Impact of dialysis therapy on insulin resistance in end-stage renal disease: comparison of haemodialysis and continuous ambulatory peritoneal dialysis.

BACKGROUND: Insulin resistance contributes to the pathogenesis of atherosclerotic cardiovascular disease and, thus, has an important impact on the mortality of uraemic patients. Haemodialysis (HD) is known to improve insulin resistance observed in uraemia. However, it is not known whether continuous ambulatory peritoneal dialysis (CAPD) alleviates insulin resistance in adult uraemic patients. The objective of this study was to compare the effect of two different dialysis modalities, HD and CAPD, on insulin resistance in adult uraemic patients and to identify the possible predictive factors for changes in insulin resistance. METHODS: Insulin resistance was examined in 19 non-diabetic patients with end-stage renal disease (ESRD) before and after dialysis therapy (HD, n=10; CAPD, n=9), as well as in 10 healthy controls using the hyperinsulinaemic euglycaemic glucose clamp technique. The glucose disposal rate (GDR mg/kg/min) was used as an index of insulin sensitivity during the clamp technique. We also determined which of various biochemical parameters might be associated with change in insulin resistance by carrying out multiple logistic regression analysis. RESULTS: GDR was significantly lower (6.44+/-1.76) in ESRD subjects than in normal subjects (9.90+/-2.01). HD and CAPD therapies significantly normalized GDR from 6.53+/-1.84 to 9.74+/-2.88 and from 6.35+/-1.65 to 8.18+/-1.76 respectively. Multiple logistic regression analysis showed that changes in BUN, haematocrit and plasma bicarbonate were significant predictive factors for the change in insulin resistance. CONCLUSION: CAPD therapy, in spite of its possible adverse effects in patients with atherosclerotic disease, has been shown to improve insulin resistance in adult uraemic patients, similarly to HD therapy.     

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.     

Audit of a decade of continuous ambulatory peritoneal dialysis

We have reviewed the results of continuous ambulatory peritonealdialysis (CAPD) in a single renal unit over the period fromDecember 1979 to the end of 1990. Case records of 211 of the222 patients treated by CAPD over this period were obtainedand age, sex, diagnoses, duration of CAPD, and cause of deathdetermined. We found marked effects of age and a diagnosis ofatheromatous vascular disease at the start of CAPD on patientsurvival. For patients aged under 45 years 5-year patient survivalwas 78%, for those aged 45–65 it was 29% and for thoseaged over 65 years it was 32%. Patients with a diagnosis ofatheromatous vascular disease at the start of CAPD had a 3-yearsurvival of 25% compared with 69% for age- and sex-matched CAPDpatients without such a diagnosis. Five-year technique survivalwas 67% if failure was denned as transfer to haemodialysis ordeath as a direct result of CAPD, but only 11% of patients wereon CAPD continuously for 5 years. Attempts to compare our resultswith those from other reports were hindered by the variety ofmethods used to calculate patient and technique survival; wesuggest that standard methods should be agreed.     

Economic evaluation of centre haemodialysis and continuous ambulatory peritoneal dialysis in Ministry of Health hospitals, Malaysia

BACKGROUND: This is a multi-centre study to determine cost efficiency and cost effectiveness of the Ministry of Health centre haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) programme. Methods: Forty-four haemodialysis and 11 CAPD centres were enrolled in this study in 2001. Sixty patients, 30 from each modality, were evaluated. Micro-costing was used to determine costs. RESULTS: The number of haemodialyses conducted ranged from 402 to 23,000 procedures per year, while for CAPD, output ranged from 70 to 2300 patient months/year. Cost ranged from RM79.61 to RM475.79 per haemodialysis treatment, with a mean cost of RM169 per HD (USD 1 = RM 3.80). The cost of CAPD treatment ranged from RM1400 to RM3200 per patient month, with a mean of RM2186. Both modalities incurred similar outpatient costs. The cost of erythropoeitin per year is RM4500 and RM2500 for haemodialysis and CAPD, respectively. The number of life years saved is 10.96 years for haemodialysis and 5.21 years for CAPD. Cost per life year saved is RM33 642 for haemodialysis and RM31 635 for CAPD. The cost for land, building, equipment, overheads, and staff were higher for haemodialysis, while consumables and hospitalization cost more for CAPD. Sensitivity analysis was performed for two discount rates (3 and 5%), varying erythropoietin doses and maximum and minimum overheads. Relative cost effectiveness of haemodialysis and CAPD was unchanged in all sensitivity scenarios, except for overhead costs, which influenced the cost effectiveness of HD. Conclusion: It is economically viable to promote the use of both CAPD and haemodialysis because the cost effectiveness of both are nearly equal.     

Comparison of the rehabilitation status of continuous ambulatory peritoneal dialysis and in-centre haemodialysis in Chinese patients

Summary: In Hong Kong, dialysis treatment has become more accessible in recent years. Due to a shortage of kidney donors patients are required to stay on dialysis for longer periods. the rehabilitation status of 181 end-stage renal failure (ESRF) patients on dialysis, 34 on in-centre haemodialysis (ICHD) and 147 on continuous ambulatory peritoneal dialysis (CAPD), at the Prince of Wales Hospital was studied. There was no statistically significant difference in physical functioning due to treatment type; however, CAPD patients were shown to be more socially active and had a better family life than ICHD patients (P < 0.01). There were no statistically significant correlations between physical functioning, social life or family life and the duration of dialysis in both ICHD and CAPD patients. In both groups of patients 52.9% of ICHD and 52.4% of CAPD patients had decreased employment status. All the patients were assessed by doctors-in-charge on their physical fitness for employment, 85.7% (n= 6) of the unemployed ICHD patients and 71% (n= 44) of the unemployed CAPD patients were considered to be physically fit to work. Due to the ageing of the general population and greater availability of dialysis treatment and higher survival rate of the chronically ill have led to an increase in the number of elderly patients on dialysis (aged 60 years and over). the proportion of elderly dialysis patients in our renal centre increased from 7–23% in the past 5 years. Continuous ambulatory peritoneal dialysis patients aged less than 60 years were found to be significantly more physically active and socially active than CAPD patients aged over 60 years (P < 0.01). In the aspect of a better family life for these patients, no statistically significant difference was found between the two groups. Rehabilitation of ESRF patients can be achieved by renal replacement therapy. It is concluded that CAPD patients have better adaptation in social life and family life than ICHD patients.     

Hyaluronic acid metabolism and its clinical significance in patients treated by continuous ambulatory peritoneal dialysis

Musculoskeletal syndromes are common in patients treated bydialysis for end-stage renal failure and abnormal connectivetissue metabolism has been implicated. Hyaluronic acid is amajor component of connective tissue ground substance. Serum,dialysate, and 24-h urine hyaluronic acid was therefore measuredin 43 patients treated by CAPD to determine hyaluronic acidmetabolism and to relate these variables to morbidity and mortalityover an 18-month period. Serum hyaluronic acid was elevated in 71% patients, being correlatedwith patient age, length of time on dialysis, and weight lossover the preceding 6 months. Small quantities of predominantlylow-molecular-weight hyaluronic acid were lost in the urine,whereas much larger amounts of mixed-molecular-weight hyaluronicacid were excreted in peritoneal dialysate. Dialysate hyaluronicacid exceeded serum hyaluronic acid. Baseline serum hyaluronicacid was closely correlated with morbidity and mortality overthe following 18 months. Serum hyaluronic acid is an accurate predictor of mortalityand morbidity over an 18-month period in patients treated byCAPD. Large quantities of hyaluronic acid are excreted in peritonealdialysate, which in part represents local hyaluronic acid production.     

Comparison of peritoneal dialysis and haemodialysis after renal transplant failure

Background. A growing number of patients are returning to dialysisafter renal transplant failure. The aim of this study is todetermine whether peritoneal dialysis (PD) is a safe and goodtreatment option for these patients. Methods. All patients returning to PD or haemodialysis (HD)after renal transplant failure before 1 October 2002 at theUniversity Hospital Gasthuisberg, Leuven, Belgium, were evaluated.Data were collected until death, retransplantation (reTx), transferto HD or PD or until 1 January 2003. Results. Twenty-one patients starting PD (PDpostTx-group) and39 patients starting HD (HDpostTx-group) after renal transplantfailure were included in the study. There were no significantdifferences in age, sex, serum albumin- and CRP-levels at baseline.The total time on renal replacement therapy at transplant failureand time to transplant failure did not differ between the twogroups either. Furthermore, the baseline comorbidity was similarin both groups. During follow-up, the outcome did not differsignificantly between the two groups. However, there was a tendencytowards higher patient survival and reTx tended to be more frequentin the PDpostTx-group. Moreover, patients in the HDpostTx-grouptended to accrue more new comorbidity. The incidence of peritonitisand the evolution of dialysis adequacy (renal and peritonealKt/V and creatinine clearances) with time in the PDpostTx-groupwas similar to that seen in our centre's PD patients who hadnever undergone transplantation before. Conclusions. This study suggests that the outcome in patientsstarting PD after renal transplant failure is at least as goodas the outcome in those starting HD. Although these observationalfindings warrant further confirmation, PD therefore can be regardedas a safe and good treatment option for patients returning todialysis after renal transplant failure.     

Relapsing Bacillus licheniformis peritonitis in a continuous ambulatory peritoneal dialysis patient

Bacillus licheniformis is a rare pathogen in continuous ambulatory peritoneal dialysis (CAPD) peritonitis. Only one case of B. licheniformis peritonitis has been previously reported but relapsing peritonitis by same species has not been reported. A 31-year-old man undergoing CAPD was admitted to our hospital with diarrhoea and turbid peritoneal effluent. Although B. licheniformis was cultured at his previous admission, we did not consider the species as a pathogen. After the same species was cultured twice consecutively at the subsequent admission, we confirmed that B. licheniformis was a pathogen of CAPD peritonitis. After appropriate intraperitoneal antibiotics therapy, the patient improved. He is currently undergoing CAPD without catheter removal.     

Lipoprotein (a) in patients on maintenance haemodialysis and continuous ambulatory peritoneal dialysis

Lipoprotein (a) concentrations and apoprotein (a) isoforms weremeasured in 99 haemodialysis and 79 peritoneal dialysis patientsand compared with a normal population. Peritoneal dialysis patientsdemonstrated a threefold and haemodialysis a twofold increasein median Lp(a) values compared to controls (P0.001). The peritonealdialysis group had significantly more patients with Lp(a) valuesgreater than 30 mg/dl compared to controls, (53% versus 22%P0.001). In addition both patient groups demonstrated significanthypertriglyceridaemia (P0.001), reduction in HDL (P0.001) andelevation of the cholesterol/HDL ratio (P0.001) compared withcontrols. Peritoneal dialysis patients also demonstrated significanthypercholesterolaemia (P0.003). Lipoprotein (a) concentrations are considerably elevated inpatients on maintenance dialysis and this occurs in additionto the typical lipoprotein disturbances. This elevation mayincrease vascular risk, particularly in the peritoneal dialysisgroup who also have hypercholesterolaemia and reduced HDL.     

Nocardia peritonitis and abdominal abscess complicating continuous ambulatory peritoneal dialysis

Peritonitis is a common problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and represents the most frequent cause of peritoneal catheter loss and discontinuation of CAPD. The incidence of peritonitis remains less than one episode per patient year of treatment. Common bacteria, particularly staphyloccal species, are the usual causative agents. Fungi and higher bacteria such as Nocardia as aetiological agents have been infrequent in patients undergoing CAPD. We report a case of Nocardia nova peritonitis complicated by an intra‐abdominal abscess requiring surgical drainage and a protracted course of antibiotics.     

Low-dose erythropoietin is effective and safe in children on continuous ambulatory peritoneal dialysis

Hypertension is one of the most important complications of erythropoietin (rHuEPO) therapy in dialysis patients. In this study, the effect of two different dosage regiments of subcutaneous rHuEPO on blood pressure [BP] was evaluated in 20 anemic children on continuous ambulatory peritoneal dialysis (CAPD). Patients were randomized to receive rHuEPO 50 U/kg, either once a week (group 1, 50 U/kg per week) or three times a week (group 2, 150 U/kg per week). At the beginning of the study, 8 patients in group 1 and 8 patients in group 2 were on antihypertensive therapy. In group 1, the hematocrit increased gradually and significantly from 18.98%±1.79% to 30.1%±1.62% after 6 months, while in group 2 it rapidly increased from 19.53%±1.86% to 32.4%±1.11% after 3 months. A significant increase in the mean arterial BP was observed in group 2. Antihypertensive therapy had to be increased in all of the 8 previously hypertensive patients and had to be initiated in 1 of the 2 originally normotensive patients in the same group. None of the patients in group 1 required a change in antihypertensive medication. We conclude that during treatment with rHuEPO pre-existing hypertension and the dose of rHuEPO are the most important risk factors for the development or worsening of hypertension in children on CAPD, and gradual elevation of hematocrit by low-dose rHuEPO avoids the development of severe hypertension. Received December 11, 1995; received in revised form September 16, 1996; accepted September 19, 1996     

Encephalopathy in patients on continuous ambulatory peritoneal dialysis and patients on chronic haemodialysis.

A group of 121 patients, 22 with a preterminal chronic renal insufficiency (PCRI), 74 on chronic haemodialysis (CHD), and 25 on continuous ambulatory peritoneal dialysis (CAPD), was evaluated by means of neurophysiological and neuropsychological studies to detect signs of central nervous system dysfunction. CHD patients were studied the day before dialysis treatment. In each patient the neurophysiological and neuropsychological studies were performed on the same day. The same overall result emerged from the neurophysiological and neuropsychological studies: all three patient groups showed significant deviations from the values obtained from a healthy reference group, whereas no differences were found between the three patient groups. Biochemical variables (a.o. PTH, Al, PO4) showed inconsistent or only minor correlations with the encephalopathic parameters. Apparently traditional biochemical variables are not a reliable measure to safeguard renal patients from neurotoxic damage. With respect to central nervous system dysfunction CAPD appears to be as 'safe' as CHD.     

Idiopathic eosinophilic peritonitis in continuous ambulatory peritoneal dialysis: experience with percutaneous catheter placement

BACKGROUND: Peritoneal fluid eosinophilia (PFE), which is classically associated with idiopathic eosinophilic peritonitis (EP), has been known as a common event in patients on continuous ambulatory peritoneal dialysis (CAPD). However, our recent retrospective study of CAPD patients following percutaneous catheter placement showed that PFE occurred rarely. The aim of this prospective study was to clarify the incidence and characteristics of idiopathic EP and PFE in patients on CAPD following percutaneous catheter placement. METHODS: Forty-eight patients on CAPD following percutanous catheter placement were recruited for the present study. Peritoneal dialysis was initiated immediately after catheter insertion without break-in period. A cytological study of dialysate was performed on days 1, 2, 3, 4, 5, 6, 7, 14 and 30 after initiation of CAPD, and then monthly for 6 months. In addition, a cytological study was performed also when a patient revealed abdominal pain or cloudy peritoneal effluent. RESULTS: PFE developed in three (6.3%) patients during the study period. The incidence of idiopathic EP and PFE without any clinical findings suggestive of PD-related peritonitis was 2.1% and 4.2% respectively. All cases of PFE, including idiopathic EP, developed on a mean of 13 day following initiation of CAPD and resolved spontaneously after a mean of 7 days. There was no significant difference in IgE levels or the occurrence of peripheral blood eosinophilia between patients with PFE and those without. CONCLUSION: Idiopathic EP is infrequent among patients on CAPD following percutaneous catheter placement, but should be differentiated from infectious PD-related peritonitis.     

One year's experience with recombinant erythropoietin in children undergoing continuous ambulatory or cycling peritoneal dialysis

Fourteen patients (aged 5.9–22.1 years) undergoing continuous ambulatory or cycling peritoneal dialysis were treated with recombinant human erythropoietin (rhEPO), which was given intravenously once a week at a dosage of 300 units/kg. The mean haematocrit level increased from 18.5% to 27.5% and the reticulocyte count from 19 to 62 within 1 month. After an average time of 3.1 months rhEPO dosage could be adjusted to 100 units/kg per week to keep the haematocrit level at 30%. Only 1 patient had an exacerbation of hypertension, which required a dosage reduction; other side-effects were not noted.     

Safety of intravenous injection of iron saccharate in haemodialysis patients

BACKGROUND.: The most frequent i.v. iron preparations used for haemodialysispatients are iron dextran, iron gluconate and iron saccharate.Possible side effects include anaphylactic reactions due topreformed antibodies to dextran or vascular reactions due tounbound iron during treatment with iron gluconate or iron saccharate. METHODS.: Four dosage regimens of i.v. iron saccharate therapy were studied:10, 20, 40 and 100 mg, which were given over a time period of1 min after the end of the dialysis session. Iron metabolismparameters (serum iron concentration, transferrin saturationand serum ferritin levels) were measured at 0, 1, 5, 15 and30 min after application and immediately prior to the next dialysissession. All 18 regular haemodialysis patients studied receivedrecombinant human erythro-poietin (rHuEpo). RESULTS.: Serum iron levels and transferrin saturation increased significantlyfollowing i.v. injection of all doses of iron saccharate. Iron‘oversaturation’ of transferrin iron binding didnot occur in patients with transferrin levels >180 mg/dl.However, in patients with transferrin levels <180 mg/dl theinjection of 100 mg iron saccharate resulted in a transferrinsaturation of 102.6±39.5% (two patients with transferrinlevels of 87 and 92 mg/dl had transferrin saturations of 119.8and 149.7%, two patients with transferrin levels of 148 and171 mg/dl had transferrin saturations of 77.9 and 63.1%, respectively).Serum ferritin levels remained unchanged during the post-injectionperiod and increased by the next dialysis session followinginjection of 100 mg iron saccharate by 165%. CONCLUSIONS.: It is concluded that intravenous iron saccharate injection (10–100mgeven within 1 min) does not result in ‘oversaturation’of transferrin iron binding if serum transferrin levels are>180mg/dl (high-risk patients: transferrin <100 mg/dl). Thismay explain, at least in part, the minimal side effects observedduring the i.v. application of iron saccharate. Low-dose i.v.iron saccharate (10–40 mg) is recommended for iron supplementationof haemodialysis patients. If injection of 100 mg is necessary,serum transferrin level should exceed 180 mg/dl. There is, however,no need for fast i.v. injection during routine iron supplementation.     

Lipid risk factors for atherosclerotic carotid artery disease in patients on continuous ambulatory peritoneal dialysis

We investigated the relationship between abnormalities of lipid metabolism and carotid atherosclerosis in 20 patients on continuous ambulatory peritoneal dialysis (11 men and nine women). Carotid ultrasonography was used to determine the combined thickness of the intima and media (I-M thickness). The apo A-I/apo B ratio showed a significant negative correlation with I-M thickness ( P <0.05). In the patients with carotid plaque, the triglycerides (TG) level and the remnant-like particle cholesterol level (RLP-C) were significantly higher than in the patients without plaque ( P <0.05), and high density lipoprotein (HDL) cholesterol and the apo AI/apo B ratio were significantly lower than in the patients without plaque ( P <0.05). Moreover, there was a strong relationship between the severity of plaque and TG, the apo AI/apo B ratio, and RLP-C. Thus, abnormal lipid metabolism may contribute to progressive atherosclerosis, while TG, the apo A-I/apo B ratio, and RLP-C levels may be useful indicators of atherosclerotic risk in peritoneal dialysis patients.