Long-term peritoneal dialysis is a risk factor of sclerosing encapsulating peritonitis for children.

OBJECTIVE: Sclerosing encapsulating peritonitis (SEP) is a clinical syndrome with a high mortality rate and is a serious complication of peritoneal dialysis (PD). Peritoneal sclerosis (PS) is a histological diagnosis. PS is usually observed in the peritoneal specimens of patients with SEP. Avoiding SEP is considered to be extremely important for pediatric patients who may require long-term PD. In this study, the characteristics of patients with PS were investigated to determine when to perform peritoneal biopsies and how long PD can be performed safely. DESIGN: A retrospective single-center study. SETTING: Tokyo Metropolitan Kiyose Children's Hospital. PATIENTS: A total of 109 children younger than 16 years have received chronic PD in our unit since 1981. Among these children, 16 patients had been on PD for more than 5 years (mean 7.4+/-2.5 years) from May 1992 to March 1999. Peritoneal biopsies were performed in 14 of the 16 patients, who were divided into two groups based on the histological diagnoses: a PS and a peritoneal fibrosis (PF) group. RESULTS: The 14 patients were on PD for a mean of 7.8+/-2.5 years. There were 8 patients with PS and 6 patients with PF. SEP was observed in 2 patients in the PS group. The risk of PS increased with the duration of PD: 57% (8/14) > 5 years, 80% (4/5) > 8 years, and 100% (3/3) > 10 years. All patients in the PS group showed both peritoneal calcifications on abdominal CT scan and poor ultrafiltration at the time of diagnoses. CONCLUSION: Long-term PD was the important risk factor of SEP. If both peritoneal calcification on abdominal CT scan and poor ultrafiltration are observed in a patient on PD more than 5 years, a peritoneal biopsy should be performed. If PS is detected, PD should be discontinued.     

Large body mass index does not predict short-term survival in peritoneal dialysis patients.

OBJECTIVE: Higher than normal body mass index (BMI) is associated with an increased risk of death in the general population. We examined the effect of higher than normal BMI on patient and technique survival in peritoneal dialysis patients (PD), controlling for comorbidity, initial albumin, dialysate-to-plasma ratio of creatinine (D/P(Cr)), and initial urea clearance (Kt/V). DESIGN: Registry database. SETTINGS: Four dialysis centers. PATIENTS: Incident PD patients. METHODS: All data were collected prospectively. Demographics, BMI, serum albumin, D/P(Cr), and comorbidity using the Charlson Comorbidity Index (CCI) were determined at the start of PD. 104 patients with a high BMI (> 27) were matched to a control group of 104 patients with normal BMI (20-27) for age, gender, presence of diabetes, and CCI. Patient and technique survival were compared using Cox proportional hazards model. MAIN OUTCOME MEASURES: Patient and technique survival. RESULTS: The groups were of similar age (56.1 vs 56.7 years), sex (60% males in both groups), race (Caucasian 80% vs 86%), presence of diabetes (40% vs 37%), CCI score (5.4 in both groups), initial albumin (3.6 vs 3.5 g/dL), and D/P(Cr) (0.65 in both groups). Kaplan-Meier survival analysis showed similar 2-year patient survival between large BMI (> 27) and control (20-27) groups (76.6% vs 76.1%). Two-year technique survival was also similar between the two groups (59.7% vs 66.8%). With Cox proportional hazards analysis, BMI was not a predictor of patient mortality or technique survival when controlling for initial albumin, D/P(Cr), and initial Kt/V. CONCLUSIONS: We conclude that a BMI above normal is not associated with any increased or decreased risk of death in patients on PD for 2 years.     

The disappearance of macromolecules from the peritoneal cavity during continuous ambulatory peritoneal dialysis (CAPD) is not dependent on molecular size.

The transport of macromolecules from the circulation to the peritoneal cavity is a size-selective restricted process, while the transport of these solutes from the peritoneal cavity is probably mainly by lymphatic absorption. If so, it should be independent of molecular size. Therefore, we studied with a clearance technique the disappearance of intraperitoneally administered inulin and polydisperse dextran 70 in nine continuous ambulatory peritoneal dialysis (CAPD) patients and compared the results with the simultaneously measured appearance clearance of serum proteins. Using gel permeation chromatography 18 dextran fractions with different molecular radii could be analyzed. Inulin clearance (2.94 mL/min) was higher than total dextran clearance (1.30 mL/min). The maximal dextran concentration in all dialysate samples was found in the 50.4 A fraction. The clearances of the dextran fractions were the same of different molecular sizes. All disappearance clearances were higher than the appearance clearances: the protein/dextran clearance ratio ranged from 0.15 for albumin/36 A to 0.04 for alpha 2-macroglobulin/91 A. This confirms that the appearance of a macromolecule, but not its disappearance is dependent on molecular size. It is concluded that the disappearance of macromolecules from the peritoneal cavity is mainly a size independent convective process, possibly by lymphatic uptake. This implies that total dextran 70 clearance can be used for measurement of lymphatic absorption in CAPD patients.     

High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis.

BACKGROUND: Patients on continuous ambulatory peritoneal dialysis (CAPD) who have high small-molecule peritoneal transport have increased mortality. OBJECTIVE: To investigate the impact of baseline peritoneal transport characteristics on patient and technique survival in incident peritoneal dialysis (PD) patients, most of whom are on automated PD (APD), with the use of icodextrin. DESIGN: Retrospective observational cohort study. SETTING: A single PD unit. Patients and METHODS: 193 new patients that began PD between January 2000 and September 2004, and had an initial peritoneal equilibration test within 6 months of commencement of PD. Patients were divided into low (L), low average (LA), high average (HA), and high (H) peritoneal transport groups. Death-censored technique failure and patient survival were examined. RESULTS: Of the 193 patients, 151 (78.1%) were on APD or on APD with icodextrin or on CAPD with icodextrin. At the end of 1, 3, and 5 years, patient survival was 91%, 82%, and 67% in LA group; 95%, 77%, and 69% in HA group; and 96%, 71%, and 71% in H group. Technique survival was 100%, 90%, and 77% in LA group; 96%, 84%, and 72% in HA group; and 92%, 87%, and 77% in H group. High peritoneal permeability did not predict worse patient survival or technique failure, while age, diabetes, a lower glomerular filtration rate, and high body mass index (> or =30 kg/m(2)) were independent predictors of death. CONCLUSION: This study suggests that higher peritoneal transport is not a significant independent risk factor for either mortality or death-censored technique failure. The favorable outcome for high transporters in this study may be due to improved management of volume status by the increased use of APD and the use of icodextrin-based dialysis fluid.     

Expression of cancer antigen 125 by peritoneal mesothelial cells is not influenced by duration of peritoneal dialysis.

OBJECTIVE: To investigate the presence of cancer antigen 125 (CA125) on mesothelial cells in the effluent of peritoneal dialysis (PD) patients and to analyze the effect of duration of PD on the number of mesothelial cells in peritoneal effluent, the number of CA125-positive cells, and dialysate CA125 concentration. DESIGN: A cross-sectional study in which long-dwell peritoneal effluents were investigated for mesothelial cells and CA125. SETTING: A university hospital population of chronic PD patients. PATIENTS: 33 stable PD patients who were free of peritonitis during the investigation and during the 4 weeks prior to the study. METHODS: Examination of cytospin preparations of peritoneal effluent stained with May-Grünwald Giemsa, and also with an immunocytochemical double-staining method consisting of anticalretinin (pan-mesothelial cell marker) and OC125. RESULTS: A close relationship was present between the numbers of mesothelial cells counted with the two staining methods (r= 0.998, p < 0.001). On average, 92% of mesothelial cells were positive for CA125, ranging between 75% and 100% in 80% of the patients. Correlations were found between the effluent CA125 concentration and the total number of mesothelial cells (r = 0.64, p < 0.001), and also the number of CA125-positive cells (r = 0.66, p < 0.001). A negative effect of time was seen on the effluent CA125 concentration, the total number of mesothelial cells, and the number of CA125-positive mesothelial cells. However, no effect of time was present on the percentage CA125-positive cells. CONCLUSIONS: On average, 92% of mesothelial cells in peritoneal effluent are positive for CA125. This figure is not dependent on the duration of PD. Long-term PD is associated with low dialysate CA125 concentrations, a low number of mesothelial cells, and a low number of CA125-positive mesothelial cells in effluent. These results support the hypothesis that dialysate CA125 can be used as a marker of mesothelial cell mass in stable PD patients.     

Renal dialysis abatement: lessons from a social study

AIM: This study aimed to examine the reasons why some people chose to abate (i.e., stop or not start) renal dialysis, together with the personal and social impact of this decision on the person concerned, and/or their families. METHOD: A qualitative design based on the principles of Grounded Theory was employed. Semi-structured interviews were conducted with sixteen patients and/or carers (depending on whether the patient was able to be interviewed) where the issue of dialysis abatement was being considered, or had recently been decided. RESULTS: Of 52 participants considered for entry into the study 41 were ineligible, with impaired cognition, rapid medical deterioration, and inability to speak sufficient English being the main reasons for exclusion. The desire not to burden others and the personal experience of a deteriorating quality of life were crucial elements in the decision to stop or decline dialysis. The problem of prognostic uncertainty and a sense of abandonment were also prominently expressed. CONCLUSIONS: From this small Australian sample, it appears that there would be considerable potential benefit from a more proactive and open approach to end-of-life issues, with incorporation of the clinical and health promoting principles of palliative care into renal dialysis practice. The high number of exclusions shows how sick and unstable this population of patients is, but the issue of data gathering from people whose main language is not English requires attention.     

Malnutrition-inflammation score is a useful tool in peritoneal dialysis patients.

BACKGROUND: Malnutrition-Inflammation Score (MIS) is a quantitative assessment tool based on Subjective Global Assessment (SGA) and predicts mortality and morbidity in maintenance hemodialysis patients. However, there are not enough data about the use of MIS in peritoneal dialysis (PD). In this study, relationships between MIS and prospective hospitalization indices, risk of developing peritonitis, anemia indices, and laboratory and anthropometric parameters were analyzed and compared with SGA in PD. METHODS: 50 PD patients (M/F 26/24, age 45.2 +/- 14.9 years, mean PD duration 30.8 +/- 23.1 months) were included. The same physician performed the SGA and MIS evaluations. Clinical, laboratory, and anthropometric parameters were measured. RESULTS: 18 patients were classified as SGA-A (without malnutrition), 24 as SGA-B (with moderate malnutrition), and 8 as SGA-C (with severe malnutrition). Increment in MIS was concordant with SGA groups A to C (p < 0.0001). Peritonitis rate, number of hospitalizations, total number of hospitalization days, erythropoietin requirements, C-reactive protein (CRP), and ferritin levels were positively correlated with MIS (p < 0.0001). Midarm muscle circumference (p = 0.04), albumin (p < 0.0001), prealbumin (p = 0.001), creatinine (p = 0.04), hemoglobin (p = 0.003), transferrin (p < 0.0001), and cholesterol (p = 0.009) were negatively correlated with MIS. Correlation coefficients of hospitalization indices, peritonitis rate, anemia indices, erythropoietin requirements, albumin, prealbumin, CRP, and anthropometric parameters were higher with MIS than with SGA. In logistic regression analysis, a higher MIS was independently associated with a higher risk of future hospitalization (p = 0.029, odds ratio 2.14, confidence interval 1.082-4.146). CONCLUSIONS: This study demonstrated that MIS significantly correlated with clinical, nutritional, inflammatory, and anthropometric parameters and anemia indices in PD patients, and that those correlations were stronger than those with SGA.     

The effect of depressive symptoms on survival in peritoneal dialysis patients.

OBJECTIVE: There is little information on the relationship between depressive symptoms and survival in peritoneal dialysis (PD) patients. We examined whether a single measurement of depressive symptoms using a simple self-administered tool predicts survival. DESIGN: Screening test of depressive symptoms as a predictor of outcome. SETTING: Three dialysis centers in Southwestern Pennsylvania. PARTICIPANTS: 66 adult PD subjects were screened in 1997-1998 for depression using the Zung scale. MAIN OUTCOME MEASURES: Baseline data collection included assessments of comorbidity, residual renal function, total Kt/V, nPNA, previous renal transplant, and serum albumin. Outcomes were collected prospectively after completion of the depression survey to 12/01. Cox regression analysis of patient survival was performed using all cofactors with p < 0.05 on univariate analysis. RESULTS: One third of patients had depressive symptoms. Compared to nondepressed patients, depressive symptom patients were older (62.5 vs 52.5 years, p = 0.012), had borderline lower serum albumin levels (3.47 vs 3.70 g/dL, p = 0.058), and were more disabled (Karnofsky score 70 vs 90, p< 0.001), but had similar Kt/V, residual renal function, and previous time on PD at the point of the testing. Using multivariate analysis and controlling for comorbidity (using a measurement that includes diabetes mellitus and age) and serum albumin, the survival of patients with depressive symptoms was significantly reduced compared to nondepressed patients. CONCLUSION: A single measurement of depressive symptoms using a simple self-administered test was an independent predictor of death in a cohort of PD patients, which extends observations in hemodialysis patients. Screening for depressive symptoms should be routine for dialysis patients, and those depressed should have thorough assessment and treatment. Whether treating depression will have an impact on survival is unclear and needs to be studied.     

The impact of social support on the survival of Chinese peritoneal dialysis patients.

BACKGROUND: Social support is an independent risk factor for mortality among new hemodialysis patients. We evaluated the effect of social support on the outcome of Chinese peritoneal dialysis (PD) patients. METHODS: We studied 167 prevalent PD patients. They completed the Medical Outcomes Study Social Support Survey, Chinese Version (MOS-SSS-C) questionnaire. Patients were followed for 1 year. Outcome measures included change in nutritional status, hospitalization, and technique and actuarial patient survival. RESULTS: Actuarial survival was 57.1%, 72.7%, 85.3%, and 88.6% for MOS-SSS-C total score quartiles I, II, III, and IV, respectively (log rank test, p = 0.037). Technique survival was 57.1%, 81.9%, 91.9%, and 91.4% (log rank test, p = 0.0044). By multivariate analysis with the Cox proportional hazard model to adjust for confounders, every 1 point increase in MOS-SSS-C total score was associated with a 0.6% [95% confidence interval (CI) 0.2%-0.9%, p = 0.003] reduction in the risk of death and a 0.5% (95%CI 0.1%-1.0%, p = 0.037) reduction in the risk of technique failure. The MOS-SSS-C score had no significant effect on change in nutritional or dialysis adequacy indices, hospitalization, or number of peritonitis episodes in 1 year. CONCLUSION: The degree of social support is an important predictor of actuarial and technique survival in Chinese PD patients. Measures to enhance social support may represent an easily achievable means of improving the clinical outcome of PD patients.