Imbalance between intraperitoneal coagulation and fibrinolysis during peritonitis of CAPD patients: the role of mesothelial cells

We compared peritoneal dialysis effluents from 18 CAPD patientswho had not suffered from peritonitis during the last 6 months(group 1) with the effluents from five patients with acute peritonitis(group 2), measuring activation markers of coagulation and fibrinolysis.These markers included prothrombin fragment F1+2 (F1+2), thrombin-antithrombinIII complex (TAT), fibrin monomer (FM), and fibrin degradationproducts (FbDP). In the dialysate of group 1 we found remarkablyhigh levels of F1+2, TAT and FM concomitant with a high concentrationof FbDP, indicating a high rate of intraperitoneal fibrin turnover.The balance between peritoneal generation and degradation offibrin was disturbed in untreated patients of group 2, who hadsignificantly higher levels of coagulation markers and a higherratio between FM and FbDP. Seven days after treatment with intraperitonealadministration of antibiotics and heparin, F1+2, TAT, FM andFbDP decreased significantly. To evaluate the role of mesothelial cells (MC) in the high peritonealfibrin turnover we investigated the expression of tissue-typeplasminogen activator (t-PA), urokinase-type plasminogen activator(u-PA), plasminogen activator inhibitor type-1 (PAI-1), andtissue factor in cultured human peritoneal MC under basal conditionsand after exposure to tumour necrosis factor (TNF) interleukin-1(IL-1), or bacterial lipopolysaccharide (LPS). The exposureof MC to TNF or to a lesser extent IL-1 or LPS reduced theirfibrinolytic activity by decreasing t-PA production and increasingPAI-1 synthesis. Furthermore the addition of TNF resulted inactivation of the coagulation cascade by the expression of tissuefactor. These in-vitro findings explain the imbalance betweenintraperitoneal coagulation and fibrinolysis during peritonitisof CAPD patients.     

Total and regional bone densities in dialysis patients.

Total and regional bone mineral densities (BMD) of ten male haemodialysis (HD) patients and ten male patients on continuous ambulatory peritoneal dialysis (CAPD) were measured using dual-energy X-ray absorptiometry (DEXA), and compared with that of age- and sex-matched controls. Our data showed that patients with renal failure on dialysis had reduced bone densities as manifested by a reduction in total body BMD, femoral neck BMD, and Ward's triangle BMD. In addition, head BMD and femoral trochanter BMD were also reduced in HD patients. Among HD patients, the length of the period of dialysis correlated with serum level of parathyroid hormone and the reductions in total body BMD and head BMD. Furthermore, there was a strong negative correlation between bone density of the skull and serum parathyroid hormone. Our results demonstrated regional variations in the reduction of bone density in patients with asymptomatic renal bone disease. DEXA bone scan is a useful adjunct in the early assessment of renal osteodystrophy and bone density of the skull can be used as a monitor in hyperparathyroid bone disease.     

Reduced peritoneal protein selectivity may indicate peritoneal fibrosis in CAPD patients

Background. We investigated peritoneal protein selectivity to evaluate whether it may indicate changes in peritoneal pores and be related to the morphological changes in the peritoneal membrane during the course of continuous ambulatory peritoneal dialysis (CAPD) therapy. Methods. Seventeen patients on CAPD (11 men, 6 women; average age, 48.4 ± 2.8 years [mean ± SE]) were studied. The duration of CAPD ranged from 1 to 42 months (21.7 ± 3.8 months [mean ± SE]). Urea nitrogen, creatinine, transferrin, and IgG in both serum and CAPD waste fluid were measured, and dialysate/plasma (D/P) ratios for these substances were determined. To evaluate changes in the large pores, in the peritoneal membrane, the peritoneal selectivity index (PSI) was calculated in the same manner as the urinary protein selectivity index is determined; namely, as the ratio of IgG clearance to transferrin clearance into CAPD waste fluid. Results. There was no significant correlation among the D/P ratios for urea nitrogen, creatinine, transferrin, IgG, and the duration of CAPD therapy. However, the PSI showed low-grade selectivity in patients on relatively shorter periods of CAPD therapy, and high-grade selectivity in patients with longer periods of CAPD therapy. There was a significant inverse correlation between the PSI (Y) and the duration of CAPD therapy (X) (Y = −0.007X + 0.75; r = 0.75, P < 0.05). We performed a prospective study after 12 months, and 8 patients were available to measure PSI again, and almost all patients showed a decrease in the PSI (−22.8 ± 0.8%; P < 0.02). In addition, we carried out morphological evaluation of the peritoneum in 13 patients who stopped CAPD. There was a significant difference in PSI value between those with and without peritoneal fibrotic change, while there was no significant difference in PSI values for those with and without mesothelial damage or with and without arteriolar sclerosis. Conclusions. From these results, we hypothesize that reduction in the PSI may reflect the shrinkage of large peritoneal pores and the presence of peritoneal fibrotic change in CAPD patients. Received: January 9, 2001 / Accepted: July 30, 2001     

Characterization of the Pro-Thrombotic State in CAPD Patients

Purpose. To investigate whether a chronic pro-thrombotic tendency, which may contribute to a high rate of atherothrombotic disease, is present in patients treated for continuous peritoneal dialysis (CAPD), and, if so, what its pattern is. We investigated this issue by jointly exploring all the systems involved, the coagulation and fibrinolytic systems and platelets. Methods. Markers of coagulation activation, markers of fibrinolysis activation, and standard fibrinolytic parameters and platelet aggregation induced by different agents were measured in 15 patients treated by CAPD and in 15 matched, healthy controls. All CAPD patients received erythropoietin, were in the stable condition, and did not have acute disease or malignancy. Results. CAPD patients had substantially (p < 0.001) increased levels of prothrombin fragments F1+2, disclosing a low-grade activation of the coagulation system. D-dimer was also significantly (p < 0.05) increased, whereas the levels of t-PA antigen and activity, PAI antigen and activity, and plasminogen were comparable to controls, suggesting that slight secondary (and not primary) activation of fibrinolysis due to coagulation activation took place. Patients had significantly (p < 0.05) elevated levels of fibrinogen. A study of platelet aggregation (induced by adenosine diphosphate, collagen, and epinephrine) did not show platelet hyperactivity in patients. Conclusions. We found that a pro-thrombotic tendency is present in the plasma of CAPD patients. The main reason for a pro-thrombotic state is chronic low-grade activation of the coagulation system and elevated levels of fibrinogen. The fibrinolytic system and platelets seemingly do not contribute to this pro-thrombotic tendency.     

Long-Term Outcome of Continuous Ambulatory Peritoneal Dialysis (CAPD) Peritonitis: Surgery can be Avoided

INTRODUCTION

Continuous ambulatory peritoneal dialysis (CAPD) has become the preferred method of home dialysis for patients with end-stage renal failure. Peritonitis is a common and serious complication and requires prompt diagnosis and treatment. The aim of this study was to assess what proportion of patients with CAPD peritonitis that required surgical intervention for on-going sepsis or for peritonitis-related bowel obstruction.

PATIENTS AND METHODS

All patients presenting with a first episode of CAPD peritonitis during the 5-year period from 1994–1998 were identified from a prospectively maintained database. Data collected included patient demographics, details of peritonitis episodes and their treatment, and details of any surgical intervention undertaken.

RESULTS

A total of 500 episodes were identified in 168 patients of whom 162 had complete follow-up representing 488 peritonitis episodes. Sixty-three patients experienced one episode of peritonitis, 33 two episodes, 20 had three episodes, and 46 had more than three episodes. None of the patients underwent surgery either primarily or for complications of the infective episode. A total of 465 episodes were due to a single organism (95%) and the remainder were due to multiple organisms (5%). The most common causative organisms were Gram-positive cocci (308 episodes; 71%) followed by Gram-negative bacilli (106 episodes; 24%). In 55 patients (34%), the same organism was implicated in consecutive admissions. Patients with autosomal dominant polycystic kidney disease (ADPKD), whilst accounting for 12 of 169 (7%) patients in the cohort, experienced 23 of 125 (18.4%) episodes of peritonitis by Gram-negative cocci. Such infections were seen in 8 of 12 (66.7%) ADPKD patients and accounted for 23 of 40 (57.5%) infections experienced by the ADPKD patients.

CONCLUSIONS

Whilst CAPD peritonitis is a common problem in the renal failure population, with almost 100 episodes per year, it would appear that most episodes can be managed using intraperitoneal antibiotics without the need for surgical intervention.     

The estimation of protein equivalents of total nitrogen in Chinese CAPD patients: an explanatory study

ObjectiveThe protein equivalent of total nitrogen appearance (PNA) formula, based on the urea nitrogen appearance (UNA), is popularly used by stable continuous ambulatory peritoneal dialysis (CAPD) patients to estimate dietary daily protein intake (DPI). However, we found that the estimated DPI was higher than that directly evaluated from the dietary records of most of our CAPD patients. Therefore, in the present study, we tried to determine possible bias in PNA estimation by UNA with a nitrogen balance study of our CAPD patients.MethodsThirty-one CAPD patients with stable clinical conditions were included. Their 3-day dietary records were reviewed by a dedicated dietitian to calculate their energy, protein, and nitrogen intake (NI). The nitrogen removal (NR) from urine and dialysate was measured by the Kjeldahl technique. Then, we calculated the proportion of urea nitrogen appearance (UNA) in total nitrogen appearance (TNA) and analyzed the possible factors that could affect this proportion.ResultsAmong these patients, 17 males and 14 females, the mean age was 64.19 ± 12.42, and the dialysate drainage volume was 6700 (2540) ml/day. The percentage of UNA in TNA was 63.22 ± 6.66%. Compared with the other classic nitrogen balance studies in the CAPD population, the protein nitrogen and other nonurea nitrogen losses in this study were all lower. Based on these 31 nitrogen balance studies, we proposed a pair of new equations to estimate PNA by UNA. (1) PNA = 9.3 + 7.73 UNA; (2) PNA = PNPNA + TPL = 6.7 + 7.28 UNA + TPL.ConclusionOur study suggested that the PNA formula generated from previous European studies overestimated DPI in our CAPD patients.     

Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis

Hyperprolactinemia is common in patients with renal failure. Because radiographic contrast material given during a computed tomographic (CT) scan of the sella as part of the evaluation for prolactinoma worsens renal insufficiency, we attempted to define the point at which hyperprolactinemia becomes an expected finding in patients with renal insufficiency in this study. Of 59 patients with serum creatinine levels of 1.5 to 12 mg/dL, 16 (27.1%) were hyperprolactinemic. Of these 16, nine were not taking medications known to raise prolactin levels and their prolactin levels were less than 100 ng/mL. In the eight patients taking medications prolactin levels were much higher. In one patient the prolactin level fell from 2,210 to 100 ng/mL when methyldopa was discontinued. In patients with chronic renal failure prolactin levels were similar regardless of the method of dialysis. We conclude that in the absence of medications known to affect prolactin secretion, hyperprolactinemia occurs infrequently (18.3%) and, when it occurs, is mild (less than 100 ng/mL). Marked hyperprolactinemia may occur in patients taking such medications. These should be stopped and the prolactin level rechecked before a CT scan is performed.     

Predictive value of dialysis adequacy and nutritional indices for mortality and morbidity in CAPD and HD patients. A longitudinal study

BACKGROUND: The effects of dialysis inadequacy on patient survival and nutritionalstatus and that of malnutrition on survival have not been clearlyassessed. Studies comparing dose/mortality and morbidity curveson continuous ambulatory peritoneal dialysis (CAPD) and on haemodialysis(HD) are also needed, to assess adequate treatment on CAPD. METHODS: We have evaluated the effects of age, 13 pretreatment risk factors,serum albumin, transferrin, normalized protein catabolic rate,Kt/V, normalized weekly creatinine clearance, residual renalfunction and subjective global assessment of nutritional statuson survival and morbidity, in a 3-year prospective study of68 CAPD and 34 HD patients. RESULTS: Survivals did not differ for CAPD and HD patients. In the Coxhazard regression model, age, peripheral vasculopathy, serumalbumin <3.5 g/dl and Kt/V < 1.0/treatment on HD and <1.7/weekon CAPD were independent factors negatively affecting survival.On the contrary, adjusted survivals were not affected by gender,modality, other comorbid factors, normalized protein catabolicrate, or subjective global assessment of nutritional status.Persistence of residual renal function significantly improvedsurvival. Observed and adjusted survival did not significantlydiffer for CAPD and HD patients with either low (HD, <1.0/treatment;CAPD, < 1.7/week) or high ( 1.0 and 1.7) Kt/V. On HD, adjustedsurvivals were similar for 1.0 Kt/V < 1.2 or 1.2. On CAPD,Kt/V 1.96/week was associated with definitely better survival,with only one death/23 patients versus 19/45, with Kt/V 1.96.Survival was not different for 1.96 Kt/V < 2.03 and 2.03.Normalized weekly creatinine clearance and wKt/V were positivelyrelated on CAPD (r 0.39, P<0.01) and wKt/V=1.96 correspondedto 58 litres of normalized weekly creatinine clearance. CONCLUSION: Indices of adequacy were predictors of mortality and morbidity,both on CAPD and HD, whereas normalized protein catabolic rateand subjective global assessment of nutritional status werenot. Serum albumin did not decrease during dialysis; hence itspredictive effect for survival is due to the predialysis conditionand not to dialysis-induced malnutrition.     

Diurnal blood-pressure variations in haemodialysis and CAPD patients

The influence of variations in fluid state on diurnal bloodpressure was studied by measuring day-time and night-time bloodpressure during a 3-day interdialytic period in 10 normotensiveand 10 hypertensive haemodialysis patients using Spacelab 90207Monitors. Ambulatory blood pressure was also measured during24 h in 11 normotensive and nine hypertensive CAPD patients,and in nine normotensive and 11 hypertensive control patientswith a normal renal function. Antihypertensive drugs had beendiscontinued for at least 3 weeks before the study period. Optimaldry weight in the haemodialysis patients was estimated by echographyof the inferior vena cava and in the CAPD patients on clinicalgrounds. Although in the dialysis patients and controls a significantnocturnal blood pressure reduction was found, day-night bloodpressure difference in the dialysis patients was blunted whencompared with the control patients. No significant differencesin diurnal blood pressure variation was found between the normotensiveand the hypertensive patients. Day-night blood pressure differencesin the haemodialysis patients did not change during the 3-dayinterdialytic period. Also the more stable fluid state of theCAPD patients was not associated with significant differentdiurnal blood pressure variation compared to the haemodialysispatients. We conclude that factors other than changes in extracellularfluid volume are responsible for a blunted day-night differencein blood pressure in dialysis patients.     

Automated vs continuous ambulatory peritoneal dialysis: a systematic review of randomized controlled trials.

BACKGROUND: A systematic review of randomized controlled trials (RCTs) comparing continuous ambulatory peritoneal dialysis (CAPD) with all forms of automated peritoneal dialysis (APD) was performed to assess their comparative clinical effectiveness. METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL, were searched for relevant RCTs. Analysis was by a random effects model and results expressed as relative risk (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI). RESULTS: Three trials (139 patients) were identified. APD when compared to CAPD was found to have significantly lower peritonitis rates (two trials, 107 patients, rate ratio 0.54, 95% CI 0.35-0.83) and hospitalization rates (one trial, 82 patients, rate ratio 0.60, 95% CI 0.39-0.93) but not exit-site infection rates (two trials, 107 patients, rate ratio 1.00, 95% CI 0.56-1.76). However no differences were detected between APD and CAPD in respect to risk of mortality (RR 1.49, 95% CI 0.51-4.37), peritonitis (RR 0.75, 95% CI 0.50-1.11), switching from the original peritoneal dialysis (PD) modality to a different dialysis modality including an alternative form of PD (RR 0.50, 95% CI 0.25-1.02), PD catheter removal (RR 0.64, 95% CI 0.27-1.48) and hospital admissions (RR 0.96, 95% CI 0.43-2.17). Patients on APD were found to have significantly more time for work, family and social activities. CONCLUSIONS: APD appears to be more beneficial than CAPD, in terms of reducing peritonitis rates and with respect to certain social issues that impact on patients' quality of life. Further, adequately powered trials are required to confirm the benefits for APD found in this review and detect differences with respect to other clinically important outcomes that may have been missed by the trials included in this review due to their small size and short follow-up periods.     

The Comparison in Terms of Early Complications of a New Technique and Percutaneous Method for the Placement of CAPD Catheters

Background. Starting continuous ambulatory peritoneal dialysis (CAPD) immediately after insertion of a peritoneal dialysis catheter is essential in end-stage renal disease (ESRD). In relation to the insertion methods, various mechanical and infectious complications may arise. In this study, we aimed to compare early complications of the laparoscopic tunneling method of CAPD placement that we developed recently in order to minimize the complications, with those of the conventional percutaneous method. Subjects and method. Included in this study were 12 consecutive patients with ESRD to whom we introduced catheters for CAPD by way of laparoscopic tunneling between April 2003 and July 2003 and followed up for at least 6 months, and 30 patients to whom the catheters were placed percutaneously in the same time period with the same follow-up time. The complications seen during the first 6 months after catheter placement with these two different methods were compared. Results. In all of the subjects, dialysis was started soon after catheter placement. No per-operative morbidity was seen in any of the patients. While with laparoscopic tunneling method no mechanical problem was seen, the percutaneous method resulted in early leakage in 10%, pericatheter bleeding in 3.3%, and hernia in 3.3% of the patients. As infectious complications, peritonitis occurred as one episode/36 patient-months in laparoscopic tunneling and one episode/22.5 patient-months in percutaneous method; catheter insertion site infection was seen in none in the laparoscopic method, while one episode/90patient-months was seen with the percutaneous method. Tunnel infection did not arise in any of the subjects. Conclusion. The authors of this study think that the peritoneal tunneling method for introducing CAPD, which has been recently developed and began to be routinely used by them, is rather safe in terms of early complications.     

Peritoneal-mediastinal leakage complication of peritoneal dialysis

The authors report a case of mediastinal fluid collection resulting from peritoneal-mediastinal communication after continuous ambulatory peritoneal dialysis (CAPD). To the best of the authors’ knowledge, this is the first reported case in the medical literature. A dry cough developed in the patient who had been receiving CAPD for 4 years. A mediastinal mass owing to peritoneal leakage of dialysate to the mediastinum was confirmed by a computed tomography scan taken 4 hours after the intraperitoneal infusion of contrast-mixed dialysate. The leakage persisted for 12 weeks after the discontinuation of CAPD fluid instillation.     

Low-density lipoprotein subfraction profiles in dialysis patients

Summary: Uraemic dyslipidaemia is a major risk factor for cardiovascular disease in end-stage renal failure patients. In patients without renal failure, high levels and qualitative abnormalities of low-density lipoprotein (LDL) are known to be atherogenic. Recently, LDL subfraction analysis has associated premature coronary artery disease with a high prevalence of small, dense LDL particles characterizing the LDL subclass phenotype B. We therefore examined the lipid profiles, LDL subfraction distribution and phenotypes in our population of haemodialysis (HD; n = 30) and peritoneal dialysis patients (PD; n = 17), and compared them to 40 asymptomatic, non-uraemic volunteers. Dialysis patients had significantly higher triglyceride and VLDL cholesterol concentrations and lower HDL cholesterol and smaller LDL peak particle diameters. PD patients had significantly higher total cholesterol, glycated haemoglobin and fasting blood glucose levels with smaller LDL peak particle diameters (24.4 [0.1] vs 24.8 [0.1 nm] than HD. Both groups showed significant negative correlations between plasma triglyceride and LDL peak particle diameter, and positive correlations between HDL cholesterol and LDL peak particle diameter. All the PD patients expressed the B phenotype (LDL peak diameter ± 25.5 nm) compared to 73% of HD patients. This study demonstrates that HD and especially PD patients have atherogenic lipid profiles which are associated with a predominance of small dense LDL particles and the highly atherogenic LDL subclass phenotype B.     

CAPD的内分泌激素与rHuEPO疗效的相关性

目的：探讨在连续性非卧床腹膜透析(CAPD)干预治疗下慢性肾衰竭尿毒症内分泌激素与人类重组促红细胞生成素(rHuEPO)疗效的关系。方法：对经CAPD治疗的慢性肾衰竭尿毒症患内分泌激素等多重因素及血红蛋白进行多元回归分析。结果：非CAPD组贫血改善程度显低于CAPD组，内生肌酐清除率、甲状旁腺素、甲状腺激素、血皮质酵及透析治疗均与Hb显相关。结论：单用rHuEPO对改善肾衰竭尿毒症的贫血状态存在较大的局限，主要和包括PTH等在内的尿毒症红细胞生长抑制因子(inhibitors of erythropoiesis，IE)有关。rHuEPO配合CAPD是清除IE、改善贫血状态、提高生活质量的很好的组合治疗方法。     

Culture-negative peritoneal dialysis peritonitis associated with pancreaticoduodenocystotomy leak of a pancreas transplant

Background:Peritoneal dialysis (PD) peritonitis is usually caused by infection and less commonly by a sterile inflammatory reaction.Methods:The authors report the case of a kidney-pancreas transplant recipient who was receiving PD after kidney transplant rejection 5 years after transplantation. The patient had a viable pancreas transplant. He had abdominal pain associated with cloudy PD effluent. The PD leukocyte count was elevated with a predominance of monocytic leukocytes.Results:Blood, urine, and PD effluent cultures were negative. An ultrasound scan of the transplanted kidney and a computerized tomography (CT) scan of the abdomen and pelvis did not identify the cause of the peritonitis. Foley catheter decompression of the bladder resulted in improvement of the abdominal pain and PD effluent leukocytosis. Twenty-five days later, the patient again experienced abdominal pain and cloudy PD effluent. Cultures of blood and PD effluent were again negative. CT scanning and cystoscopy of the transplanted pancreas identified a leak at the pancreaticoduodenocystotomy anastamosis. Urinary bladder decompression was followed by surgical exploration that identified an erosion of the distal transplanted duodenum, necessitating enteric diversion of the transplanted pancreas's exocrine secretions. The patient underwent conversion to hemodialysis, and the pancreas transplant continued to function well. He has subsequently received a living related kidney transplant.Conclusion:This is the first reported case of noninfectious PD peritonitis caused by pancreaticoduodenocystotomy leak in a patient with a functional pancreas transplant.     

A randomized prospective comparison of oral versus intraperitoneal ofloxacin as the primary treatment of CAPD peritonitis

Summary: Oral ofloxacin has been successfully used in our centres for the primary treatment of peritonitis complicating continous ambulatory peritoneal dialysis (CAPD). In view of the progressive rise in the resistance rate to ofloxacin among peritoneal bacterial isolates, a study was conducted to determine if oral ofloxacin remains a viable first line treatment for CAPD peritonitis in our centres and if the result can be improved by changing from an oral to an intraperitoneal (i.p.) route. In patients on three 2 L daily CAPD exchanges, ofloxacin given at the i.p. dosage of 200 mg loading followed by 25 mg/L of peritoneal dialysate achieved overnight trough peritoneal levels which are at least four times the minimal 90% inhibitory concentration (MIC90) of most bacterial pathogens without significant accumulation in the systemic circulation. This i.p. dosage was therefore chosen for the clinical study and the result was compared to that using ofloxacin given in the oral dosage of 400 mg loading followed by 300 mg once daily as maintenance. of all the recruited episodes, 35 were eligible for analysis. the overall primary cure rate including primary failures and relapses was 55.6% (10/18) in the oral treatment group and 70.6% (12/17) in the i.p. treatment group. the corresponding figures for gram positive bacterial (g +) infections were 36.4% and 50%, for gram negative bacterial (g -) infections were 66.7 and 80% and for culture negative infections were 75 and 80%. In culture positive cases, all treatment failures were due to resistant infections which were observed in 42.3% of all bacterial isolates, 47.1% of g + isolates and 33.3% of g - isolates. Due to the high background level of bacterial resistance among our CAPD population, ofloxacin monotherapy given either by the oral or the i.p. route can no longer be recommended for the primary treatment of CAPD peritonitis.     

Pyridinium crosslinks in patients on haemodialysis and continuous ambulatory peritoneal dialysis

BACKGROUND: The urine excretion of the pyridinium crosslinks of collagen,pyridinoline (PYD) and deoxypyridinoline (DPD) closely reflectbone resorption and their assay has been used as specific markersof mature collagen turnover. The aims of this study were toevaluate the use of these markers to predict the severity ofosteodystrophy in patients with chronic renal failure. METHODS: Using an isocratic ion-paired reverse-phase high-performanceliquid chromatography, PYD and DPD were determined in the serum,urine and dialysate of 48 patients with chronic renal failureundergoing haemodialysis (n=28) or continuous ambulatory peritonealdialysis (n=20). Nineteen apparently healthy subjects were studiedas controls. RESULTS: In all groups, serum and urine crosslinks excretion showed poorcorrelation with age. In the patients urine PYD/creatinine andDPD/creatinine were significantly (P0.03 and 0.001 respectively)higher than normal; urine PYD and DPD levels were highly correlatedwith each other (r=0.98) and with serum PTH (r=0.84 and 0.83respectively). The mean (SD) predialysis serum PYD, 269 (334)nmol/l, was significantly (P0.003) elevated compared with normalpatients, 4.1 (0.6) and pre-dialysis serum DPD was 82.9 (93.7)nmol/l. DPD was below the detection limit of the assay in normalsera. In the patients postdialysis decreases in serum PYD andDPD were statistically significant (P<0.0002 and P<0.0007respectively). PYD and DPD were found in the dialysate of patientson haemodialysis as well as 24-h dialysate in patients on CAPD.Dialysate PYD and DPD were highly correlated with each other(r=0.80) and with dialysate creatinine (r=0.76 and r=0.62 respectively).In the patients, the mean serum, urine and dialysate PYD andDPD increased with the duration on dialysis. These findingsconfirm that metabolic bone disease increases in patients withduration of chronic renal failure. CONCLUSION: Estimation of serum crosslinks levels has potential as an additionaltool in the diagnosis and monitoring of renal osteodystrophy.The ability to determine crosslink levels in serum and dialysateshould be particularly useful in patients who are unable toproduce urine.     

Ten years experience of CAPD in diabetics: comparison of results with non-diabetics

CAPD outcomes were compared between a group of 301 diabeticpatients (mean age±SD, 58.9±12.7 years, 55.8%males) and a group of 1689 non-diabetic patients (mean age±SD57.8±14.8 years, 55.9% males) treated in 30 centres participatingin the Italian Cooperative Peritoneal Dialysis Study Group from1980 to 1989, with follow-up observation periods of 444 years(mean±SD, 1.48± 1.24) and of 3502 years (mean±SD,2.07± 1.91) respectively. CAPD was the first modality for 87.2% of diabetics and 78.1%of non-diabetics (P<<0.001). The percentage of patientswho needed a partner for CAPD was 45.9% in diabetics and 30.2%in non-diabetics (P<0.00l). In diabetics compared with non-diabetics, cardiovas cular diseasesand cachexia were nearly twice and infections other than peritonitismore than three times as frequent in causing death. In diabetics,survival was significantly worse (P<0.0001) and the relativerisk of death 2.13 times higher (P<0.001). The technique survival and the relative risk of drop out werenot significantly different in the two groups. Clinical problemswere the most important cause of drop-out among diabetics. Theprobability and relative risk of drop-out due to peritonitis,as well as of the first peritonitis episode, were not significantlydifferent between the two groups and between diabetics usingor not using intraperitoneal insulin. Days per patient year of hospitalization, excluding the first,were 18.4 in diabetics and 14.3 in non diabetics. CAPD-relatedproblems caused hospitalization in a similar way in the twogroups. In conclusion, compared to non-diabetics on CAPD, diabeticson the same treatment showed more clinical problems that accountfor a higher need of partner, death, and hospitalization andare the first reason for technique failure; on the other hand,problems closely related to the CAPD technique seem to occurwith the same frequency in the two groups.