A comparison of reported sleep disorders in patients on chronic hemodialysis and continuous peritoneal dialysis.

There are few data about the prevalence and characteristics of reported sleep disorders in chronic dialysis patients and, although insomnia is often used as a marker of uremia, there are few data relating complaints of sleep to adequacy of dialysis. We therefore surveyed 48 hemodialysis (HD) patients, 22 continuous peritoneal dialysis (PD) patients, and 41 healthy control subjects about disordered sleep. The questionnaire included demographic data, questions characterizing the reported sleep problems, and linear analogue scales quantitating the severity of the sleep disturbance and feelings of anxiety, worry, and sadness. Kt/V determinations were also made for each dialysis patient. Fifty-two percent of the HD, 50% of the PD, and 12% of the control subjects reported problems sleeping (P less than 0.001, all dialysis patients v controls). No differences between HD and PD in characteristics of sleep problems were seen. Sleep severity scale results confirmed sleep disorders (7.2 in those with v 0.95 in those without sleep disorders, where 0 = sleep a little problem and 10 = a big problem, P less than 0.001). Caffeine intake (P less than 0.05) and worry (P less than 0.004) were the only factors associated with reported sleep disturbances. Kt/V values (1.4 +/- 0.3) did not predict reported sleep problems. Mean reported hours of sleep per night (5.5 +/- 2 v 5.8 +/- 1.4) and desired hours of sleep per night (8.3 +/- 2 v 7.6 +/- 1.3) were similar among dialysis patients and controls reporting sleep problems. Dialysis patients and controls without self-reported sleep disorders slept a mean of 7.1 +/- 2.4 and 7 +/- 1.1 h/night, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Self-assessed quality of life in peritoneal dialysis patients.

BACKGROUND/AIMS: Studies comparing quality of life (QOL) between peritoneal and hemodialysis patients have yielded inconsistent results. Physical (PCS) and mental component summary (MCS) scales of Short Form 36 (SF-36) health survey are highly validated measures of self-assessed QOL. We sought to evaluate these indices in PD patients: (1) as measures of QOL, (2) predictors of QOL, (3) to study change in QOL over time, and (4) to compare QOL in PD vs. hemodialysis patients. METHODS: SF-36 questionnaires were administered every 3 months to patients over a 2-year period and PCS and MCS were calculated. Mean follow-up was 15.3 +/- 6.6 months for PD and 14.5 +/- 5.7 months for HD. RESULTS: Average PCS in PD (31.8 +/- 7.8) was lower than HD (36.9 +/- 9.8) (p < 0.02), while MCS was similar in the groups (p = NS). The prevalence of depression was 26.1% in PD and 25.4% in HD patients (p = NS). Serum albumin was the only significant predictor of PCS among PD patients and explained much of the decrease in PCS in them. The number of hospitalizations and in-hospital days were significantly lower for PD compared to HD patients (p < 0.05). PCS as well as MCS remained stable in both groups throughout the observation period. CONCLUSION: Self-assessed physical function is diminished, while mental function is similar in PD compared to HD patients. When corrected for serum albumin, this difference is eliminated. Over time, QOL in patients treated with PD remained stable.     

Hemorrhagic stroke in chronic dialysis patients

AIMS: This study was designed to retrospectively investigate the clinical profiles, disease course and management of hemorrhagic stroke in chronic dialysis patients. We emphasized on the factors affecting the prognosis. PATIENTS AND METHODS: We retrospectively studied (January 1991-June 1999) the chronic dialysis patients who were admitted to our facility with a diagnosis of acute hemorrhagic stroke. The medical results were reviewed in detail and the clinical characteristics, laboratory data and management records of each individual were collected for analysis. RESULTS: There were 16 patients analyzed in total, 9 males and 7 females. The average age was 59.4+/-13.3 years old. Before admission, 14 patients received chronic hemodialysis (HD) and two patients peritoneal dialysis (PD). The co-morbidities included hypertension (16/16), Diabetes Mellitus (DM) (9/16), previous cerebrovascular accidents (9/16) and hyperlipidemia (5/16). The locations of cerebral hemorrhage (CH) were: the putamen (6/16), brain stem (3/16), thalamus (3/16) and others (4/16). Among the 14 HD patients, 8 remained on HD after onset of CH, while 6 switched to PD. Those who received PD before their development of CH continued to perform PD. The overall mortality was 44% (7/16). One of the 8 patients who continued on HD died (mortality 12.5%). Among the 8 patients who received PD, 6 died (mortality 75%). Two patients who underwent surgical intervention also passed away. The major cause of death was neurological deterioration. The interval between the onset of CH and death was short (15+/-13 days, range 2-39 days). CONCLUSION: The overall prognosis of CH in the chronic dialysis population is poor. Patients with lower hemoglobin levels upon presentation and those performing PD after CH may have even worse prognosis.     

Brain natriuretic peptide and its relationship to left ventricular hypertrophy in patients on peritoneal dialysis or hemodialysis less than 3 years

An increase of brain natriuretic peptide (BNP) levels is commonly observed in patients on dialysis. Increased circulating levels of BNP are related to future cardiac events and associated with shorter survival in patients on chronic hemodialysis (HD). During the first 1 or 2 years on dialysis, patients on peritoneal dialysis (PD) have been shown to have an improvement in left ventricular hypertrophy, blood pressure, and volume status. This study compares BNP levels and cardiac status of PD and HD patients without cardiovascular disease and on dialysis for less than 36 months. The correlation between plasma BNP concentration and findings of echocardiography before HD scans were examined and compared with findings of PD. Twenty-two HD patients (15 men, 7 women; mean age, 52.5 +/- 13.9 years) and 19 PD patients (10 men, 9 women; mean age, 47.6 +/- 11.3 years) were studied. There were no significant differences between HD and PD patients with regard to age, gender, duration of dialysis, left ventricular mass, left ventricular mass index (p > 0.05). Plasma BNP levels were markedly greater in HD patients (467.8 +/- 466.5 pg/ mL) than those of PD patients (143.1 +/- 165.2 pg/mL). Urine output was significantly higher in PD patients compared with HD patients (p < 0.05). A positive correlation between systolic blood pressure, diastolic blood pressure, and plasma BNP in HD patients (r: 0.653, p: 0.001; r: 0.493, p: 0.023, respectively) was detected. Additional studies are needed to investigate whether lower BNP level in PD patients is an advantage.     

Timely transfer of peritoneal dialysis patients to hemodialysis improves survival rates

AIMS: The two main renal replacement therapies (RRT)--hemodialysis (HD) and peritoneal dialysis (PD)--have been considered to be antagonistic in most published studies on the clinical outcomes of dialysis patients. Recently, it has been suggested that the complementary use of both modalities as an integrated care (IC) strategy might improve the survival rate of end-stage renal disease patients. The aim of this study was to estimate the final clinical outcome of PD patients when they transfer to HD because of complications related to PD. MATERIALS AND METHODS: We retrospectively analyzed data from the following patients that started RRT during the last 10 years: 33 PD patients (IC group; age 55 +/- 15 years, mean +/- SD) who transferred to HD, 134 PD patients (PD group, age 64 +/- 11 years) who remained in PD, and 132 HD patients (HD group, age 48 +/- 16 years) who started and continued in HD. The main reasons for the transfer to HD were relapsed peritonitis and loss of ultrafiltration, while various comorbid risk factors were adjusted by Cox hazards regression model (age, presence of diabetes or/and cardiovascular disease, serum hemoglobin and albumin levels, as well as the modality per se). RESULTS: 3- and 5-year survival rates for the IC, PD and HD groups were 97% and 81%, 54% and 28%, and 92% and 83%, respectively. The 5-year survival rate was significantly higher in IC patients than in PD patients (p < 0.00001) but, was not different from that in HD patients. CONCLUSIONS: Our results show that the IC of dialysis patients undergoing RRT improves the survival of patients on PD if they are transferred to HD upon the appearance of PD related complications.     

Cholecystokinin and leptin: their influence upon the eating behaviour and nutrient intake of dialysis patients.

BACKGROUND: We have used serial visual analogue scores to demonstrate disturbances of the appetite profile in dialysis patients. This is potentially important as dialysis patients are prone to malnutrition yet have a lower nutrient intake than controls. Appetite disturbance may be influenced by accumulation of appetite inhibitors such as leptin and cholecystokinin (CCK) in dialysis patients. METHODS: Fasting blood samples were drawn from 43 controls, 50 haemodialysis (HD) and 39 peritoneal dialysis (PD) patients to measure leptin and CCK. Hunger and fullness scores were derived from profiles compiled using hourly visual analogue scores. Nutrient intake was derived from 3 day dietary records. RESULTS: Fasting CCK was elevated for PD (6.73 +/- 4.42 ng/l vs control 4.99 +/- 2.23 ng/l, P < 0.05; vs HD 4.43 +/- 2.15 ng/l, P < 0.01). Fasting CCK correlated with the variability of the hunger (r = 0.426, P = 0.01) and fullness (r = 0.52, P = 0.002) scores for PD. There was a notable relationship with the increase in fullness after lunch for PD (r = 0.455, P = 0.006). When well nourished PD patients were compared with their malnourished counterparts, CCK was higher in the malnourished group (P = 0.004). Leptin levels were higher for the dialysis patients than controls (HD and PD, P < 0.001) with pronounced hyperleptinaemia evident in some PD patients. Control leptin levels demonstrated correlation with fullness scores (e.g. peak fullness, r = 0.45, P = 0.007) but the dialysis patients did not. PD nutrient intake (energy and protein intake, r = -0.56, P < 0.0001) demonstrated significant negative correlation with leptin. CONCLUSION: Increased CCK levels appear to influence fullness and hunger perception in PD patients and thus may contribute to malnutrition. Leptin does not appear to affect perceived appetite in dialysis patients but it may influence nutrient intake in PD patients via central feeding centres.     

Assessment and comparison of endothelial function between dialysis and kidney transplant patients

Dialysis and kidney transplant patients display endothelial dysfunction. Previous studies concerning comparisons of endothelial function in dialysis and kidney transplant patients included subjects with cardiovascular risk factor(s) that alone may lead to endothelial dysfunction. In this study, we compared endothelial function between dialysis and transplant patients who did not show known cardiovascular risk factors that lead to endothelial dysfunction. We studied age- and gender-matched cohorts: 30 hemodialysis (HD), 30 peritoneal dialysis (PD), and 30 kidney transplant patients. We also included 20 age- and gender-matched healthy controls. We assessed the endothelial function of patients and controls by a noninvasive technique. Serum biochemistry profiles of patients were also similar to controls in terms of lipid profile and fasting blood glucose level. Although mean FMD% levels of HD and PD patients were similar (6.6% +/- 3.1% vs 6.8% +/- 3.0%, P > .05), the mean percent of flow-mediated endothelium-dependent dilatation (FMD%) level in transplant patients was higher than those in HD or PD patients (10.50% +/- 3.0% vs 6.6% +/- 3.1% and 6.8% +/- 3.0%, respectively; P < .01). In addition, the mean FMD% level in healthy controls was higher than those in HD, PD, and transplant patients (14.0% +/- 2.3% vs 6.6% +/- 3.1%, 6.8% +/- 3.0% and 10.50% +/- 3.0%; P < .01, respectively). In conclusion, endothelial functions in transplant patients were better than those in dialysis patients.     

Analysis of the factors conditioning the diffusion of peritoneal dialysis in Italy.

BACKGROUND: The diffusion of peritoneal dialysis (PD) in Italy is lower than expected on the basis of indications and contraindications reported in literature. METHODS: To analyse the factors influencing the use of PD in Italy, we used data from the first National Census of the Italian Society of Nephrology relating to 9773 incident patients (Incid(HD + PD)) in 2004 and 43 293 prevalent patients dialysed in 658 centres at 31/12/2004 (337 public centres, 286 private centres, 12 paediatric centres, 15 research or religious institutions and 8 unspecified). RESULTS: The percentages on PD of total incident (Inc(PD)%) and prevalent dialysis patients (Prev(PD)%) were 15.9% and 10.3%, respectively with considerable variations from region to region and from centre to centre. The Inc(PD)% was higher in regions with fewer patients on dialysis in private centres. In the private centres, the Inc(PD)% was 0.4%. Of the 325 non-paediatric public centres, 116 (35.7%) do not use PD: compared with the 209 centres which do, these centres have a lower mean Inc(HD + PD) and Prev(HD + PD) per centre (13.0 +/- 12.3 vs 28.6 +/- 18.0 - 51.8 +/- 35.7 vs 117.3 +/- 66.4 patients, P < 0.0001), and more haemodialysis (HD) stations available (3.0 vs 3.5 patients per HD station, P < 0.0001). However, the significant influence of cultural and motivational factors on the use of this method is demonstrated by the fact that it is used by 34% of the smaller non-paediatric public centres, and is not used by 19% of the larger non-pediatric public centres.     

Impact of mode of dialysis on intra-abdominal infection after simultaneous pancreas-kidney transplantation

BACKGROUND: Whether peritoneal dialysis is a risk factor for the development of intra-abdominal infection (IAI) after simultaneous pancreas kidney (SPK) transplantation is controversial. METHODS: We investigated the incidence of IAI, and patient and pancreas graft survival rates of 120 patients that received SPK between November 1995 and August 2003. All patients were dialysis-dependent prior to transplantation; mean duration of peritoneal dialysis (PD; n=52) and hemodialysis (HD; n=68) was 20+/-15 months and 23+/-16 months, respectively. RESULTS: IAI developed in five PD and six HD patients (P=0.88). The time of diagnosis of IAI and the spectrum of organisms cultured were similar in the two groups of patients. Age, duration of dialysis, and method of exocrine drainage did not have a significantly impact on infection rate. Patient and pancreas graft survival rates were 92.3% and 88.4% in the PD group and 95.5% and 92% HD group (p=ns) after a mean follow-up of 42+/-27 months and 39+/-27 months, respectively. Overall patient and pancreas graft survival was not significantly affected by IAI. CONCLUSIONS: PD does not adversely affect IAI rate and is a safe mode of dialysis for patients awaiting SPK transplantation.     

Frequency and severity of acute pancreatitis in chronic dialysis patients.

BACKGROUND: The incidence and severity of acute pancreatitis in patients undergoing dialysis treatment are unknown. METHODS: A questionnaire asking for the incidence and the severity of a first attack of acute pancreatitis in chronic dialysis patients in the year 2002 was sent to the members of QuaSi-Niere gGmbH, an organization representing almost all dialysis centres in Germany. A second questionnaire was sent to those who reported such patients. RESULTS: Response rates for the first and second questionnaire were 72% (832 out of 1150 centres) and 100% (72 out of 72 centres), respectively. After the exclusion of patients with invalid data, 55 patients with acute pancreatitis remained: 46 patients out of 68 715 haemodialysis (HD) patients (incidence rate 67/100 000/year; 95% confidence interval, 49 to 89/100 000/year) and 9 out of 3386 peritoneal dialysis (PD) patients (incidence rate 266/100 000/year; 95% confidence interval, 122 to 504/100 000/year; Fisher's exact test: P = 0.002). Twenty-eight patients (51%) had a known risk factor for acute pancreatitis. When these were excluded, the incidence of pancreatitis of unknown aetiology was 32/100 000/year (20-48) for HD patients (n, 22) and 148/100 000/year (48-345) for PD patients (n, 3; Fisher's exact test: P = 0.016). PD patients required hospital admission more frequently than HD patients (100% versus 76%) and suffered more frequently from necrotizing pancreatitis (50% versus 19%). CONCLUSIONS: Dialysis-especially PD-is another risk factor that increases the susceptibility of the pancreas to acute pancreatitis. Acute pancreatitis in patients undergoing PD is more frequent and seems to be more severe than in those receiving HD treatment.     

Changes in quality of life during hemodialysis and peritoneal dialysis treatment: generic and disease specific measures

Despite more than 20 yr of use, relative differences in health-related quality of life (HRQOL) between hemodialysis (HD) and peritoneal dialysis (PD) are not clearly known. The objective of this study was to compare self-reported HRQOL and overall health status for HD and PD patients at the initiation of dialysis therapy and 1 yr later. A prospective cohort of incident ESRD patients was enrolled between October 1995 and June 1998 at 81 outpatient dialysis units in 19 states and included 698 HD and 230 PD patients who completed a baseline CHOICE Health Experience Questionnaire. The main outcome measured was change in qualify-of-life scores from start of dialysis to 1 yr on dialysis and overall health status. Of 928 patients who completed the baseline questionnaire, 585 also completed the 12-mo questionnaire; 101 had died, 55 had received a kidney transplant, and 88 had moved to a new dialysis clinic. PD patients were slightly younger, were more likely to be white, were well-educated, were employed, were married, had less comorbidity, and had higher hematocrit. Unadjusted baseline scores showed better HRQOL for PD patients in both generic and ESRD domains (bodily pain, travel, diet restrictions, and dialysis access [P < 0.05]). At 1 yr, SF-36 scores improved, whereas some ESRD domains improved and others deteriorated. HD patients had greater improvements in two SF-36 domains (physical functioning and general health perception) than PD patients, but results were mixed for ESRD domains (PD is better for finances, HD is better for sleep and overall quality of life). HD and PD patients did not differ in change in overall health status. HD and PD are associated with similar HRQOL outcomes at 1 yr. Generic HRQOL in two domains improved more for HD patients. However, for ESRD-specific HRQOL, results were not consistent; some domains were better for PD patients whereas others were better for HD patients. In advising patients about modality choices, trade-offs should be discussed and individual preferences for specific aspects of HRQOL should be elicited.     

Hyperhomocysteinemia and oxidative stress during dialysis treatment

BACKGROUND/AIMS: The concomitant presence of hyperhomocysteinemia and oxidative stress may represent a determinant factor for the occurrence of vascular alterations and cardiac diseases, the main cause of death among dialysis patients. The aim was to analyze the occurrence of hyperhomocysteinemia and oxidative stress and their possible relationship in dialysis patients. METHODS: Antioxidant substances, homocysteine, folate, and vitamin B12 were determined in blood from 32 patients on hemodialysis (HD), 21 patients on peritoneal dialysis (PD), and 12 healthy individuals. RESULTS: Different degrees of hyperhomocysteinemia were observed in all HD patients and in 95% of the PD patients (45.30 +/- 24.89 microM in HD and 35.50 +/- 26.53 microM in PD). Oxidative stress defined as an imbalance between oxidant and antioxidant forces was observed in all dialysis patients, but was more intense in HD individuals. In this group, lipoperoxidation and protein oxidation were associated with lower concentrations of antioxidants such as erythrocyte vitamin E and vitamin C. CONCLUSIONS: Hyperhomocysteinemia and oxidative stress occur in both types of dialysis treatment, possibly contributing to the establishment of complications in these patients.     

Mineral metabolism and cardiovascular morbidity and mortality risk: peritoneal dialysis patients compared with haemodialysis patients.

BACKGROUND: The K/DOQI guideline for bone metabolism and disease in chronic kidney disease is predominantly based on studies in haemodialysis (HD) patients. However, in clinical practice, this guideline is also applied to peritoneal dialysis (PD) patients. To validate the implementation of this guideline in PD patients, we evaluated the associations between plasma concentrations outside the K/DOQI-targets and the risk of cardiovascular morbidity and mortality in incident PD patients compared with HD patients. METHODS: In a large prospective multicentre study in the Netherlands (The Netherlands Cooperative Study on the Adequacy of Dialysis, NECOSAD), we included patients starting PD or HD between 1997 and 2004. Relative risk of cardiovascular morbidity and mortality were estimated using time-dependent Cox regression modelling. RESULTS: We included 586 PD patients with mean age 52 +/- 15 years (66% males) and 1043 HD patients with mean age 63 +/- 14 years (58% males). Cardiovascular disease (CVD) was the reason for hospitalization in 102 PD and 271 HD patients. In HD patients, the relative risk of CVD-related hospitalization increased with elevated plasma calcium concentrations (hazard ratio: 1.4; 95% CI: 1.1-1.9). Cardiovascular mortality was significantly higher for phosphorus concentrations above the K/DOQI-threshold in PD (2.4; 95% CI: 1.3-4.2) and HD patients (1.5; 95% CI: 1.1-2.1), and for elevated Ca x P in PD (2.2; 95% CI: 1.3-3.8) and HD patients (1.5; 95% CI: 1.1-2.1). CONCLUSIONS: Plasma calcium concentrations above the K/DOQI-threshold increase the relative risk of CVD-related hospitalization in HD patients. Associations with cardiovascular mortality were more pronounced. Both in PD and HD patients with elevated plasma phosphorus and Ca x P concentrations, the cardiovascular mortality risk is increased. Therefore, it seems appropriate to adopt the current guideline in PD patients.     

Effect of vitamin E therapy on oxidative stress and erythrocyte osmotic fragility in patients on peritoneal dialysis and hemodialysis

BACKGROUND: Several medications have been tested with the aim of decreasing oxidative stress and erythrocyte osmotic fragility in patients on dialysis. The aim of the present study was to assess the influence of vitamin E therapy on oxidative stress and erythrocyte osmotic fragility in patients on hemodialysis (HD) and peritoneal dialysis (PD). METHODS: This was a placebo-controlled study. The study was performed on 34 HD patients, 13 PD patients and 22 healthy volunteers with a mean age of 45.57 +/- 8.54 years. HD patients were divided into 2 groups: treatment (n=19) and control (n=15). Vitamin E was administered, 300 mg/day, to the HD treatment group and PD patients for 20 weeks. Lipid peroxidation, antioxidant condition and erythrocyte osmotic fragility (EOF) were examined before and after treatment. RESULTS: Before the treatment, the levels of EOF (p<0.001) and malondialdehyde (MDA) (p<0.001) were significantly lower, and erythrocyte superoxide dismutase (SOD) (p=0.001) and vitamin E levels (p<0.001) were significantly higher in the healthy group than PD and HD groups. Serum vitamin E increased from 0.93 +/- 0.16 to 1.09 +/- 0.14 mg/dL (p=0.001), EOF decreased from 0.49% +/- 0.03% to 0.42% +/- 0.04% NaCl (p<0.001), and plasma MDA values decreased from 2.77 +/- 0.87 to 2.20 +/- 0.767 nmol/mL (p=0.018) in the HD treatment group after vitamin E treatment. Levels of EOF decreased from 0.51% +/- 0.09% to 0.43% +/- 0.03% NaCl in the PD treatment group after vitamin E treatment (p=0.021). CONCLUSION: Vitamin E therapy is effective in decreasing the levels of EOF in patients on HD and PD, and it is also effective in decreasing lipid peroxidation in patients on HD.     

Quality of life and psychological issues in peritoneal dialysis patients

Both peritoneal dialysis (PD) and hemodialysis (HD) patients have diminished quality of life (QOL) scores compared to healthy patients. QOL tends to decline over time, with the perception of the quality of physical health deteriorating more than mental health. However, many patients continue to feel hopeless, anxious, and worry about finances, loss of sexual function, family burden, and loss of independence. Depression is the most widely acknowledged psychosocial factor seen in patients with chronic kidney disease. Major depression occurs in 25% of patients facing impending dialysis. Once on PD, the proportion with major depression sharply declines to approximately 6%. This may be due to adjustment to dialysis, but may also be because depressive symptoms are associated with an increased risk of death. A low QOL score and depression are associated with higher comorbidity, poorer nutritional status, anemia, lower residual renal function, and increased hospitalization rates. Increased depressive scores are independently predictive of an elevated peritonitis risk, perhaps due to inattentiveness, or alternatively from a decrease in immune defenses. Small molecule clearances appear to have little to do with depressive symptoms. Depression is a significant problem in PD and other dialysis patients. There is an interrelationship between psychosocial factors, perception of illness, and clinical outcome that requires further study. Serial and simple measures of both depression and QOL should be obtained routinely in all PD patients. This permits rapid recognition of problems and may enhance patients' education on the importance of depression. Further research on interventions is urgently needed.     

Dialysis patients' attitudes about cardiopulmonary resuscitation and stopping dialysis

Dialysis patients are a unique population because of their chronic dependence on complex medical technology. Furthermore, their illness forces them to make critical decisions about medical care (mode of dialysis, renal transplantation, withdrawal from dialysis). The reasons dialysis patients discontinue therapy are not well understood, nor is it known whether they view dialysis therapy differently from other life-support interventions. We asked four groups of patients - in-center hemodialysis (HD), peritoneal dialysis (PD), renal transplant, and ambulatory elderly - questions about their wishes for (1) medical information, (2) participation in medical decision-making, (3) life-supporting therapy including cardiopulmonary resuscitation (CPR) and ventilatory support, and (4) stopping dialysis at the time of the study and in certain hypothetical situations. All groups wanted information and involvement in making medical decisions. Most patients desired CPR (96% of renal transplant, 76% of HD, 63% of PD, 82% of elderly), but PD patients chose CPR less often in all circumstances (at study, p = 0.004; in coma, p = 0.004; in permanent coma, p = 0.04), and they were less willing to undergo chronic ventilation (p = 0.001). PD patients were more likely to stop dialysis (p = 0.02) in coma than were HD patients. PD patients attended religious services more frequently and were less comfortable with machines, but these differences did not correlate with their decisions about life-support therapy. Dialysis patients have rarely considered stopping dialysis; they are similar to ambulatory elderly patients with regard to decisions about CPR and desire for involvement in medical decision-making. PD patients are a distinct subgroup worthy of further study.     

Peritoneal dialysis underutilization: the impact of an interventional nephrology peritoneal dialysis access program

Peritoneal dialysis (PD) is an underutilized form of renal replacement therapy. Recent data have emphasized that only 12% of end-stage renal disease (ESRD) patients are initiated on this form of therapy in the United States. Patients requiring PD have most often been referred to general surgeons for catheter placement. This has incurred additional delays in starting treatment and loss of decision-making control by the referring nephrologist. To address this issue, we developed and incorporated our own PD access placement program into the preexisting chronic kidney disease (CKD) education program. To date, 46 patients have undergone 71 procedures. These included 51 (72%) PD catheter insertions, 14 (20%) removals, and 6 (8%) repositioning procedures for poor drainage. PD catheter insertion was performed peritoneoscopically under local anesthesia and a Fogarty catheter was used to reposition a migrated catheter. All of the procedures were performed by nephrologists in a dedicated interventional nephrology (IN) laboratory. All six repositioning procedures failed to restore optimal drainage. Five of these patients had the catheter removed and a new catheter placed during the same procedure. Of these five patients, one had recurrence of poor drainage and opted for hemodialysis (HD). The sixth patient declined reinsertion and chose HD. Of the remaining seven removal procedures, three were due to fungal peritonitis, one due to bowel perforation, one due to severe depression, one due to transplant, and one catheter was removed at the request of the primary physician in a terminally ill patient. Eight of the 51 catheter insertions were during the initial admission of a catastrophic dialysis start. Two of these patients started acute PD and avoided catheter placement for HD. Thirty-seven of 46 patients have a functional PD catheter with a follow-up of 8.6 +/- 0.8 (mean +/- SE) months. During an 18-month period our PD population has increased from 43 to 80 patients. We conclude that a dedicated PD access placement program coupled with a CKD education program can have a dramatic impact on patient choice and PD growth.     

Comparison of cognitive function between patients with hemodialysis and peritoneal dialysis

Objective To evaluate whether dialysis modality will affect cognitive function in dialysis population. Methods This was a cross-sectional study. Chronic dialysis patients in our center was screened from July 2013 to July 2014. All of the subjects received brain magnetic resonance imaging (MRI) examination and comprehensive cognitive function evaluation. Results A total of 189 chronic dialysis patients were enrolled in this study, 122 cases on hemodialysis (HD) and 67 cases on peritoneal dialysis (PD). There was no significant difference in age between HD and PD groups [(56.4±13.2) years vs (56.4±16.1) years, t=0.004, P=0.997]. The dialysis vintage and serum albumin of HD patients was higher than those of PD patients[58.0(16.8, 107.5) months vs 31.0(7.0, 67.0) months, Z=-3.490, P＜0.001; (39.6±3.9) g/L vs (35.3±3.8) g/L, t=7.328，P＜0.001, respectively]. The prevalence of cerebral small vessel diseases (CSVDs) was comparable between HD and PD groups (all P＞0.05). Compared with HD patients, PD patients presented a 11.90-fold risk of immediate memory impairment (95%CI 1.40-101.08, P=0.023) and a 6.18-fold risk of long-delayed memory impairment (95%CI 2.12-18.05, P=0.001). After adjusting for age, educational lever, dialysis vintage, serum creatinine, and CSVDs, the influence of dialysis modality on memory still worked. PD patients presented a 43% risk of executive function impairment of HD patients (OR=0.43, 95%CI 0.17-1.04, P=0.061). Conclusions HD patients manifested better memory than PD patients, while PD probably performed better in executive function than HD patients. There was no significant difference in language function between the two groups. The difference in cognitive function may not be related to CSVDs.     

血液透析和腹膜透析对肾移植术后并发症和预后的影响

目的 探讨血液透析(HD)与腹膜透析(PD)对肾移植术后并发症和预后的影响。 方法 回顾分析402例术前维持性透析超过3个月的同种异体尸体肾移植术患者的临床资料。按透析方式将患者分为HD组（303例）和PD组（99例），并对345例随访（30.2±15.2）月。比较术前HD和PD对肾移植术后受者和移植肾存活率以及肾移植术后并发症，包括急性排斥、移植肾功能延迟恢复（DGF）、感染、慢性排斥等的影响。 结果 除了术前平均透析时间PD组长于HD组，乙型肝炎（乙肝）感染率HD组明显高于PD组外，在原发病、年龄、性别、血压、血红蛋白、HLA配型、冷热缺血时间、丙型肝炎感染等方面两组间差异无统计学意义。移植术后两组在DGF、急性排斥、慢性排斥、巨细胞病毒（CMV）感染和其他感染的发生率等方面差异无统计学意义。HD组术前透析时间>12个月的患者急性排斥的发生率显著高于<12个月的患者（P ＜ 0.05）。乙肝患者比非乙肝患者更易发生移植肾丧失功能（19.23% 比 8.86％，P = 0.021）。PD组乙肝病毒阴性的患者术后感染发生率较低。术后患者1年和5年存活率在两组间差异无统计学意义（1年：HD 94.34%，PD 91.25%；5年：HD 92.83%，PD 90%）；同样移植肾1年和5年存活率两组间差异也无统计学意义（1年：HD 93.21%，PD 96.25%；5年：HD 87.17%，PD 91.25%）。 结论 HD和PD对肾移植术后并发症、患者及移植肾1年和5年存活率的影响相似，均可作为慢性肾衰竭患者肾移植术前替代治疗。HD患者的急性排斥发生率随着透析时间的延长而增加，因此，缩短肾移植前透析时间将有助减少肾移植术后并发症。     

Influence of dialysis on post-transplant events

INTRODUCTION: We examined the effect of haemodialysis (HD) or peritoneal dialysis (PD) on acute rejection, delayed graft function (DGF), graft and patient survival after cadaveric renal transplantation. MATERIALS AND METHODS: We carried out a retrospective analysis of 325 patients (cyclosporin [CyA]-based therapy) who had their first cadaver renal transplant between January 1991 and December 1996 and followed up for a mean of 61 +/- 26 months. They were divided into three groups: HD, PD and CD (where both PD and HD was used for at least 3 months). Delayed graft function was diagnosed if the patient needed dialysis in the first week post-transplant while primary non-function (PNF) was diagnosed if the kidney never achieved function. Graft rejection was confirmed by biopsy; early acute rejection (EAR) was defined as acute rejection occurring before 90 days and late acute rejection (LAR) as one after 90 d. RESULTS: A total of 183 patients had PD, 117 HD and 25 CD. The mean time period in which the patients were on dialysis for PD was 24 months, HD 34.5 months and CD 50.6 months (p < 0.01). The recipients were matched for age and gender. The donor variables (age, gender and cold ischaemia time) did not differ between the groups. The mean time for the development of first acute rejection following renal transplant in each group was as follows: PD group: 68.8 d, HD group: 81.3 d and CD group: 105 d (p = 0.08). The number of patients who developed EAR was 90 (49.2%) in PD group, 51 (43.6%) in HD group and 11 (56%) in CD group (p = 0.6); the number who developed LAR was nine in PD group (4.9%), six in HD group (5.1%) and one in CD group (4%) (p = 0.9). Fifty-six patients with PD had DGF compared with 58 with HD (p = 0.01). There was no difference in the number and severity of rejection episodes or DGF based on the duration of dialysis. The 5-yr survival of patients was 79% for PD, 81% HD and 78% CD groups (p = n.s), while the graft survival for PD group was 61%, HD group 63% and CD group 74% (p = n.s). SUMMARY: We could find no difference in the patient or graft survival between patients who had pre-transplant HD, PD or CD. There was no difference in the incidence of acute rejection episodes between the three groups of patients as well. However, we found a significantly higher rate of DGF in the HD versus PD patients.