The Effect of Fluid Overload on Clinical Outcome in Southern Chinese Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

♦ Background:

Fluid overload is frequently present in dialysis patients and one of the important predictors of patient outcome. This study aimed to investigate the influence of fluid overload on all-cause mortality and technique failure in Southern Chinese continuous ambulatory peritoneal dialysis (CAPD) patients.

♦ Methods:

This was a post hoc study from a cross-sectional survey originally designed to investigate the prevalence and associated risk factors of fluid overload defined by bioimpedance analysis (BIA) in CAPD patients from January 1, 2008, to December 31, 2009. All 307 CAPD patients completing the original study were followed up until December 31, 2012.

♦ Results:

With a median follow-up period of 38.4 (19.2 – 47.9) months, 52 patients died. Patients with fluid overload (defined by extracellular water/total body water [ECW/TBW] ≥ 0.40) had a significantly higher peritonitis rate (0.016 vs 0.011 events/month exposure, p = 0.018) and cerebrovascular event rate (3.9 vs 1.1 events/100 patient years, p = 0.024) than the normal hydrated patients. Moreover, the results showed a significant rising of all-cause mortality (log-rank test = 5.59, p = 0.018), and a trend of increasing cardiovascular disease (CVD) mortality (log-rank test = 2.90, p = 0.089) and technique failure (log-rank test = 3.78, p = 0.052) in the patients with fluid overload. Fluid overload independently predicted all-cause mortality (hazard ratio [HR] = 12.98, 95%, confidence interval [CI] = 1.06 – 168.23, p = 0.042) and technique failure (HR = 13.56, 95% CI = 2.53 – 78.69, p = 0.007) in CAPD patients after adjustment for confounders.

♦ Conclusions:

Fluid overload defined by BIA was an independent predictor for all-cause mortality and technique failure in CAPD patients. Continuous ambulatory peritoneal dialysis patients with fluid overload had a higher peritonitis rate, cardiovascular event rate, and poorer clinical outcome than those patients with normal hydration.     

The Negative Impact of Early Peritonitis on Continuous Ambulatory Peritoneal Dialysis Patients

♦ Background: Peritonitis rate has been reported to be associated with technique failure and overall mortality in previous literatures. However, information on the impact of the timing of the first peritonitis episode on continuous ambulatory peritoneal dialysis (CAPD) patients is sparse. The aim of this research is to study the influence of time to first peritonitis on clinical outcomes, including technique failure, patient mortality and dropout from peritoneal dialysis (PD).♦ Methods: A retrospective observational cohort study was conducted over 10 years at a single PD unit in Taiwan. A total of 124 patients on CAPD with at least one peritonitis episode comprised the study subjects, which were dichotomized by the median of time to first peritonitis into either early peritonitis patients or late peritonitis patients. Cox proportional hazard model was used to analyze the correlation of the timing of first peritonitis with clinical outcomes.♦ Results: Early peritonitis patients were older, more diabetic and had lower serum levels of creatinine than the late peritonitis patients. Early peritonitis patients were associated with worse technique survival, patient survival and stay on PD than late peritonitis patients, as indicated by Kaplan-Meier analysis (log-rank test, p = 0.04, p < 0.001, p < 0.001, respectively). In the multivariate Cox regression model, early peritonitis was still a significant predictor for technique failure (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.30 - 0.98), patient mortality (HR, 0.34; 95% CI, 0.13 - 0.92) and dropout from PD (HR, 0.50; 95% CI, 0.30 - 0.82). In continuous analyses, a 1-month increase in the time to the first peritonitis episode was associated with a 2% decreased risk of technique failure (HR, 0.98; 95% CI, 0.97 - 0.99), a 3% decreased risk of patient mortality (HR, 0.97; 95% CI, 0.95 - 0.99), and a 2% decreased risk of dropout from PD (HR, 98%; 95% CI, 0.97 - 0.99). Peritonitis rate was inversely correlated with time to first peritonitis according to the Spearman analysis (r = -0.64, p < 0.001).♦ Conclusions: Time to first peritonitis is significantly correlated with clinical outcomes of peritonitis patients with early peritonitis patients having poor prognosis. Patients with shorter time to first peritonitis were prone to having a higher peritonitis rate.     

持续性非卧床腹膜透析患者退出原因的分析

【目的】探讨持续性非卧床腹膜透析（CAPD）患者退出治疗的原因及防治对策。【方法】回顾1997年5月至2009年2月因终末期肾病接受CAPD患者临床资料56例,统计分析患者腹膜透析（PD）退出原因。【结果】因各种原因退出PD共43例,退出率为76．78％（43／56）。其中主要原因为：①死亡,26例（60．47％）;②转血透10例（23．26％）;③肾移植3例（6．97％）;④经济原因2例（4．65％）。【结论】死亡是CAPD患者退出PD的主要原因。而心脑血管疾病、腹膜炎是导致CAPD患者退出的重要原因,因此应积极制定CAPD患者个体化透析方案。     

High Glucose Concentrations in Peritoneal Dialysate Are Associated with All-Cause and Cardiovascular Disease Mortality in Continuous Ambulatory Peritoneal Dialysis Patients

♦ Background: The effect of high peritoneal dialysate glucose concentration (PDGC) on all-cause and cardiovascular disease (CVD) mortality in peritoneal dialysis (PD) patients is unclear.♦ Objective: Our study aimed to investigate the effect of high PDGC on all-cause and CVD mortality in continuous ambulatory PD (CAPD) patients.♦ Methods: The study enrolled 716 patients newly initiated on CAPD therapy between January 2006 and December 2010. We allocated the patients to low (<1.56%), medium (≥1.56% to <1.74%), and high (≥1.74%) average PDGC groups according to the tertile of average PDGC in the first 6 months after PD initiation. Cox regression and ordinal logistic regression were used to analyze determinants of mortality and of PDGC use respectively.♦ Results: Mean follow-up in the study cohort was 31 ± 15 months. The all-cause mortality was 4.7 events per 100 patient-years, and the leading cause of death was CVD. Patients with a higher PDGC had significantly higher cumulative rates of all-cause (log-rank p < 0.001) and CVD mortality (log-rank p < 0.001). In Cox regression analysis, high PDGC independently predicted higher all-cause (hazard ratio: 2.63; p = 0.004) and CVD mortality (hazard ratio: 2.78; p = 0.01). Compared with a lower PDGC, a higher PDGC was significantly associated with older age [odds ratio (OR): 1.02; p < 0.001], low residual renal function (OR: 0.91; p < 0.001), and high dialysate-to-plasma ratio of creatinine (OR: 28.61; p < 0.001) in ordinal logistic regression.♦ Conclusions: Higher PDGC is associated with higher allcause and CVD mortality in CAPD patients.     

Association of Pulmonary Hypertension with Mortality in Incident Peritoneal Dialysis Patients

♦ Background:

The prognostic value of pulmonary hypertension at the start of peritoneal dialysis (PD) in patient survival is unclear.

♦ Methods:

We conducted a retrospective study of incident patients who initiated PD therapy from January 2007 to December 2011, and followed up through June 2013. Pulmonary hypertension was defined as an estimated systolic pulmonary artery pressure (PAP) of ≥ 35 mm Hg using echocardiography. Clinical parameters and laboratory findings were compared between patients with and without pulmonary hypertension and a logistic regression model was elaborated. Patient outcomes (all-cause and cardiovascular mortality) were recorded during follow-up. Survival curves were constructed by the Kaplan-Meier method, and the influences of pulmonary hypertension on outcomes were analyzed by Cox regression models.

♦ Results:

Pulmonary hypertension was prevalent in 99 (16.0%) of the 618 patients studied. The independent risk factors for pulmonary hypertension were female (odds ratio [OR] = 2.12; 95% confidence interval [CI]: 1.29 – 3.46), left atrial diameter (OR = 1.15; 95% CI: 1.10 – 1.20), left ventricular ejection fraction (OR = 0.97; 95% CI: 0.95 – 0.99), and serum sodium (OR = 0.94; 95% CI: 0.89 – 0.99). Over a median follow-up of 29.4 months, 93 patients (15.0%) died, 59.1% of them due to cardiovascular disease. Kaplan-Meier survival analysis showed that patients with pulmonary hypertension had worse overall rates of survival and cardiovascular death-free survival than those without pulmonary hypertension. After multivariate adjustment, pulmonary hypertension was independently associated with increased risk for both all-cause and cardiovascular mortality, with hazard ratios (HRs) of 2.10 (95% CI: 1.35 – 3.27) and 2.60 (95% CI: 1.48 – 4.56), respectively.

♦ Conclusions:

The prevalence of pulmonary hypertension at the start of PD was common and associated with increased risk of both all-cause and cardiovascular mortality in incident PD patients.     

腹透患者低血压的原因及对策探讨

目的：了解持续非卧床腹膜透析（CAPD）患者低血压的原因、对策及转归。方法：比较有低血压的CAPD患者与对照组的一般资料、营养状况、透析充分性、心脏功能、治疗和转归等。结果：低血压组与对照组在性别、年龄、透析时间、原发病的组成、血红蛋白、血白蛋白、肱三头肌皮肤皱褶厚度、尿素清除指数、血尿素氮和血清肌酐等方面无显著差异。低血压组的射血分数小于对照组。低血容量引起的低血压易纠正。低血压组的病死率高于对照组。结论：CAPD患者的低血压主要与低血容量、降血压药、心衰等有关，有效防治低血压的发生可以改善CAPD患者的预后。     

The Effect of Glycated Hemoglobin and Albumin-Corrected Glycated Serum Protein on Mortality in Diabetic Patients Receiving Continuous Peritoneal Dialysis

♦ Objective:

To explore the effect of glycated hemoglobin (HbA1c) and albumin-corrected glycated serum proteins (Alb-GSP) on the mortality of diabetic patients receiving continuous peritoneal dialysis (PD).

♦ Methods:

In this single-center retrospective cohort study, incident diabetic PD patients from January 1, 2006, to December 31, 2010, were recruited, and followed up until December 31, 2011. The effect of HbA1c and Alb-GSP on mortality was evaluated by Cox proportional hazards models.

♦ Results:

A total of 200 patients (60% male, mean age 60.3 ± 10.6 years) with a mean follow-up of 29.0 months (range: 4.3 – 71.5 months) were recruited. Sixty-four patients died during the follow-up period, of whom 21 died of cardiovascular disease (CVD). Mean values for HbA1c, GSP and Alb-GSP were 6.7% (range: 4.1 – 12.5%), 202 μmol/L (range: 69 – 459 μmol/L), and 5.78 μmol/g (range: 2.16 – 14.98 μmol/g), respectively. The concentrations of GSP and Alb-GSP were closely correlated with HbA1c (r = 0.41, p < 0.001 and r = 0.45, p < 0.001, respectively). In multivariate Cox proportional hazards models, patients with HbA1c ≥ 8% were associated with increased risk of all-cause mortality (hazard ratio [HR] = 2.29, 95% confidence interval [CI]: 1.06 – 4.96, p = 0.04), but no increased mortality in patients with 6.0% ≤ HbA1c ≤ 7.9%. Patients with Alb-GSP ≤ 4.50 μmol/g had increased all-cause and non-cardiovascular mortality (HR = 2.42, 95% CI: 1.13 – 5.19, p = 0.02; and HR = 2.98, 95% CI: 1.05 – 8.48, p = 0.04 respectively).

♦ Conclusions:

Increased HbA1c and decreased Alb-GSP may be associated with poorer survival in diabetic PD patients, with a non-significant trend observed for poorer survival with the highest level of Alb-GSP.     

亚临床甲状腺功能减退症对腹膜透析患者容量负荷、贫血的影响及干预研究

【目的】探讨亚临床甲状腺功能减退（SCH）对持续不卧床腹膜透析（CAPD）患者容量负荷及贫血的影响。并观察左旋甲状腺素（LT）的干预作用。【方法】检测30例CAPD合并SCH患者及60例甲状腺功能正常的CAPD患者（B组）的超敏促甲状腺素（TSH）,游离三碘甲状腺原氨酸（FT3）,游离甲状腺素（FT4）及血红蛋白（Hb）,细胞外液（ECW）,体液总量（TBW）,细胞外液与总体液总量之比（E／T）。将A组中的15例患者进行LT治疗（A1组）4周,观察Hb,容量负荷变化情况,并与未治疗的亚甲减组（A2组）进行比较。【结果】A组容量负荷高于,而Hb则低于B组。且差异有显著性（P〈0．01）。经予LT治疗4周后,A1组ECW减少,Hb上升,与治疗前比较差畀均有显著性（P〈0．01）,较未治疗的A2组差异均有显著性（P〈0．05）,且接近同时期单纯CAPD组患者水平。【结论]SCH可以加重CAPD患者容量负荷及贫血水平。LT干预治疗可以减轻该类患者的容量负荷并改善其贫血状况。     

老年终末期肾病维持性腹透与血透患者生活质量比较

目的 比较老年持续性不卧床腹膜透析(CAPD)与维持性血液透析(HD)治疗的患者生活质量(Qol),寻求提高老年终末期肾病患者生活质量的最佳透析方法。方法 运用KDQOL-SFTMV1.3量表,在2008年-2009年期间,采取患者应答,医护人员记录的方式,对106例老年(年龄≥65岁,透龄≥3月且≤3年)患者进行Qol评估,其中CAPD组56例,血透组50例。根据Hays R.D.提供的记分方法进行评分,并运用SPSS15.0软件包对数据进行统计分析。结果 CAPD组与维持性血透组总体上生活质量相类似,但在个别单项得分上存在差异。源于SF-36项目中HD组体力状况(65.60?24.26)、体力因素对工作的影响(36.50?39.52)得分高于CAPD组,P<0.05;而CAPD组在情绪精神状态对工作的影响(48.67?44.78)得分高于HD组,P<0.05。源于KDTA中HD组在症状与不适(79.21?11.52)、睡眠状况(65.90?15.74)得分高于CAPD组,P<0.05;而CAPD组在工作状况(44.29?26.49)、透析医护人员的鼓励和支持(93.93?11.49)得分高于HD组,P<0.05。结论 两种透析方法对老年终末期肾病患者的生活质量均有所改善,但在生活质量的不同方面存在差异。     

The Impact of Timing of Dialysis Initiation on Mortality in Patients with Peritoneal Dialysis

♦ Background:

The impact of timing of dialysis initiation on mortality is controversial in patients with peritoneal dialysis (PD). In this study, we analyzed the impact of timing of dialysis initiation on mortality in the incident PD population.

♦ Methods:

Incident patients with PD were selected from the Clinical Research Center (CRC) registry for end-stage renal disease (ESRD), a prospective cohort study on dialysis in Korea. Patients were categorized into 3 groups according to the estimated glomerular filtration rate (eGFR) at the initiation of PD using the Modification of Diet in Renal Disease (MDRD) equation. Group A was defined as eGFR < 5 mL/min/1.73m², group B as eGFR 5 – 10 mL/min/1.73m², and group C as eGFR > 10 mL/min/1.73m². Cox regression analysis was used to calculate the adjusted hazard ratio (HR) of mortality with group B as the reference. The primary outcome was all-cause mortality.

♦ Results:

A total of 495 incident PD patients were included. The number of patients in group A was 109, group B was 279, and group C was 107. The median follow-up period was 23 months. Multivariate Cox regression analysis showed that group A had a significantly higher risk of all-cause mortality compared with group B (HR 4.13, 95% confidence interval [CI], 1.55 – 11.03, p = 0.005) after adjustment for age, gender, cause of ESRD, serum albumin level, diabetes mellitus, and cardiovascular disease. There was no significant difference in mortality between group C and group B (HR 1.50, 95% CI, 0.59 – 3.80, p = 0.398) after adjustment for clinical variables.

♦ Conclusion:

An eGFR < 5 mL/min/1.73m² at the initiation of PD was a significant risk factor for death, while an eGFR >10 mL/min/1.73m² at the initiation of PD was not associated with improved survival compared with an eGFR of 5 – 10 mL/min/1.73m² at the initiation of PD.     

持续非卧床腹膜透析患者腹膜炎及相关因素的临床研究

【目的】探讨腹膜透析（PD）相关性腹膜炎的发生原因、相关因素、致病菌及其对药物的敏感性。【方法】回顾性分析本院持续非卧床腹膜透析（CAPD）相关性腹膜炎患者的临床资料,对腹膜炎发生原因进行分析;观察原发病与发生腹膜炎的关系;患者营养状况、血红蛋白（Hb）、血清白蛋白（Alb）与发生腹膜炎的关系;细菌学培养结果及药敏。【结果】腹膜炎发生原因以患者操作不规范为主,与非腹膜炎组比较,腹膜炎组Hb、Alb明显低于非腹膜炎组,且差异有显著性（P〈0．05）,而原发病与腹膜炎的发生无明确相关性;CAPD相关腹膜炎致病菌仍以革兰阳性球菌为主,但革兰阴性杆菌及真菌所致腹膜炎比例有上升趋势,治疗时根据病原茵不同选择不同的治疗方案。【结论】正规培训,严格无茵操作,培养良好的卫生习惯,有助于预防PD相关性腹膜炎的发生。     

Clinical Outcome of Home Hemodialysis in Patients with Previous Peritoneal Dialysis Exposure: Evaluation of the Integrated Home Dialysis Model

♦ Background:

Home dialysis is a cost-effective modality of renal replacement therapy associated with excellent outcomes. Peritoneal dialysis (PD) is the most common home-based modality, but technique failure remains a problem. Transfer from PD to home hemodialysis (HHD) allows the patient to continue with a home-based modality, but the outcomes of patients transitioning to HHD after PD are largely unknown.

♦ Methods:

In a retrospective cohort study, including all consecutive HHD patients between January 1996 and December 2011, we evaluated the outcomes of patients with previous PD exposure compared to those without. The primary outcome was the cumulative patient and technique survival. Secondary outcomes included time to first hospitalization and hospitalization rate. Data were compared using the log-rank test and a multivariable Cox proportional hazards model.

♦ Results:

Among our cohort of 207 consecutive HHD patients, 35 (17%) had previous exposure to PD. Median renal replacement therapy (RRT) vintage (12.3 years, interquartile range (IQR) 8.5 – 18.9 vs 0.9 years, IQR 0.2 – 7.5, p < 0.001) and Charlson comorbidity index (CCI) (4, IQR 2 – 6 vs 3, IQR 2 – 4, p = 0.044) were higher among patients with PD exposure than those without. Despite the difference in vintage, cumulative patient and technique survival was similar in the two groups, in both unadjusted (log-rank p = 0.893) and Cox adjusted models (hazard ratio (HR) 1.15, 95% confidence interval (CI) 0.51 – 2.59) for patients with PD exposure compared to those without. The time to first hospitalization was shorter in patients with previous PD exposure compared to PD-naïve patients (log-rank p = 0.021). This association was preserved in the Cox proportional model (HR 1.65, 95% CI 1.08 – 2.54).

♦ Conclusion:

Despite a higher burden of comorbidity, patients with previous PD exposure had similar cumulative patient and technique survival on HHD compared to those without PD exposure. Whenever possible, HHD should be considered in PD patients in need of a new dialysis modality.     

腹膜透析病人的生存率及多变量预后分析

目的：调查腹膜透析病人的生存率及其独立的预后因素，识别病人死亡的高危人群，以指导临床治疗。方法：随诊腹膜透析病人268例，采用Kaplan-Meirie法分析生存率，采用COX模型多变量分析透析前各临床指标对预后的影响。结果：268例病人中位数随访时间为26个月；1年、2年、3年及4年总体生存率分别为85．6％、67．1％、56．9％及44．4％；经时序检验，透析前病人年龄、体重、经济状况、残余尿量、原发病、合并疾病、血红蛋白、血清白蛋白、血清尿素氮、肌酐及血磷浓度对生存率均有影响（P值均＜0．05）；经COX回归分析，透析前病人年龄、血清白蛋白及合并疾病成为独立的预后因素。结论：我国腹膜透析远期生存率稍低于西方发达国家。根据透析前年龄、血清白蛋白及有无合并疾病，可对腹透病人的预后进行初步判断。     

Patient and Technique Survival of Older Adults with ESRD Treated with Peritoneal Dialysis

The number of older adults worldwide is increasing as societies gain success in improving the health and lifespan of their citizens. As a result, increasing numbers of older adults are presenting to the medical community with advanced kidney failure. Historically, dialysis treatments were withheld from older adults particularly those with severe co-existing illnesses. This has changed in most parts of the world, and there is now an increasing emphasis on shared decision-making to determine whether dialysis is appropriate and to determine which modality meets the needs, expectations, and desire of patients. Evidence examining the difference in risk for death of older adults treated with hemodialysis (HD) or peritoneal dialysis (PD), and the probability of those treated with PD to transfer to HD among older compared to younger adults, is largely derived from prospective cohort studies or analyses of data from national registries. In such studies, it is difficult to distinguish whether differences in outcomes reflect the effect of dialysis modality or differences in health status of different groups of patients. Longevity and technique survival are important, albeit not the only or most important consideration in such decision-making. Given the risk for bias in observational studies and the profound effect of dialysis modality on patients'' lifestyle, the selection of dialysis modality should remain a decision made by the patient, caregivers, and his/her physician after thorough education and review of the available data.     

家庭腹膜透析病人首次发生腹膜炎的原因及影响因素分析

目的探讨家庭持续非卧床腹膜透析病人首次发生腹膜炎的原因及相关因素。方法分析193例家庭腹膜透析病人首次发生腹膜炎的情况,通过与病人及家属或腹膜透析操作者交流,观看操作者操作流程,记录并分析腹膜炎发生的原因;采用单因素分析,比较是否并发腹膜炎病人性别、年龄、原发病、营养状况、透析时间、血肌酐水平、随访情况、医疗付费方式、病人和操作者的文化程度有无差异,对单因素分析筛选出的影响因素进行多因素分析。结果193例病人中首次发生腹膜炎者44例;腹膜炎发生原因中,主要是因操作不规范而致,占68%;多因素分析显示：不规律随诊、无独立透析间病人腹膜炎发生率显著高于定期来院随诊、有独立透析间者（P〈0.05）。结论腹膜炎发生的主要原因是操作不规范,其次是便秘、腹泻、导管出口处感染;对腹膜透析病人要加强追踪管理,尤其是操作不规范、不定期来院随访、无独立透析间的家庭腹膜透析病人,应定期评估他们的透析情况并再培训,协助改善透析环境,减少腹膜炎发生率,降低病人退出率。     

The Association Between Body Mass Index and Mortality on Peritoneal Dialysis: A Prospective Cohort Study

♦ Background: Previous studies have demonstrated that increased body mass index (BMI) is associated with decreased mortality in hemodialysis (HD) patients. However, the association between BMI and survival has not been well established in patients undergoing peritoneal dialysis (PD). The aim of the study was to determine the association between BMI and mortality in the PD population using the Clinical Research Center (CRC) registry for end-stage renal disease (ESRD) cohort in Korea.♦ Methods: Prevalent patients with PD were selected from the CRC registry for ESRD, a prospective cohort study on dialysis patients in Korea. Patients were categorized into four groups by quartiles of BMI. Cox regression analysis was used to calculate the adjusted hazard ratio (HR) of mortality with a BMI of quartile 2 (21.4 - 23.5 kg/m²) as the reference.♦ Results: A total of 900 prevalent patients undergoing PD were included. The median follow-up period was 24 months. The multivariate Cox proportional hazard model showed that the lowest quartile of BMI was associated with higher mortality (HR 3.00, 95% confidence interval (CI), 1.26 - 7.15). However, the higher quartiles of BMI were not associated with mortality compared with the reference category of BMI quartile 2 (Quartile 3: HR 1.11, 95% CI, 0.43 - 2.85, Quartile 4: HR 1.64, 95% CI, 0.66 - 4.06) after adjustment for clinical variables.♦ Conclusions: Lower BMI was a significant risk factor for death, but increased BMI was not associated with mortality in Korean PD patients.     

Long-Term Clinical Outcomes of Peritoneal Dialysis Patients: 9-Year Experience of a Single Center from North India

♦ Objective: There is a paucity of published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of continuous ambulatory PD (CAPD) in India in 1991. The purpose of this study is to report long-term clinical outcomes of PD patients at a single center.♦ Design: Retrospective study.♦ Setting: A government-owned tertiary-care hospital in North India.♦ Patients: Patients who were initiated on CAPD between October 2002 and June 2011, and who survived and/or had more than 6 months’ follow-up on this treatment with last follow-up till December 31, 2011, were studied.♦ Results: A total of 60 patients were included in the analysis. The mean age of the patients was 60.2 ± 9.2 years. The majority (65%) of the patients lived in rural areas. A high proportion (47%) were diabetic and 62% had ≥ 2 comorbidities. Total duration on peritoneal dialysis treatment was 1,773 patient-months (148 patient-years) with a mean duration of 29.6 ± 23 patient-months and median duration of 25 patient-months (range 6 - 110 patient-months). Overall patient and technique survival at 1, 2, 3, 4 and 5 years was 77%, 53%, 25%, 15%, and 10% respectively. Patient survival of diabetics vs non-diabetics at 1, 2, 3, 4, and 5 years was 68% vs 84%, 54% vs 53%, 14% vs 34%, 11% vs 19%, and 11% vs 13%, respectively. The mortality in non-diabetics (16/32) was less than that in diabetic (18/28) patients (p = not significant). The main cause of mortality in these patients was cardiac followed by sepsis. There were 58 episodes of peritonitis. The rate of peritonitis was 1 episode per 30.6 patient-months or 0.39 episodes per patient-year. Furthermore, the total number of episodes of peritonitis and number of episodes of peritonitis per patient were higher in the non-survival group (p < 0.05). The incidence of tuberculosis (TB), herpes zoster (HZ) and hernias was 15%, 10% and 5% respectively.♦ Conclusion: The study reports long-term outcomes of the PD patients, the majority of whom were elderly with a high burden of comorbidities. There was a high proportion of diabetics. The survival of diabetic vs non-diabetic and elderly vs non-elderly PD patients was similar in our study. The mortality in non-diabetics was less than that in diabetic patients. TB and HZ were common causes of morbidity. Peritonitis was associated with mortality in these patients.     

Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis

♦ Background:

Accidental falls are common in the hemodialysis (HD) population. The high fall rate has been attributed to a combination of aging, kidney disease-related morbidity, and HD treatment-related hazards. We hypothesized that patients maintained on peritoneal dialysis (PD) would have fewer falls than those on chronic HD. The objective of this study was to compare the falls risk between cohorts of elderly patients maintained on HD and PD, using prospective data from a large academic dialysis facility.

♦ Methods:

Patients aged 65 years or over on chronic in-hospital HD and PD at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first year recorded. Fall risk between the 2 groups was compared using both crude and adjusted Poisson lognormal random effects modeling.

♦ Results:

Out of 258 potential patients, 236 were recruited, assessed at baseline, and followed biweekly for falls. Of 74 PD patients, 40 (54%) experienced 86 falls while 76 out of 162 (47%) HD patients experienced a total of 305 falls (crude fall rate 1.25 vs 1.60 respectively, odds ratio [OR] falls in PD patients 0.78, 95% confidence interval [CI] 0.61 – 0.92, p = 0.04). After adjustment for differences in comorbidity, number of medications, and other demographic differences, PD patients were no less likely to experience accidental falls than HD patients (OR 1.63, 95% CI 0.88 – 3.04, p = 0.1).

♦ Conclusions:

We conclude that accidental falls are equally common in the PD population and the HD population. These data argue against post-HD hypotension as the sole contributor to the high fall risk in the dialysis population.     

持续性腹膜透析和血液透析对慢性肾功能衰竭多发性神经病转归的影响

目的通过电生理测试结果评估持续腹膜透析（PD）或血液透析（HD）的慢性肾功能衰竭患者周围神经病的发生率,并根据残余肾功能判断透析方式对周围神经功能的影响。方法将131例慢性肾功能衰竭患者按透析方式分为HD组（n=73）和PD组（n=58）。根据透析治疗期间肌电图的结果分别将HD组、PD组各分为MN亚组和非MN亚组。采用德国Medelec Shaphire 2MED仪对每例患者的正中神经、尺神经、腓总神经和胫神经的神经传导速度（NCV）进行电生理测定,感觉神经检测包括波幅、潜伏期和传导速度;运动神经检测则包括复合肌肉动作电位的波幅、潜伏期和传导速度。电生理检测发现至少2条神经异常结果可诊断为多发性神经病。在透析开始后的第1、6、12、18、24月检测每位患者的残余肾功能。结果 131例患者中在观察末期有78例存在感觉障碍。78例患者经肌电图检查诊断为MN者77例,其中HD组中MN患者44例（60.3%）,PD组中MN患者33例（56.9%）,2组比较差异无统计学意义（P〉0.05）。透析治疗初期HD组中的MN亚组、非MN亚组,PD组中的MN亚组、非MN亚组对残余肾功能（RRF）变化进行多重比较,差异均无统计学意义（均P〉0.05）。随着透析的进行,第12、24个月2种透析组的MN亚组RRF显著下降（P〈0.05）,非MN亚组RRF比较差异无统计学意义（P〉0.05）。结论 MN在慢性肾衰患者中是常见的并发症,发生率与治疗方法无明显关系;PD或HD治疗不能阻止慢性肾功能衰竭患者周围神经病变的发生。残留肾功能在保护慢性肾功能衰竭患者周围神经功能方面起了重要的作用。     

The Risk Factors and the Impact of Hernia Development on Technique Survival in Peritoneal Dialysis Patients: A Population-Based Cohort Study

♦ Objectives:

There is a lack of consensus on the risk factors for hernia formation, and the impact on peritoneal dialysis (PD) survival has seldom been studied.

♦ Methods:

This was a population-based study and all collected data were retrieved from the National Health Insurance Research Database of Taiwan. Patients who commenced PD between January 1998 and December 2006 were screened for inclusion. Multiple logistic regression and Cox proportional hazards models were applied to estimate the predictors for hernia formation and determine the predictors of PD withdrawal.

♦ Results:

A total of 6,928 PD patients were enrolled and followed until December 2009, with 631 hernia events and 391 hernioplasties being registered in 530 patients (7.7%). The incidence rate was 0.04 hernias/patient/year. Longer PD duration (per 1 month increase, hazard ratio (HR) 1.019) and history of mitral valve prolapse (MVP) (HR 1.584) were independent risk factors for hernia formation during PD, and female gender (HR 0.617) was a protective factor. On the other hand, there were 4,468 PD withdrawals, with cumulative incidence rates of 41% at 1 year, 66% at 3 years, and 82% at 5 years. Independent determinants for cumulative PD withdrawal included hernia formation during PD (HR 1.154), age (per 1 year increase, HR 1.014), larger dialysate volume (per 1 liter increase, HR 0.496), female gender (HR 0.763), heart failure (HR 1.092), hypertension (HR 1.207), myocardial infarction (HR 1.292), chronic obstructive pulmonary disease (COPD) (HR 1.227), cerebrovascular accident (CVA) (HR 1.364), and history of MVP (HR 0.712)

♦ Conclusions:

Prolonged PD duration was a risk factor for hernia formation, and female gender was protective. Hernia formation during PD therapy may increase the risk of PD withdrawal.