Hepatitis C infection among dialysis patients: a comparison between patients on maintenance haemodialysis and continuous ambulatory peritoneal dialysis.

Three hundred and thirty-nine dialysis patients from two centres (278 patients on continuous ambulatory peritoneal dialysis (CAPD) and 61 on maintenance haemodialysis (HD) were tested for antibody against hepatitis C virus (anti-HCV) using first-generation enzyme immunoassay kits (Ortho Diagnostics). Anti-HCV was detected in five (1.8%) CAPD patients and ten (16.4%) HD patients (P less than 0.00001). Anti-HCV was confirmed to be positive in three (1.1%) CAPD patients and eight (13.2%) HD patients using neutralisation enzyme immunoassay kits (Abbott Laboratories). The marked difference in prevalence of anti-HCV among CAPD and HD patients was related to a significantly greater transfusion requirement of the HD patients. All the anti-HCV positive patients had been transfused. The risk of HCV infection was significantly increased in those who had received more than five units of blood. Four (26.7%) anti-HCV positive patients had one or more episodes of elevated serum alanine aminotransferase (ALT) values.     

Hepatitis G virus infection in haemodialysis and in peritoneal dialysis patients

The aim of this study was to detect hepatitis G virus RNA (HGV RNA) and antibodies against the virus envelope protein E2 (anti-E2) in 107 patients either on maintenance haemodialysis (n = 78) or peritoneal dialysis (n = 29) to evaluate the prevalence of HGV infection and to establish its role in liver disease. The total prevalence of HGV infection was of 15.4% among haemodialysis patients, whereas it was 10.3% among peritoneal dialysis patients. HGV RNA was detected in 2 haemodialysis patients (2.6%) and in 3 peritoneal dialysis patients (10.3%). Anti-E2 was found in 10 haemodialysis patients (7.8%), whilst all peritoneal dialysis patients resulted negative. In only 1 patient the alanine aminotransferase level was elevated. This patient underwent liver biopsy that did not reveal evidence of chronic hepatitis. The lower HGV prevalence in haemodialysis patients, when compared with data reported by other European authors, should be related to the lower rate of polytransfused patients in our series (29.5%). Multiple blood transfusions should be considered as the main factor to explain the different prevalence of HGV infection among various European dialysis centres. Detection of both antibody and viraemia is important to establish the real rate of the infection.     

Hepatitis B vaccination in dialysis patients and nutritional status.

35 dialysis patients underwent anti-HBV vaccination. We classified patients in responders or non-responders using an anti-HBs titer of 50 UI/l as the discriminating serum level and tried to assess whether the antibody response bears any relationship with the nutritional status. 26 patients (74%) reached the target atb titer, which was maintained during follow-up (average 360 UI/l). The weak response in the other 9, with values never exceeding 20 UI/l, was short-lived. Anthropometric and impedenziometric parameters were higher in responders than in nonresponders, but the difference did not reach statistical significance. We conclude that the atb titer which discriminates uremics in responders or not must be greater than 50 UI/l and that the nutritional status may interfere with the seroconversion rate, but this conclusion needs to be validated in a wider population.     

Hepatitis C virus antibodies in dialysis pediatric patients.

A new 4-antigen recombinant immunoblot assay (4-RIBA) for confirmation of hepatitis C virus (HCV) C-100 enzyme-linked immunosorbent assay (ELISA) reactivity was tested in serum samples of 11 pediatric patients on dialysis. Of 6 HCV C-100 ELISA-positive samples, all were 4-RIBA positive. The 2nd generation ELISA picked up 1 additional case confirmed by 4-RIBA. The 2nd generation tests increased the prevalence of HCV-positive cases.     

Hepatitis C virus infection in renal dialysis patients in Glasgow

A survey of all 483 adult dialysis patients in the three renalunits in Glasgow using second-generation ELISA was carried outto determine hepatitis C virus (HCV) seroprevalence in the summerof 1991 before the introduction of blood donor screening forantibody to HCV in the UK. Supplementary testing of ELISA positivesera was by second-generation immunoblot assay (RIBA-2, Chiron).Retrospective case note analysis and testing of stored serawere performed to assess liver function and the risk factorsfor acquisition of the virus. Nineteen of the 483 patients (3.9%)were seropositive. Sixteen patients had been transfused and12 had previous transplants. Seropositivity was associated withcurrent haemodia-lysis (P<0.01) rather than continuous ambulatoryperitoneal dialysis (CAPD). Of those on haemodialysis, the timesince first dialysis was longer for seropositives (13.6 years)than for seronegatives (6.3 years) (P<0.01) but this didnot apply to those on CAPD. Twelve of 19 (63.2%) seropositiveshad persistent elevations of alanine transferase compared toseven of 38 (18%) seronegative controls (P<0.01). This large group of dialysis patients is at special risk ofHCV infection but the seroprevalence is less than that reportedfrom outside the UK despite the use of more sensitive techniques.The risk is associated with haemodialysis and is probably largelydue to blood transfusion. The introduction of screening of donatedblood for HCV antibody should reduce the incidence of new infectionin dialysis patients.     

Carnitine supplementation improves apolipoprotein B levels in pediatric peritoneal dialysis patients

There have been conflicting reports concerning the effect of carnitine supplementation on lipid metabolism in patients on peritoneal dialysis (PD). We investigated several parameters of lipid metabolism in pediatric PD patients supplemented with carnitine. The study included 20 patients receiving PD (treatment group) aged 2–18 years and a matched healthy control group. In the treatment group, baseline triglyceride, total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, and apolipoprotein B levels were higher than in the control group. High-density lipoprotein cholesterol, free fatty acid, phospholipids, and apolipoprotein A-I levels were not different from those in the control group. The baseline plasma free carnitine level was lower and acyl-carnitine level was higher in the treatment group. No difference was found between the groups with respect to plasma total carnitine levels. Oral l-carnitine supplementation (50 mg/kg per day for 30 days) led to a significant decrease (from a baseline value of 146.6±51.8 mg/dl to 63.6±22.2 mg/dl, P<0.001) in apolipoprotein B levels, and no significant change in the other lipid parameters of the treatment group. Oral l-carnitine supplementation does not ameliorate the lipid profile in pediatric PD patients, but it causes a significant decrease in apolipoprotein B levels. Hence, carnitine supplementation may be recommended for decreasing apolipoprotein B levels in this patient population.     

Hyponatremia in peritoneal dialysis patients

BACKGROUND: Low serum sodium is uncommon in peritoneal dialysis (PD), which is surprising in view of the important role of normal kidney function to regulate water and sodium balance. METHODS: We report 2 cases of persistent hyponatremia with balance studies in Case 1. We performed measurements of dialysate sodium and volume output over 24 hours in a group of chronic PD patients. RESULTS: The low serum sodium concentration did not vary too much with overall fluid removal via dialysis in patient 1, mainly because large quantities of sodium were removed in the dialysate. In the 24-hour studies, a significant relationship was found between net daily PD sodium removal and net daily dialysate volume removed (r = 0.65). There was no relationship between net daily PD sodium removal and serum sodium concentration. There was a linear direct correlation between serum and dialysate sodium concentration (r = 0.8) as shown by others previously. CONCLUSIONS: These results suggest that the main determinant of PD sodium loss is net dialysate ultrafiltration volume. Water loss via dialysis is necessarily associated with sodium loss. In order to maintain a normal serum sodium concentration salt intake must be proportional to the water loss induced by dialysis. The stimuli that allow dialysis patients to maintain this delicate balance between water and salt intake are of considerable interest but remain undetermined.     

Vitamin B6 requirements of patients on chronic peritoneal dialysis

Patients with chronic renal failure often develop vitamin B6 deficiency, which is of clinical concern because the multiorgan system manifestations are similar to those of uremia. Vitamin B6 deficiency in hemodialysis patients has been previously studied, but the need for daily pyridoxine supplementation in patients on chronic peritoneal dialysis (CPD) remains unclear. Therefore, we studied a group of 11 stable patients, nine on CAPD and two CCPD, to test for vitamin B6 deficiency and to establish daily requirements. Adequacy of vitamin B6 nutrition was assessed by measurement of plasma and dialysate effluent total vitamin B6 and pyridoxal 5'-phosphate (PLP), the latter using a very sensitive modification of the tyrosine apodecarboxylase enzyme assay. After four weeks without vitamin B6 supplements on a diet containing 1.3 +/- 0.2 mg vitamin B6/day (7.7 +/- 1.2 mumol/day), all patients had subnormal plasma PLP levels, 16 +/- 3 nmol/liter (nml 40 to 60), seven having a severe deficiency (less than or equal to 20 nmol/liter). Plasma total vitamin B6 levels (which includes non-PLP forms of the vitamin) were normal in all patients at baseline, 116 +/- 29 nmol/liter. Peritoneal losses were small, 8 +/- 2 nmol PLP/day and 545 +/- 61 nmol total vitamin B6/day. Supplementation with 5 mg/day oral pyrodoxine HCl for up to 16 weeks adequately repleted eight patients (65 +/- 7 nmol PLP/L), while three patients required 10 mg/day to achieve normal plasma PLP levels. During three episodes of peritonitis, dialysate losses of PLP did not increase.(ABSTRACT TRUNCATED AT 250 WORDS)     

Encapsulating peritoneal sclerosis in paediatric peritoneal dialysis patients

Encapsulating peritoneal sclerosis (EPS) is a serious complication of chronic peritoneal dialysis (CPD). In contrast to the adult population, there are few studies regarding EPS in paediatric CPD patients, and the majority of reported patients are from Japan. The aim of the present report is to define the incidence of EPS in our paediatric CPD patients and to describe the clinical and laboratory characteristics. A total of 104 paediatric patients were followed from November 1989 to November 2003 and two were diagnosed as EPS (1.9%). The dialysis periods of these patients were 45 and 53 months with 6 and 8 peritonitis episodes, respectively. Clinical signs of EPS developed 7 and 14 days after the removal of the dialysis catheter, and CPD was replaced by haemodialysis because of persistent peritonitis. One patient was well after surgical management but died 6 months later. The second patient who was treated with prednisolone remained well at 16 months. In conclusion, EPS is a rare but important complication of CPD. We recommend that all patients on CPD who develop ultrafiltration failure be evaluated radiologically for the occurrence of EPS. Management should be tailored to the individual patient.     

Dialysate copeptin and peritoneal transport in incident peritoneal dialysis patients

International Urology and Nephrology - Systemic and intraperitoneal inflammation are characteristic features of patients with end-stage renal disease undergoing chronic peritoneal dialysis (PD)....     

Malnutrition and inflammation in peritoneal dialysis patients

BACKGROUND: Malnutrition, cardiovascular disease, and heightened inflammation are highly prevalent in dialysis patients, and major contributors to morbidity and mortality. We have investigated the inter-relationship between malnutrition and inflammation, and their impact on morbidity and mortality in peritoneal dialysis (PD) patients. METHOD: We enrolled 63 PD patients beginning in November 2000, and measured C-reactive protein (CRP) and various nutritional markers, including prealbumin. RESULTS: CRP level was elevated in 29% of the PD patients. Diabetics had higher CRP than non-diabetics (24 vs. 9.3 mg/L, P = 0.016). Patients who were hospitalized during the study had higher enrollment CRP (16 vs. 12.5 mg/L, P = 0.05) and lower enrollment albumin (3.5 vs. 3.9 g/dL, P = 0.002), blood urea nitrogen (BUN) (40 vs. 49 mg/dL, P = 0.034), and protein catabolic rate (nPCR) (0.88 vs. 1.0 g/kg/day, P = 0.02) than those who were not hospitalized. Enrollment level of CRP was inversely correlated with nutritional markers prealbumin (r = -0.5, P < 0.0001) and creatinine (r =-0.35, P < 0.01). After adjusting for age, race, gender, diabetes, and CRP level, prealbumin continued to correlate with other nutritional markers. There was a trend toward association of elevated CRP with all-cause mortality in PD patients. CONCLUSION: It is useful to incorporate prealbumin and CRP in the regular assessment of PD patients, whose survival may be improved by better management of malnutrition and inflammation.     

Effects of seasonal changes on peritoneal dialysis associated peritonitis in peritoneal dialysis patients

Objectives To investigate the effects of seasonal changes on peritoneal dialysis associated peritonitis (PDAP) in patients on peritoneal dialysis (PD), and to provide evidence for clinical prevention and treatment of PDAP. Methods All episodes of PD-related peritonitis during clinic follow-up in maintenance PD patients from Jan 1st, 2007 to Dec 31st, 2015 in Peking University People's Hospital were reviewed. The incidence of peritonitis, laboratory indexes, pathogens and clinical outcomes in different seasons were recorded and analyzed. One-way ANOVA and chi square test were employed to compare the incidence of PDAP and related data in different seasons, and Pearson correlation was used to analyze correlations between PDAP rate and monthly mean temperature and mean humidity. Results During nine years, a total of 119 PD patients occurred 190 times of peritonitis during home PD. The PDAP rate in summer was the highest, 0.21 episodes/year, followed by spring (0.16 episodes/year) and autumn (0.16 episodes/risk year), but there was no significant difference among peritonitis rates in four seasons. There were significant positive correlation between monthly mean temperature, monthly mean humidity and the peritonitis rate (mean temperature: r=0.828, P＜0.01; mean humidity r=0.657, P＜0.05). (2) As for bacteria, in Summer the PDAP rate caused by Staphylococcus aureus and Coagulase negative staphylococcus (CoNS), and Gram-negative bacteria was higher than that in other seasons, but there was no statistical difference. There were significant positive correlation between monthly mean temperature, mean humidity and the rate of CoNS peritonitis (mean temperature: r=0.704, P＜0.05; mean humidity: r=0.607, P＜0.05). (3) There were no statistical difference among results of PD related peritonitis in different seasons about general situation, clinical manifestation, causes of peritonitis and laboratory index before peritonitis episodes. PD procedure-related problems were the main cause of peritonitis in summer and autumn. (4) The cure rate of all peritonitis was 90%. The highest cure rate was in autumn and winter, while the lowest cure rate was in summer, but no statistical difference. Among the peritonitis episodes with treatment failure, 52.6% occurred in summer. Conclusions There is some correlation between the rate of PDAP and seasons. Higher temperature and higher humidity were significantly correlated with higher peritonitis rate, especially the rate of CoNS peritonitis. The prognosis of PDAP in summer was relatively poor, with higher proportion of hospitalization and lower cure rate.     

Pneumoperitoneum in peritoneal dialysis patients.

The prevalence and clinical significance of pneumoperitoneum in peritoneal dialysis (PD) patients is not fully defined in current literature and some reports suggest that unlike in non-PD patients, it is rarely caused by gastrointestinal perforation. We reviewed 403 chest X-ray films of the 118 PD patients following our PD program in 1995-96, in order to define the prevalence of pneumoperitoneum. We found pneumoperitoneum in 3.7% of the X-rays (15/403) from five patients (4.2%). Its causes might have been: faulty bag exchange technique in two cases and extension tube exchange in three. One patient suffered from a simultaneous episode of peritonitis. Our data and the literature review suggest that 0-11% of pneumoperitoneum episodes in PD patients are due to gastrointestinal perforation; the main causes generally are abdominal operations and catheter manipulation. The amount of air is not useful in assessing the cause of pneumoperitoneum, which takes some weeks to disappear. Computed tomography is more sensitive than standard X-ray in diagnosis.     

Fatigue in chronic peritoneal dialysis patients

Fatigue is a common complaint in long termdialysis patients that may influence theirquality of life. The present study was carriedout in order to evaluate the prevalence andcourse of fatigue in a group of chronic PDpatients and to find the possible factor(s)related to its development. We retrospectivelyreviewed 100 charts of the patients previouslyon PD. The presence or absence of fatigue inthe 1st and last clinic visits and the 1st and2nd changes in fatigue state were studiedaccording to the monthly clinical records ofthe primary nurses. Data regarding dialysatevolume, urine volume, weekly erythropoietin(EPO) dose, hemoglobin, hematocrit, blood urea,serum creatinine, residual renal creatinine andurea clearances, dialysate to peritonealcreatinine ratio (D/P Cr), total weekly Kt/Vand total creatinine clearance/l.73 m² bodysurface area (TCrCl) were collected. Fifty-fivepatients were male and 45 female. The mean ageat the 1st clinic visit was 61.3 ± 16 years.At the 1st visit 55 patients had fatigue and 45did not. In 32 of the 55 patients fatiguedisappeared after a mean duration of 7.9 ± 8.4months and in 31 of the 45 patients fatigueappeared after a mean duration of 8 ± 6.8months. So at the last visit the frequency offatigue increased significantly from 55% to67% (p < 0.001). In patients with fatigue themean age and female percentage were higher(64.2 ± 14.1 vs 57.8 ± 17.6, p = 0.05 and 1.2vs 0.5, p < 0.05 respectively), mean hemoglobinconcentration was lower (104.4 ± 14.7 vs110.6 ± 14.2 g/L, p < 0.04) and mean EPO dosewas higher (6379.6 ± 7142 vs 3395.4 ± 4337.8units/week, p < 0.02) at the 1st clinic visit.EPO dose was also higher in patients withfatigue at the last visit (8253.7 ± 10317.3units/wk vs 4736.4 ± 5432.5, p < 0.03). Nocorrelation was found between dialysis adequacyaccording to either weekly Kt/V or TCrCl andnutritional state according to nPCR andfrequency of fatigue. We conclude that fatigueis a common symptom in PD patients and it'sprevalence increases over time. Anemia seemsto be the most important factor associated withfatigue. Dialysis adequacy and nutritionalstate did not show any correlation with thefrequency of fatigue in our study.     

Protein-energy wasting and peritoneal function in elderly peritoneal dialysis patients

Background

Nutritional status is important in peritoneal dialysis (PD) patients. We aimed to compare the peritoneal transport (PT) characteristics and indicators of nutritional status in elderly and non-elderly PD patients.

Methods

One-hundred and four consecutive patients were divided into either the elderly (>65?years old; n?=?44) or the non-elderly (≤65?years old; n?=?60) group. PT was assessed via the peritoneal equilibration test, Kt/V (K dialyzer clearance of urea, t dialysis time, V volume of distribution of urea), total creatinine clearance (CrCl), and glomerular filtration rate. Subjective global assessment (SGA), serum albumin (ALB), hemoglobin, prealbumin (PA), transferrin (TF), fat-free edema-free body mass (fat-free edema-free BM), and normalized protein intake (nPNA) were determined, and were used to indicate nutritional status.

Results

Elderly PD patients had higher dialysate to plasma creatinine ratios (D/P Cr) and CrCl, but lower serum creatinine body weights, ALB, PA, TF, fat-free edema-free BM, SGA, and nPNA than the non-elderly group. Multivariate analysis indicated that, after adjusting for PD time, body weight, diabetes mellitus, age, and sex, SGA negatively correlated with D/P Cr, whereas after adjusting for PD time, diabetes mellitus, and sex, D/P Cr positively correlated with age in all patients.

Conclusions

Protein-energy wasting and a high PT are more common in elderly than non-elderly PD patients. Nutritional status should be carefully considered when prescribing the PD dose and frequency, especially in elderly patients.     

黄芪改善腹透患者腹腔巨噬细胞功能的临床研究

目的：研究黄芪对尿毒症患腹腔巨噬细胞功能的影响。方法：对43例尿毒症初始行腹膜透析的患在腹透液中不加（对照组）和加入黄芪注射液（用药组）治疗1周,用ELISA法检测观察前后腹腔巨噬细胞分泌TNF－a能力和吞噬功能的变化。结果：黄芪用药组腹腔巨噬细胞吞菌率、吞噬指数、杀菌率和巨噬细胞分泌TNF－a水平和对照组相比均明显上升（P＜0．01）,巨噬细胞分泌TNF－a水平与用药前自身对比也显提高（P＜0．05）。结论：腹透液中加入黄芪注射液可提高腹透患腹腔巨噬细胞功能。     

Phosphorus control in peritoneal dialysis patients

Hyperphosphatemia is independently associated with an increased risk of death among dialysis patients. In this study, we have assessed the status of phosphate control and its clinical and laboratory associations in a large international group of patients on chronic peritoneal dialysis (PD) treatment. This cross-sectional multicenter study was carried out in 24 centers in three different countries (Canada, Greece, and Turkey) among 530 PD patients (235 women, 295 men) with a mean+/-s.d. age of 55+/-16 years and mean duration of PD of 33+/-25 months. Serum calcium (Ca(2+)), ionized Ca(2+), phosphate, intact parathyroid hormone (iPTH), 25-hydroxy vitamin D(3), 1,25-dihydroxy vitamin D(3), total alkaline phosphatase, and bone alkaline phosphatase concentrations were investigated, along with adequacy parameters such as Kt/V, weekly creatinine clearance, and daily urine output. Mean Kt/V was 2.3+/-0.65, weekly creatinine clearance 78.5+/-76.6 l, and daily urine output 550+/-603 ml day(-1). Fifty-five percent of patients had a urine volume of <400 ml day(-1). Mean serum phosphorus level was 4.9+/-1.3 mg per 100 ml, serum Ca(2+) 9.4+/-1.07 mg per 100 ml, iPTH 267+/-356 pg ml(-1), ionized Ca(2+) 1.08+/-0.32 mg per 100 ml, calcium phosphorus (Ca x P) product 39+/-19 mg(2)dl(-2), 25(OH)D(3) 8.3+/-9.3 ng ml(-1), 1,25(OH)(2)D(3) 9.7+/-6.7 pg ml(-1), total alkaline phosphatase 170+/-178 U l(-1), and bone alkaline phosphatase 71+/-108 U l(-1). While 14% of patients were hypophosphatemic, with a serum phosphorus level lower than 3.5 mg per 100 ml, most patients (307 patients, 58%) had a serum phosphate level between 3.5 and 5.5 mg per 100 ml. Serum phosphorus level was 5.5 mg per 100 ml or greater in 28% (149) of patients. Serum Ca(2+) level was > or =9.5 mg per 100 ml in 250 patients (49%), between 8.5 and 9.5 mg per 100 ml in 214 patients (40%), and lower than 8.5 mg per 100 ml in 66 patients (12%). Ca x P product was >55 mg(2)dl(-2) in 136 patients (26%) and lower than 55 mg(2)dl(-2) in 394 patients (74%). Serum phosphorus levels were positively correlated with serum albumin (P<0.027) and iPTH (P=0.001), and negatively correlated with age (P<0.033). Serum phosphorus was also statistically different (P = 0.013) in the older age group (>65 years) compared to younger patients; mean levels were 5.1+/-1.4 and 4.5+/-1.1 mg per 100 ml, respectively, in the two groups. In our study, among 530 PD patients, accepted uremic-normal limits of serum phosphorus control was achieved in 58%, Ca x P in 73%, serum Ca(2+) in 53%, and iPTH levels in 24% of subjects. Our results show that chronic PD, when combined with dietary measures and use of phosphate binders, is associated with satisfactory serum phosphorus control in the majority of patients.     

Peritoneal sclerosis in peritoneal dialysis patients

Peritoneal sclerosis, a disorder similar to that previously identified in nonuremic patients, is being noted in peritoneal dialysis patients with increasing frequency. The etiology in dialysis patients remains unknown. An association with previous or ongoing peritoneal inflammation or irritation suggests that the incidence of peritoneal sclerosis could be reduced by rapidly controlling peritonitis and by eliminating the irritant properties of catheters, dialysate, and other materials used in performing peritoneal dialysis. If peritoneal sclerosis does supervene, weight loss, abdominal pain, and intestinal obstruction may occur and further peritoneal dialysis may become impossible because of abdominal pain or poor fluid and solute transfer.