Standard Continuous Ambulatory Peritoneal Dialysis Research Articles

Sodium removal per ultrafiltration volume in automated peritoneal dialysis in pediatric patients.

The standard rate of sodium removal in adult anuric patients on continuous ambulatory peritoneal dialysis (CAPD) is 7.5g/L of ultrafiltration volume (UFV). Although automated PD (APD) is widely used in pediatric patients, no attempt has yet been made to estimate sodium removal in APD. The present, retrospective cohort study included pediatric patients with APD who were managed at Tokyo Metropolitan Children's Medical Center between July 2010 and November 2017. The patients underwent a peritoneal equilibrium test (PET) at our hospital. Sodium removal per UFV was calculated by peritoneal function and dwell time using samples from patients on APD with 1- and 2-h dwell effluent within three months of PET and 4- and 10-h dwell effluent at PET. In total, 217 samples from 18 patients were included, with 63, 81, and 73 of the samples corresponding to the High [H], High-average [HA], and Low-average [LA] PET category, respectively. Sodium removal per UFV (g/L in salt equivalent) for dwell times of one, two, four, and ten hours was 5.2, 8.8, 8.0, and 11.5 for PET [H], 5.3, 5.8, 5.6, and 8.1 for PET [HA], and 4.6, 5.1, 5.1, and 7.1 for PET [LA], respectively. Sodium removal per UFV in pediatric APD was less than the standard adult CAPD and tended to be lower with shorter dwell times, leading to sodium accumulation. Therefore, salt intake should be restricted in combination with one or more long daytime dwells, especially in anuric patients.

MO1051: Standardized Simulation Education Program with Summative Assessment on Exchange Procedure of Ultrabag System for Peritoneal Dialysis: Innovations in Practical Recommendations

Abstract BACKGROUND AND AIMS Inexperience in practicing peritoneal dialysis (PD) and lack of standard education program under the instruction of qualified renal nurses are known causes of peritonitis in patients with chronic renal failure [1]. Thus far, the standardized and validated curriculum for Continuous Ambulatory Peritoneal Dialysis (CAPD) training has not been well-established under simulation-based education model [2]. We aimed i) to develop a well-structured and standardized educational training program on exchange procedure of Ultrabag system and ii) to evaluate the degree of acquisition in domains of cognitive (knowledge) and psychomotor (skills) by summative assessment using valid and reliable knowledge evaluation index and performance checklist. METHOD Following an invention of 3D-printed CAPD device, ‘Helping Hands’ in closed system operation, the Renal Unit in the Department of Medicine and Multi-Disciplinary Simulation and Skills Centre (MDSSC) in Queen Elizabeth Hospital (QEH) formulated a standard 5-day CAPD training to equip PD patients with knowledge and skills for safe Ultrabag exchange. In order to optimize training effectiveness and assessment standards, the program was designed with ‘6 (+2 additional) guiding questions’ from the International Society for Peritoneal Dialysis (ISPD) document [3]. Scoring Checklist with specific and relevant items, such as fixation of the connecting catheter, parallel point-to-point connection and procedures in placing disinfection cap, could strengthen internal validity. RESULTS In 2021, 17 CAPD patients with partial impairment in vision (12, 71%) or eye-hand coordination (13, 77%) attended this education program. Post-training assessment showed that participants had improved cognitive knowledge (M = 71%; A Grade (>80 marks) = 5, 29% B Grade (60–80 marks) = 9, 53%; C Grade (<60 marks) = 3, 18%) and psychomotor skills (100% achievement in simulation task). Except for 1 participant who required additional training session and re-assessment, 94% of them passed the simulation examination by completing all procedures without any assistance in one-take. A validated educator-guided scheme of psychomotor skills in proper use of CAPD is recommended with six operational phases: CONCLUSION Repetitive performance in task-specific procedure of bag exchange, coupled with constructive feedback from experienced renal nurse educators and well-validated assessment (with a standardized scoring sheet and checklist), resulted in improved skill performance. The training program, correspondent with traditional concept of Miller's pyramid (1990), demonstrated how CAPD novice turns skillful user by developing competence in cognition with factual knowledge of dialysis (‘Knows’) and verbalization of rationale and flows of PD (‘Knows How’); and competence in behavior with simulation practice with CAPD device (‘Shows’) and summative assessment demonstrating mastery of safe bag exchange skills to be integrated into everyday practice (‘Does’). Further studies may be warranted to investigate whether knowledge and skills acquired before use of CAPD could be carried over time and on how education program accounts for risk minimization of CAPD-related peritonitis and survival rate.

Mild sodium reduction in peritoneal dialysis solution improves hypertension in end stage kidney disease: a case-report study

IntroductionBlood Pressure (BP) control is largely unsatisfied in End Stage Kidney Disease (ESKD) principally due to sodium retention. Peritoneal Dialysis (PD) is the most common type of home dialysis, using a peritoneal membrane to remove sodium, though sodium removal remains challenging.MethodsThis is a case-study reporting two consecutive ESKD patients treated by a novel peritoneal PD solution with a mildly reduced sodium content (130 mmol/L) to treat hypertension.ResultsIn the first case, a 78-year-old woman treated by Continuous Ambulatory PD (CAPD) with standard solution (three 4 h-dwells per day 1.36% glucose 132 mmol/L) showed resistant hypertension confirmed by ambulatory blood pressure monitoring (ABPM), reporting 24 h-BP: 152/81 mmHg, day-BP:151/83 mmHg and night-ABP: 153/75 mmHg, with inversion of the circadian systolic BP rhythm (1.01), despite use of three anti-hypertensives and a diuretic at adequate doses. No sign of hypervolemia was evident. We then switched from standard PD to low-sodium solution in all daily dwells. A six-months low-sodium CAPD enabled us to reduce diurnal (134/75 mmHg) and nocturnal BP (122/67 mmHg), restoring the circadian BP rhythm, with no change in ultrafiltration or residual diuresis. Diet and drug prescription were unmodified too.The second case was a 61-year-old woman in standard CAPD (three 5 h-dwells per day) suffering from hypertension confirmed by ABPM (mean 24 h-ABP: 139/84 mmHg; mean day-ABP:144/88 mmHg and mean night-ABP:124/70 mmHg). She was switched from 132-Na CAPD to 130-Na CAPD, not changing dialysis schedule. No fluid expansion was evident. During low-sodium CAPD, antihypertensive therapy (amlodipine 10 mg and Olmesartan 20 mg) has been reduced until complete suspension. After 6 months, we repeated ABPM showing a substantial reduction in mean 24 h-ABP (117/69 mmHg), mean diurnal ABP (119/75 mmHg) and mean nocturnal ABP (111/70 mmHg). Ultrafiltration and residual diuresis remained unmodified. No side effects were reported in either cases.ConclusionsThis case-report study suggests that mild low-sodium CAPD might reduce BP in hypertensive ESKD patients.

Standard continuous ambulatory peritoneal dialysis therapy provides similar initial T-Kt/V regardless of the patient's peritoneal membrane transporter category: Single-center experience.

Patients on continuous ambulatory peritoneal dialysis (CAPD) are routinely evaluated using the peritoneal equilibrium test (PET) to determine the best method for achieving target total dialysis clearance (T-Kt/V). In this study, we tested the hypothesis that standard CAPD prescription would achieve an initial T-Kt/V of more than 1.7 in all the patients regardless of their PET measurements. This is a retrospective study that included patients who started standard CAPD of four two-liter exchanges per day. The study included 118 patients; their mean age was 51.5 years with a standard deviation (SD) of 14.39 years. There were 83 males (70.3%) and 35 females (29.7%). PET and Kt/V were performed during the first four to six weeks of the study. The PET classified the patients into four categories: 24 (20.3%), high transporters; 65 (55.1%), high average; 28 (23.7%), low average; and one (0.8%), low transporter. Patients were then divided in two groups: Group 1 comprised of the high transporters while Group 2 included all the other patients. The T-Kt/V of the two groups was similar; in Group 1, it was 2.57 (± 1.17) and in Group 2 it was 2.50 (± 0.88) (P = 0.77). The T-Kt/V of patients with no residual renal function was also similar; in Group 1 and Group 2 it was 1.8 (± 0.29) and 1.97 (± 0.56), respectively (P = 0.45). All patients in our study who started on standard CAPD treatment had an adequate initial T-Kt/V. Thus, our data demonstrate that all patients with end-stage renal disease can safely begin standard CAPD without PET, which only needs to be performed if the patient encounters trouble in his/her T-Kt/V or fluid removal.

Sequential change of asymmetric dimethylarginine levels after initiation of peritoneal dialysis in patients with end‐stage renal disease

We hypothesized that the asymmetric dimethylarginine (ADMA) metabolism in end-stage renal disease may be linked to the rate of protein turnover and to the vast pool of amino acids. In order to determine a correlation between the plasma levels of ADMA and the protein catabolic rate, we measured the ADMA levels as well as nutritional markers such as the normalized protein catabolic rate (nPCR) in patients with newly initiated continuous ambulatory peritoneal dialysis (CAPD). Twenty-four patients were recruited for this study. All patients were on the standard CAPD protocol, and followed for at least 1 year. Blood samples were collected at baseline before the initiation of peritoneal dialysis, and every 6 months for 1 year. The blood parameters studied included the serum albumin, total cholesterol, glucose, urea nitrogen, creatinine and ADMA. Peritoneal equilibrium test and measurements of weekly Kt/Vurea and nPCR were performed within 4 weeks of the blood sampling. The change of ADMA levels over 1 year was positively correlated with that of haemoglobin (r = 0.592, P = 0.002) and nPCR during the same period (r = 0.508, P = 0.026). The findings of our study suggest that nPCR might influence the change of ADMA levels after initiation of CAPD.

Commencing peritoneal dialysis with 1.1% amino acid solution does not influence biochemical nutritional parameters in incident CAPD patients

Objective: To evaluate the influence of 1.1% amino acid dialysis solutions on nutritional parameters in incident continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: The effect of daily use of 1.1% amino acid solution was studied retrospectively in 32 incident CAPD patients (14 women and 18 men, mean age 54 ± 13 years) who began CAPD at our tertiary university hospital between July 2005 and February 2009 (amino acid solution (AAS) group). Serum total protein, albumin, and creatinine were assessed for all patients prior to dialysis and at the end of the study period. Thirty-two control patients (12 women and 20 men, mean age 52 ± 14 years) who started peritoneal dialysis with a standard CAPD program were also investigated and grouped as the dextrose solution (DS) group. Results: Baseline serum albumin levels were significantly lower in the AAS group compared to the DS group (3.4 ± 0.4 g/dL vs. 3.7 ± 0.5 g/dL, p = 0.011). At the end of the 12-month follow-up period, mean serum albumin levels had decreased from 3.4 to 3.3 g/dL in the AAS group (p = 0.218) and increased from 3.7 to 3.8 g/dL in the DS group (p = 0.360). Overall, no significant changes were observed in serum total protein, creatinine, or albumin in either group. Conclusions: Amino acid solutions conferred no demonstrable benefit on biochemical parameters in incident CAPD patients. The effects of AAS may be different when added to the CAPD regimen of patients undergoing prior CAPD treatment.

Increasing the Dialysis Volume and Frequency in a Fixed Period of Time in CPD Patients: The Effect on Kpt/V and Creatinine Clearance

The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) has evidence- and opinion-based recommendations for weekly Kt/V(urea) and weekly total creatinine clearance (CC) in chronic peritoneal dialysis (CPD) patients. Using standard continuous ambulatory peritoneal dialysis technique, it is often difficult to achieve the suggested targets in anuric patients with large body mass. Thus, the use of automated peritoneal dialysis (APD) has been increasingly utilized to achieve adequate clearances. Automated dialysis is usually performed at night over an 8- to 10-hour period. The role of increases in dialysate volume and frequency of exchanges during this time period to achieve these target K/DOQI recommendations remains uncertain. We decided to study the effects of increasing the volume and number of exchanges in a fixed period of time in CPD patients. In the New Haven CAPD unit, 29 patients maintained on APD were considered eligible for the study and 11 agreed to participate. The patients were characterized according to standard peritoneal equilibration test criteria. The patients were placed into two groups: group 1 included high (H) and high-average (HA), and group 2 low-average (LA) transporters. The patients were dialyzed at night for 9 hours with standard cycling technique, using 2.5% Dianeal (Baxter Healthcare, Deerfield, Illinois, USA) solution, with a cycle volume of 2,500 mL, and a 2,000-mL daytime dwell. Three studies were done on each patient using a total dialysis volume of 9.5 L (3 cycles), 14.5 L (5 cycles), and 19.5 L (7 cycles). Daily Kpt/V(urea) and daily CCp (peritoneal) (L/day/1.73 m2) were obtained. Six patients were H or HA (group 1) and 5 were LA transporters (group 2). For the group 1 patients, mean weight was 86.6 +/- 13.5 kg; Kpt/V(urea) was 1.68 +/- 0.21 using 9.5 L, 2.03 +/- 0.28 for 14.5 L (p < 0.05 compared to 10 L), and 2.28 +/- 0.28 with 19.5 L (p < 0.05 compared to 10 L and 15 L); mean weekly CCp was 45.43 +/- 7.63 L/1.73 m2 for 9.5 L (p < 0.05 compared to 14.5 L and 19.5 L), 51.17 +/- 7.07 with 14.5 L, and 54.67 +/- 10.08 for 19.5 L; ultrafiltration rates were not different in the three studies. For the group 2 patients, mean weight was 74.3 +/- 17.7 kg; mean weekly Kpt/V(urea) was 1.68 +/- 0.35 using 9.5 L, 2.10 +/- 0.42 for 14.5 L (p < 0.05 compared to 9.5 L), and 2.31 +/- 0.56 for 19.5 L (p < 0.05 compared to 9.5 L and 14.5 L); mean weekly CCp was 42.56 +/- 10.64 L/1.73 m2 for 9.5 L (p < 0.05 compared to 14.5 L and 19.5 L), 50.89 +/- 12.66 for 14.5 L, and 51.94 +/- 11.20 for 19.5 L; ultrafiltration was lower in the 9.5-L study than in the 14.5-L and 19.5-L studies, but was not different in the 14.5-L and 19.5-L studies. In both H/HA and LA transporters, Kpt/V(urea) and CCp rise significantly when the frequency of exchanges and total volume of dialysate are increased. Thus, the use of larger volumes of dialysate with cycling peritoneal dialysis may result in increased clearances of urea and creatinine.

QT Dispersion in Hemodialysis and CAPD Patients

Prolongation of repolarization dispersion (QT interval dispersion) measured from the 12-lead surface ECG has been associated with sudden cardiac death and ventricular tachyarrhythmias in a variety of cardiac disorders. The aim of our study was to assess the effects of hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) on QT dispersion in end-stage renal disease patients. 20 chronic HD patients (mean age 57.75 ± 13.79 years) and 20 CAPD patients (mean age 50.79 ± 14.94 years) who had no complaints and symptoms of cardiac arrhythmias as well as 20 healthy volunteers (mean age 48.74 ± 10.88 years) underwent ECG testing. All HD patients were on bicarbonate three times weekly with cuprophane capillaries. 12-lead ECGs were recorded on the day after HD. The CAPD patients were on a standard CAPD program (four times daily with 2,000 cm³ peritoneal fluid). ECGs were recorded when the patients were receiving their regular standard CAPD program. All ECGs were analyzed manually by one observer. There were no statistically significant differences in dialysis duration, blood urea nitrogen, creatinine, sodium, calcium, and parathormone values between the HD and CAPD patients. The serum potassium values were significantly higher in HD patients when compared to CAPD patients. There was no difference in the mean of maximal QT among all three groups. The rate of QT interval dispersions was significantly higher in HD and CAPD patients as compared with healthy controls (p < 0.05). There was no statistically significant difference in the QT dispersion rates between HD and CAPD patients. In conclusion, there is a tendency to cardiac arrhythmias in HD patients during the postdialysis period. Although CAPD patients are receiving dialysis daily, they also have higher rates of QT dispersions and accordingly a tendency to arrhythmias.

Dialysis adequacy and transport test for characterization of peritoneal transport type in chinese peritoneal dialysis patients receiving three daily exchanges

Dialysis adequacy and transport test (DATT) is an accurate method to classify peritoneal transport type for continuous ambulatory peritoneal dialysis (CAPD) patients with a regimen of four exchanges of 2 L/d. We examined the accuracy of DATT for the characterization of peritoneal transport type in patients with a regimen of three exchanges of 2 L/d, which is the standard CAPD regimen in Hong Kong Chinese. We studied 189 adult Chinese CAPD patients with a prescription of three exchanges of 2 L/d. Patients who had a peritonitis episode within the previous 30 days were excluded. Standard peritoneal equilibration test (PET) and DATT were performed on consecutive days. Correlation coefficients between dialysate-to-plasma ratios of creatinine (D/P) obtained for the PET and the DATT was 0.698 (P < 0.001). Peritoneal transport type was classified according to the reported D/P creatinine reference values obtained from the PET at 4 hours. When the result was compared with the transport type classified by the DATT result using the linear regression formula derived, the Cohen κ was 0.433 (95% confidence interval, 0.329 to 0.537), which could be regarded as a moderate level of agreement. For classification of the low transporters, the specificity of DATT was 90.1%, and sensitivity was 72.3%. For classification of the high transporters, the specificity of DATT was 96.6%, and sensitivity was 57.1%. DATT and PET had a reasonable agreement in the classification of peritoneal transport type for Chinese CAPD patients receiving a daily schedule of three exchanges of 2 L/d. Although DATT may be less accurate for CAPD patients with three daily exchanges, it remains a specific method to identify low and high transporters. © 2002 by the National Kidney Foundation, Inc.

Review: double bag or Y-set systems reduce peritonitis in patients on continuous ambulatory peritoneal dialysis

. Daly C, Campbell M, Cody J, et al. Double bag or Y-set versus standard transfer systems for continuous ambulatory peritoneal dialysis in end-stage renal disease . Cochrane Database Syst...

Peritoneal Sodium Mass Removal in Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis: Influence on Blood Pressure Control

Background/Aim: Sodium and water retention is common in peritoneal dialysis patients and contributes to cardiovascular disease. As peritoneal sodium removal depends partly on dwell time, and automated peritoneal dialysis (APD) often uses short dwell time exchanges, the aim of this study was to compare the 24-hour peritoneal sodium removal in APD and standard continuous ambulatory peritoneal dialysis (CAPD) patients and to analyze its possible influence on blood pressure control. Methods: A total of 53 sodium balance studies (30 in APD and 23 in CAPD) were performed in 36 stable peritoneal dialysis patients. The 24-hour net removal of sodium was calculated as follows: M = ViCi – VdCd, where Vd is the 24-hour drained volume, Cd is the solute sodium concentration in Vd, Vi is the amount of solution used during a 24-hour period, and Ci is the sodium concentration in Vi. Peritoneal sodium removal was compared between APD and CAPD patients. Residual renal function, serum sodium concentration, daily urinary sodium losses, weekly peritoneal Kt/V and creatinine clearance, 4-hour dialysate/plasma creatinine ratio, proportion of hypertonic solutions, net ultrafiltration, systolic and diastolic blood pressures, and need for antihypertensive therapy were also compared between the groups. Results: Peritoneal sodium removal was higher (p < 0.001) in CAPD than in APD patients. There were no significant differences in residual renal function, serum sodium concentration, urinary sodium losses, peritoneal urea or creatinine clearances, 4-hour dialysate/plasma creatinine ratio, or proportion of hypertonic solutions between groups. The net ultrafiltration was higher in CAPD patients and correlated strongly (r = 0.82; p < 0.001) with peritoneal sodium removal. In APD patients, peritoneal sodium removal increased significantly only in those patients with a second daytime exchange. The systolic blood pressure was higher (p < 0.05) in APD patients, and the proportion of patients with antihypertensive therapy was also higher in APD patients, although no significant relationship between blood pressure values and amount of peritoneal sodium removal was found. Conclusions: The 24-hour sodium removal is higher in CAPD than in APD patients, and there is a trend towards better hypertension control in CAPD patients. As hypertension control and volume status are important indices of peritoneal dialysis adequacy, our results have to be considered in the choice of the peritoneal dialysis modality.

Peritoneal dialysis adequacy: A model to assess feasibility with various modalities

The current standard of adequacy for peritoneal dialysis (PD) is to provide a weekly normalized urea clearance (Kt/V) of 2.0 or more and a creatinine clearance (CCr) of 60 liter/1.73 m2 or more. As native renal function is lost, it is important to determine the effectiveness of the available therapeutic modalities in achieving these goals. A model to assess our ability to provide a weekly Kt/Vurea of 2.0 or more and a CCr of 60 liter/1.73 m2 or more to anuric patients undergoing continuous ambulatory PD (CAPD) and automated PD (PD Plus) was developed. The body surface area (BSA) distribution was obtained from 38,768 patients undergoing dialysis during January 1997. The distribution of peritoneal transport rates (PTRs) was obtained from 2531 peritoneal equilibration tests performed during 1996. The weekly Kpt/Vurea was calculated for the various PTR groups and the range of BSA with four PD prescriptions: CAPD 8 liters, CAPD 10 liters, PD Plus 12 liters, and PD Plus 15 liters, using a previously validated kinetic program (PackPD). The predicted percentage of patients capable of achieving the adequacy goals for Kt/V and CCr, respectively, were 24.8 and 11. 2 for CAPD 8 liters, 54.2 and 33.0 for CAPD 10 liters, 77.8 and 54.9 for PD Plus 12 liters, and 93.2 and 72.9 for PD Plus 15 liters. Most patients can attain the current adequacy standards of therapy with automated PD, but few (less than 25%) can do so with standard CAPD in the absence of residual renal function.

Leptin in CAPD patients: serum concentrations and peritoneal loss.

To determine whether serum leptin concentrations in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) are influenced by peritoneal loss of leptin and to compare serum leptin levels of normal subjects with those of patients receiving renal replacement therapy such as haemodialysis (HD), CAPD, or kidney transplantation. Eighty-four individuals were investigated: six females and 14 males on standard CAPD; 13 females and 13 males on chronic HD; 10 female and eight male kidney transplant recipients, and 10 female and 10 male subjects as controls. Morning serum, 8-h and 24-h samples of peritoneal fluid concentrated to 6-20-fold by Centricon 3 (cutoff 3000 daltons), and 24-h urinary concentrations of leptin were measured with commercial RIA (Linco Research, Inc., USA). Venous blood and peritoneal fluid samples of albumin, beta2-microglobulin, glucose, urea, and creatinine were determined by standard laboratory techniques. Serum insulin levels were measured by radioimmunoassay. Patients (men and women) on CAPD and after kidney transplantation exhibited significantly higher serum concentrations of leptin and leptin/BMI ratios than control subjects. These increased values did not reach statistical significance in HD patients. Serum leptin concentrations were correlated very significantly with BMI in all cases (r=0.380, P<0.001). Moreover, in CAPD patients (r=0.630, P<0.007) and in HD patients (r=0.668, P<0.005), but not in kidney transplant recipients or control subjects, significant correlations were observed between serum leptin and insulin concentrations. Residual renal function (RRF) in the range 0-12.8 ml/min and serum beta2-microglobulin levels in the range 7.9-47.1 mg/l did not influence serum leptin levels in CAPD and HD patients. As expected, leptin was detected in the peritoneal fluid of CAPD patients. Twenty-four-hour peritoneal loss (30.95+/-21.05 ng/min) and 24-h peritoneal clearance (0.01+/-0.01 ml/kg/min) of leptin account for only 3.9% of estimated whole-body leptin production rate and 0.7% of leptin clearance from plasma respectively. Twenty-four-hour urinary losses of leptin in CAPD patients were negligible, accounting for 5.6+/-1.8% (range 0.3-15.2%) of total (peritoneal and urinary) loss of this hormone. These findings suggest that serum leptin levels are not affected by continuous peritoneal loss of leptin during CAPD and that insulin resistance and hyperinsulinaemia contribute to elevated serum leptin concentrations in CAPD and HD patients. The aetiology of increased serum leptin levels in kidney transplant recipients is probably different from that in dialysis patients.

Residual Renal Function Affects Lipid Profile in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

To determine whether lipoprotein abnormalities associated with continuous ambulatory peritoneal dialysis (CAPD) are influenced by residual renal function (RRF). Open, nonrandomized prospective and comparative study. Single university teaching hospital dialysis unit and outpatient clinic. Twenty adult patients on standard CAPD (1-38 months) were divided into two groups: group A (RRF < or = 0.8 mL/min, n = 10) and group B (RRF > or = 1.1 mL/ min, n = 10), Patients in the two groups were matched for age, time on dialysis, body weight, body mass index, serum urea and albumin levels, peritoneal and urinary albumin losses, and peritoneal transport characteristics such as overnight 8-hour peritoneal creatinine and beta 2-microglobulin clearances and overnight B-hour effluent glucose concentrations. The degree of uremia in patients with preserved RRF (group B) was obviously lower than in patients with negligible RRF (group A), that is, patients in group B had significantly lower serum creatinine and beta 2-microglobulin levels and significantly higher weekly KT/V than group A patients. Despite the prevalence of allele 4 of apolipoprotein E genotype in group A patients, their levels of serum total cholesterol, low-density lipoprotein cholesterol, lipoprotein (a) [Lp(a)], apolipoprotein B(ApoB), and apolipoprotein A1 (ApoA1) were significantly lower than those of patients with preserved RRF (group B). The two groups did not differ significantly in the serum levels of triglyceride or high-density lipoprotein cholesterol. Serum concentrations of Lp(a) and ApoA1, as well as ratios of ApoA1 to ApoB, were correlated significantly with RRF (r = 0.63, r = 0.51, and r = 0.61, respectively). The findings suggest that RRF affects the lipid profile of CAPD patients, especially serum levels of cholesterol-rich lipoproteins.

Measuring the adequacy of peritoneal dialysis: is there a link with nutrition and outcome?

Adequacy of peritoneal dialysis is predictive of outcome but the absolute evidence for setting optimal levels or targets is still lacking. The link between adequacy and nutrition is also tenuous and appears to be based on a mathematical relationship. The ability of standard continuous ambulatory peritoneal dialysis regimes to provide adequate dialysis may be limited in anuria and in large individuals.

Continuous ambulatory peritoneal dialysis complicating with abdominal hernias in children.

From May 1991 through December 1995, 10 uremic children ranging in age from 3.6 years old to 14.4 years old underwent insertion of 13 peritoneal dialysis catheters for continuous ambulatory peritoneal dialysis (CAPD). Eight abdominal hernias developed, associated with five catheters (38.5%) in four of the patients. Three hernias were inguinal, three were umbilical, one was epigastric, and one occurred at the catheter insertion site. Six hernias, including one umbilical hernia developing incarceration, were repaired. After operations because of recurrent hernias, two patients were switched from standard CAPD to night intermittent PD (NIPD) using low volumes of dialysate. Male sex and age younger than six years were possible associated risk factors (P = 0.19). In conclusion, hernia in young children undergoing CAPD is not unusual, and early surgical repair is advisable to avoid complications.

Weight Limitations for Weekly Urea Clearances Using Various Exchange Volumes in Continuous Ambulatory Peritoneal Dialysis

To calculate the relationships of weekly KT/V urea to standard body weight with different exchange volumes (2, 2.5, or 3 L) for continuous ambulatory peritoneal dialysis (CAPD) in functionally anephric patients and to display the results in graphic form. Theoretical calculations using previously measured 24-hour dialysate/plasma urea values in 77 CAPD patients and other defined components of weekly KT/V urea. Measurements and calculations in theoretical patients doing standard CAPD with four daily exchanges. Theoretical functionally anephric patients on standard CAPD as above. Theoretical calculations based on instillation of 2-, 2.5-, and 3-L exchange volumes. Weekly urea clearances normalized to total body water (weekly KT/V urea). The values using different exchange volumes were related to standard body weight. Although a minimum recommended weekly KT/V urea target is arbitrary, the results illustrate the range of flexibility of CAPD relative to KT/V urea values with variations in exchange volume. The standard weights above which anephric patients on CAPD using four exchanges per day with 2-, 2.5-, and 3-L exchanges cannot reach a weekly KT/V urea target of 1.7, have been identified. The range of weekly KT/V urea levels possible with different exchange-volume programs has been graphically illustrated. Weights above which a weekly KT/V urea of 1.7 cannot be reached in functionally anephric patients are 64, 77.6, and 91 kg for CAPD using 2-, 2.5-, and 3-L exchanges, respectively.

Short Term Clinical Study with Bicarbonate-Containing Peritoneal Dialysis Solution

The evaluation of the efficacy, adequacy, clinical tolerance, and safety of a new bicarbonate continuous ambulatory peritoneal dialysis (CAPD) solution. A 6-week cross-over clinical study in 6 stable CAPD patients was performed. After a control period (2 weeks) with a standard CAPD solution (lactate, 35 mmol/L), a two-chamber bag containing 34 mmol/L of bicarbonate was used for 4 weeks. A breakable valve divided the two chambers, one containing bicarbonate and the other calcium. The two solutions were mixed just before use, thus avoiding the calcium and magnesium carbonate precipitation. No differences between control and study periods were found for blood urea nitrogen, creatinine, total proteins, albumin, total and ionized calcium, phosphate, sodium, potassium, chlorine, and hemoglobin. Blood bicarbonate significantly increased from 21.25 +/- 2.02 to 23.36 +/- 1.15 (p < 0.05) during the study. The peritoneal equilibration tests for urea nitrogen, creatinine, proteins, sodium, potassium, and glucose were slightly reduced during bicarbonate dialysate, but this effect was compensated for by a slight increase of ultrafiltration, thus keeping peritoneal clearances constant. Residual renal function did not change during the study. No side effects occurred during the bicarbonate period. A CAPD bicarbonate solution is effective in uremic acidosis correction, does not affect dialysis adequacy, is safe, and well tolerated.

Body Composition and Lipid Abnormalities in Hispanic and Black Patients on Continuous Ambulatory Peritoneal Dialysis

Cardiovascular disease is the leading cause of death in patients undergoing maintenance dialysis. This study was undertaken to evaluate the lipid abnormalities and body composition by bioelectrical impedance in patients receiving continuous ambulatory peritoneal dialysis (CAPD). The patients were between the ages of 28 and 77 and had been on dialysis for periods ranging from 6-48 months. Body composition studies performed by electrical impedance showed that the CAPD patients generally had elevated levels of body fat. Most of these patients had waist-to-hip fat ratios of more than 1.0, and lean tissue was decreased. Serum chemistries showed that most of the patients had albumin levels less than 3.5 g/dL. The most frequent lipid abnormalities found were: hypertriglyceridemia; hypercholesterolemia; decreased HDL levels; elevated cholesterol/HDL and apoproteins (Apo B/A-1); and elevated lipoprotein [Lp(a)] levels. Cardiovascular disease was prevalent in the patients studied. Ten had a positive history of angina, with three documented myocardial infarction and two documented cardiovascular disease. In conclusion, standard CAPD treatment may increase the risk of cardiovascular disease.

Multicenter Study of Change in Dialysis Therapy-Maintenance Hemodialysis to Continuous Ambulatory Peritoneal Dialysis

Serial prospective observations were made on 40 patients with end-stage renal failure who transferred voluntarily from long-term maintenance hemodialysis (MHD) to continuous ambulatory peritoneal dialysis (CAPD). Adequate data were available through 6 months on CAPD in 26 participants, whereas 20 completed the study (1 year on CAPD). There were 12 (30%) treatment failures, including two deaths. Standard CAPD (four 2-L exchanges per day) proved to be inadequate therapy in large, young males with low total urea clearances (Ktu) on MHD. There was a large variation in Ktu within MHD and CAPD therapies that employed apparently similar or identical dialysis prescriptions; this underscores the need to quantify dialysis by a measure such as Ktu. Hematocrit, white blood cell (WBC) and platelet counts, and serum bicarbonate levels were significantly higher, whereas blood urea nitrogen (BUN) and serum potassium levels were significantly lower on CAPD than on MHD. While body weight, blood pressure, bone disease, parathyroid hormone (PTH) levels, and lipid profile did not change significantly, nutritional indices tended to decline with time on CAPD. Urea generation rate (Gu) decreased significantly after transfer to CAPD and correlated with Ktu regardless of treatment modality. Central nervous system (CNS) function reflecting uremic symptomatology and as indexed by average quantified electroencephalogram (EEG) discriminant scores did not change significantly. Hospitalization rates and stays were similar during equal time intervals on both therapies. Sufficiently diverse responses followed the MHD to CAPD therapy change to warrant more extended observations on larger numbers of patients.