Evaluation of nutritional status in patients on continuous ambulatory peritoneal dialysis (CAPD)

We designed this study to evaluate the nutritional conditions of 16 continuous ambulatory peritoneal dialysis (CAPD) patients. In all these patients we did a monthly 1-day clinical, anthropometrical, biochemical, and nitrogen balance evaluation: a minimum of 3 and a maximum of 9 monthly evaluations in all patients. The results were analyzed in two groups: Group I (N = 8) with neutral or positive nitrogen balances, and Group II (N = 8) with one or more negative nitrogen balances. The sex distribution, mean age in years, time on CAPD, and period of study in this protocol were similar in both groups. Group I maintained a positive nitrogen balance and steady values in the anthropometric measurements (triceps fat fold, upper-arm circumference, body weight). Group II showed a significant decrease in both the anthropometric values and the nitrogen balance during the episodes of peritonitis. In this same group, when peritonitis subsided, the protein intake increased, nitrogen balance became positive, and the anthropometric values improved. When all the nutritional evaluations were analyzed we found a significant and direct linear correlation between nitrogen intake and nitrogen balance in g/kg/day (N = 60; nitrogen balance = nitrogen intake x 0.75 - 0.101; r = 0.71; p less than 0.001). We also contrasted the presence of peritonitis with the nitrogen balance and the anthropometric values using Spearman rank correlation coefficient and obtained a very high correlation (0.997 to 0.999). Blood values (blood urea, serum creatinine, serum phosphate, serum potassium, and hemoglobin) were not very sensitive to detect differences within or between groups along the study.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of nutritional status and factors related to malnutrition in children on CAPD.

OBJECTIVE: The aim of this study was to investigate the nutritional status of children on continuous ambulatory peritoneal dialysis (CAPD) and to relate it to the dose of dialysis and serum levels of inflammatory cytokines and insulin-like growth factor-1 (IGF-1). PATIENTS: 17 CAPD patients (8 girls, 9 boys; mean age 13.1 +/- 3.5 years, median 15 years) were included in the study. Anthropometric measurements and serum albumin levels were used in the evaluation of nutritional status. Serum interleukin (IL)-1beta, IL-6, tumor necrosis factor alpha, and IGF-1 levels were determined in all CAPD patients and in a healthy control group. Weekly Kt/V and creatinine clearance (CCr) were measured to determine adequacy of dialysis. RESULTS: The mean dialysis period was 23.7 +/- 15.2 months (median 23 months). Anthropometric measurements and serum albumin level were as follows: height 130.2 +/- 15.6 cm, height standard deviation score (HtSDS) -4.2 +/- 2.4, body mass index (BMI) 16.3 +/- 1.6 kg/m2, body mass index standard deviation score (BMISDS) -0.8 +/- 0.9, triceps skinfold thickness (TST) 4.2 +/- 1.4 mm, midarm circumference (MAC) 16.21 +/- 2.3 cm, upper arm muscle area (AMA) 1799.1 +/- 535.7 mm2, upper arm fat area (AFA) 334.5 +/- 143 mm2, and serum albumin 3.1 +/- 0.7 g/dL. The BMI was above the fifth percentile in all patients; TST and MAC were below the fifth percentile in 14 patients (82.4%) and 10 patients (58.8%) respectively. The AMA was below the fifth percentile in 8 patients; however, the AFA was below the fifth percentile in all patients. Mean serum albumin level was under 3.5 g/dL in 70.5% of the children. We found significant positive correlations between BMI and Kt/V (r = 0.69, p < 0.01), CCr (r = 0.64, p < 0.05), and IL-6 (r = 0.61, p < 0.01). There was an inverse correlation between BMISDS and dialysis period (r = -0.58, p < 0.05); and between IL-6 and serum albumin (r = -0.49, p < 0.05). A significant positive correlation between BMISDS and serum IGF-1 level (r = 0.62, p < 0.01) was noted. We also found a significant positive correlation between serum IGF-1 level and both HtSDS (r = 0.57, p < 0.05) and TST (r = 0.52, p < 0.05). Significant positive correlations between AFA and CCr and IGF-1 were also noted (both r = 0.56, p < 0.05). CONCLUSION: Although many factors may be responsible for malnutrition and growth retardation, we found that prolonged period of dialysis, inadequate dialysis, and low IGF-1 levels are the most important risk factors in CAPD patients.     

维持性血液透析患者营养状态对预后影响的临床研究

目的 观察维持性血液透析患者营养状态,评价各种营养指标对预后的影响.方法 入选2006年6月在北京大学第三医院维持性血液透析患者97例,资料收集包括一般资料、主观综合营养评估(subjective global assessment,SGA)、饮食记录和分析、体测量、生化指标.随访截止时间 2009年6月,记录生存、退出透析或死亡等结局.Cox回归模型分析不同营养指标对预后的影响,ROC 曲线分析各因素预测死亡的效果.结果 36个月后,97例维持性血液透析患者中有3例转为肾移植,1例转为腹膜透析,23例死亡,共27例(28%)退出血液透析.主观营养评估SGA评分良好组生存率明显高于SGA营养不良组(P=0.000),SGA、饮食蛋白摄入、血白蛋白、胆固醇和体质量指数是影响预后的独立危险因素.SGA预测死亡的ROC曲线下面积(0.76)最大,是预测死亡效果最好的营养指标.结论 维持性血液透析患者营养状态良好者生存率明显高于营养不良者,SGA是最有效预测患者死亡的指标,而且简单易行,适合维持性血液透析患者营养的评估.     

Prevention of fungal peritonitis with nystatin prophylaxis in patients receiving CAPD.

OBJECTIVE: Fungal peritonitis (FP) is a serious complication of continuous ambulatory peritoneal dialysis (CAPD), being associated with significant morbidity and mortality. The role of nystatin prophylaxis during antibiotic therapy in the prevention of FP remains controversial, especially in programs with a modest or low baseline FP rate. The aim of the present study was to evaluate the effect of nystatin prophylaxis on the occurrence of FP in programs with a relatively modest baseline FP rate. PATIENTS AND METHODS: Incident and prevalent patients receiving CAPD between April 1995 and April 2005 at our center were included and divided into 2 groups. The control group included 320 patients (total follow-up 8875 patient-months) being treated without nystatin before October 1999; the nystatin group included 481 patients (total follow-up 13725 patient-months) being treated after October 1999. Nystatin tablets (500,000 units, 4 times per day) were given orally during whatever use of antibiotics to cover the whole course of antibiotic therapy. Occurrence of FP and antibiotic-related FP (AR-FP) in patients with and without nystatin prophylaxis was compared. RESULTS: The two groups were of similar age but the nystatin group had a significantly higher percentage of diabetics. In addition, the nystatin group had a higher proportion of patients using disconnecting twin-bag exchange systems and had a significantly lower peritonitis rate compared with the control. There were 13 and 14 episodes of FP in the nystatin and control groups respectively. The fungal peritonitis rate of the nystatin group was slightly lower than that of the control group (0.011 vs 0.019 per patient-year) but it did not reach statistical significance. There was, however, a significant decrease in the incidence and proportion of AR-FP in the nystatin group compared with the control group, which persisted even after adjustment for the peritonitis rate. Kaplan-Meier analysis further demonstrated significantly better AR-FP-free survival in the nystatin group compared with the control group. No significant side effects were observed for nystatin. Subgroup analyses in patients of the 2 different connecting systems revealed a similar but nonsignificant trend toward reduction of AR-FP in patients given nystatin prophylaxis. CONCLUSION: Oral nystatin prophylaxis might prevent the occurrence of AR-FP in CAPD patients, resulting in a trend toward reduction in the incidence of FP even in programs with a modest baseline FP rate. A large scale, prospective, randomized controlled trial is needed to further examine this issue.     

Risks and outcomes of peritonitis after flexible colonoscopy in CAPD patients.

OBJECTIVE: The ISPD 2005 guidelines for peritonitis recommend antibiotic prophylaxis for patients undergoing colonoscopy with polypectomy while on continuous ambulatory peritoneal dialysis (CAPD) but there is little literature to support this recommendation. This study aimed to look into the risks and outcomes of peritonitis after colonoscopy in CAPD patients. PATIENTS and METHODS: All records of flexible colonoscopy performed on our CAPD patients from January 1994 to January 2006 were retrieved. Demographic and clinical data, use of antibiotics before colonoscopy, endoscopic findings, procedure performed, and peritonitis data were analyzed. RESULTS: 77 CAPD patients underwent 97 colonoscopies. No peritonitis developed in the 18 cases where antibiotics were given before colonoscopy. Among those without antibiotic prophylaxis, 4 episodes of peritonitis occurred within 24 hours after the procedure and 1 occurred 5 days later. All responded to intraperitoneal antibiotics. Colonic biopsy and polypectomy were not associated with more peritonitis (2 in 41 with biopsy vs 3 in 38 without biopsy, p = 0.67; 1 in 30 with polypectomy vs 4 in 49 without polypectomy, p = 0.64). CONCLUSION: The risk of peritonitis after colonoscopy without antibiotic prophylaxis was 6.3%. All peritonitis episodes responded to intraperitoneal antibiotics. Colonic biopsy or polypectomy did not appear to increase the risk of peritonitis. Although statistically not significant when compared with patients without antibiotic prophylaxis, we observed no peritonitis after colonoscopy in patients that were given antibiotics for prophylactic purposes or for other reasons. The efficacy of prophylactic antibiotics would be better defined by large randomized trials.     

Diagnostic value of effluent endotoxin level in gram-negative peritonitis in CAPD patients.

OBJECTIVE: To evaluate the diagnostic usefulness of effluent endotoxin by Limulus amoebocyte lysate (LAL) assay in gram-negative peritonitis patients on continuous ambulatory peritoneal dialysis (CAPD) therapy. DESIGN: Prospective study with patients serving as their own controls. Standard microbiologic work up and endotoxin analysis of effluents (night dwell) were done during the pre- and posttreatment phases. SETTING: Specimens from three teaching hospitals were processed and tested at a common center. Patients were left for treatment at their respective centers without intervention. PATIENTS: 32 clinical peritonitis and 40 infection-free CAPD patients were studied. RESULTS: 75% (n = 24) of cultures were positive: 41.6% (n = 10) gram-negative and 58.4% (n = 14) gram-positive bacteria. Effluents of pre- and posttreated gram-negative cultures had endotoxin levels of 1.53 +/- 0.169 and 0.214 +/- 0.085 endotoxin units (EU)/mL, respectively (p < 0.0001); pre- and posttreated gram-positive levels of 0.102 +/- 0.06 and 0.122 +/- 0.052 EU/mL, respectively (p > 0.05); pre- and posttreated culture-negative peritonitis levels of 0.110 +/- 6.025 and 0.087 +/- 0.031 EU/mL, respectively (p > 0.05); peritonitis-free effluents contained 0.117 +/- 0.079 EU/mL. The diagnostic specificity and the sensitivity of LAL assay were 100% and 98.2% respectively. CONCLUSION: Where initial microbiological work-up cannot demonstrate a pathogen, effluent endotoxin determined by quantitative LAL assay is a useful marker for diagnosis and management, within safe time limits, of gram-negative peritonitis in CAPD patients.     

Risk factors and outcomes of extended-spectrum beta-lactamase-producing E. coli peritonitis in CAPD patients.

OBJECTIVE: To determine the risk factors and outcomes of peritonitis caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in continuous ambulatory peritoneal dialysis (CAPD). PATIENTS AND METHODS: Episodes of E. coli CAPD peritonitis in our unit from October 1994 to August 2003 were reviewed. Demographic data, underlying medical conditions, recent use of gastric acid inhibitors (including H2 antagonist and proton pump inhibitor), recent antibiotic therapy, antibiotic regimen for peritonitis episodes, sensitivity test results of the E. coli isolated, and clinical outcomes were examined. RESULTS: Over a 10-year study period, 88 episodes of E. coli peritonitis were recorded; 11 of the 88 cases were caused by ESBL-producing E. coli. Recent use of cephalosporins and gastric acid inhibitor were associated with the development of ESBL-producing E. coil peritonitis. Compared with non-ESBL-producing E. coli peritonitis, more cases in the ESBL-producing E. coli group developed treatment failure (45.5% vs 13.0%, p = 0.02) and died of sepsis (27.3% vs 3.9%, p = 0.02). Peritoneal failure rate was higher in the ESBL-producing E. coli group, although the difference was not statistically significant (18.2% vs 3.9%, p = 0.12). CONCLUSION: Peritonitis caused by ESBL-producing E. coli is associated with worse clinical outcomes. The use of cephalosporins and gastric acid inhibitors may contribute to its development. Further studies are warranted to investigate and determine the predisposing factors for ESBL-producing E. coli peritonitis.