A rational approach to nutritional assessment.

Summary Background and objectives Heart failure occurs frequently in end-stage renal disease patients. However, there are no prospective, longitudinal follow-up data on its prevalence, severity, and risk factors in longterm peritoneal dialysis (PD) patients. Design, setting, participants, & measurements A prospective observational study was conducted in 220 longterm PD patients followed up for 4 years or until death. Echocardiography was obtained at baseline. Primary study end points were heart failure and mortality. Results Eighty-six patients had a previous history of heart failure at study entry. The cumulative 4-year survival probability was 37.4% and 64.7% for patients with and without previous heart failure, respectively (P 0.0001). During follow-up, 87 patients (40.9%) developed heart failure, of which 53 were recurrence and 34 were new-onset heart failure. Diabetes, background atherosclerotic vascular disease, systolic hypertension, left ventricular (LV) mass index, systolic dysfunction, and hypoalbuminemia were significant risk factors predicting heart failure in the entire cohort. Diabetes and LV mass and volume index were significant predictors of new-onset heart failure. Systolic hypertension, LV volume index, and hypoalbuminemia were significant predictors of recurrent heart failure. Conclusions Heart failure is a highly prevalent complication in long-term PD patients and predicts adverse clinical outcomes. More attention should be focused on improving BP and volume control and identifying treatment strategies that effectively lower atherosclerotic burden and reverse LV hypertrophy, remodeling, and systolic dysfunction in PD patients. Clin J Am Soc Nephrol 6: ●●● –●●● , 2011. doi: 10.2215/CJN.07130810

Heart Failure in Long-Term Peritoneal Dialysis Patients: A 4-Year Prospective Analysis

Dangers, and benefits of the cytokine mediated response to injury and infection

Hypoalbuminemia is a major risk factor for morbidity and mortality in dialysis patients. With increasing interest in highly permeable membranes and convective therapies to improve removal of middle molecules, transmembrane albumin loss increases accordingly. Currently, the acceptable upper limit of albumin loss for extracorporeal renal replacement therapies is unknown. In theory, any additional albumin loss should be minimized because it may contribute to hypoalbuminemia and adversely affect the patient's prognosis. However, hypoalbuminemia-associated mortality may be a consequence of inflammation and malnutrition, rather than low albumin levels per se. The purpose of this review is to give an overview of albumin handling with different extracorporeal renal replacement strategies. We conclude that the acceptable upper limit of dialysis-related albumin loss remains unknown. Whether enhanced middle molecule removal outweighs the potential adverse effects of increased albumin loss with novel highly permeable membranes and convective therapies is yet to be determined.

Albumin handling in different hemodialysis modalities.

Hypertension is prevalent in an estimated 29% to 80% of patients treated with peritoneal dialysis (PD). Cardiovascular disease represents the most common cause of mortality in this population, and hypertension (HTN) plays an important role. Volume overload is prevalent in PD patients because of liberal intake of fluids and loss of residual renal function (RRF). Noncompliance with salt restriction causes weight gain and makes HTN more difficult to manage. Physiology of the peritoneal membrane and its transport characteristics governs the ultrafiltration rate and consequently both volume and HTN. Therapeutic options for blood pressure control are ultrafiltration through the osmotic or colloid osmotic effects of dialysis solutions, salt restriction, and the use of antihypertensive medications such as diuretics, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Loop diuretics are used to maintain urine output in nonoliguric patients. Doses may exceed 250 mg of furosemide; ototoxicity is not problematic if blood levels are monitored carefully. Preservation of RRF is important for maintaining volume control and, thereby, control of HTN.

Hypertension in peritoneal dialysis patients: epidemiology, pathogenesis, and treatment

Hypoalbuminemia may be secondary to volume expansion conditions and an independent risk factor for cardiovascular disease. Bioelectrical impedance analysis (BIA) is an accurate, non-invasive method to measure body composition, especially the water compartments in humans. The aim of this cross-sectional study is to evaluate the relationship between serum albumin concentration (SA) and hydration state measured by whole BIA. The study investigated 108 non-selected patients (73 on hemodialysis, 35 on peritoneal dialysis) with a mean age of 61.4 +/- 15.6 years, 42.7% of whom were female. The patients were allotted to groups according to their SA: Group 1, 4.0 g/dL. The BIA parameters used included: total body water, intracellular water (ICW), extracellular water (ECW), phase angle (PA), body cell mass (BCM), ICW/ECW ratio and ICW/ECW ratio patients/controls (fluid index). Seventy-five healthy volunteers formed the control group. A strong positive correlation was found between the PA and fluid index (r (2) = 0.993, P < 0.001), as well as between the PA and SA (r = 0.386, P < 0.001), and the ICW/ECW ratio and SA (r = 0.227, P < 0.001). The ECW was negatively correlated with SA (r = -0.330, P < 0.001). Every 0.1 g/dL decrease in SA was associated with a 0.33 L increase in ECW. Group 1 patients had lower reactance (P = 0.006), PA (P < 0.001), BCM (P = 0.012), fluid index (P < 0.001) and ICW/ECW ratio (P = 0.015), and an increased ECW (NS) than groups 2 and 3. We conclude that hypoalbuminemia is also a marker of fluid excess. The SA is associated to the fluid index and the PA allows assessment of the dry weight and its variations in an individualized manner in dialysis patients.

Isabel Herraez

Papers

Hypoalbuminemia is also a marker of fluid excess determined by bioelectrical impedance parameters in dialysis patients.