Years Of Continuous Ambulatory Peritoneal Dialysis Research Articles

Adverse factors on nonenhanced abdominal CT for long-term continuous ambulatory peritoneal dialysis: a comparative study between patients who withdraw from and maintain long-term peritoneal dialysis.

PurposeTo investigate the imaging features of patients with long-term continuous ambulatory peritoneal dialysis (CAPD) on nonenhanced abdominal CT and to identify adverse factors for long-term CAPD.MethodsA total of 109 patients with less than 5 years of CAPD for peritoneal ultrafiltration failure who switched to hemodialysis (withdrawal group) and 23 patients with more than 10 years of CAPD (long-term group) were retrospectively enrolled. Nonenhanced CT manifestations in both groups were compared, including thickening and calcification of the parietal peritoneum, calcification of the mesangial margin and free margin of the small intestine wall, and calcification of the mesentery and abdominal aorta. A risk stratification model was proposed based on CT manifestations with statistically significant differences.ResultsThe presence of the following CT findings was significantly different between two groups: extensive thickening of the parietal peritoneum (78.9% vs. 21.7%, P < 0.01); severe calcification of the parietal peritoneum (60.6% vs. 8.7%, P < 0.01); calcification of the mesentery (32.1% vs. 4.3%, P < 0.05); and calcification of the free margin of the small intestine wall (49.5% vs. 13.0%, P < 0.05). However, there was no significant difference in calcification of the mesangial margin of the small intestine wall (40.3% vs. 30.4%) or in abdominal aortic calcification (56.9% vs. 61.1%) (P > 0.05). The area under the receiver operating characteristic curve (AUC) was 0.906 (sensitivity 87.6% and specificity 82.6%).ConclusionExtensive thickening of the parietal peritoneum, severe calcification of the parietal peritoneum, and calcification of the mesentery and the free margin of the small intestine wall are adverse factors for long-term CAPD.

Atherogenic ratios and serum lipid levels in patients with end-stage renal disease on continuous ambulatory peritoneal dialysis

Background: Patients with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) often have an atherogenic lipid profile. Lipid disturbances that have been observed in patients with ESRD on CAPD include hypercholesterolemia, hypertriglyceridemia, and decreased high-density lipoprotein cholesterol (HDL-c). Aim and Objectives: To study the atherogenic ratios and serum lipid levels in patients with ESRD on CAPD and compare with healthy controls. Materials and Methods: This study included 30 patients with ESRD before and after the initiation of continuous ambulatory peritoneal dialysis and 30 healthy controls. Thirty patients with ESRD after the start of peritoneal dialysis were regularly followed up for 3rd, 6th, 9th, 12th, and 15th months. The biochemical parameters were measured in baseline and follow-up samples. Results: The concentrations of (TC), serum triglycerides (TGs), very low-density lipoprotein cholesterol (VLDL-c), and atherogenic ratios were increased and levels of serum TC, low-density lipoprotein cholesterol (LDL-c), and HDL-c were decreased significantly during 3rd and 6th months. However, after 1 year of CAPD, the serum TGs, VLDL-c, TC, and LDL-c levels were significantly higher than the baseline values and HDL-c was significantly lower than the baseline values. Conclusion: The present study findings conclude that the continuous peritoneal absorption of glucose during CAPD contributes to alteration in serum lipids. However, the changes are fluctuating as an adaptation to the peritoneal absorption of glucose.

Predicting Tree-Year Clinical Outcomes Using the Baseline and Trajectories of Serum Albumin in Patients on Peritoneal Dialysis

Background: The change and trend in serum albumin levels after initiation of peritoneal dialysis may be a crucial determinant for clinical outcomes. Objectives: The current study aimed at determining the association between the trajectory of serum albumin and the 3-year clinical outcomes using a novel approach joint modeling longitudinal and survival data. Furthermore, the current study was performed to compare the impact of baseline and trajectory serum albumin on predictability of 3-year outcomes. Methods: The current retrospective longitudinal study reviewed all of the available files of the patients undergoing continuous ambulatory peritoneal dialysis (CAPD) in Al-Zahra hospital, Isfahan, Iran, from May 2005 to March 2015. A total of 183 patients with at least 3 years follow-up were selected for the study. The independent variables of interest were baseline and the trajectories of serum albumin, age, gender, history of previous hemodialysis (HD), body mass index (BMI), baseline serum creatinine, and comorbidity including cardiovascular disease and diabetes. The outcomes of interest were death from all causes, transfer to HD and transplantation during the first 3 years of CAPD. Results: The patient and technique survival rates at 36 months were 71% and 77%, respectively. C-indexes (prediction errors) of mortality, transfer to HD, and transplantation for joint modeling with trajectories of serum albumin were higher (lower) than those of the Cox regression with baseline albumin. Hazard ratios of mortality, transfer to HD, and transplantation for trajectories of serum albumin were 0.409, 0.273, and 3.394, respectively. Conclusions: The current study indicated that the predictability of 3-year clinical outcomes using trajectories of serum albumin was higher than those of the baseline. According to the findings of the current study, it seems that controlling serum albumin over time in patients undergoing CAPD, particularly the ones with the history of diabetes and HD, can help to prevent or modify the clinical outcomes during the PD period.

Difficulty in Improving Malnutrition and Low‐grade Inflammation in Diabetic Patients on Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is commonly used for renal replacement therapy in diabetes mellitus (DM) patients. We investigated the changes of peritoneal transport characteristics, nutritional status, and adequacy and inflammation parameters in diabetic CAPD patients (N = 17) compared to non-diabetic patients (N = 23). Peritoneal equilibrium testing, nutritional, biochemical, and anthropometric parameters and adequacy were prospectively assessed at 1 (baseline), 6 and 12 months after initiating CAPD. The levels of several nutritional parameters were lower and did not change in DM patients over time (P < 0.05) and significantly improved in the non-DM patients over time (P < 0.05). Total weekly creatinine clearance and residual renal function exhibited a rapid decline (P < 0.05) and inflammation parameter levels were higher in DM patients (P < 0.05). Our results showed the difficulty in improvement of nutritional status and inflammatory parameters in diabetic patients during at least the first year of CAPD compared to non-DM patients.

Localization and Extent of Peritoneal Calcification in Three Uremic Patients on Continuous Ambulatory Peritoneal Dialysis

Peritoneal calcification in three patients on continuous ambulatory peritoneal dialysis (CAPD) was reviewed, and the relation between the localization and extent of calcium deposits detected by abdominal computed tomography (CT) and clinical signs was evaluated. Case 1 was a 48-year-old man with abdominal pain, hemoperitoneum and secondary hyperparathyroidism after receiving CAPD for seven years. An abdominal CT revealed linear peritoneal calcification in the pelvic cavity and liver surface, and his symptoms resolved after switching to hemodialysis. His clinical course and pathological findings were compatible with those in progressive calcifying peritonitis. Case 2 was a 26-year-old man presenting with abdominal pain, vomiting and fullness two years after switching to hemodialysis, because of uncontrolled overhydration following 13 years of CAPD. Plaque-like calcification outlining the small intestine and parietal peritoneum was noted on CT. Case 3 was a 59-year-old man who had abdominal distention, vomiting and diarrhea three months after switching to hemodialysis due to loss of peritoneal function following 10 years of CAPD. CT revealed diffuse sheet-like calcification surrounding the bowel and mesentery, adherent dilated bowel loops and ascites. These CT findings suggested the existence of encapsulating peritoneal sclerosis (EPS) in cases 2 and 3. Findings from our three patients indicate that peritoneal calcification is not always accompanied by EPS; however, monitoring peritoneal calcification and other findings by abdominal CT, even after cessation of CAPD, is crucial to maintain vigilance on whether the subclinical signs, which are temporally diagnosed as progressive calcifying peritonitis, advance to EPS.

Dialysate leaks in peritoneal dialysis.

Dialysate leakage represents a major noninfectious complication of peritoneal dialysis (PD). An exit-site leak refers to the appearance of any moisture around the PD catheter identified as dialysate; however, the spectrum of dialysate leaks also includes any dialysate loss from the peritoneal cavity other than via the lumen of the catheter. The incidence of dialysate leakage is somewhat more than 5% in continuous ambulatory peritoneal dialysis (CAPD) patients, but this percentage probably underestimates the number of early leaks. The incidence of hydrothorax or pleural leak as a complication of PD remains unclear. Factors identified as potentially related to dialysate leakage are those related to the technique of PD catheter insertion, the way PD is initiated, and weakness of the abdominal wall. The pediatric literature tends to favor Tenckhoff catheters over other catheters as being superior with respect to dialysate leakage, but no consensus on catheter choice exists for adults in this regard. An association has been found between early leaks (< or =30 days) and immediate CAPD initiation and perhaps median catheter insertion. Risk factors contributing to abdominal weakness appear to predispose mostly to late leaks; one or more of them can generally be identified in the majority of patients. Early leakage most often manifests as a pericatheter leak. Late leaks may present more subtly with subcutaneous swelling and edema, weight gain, peripheral or genital edema, and apparent ultrafiltration failure. Dyspnea is the first clinical clue to the diagnosis of a pleural leak. Late leaks tend to develop during the first year of CAPD. The most widely used approach to determine the exact site of the leakage is with computed tomography after infusion of 2 L of dialysis fluid containing radiocontrast material. Treatments for dialysate leaks include surgical repair, temporary transfer to hemodialysis, lower dialysate volumes, and PD with a cycler. Recent recommendation propose a standard approach to the treatment of early and late dialysate leaks: 1-2 weeks of rest from CAPD, and surgery if recurrence. Surgical repair has been strongly suggested for leakage causing genital swelling. Delaying CAPD for 14 days after catheter insertion may prevent early leakage. Initiating CAPD with low dialysate volume has also been recommended as a good practice measure. Although peritonitis and exit-site infections are the most frequent causes of technical failure in peritoneal dialysis (PD), dialysate leaks represent one of the major noninfectious complications of PD. In some instances, dialysate leakage may lead to discontinuation of the technique (1). Despite its importance, the incidence, risk factors, management, and outcome of dialysate leakage are poorly characterized in the literature. We will review the limited available information on this topic in the next few sections.

Acquired cystic kidney disease in children undergoing continuous ambulatory peritoneal dialysis. Kyushu Pediatric Nephrology Study Group.

Our cross-sectional study aims to elucidate the prevalence of acquired cystic kidney disease (ACKD), time of occurrence of ACKD, relationship between the prevalence of ACKD and duration of dialysis, progression of cysts, and ACKD-related complications in 54 children undergoing continuous ambulatory peritoneal dialysis (CAPD). ACKD was defined as four or more cysts detected in each kidney by ultrasonography, computed tomography (CT), or magnetic resonance imaging. The presence of less than four cysts was diagnosed as solitary cysts (SCs). Noncystic primary disease was present as glomerulonephritis in 23 patients (42.6%); hypoplastic kidney, 7 patients (13.0%); reflux nephropathy, 6 patients (11.1%); and other, 18 patients (33.3%). ACKD was evident in 16 patients (29.6%) during the 57.9 +/- 39.8 months after the start of CAPD. Nine patients (16. 7%) had SCs. SCs and ACKD were detected initially in patients with 1 and 3 years of CAPD, respectively. The mean duration of CAPD for patients with ACKD (96.1 +/- 36.6 months) differed from that of patients with SCs (49.8 +/- 29.9 months) and no cysts (38.3 +/- 25.8 months). The groups were classified according to time after the start of CAPD: 0 to 4 years (n = 33), 5 to 9 years (n = 16), and longer than 10 years (n = 5). The prevalence of ACKD among these three groups was 9.1%, 50%, and 80%, respectively, and this prevalence increased significantly with increasing duration of CAPD. Of 15 patients examined two to four times by ultrasonography or CT, the number and size of cysts increased in 7 patients with ACKD and 2 patients with SC. Two patients with many and large cysts experienced gross hematuria, and one of those patients had intracystic and retroperitoneal bleeding caused by cyst rupture. No solid mass lesion was found by imaging diagnostic modalities in the 54 patients. In conclusion, the prevalence of ACKD in children undergoing CAPD is just as high as that in adults. The prevalence of ACKD and number and size of cysts increased with increasing duration of CAPD.

Peritoneal dialysis in nondiabetic patients older than 70 years: Comparison with patients aged 40 to 60 years

In all industrial countries, the number of elderly patients who need dialysis has increased in recent years. In the present study, we retrospectively analyzed two different age groups of nondiabetic peritoneal dialysis patients treated at the same unit by the same team of physicians and nurses with the same protocols. However, our purpose was to study possible differences in technique and survival rates, causes of dropout, complications, hospitalization rate, and everyday needs between the two groups. The results of 63 consecutive nondiabetic patients older than 70 years treated with continuous ambulatory peritoneal dialysis (CAPD) were compared with those of 86 nondiabetic patients aged 40 to 60 years treated during the same period. Patient survival was significantly worse in the elderly patients, but the observed to expected survival ratio with respect to age was similar. Technique survival was comparable in the two groups. Total hospitalization was 5,501 days (32 d/yr) in the elderly patients and 4,511 days (18 d/yr; P < 0.05) in the younger group. The peritonitis rate was 0.52 episodes/patient-year in the elderly patients and 0.37 episodes/patient-year in the younger patients (P < 0.002). The exit site infection rate was similar in the two groups (0.30 episodes/yr v0.29 episodes/yr). Other complications related to CAPD did not differ between the elderly and younger patients. Rehabilitation and biochemical data after 1 year of CAPD were similar in the two groups of patients. After 1 year of treatment, 12% of the younger patients and 43% of the elderly patients (P < 0.005) needed a partner for dialysis. Twenty-nine of 39 (74%) of the elderly patients and 30 of 53 (57%) of the younger patients considered their lifestyle acceptable after 1 year of dialysis. Thirty-four of 39 (87%) of the elderly patients and 32 of 53 (60%) of the younger patients (P < 0.02) rated their physical and social state after rehabilitation as better or comparable to that they had before terminal uremia. (Am J Kidney Dis 1998 Mar;31(3):479-90)

Role of an improvement in acid-base status and nutrition in CAPD patients

Short-term correction of metabolic acidosis in normal and uremic subjects has been shown to decrease protein degradation, but the long-term effects of better correction of acidosis on nutrition in ESRF are unknown. The aim of this study was to assess the possible benefits, in the nutritional state and morbidity, of improved correction of acidosis in the first year of treatment with continuous ambulatory peritoneal dialysis (CAPD). Two hundred consecutive new CAPD patients were randomized, in a single-blind fashion, to receive a high (HA; lactate 40 mmol/liter) or low (LA; lactate 35 mmol/liter) alkali dialysate for one year. Calcium carbonate and sodium bicarbonate were also used to correct acidosis in the HA group. At one year, the venous serum bicarbonate and arterial pH were 7.44 +/- 0.004 and 27.2 +/- 0.3 mmol/liter in the HA group, and 23.0 +/- 0.3 mmol/liter and 7.4 +/- 0.004 in the LA group (P < 0.001). Dialysis dose, at one year or at the point of leaving the study (HA 8.0 +/- 0.1 liters/day vs. LA 8.5 +/- 0.3 liters/day) was not significantly different (P = 0.18). At one year, the increase in body weight in the HA group (6.1 +/- 0.66 kg) was higher than in the LA group (3.71 +/- 0.56 kg, P < 0.05). The increase in midarm circumference in the HA patients (1.26 +/- 0.16 cm) was significantly higher than the increase in the LA patients (0.61 +/- 0.16 cm, P < 0.05). The increase in triceps skinfold thickness were not significantly different (HA 2.5 +/- 0.41 mm vs. LA 1.24 +/- 0.38 mm, P = 0.1). Serum albumin was 37.8 +/- 0.4 g/dl at one year in the HA group, and 38.2 +/- 0.5 g/dl in the LA group (NS). Dietary protein intake at one year (HA 0.9 +/- 0.2 g/kg/day vs. LA 1.0 +/- 0.1 g/kg/day) was not significantly different. There were fewer hospital admissions in the HA group (1.13 +/- 0.16 per patient per year) compared to the LA group (1.71 +/- 0.22 per patient per year, P < 0.05). The HA patients spent less days in hospital per year than the LA patients (16.4 +/- 1.4 days/year vs. 21.2 +/- 1.9 days/year; P < 0.05). It is concluded that better correction of metabolic acidosis leads to greater increases in body weight and midarm circumference, but not triceps skinfold thickness, in the first year of CAPD. The improvement in morbidity, in terms of number of admissions and days in hospital per year, may be associated with the improvement in nutritional state.

Survival of 138 Surgically Placed Straight Double-Cuff Tenckhoff Catheters in Patients on Continuous Ambulatory Peritoneal Dialysis

To determine the natural history of a surgically placed Tenckhoff catheter in patients on continuous ambulatory peritoneal dialysis (CAPD). Prospective 7-year study analyzing catheter survival of all catheters using the Kaplan-Meier life table methodology. Teaching hospital, department of nephrology. One hundred and fifteen unselected patients beginning CAPD. Removal of the catheter required for the following complications: exit-site or tunnel infections or relapsing peritonitis, outflow obstruction, pericatheter leak, and development of hernias. Period between insertion and removal of the catheter. The cumulative survival of all catheters after 1, 2, and 3 years of CAPD was 87%, 69% and 65%. Catheter survival of the first versus the second catheter after 1 year was significantly longer (p = 0.03). The difference was not significant in relation to diabetes, age, and sex. Infectious complications caused 61% (n = 19) of all 31 catheter failures, mainly due to tunnel infections caused by Staphylococcus aureus (n = 12). "Mechanical" complications accounted for 49% (n = 12) of catheter failures. Eight of 12 mechanical complications were outflow failures. Seven patients had to be transferred to hemodialysis. The straight Tenckhoff catheter is a reliable peritoneal access device for CAPD in an unselected patient population.

Functional Characteristics of the Peritoneal Membrane in Long-Term Continuous Ambulatory Peritoneal Dialysis

Peritoneal transport characteristics of 20 long-term (LT) patients with a mean duration on continuous ambulatory peritoneal dialysis (CAPD) of 60 months were compared with those of 20 matched patients who recently started (RS) CAPD (mean 39 days, range 11-63). Mass transfer area coefficients (MTC) of creatinine, glucose and inulin were higher in the LT group than in the RS group (12.1 versus 9.2 ml/min, p less than 0.01; 9.9 versus 8.3 ml/min, p less than 0.05; 4.1 versus 3.5 ml/min, p less than 0.05). The MTC of alpha 2-macroglobulin were lower in the LT group (13 versus 25 microliters/min; p less than 0.01). The size selectivity of the membrane for the transport of macromolecules, determined as protein MTC ratios, showed a more restricted passage for macromolecules in the LT group. Net fluid removal using glucose 3.86% was lower in the LT patients (487 versus 826 ml/4 h; p less than 0.001). The results indicate the development of a larger effective peritoneal surface area combined with a less permeable peritoneal membrane after many years of CAPD.

Peritoneal Solute Clearances after four Years of Continuous Ambulatory Peritoneal Dialysis (CAPD)

In order to evaluate peritoneal membrane function and responsiveness of peritoneal microcirculation to vasoactive agents in long-term continuous ambulatory peritoneal dialysis (CAPD) patients, we studied peritoneal clearances of urea (Curea) and creatinine (Ccr), protein concentrations in drained dialysate (DPC), peritoneal glucose absorption (% GA), and drained dialysate volume (VD) before and after nitroprusside (NP) addition to dialysis solution in 17 long-term CAPD patients (mean duration of CAPD: 52 months) and the results were compared to those of 18 patients who were just trained for CAPD (mean duration: 0.6 month). There were no differences in the control (without NP) Curea, Ccr, DPC, %GA, and VD between the new and long-term CAPD patients. Curea, Ccr, and DPC increased significantly with NP in both new and long-term patients. Curea and Ccr with NP were not different between the new and long-term patients but DPC with NP was significantly lower in the long-term CAPD patients. The results of this study suggest that peritoneal solute clearances and the responsiveness of peritoneal microcirculation to NP remain unchanged after four years of CAPD, despite recurrent episodes of peritonitis.

Serum Lipids and Lipoproteins during Continuous Ambulatory Peritoneal Dialysis

The effects of continuous ambulatory peritoneal dialysis (CAPD) on serum lipids and lipoproteins over the initial year of therapy were studied in 23 uremic patients. Lipoprotein abnormalities typical for the uremic dyslipoproteinemia were present at the start of CAPD. During the first months of CAPD these abnormalities were accentuated. The concentrations of very low density lipoprotein (VLDL)-cholesterol (CHOL), low density lipoprotein (LDL)-CHOL, serum CHOL and serum triglycerides (TG) increased significantly. However, after one year of CAPD only the VLDL-CHOL and serum CHOL levels remained significantly higher than the baseline values. VLDL-TG, VLDL-CHOL and serum TG, and the changes of these variables over the study period, correlated with the amount of glucose in the dialysates. We conclude that the continuous peritoneal absorption of glucose (100-200 g/24 h) during CAPD contributes to potentially atherogenic changes in serum lipids and lipoproteins. However, some of the changes are transitory, indicating an adaptation to the peritoneal glucose load.

Secondary hyperparathyroidism in diabetic and nondiabetic patients on long-term continuous ambulatory peritoneal dialysis (CAPD).

Serum values of calcium, phosphate, alkaline phosphatases and parathyroid hormone (PTH) are reported for 24 diabetic and 26 nondiabetic patients treated with continuous ambulatory peritoneal dialysis (CAPD) for a total of 779 months, without the use of vitamin D or calcium supplements. Radiographic data are reported for 25 patients followed on CAPD for at least 12 months. Serum calcium was well maintained and control of hyperphosphataemia acceptable, but phosphate-binding therapy had to be continued in the majority of patients. Diabetic patients had lower serum phosphate levels and higher serum calcium than nondiabetic patients during the first year of CAPD. In nondiabetic patients the institution of CAPD was followed by a fall in PTH, possibly largely reflecting transperitoneal PTH elimination. No patient achieved normalization of serum PTH on CAPD. Although no symptomatic bone disease was observed, radiographic evidence of progressive hyperparathyroid bone disease developed in 3 of the 25 examined patients, all nondiabetic. In summary, long-term CAPD with a dialysate calcium concentration of 1.75 mmol/l seems to be compatible with normocalcaemia and a steady-state situation with regard to secondary hyperparathyroidism in the majority of patients. Despite transperitoneal elimination, serum PTH remains elevated, and definite progression of hyperparathyroidism is observed in some patients, however, probably making a case for vitamin D therapy and/or intraperitoneal or peroral calcium supplementation in these patients.

Characteristics of the Hematocrit Response to Continuous Ambulatory Peritoneal Dialysis

Markedly heterogeneous increases in hematocrit readings were noted in a group of nine patients who previously had undergone hemodialysis, none of whom had polycystic disease. They had been receiving continuous ambulatory peritoneal dialysis (CAPD) for at least one year. There was no correlation between change in Hct reading and serum urea nitrogen, creatinine, total protein, or albumin levels. Respective contributions of blood transfusions and venipuncture were likewise negligible. The increase in Hct reading in several patients was gradual and still ongoing at one year of CAPD. Other patients, two of whom had a decrease in transfusion requirement with CAPD, had either no increase in Hct reading or a small increase that was not sustained. A return to hemodialysis (or, in one case, discontinuation of all dialysis with partial return of renal function) lowered Hct readings in patients who had initially responded to CAPD. The individual response in Hct reading to CAPD maintenance therapy is highly variable and is not predictable from clinically available measurements.

PERITONITIS IN CONTINUOUS AMBULATORY PERITONEAL DIALYSIS: Laboratory and Clinical Studies

During a three year period, 1979-81, 82 patients were treated by continuous ambulatory peritoneal dialysis (CAPD). The incidence of peritonitis was reduced significantly during the three years from one episode per 20 patient-weeks to one episode every 37 patient-weeks. 83% of the 136 episodes of peritonitis were treated successfully by antibiotic therapy alone. 62% of the total episodes were managed successfully with intraperitoneal cefuroxime. In 13 (16%) patients, CAPD failed because of peritonitis. Hospital admission for peritonitis has been reduced to a mean of 4-3 days per patient per year of CAPD. From January to September, 1982, Clostridium-difficile colitis developed in 13 patients. This complication was associated with considerable mortality and morbidity and has prompted a change in antibiotic policy. Patients with peritonitis are now given intraperitoneal netilmicin and intravenous vancomycin. Peritonitis remains the main complication of CAPD, but can be minimised by development of adequate facilities for performing CAPD.