Showing papers on "Peritoneal dialysis published in 1998"

Epidemiology of cardiovascular disease in chronic renal disease.

Abstract: The risk of cardiovascular disease in patients with chronic renal disease appears to be far greater than in the general population. For example, among patients treated by hemodialysis or peritoneal dialysis, the prevalence of coronary artery disease is approximately 40% and the prevalence of left ventricular hypertrophy is approximately 75%. Cardiovascular mortality has been estimated to be approximately 9% per year. Even after stratification by age, gender, race, and the presence or absence of diabetes, cardiovascular mortality in dialysis patients is 10 to 20 times higher than in the general population. Patients with chronic renal disease should be considered in the highest risk group for subsequent cardiovascular events. Cardiac failure is more common in chronic renal disease patients than in the general population, and is an independent predictor of death in chronic renal disease. Among hemodialysis and peritoneal dialysis patients, the prevalence of cardiac failure is approximately 40%. Both coronary artery disease and left ventricular hypertrophy are risk factors for the development of cardiac failure. In practice, it is difficult to determine whether cardiac failure reflects left ventricular dysfunction or extracellular fluid volume overload. Patients who develop clinical manifestations of cardiac failure should be evaluated for cardiovascular disease.

Poor Long-Term Survival after Acute Myocardial Infarction among Patients on Long-Term Dialysis

Abstract: Background Cardiovascular disease is common in patients on long-term dialysis, and it accounts for 44 percent of overall mortality in this group. We undertook a study to assess long-term survival after acute myocardial infarction among patients in the United States who were receiving long-term dialysis. Methods Patients on dialysis who were hospitalized during the period from 1977 to 1995 for a first myocardial infarction after the initiation of renal-replacement therapy were retrospectively identified from the U.S. Renal Data System data base. Overall mortality and mortality from cardiac causes (including all in-hospital deaths) were estimated by the life-table method. The effect of independent predictors on survival was examined in a Cox regression model with adjustment for existing illnesses. Results The overall mortality (±SE) after acute myocardial infarction among 34,189 patients on long-term dialysis was 59.3±0.3 percent at one year, 73.0±0.3 percent at two years, and 89.9±0.2 percent at five years...

Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group.

Abstract: The objective of this study was to evaluate the association of peritoneal membrane transport with technique and patient survival. In the Canada-USA prospective cohort study of adequacy of continuous ambulatory peritoneal dialysis (CAPD), a peritoneal equilibrium test (PET) was performed approximately 1 mo after initiation of dialysis; patients were defined as high (H), high average (HA), low average (LA), and low (L) transporters. The Cox proportional hazards method evaluated the association of technique and patient survival with independent variables (demographic and clinical variables, nutrition, adequacy, and transport status). Among 606 patients evaluated by PET, there were 41 L, 192 LA, 280 HA, and 93 H. The 2-yr technique survival probabilities were 94, 76, 72, and 68% for L, LA, HA, and H, respectively (P = 0.04). The 2-yr patient survival probabilities were 91, 80, 72, and 71% for L, LA, HA, and H, respectively (P = 0.11). The 2-yr probabilities of both patient and technique survival were 86, 61, 52, and 48% for L, LA, HA, and H, respectively (P = 0.006). The relative risk of either technique failure or death, compared to L, was 2.54 for LA, 3.39 for HA, and 4.00 for H. The mean drain volumes (liters) in the PET were 2.53, 2.45, 2.33, and 2.16 for L, LA, HA, and H, respectively (P < 0.001). After 1 mo CAPD treatment, the mean 24-h drain volumes (liters) were 9.38, 8.93, 8.59, and 8.22 for L, LA, HA, and H, respectively (P < 0.001); the mean 24-h peritoneal albumin losses (g) were 3.1, 3.9, 4.3, and 5.6 for L, LA, HA, and H, respectively (P < 0.001). The mean serum albumin values (g/L) were 37.8, 36.2, 33.8, and 32.8 for L, LA, HA, and H, respectively (P < 0.001). Among CAPD patients, higher peritoneal transport is associated with increased risk of either technique failure or death. The decreased drain volume, increased albumin loss, and decreased serum albumin concentration suggest volume overload and malnutrition as mechanisms. Use of nocturnal cycling peritoneal dialysis should be considered in H and HA transporters.

Sclerosing peritonitis: the experience in Australia

Abstract: Background. Sclerosing peritonitis (SP) is a rare but serious complication of peritoneal dialysis (PD). Small-bowel obstruction (SBO) due to encapsulation, dense adhesions, or mural fibrous is characteristic, often associated with peritonitis. The aim of the study was to determine the incidence, clinical features, effect of duration of dialysis, and other possible aetiological factors in severe SP.

The current place of urea kinetic modelling with respect to different dialysis modalities.

Abstract: The range of dialysis treatment schedules is rapidly toxic solutes along the nephron similar to that of urea increasing, with renewed interest in daily haemodialysis [3], and hence reasonable to choose Kr as the renal (HD), continuous ambulatory peritoneal dialysis function reference standard for assessing the dose (CAPD), automated peritoneal dialysis (APD), APD of dialysis. combined with CAPD, and HD combined with It is necessary to go back some 50 years to find the CAPD. A scale has not been developed previously for major studies of renal urea clearance. The dependence uniform measurement and comparison of the dialysis of Kr on urine flow rate (Qu) was modelled by Dole doses provided by this broad range of therapies. The in 1943 [4] as a function of GFR, tubular area, purpose of this communication is to report a model permeability to urea and urine flow rate. These relawhich can be used uniformly to measure and thus tionships were studied in humans by Chassis et al. [5]. explicitly compare the doses of dialysis provided by The theoretical Dole equation constants were fit to any combination of intermittent and continuous dia- human data of Chassis et al. by Homer Smith [6 ], lysis treatments. In the development which follows, resulting in these therapies will be analysed with respect to low molecular weight solute clearance using urea as a Kr=0.57(GFR) *exp[’0.36/Qu] (1)

Peritoneal Catheters and Exit-Site Practices toward Optimum Peritoneal Access: 1998 Update: (Official Report from the International Society for Peritoneal Dialysis)

Abstract: The peritoneal catheter is the PD patient's lifeline. Advances in catheter knowledge have made it possible to obtain access to the peritoneal cavity safely and to maintain access over an extended p...

Effectiveness and efficiency of methods of dialysis therapy for end-stage renal disease : a review

Abstract: s 11,876 Not relevant to ESRD 9791 Relevant to ESRD 2085 Not relevant to the six topics 1745 Relevant to the six topics 340 Not included in final reviews 301 Included in final reviews 39 FIGURE 8 Number of possible RCTs or quasi-RCTs as screening process progresses (electronic searches only)

Peritoneal solute transport predicts survival on CAPD independently of residual renal function.

Abstract: Background. Loss of residual renal function has a profound effect on the survival of peritoneal dialysis patients. Less is known of the impact of peritoneal function. The purpose of this study was to investigate the influence of solute transport on clinical outcome in CAPD patients. Methods. Two hundred and ten consecutive patients commencing CAPD since 1990 were enrolled into a single centre prospective longitudinal observational study of urea, protein, and peritoneal kinetics. On entry, and at 6-monthly intervals, estimations were made of weight, body mass index (BMI), plasma albumin, Kt/V, residual renal function (RRF), NPCR, low-molecular-weight solute transport (D/P creat ), and peritoneal protein losses. All patients were censored in 1996, regardeless of treatment modality. Results. During the 6-year follow up period (median 22 months) there were 51 deaths, and the actuarial survival was 58% at 5 years. Urea, protein and peritoneal kinetics varied with time on dialysis: as anticipated there was a reduction in Kt/V, attributable to loss of RRF, whereas plasma albumin was stable for the first 2 years of treatment, but subsequently started to decline, a trend that became significant at 42 months. Peritoneal kinetics stabilized within the first 6 months of treatment and then showed a trend of increased solute transfer with time on treatment. which became significant by the end of the study. Comparing survivors with non-survivors Kt/V and RRF were similar at the start of treatment, but loss of RRF occurred significantly earlier in non-survivors than survivors (0.37 vs 0.68, P = 0.02 at 6 months, 0.19 vs 0.54, P=0.01 at 12 months). D/P creat was also identical at commencement of treatment, but subsequently whilst survivors had stable solute transfer, non-survivors had consistently higher solute transfer beyond 6 months that reached increasing significance after 18 months, (0.70 vs 0.67, P=0.05 at 18 months, 0.72 vs 0.66, P = 0.03 at 24 months). A Cox proportional hazard model constructed for the variables age, sex, BMI, albumin, Kt/V and D/Pcreat at 6 months of treatment indicated that low Kt/V (P=0.004), high D/P creat (P=0.013) and age (P = 0.028) were independent predictors of death. Conclusion. There is good reason to believe that high peritonel solute transport is an independent marker of poor outcome in CAPD patients.

Increased peritoneal permeability is associated with decreased fluid and small-solute removal and higher mortality in CAPD patients.

Abstract: Background. Recent studies suggest that increased peritoneal membrane permeability is associated with higher morbidity and mortality in peritoneal dialysis patients. It is not known, however, whether the difference in clinical outcome among different peritoneal transport groups is due to differences in peritoneal fluid and solute removal. In the present study, we compared the peritoneal fluid and solute transport and clinical outcome in CAPD patients with high (H), high-average (H-A), low-average (L-A) and low (L) peritoneal transport patterns. Design. A 6-h dwell study was performed in 46 patients with frequent dialysate and plasma samples using 21 of 3.86% glucose dialysate with 131 I albumin as an intraperitoneal volume marker. The patients were divided into four transport groups according to their D/P of creatinine at 240 min. Results. The results showed that high transporters had significantly lower peritoneal fluid and small-solute removal but high glucose absorption and high protein loss during a 6-h exchange. The serum albumin was lower and blood pressure and triglycerides were higher in high transporters compared with the other groups. Two-year patient survival from the start of CAPD treatment was significantly lower for high transporters (64, 85, 90 and 100% for H, H-A, L-A and L respectively, P < 0.01 ). The 1-year patient survival from the dwell study was also significantly lower in high transporters (16, 63, 90 and 100% for each group, P<0.01). Conclusion. Our results suggest that high transporters remove less fluid and small solutes and have higher protein loss and increased glucose absorption. These alterations may contribute to fluid overload, malnutrition and lipid abnormalities that perhaps contribute to the increased mortality among the high transporters.

Mode of dialysis therapy and mortality in end-stage renal disease

Abstract: Despite considerable differences in technique and blood purification characteristics, hemodialysis and peritoneal dialysis have been thought to have similar patient outcomes. An inception cohort of433 end-stage renal disease patients was followed prospectively for a mean of 4 1 mo. The outcomes of hemodialysis (HD) and peritoneal dialysis (PD) patients were compared using intention to treat analysis based on the mode of therapy at 3 mo. After adjustment for PD patients less likely to have chronic hypertension and more likely to have diabetes, ischemic heart disease, and cardiac failure at baseline (P < 0.05), a biphasic mortality pattern was observed. For the first 2 yr, there was no statistically significant difference in mortality. After 2 yr, mortality was greater among PD patients with an adjusted PD/HD hazard ratio of 1.57 (95% confidence interval (CI), 0.97 to 2.53). Both the occurrence (adjusted hazards ratio 6.87 (95% CI, 2.01 to 23.5)) and the direction (toward PD, adjusted hazards ratio 6.25 (95% CI, 1.54 to 25)) of a therapy switch were subsequently associated with mortality after 2 yr. Progressive clinical and echocardiographic cardiac disease were not responsible for this late mortality. Lower mean serum albumin levels in PD patients in the first 2 yr of therapy (3.5 ± 0.5 versus 3.9 ± 0.5 g/dl, P < 0.0001) accounted for a large proportion of the increase in subsequent mortality. Hemodial- ysis has a late survival advantage over peritoneal dialysis; antecedent hypoalbuminemia is a major marker of the in- creased late mortality in PD patients. (J Am Soc Nephrol 9:

Biological basis of hypoalbuminemia in ESRD.

Abstract: Hypoalbuminemia is associated with mortality in patients with end-stage renal disease (ESRD) maintained either on peritoneal dialysis (PD) or hemodialysis (HD). Serum albumin concentration is determined by its rate of synthesis, by the catabolic rate constant (the fraction of the vascular pool catabolized per unit time), by external losses, and by redistribution from the vascular to the extravascular space. Hypoalbuminemia in dialysis patients is primarily a consequence of reduced albumin synthesis rate in both HD and PD patients, and in the case of PD patents, of transperitoneal albumin losses as well. Continuous ambulatory peritoneal dialysis patients are able to increase albumin synthesis to replace losses. Thus, ESRD does not directly suppress albumin synthesis. The rate of albumin synthesis is inversely proportional to the serum concentration of one potential acute phase protein (alpha2 macroglobulin), and albumin concentration is inversely proportional to that of either C-reactive protein or serum amyloid A in both HD and PD patients. The cause of decreased albumin synthesis is primarily a response to inflammation (the acute phase response), although it is possible that inadequate nutrition may also contribute. The cause of the inflammatory response is not immediately evident. There is no evidence that shifts of albumin to the extravascular space or that dilution of the plasma by volume expansion plays any role in causing hypoalbuminemia in ESRD patients.

Serum C-reactive protein: a predictor of mortality in continuous ambulatory peritoneal dialysis patients.

Abstract: ObjectiveTo evaluate the predictive value of a single baseline serum C-reactive protein (sCRP) as a marker of mortality in continuous ambulatory peritoneal dialysis (CAPD) patients.DesignA review o...

The impact of haematocrit levels and erythropoietin treatment on overall and cardiovascular mortality and morbidity--the experience of the Lombardy Dialysis Registry.

Abstract: The major aims of dialysis therapy consist in pro- in prospective randomized multicentre studies. Therelonging patients’ survival, reducing the patients mor- fore the question arises as to what extent anaemia bidity and improving their quality of life. However should be corrected in order to avoid undesirable despite many technical advances in the medical care side-eVects. and in the delivery of dialysis over the past years, mortality and morbidity of dialysis patients remains persistently high and their quality of life is rather poor. The Japanese data A Japanese retrospective study [6 ], analysing a total Anaemia as cardiovascular risk factor of 2116 patients has reported that the administration of rHuEpo might be responsible for an increased risk Hypertension and anaemia play a pivotal role in the of cardiovascular disease (especially stroke and acute increased mortality and morbidity in uremic patients myocardial infarction), although only a trend towards and should be managed appropriately. In fact anaemia an increase in the incidence of stroke and acute has been found to be an independent risk factor for myocardial infarction was noted. However, some relevdeveloping cardiac morbidity and mortality in dialysis ant methodological drawbacks were underlined [7,8]. patients [1,2] and cardiovascular disease is the major This study prompted us to further clarify this important cause of death in these patients. It is well known that aspect. We performed a historical prospective study cardiac hypertrophy is very frequent in dialysis patients concerning the clinical eVects of the use of rHuEpo in and anaemia and hypertension are very important risk patients dialysed in Lombardy. The study aimed at factors in this complication, clearly related to the clarifying the clinical impact of anaemia and rHuEpo cardiovascular mortality, as anaemia is accompanied treatment on general and cardiovascular mortality and by an increase of cardiac work that induces left morbidity. ventricular hypertrophy. Of course other factors are important in inducing left ventricular hypertrophy, as arteriovenous fistula and, among other hormones, The Lombardy data parathyroid hormone [3].

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis.

Abstract: The purpose of this study was to analyze the microbiological and clinical features of fungal peritonitis in patients with endstage renal failure treated with continuous ambulatory peritoneal dialysis (CAPD). The diagnosis of peritonitis was based on abdominal discomfort or pain, cloudy peritoneal effluent with an elevated leukocyte count and isolation of fungi from the peritoneal effluent. Amphotericin B, flucytosine, ketoconazole, miconazole and more recently fluconazole were used for antifungal therapy. From 1983 to 1997 13 patients experienced 14 episodes of fungal peritonitis, comprising 3.1% of all episodes of peritonitis in the dialysis centre. Isolates from the peritoneal effluent comprised Candida tropicalis in two cases, Candida parapsilosis in two cases, Candida albicans in one case, Candida lusitaniae in one case,Cephalosporium spp. in three cases, Aspergillus fumigatus in two cases, and an Aspergillus sp., a Trichoderma sp. and a yeast in one case each. In eight cases bacterial infection shortly before the episode of fungal peritonitis was documented. In 12 (86%) cases the peritoneal catheter had to be removed. Four patients died during the treatment, and one patient died 2 months after the end of treatment due to intra-abdominal bleeding from peritoneal adhesions. Only two patients continued CAPD later; the other patients were switched to hemodialysis. It is concluded that fungal peritonitis is a rare but serious complication in CAPD patients with high rates of morbidity, mortality and drop-out from the CAPD programme (85%). The most frequent isolates were Candida spp. A predisposing factor for fungal peritonitis could be a recent bacterial infection treated with antibiotics. Early peritoneal catheter removal is recommended.

Risk factors for development of acute renal failure (ARF) requiring dialysis in patients undergoing cardiac surgery

Abstract: Acute renal failure (ARF) is one of the major complications after cardiopulmonary bypass for open heart operations. The present study was undertaken to identify the risk factors for the development of ARF following cardiopulmonary bypass (CPB). Four hundred and forty-seven consecutive patients who underwent open heart procedures from July 1994 to June 1995 were analyzed retrospectively. Their mean age was 55.6 +/- 14.2 (SD) years (range, 18 to 80). Dialysis was instituted whenever a patient exhibited inadequate urine output ( 5 cm, preoperative congestive heart failure, renal insufficiency (serum creatinine > or =130 micromol/L on two occasions), and sepsis--10 intraoperative variables--duration of CPB, redo procedures, emergency surgery, use of intraaortic balloon pump (IABP) in operating room, use of gentamicin, use of ceftriaxone, use of sulbactam/ampicillin, requirement of deep hypothermic circulatory arrest, duration of low mean perfusion pressure (mean pressure <50 mmHg for more than 30 minutes), operation on multiple valves--and one postoperative variable--significant hypotension (systolic blood pressure less than 90 mmHg for more than 1 hour). Significant variables or the variables having a trend (p<0.1) to be associated with ARF were included in stepwise multiple logistic regression analyses. Three regression analyses were performed separately. The incidence of ARF requiring dialysis in the study period was 15.0%. Significant risk factors for whole group of patients (regression I) were preoperative renal insufficiency (p<0.0001), postoperative hypotension (p<0.0001), cardiopulmonary bypass time more than 140 min (p<0.005), preoperative congestive heart failure (p<0.01), and history of diabetes mellitus (p<0.01). The risk factors in the valve group of patients (regression II) were preoperative renal insufficiency (p<0.0001) and postoperative hypotension (p<0.05). Risk factors in the CABG patients (regression III) were postoperative hypotension (p=0.0001), CPB time more than 140 min (p<0.05), preoperative renal insufficiency (p<0.05), and age (p<0.05). The authors conclude that preoperative renal insufficiency and postoperative hypotension are the most important independent risk factors for ARF in postcardiac surgical patients. In addition, CPB time greater than 140 minutes and old age are also independent risk factors for ARF in CABG patients. CPB time more than 140 minutes, history of diabetes mellitus, and preoperative congestive heart failure are independent risk factors for development of ARF in our total group of patients. These findings may have important clinical implications in the prevention of ARF in postcardiac surgical patients.

Endothelium-dependent vasodilatation is impaired in peritoneal dialysis patients.

Abstract: BACKGROUND Peritoneal dialysis (PD) patients have a high risk of cardiovascular mortality, which is not completely explained by conventional risk factors. Other factors related to chronic renal failure and/or dialysis treatment might lead to endothelial dysfunction, which is associated with an adverse cardiovascular outcome. One such factor is hyperhomocysteinaemia, which has a high prevalence in PD patients. METHODS A vessel wall movement detector system was used to investigate endothelium-dependent, flow-mediated, and endothelium-independent, glyceryl trinitrate-induced, vasodilatation of the brachial artery in 29 PD patients and 29 control subjects. RESULTS Endothelium-dependent vasodilatation was markedly reduced in the PD group: 5.7 +/- 1.0% vs 10.4 +/- 1.3% in the control group (P = 0.004). Endothelium-independent vasodilatation was not impaired. Plasma total homocysteine was elevated in the PD patients (45.2 +/- 6.2 micromol/l), but was not related to endothelium-dependent vasodilatation. CONCLUSION Chronic peritoneal dialysis patients have impaired endothelium-dependent vasodilatation, which may reflect an increased susceptibility for the development of atherosclerosis and thrombosis.