoneal Dialysis Research Articles

#4797 ASSOCIATION BETWEEN BLOOD PRESSURE AND SALT CONSUMPTION WITH FLUID STATUS USING BIOIMPEDANCE SPECTROSCOPY IN PERITONEAL DIALYSIS PATIENTS

Abstract Background and Aims Control of extracellular volume in peritoneal dialysis (PD) patients requires both removal of sodium and water. Hypervolemia occurs more frequently in PD patients and is associated with greater morbidity and mortality. Dietary salt restriction (Na+ < 2g) is recommended in all PD patients. Most patients do not comply with this recommendation (prevalence difficult to assess). Bioimpedance spectroscopy (BIS) devices can help assess volume overload in patients receiving maintenance PD. The aim of our study was to determine the association between fluid status as measured using BIS to BP and salt consumption in continuous ambulatory peritoneal dialysis (CAPD) patients. Method We performed a retrospective, longitudinal study, that included 60 PD patients followed at our unit. Demographic and clinical characteristics, such as age, gender, chronic kidney disease (CKD) etiology, time on PD program, dialytic efficacy (Kt/V), peritoneal equilibration test results, BIS results and episodes of peritonitis were registered from our unit database. We measured total sodium removal and estimated daily sodium intake using dietary recall for one day, during the assessment of dialysis adequacy. Based on a 2017 study of 87 patients on PD that sought a correlation between effective daily sodium intake (memory recollection) and urinary + peritoneal sodium sieving. It allowed, through logistic regression, the creation of equations for patients with and without renal residual function (RRF) (Pearson's 0.6). Statistical analyses were performed using SPSS statistics version 23.0. The statistical hypothesis tests with p-value <0.05 were considered significant. Results Sixty patients (male: 60%) with a mean age of 55,9 ± 9 years were selected. Mean time on dialysis was 24,8 months ± 11,9 (min. 2, max. 63). The most common etiology of CKD was glomerular diseases (n = 16, 26.7%), followed by uncertain etiology (n = 11, 18.3%) and diabetic kidney disease (n = 9, 15%). In total, 71,7% of patients were on continuous ambulatory peritoneal dialysis (CAPD). Mean Kt/V was 2,2 ± 0,6 and the majority of patients were high-average transporters. Previous comorbidities were arterial hypertension (n = 60, 100%), diabetes (n = 16, 26,7%), heart failure (n = 13, 21,7%), body mass index >30 kg/m2 (n = 22, 36,7%) and dyslipidemia (n = 40, 66,7%). According to European Society of Cardiology we define three stages of hypertension: stage 1 (140–159/90–99 mmHg) with 15 patients (25%), stage 2 (160–179/100–109 mmHg) with 14 patients (23,3%) and stage 3 (≥180/≥110 mmHg) with 4 patients (6,7%). In total, we have 27 patients (45%) with hypertension under control. A statistically significant positive correlation was found between a status of overhydration (≥2liters) with salt consumption (Na+ >2g) (p = 0,01) and also of hypertension stages 2 and 3 (p = 0,03). Conclusion In PD patients, BIS is a reliable method for evaluating volume status. We found that stable CAPD patients with uncontrolled BP had higher overhydration and salt consumption compared to patients whose BP was controlled. Control of hypervolemia and blood pressure is associated with better cardiac condition. Thus, it is important to encourage patients on peritoneal dialysis to significantly restrict salt intake.

The association between office blood pressure and fluid status using bioimpedance spectroscopy in stable continuous ambulatory peritoneal dialysis patients

BackgroundHypertension is common in continuous ambulatory peritoneal dialysis (CAPD) patients. It remains to be determined the extent to which fluid overload contributes to uncontrolled blood pressure (BP) in this population. The aim was to determine the association between fluid status as measured using bioimpedance spectroscopy (BIS) and BP in CAPD patients.MethodsA cross-sectional study was performed involving 50 stable CAPD patients at a single center in Cape Town, South Africa. All participants were known to have hypertension and were divided into two groups based on office BP measurements: an uncontrolled BP group (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) and a controlled BP group. Fluid status was determined using BIS (Body Composition Monitor®, Fresenius Medical Care, Bad Homburg, Germany).ResultsThere was a statistically significant difference in overhydration (OH) between the uncontrolled BP group and the controlled BP group (3.0 ± 2.3 L vs. 1.4 ± 1.6 L, respectively, P = 0.01). The uncontrolled BP group was older (37.7 ± 9.5 years vs. 32.0 ± 8.0 years, P = 0.04) and had a shorter dialysis vintage (15 [IQR, 7–22] months vs. 31 [IQR, 12–39] months, P = 0.02). Significant correlations were found between OH and the extracellular water (ECW) (r = 0.557, P < 0.01) and ECW to total body water (TBW) ratio (r = 0.474, P < 0.01). Mixed ancestry, presence of residual kidney function, ECW, and ECW to TBW ratio were identified as predictors of OH on multivariable linear regression.ConclusionsWe found that stable CAPD patients with uncontrolled BP had higher OH compared to patients whose BP was controlled.

The estimation of protein equivalents of total nitrogen in Chinese CAPD patients: an explanatory study

Objective The protein equivalent of total nitrogen appearance (PNA) formula, based on the urea nitrogen appearance (UNA), is popularly used by stable continuous ambulatory peritoneal dialysis (CAPD) patients to estimate dietary daily protein intake (DPI). However, we found that the estimated DPI was higher than that directly evaluated from the dietary records of most of our CAPD patients. Therefore, in the present study, we tried to determine possible bias in PNA estimation by UNA with a nitrogen balance study of our CAPD patients. Methods Thirty-one CAPD patients with stable clinical conditions were included. Their 3-day dietary records were reviewed by a dedicated dietitian to calculate their energy, protein, and nitrogen intake (NI). The nitrogen removal (NR) from urine and dialysate was measured by the Kjeldahl technique. Then, we calculated the proportion of urea nitrogen appearance (UNA) in total nitrogen appearance (TNA) and analyzed the possible factors that could affect this proportion. Results Among these patients, 17 males and 14 females, the mean age was 64.19 ± 12.42, and the dialysate drainage volume was 6700 (2540) ml/day. The percentage of UNA in TNA was 63.22 ± 6.66%. Compared with the other classic nitrogen balance studies in the CAPD population, the protein nitrogen and other nonurea nitrogen losses in this study were all lower. Based on these 31 nitrogen balance studies, we proposed a pair of new equations to estimate PNA by UNA. (1) PNA = 9.3 + 7.73 UNA; (2) PNA = PNPNA + TPL = 6.7 + 7.28 UNA + TPL. Conclusion Our study suggested that the PNA formula generated from previous European studies overestimated DPI in our CAPD patients.

Associations between dialysate interleukin-6 and Tie-2 and peritoneal solute transport rate and outcomes for patients undergoing peritoneal dialysis: A prospective cohort study.

Objectives:We designed this prospective observational study to clarify the associations between dialysate IL-6, a marker of ongoing peritoneal inflammation, Tie2, an important factor in angiogenesis in the peritoneum, and a high peritoneal solute transport rate (PSTR) in patients undergoing peritoneal dialysis (PD) and to investigate their outcome predictive roles.Methods:A total of 60 stable continuous ambulatory peritoneal dialysis (CAPD) patients from a single center in China were analyzed in this prospective study. We measured dialysate levels of IL-6 and Tie-2 using ELISAs. Our primary study endpoint was all-cause mortality with 10 years’ follow-up.Results:For the evaluation of PSTR, we used the Dialysis/Plasma creatinine (D/Pcr) ratio. We subdivided the patients into two groups for statistical evaluation: low and low average D/Pcr (<0.64; L/A), and high and high average D/Pcr (≥0.65; H/A) transporters. The mean levels of dialysates IL-6 (21.71 ± 8.88 pg/mL) and Tie-2 (1.23 ± 0.43 ng/mL) were significantly higher in the H/A (high and high average, group than those in the L/A group (13.94 ± 5.43 pg/mL, p<0.001 and 0.95 ± 0.43 ng/mL, p=0.019; respectively). Moreover, IL-6 and Tie-2 were positively correlated with D/Pcr (r=0.366, p=0.004 and r=0.402, p=0.001; respectively). Both dialysates IL-6 and Tie-2 were independent determinants of a high peritoneal solute transport rate. After follow-up for 42.65±18.08 months, 30 patients (50.0%) had died. An increased D/Pcr increased the risk of all-cause mortality in patients with CAPD (p=0.018), but the dialysates IL-6 and Tie2 were not independent predictors of all-cause mortality (p>0.05).Conclusion:Our results suggest that patients undergoing CAPD have a high peritoneal solute transport status with local peritoneal inflammation and angiogenesis. Increased D/Pcr is a relative risk factor for mortality and technique failure in patients undergoing CAPD.

Platelet-to-lymphocyte ratio is associated with cardiovascular disease in continuous ambulatory peritoneal dialysis patients

BackgroundChronic kidney disease (CKD) patients have a high incidence of cardiovascular disease (CVD) events, which is related to the inflammatory status of this population. Platelet–to–lymphocyte ratio (PLR) is a relatively new indicator of inflammation. The aim of this study was to investigate the relationship between PLR and the CVD events in continuous ambulatory peritoneal dialysis (CAPD) patients. MethodsA total of 70 stable CAPD patients were included in this study from February 2014 to March 2017, and complete demographic characteristics and clinical laboratory baseline data were collected at enrollment. The primary endpoint was defined as the experienced of CVD events during the follow-up period. Binary logistic regression was used to assess the association between PLR and CVD events in CAPD patients. ResultsDuring a median follow-up period of 22 months, 28 (40%) CAPD patients experienced CVD events. Patients in the CVD event group had a high level of platelets (P < 0.01), C-reactive protein (P < 0.01), PLR (P < 0.01) and neutrophil-to-lymphocyte ratio (NLR) (P < 0.01). However, lymphocyte counts (P < 0.01) were significantly lower than patients without CVD events. Following adjusted binary regression analysis revealed no relationship between high NLR and CVD events (OR, 1.21; 95% CI, 0.52–2.85; p = 0.44). However, the correlation between high PLR and CVD events was significant (OR, 1.05; 95% CI, 1.02–1.08; p < 0.01). High PLR was confirmed as an independent predictor of CVD events. ConclusionOur results demonstrated that PLR was independently associated with CVD events. High PLR can be used to predict the risk of CVD events in CAPD patients. PLR was easy to obtain and can be considered as a routine test to serve the clinic.

Associated factors for depressive disorder in patients with end-stage renal disease treated with continuous ambulatory peritoneal dialysis.

BackgroundThe aim of this study was to primarily determine factors associated with the depressive disorders in continuous ambulatory peritoneal dialysis (CAPD).MethodsCAPD patients were recruited from the chronic kidney disease and CAPD Clinic of University Hospital. The stable CAPD patients for at least 3 months were included in the study. Sociodemographic data, renal conditions, and depressive disorder were evaluated. In addition to determining prevalence rate of depressive disorders, identification of factors associated with depressive disorders in CAPD patients were analyzed by using the multivariable logistic regression analysis with backward elimination procedure.ResultsThe eligible participants were 108 patients. The study found that 11% of CAPD patients were diagnosed with depressive disorders including, minor depressive, dysthymic, and major depressive disorders. Additionally, the depressive disorders were associated with the duration between the diagnosis date of the end-stage renal disease (ESRD) and the initial treatment date (P=0.043). Accordingly, the ESRD patients diagnosed in <12 months had 3.57-fold higher risk of depressive disorders than the patients diagnosed after a long time.ConclusionThe rate of prevalence for depressive disorder is high in the CAPD patients. Additionally, the results of this study have shown the relationship between depressive disorder and time for diagnosis of ESRD. Specifically, the risk of depressive disorder increases when patients have a shorter duration between the dates of ESRD diagnosis and initial treatment. In addition to closed monitoring for those patients, the psychiatrists should be consulted for evaluation and treatment of depressive disorders for the suspected high risk patients.

High Intraperitoneal Interleukin-6 Levels Predict Peritonitis in Peritoneal Dialysis Patients: A Prospective Cohort Study

Background: To evaluate the predictive value of dialysate interleukin-6 (IL-6) representing local subclinical intraperitoneal inflammation for the development of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: Stable prevalent CAPD patients were enrolled in this prospective study. IL-6 concentration in the overnight effluent was determined and expressed as the IL-6 appearance rate (IL-6AR). Patients were divided into 2 groups according to the median of IL-6AR and prospectively followed up until the first episode of peritonitis, cessation of PD, or the end of the study (December 30, 2017). The utility of IL-6AR in predicting peritonitis-free survival was analyzed using the Kaplan-Meier and Cox proportional hazards models. Results: A total of 149 patients were enrolled, including 72 males (48%) with mean age 52.0 ± 13.6 years and median PD duration 26 (5.9–45.5) months. During follow-up, 7,923 patient months were observed and 154 episodes of peritonitis occurred in 82 patients. Previous peritonitis episodes were significantly associated with log dialysate IL-6AR levels (β = 0.187 [0.022–0.299], p = 0.023). Patients in the high IL-6AR group showed a significantly inferior peritonitis-free survival when compared with their counterparts in the low IL-6AR group (48.8 vs. 67.7 months, p = 0.026), as well as higher treatment failure percentage of peritonitis (20.3 vs. 9.3%, p = 0.049). A multivariate Cox regression showed that high dialysate IL-6AR (hazard ratio [HR] 1.247 [1.052–1.478]; p = 0.011) and high serum C-reactive protein (HR 1.072 [1.005–1.144]; p = 0.036) were independent risk factors for inferior peritonitis-free survival. Conclusion: This prospective study suggested that the intraperitoneal inflammation marker, dialysate IL-6 level, might be a potential predictor of peritonitis development in patients undergoing PD.

A new peritoneal dialysis fluid for Japanese patients: a randomized non-inferiority clinical trial of safety and efficacy

BackgroundWe report here two new peritoneal dialysis fluids (PDFs) for Japan [BLR 250, BLR 350 (Baxter Limited, Japan)]. The PDFs use two-chamber systems, and have bicarbonate and lactate buffer to a total of 35 mmol/L. In separate trials, the new PDFs were compared to two “standard” systems [PD-4, PD-2 (Baxter Limited, Japan)]. The trials aimed to demonstrate non-inferiority of peritoneal creatinine clearance (pCcr), peritoneal urea clearance (pCurea) and ultrafiltration volume (UF), and compare acid–base and electrolyte balance.MethodsWe performed randomized, multicenter, parallel group, controlled, open-label clinical trials in stable continuous ambulatory peritoneal dialysis (CAPD) patients. The primary endpoints were pCcr and UF. The secondary endpoints were serum bicarbonate and peritoneal urea clearance. The active phase was 8 weeks. These trials were performed as non-inferiority studies, with the lower limit of non-inferiority for pCcr and UF set at 3.2 L/week/1.73 m2 and 0.12 L/day, respectively.Results108 patients (28 centers) and 103 patients (29 centers) took part in the two trials. Groups were well balanced at baseline. The investigative PDFs were non-inferior to the “standard” ones in terms of primary endpoints, comparable in terms of pCurea, and superior in terms acid–base balance, especially correcting those with over-alkalinization at baseline.ConclusionsWe demonstrated fundamental functionality of two new PDFs and showed superior acid–base balance. Given the propensity of Japanese CAPD patients for alkalosis, it is important to avoid metabolic alkalosis which is associated with increased cardiovascular mortality risk and accelerated vascular calcification. The new PDFs are important progress of CAPD treatment for Japanese patients.

Intraperitoneal Interleukin-6 Levels Predict Peritoneal Solute Transport Rate: A Prospective Cohort Study

Background: To evaluate the association of dialysate interleukin-6 (IL-6), a marker of ongoing peritoneal inflammation, with the alteration of peritoneal solute transport rate (PSTR) in continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: Stable CAPD patients were enrolled in the present study. A total of 128 patients were analyzed in this prospective study. IL-6 concentration in the overnight effluent was determined and expressed as the IL-6 appearance rate (IL-6AR). Mass transfer area coefficients of creatinine (MTACcr) were measured at enrollment and 12 months later. Logistic regression was used to examine the association between IL-6AR and change in MTACcr. Results: Multivariable linear regression showed that historical glucose exposure was significantly associated with dialysate IL-6AR level [β = 0.008 (0.001-0.015), p = 0.021]. After 12 months, MTACcr was significantly increased [6.40 (4.70-8.75) vs. 7.14 (5.69-8.73) ml/min, p = 0.004], while ultrafiltration capacity decreased [4 h UF 340 (220-400) vs. 280 (180-380) ml, p = 0.006]. Compared to the patients with stable PSTR, the dialysate IL-6AR in patients with increasing PSTR was significantly higher [277.08 (247.45-349.53) vs. 263.18 (69.94-286.72) pg/min, p = 0.015]. Patients with increasing PSTR had lower residual renal function [0.79 (0-2.12) vs. 1.70 (0.39-3.38) ml/min, p = 0.006] and less urine output [225 (0-600) vs. 500 (125-900) ml/24 h, p = 0.014]. Logistic analysis showed that both high dialysate IL-6AR [OR 1.333 and 95% CI (1.024-1.735), p = 0.033] and low RRF [OR 0.831 and 95% CI (0.699-0.988), p = 0.036] were independent risk factors for increasing PSTR. Conclusions: This prospective study suggests that intraperitoneal IL-6 is a predictor of increasing PSTR in peritoneal dialysis patients.

Potassium metabolism in continuous ambulatory peritoneal dialysis patients

Background: Hypokalemia is common and may have contributed to the poor clinical outcome in peritoneal dialysis (PD) patients. In this study, we made a detailed investigation on the potassium metabolism in continuous ambulatory peritoneal dialysis (CAPD) patients and tried to find out the possible factors associated with the high prevalence of hypokalemia in PD patients. Methods: A cross-sectional survey in 243 clinically stable CAPD patients was made in our PD center in 2010. Patients were divided into four groups according to whether they were anuric or not and different dialysis regimens. Patients’ demographic data and data on potassium metabolism including dietary potassium intakes, residual renal potassium, and peritoneal dialysis potassium removal were collected. Results: The average potassium intake in our 243 PD patients was 32.1 ± 11.1 mmol/day. The total potassium removal was significantly higher in non-anuric patients as compared to anuric patients (33.2 ± 9.1 vs. 23.0 ± 4.7 mmol/day for 3 exchanges per day and 35.2 ± 8.9 vs. 28.6 ± 6.3 mmol/day for 4 exchanges per day, respectively, p < 0.01) and in anuric patients dialyzed with 4 exchanges per day as compared to anuric patients dialyzed with 3 exchanges per day (28.6 ± 6.3 vs. 23.0 ± 4.7 mmol/L, p < 0.05). Compared to non-anuric patients dialyzed with 3 exchanges per day, serum potassium level was significantly lower (4.1 ± 0.7 vs. 4.5 ± 0.7 mmol/L, p < 0.05) while the prevalence of hypokalemia was significantly higher (22.2% vs. 9.3%, p < 0.05) in non-anuric patients that dialyzed with 4 exchanges per day. There was a strong correlation between renal potassium removal and renal urea Kt/V (R2 linear = 0.645, p < 0.05). In a linear multiregression analysis, dietary potassium intake, intracellular water (ICW) significantly positively predicted serum potassium level while dialysis exchanges, residual renal function (RRF), D/P potassium all significantly negatively predicted serum potassium levels. Conclusions: Our study suggested that if potassium intake was limited in PD patients, we should be aware of the risk of hypokalemia with high doses of PD when patients have good RRF. Our study also suggested that potassium removal in PD patients may not necessarily reflect potassium intake even if serum potassium is normal, the effect of ICW should be considered when evaluating potassium homeostasis.

Could mini-PET be used to instead of 4 h original-PET to assess peritoneal permeability in children on peritoneal dialysis?

Background: Original peritoneal equilibration test (PET) is an implementation that requires hard work for peritoneal dialysis (PD) staff. Therefore, several authors have attempted to validate short and fast PET protocols, with controversial results. The aim of this study was to evaluate the concordance between the mini-PET and original PET in children. Methods: In 26 stable continuous ambulatory PD patients, we performed an original PET with 2.27% (4 h) and a mini-PET with 3.86% glucose PD fluid (1 h) and compared ultrafiltration (UF) and small solute transports obtained with the two methods. Results: Twenty-six children, 14 males, mean age 11.4 ± 5.6 (range 2.5–19 years), were included. Meantime on PD at time of enrollment was 35.2 ± 24.5 months (range 6–84 months). Based on the 4-h creatinine D/P data, the number of the patients within each transport category was as follow: high, 5; average, 18; low, 3. Kappa test showed a significant concordance between original PET and mini-PET (k = 0.610). Based on the 4-h glucose D/D0 data, the number of the patients within each transport category was as follow: high, 5; average, 17; low, 4. Kappa test showed a moderate agreement between original PET and mini-PET (0.514, p = 0.000). When Pearson correlation analysis between original PET and mini-PET was performed, there were significant positive correlations between original 2.27% PET and mini-PET (r = 0.720, p = 0.000, r = 0.638, p = 0.000, respectively). When comparing the numeric results of mini-PET and 4 h of original PET for D/Creatinine, by simple regression analysis, we found statistically significant correlation among PETs. Conclusions: In this study, we showed concordance between the mini-PET and original PET. The 3.86% mini-PET is simple and fast methods to assess free water transport. This also gives information about total UF and small solute transports and it is in good agreement with the original PET.

Sequential peritoneal equilibration test: a new method for assessment and modelling of peritoneal transport

In spite of many peritoneal tests proposed, there is still a need for a simple and reliable new approach for deriving detailed information about peritoneal membrane characteristics, especially those related to fluid transport. The sequential peritoneal equilibration test (sPET) that includes PET (glucose 2.27%, 4 h) followed by miniPET (glucose 3.86%, 1 h) was performed in 27 stable continuous ambulatory peritoneal dialysis patients. Ultrafiltration volumes, glucose absorption, ratio of concentration in dialysis fluid to concentration in plasma (D/P), sodium dip (Dip D/P Sodium), free water fraction (FWF60) and the ultrafiltration passing through small pores at 60 min (UFSP60), were calculated using clinical data. Peritoneal transport parameters were estimated using the three-pore model (3p model) and clinical data. Osmotic conductance for glucose was calculated from the parameters of the model. D/P creatinine correlated with diffusive mass transport parameters for all considered solutes, but not with fluid transport characteristics. Hydraulic permeability (L(p)S) correlated with net ultrafiltration from miniPET, UFSP60, FWF60 and sodium dip. The fraction of ultrasmall pores correlated with FWF60 and sodium dip. The sequential PET described and interpreted mechanisms of ultrafiltration and solute transport. Fluid transport parameters from the 3p model were independent of the PET D/P creatinine, but correlated with fluid transport characteristics from PET and miniPET.

Effects of peritoneal dialysis and hemodialysis on arterial stiffness compared with predialysis patients

Arterial stiffness is one of the major complications in chronic kidney disease. In this study, we investigated the association between glomerular filtration rate (GFR) and arterial stiffness in chronic kidney disease (CKD), and studied the effect of dialysis on arterial stiffness. A total of 62 stable continuous ambulatory peritoneal dialysis (CAPD) patients, 56 patients on maintenance hemodialysis, 128 predialysis CKD patients and 40 healthy controls were included into this study. These four groups were all nondiabetic and comparable in age and gender. The pulse wave velocity (PWV) and augmentation index (AIx) were evaluated by an applanation tonometry (SphygmoCor). Clinical data and lab tests were collected from inpatient case history and dialysis data base. Female patients had higher AIx than male patients in both predialysis and dialysis patients. Both PWV and AIx were positively correlated with age, and were significantly higher in patients requiring antihypertensive drugs (p < 0.05). PWV and AIx were negatively correlated with GFR in predialysis CKD patients (p < 0.05). Patients on peritoneal dialysis or hemodialysis had better PWV and AIx than predialysis CKD 5 patients (19.8 ± 10.9%, 19.7 ± 9.4% vs. 25.3 ± 10.1%, p < 0.05), indicating that dialysis may improve arterial stiffness. No difference was found between peritoneal dialysis and hemodialysis patients. This study demonstrates that arterial stiffness progresses with deterioration of renal function in CKD patients, and both peritoneal dialysis and hemodialysis can improve arterial stiffness in patients with uremia.

Association between Depression Symptoms with Inflammation and Cardiovascular Risk Factors in Patients Undergoing Peritoneal Dialysis

Despite medical progress, high morbidity and mortality rates, due primarily to cardiovascular diseases, have persisted in patients with end-stage renal disease (ESRD). Recently, nontraditional risk factors, such as inflammation and malnutrition, have been emphasized in the development or progression of atherosclerosis in ESRD patients. Depression, the most common psychological problem in the ESRD population, is also known to be associated with inflammation and malnutrition, suggesting a possible link between depression with inflammation and cardiovascular diseases. The purpose of this study was to investigate the relationship between depression with cardiovascular risk factors and inflammation in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Eighty-one stable CAPD patients were enrolled. Depressive symptoms were assessed with the Beck Depression Inventory. Various cardiovascular risk factors and inflammatory markers were measured. Forty-three patients had depressive symptoms (53.8%). Patients with depressive symptoms showed significantly lower levels of albumin and IL-10, but higher levels of inflammatory markers than patients without depressive symptoms. Left ventricular hypertrophy was also found more frequently and pulse wave velocity and asymmetric dimethylarginine were all significantly increased in patients with depressive symptoms. Depression in CAPD patients was associated with inflammation and cardiovascular risk factors, and might be used as a predictor of cardiovascular diseases.

The Influence of Risk Factors in Remodelling Carotid Arteries in Patients Undergoing Peritoneal Dialysis

Accelerated atherosclerosis and vascular calcification, with oxidative stress, endothelial dysfunction, and other factors causing the arterial stiffness, increases cardiovascular morbidity and mortality in patients on peritoneal dialysis. The aim of this paper is to assess changes in intima media thickness (IMT) at common carotid arteries (CCA) in patients with stable continuous ambulatory peritoneal dialysis (PD) and examine the relationship of these changes and other risk factors on the occurrence of atherosclerosis. The study was conducted on 35 stable PD patients (25 type 2 diabetic patients), aged 58.6 +/- 10.6 years. CCA-IMT was assessed using ultrasound B-mode technique, bilaterally. Other risk factors for the occurrence of atherosclerosis were monitored through regular laboratory control. One atheromatous plaque was found in 19 patients (54.3%). Among 25 type 2 diabetic patients, vascular calcifications were found in 80% patients. In all PD patients, CCA-IMT is 0.77 +/- 0.23, in PD patients with vascular calcifications CCA-IMT is 1.05 +/- 0.2 mm, while in group without vascular calcifications the value of this parameter is 0.56 +/- 0.09 (p<0.01 ). Significant differences were found between PD patients with and without vascular calcifications on CCA in patients age (p<0.001), as well as values of systolic blood pressure (p=0.001), serum phosphorus (p=0.017), product calcium and phosphorus (p=0.021), CRP (p=0.039), triglycerides (p<0.05) and lipoprotein (a) values (p=0.044). Our results suggest an important determination of common carotid arteries intima media thickness and its relation to other risk factors for the occurrence and progression of atherosclerosis in patients undergoing peritoneal dialysis.

Cell‐free DNA in the Peritoneal Effluent of Peritoneal Dialysis Solutions

The beneficial effects of novel peritoneal dialysis solutions low in glucose degradation products regarding peritoneal cell apoptosis and necrosis are well established in vitro, however in vivo data is lacking. Cell-free DNA quantification is a possible method to determine cell damage through apoptosis and necrosis in vivo. We performed a prospective, cross-over study on 26 stable continuous ambulatory peritoneal dialysis (CAPD) patients, treating each patient for 3 months in a randomized order with a conventional, lactate-buffered, acidic solution (solution D) and a novel, bicarbonate/lactate-buffered neutral solution (solution P). The timed overnight peritoneal effluent was sampled for cell-free DNA quantification using a fluorometric assay. The effluent samples of eighteen patients were finally available for DNA quantification. The concentration range of cell-free DNA in the peritoneal effluents was 1.8-9.5 microg/L. The coefficient of intrapatient variation in overnight effluent cell-free DNA appearance was 15.6 +/- 12.4%. Cell-free DNA peritoneal appearance using solutions D and P was 14.9 +/- 6.8 microg and 11.8 +/- 3.4 microg, respectively (P = 0.02), with the average difference of 3.1 microg (95% CI, 0.7-5.6 microg). Our results show that cell-free DNA is present in the overnight peritoneal effluent of stable CAPD patients. A significant decrease in the cell-free DNA appearance with solution P was found; however, before accepting this as an indicator of a more biocompatible profile causing less peritoneal membrane cell necrosis and apoptosis, confirmatory data on larger patient samples are needed. Our results indicate the potential future role of cell-free DNA in the diagnosis and prognosis of therapy-related peritoneal membrane degeneration.

Randomized Controlled Trial of Icodextrin versus Glucose Containing Peritoneal Dialysis Fluid

While peritoneal dialysis with icodextrin is commonly used in patients with poor peritoneal membrane characteristics, the data on the usefulness of this solution in patients with lower transport characteristics are limited. The study was designed to compare icodextrin to glucose in Chinese prevalent peritoneal dialysis patients of different peritoneal transport characteristics (PET) categories. This was a randomized, double-blind, perspective control study. Stable prevalent continuous ambulatory peritoneal dialysis (CAPD) patients were randomized to either 7.5% icodextrin (ICO) or 2.5% glucose (GLU) solution for 4 wk. Peritoneal membrane function was measured to define PET category in baseline. Creatinine clearance (Ccr), urea nitrogen clearance (C(BUN)), ultrafiltration (UF) during the long night dwell, dialysate, and metabolic biomarkers were measured at baseline, 2, and 4 wk. UF, Ccr, and C(BUN) were compared among different PET categories. A total of 201 CAPD patients were enrolled in the study. There were no baseline differences between the groups. Following 2 and 4 wk of therapy, Ccr, C(BUN,) and UF were all significantly higher in the ICO versus the GLU group. Additionally, switching to ICO resulted in a significant increase in UF in high, high-average, and low-average transporters as compared with baseline. The extent of increased UF was more obvious in higher transporters. Blood cholesterol level in the ICO group decreased significantly than that in the GLU group. Compared with glucose-based solution, 7.5% icodextrin significantly improved UF and small solute clearance, even in patients with low-average peritoneal transport.

The Effect of Low Calcium Dialysate on Calcium‐Phosphate Metabolism and Its Correlation With Other Coefficient Factors in CAPD

AbstractOBJECTIVEIt has been suggested that low calcium concentration dialysate could be used in the treatment of continuous ambulatory peritoneal dialysis (CAPD) patients with renal osteodystrophy. This study aims to investigate the effect and safety of low calcium concentration dialysate (1.25 mmol/L) compared with high calcium concentration dialysate (1.75 mmol/L) in treating CAPD‐caused renal osteodystrophy, and the correlation between clinical parameters and the serum calcium level in CAPD patients.METHODSThe study was performed on 57 clinically stable CAPD patients with hypercalcemia. All patients were randomized to switch to 1.25 mmol/L calcium dialysate (group A) or continue on 1.75 mmol/L calcium dialysate (group B) for a period of 48 weeks. Biochemical data was evaluated at 0, 4, 8, 12, 16, 32, and 48 weeks. The clinical manifestations were recorded.RESULTSA total of 53 patients completed the study. After 48 weeks of observation there was no difference in the level of blood albumin, volume of dialysate, and ultrafiltration (p &gt; .05). After 8 weeks, the level of serum calcium, as well as phosphate and magnesium, showed a significant decrease in the patients of group A (p &lt; .05). Comparison between the 2 groups showed an increase in serum parathyroid hormone (PTH) level in group A (p &lt; .05). But the biochemical data was no different in group B. The intake of calcium carbonate increased significantly in group A after 8 weeks (p &lt; .05). The decrease percentage index of calcium showed a negative correlation with age and a positive correlation with volume of dialysis.CONCLUSIONSThe administration of 1.25 mmol/L calcium dialysate may benefit abnormal calcium‐phosphate metabolism and decrease suppression of parathyroid hormone in CAPD patients with adynamic bone diseases. Individualization should be noticed with low calcium dialysate.

Comparison of Icodextrin and 2.5% Glucose in Potassium Metabolism by Acute K+ load via Dialysate in Continuous Ambulatory Peritoneal Dialysis Patients

This study aimed to compare the increment in plasma potassium concentration ([K+]) as well as the role of internal K+ balance for its changes following acute K+ supplementation between conventional 2.5% glucose (GD) and non-glucose containing dialysate (icodextrin, ID) in continuous ambulatory peritoneal dialysis (CAPD) patients. A total of 9 stable CAPD patients (5 men and 4 women; age, 56±13 years; 7 type-2 diabetics and 2 non-diabetics) on daily 4 exchanges of 2 L of glucose dialysate underwent the 6-hr dwell on fasting in the morning with 2 L of 2.5% glucose mixed with 20 mEq/L of KCl, and then the same regimen was repeated with icodextrin after 1-wk interval. The degree of intraperitoneal absorption was comparable, 65±2% in GD and 68±2% in ID, respectively (p=NS). However, despite the similar plasma K+ levels at the baseline of both regimens, its increment was significantly less in GD than ID, which was accompanied by more marked increase in the calculated intracellular K+ redistribution (68±3% vs. 52±3%, p<0.05). The basal levels of insulin were similar between the GD and ID groups. However, the change, checked up after 2 hours' dwell, from the basal insulin levels was much lower on ID. ID with a lesser degree of transcelluar K+ shift by the decreased secretion of insulin is more effective than the conventional glucose solution for acute K+ repletion via dialysate during CAPD. Furthermore, these results suggested that the role of insulin for the internal K+ balance was intact even in type-2 diabetic patients on CAPD.

Impact of Dialysis Duration and Glucose Absorption on Nutritional Indices in Stable Continuous Ambulatory Peritoneal Dialysis Patients

The presence of comorbidity is a risk factor for both poor nutrition and poor outcome in continuous ambulatory peritoneal dialysis (CAPD) patients. In CAPD specifically, peritoneal glucose load is associated with a possible suppression of appetite, contributing to protein malnutrition. This study sought to explore the factors associated with malnutrition indices in stable peritoneal dialysis patients without significant comorbidity, and to assess the impact of peritoneal glucose absorption on nutrition parameters. This was a cross-sectional observational study. This study took place in the peritoneal dialysis department of a university hospital, and involved outpatients. There were 23 stable, comorbidity-free CAPD patients (9 women), aged 54 +/- 12 years, with a CAPD duration of 28 +/- 25 months (values are mean +/- SD unless otherwise noted). Nutritional status was evaluated by means of anthropometric and serum measurements. A peritoneal equilibration test was performed, and daily glucose absorption was measured. Lean body mass (LBM) was assessed through creatinine kinetics. A significant impact of CAPD duration was found. Patients in the upper quartile of CAPD duration had worse nutritional parameters compared with the rest of the group: their mid-upper-arm surface area and fat surface area were lower (65 +/- 9 cm(2) vs. 78 +/- 6.2 cm(2) and 16 +/- 5.3 cm(2) vs. 26 +/- 9.5 cm(2), respectively, P < .05), their albumin concentration was lower (36 +/- 0.5 g/L vs. 42 +/- 4 g/L, P < .05), and their cholesterol and triglycerides were lower (3.5 +/- 0.5 vs. 5.2 +/- 1 mmol/L and 1.3 +/- 0.6 vs. 2.3 +/- 1.1 mmol/L, respectively, P < .05). No significant correlations between peritoneal glucose absorption and these indices were found. The duration of dialysis treatment, but not peritoneal glucose absorption, is a predictor of malnutrition in stable, comorbidity-free CAPD patients.