Inflammation and extracellular volume expansion are related to sodium and water removal in patients on peritoneal dialysis.

BACKGROUND: Inflammation is an important risk for mortality in dialysis patients. Extracellular fluid volume (ECFv) expansion, a condition commonly seen in peritoneal dialysis (PD) patients, may be associated with inflammation. However, published support for this relationship is scarce. OBJECTIVES: To quantify the proportion of patients on PD with inflammation and to analyze the role of ECFv expansion and the factors related to these conditions. DESIGN: A prospective, multicenter cross-sectional study in six hospitals with a PD program. Patients and METHODS: Adult patients on PD were studied. Clinical data, body composition, and sodium and fluid intake were recorded. Biochemical analysis, C-reactive protein (CRP), and peritoneal and urinary fluid and sodium removal were also measured. RESULTS: CRP values positive (>or=3.0 mg/L) for inflammation were found in 147 (80.3%) and negative in 36 patients. Patients with positive CRP had higher ECFv/total body water (TBW) ratio (women 47.69 +/- 0.69 vs 47.36 +/- 0.65, men 43.15 +/- 1.14 vs 42.84 +/- 0.65; p < 0.05), higher serum glucose (125.09 +/- 81.90 vs 103.28 +/- 43.30 mg/dL, p < 0.03), and lower serum albumin (2.86 +/- 0.54 vs 3.17 +/- 0.38 g/dL, p < 0.001) levels. They also had lower ultrafiltration (1003 +/- 645 vs 1323 +/- 413 mL/day, p < 0.005) and total fluid removal (1260 +/- 648 vs 1648 +/- 496 mL/day, p < 0.001), and less peritoneal (15.59 +/- 162.14 vs 78.11 +/- 110.70 mEq/day, p < 0.01) and total sodium removal (42.06 +/- 142.49 vs 118.60 +/- 69.73 mEq/day, p < 0.001). In the multivariate analysis, only ECFv/TBW was significantly (p < 0.04) and independently associated with inflammation. ECFv/TBW was correlated with fluid removal (r = 0.16, p < 0.03) and renal sodium removal (r = 0.2, p < 0.01). CONCLUSION: The data suggest that ECFv expansion may have a significant role as an inflammatory stimulus. The results disclose a relationship between the two variables, ECFv expansion and inflammation, identified as independent risk factors for mortality in PD patients.     

Volume overhydration is related to endothelial dysfunction in continuous ambulatory peritoneal dialysis patients

OBJECTIVE: In dialysis patients, volume overhydration is common and is related to increased risk of cardiovascular morbidity and mortality. However, it remains unclear whether volume overload imposes those detrimental effects through endothelial dysfunction. METHODS: In this cross-sectional study, 81 stable patients on continuous ambulatory peritoneal dialysis in a single center were recruited. Volume status was evaluated by extracellular water, assessed by bioimpedance analysis, and normalized to individual height (nECW). Endothelial function was estimated by endothelial-dependent flow-mediated dilatation (FMD) of the brachial artery and expressed as percentage change relative to baseline diameter. RESULTS: There were 37 male and 44 female patients (mean age 61 +/- 12 years, dialysis vintage 20 +/- 23 months). FMD in female patients was significantly higher than that in male patients (9.17% +/- 6.23% vs 6.31% +/- 5.01%, p < 0.05). FMD was negatively correlated with weight (r = -0.308, p < 0.01), body mass index (r = -0.242, p < 0.05), systolic blood pressure (r = -0.228, p < 0.05), ECW (r = -0.404, p < 0.001), and nECW (r = -0.418, p < 0.001). No correlation was found between FMD and other variables. In multiple stepwise regression analysis, calcium x phosphate product (beta = 0.422, p < 0.001), nECW (beta = -0.343, p < 0.01), and dialysis vintage (beta = -0.237, p < 0.05) were independent determinants of FMD (adjusted R(2) = 0.327 for this model). CONCLUSION: There was independent correlation between index of volume status and FMD, and higher nECW was related to worse endothelial function. The results of this study may help us understand the underlying mechanism of volume overhydration leading to increased cardiovascular morbidity and mortality in dialysis patients.     

Influence of residual renal function on dietary protein and caloric intake in patients on incremental peritoneal dialysis.

OBJECTIVE: To evaluate protein and caloric intake in peritoneal dialysis (PD) patients on an incremental dialysis schedule, in an attempt to discriminate the influence of residual renal function (RRF) on these nutritional parameters. DESIGN: Prospective observational study. PATIENTS: Nine patients who had significant RRF at the beginning of PD therapy, which permitted a schedule of incremental PD (i.e., the number of peritoneal exchanges was increased as the RRF fell) in order to maintain the sum of renal and peritoneal clearance (weekly Kt/V urea) at approximately 2. METHODS: The mean adequacy parameters (urine and peritoneal Kt/V urea and creatinine clearance) along with the mean dietary energy (DEI) and protein intake (DPI) estimated by 3-day diet histories, were determined 6 and 9 months after the beginning of PD, when patients had RRF (period 1), and 6 and 9 months after the loss of RRF (period 2). The mean data obtained in both periods were compared. The best determinants for the changes in DEI and DPI after the loss of RRF were also investigated. RESULTS: Mean total Kt/V urea was very similar in both periods (2.16+/-0.32 vs 2.15+/-0.18), although creatinine clearance decreased significantly after the loss of RRF (74.41+/-12.28 L/week/1.73 m2 vs 56.78+/-11.77 L/week/1.73 m2, p = 0.0001). Absolute and normalized DPI values for actual body weight decreased after the loss of RRF (68.21+/-11.87 g/kg vs 59.27+/-13.66 g/kg, p = 0.02; and 1.17+/-0.32 g/kg/day vs 0.97+/-0.32 g/kg/day, p = 0.01). Although the energy delivered by peritoneal glucose uptake increased significantly after the loss of RRF, the mean total energy intake (DEI plus peritoneal glucose uptake) was very similar in both periods (2141+/-339 kcal/day vs 2010+/-303 kcal/day, p = 0.13). However, the mean total energy intake normalized for actual body weight decreased significantly after the loss of RRF (37.5+/-10.1 kcal/kg/day vs 32.8+/-8.9 kcal/kg/day, p = 0.02). The changes in DEI and DPI between periods 1 and 2 correlated negatively with the difference of the energy delivered by peritoneal glucose uptake (r = 0.65, p = 0.05, and r = 0.88, p = 0.001, respectively). The magnitude of DPI changes between both periods correlated significantly with the magnitude of urinary Kt/V urea changes (r = 0.77, p = 0.01). However, there was no correlation between the changes in DPI and the changes in total Kt/V urea, total or renal creatinine clearance, or the length of time on PD. CONCLUSIONS: The loss of RRF led to a reduction in dietary caloric and protein intake. The magnitude of the reduction in the DPI was strongly correlated with the increase in the energy delivered by peritoneal glucose uptake and with the decrease in the urinary Kt/V urea, but not with the total Kt/V urea.     

Resting energy expenditure in peritoneal dialysis patients.

OBJECTIVES: This study aimed to evaluate whether resting energy expenditure (REE) of patients undergoing peritoneal dialysis (PD) therapy differs from that of healthy individuals, as well as to investigate the factors associated with REE in this sample of patients. DESIGN: Cross-sectional study. SETTING: Dialysis Unit of the Nephrology Division, Federal University of Sao Paulo-Oswaldo Ramos Foundation, Brazil. Subjects and METHODS: The study examined the REE of 37 patients (20 males, age 44.5 +/- 13 years) undergoing PD therapy. Only patients older than 18 years, on PD for at least 3 months, without catabolic illness, and with normal thyroid function were included. Patients were pair matched for age and gender with 37 healthy individuals. REE was measured by indirect calorimetry. Body composition was assessed by dual-energy x-ray absorptiometry in the patients and by bioelectrical impedance in the healthy individuals. RESULTS: The REE of PD patients was similar to that of pair-matched controls (1372 +/- 266 and 1453 +/- 252 kcal/day respectively, p = 0.13) even when adjusted for lean body mass and gender (p = 0.56). The REE of PD patients was positively correlated with lean body mass (r = 0.60, p < 0.01), fat mass (r = 0.43, p < 0.01), body mass index (r = 0.60, p < 0.01), serum glucose (r = 0.36, p < 0.05), and protein equivalent of nitrogen appearance (PNA; r = 0.42, p < 0.01). There were no correlations between REE and glucose absorption, dialysis-related parameters, C-reactive protein, and energy or protein intake by 3-day food diary. In the multiple linear regression analysis, using REE as the dependent variable, the final model showed that lean body mass and female gender were determinants of REE in PD patients (R(2) = 0.44). When separate analysis by gender was performed, REE correlated directly with body fat in female patients (r = 0.70, p < 0.01) but not in male patients (r = 0.29, p = 0.21). On the other hand, lean body mass was significantly correlated with REE in male patients (r = 0.78, p < 0.01) but not in female patients (r = 0.47, p = 0.06). CONCLUSIONS: This study showed that REE of PD patients did not differ from that of healthy individuals. The strong association between body fat and REE in female patients remains to be further investigated.     

Bioimpedance Spectroscopy for the Detection of Fluid Overload in Chinese Peritoneal Dialysis Patients

♦ Background: Fluid overload probably contributes to the cardiovascular risk of peritoneal dialysis (PD) patients. We studied the relationship between over-hydration as determined by bioimpedance spectroscopy and dialysis adequacy, nutritional status, and arterial stiffness in Chinese PD patients.♦ Methods: We studied 122 asymptomatic prevalent PD patients: bioimpedance spectroscopy, arterial pulse wave velocity, dialysis adequacy and nutritional status were determined.♦ Results: Of the 122 patients, 88 (72.1%) had over-hydration of ≥ 1 L, while 25 (20.5%) were ≥ 5 L. Over-hydration significantly correlated with total body water (r = 0.474, p < 0.001) and extracellular water (r = 0.755, p < 0.001). Over-hydration was more severe in male and diabetic patients, and significantly correlated with Charlson’s comorbidity score, blood pressure, body mass index, body weight, peritoneal transport characteristics, and carotid-femoral pulse wave velocity. Over-hydration significantly correlated with Kt/V (r = -0.287, p = 0.016), serum albumin level (r = -0.465, p < 0.001) and malnutrition inflammation score (r = 0.410, p = 0.006), but not residual renal function.♦ Conclusion: Over-hydration is common in asymptomatic Chinese PD patients. The degree of over-hydration is particularly pronounced in patients who are inadequately dialyzed, have multiple comorbid conditions and low serum albumin levels. Over-hydration is associated with high blood pressure and arterial stiffness, and may contribute to the excessive risk of cardiovascular disease in this group of patients.     

Survival of elderly patients on peritoneal dialysis: retrospective study of 292 patients, from 1982 to 1999.

BACKGROUND: Dialysis is becoming increasingly frequent in patients over 75 years of age. Age is a superimposed comorbid factor commonly associated with poor prognosis in these patients. OBJECTIVE: To analyze the survival of 292 patients aged over 75 years on initiation of peritoneal dialysis (PD) from September 1982 to September 1999. DESIGN: Retrospective study. SETTING: Nephrology department in a University Hospital. RESULTS: Mean age was 81.5 years (range 75-92 years); 178 patients were over 80 years and 60 patients were over 85 years. Sex ratio was 136F/156M. Ninety-day mortality rate was 12%. Excluding the first 3 months, median patient survival was 21.6 months; 226 patients died on PD and 24 were shifted to hemodialysis. Survival was inversely correlated with the Charlson combined comorbidity index (CCI), but independent of predialysis hemoglobin and serum albumin levels. Over three selected periods, 1982-1989, 1989-1995, and 1995-1999, an increase was found in mean age (79.7 +/- 3.3, 82.6 +/- 3.9, and 81.8 +/- 4.4 years; p < 0.001), CCI (7.6 +/- 1.59, 8.0 +/- 1.52, and 8.5 +/- 1.63; p = 0.01), and predialysis creatinine clearance (6.2 +/- 2.3, 6.4 +/- 2.4, and 9.8 +/- 3.8 mL/minute; p < 0.001). Median survival was similar in the various selected periods (21.0, 21.5, and 25.4 months). The incidence of peritonitis decreased from 0.63 to 0.21 episodes per patient year. CONCLUSION: From 1982 to 1999, mean age and comorbidity increased on initiation of dialysis in elderly patients, with no increase in mortality. Survival in elderly patients on PD was related to the age-comorbidity index.     

Peritoneal loss of growth hormone in children on automated peritoneal dialysis.

OBJECTIVE: To provide quantitative data regarding the daily dialytic loss of growth hormone (GH) in children on peritoneal dialysis (PD). DESIGN: Prospective study involving 24-hour dialysate collections on 3 consecutive days in patients with and without recombinant human GH (rhGH) treatment. SETTING: Single-center outpatient PD program. PATIENTS: Twenty-six children undergoing automated PD (APD): 6 with and 20 without daily rhGH. MAIN OUTCOME MEASURES: Daily peritoneal losses of GH, alpha1-, beta2-microglobulin, transferrin, and albumin. RESULTS: The mean (+/-SEM) daily dialytic GH loss was 2.18+/-0.62 microg/1.73 m2 per day in rhGH-treated patients and 0.42+/-0.28 microg/1.73 m2 per day in untreated patients, (p < 0.05). The intraindividual coefficient of variation of daily GH loss was 65%. The peritoneal loss of GH was positively correlated with that of beta2-microglobulin (r = 0.77, p < 0.001) and alpha1-microglobulin (r = 0.51, p < 0.01). The variability in beta2-microglobulin and alpha1-microglobulin elimination, together with the use of rhGH, explained 66% of the total variability of daily GH excretion. In patients without rhGH therapy, the daily peritoneal GH loss was approximately 0.05% of the estimated daily endogenous production rate based on previous estimates in children with end-stage renal failure. In patients on rhGH therapy, less than 0.1% of the injected rhGH dose was eliminated by dialysis. CONCLUSION: Peritoneal losses of GH in children on APD account only for a minute fraction of endogenous metabolic clearance, and do not explain the variability of the rhGH treatment response. The assessment of dialytic GH elimination may be used to estimate time-integrated mean plasma GH concentrations, and to monitor rhGH treatment compliance.     

Patient mood and carer strain during stroke rehabilitation in the community following early hospital discharge

PURPOSE: Patient mood and carer stress were assessed for stroke patients in the community following early hospital discharge. METHOD: Patients had low Barthel Indices (13.0 (mean) +/- 4.9 (SD)) with high anxiety and depression scores, and carers had high stress scores, on starting rehabilitation. On starting rehabilitation, patient Barthel Indices correlated inversely with patient depression (r = -0.33, p < 0.02) and carer stress scores (r = -0.48, p < 0.001). RESULTS: During rehabilitation improvements occurred in patient Barthel Indices, patient anxiety scores and carer stress scores, but not in patient depression scores. Incremental increases in patient Barthel Indices during rehabilitation correlated with reductions in carer stress scores (r = -0.55, R2 = 29.4%, p < 0.001). Following early hospital discharge stroke patients display mood abnormalities which do not resolve during rehabilitation. CONCLUSION: Carer stress and patients depression scores are related to the severity of stroke-related disability. Strategies to address patient mood and carer stress should be present in community services providing early stroke rehabilitation.     

Dyslipidemia in peritoneal dialysis--relation to dialytic variables.

OBJECTIVE: To investigate whether the specific lipoprotein (LP) abnormalities of peritoneal dialysis (PD) are associated with functional variables of this mode of dialysis. DESIGN: A survey of the LP profile in relation to peritoneal dialysis capacity (PDC) variables.The LP profile was compared to that of a group of age- and sex-matched controls. SETTING: The Peritoneal Dialysis Unit at Sahlgrenska University Hospital in Gothenburg, Sweden. PATIENTS: Twenty-two nondiabetic PD patients (5 women, 17 men) who had been on PD for at least 6 months. MAIN OUTCOME MEASURES: The LP profile included plasma lipids, apolipoproteins (Apo), and individual ApoA- and ApoB-containing LP. The PDC measurement determined peritoneal glucose uptake, protein losses, effective peritoneal surface area, and total weekly creatinine clearance. RESULTS: The patients had been on PD for 6 to 48 months (mean 15.3 months) and had a total weekly creatinine clearance of 69.7+/-13.3 L/1.73 m2 body surface area, an average peritoneal glucose uptake corresponding to 446+/-162 kcal/24 hour, and a protein loss of 8.1+/-2.5 g/24 hr. The patients had significantly higher total cholesterol (7.1 mmol/L),VLDL-cholesterol (1.0 mmol/L), LDL-cholesterol (4.7 mmol/L), and triglyceride levels (2.5 mmol/L); whereas the HDL-cholesterol level (1.2 mmol/L) was significantly lower than in controls. The PD patients had increased levels of ApoB-containing LPs, both of the cholesterol-rich LP-B and of the triglyceride-rich LP-B complex, reflected in higher plasma concentrations of ApoB, ApoC-III, and ApoE. Furthermore, they had significantly lower levels of LP-A-I:A-II, as well as of ApoA-I and ApoA-II. The LP-A-I:A-II and ApoA-II levels correlated inversely with the duration of PD treatment (r = 0.54, p < 0.01 and r = 0.52, p < 0.05, respectively).The ApoA-II level was inversely correlated with the peritoneal surface area (r = 0.53, p < 0.05). There were no other correlations between LP variables and PDC variables, nor did any of the LP variables correlate with peritoneal glucose uptake or protein losses. CONCLUSION: The proatherogenic lipoprotein profile of patients on PD is characterized by increased concentrations of cholesterol-rich and triglyceride-rich ApoB-containing LPs. While the duration of treatment appears to have some influence on the development of this type of dyslipidemia, the pathophysiological links to the dialysis mode must be further explored.     

Application of an erythrocyte aluminum assay in the diagnosis of aluminum-associated microcytic anemia in patients undergoing dialysis and response to deferoxamine therapy

A method for measuring erythrocyte aluminum content was developed. Erythrocyte aluminum levels correlated with plasma aluminum concentrations in normal controls and in patients undergoing dialysis (r = 0.90, p less than 0.001). In vitro studies showed that erythrocyte aluminum concentrations were not altered by contamination of blood samples, which is a common problem with plasma determinations. The need for anticoagulation and rapid processing were disadvantages of this assay. In the dialysis population studied, the correlative data between mean cell volume and both plasma and erythrocyte aluminum levels (r = -0.50, p less than 0.001; and r = -0.69, p less than 0.001) and lack of correlation with serum ferritin suggested that aluminum overload and not iron deficiency was the cause of microcytic anemia. Patients undergoing continuous ambulatory peritoneal dialysis had lower plasma and erythrocyte aluminum levels and absence of microcytic anemia compared with patients undergoing hemodialysis. Therapy with deferoxamine in 13 patients with aluminum-related microcytic anemia resulted in a decrease in erythrocyte and plasma aluminum content in all patients (265.5 +/- 69.2 micrograms/L to 22.6 +/- 9.7 micrograms/L and 196 +/- 30 micrograms/L to 129 +/- 13.8 micrograms/L). The relatively smaller decrease in plasma aluminum levels suggested mobilization of aluminum from tissues other than erythrocytes. Aluminum chelation most probably occurred from premature erythrocytes, because in vitro studies showed that deferoxamine was unable to chelate aluminum from mature erythrocytes. Hemoglobin level, hematocrit measurement, and mean cell volume showed significant improvement (p less than 0.001). Ten patients showed normalized mean cell volume after 6.2 +/- 2 months of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Sleep related respiratory disorders in end-stage renal disease patients on peritoneal dialysis.

STUDY OBJECTIVE: To assess the possible effects of peritoneal dialysis (PD) on sleep-related respiration, which might result from dialysate bulk load in the abdomen and/or alterations in metabolic control of respiration during sleep. DESIGN: Subjective and objective measures of sleep were prospectively compared on randomly assigned nights with PD fluid (2.0 L) and without PD fluid in the peritoneal cavity in 11 end-stage renal disease (ESRD) patients on PD. SETTING: Tertiary-referral university hospital. PATIENTS AND METHODS: Fifteen consecutive patients on peritoneal dialysis who complained of chronic sleep disturbance and requested sedative were selected. Four patients declined polysomnographic studies. Consequently, 11 ESRD patients (8 males and 3 females) with a mean age of 63 +/- 4 (SEM) years were studied. RESULTS: Eight of the 11 patients reported multiple types of sleep difficulties. Polysomnographic recordings revealed significant primarily obstructive sleep apnea in 6 of 11 patients on at least 1 of 2 nights. Arterial blood pH, paO2, and paCO2 did not differ between nights with and without PD fluid in the peritoneal cavity in the group as a whole. In the 6 patients with sleep apnea, PaO2 was significantly lower (p less than 0.05) during the night with (PaO2 = 78 +/- 7 mmHg) than during the night without PD fluid (PaO2 = 92 +/- 4 mmHg). In the apneic patients, the amount of dialysate drained in the morning was negatively correlated with the minimum arterial oxygen saturation during the night (r = -0.94; p less than 0.005). CONCLUSIONS: This study indicates a significant relationship between PD patients with chronic sleep disturbance and sleep apnea syndrome. These data suggest that apneic patients may be susceptible to complications of dialysate bulk effect on oxygen desaturation.     

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

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

Anti-inflammatory effects of 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors (statins) in peritoneal dialysis patients.

OBJECTIVE: Elevated C-reactive protein (CRP) level is an independent predictor of all-cause and cardiovascular mortality in peritoneal dialysis (PD) patients. Statins have been demonstrated to have anti-inflammatory properties by virtue of their CRP lowering effects in hemodialysis patients. However, whether statins have an anti-inflammatory effect in PD patients is unknown. DESIGN: All prevalent PD patients at our center were reviewed. Eligible (257) patients were categorized into 2 groups: those on statin therapy (n = 137) and those not on statins (n = 120). Data were abstracted for hemoglobin, albumin, phosphates, cholesterol, CRP, Kt/V, and erythropoietin dose, along with relevant clinical data. RESULTS: The two groups had similar concentrations of hemoglobin, albumin, and phosphates. They were also matched for dialysis adequacy and duration of dialysis but the statin group patients were older (57 +/- 13 vs 52 +/- 17 years, p = 0.01). Serum cholesterol was lower in the statin group (4.74 +/- 1.05 vs 5.02 +/- 1.17 mmol/L, p < 0.05). Single-point (14 +/- 13 vs 19 +/- 18 mg/L, p < 0.02) and serially measured CRP (9 +/- 7.4 vs 12 +/- 10 mg/L, p < 0.02) levels were significantly lower in the statin group despite increased comorbidity (0.84 vs 0.54, p < 0.02) and greater incidence of diabetes mellitus (52% vs 25%, p < 0.01). CONCLUSION: Statin therapy is associated with low single-point and serially measured CRP levels in PD patients, thereby suggesting that their anti-inflammatory properties persist in PD. These data have implications for considering statin therapy in PD patients as an anti-inflammatory agent in addition to a cholesterol lowering drug.     

Impact of dialysis adequacy on cardiac function in pediatric CAPD patients.

BACKGROUND: Left ventricular hypertrophy is a major cause of morbidity and mortality among patients with chronic renal failure. Uremia-related risk factors play a fundamental role in its occurrence, thus better prognosis and prolonged survival can be attained by successful dialytic therapies. OBJECTIVE: To investigate whether dialysis adequacy has a beneficial effect on cardiac structure and function in children receiving continuous ambulatory peritoneal dialysis (CAPD). DESIGN: Cross-sectional study in the Pediatric Peritoneal Dialysis Unit of a university hospital. PATIENTS: Eighteen children, aged 13.3 +/- 2.8 years, being treated with CAPD, and 20 healthy age- and sex-matched control subjects were enrolled in this study. MAIN OUTCOME MEASURES: Echocardiographic evaluation was performed in all subjects. Dialysis adequacy indices [weekly urea (Kt/V) and creatinine clearance (TCCr)] were calculated in the dialysis group. RESULTS: Interventricular septal thickness, left ventricular (LV) posterior wall thickness, LV mass index (LVMI), and LV end systolic and diastolic dimensions were all found to be significantly higher in the CAPD group compared to the control subjects (p < 0.01). Ejection fraction and fractional shortening of the LV were not significantly different between the two groups. Mean Kt/V was 2.02 +/- 0.71 and mean TCCr was 58 +/- 33 L/wk/1.73 m2. There were significant negative correlations between dialysis adequacy indices and LV end systolic and diastolic dimensions (p < 0.05 and p < 0.001). Ejection fraction and fractional shortening were positively correlated with Kt/V (p < 0.01). Systolic and diastolic blood pressures were positively correlated with LVMI (r= 0.501 and r = 0.523). Significant inverse correlations between mean arterial pressure and both Kt/V and TCCr (r = -0.555 and r = -0.520) were detected. CONCLUSION: These data clearly document that cardiac structure and function are remarkably influenced by the uremic state and dialysis therapy in pediatric CAPD patients. The close relationships between echocardiographic findings and dialysis adequacy indices suggest that adequate dialysis has a beneficial effect on cardiac function via effective removal of toxic substances.     

Ultrafiltration and small solute transport at initiation of PD: questioning the paradigm of peritoneal function.

BACKGROUND: Human peritoneal function on commencing peritoneal dialysis (PD) is not yet adequately understood. The objective of this study was to determine peritoneal functional patterns on commencing PD. METHODS: 367 end-stage renal disease (ESRD) patients on PD for the first time were studied between their initial second to sixth weeks on PD. Urea and creatinine mass transfer area coefficients (MTAC) and standardized ultrafiltration (UF) capacity were determined. RESULTS: Mean parametric values were MTAC urea 22.9 +/- 7.04 mL/min, MTAC creatinine 10.31 +/- 4.68 mL/min, and UF 896 +/- 344 mL. Gender, patient size, and diabetes or kidney disease did not affect these parameters. The relationship between values of MTAC creatinine and UF reached statistical significance, although with a low value for Pearson's coefficient (r = -0.30, p = 0.001). Age showed a significant inverse linear correlation with UF capacity (r = -0.15, p = 0.003) and MTAC urea (r = -0.11, p < 0.05). Logistic regression analysis demonstrated that UF below 400 mL was independently related to a high MTAC creatinine and older age. Diabetes was least frequent in patients with the lowest UF. However, in the analysis of MTAC creatinine quintiles, UF values did not follow the expected inverse pattern. The lack of differences in UF between the second and third to fourth MTAC creatinine quintiles is remarkable; MTAC creatinine ranged from 6.71 to 13.54. CONCLUSIONS: The functional characteristics of human peritoneum varied markedly and there was a less intense than expected relationship between solute and water transports. This mild inverse relationship is intriguing and suggestive of the necessity of redefining some basic concepts. Age was associated with a lower peritoneal UF capacity, in part independently of small solute transport.     

Clinical utility of measuring free thyroxin and free triiodothyronine in serum of critically ill patients by ultrafiltration

Free thyroxin (FT4) measurements by ultrafiltration were compared with results obtained by equilibrium dialysis and commercial RIA methods. In a group of critically ill patients, the mean +/- 2 SD FT4 value by ultrafiltration (26.5 +/- 21.4 ng/L) was higher than in the healthy reference population (19.3 +/- 9.8 ng/L, p less than 0.0001), and correlated well with equilibrium dialysis (23.8 +/- 20 ng/L, r = 0.87). By a two-step RIA method (Clinical Assays), the FT4 value was greater in the critically ill (14.7 +/- 9.6 ng/L) than in the reference population (12.8 +/- 5 ng/L, p less than 0.001) and was also correlated with ultrafiltration results (r = 0.71). FT4 values for the ill patients were lower than for the reference population in two one-step RIA methods (Clinical Assays: 8.6 +/- 7.1 ng/L; Corning Medical: 12.7 +/- 9.4 ng/L), neither of which gave results correlated with ultrafiltration (r = 0.16 and 0.22, respectively). The concentration of free triiodothyronine (FT3), also measured by ultrafiltration, was 4.5 +/- 2.2 ng/L in healthy subjects, 12.5 +/- 14.2 ng/L in hyperthyroidism, 1.7 +/- 2.0 ng/L in hypothyroidism, 2.2 +/- 1.9 ng/L in the critically ill subjects, and 3.8 +/- 0.9 ng/L in pregnancy. Thus, FT4 and FT3 measured by ultrafiltration accurately affects assessment of the thyroid status of the patient except in critical illnesses in which FT3 values are indistinguishable from those in hypothyroidism.     

Assisted peritoneal dialysis. Experience in a French renal department.

BACKGROUND: The French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system. OBJECTIVE: This study was conducted to evaluate the impact of a private home-nurse network on one dialysis program. METHODS: This was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003. RESULTS: Of these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 +/- 10 vs 52 +/- 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 +/- 2.5 vs 4.3 +/- 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year. CONCLUSION: Assisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.     

PS1-28: Psychosocial Factors Associated With Angina Occurrence, Physical Limitation, and Diminished Quality of Life After Hospitalization for an Acute Coronary Syndrome: Preliminary Data from TRACE-CORE

Background/Aims Depression, anxiety, and perceived stress are common in patients with coronary heart disease (CHD) and are associated with an increased risk for dying after an acute coronary syndrome (ACS). Data are needed on how these psychosocial factors relate to quality of life, physical functioning, or anginal status after hospital discharge in ACS patients. Methods Adults admitted with an ACS at 3 medical centers in MA and GA were interviewed during their hospitalization and again at 1-month (1M) after discharge as part of the Transitions, Risk, and Actions in Acute Coronary Events: Center for Outcomes Research and Education (TRACE-CORE). At enrollment, patients completed standardized assessments of depression (PHQ-9; cut-point: >4), perceived stress (PSS-4; cut-point: > 7) and anxiety (GAD-8; cut-point: >4). At 1M after discharge, participants (n=281) completed the Seattle Angina Questionnaire, including questions regarding frequency of angina, physical limitation, and disease-specific quality of life (QoL). Tertiles representing the worst physical limitation and QoL scores defined high limitation and low QoL, respectively. Presence of angina, physical limitation, and low QoL at 1M were examined in relation to in-hospital psychosocial factors. Results Approximately one-third of participants were women (98 of 281), 77% were non-Hispanic white (216 of 281), and their mean age was 61.3 ± 11.0 years. At 1M after discharge, 44% (36 of 281) reported angina. Those depressed at baseline (45%, 126 of 281) were significantly more likely to report low QoL, high physical limitations, and angina at 1M than those without depression (p <0.05 for all). Enrollees with anxiety (46%, 131 of 281) at baseline were more likely to report low QoL, and high physical limitation, than patients without anxiety (p <0.001 for all) at 1M. Participants with highest baseline perceived stress (25%, 60 of 281) were significantly more likely to report lower QoL, high physical limitations, and angina than participants with lower perceived stress at 1M (p for all <0.001). Discussion Depression, anxiety, and perceived stress during ACS admission are related to CHD-specific functional status, angina, and QoL 1M after hospital discharge. These psychosocial factors may help identify patients at higher risk for poor outcomes after an ACS.