Inaccurate self-monitoring of blood glucose readings in patients on chronic ambulatory peritoneal dialysis with icodextrin.

Patients on chronic ambulant peritoneal dialysis (CAPD) are increasingly likely to be treated with a new solution of corn starch-derived glucose polymers called icodextrin. This solution involves a very low carbohydrate absorption leading to a better glycemic control in diabetic patients. However these glucose polymers pass to the blood and are metabolized to oligosaccharids which interfere with blood glucose in distinct capillary glucose analyzers leading to overestimation of glycemia. We assessed the accuracy of glucose measurements with the three most commonly used glucose analyzers compared to venous plasma glucose measurement at our institution in 8 patients (4 patients with type 2 diabetes) on CAPD using icodextrin. Glycemia was measured simultaneously in plasma of venous blood using a reference laboratory method and in capillary blood using Accu-Chek sensor (Rotkreuz, Switzerland) (glucose dehydrogenase method), Glucotrend 2 (Rotkreuz, Switzerland) (glucose-dye-oxyreductase method) and Ascensia elite (Zurich, Switzerland) (glucose oxidase method) glucose analyzers. Only glucose readings with Ascensia elite correspond correctly with venous plasma glucose results (+0.3 mmol/l; n. s.), whereas glycemia was significantly overestimated by Accu-Chek sensor (+4.3 mmol/l; p<0.0001) and Glucotrend 2 glucose analyzers (+3.7 mmol/l; p<0.0001). Thus we conclude that distinct glucose analyzers overestimate real blood glucose concentration and are not suitable for monitoring glycemia in patients on CAPD with icodextrin. On the basis of our results, these patients should use glucose analyzers using glucose oxidase methods. All glucose analyzers should be cross-checked with a laboratory reference method before the application in patients on CAPD with icodextrin is recommended.     

Benefit of glucose-free dialysis solutions on glucose and lipid metabolism in peritoneal dialysis patients

BACKGROUND: Glucose absorbed from conventional peritoneal dialysis (PD) solutions contributes to unfavorable metabolic effects. Its replacement with a glucose-free osmotic agent such as icodextrin (ID) or amino acids (AA) may have some benefit on glucose and lipid metabolism. METHODS: Serum lipids, insulin sensitivity and substrate oxidation (calorimetry) were measured before and after 8 weeks use of ID or AA in 22 patients. Calorimetry and blood tests (HbA1c, lipids) were also performed after 8 weeks of simultaneous use of ID and AA in 8 patients. RESULTS: Cholesterol declined during the use of AA (4.8 +/- 0.3-4.5 +/- 0.3 mmol/l, p = 0.045). Triglycerides decreased during the use of both ID (2.2 +/- 0.2-1.9 +/- 0.1 mmol/l, p = 0.019) and AA (1.9 +/- 0.2-1.6 +/- 0.1 mmol/l, p = 0.024). Free fatty acids declined during the use of AA. There were no significant changes in insulin sensitivity. Glucose oxidation decreased and lipid oxidation increased during the use of ID, the changes in substrate oxidation were accentuated during the simultaneous use of ID and AA. CONCLUSION: Replacement of glucose with ID or AA had a benefit on glucose and lipid metabolism.     

Infections in patients undergoing peritoneal dialysis

Considering experience acquired in the past years, it seems as though physicians have reached a plateau in the frequency of peritonitis. A peritonitis rate of 1 every 2 patient years may be acceptable. Further reduction of this peritonitis rate will require inordinately large efforts on all fronts. One will have to consider what are the acceptable costs and risks of peritonitis in patients on peritoneal dialysis. New developments in catheter technology, improved connections, better understanding of patient selection and training programs, improved diagnostic and therapeutic methods in the management of peritonitis, and understanding of the infectious and immune processes are eagerly awaited developments.     

Comparison of rehabilitation in patients undergoing home dialysis. Continuous ambulatory or cyclic peritoneal dialysis vs home hemodialysis

Rehabilitation was assessed in 70 patients undergoing continuous ambulatory (CAPD; n = 67) or cyclic (CCPD; n = 3) peritoneal dialysis and 76 patients undergoing home hemodialysis (HHD). In the CAPD/CCPD group, there were more blacks (83% vs 53%) and diabetics (24% vs 8%). If patients too infirm to work were excluded, no statistically significant differences were found between those working for gain and in school (19% for CAPD/CCPD vs 32% for HHD); homemakers (16% for CAPD/CCPD vs 28% for HHD); and those not working (66% for CAPD/CCPD vs 41% for HHD). Although the CAPD/CCPD group had less formal education (8.9 +/- 3.7 years vs 10.9 +/- 2.2 years for HHD), illiteracy rates were similar (CAPD/CCPD, 16%; HHD, 7%). If unemployable (elderly and debilitated) patients were excluded, full rehabilitation was excellent in both groups (57% for CAPD/CCPD vs 65% for HHD), despite the greater number of blacks and diabetics in the CAPD group.     

Allergic reactions to the polymeric glucose-based peritoneal dialysis fluid icodextrin in patients with renal failure

A new glucoee polymer, icodextrin, related to maltose, is in increasing use as a peritoneal dialysis fluid. We report on adverse events seen in our unit during a 12-month period after the introduction of this reagent.     

Effects of icodextrin on insulin resistance and adipocytokine profiles in patients on peritoneal dialysis

Icodextrin peritoneal dialysis solution reportedly benefits patients suffering from metabolic derangement due to glucose load from dialysate. However, the effects of icodextrin on insulin resistance and adipocytokine profile remain unclear. Subjects comprised 14 stable patients on peritoneal dialysis for >6 months. Their mean age was 57 +/- 11 years and the mean duration of peritoneal dialysis was 49 +/- 30 months. Patients were classified into groups according to the index of insulin resistance (index of homeostasis model assessment: HOMA-IR): Group A, HOMA-IR < 2.0 (n = 7); and Group B, HOMA-IR >or= 2.0 (n = 7). Glucose peritoneal dialysis solution was subsequently switched to icodextrin once daily during the night. Changes in HOMA-IR and adipocytokine profiles were examined after three months. The glucose absorption dose tended to decrease in both groups after icodextrin introduction, with significant reductions in Group B. No changes were seen in body mass index, fluid status, peritoneal dialysis dose, residual renal function or fasting plasma glucose levels in either group. Plasma insulin levels were unchanged in Group A, but decreased significantly in Group B. The index of insulin resistance was thus unchanged in Group A (from 1.4 +/- 0.4 to 1.5 +/- 0.8) and significantly decreased in Group B (from 5.9 +/- 2.2 to 3.2 +/- 0.6; P < 0.01). Regarding plasma adipocytokine profiles, no changes were found in plasma leptin, tissue necrosis factor-alpha or total plasminogen activator inhibitor-1 levels in either group. Plasma adiponectin levels were unchanged in Group A, but significantly increased in Group B. Icodextrin solution could ameliorate insulin resistance by decreasing insulin levels due to a reduction in the glucose load and an increase in plasma adiponectin levels.     

Blood eosinophilia in patients undergoing maintenance peritoneal dialysis

To determine the prevalence of blood eosinophilia in patients receiving maintenance peritoneal dialysis, routine peripheral WBC counts of 49 such patients were reviewed. In 29 patients, blood eosinophilia was noted. Elevations in blood eosinophil counts tended to be mild and episodic. They were often associated with concomitant elevation of peritoneal fluid eosinophil counts. Possible predisposing factors included recent peritoneal catheter insertion and antibiotic therapy for peritonitis.     

糖尿病终末期肾病患者透析方式的探讨

目的比较腹膜透析（PD）及血液透析（HD）对糖尿病终末期肾病患者长期预后的影响,以便为临床选取适当治疗方法提供参考。方法将131例糖尿病终末期肾病患者分为HD组（58例）和PD组（73例）,比较两组患者的血液生化指标、生存率和死亡原因。结果两组患者年龄比较无显著性差异,但大于65岁的老年糖尿病患者PD组明显增多（P〈0．01）。透析第1、第2年两组患者死亡率比较无显著性差异,第3、4年PD组死亡率大幅上升,显著高于HD组（P〈0．01）。HD组18例死亡患者中,年龄大于65岁者4例（22．2％）;PD组29例死亡患者中,年龄大于65岁者17例（58．6％）,两组比较有显著性差异（P〈0．01）。HD组死亡主要原因为脑血管病变（占38．9％）,PD组死亡主要原因为感染（占34．5％）。PD组空腹血糖、甘油三酯、胆固醇均高于HD组,两组比较差异有显著性（P〈0．01）。PD组患者血浆白蛋白、血钾明显低于HD组（P〈0．01）。结论糖尿病终末期肾病患者适于PD,但PD组患者2年以上远期生存率明显低于HD组,尤其是大于65岁高龄糖尿病患者PD死亡率明显上升。腹膜透析相对于血液透析仍存在局限性。     

Fibroblast growth factor 23 in patients undergoing peritoneal dialysis

Summary

Background and objectives

Fibroblast growth factor 23 (FGF23) is an independent risk factor for mortality in patients with ESRD. Before FGF23 testing can be integrated into clinical practice of ESRD, further understanding of its determinants is needed.

Design, setting, participants, & measurements

In a study of 67 adults undergoing peritoneal dialysis, we tested the hypothesis that longer dialysis vintage and lower residual renal function and renal phosphate clearance are associated with higher FGF23. We also compared the monthly variability of FGF23 versus parathyroid hormone (PTH) and serum phosphate.

Results

In unadjusted analyses, FGF23 correlated with serum phosphate (r = 0.66, P < 0.001), residual renal function (r = −0.37, P = 0.002), dialysis vintage (r = 0.31, P = 0.01), and renal phosphate clearance (r = −0.38, P = 0.008). In adjusted analyses, absence of residual renal function and greater dialysis vintage associated with higher FGF23, independent of demographics, laboratory values, peritoneal dialysis modality and adequacy, and treatment with vitamin D analogs and phosphate binders. Urinary and dialysate FGF23 clearances were minimal. In three serial monthly measurements, within-subject variability accounted for only 10% of total FGF23 variability compared with 50% for PTH and 60% for serum phosphate.

Conclusions

Increased serum phosphate, loss of residual renal function, longer dialysis vintage, and lower renal phosphate clearance are associated with elevated FGF23 levels in ESRD patients undergoing peritoneal dialysis. FGF23 may be a more stable marker of phosphate metabolism in ESRD than PTH or serum phosphate.     

Volume control in peritoneal dialysis patients: role of new dialysis solutions

This paper reviews the most recent clinical data on the volume status of long-term peritoneal dialysis (PD) patients. It appears that many PD patients are volume overloaded, associated with a high prevalence of hypertension and left ventricular hypertrophy. In the presence of the poor results in patients with peritoneal ultrafiltration, the introduction of the polyglucose solution, icodextrin, has ameliorated volume control in some of these patients. In a second part of the review, some of the structural and functional alterations in the peritoneal membrane and the role of glucose degradation products (GDP) in the commonly used dialysates as well as the resulting formation of advanced glycation end products are described. The introduction of low GDP-containing solutions at normal pH has at least in experimental models of PD attenuated the hemodynamic changes observed with the classical solutions. The solutions at normal pH containing either bicarbonate or a mixture of bicarbonate/lactate were clinically associated with less inflow pain.     

Demographic factors associated with dialysis technique failures among patients undergoing continuous ambulatory peritoneal dialysis

We evaluated factors that would predict a successful outcome on continuous ambulatory peritoneal dialysis. We found that poverty, the need for a helper to carry out the dialysis, and physician allocation to therapy was associated with a poorer technique success. Neither age, education, marital status, sex, rural home, nor the presence of diabetes were important risk factors by themselves.     

Rhodotorula rubra peritonitis in patients undergoing continuous ambulatory peritoneal dialysis

Although still uncommon, fungal peritonitis is being reported with increasing frequency in patients with renal failure who are undergoing long-term peritoneal dialysis. Although most cases have involved Candida albicans, other opportunistic pathogens have been reported as well. Recently, three patients were seen with serious peritoneal infections due to Rhodotorula rubra, a "nonpathogenic" fungus. In two patients, peritoneal fibrosis made further peritoneal dialysis impossible. The third patient died from complications of peritonitis. Environmental cultures revealed a possible common-source outbreak. Literature review reveals that infection due to this organism is most unusual and occurs only in the hospital setting in patients with serious compromise of host defenses.     

Peritonitis caused by Pseudomonas putrefaciens in patients undergoing continuous ambulatory peritoneal dialysis.

Three cases of peritonitis caused by Pseudomonas putrefaciens in patients undergoing continuous ambulatory peritoneal dialysis are described. In two cases asymptomatic colonization of the dialysate preceded overt infection. All patients responded successfully to standard antibiotic therapy with gentamicin or ofloxacin. This is the first report of peritonitis caused by P. putrefaciens.     

Controlled study of renal osteodystrophy in patients undergoing dialysis. Improved response to continuous ambulatory peritoneal dialysis compared with hemodialysis

To assess the effect of different dialysis modalities on renal osteodystrophy, a controlled study was performed in six patients undergoing continuous ambulatory peritoneal dialysis and six hemodialysis-treated patients. All patients were enrolled at the initiation of dialysis, and age, sex, cause of renal failure, prior treatment of renal osteodystrophy, and baseline serum and bone histologic variables were similar in the two groups. After initial blood samples and bone biopsy specimens (with double-tetracycline labels) were obtained, renal osteodystrophy in both groups received comparable treatment with aluminum hydroxide to maintain serum phosphorus levels between 3.5 and 5.5 mg/dl, and with calcium carbonate and calcitriol to maintain total serum calcium levels between 10 and 11 mg/dl. Blood and bone samples were obtained again after nine months. All patients were asymptomatic at the beginning and end of the study. Phosphorus values were well controlled, and total calcium increased similarly in both groups. Although ionized calcium levels increased in both groups, the final level was higher in hemodialysis-treated patients than in patients undergoing continuous ambulatory peritoneal dialysis (2.82 +/- 0.07 meq/liter and 2.5 +/- 0.05 meq/liter, respectively; p = 0.005). Amino-terminal parathyroid hormone levels normalized in both groups, and histologic improvement of osteitis fibrosa occurred in a similar proportion of patients in both groups; however, quantitative improvement was greater in the hemodialysis-treated patients. Osteomalacia, assessed qualitatively and by dynamic histomorphometric measurements, was ameliorated to a much greater degree in patients undergoing continuous ambulatory peritoneal dialysis compared with hemodialysis-treated patients. Bone aluminum staining was absent in all biopsy specimens. Overall, bone histologic findings improved to a greater degree in patients undergoing continuous ambulatory peritoneal dialysis. When patients undergoing continuous ambulatory peritoneal dialysis or hemodialysis and receiving similar treatment for renal osteodystrophy were compared, patients treated with continuous ambulatory peritoneal dialysis appeared to have a greater improvement in their metabolic bone disease.     

Impaired fasting glucose association with mortality in nondiabetic patients on maintenance peritoneal dialysis

IntroductionThe aim of this study was to investigate clinical significance of impaired fasting glucose (IFG) in nondiabetic patients on maintenance peritoneal dialysis (PD).MethodsIn total, 362 maintenance PD patients were enrolled and followed up for 2-years. According to 1997 definitions, patients were divided into 3 groups: diabetic (n = 85), nondiabetic with IFG (n = 62) and nondiabetic with normal fasting glucose levels (n = 215). After basal data were collected for cross-sectional analyses, mortality and cause of death were recorded for longitudinal analyses.ResultsAfter adjusting for related variables by multivariate logistic regression analysis, IFG was found to be positively associated with age but negatively associated with normalized protein nitrogen appearance and transferrin saturation in nondiabetic maintenance PD patients. Thirty nondiabetic patients had died after the 2-year follow-up. Cox multivariate analysis showed that age (hazard ratio: 1.037; 95% confidence interval: 1.0021.073; P = 0.036) and presence of IFG (hazard ratio: 2.719; 95% confidence interval: 1.082-6.833; P = 0.033) were significant risk factors for all-cause 2-year mortality in nondiabetic maintenance PD patients.ConclusionsIFG, a preventable and treatable condition, was associated with all-cause 2-year mortality in nondiabetic maintenance PD patients.     

血液透析和腹膜透析患者死亡原因分析及比较

目的:分析血液净化患者的死亡原因,并比较血液透析(HD)和腹膜透析(PD)患者的死因差异.方法:纳入2005-01-01至2008-12-31期间新进入透析的患者,随访至2009-03-31.结果:460例透析患者中,247例起始采用HD治疗,213例起始采用PD治疗.HD组男性比例和血肌酐显著较高,而PD组基础疾病为高血压肾病比例显著较高,其余基线资料包括透始年龄、体重指数、透析前已知的肾功能不全病程、首次透析治疗前eGFR、平均动脉压、心脑血管事件、Charlson并发症指数等两组间均无明显统计学差异.共87例死亡患者,其中HD患者40例,PD患者47例.HD总体死亡率低于PD患者(0.102和0.171/患者年,P＜0.01).HD 1年死亡率与PD患者无显著差异(0.133和0.196/患者年,P＞0.05),HD 2年死亡率低于PD患者(0.101和0.170/患者年,P＜0.05),HD 3年死亡率低于PD患者(0.101和0.165/患者年,P＜0.05).透析患者的主要死亡原因为心血管疾病(31.0%)、脑血管疾病(21.8%)、感染(16.1%).PD患者心血管病因死亡率显著高于HD患者(0.064和0.022/患者年,P＜0.01),而两组的脑血管疾病、感染、多脏器衰竭和恶性肿瘤导致的死亡率均无显著差异.年龄＜65岁患者中,HD总体死亡率与PD无显著差异,两组患者的心血管疾病、脑血管疾病、感染、多脏器衰竭和恶性肿瘤死亡率均无显著差异.年龄≥65岁患者中,HD总体死亡率低于PD(0.179和0.378/患者年,P＜0.05),PD患者心血管疾病死亡率高于HD患者(0.164和0.004/患者年,P＜0.05),两组患者的脑血管疾病、感染、多脏器衰竭和恶性肿瘤死亡率均尤显著差异.透析龄≤1年患者中,HD总体死亡率与PD患者无显著差异;PD患者多脏器衰竭导致的死亡率显著高于HD患者(0.082和0.000/患者年,P＜0.05),而两组的心血管疾病、脑血管疾病、感染和恶性肿瘤导致的死亡率均无显著差异.透析龄＞1年患者中,HD总体死亡率与PD患者无显著差异;PD患者心血管病因死亡率高于HD患者(0.026和0.006/患者年,P＜0.05),感染导致的死亡率显著高于HD患者(0.013和0.000/患者年,P＜0.05),两组的脑血管疾病、多脏器衰竭、恶性肿瘤导致的死亡率均无显著差异.结论:透析患者最主要的死因为心、脑血管疾病和感染.HD总体死亡率可能低于PD,尤其是心血管疾病和感染导致的死亡率.应该强调透析患者的心脑血管并发症和感染的防治,以提高透析质量,改善长期预后.     

糖尿病肾病与非糖尿病肾病患者应用葡萄糖透析液进行持续性非卧床腹膜透析的全天血糖谱比较

目的研究持续性非卧床腹膜透析（CAPD）患者全天血糖谱的变化规律。方法选取2009年4月至2011年12月在中山大学附属第一医院腹膜透析中心行腹膜透析的终末期肾病患者28例,其中15例为2型糖尿病肾病患者（DN组）,13例为非糖尿病肾病患者（NDN组）。另设健康对照组12名,为同期来我院门诊体格检查各项指标均正常者。应用动态血糖监测系统（CGMS）对3组进行连续72h的动态血糖监测,分析各组动态血糖参数特点。用多元协方差分析控制组问基线差异,并处理血红蛋白对HbAlc的影响效应。结果与正常对照组相比,NDN组〉11．1mmol／L血糖百分比（胛）明显高于正常对照组,差异有统计学意义[（1％（0～5％）比0,P〈0．05],且〉7．8mmol／L曲线下面积（AUC）、〉11．1AUC、平均血糖水平的标准差（SDBG）、血糖最大值（MAX）、日内最大血糖波动幅度（LAGE）均有升高趋势（P值介于0．056～0．094）。而DN组上述指标则更高。此外DN组平均血糖水平（MBG）、24hAUC、透析相关指标如腹膜透析时血糖、透析后MAX也明显高于NDN组[（9．4±2．5）比（6．4±1．3）mmol／L,（7．0±2．7）比（4．2±1．3）mmol·L-1·d-1,透析时血糖（8．6±2．8）比（6．2±1．4）mmoL／L,透析后MAX（11．5±2．6）比（8．5±2．4）mmol／L]（均P〈0．05）。糖化血红蛋白〈7％的DN组患者的血糖指标如MBG、24hAUC、〉7．8AUC及PT、〉11．1PT,腹膜透析相关指标如透析后MAX也较NDN组显著升高（t值为1．808～3．627,均P〈0．05）。DN组的夜间低血糖检出率明显高于NDN组及正常对照组。在DN患者中,使用2．5％葡萄糖透析液与1．5％透析液的患者相比,各项血糖指标均有升高趋势（均P〉0．05）。结论CAPD时葡萄糖腹膜透析液可影响患者的血糖稳态,对DN患者的影响更为明显。