Peritoneal membrane structural and functional changes during peritoneal dialysis

Peritoneal dialysis is now utilized as a renal replacement therapy modality in a substantial percentage of patients with end-stage renal disease, with excellent short-term patient and technique survival rates. However, the potential complications associated with longer-term therapy, such as ultrafiltration failure or encapsulating peritoneal sclerosis, have led to raise some concern about peritoneal dialysis as an adequate mode of treatment of end-stage renal disease in the long term. In the last decade, a substantial amount of information has been gathered on the characteristics of the peritoneal membrane at the onset of peritoneal dialysis, and on the anatomical and pathophysiologic changes that occur with long-term peritoneal dialysis. I will review this subject with a special focus on the various strategies that can help protect the peritoneal membrane during peritoneal dialysis so as to allow peritoneal dialysis to succeed as a long-term dialysis modality.     

老年腹膜透析患者相关危险因素的分析

目的：探讨老年腹膜透析患者的相关危险因素。方法：通过观察分析危险因素：性别、原发病情况（糖尿病、高血压）、营养状态指标、贫血指标、腹膜透析充分性指标、钙磷代谢情况,并分析腹膜透析患者相关性感染及其心脑血管并发症情况。结果：高血糖、腹膜透析充分性（总Kt/V和总Ccr）及血浆白蛋白（Alb）成为腹膜透析患者老年组独立影响危险因素;另外,31例患者中有2例患者出现腹膜透析相关性腹膜炎情况,1例患者出现严重的脑血管并发症。结论：积极控制老年腹膜透析患者的血糖,并改善患者血清白蛋白及正确评估老年腹膜透析患者的透析充分性,这对于提高老年腹膜透析的生存质量具有重要作用。     

An unusual complication of peritoneal dialysis

Abdominal pain during peritoneal dialysis can be due to an inflow pain or most frequently be associated with peritonitis. However, other unusual pathologies can also occur in patients with peritoneal dialysis. Herein, pelvic inflammatory disease in a pediatric peritoneal dialysis patient is presented. After exclusion of the most common causes, abdominal ultrasonography and laparoscopy will guide clinicians for the diagnosis of the other rare diseases in patients with peritoneal dialysis.     

Thoracic complications of peritoneal dialysis.

Approximately 20% of the 100,000 patients in the United States currently undergoing dialysis therapy for end-stage renal disease use the technique of peritoneal dialysis. We present a patient on peritoneal dialysis who developed a large posterior mediastinal mass, which on surgical exploration was found to be a paraesophageal hernia sac filled with omentum and dialysis fluid. We use this case as an introduction to review the thoracic complications of peritoneal dialysis.     

Transfer from chronic haemodialysis to peritoneal dialysis

Peritoneal dialysis patients are frequently transferred from peritoneal dialysis to haemodialysis. In contrary transfer from chronic haemodialysis to peritoneal dialysis is rare. The aim of this study is to describe the main characteristics and the outcome of the dialysis patients transferred from haemodialysis to peritoneal dialysis. We retrospectively analyzed the files of 25 patients treated by haemodialysis for more than 3 months between 1992 and 2002 and subsequently transferred on peritoneal dialysis. Technique survival was 56% at 1 year and 40% at two years in haemodialysis. Technique survival was lower in the group starting haemodialysis in emergency compared with the group of patients who did not need emergent haemodialysis (33 vs 77% at 1 year, P<0.05). The reasons for transfer from haemodialysis to peritoneal were vascular access problems (13/25), cardiovascular problems (7/25), and patient's choice (5/25). Automated peritoneal dialysis was used in 9 cases and continuous ambulatory peritoneal dialysis in 16 cases. In 13 cases peritoneal dialysis was performed by a home care nurse. At the initiation of peritoneal dialysis the mean age was 58+/-18 years, the mean Charlson's comorbidity score was 6.1+/-2.5 and 15 patients had a cardiovascular disease. The median time on peritoneal dialysis was 5.2 months. During the time on peritoneal dialysis sixteen patients presented at least one complication related to peritoneal dialysis. In addition fourteen patients were hospitalized for a reason which was not associated with peritoneal dialysis. Survival on peritoneal dialysis was 61% at six months and 35% at one year. In conclusion, in our study, patients transferred from haemodialysis to peritoneal dialysis have had a poor outcome on peritoneal dialysis. However, these patients presented numerous comorbid conditions at peritoneal dialysis initiation which could explain the poor outcome on peritoneal dialysis.     

Peritoneal damage by peritoneal dialysis solutions

Continuous ambulatory peritoneal dialysis is a well-accepted treatment for end-stage renal disease, but its long-term success is limited. Peritoneal sclerosis is still one of the most important complications of long-term peritoneal dialysis and the low biocompatibility of peritoneal dialysis solutions plays a major role in the development of such sclerosis. In this review, we summarize recent experimental data about the biocompatibility of peritoneal dialysis solutions.     

Automated and continuous ambulatory peritoneal dialysis have similar outcomes

We compared survival and death-censored technique survival in patients on automated peritoneal dialysis (automated dialysis) or on continuous ambulatory peritoneal dialysis. All 4128 patients from the Australia and New Zealand Dialysis and Transplant Registry who started peritoneal dialysis over a 5-year period through March 2004 were included. Times to death and death-censored technique failure were analyzed by Cox proportional hazards models while a conditional risk set model computed technique failure. Compared to patients treated entirely with continuous ambulatory peritoneal dialysis, automated peritoneal dialysis patients were more likely to be young, Caucasian, have marginally lower body mass index, and were less likely to have baseline cardiovascular disease or diabetes. Using univariate and multivariate analysis, our study showed there were no significant differences in patient survival and death-censored technique failure between the two types of peritoneal dialysis modalities.     

Supporting peritoneal dialysis in remote Australia

SUMMARY:   Peritoneal dialysis is usually considered a first-choice treatment for end-stage renal disease for patients living in remote areas. The advantages of peritoneal dialysis over haemodialysis are that peritoneal dialysis preserves the residual renal function for longer, provides patients with more independence and gives patients a greater opportunity to return home quickly. In Australia, Aboriginal people suffer end-stage renal failure at disproportionately higher rates than the general population. Given that many Aboriginal people live in remote communities a task of peritoneal dialysis units is to ensure the successful setting up and maintenance of peritoneal dialysis programmes in the outback. This paper examines how peritoneal dialysis units located in the city are able to deliver peritoneal dialysis to patients located often hundreds of kilometres and at times thousands of kilometres away in very remote communities. In preparing this paper interviews were conducted with renal and remote community-based health professionals in Western Australia and the Northern Territory, and with peritoneal dialysis patients in Western Australia. The success of remote peritoneal dialysis programmes relies on many elements, most importantly an integrated approach to care by all members of the peritoneal dialysis team. The peritoneal dialysis team included not just health professionals but also patients, their families, their communities and other support people such as those involved in the transport of peritoneal dialysis supplies to the outback. Careful communication, a willingness to participate, friendliness and delivering care and supplies with a smile are essential ingredients to a winning program. Without all of these ingredients dialysis in the bush may fail.     

Quality of life in patients treated with hemodialysis or peritoneal dialysis: what are the important determinants?

BACKGROUND: Patients with end-stage renal disease (ESRD) have significant impairments in health-related quality of life (HRQOL). In part, this is due to the intrusiveness of the treatment (hemodialysis or peritoneal dialysis) that is required. It is unclear whether hemodialysis or peritoneal dialysis is associated with a higher HRQOL. METHODS: 192 prevalent patients who self-selected treatment with hemodialysis (either in-center, satellite or home/self-care hemodialysis) or peritoneal dialysis were studied to determine whether treatment with hemodialysis or peritoneal dialysis is associated with a higher HRQOL. Demographic, laboratory and clinical information (including the presence of comorbid conditions using the Charlson comorbidity index) was assessed at baseline. The outcome of interest was HRQOL, which was measured using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), the Short-Form 36 (SF-36) and the EuroQol EQ-5D at baseline and after 6 and 12 months of follow-up. RESULTS: There was no significant difference in HRQOL scores for the SF-36, the EQ-5D and for 9 of 11 KDQOL dimensions for patients treated with hemodialysis or peritoneal dialysis at baseline. As expected, HRQOL was significantly lower for patients who had more comorbid disease, required assistance with their daily care, and for patients with less than a grade 12 education. After controlling for the effect of other important variables, HRQOL (as measured by the EQ-5D visual analog or index scores) did not differ between hemodialysis and peritoneal dialysis patients. HRQOL was stable over time, both for patients who started on hemodialysis or peritoneal dialysis. CONCLUSIONS: There is no significant difference in HRQOL for prevalent ESRD patients treated with hemodialysis or peritoneal dialysis. It will be important to determine if this finding holds true for incident patients treated with hemodialysis or peritoneal dialysis.     

Cholecystectomy in the peritoneal dialysis patient

Laparoscopic cholecystectomy has proven to be a safe and effective treatment for symptomatic gallstone disease. Several subsets of patients, however, may not be candidates for the laparoscopic approach, including patients with morbid obesity, acute cholecystitis, and previous abdominal surgery. Because of peritoneal thickening and abdominal adhesions secondary to peritoneal dialysis, the applicability of laparoscopic cholecystectomy in patients maintained on chronic peritoneal dialysis is also unclear. We performed laparoscopic cholecystectomy on three peritoneal dialysis patients without intraoperative complications. We have noted several unique advantages to laparoscopic surgery in this patient population and advocate this approach in peritoneal dialysis patients requiring cholecystectomy.     

Association between human recombinant EPO and peripheral vascular disease in diabetic patients receiving peritoneal dialysis

Peripheral vascular disease is a serious and frequent problem in diabetic patients. Since the beginning of the widespread use of erythropoietin (EPO), we have noted an increase in peripheral vascular disease in diabetic patients receiving peritoneal dialysis and erythropoietin. This prompted us to study the effects of erythropoietin on peripheral vascular disease in patients receiving peritoneal dialysis. We retrospectively reviewed medical records of all diabetic patients in our program who received peritoneal dialysis from 1990 to 1996. Demographic and laboratory data as well as EPO use data were collected. Hospital days and occurrence of vascular events (defined as peripheral vascular surgery, amputation, or recommendation of vascular surgery or amputation by a vascular surgeon) were determined for diabetic patients receiving peritoneal dialysis. Comparisons were made between those who received EPO and those who did not received EPO, as well as comparing vascular events in 28 patients who received peritoneal dialysis before and after beginning EPO. Patients who received erythropoietin were found to have a significantly shorter time to a first vascular event, a greater number of vascular events, and more hospital days associated with vascular disease than diabetic patients who did not receive erythropoietin. With multivariate analysis, significant risk factors for the development of peripheral vascular disease in these patients were erythropoietin use, erythropoietin dose, and smoking. Twenty-eight patients who initially performed peritoneal dialysis without receiving EPO, and later received EPO, had a significant increase in vascular events, including amputations only while receiving EPO. We found the use of erythropoietin to be associated with peripheral vascular events in diabetic patients who receive peritoneal dialysis. Further investigation is warranted.     

Advantages of peritoneal dialysis in comparison to hemodialysis,in cardiac allograft recipients with end stage renal disease

End stage renal disease is a serious complication in heart or heart–lung transplant recipients and is associated with high morbidity and mortality. The majority of these patients are currently treated with hemodialysis. Since there are no randomized control trials comparing hemodialysis to peritoneal dialysis in this patient population, the potential beneficial effects of peritoneal dialysis remain largely unknown. We compared the clinical outcome of such patients on peritoneal dialysis with another group on hemodialysis. Our results indicate that patients on peritoneal dialysis had fewer episodes of congestive heart failure, fluid overload and a lower overall hospitalization rate, despite having worse cardiac function than patients on hemodialysis.     

Cat-bite peritonitis: Pasteurella multocida peritonitis following feline contamination of peritoneal dialysis tubing

We report a case of a 55-year-old woman with end-stage renal disease undergoing intermittent peritoneal dialysis who developed peritonitis secondary to an infection with Pasteurella multocida resulting from a cat bite or cat scratch penetrating her peritoneal dialysis tubing. This case points out the potential importance of household pets as a source of peritoneal contamination.     

Blastomyces dermatitidis peritonitis complicating peritoneal dialysis

Fungal peritonitis is an uncommon complication in peritoneal dialysis patients. We report a case of blastomyces dermatitis peritonitis in a nonimmunocompromised peritoneal dialysis patient, who initially presented with symptoms of lower extremity weakness and altered mental status. Peritoneal blastomycosis is rare condition and not previously reported in end stage renal disease patients on peritoneal dialysis. Fungal peritonitis can present with subtle clinical findings so a high index of suspicion is needed as early detection and treatment may decrease mortality and morbidity.     

Effect of starting with hemodialysis compared with peritoneal dialysis in patients new on dialysis treatment: a randomized controlled trial

BACKGROUND: Up-until-now, the survival and health-related quality of life of hemodialysis and peritoneal dialysis patients has only been compared in observational studies. These studies have reported small and opposing differences between both modalities. The aim of this study was to compare the outcome of hemodialysis as initial chronic dialysis treatment with that of peritoneal dialysis in a randomized controlled trial. METHODS: All new dialysis patients from 38 dialysis centers in The Netherlands without indications against either modality were invited to participate. Patients were assigned to start with hemodialysis or peritoneal dialysis. The primary outcome was mean quality-adjusted life year (QALY) score. Secondary outcome was survival. RESULTS: Due to the low inclusion rate, the trial was prematurely stopped after which 38 patients had been randomized: 18 patients to hemodialysis and 20 to peritoneal dialysis. The mean QALY score in the first 2 years was 59.1 (SD 12) for hemodialysis patients versus 54.0 (SD 19) for peritoneal dialysis patients, which constitutes a small difference in favor of hemodialysis of 5.1 (95%CI -7.3 to 17.6) After 5 years of follow-up, nine hemodialysis and five peritoneal dialysis patients had died, a significant difference in survival; hazard ration of hemodialysis versus peritoneal dialysis of 3.8 (95%CI 1.1 to 12.6). After adjustment for age, comorbidity, and primary kidney disease the hazard ratio was 3.6 (0.8 to 15.4). CONCLUSION: Only a small difference in QALY score was observed between patients who started with hemodialysis compared to patients who started with peritoneal dialysis, lending support for the equivalence hypothesis. The significant difference in longer-term survival, which favored peritoneal dialysis in this small group of patients, could be used to posit that incident dialysis patients might benefit from starting on peritoneal dialysis.     

Pleuroperitoneal communication in a patient on automated peritoneal dialysis: A rare but important complication

Despite its rare frequency, a pleuroperitoneal communication is a well-documented complication for patients on peritoneal dialysis. It occurs in ~2% of continuous ambulatory peritoneal dialysis, with uncertain incidence for those on automated peritoneal dialysis. We report a case of a 30-year-old female patient with end-stage kidney disease with sudden dyspnea 2 days after starting automated peritoneal dialysis. Her chest x-ray revealed a significant pleural effusion on the right side. A thoracocentesis was performed, with a pleural glucose/plasma glucose of 1.08. Additionally, a computed tomography scan revealed a pleuroperitoneal communication upon dialysate infusion added with media contrast. A pleural-to-serum glucose gradient of greater than 50 mg/dL may indicate the diagnosis of a pleuroperitoneal communication in patients on peritoneal dialysis. Current literature also indicates that a pleural-to-serum glucose ratio above 1.0 may provide a more sensitive analysis. This case highlights the diagnosis process for this complication, with both laboratory and image findings corroborating the clinical hypotheses of a pleuroperitoneal communication in a patient on automated peritoneal dialysis.     

Clearance of inorganic sulfate by peritoneal dialysis in children with chronic renal failure

The peritoneal clearance of inorganic sulfate was measured in 6 infants and 12 children with end-stage renal disease who were receiving continuous ambulatory peritoneal dialysis. Serum sulfate, which was elevated before dialysis, changed little during the 5-hour dialysis period. The dialysis sulfate concentration increased at the same rate as creatinine. Net clearance of the two metabolites was not different. It was calculated that the removal by continuous ambulatory peritoneal dialysis in 24 h is comparable to the daily excretion of SO4 in healthy children.     

Hyperlipidemia in uremic children: response to peritoneal dialysis and hemodialysis.

Hemodialysis and hyperlipidemia have been associated in both adults and children. The present study indicates hyperlipidemia in uremic children treated with peritoneal dialysis and implies that the cardiovascular risk felt to exist with hemodialysis also exists in peritoneal dialysis. Thirty-eight children with chronic renal insufficiency or end-stage renal disease were followed serially under varying conditions of medical management, hemodialysis, peritoneal dialysis, and transplantation. Serum triglyceride concentrations in patients on peritoneal dialysis were not significantly different from those in patients on hemodialysis, but both were significantly higher (P less than 0.01) than concentrations in patients on medical management and transplantation.     

Why and how to promote peritoneal dialysis?

The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.     

Differences in survival on peritoneal dialysis between oriental Asians and Caucasians: One center's experience

BACKGROUND: Recently it has been suggested that the survival of dialysis patients may differ among different races. Both registry data and data from Asian countries indicates that Asians on peritoneal dialysis may survive longer than their Caucasian counterparts. In the present study, we performed a detailed analysis of survival differences between oriental Asians and Caucasians on peritoneal dialysis in our multiethnic, multicultural program. METHODS: Retrospectively we analyzed the survival data for patients who started peritoneal dialysis after January 1, 1996 and before December 31, 1999, in our hospital. They were followed for at least for two years. Excluded from the present analysis were those who survived for less than three months on peritoneal dialysis. The patient demographic characteristics, comorbidities, and residual renal function at the start of dialysis were collected. Indices for adequacy of dialysis were collected 1-3 months after the initiation of dialysis. Actuarial survival rates were determined by the Kaplan-Meier method. The Cox proportional hazards model was used to classify risk factors for a high mortality. RESULTS: There were 87 Caucasians and 29 Oriental Asian peritoneal dialysis patients. No differences were found in age, gender, primary renal disease, and residual renal function between the two groups. The Caucasians had significantly higher body surface area and urea volume and higher incidence of cardiovascular diseases. Even with slightly higher dialysis dose, the peritoneal creatinine clearance was significantly lower among the Caucasians than among Asians. There was no difference in the peritoneal D/P value between the two groups. However, compared to the Caucasians, the 24hr peritoneal fluid removal and total fluid removal volumes were significantly lower in the Asian patients. The one, two, three and four year survival rates were 95.8%, 91%, 86% and 80% for Asians and 91.3%, 78.1%, 64.7% and 54.1% for Caucasians. Significant predictors for a higher mortality were the presence of cardiovascular disease (42% increase in risk), Caucasians (39% increase in risk) and older age (37% increase in risk for age older than 65). CONCLUSIONS: Our study confirms that oriental Asians on peritoneal dialysis patients survive much longer than their Caucasian counterparts; this was partly due to the fact that Asian patients have less cardiovascular disease when they began peritoneal dialysis. Due to their smaller body size, the Asians tended to have a higher peritoneal small solute clearances despite their smaller dialysis doses, indicating that, to achieve the same solute clearance targets, Asians need a smaller dialysis dose compared to Caucasians.