History of peritoneal dialysis in Latin America.

Latin America is a region formed by a number of countries of Latin heritage in which the common languages spoken are Spanish and Portuguese. Latin America was not isolated from the evolution of peritoneal dialysis (PD) throughout the rest of the world, as evidenced by the fact that, between the 1940s and the 1960s, PD was used to treat acute renal failure patients and later for the intermittent treatment of end-stage renal failure patients. The true development of PD took place toward the end of the 1970s and beginning of the 1980s with the introduction of continuous ambulatory peritoneal dialysis (CAPD). It is evident that the introduction of CAPD in most countries was a result of the personal effort and interest of individuals or groups of nephrologists. Initially, PD was not always implemented under ideal circumstances; locally manufactured, improvised supplies were associated with poor results. The arrival of companies with appropriate equipment and supplies led to widespread dissemination of this new modality. Furthermore, regulations and reimbursement by health authorities were additional obstacles. It is clear that PD in Latin America is still largely utilized to treat acute renal failure patients, particularly in countries where hemodialysis is not readily available. It is still employed intermittently to manage end-stage renal failure patients when hemodialysis is not available. With the exception of Colombia and Mexico, CAPD penetration is below 10%. While CAPD is nonexistent in certain countries, such as Cuba, due to lack of supplies, in other countries, such as Chile, it is restricted to patients that cannot be placed or continued on hemodialysis, those for example who lack vascular access, or those from remote rural areas. In addition, automated PD is relatively more costly and is therefore restricted in some countries.     

Renal replacement therapy in end-stage renal disease patients with chronic liver disease and ascites: role of peritoneal dialysis.

Chronic liver disease and cirrhosis account for several thousand deaths in the United States and often these patients have renal disease that progresses to end-stage renal disease (ESRD), necessitating renal replacement therapy. These patients provide significant challenges to their physicians, especially in the management of their ESRD with dialysis. ESRD patients with chronic liver disease and ascites are more difficult to manage on hemodialysis (HD) due to their hemodynamic status and risk of bleeding. Peritoneal dialysis (PD) offers them a viable alternative, along with a stable hemodynamic status and a lower risk of bleeding. The overall morbidity and mortality as well as the risk of peritonitis appear to be almost similar between cirrhotic and non-cirrhotic PD patients. In the absence of clinical trials comparing HD versus PD in such a population, and despite the limited clinical observations, the authors support PD as a viable and effective form of renal replacement therapy for patients with ESRD and associated chronic liver disease with cirrhosis and ascites.     

Unplanned Start on Peritoneal Dialysis Right after PD Catheter Implantation for Older People with End-Stage Renal Disease

Unplanned start on dialysis remains a major problem for the dialysis community worldwide. Late-referred patients with end-stage renal disease (ESRD) and urgent need for dialysis are overrepresented among older people. These patients are particularly likely to be started on in-center hemodialysis (HD), with a temporary vascular access known to be associated with excess mortality and increased risks of potentially lethal complications such as bacteremia and central venous thrombosis or stenosis.The present paper describes in detail our program for unplanned start on automated peritoneal dialysis (APD) right after PD catheter implantation and summarizes our experiences with the program so far. Compared with planned start on PD after at least 2 weeks of break-in between PD catheter implantation and initiation of dialysis, unplanned start may be associated with a slight increased risk of mechanical complications but apparently no detrimental effect on mortality, peritonitis-free survival, or PD technique survival.In our opinion and experience, the risk of serious complications associated with the implantation and immediate use of a PD catheter is less than the risk of complications associated with unplanned start on HD with a temporary central venous catheter (CVC). Unplanned start on APD is a gentle, safe, and feasible alternative to unplanned start on HD with a temporary CVC that is also valid for the late-referred older patient with ESRD and urgent need for dialysis.     

End-stage renal disease: symptom management and advance care planning

The prevalence of end-stage renal disease continues to increase, and dialysis is offered to older and more medically complex patients. Pain is problematic in up to one-half of patients receiving dialysis and may result from renal and nonrenal etiologies. Opioids can be prescribed safely, but the patient's renal function must be considered when selecting a drug and when determining the dosage. Fentanyl and methadone are considered the safest opioids for use in patients with end-stage renal disease. Nonpain symptoms are common and affect quality of life. Phosphate binders, ondansetron, and naltrexone can be helpful for pruritus. Fatigue can be managed with treatment of anemia and optimization of dialysis, but persistent fatigue should prompt screening for depression. Ondansetron, metoclopramide, and haloperidol are effective for uremia-associated nausea. Nondialytic management may be preferable to dialysis initiation in older patients and in those with additional life-limiting illnesses, and may not significantly decrease life expectancy. Delaying dialysis initiation is also an option. Patients with end-stage renal disease should have advance directives, including documentation of situations in which they would no longer want dialysis.     

Acute renal failure

Acute renal failure occurs in 5 percent of hospitalized patients. Etiologically, this common condition can be categorized as prerenal, intrinsic or postrenal. Most patients have prerenal acute renal failure or acute tubular necrosis (a type of intrinsic acute renal failure that is usually caused by ischemia or toxins). Using a systematic approach, physicians can determine the cause of acute renal failure in most patients. This approach includes a thorough history and physical examination, blood tests, urine studies and a renal ultrasound examination. In certain situations, such as when a patient has glomerular disease, microvascular disease or obstructive disease, rapid diagnosis and treatment are necessary to prevent permanent renal damage. By maintaining euvolemia, recognizing patients who are at increased risk and minimizing exposure to nephrotoxins, physicians can decrease the incidence of acute renal failure. Once acute renal failure develops, supportive therapy is critical to maintain fluid and electrolyte balances, minimize nitrogenous waste production and sustain nutrition. Death is most often caused by infection or cardiorespiratory complications.     

The Role of Tyrosine Kinase Receptors in Peritoneal Fibrosis

Peritoneal dialysis (PD) is a modality for treatment of patients with end-stage renal disease (ESRD) that depends on the structural and functional integrity of the peritoneal membrane. However, long-term PD can lead to morphological and functional changes in the peritoneum; in particular, peritoneal fibrosis has become one of the most common complications that ultimately results in ultrafiltration failure (UFF) and discontinuation of PD. Several factors and mechanisms such as inflammation and overproduction of transforming growth factor-β1 have been implicated in the development of peritoneal fibrosis, but there is no effective therapy to prevent or delay this process. Recent studies have shown that activation of multiple receptor tyrosine kinases (RTKs) is associated with the development and progression of tissue fibrosis in various organs, and there are also reports indicating the involvement of some RTKs in peritoneal fibrosis. This review will describe the role and mechanisms of RTKs in peritoneal fibrosis and discuss the possibility of using them as therapeutic targets for prevention and treatment of this complication.     

Survivors of acute renal failure who do not recover renal function

Overall survival in 1095 with severe acute renal failure (ARF) between 1984 and 1995 was 59.5%. Of these, 107 (16.2%) remained dependent on long-term dialysis. The frequency of end-stage renal failure (ESRF) in survivors of ARF varied between 3% and 41% according to the cause of ARF, being highest in those with acute renal parenchymal disease (in whom survival was also among the highest at 84%) and lowest in ARF due to obstetrics and trauma. Patients failing to regain adequate renal function did not appear to differ on clinical grounds from survivors who became dialysis-independent. Survival in those requiring long-term dialysis was less good than for other patients with ESRF, partly due to excess mortality in those for whom vascular disease or surgery was the precipitating cause of ARF. Six patients recovered sufficient renal function to become independent of dialysis after 3-18 months on regular dialysis therapy (6-21 months after onset of ARF). ESRF resulting from ARF is more frequent than previously reported. This increase may be due to a changing case-mix, increasing age of patients (and hence reduced capacity for renal recovery), and an increase in aggressive surgery for patients with advanced vascular disease. This presents a significant and increasing problem, with implications for both clinical management and the provision of dialysis services.      

An emerging and devastating acute abdomen in a patient under peritoneal dialysis: encapsulating peritoneal sclerosis

Peritoneal dialysis (PD) has been applied to patients with end-stage renal disease for more than 2 decades. It should raise physicians' concern about the serious complications of prolonged PD therapy, particularly encapsulating peritoneal sclerosis (EPS), the most potentially life-threatening one. The prevalence and mortality rate of EPS increase as PD duration increases. We report a case of EPS presented with blood-tinged effluents and abdominal pain.     

Adverse renal effects of legal and illicit drugs

The most important task of clinical and experimental nephrology is to identify risk factors for progression of renal failure with the ultimate goal to counteract the dramatic increase of patients reaching end-stage renal disease. Recently, cigarette smoking has been recognized to be one of the most important remediable renal risk factors. The adverse renal effects of smoking seem to be independent of the underlying renal disease and the current evidence suggests a near doubling of the rate of progression in smokers vs. non-smokers. Cessation of smoking slows the rate of progression. Besides smoking, alcohol abuse has also been implicated as a renal risk factor. The present article reviews the current knowledge about the adverse renal effects of these legal drugs. Furthermore, the acute and chronic renal complications due to illegal recreational drugs is discussed. The impact of these drugs on the risk to reach end-stage renal failure is difficult to assess, which is mainly due to the fact that it is difficult to perform controlled prospective studies in substance abusers. According to estimates, 5-6% of new patients starting end-stage renal disease therapy may have opiate-use-related renal diseases in the USA--a figure which documents the magnitude of the problem. Thus, in any case of unexplained renal functional impairment substance abuse should be considered by the physician.     

尿毒症严重并发症的救治

报告了救治５７例尿毒症严重并发症的临床研究。其中心脏并发症占首位，３４例，严重感染１０例，消化道并发症７例，神经系统并发症６例。经及时腹膜透析超滤水分、改善尿毒症症状并迅速对症处理后，存活４５例。死亡１２例。     

Recovery of renal function in Black South African patients with malignant hypertension: superiority of continuous ambulatory peritoneal dialysis over hemodialysis.

OBJECTIVE: To describe recovery of renal function (RC) in Black South African patients with primary malignant hypertension (MHT) and end-stage renal failure, according to the type of dialysis provided. DESIGN: A retrospective analysis of the records of 31 patients with MHT. SETTING: A university-based, large tertiary-care hospital and its community-based satellite continuous ambulatory peritoneal dialysis (CAPD) clinics. PATIENTS: Only patients with renal failure caused by MHT and who were on dialysis between January 1997 and June 2000. There were 11 patients on peritoneal dialysis (PD) that regained renal function; 11 patients on hemodialysis (HD), none of whom recovered renal function; and 9 patients on PD who did not recover renal function during the same time period. OUTCOME MEASURES: The groups were investigated for variables that might predict RC. RESULTS: Peritoneal dialysis compared with HD was highly significant as an indicator of RC (p < 0.0001), with 60% of patients on PD regaining renal function, versus 0% on HD. Median time to recovery was 300 (150 -365) days. There was no significant difference in decline of mean arterial pressure (MAP) between the groups; MAP declined significantly in all groups (p = 0.00002). All groups received similar drug therapy. In the RC group, initial MAP, kidney size, and urine output tended to be higher and creatinine lower (p = not significant). Dialysis adequacy was similar in the different groups. CONCLUSIONS:This retrospective study suggests there may be benefit from PD as the primary form of dialysis when patients have MHT as a cause of their renal failure. Possible predictors of RC include blood pressure control, initial MAP, initial serum creatinine, initial urine output, and kidney size. Time should be allowed for RC before transplantation is undertaken. Prospective studies are needed to confirm the benefit of CAPD in patients with MHT.     

Assisted Peritoneal Dialysis for Older People with End-Stage Renal Disease: The French and Danish Experience

Older people are the largest and fastest growing group of patients with end-stage renal disease (ESRD), and, due to advanced age and a heavy burden of comorbidities, they are usually not candidates for renal transplantation or home-based dialysis treatment. Some of the barriers for home treatment are non-modifiable, but the majority of physical disabilities and psychosocial problems can be overcome provided that assistance is offered to the patients at home.In the present review, we describe the programs for assisted peritoneal dialysis (PD) in France and Denmark, respectively. In both nations, assisted PD is totally publicly funded, and the cost of assisted PD is comparable to the cost of in-center HD. Assisted continuous ambulatory PD (aCAPD) is the preferred modality in France whereas assisted automated PD (aAPD) is the preferred modality in Denmark. Assistants are professional nurses or healthcare technicians briefly educated by expert PD nurses from the dialysis unit.The establishment of a program for assisted PD may increase the number of patients actually treated with PD and may reduce the risk of PD technique failure and prolong PD duration. Compared with autonomous PD patients, patients on assisted PD may have shorter patient survival and peritonitis-free survival indicating that, besides advanced age and the burden of comorbidities, dependency on help may be an independent risk factor for poorer outcome.Assisted PD is an evolving dialysis modality, and may in the future prove to be a feasible complementary alternative to in-center hemodialysis (HD) for the growing group of dependent older patients with ESRD.     

Cardiac troponin T and I in end-stage renal failure

BACKGROUND: In patients suffering from end-stage renal failure, cardiac troponin T (cTnT) and I (cTnI) may be increased in serum without other signs of acute myocardial damage. Whether these increases are specific to myocardial injury or nonspecific is not completely clear. METHODS: We investigated time courses of cTnT and cTnI over 1 year and the clinical outcome over 2 years in 59 patients with end-stage renal failure undergoing chronic hemodialysis. At the start of the study, we divided the patients into two groups, group 1, without history of cardiac failure, and group 2, with history of cardiac failure, and looked for differences between the groups in later adverse outcome. cTnT was measured using the Enzymun((R)) troponin T assay on an ES 700 analyzer (Roche). cTnI was measured on a Stratus((R)) II analyzer (Dade Behring). Creatinine and blood urea nitrogen were measured on a Vitros((R)) 950 IRC (Ortho). RESULTS: Dialysis acutely increased cTnT (P: <0.01) and decreased cTnI (P: <0.001) regardless of the dialysis membrane used. Although statistically not significant, cTnT but not cTnI was increased more frequently in group 2 than in group 1, in some cases over the whole study period. Five patients (8.5%) died of cardiac complications within 2 years; all of them had mostly increased cTnT and, in one or more samples, increased cTnI. CONCLUSIONS: Dialysis alters measured cTnT and cTnI concentrations in serum. In patients suffering from end-stage renal failure, sporadic or persistently increased cTnT and cTnI appear to predict cardiac complications. Because of the effects of the dialysis procedure on troponin values, we recommend that blood be collected before dialysis.     

腹膜透析治疗慢性肾脏病基础上的急性肾损伤

目的观察腹膜透析(peritoneal dialysis,PD)对慢性肾脏病基础上的急性肾损伤的疗效,并与间歇性血液透析(inermittent hemodialysis,IHD)进行比较。方法回顾性分析上海交通大学附属第一人民医院2005年至2009年收治的共183例慢性肾脏病基础上的急性肾损伤患者,其中78例采用PD或IHD治疗:PD组(35例):使用持续不卧床腹膜透析(continuous ambulatory peritoneal dialysis,CAPD)、间歇性腹膜透析(intermittent peritoneal dialysis,IPD)或自动腹膜透析(automated peritoneal dialysis,APD)治疗;IHD组(45例):采用IHD 1周3～4次治疗。观察一般资料(年龄、性别、原发病),透析前和透析后连续血尿素氮、肌酐、钾的变化,预后(肾功能恢复和存活),透析相关并发症。使用SPSS 10.0软件进行统计学分析,进行两组比较。结果两组患者治疗前年龄、性别、原发病构成及疾病严重程度差异无统计学意义(P0.05)。PD组透析后连续血尿素氮、肌酐水平明显高于IHD组(P0.05),而两组患者血钾、二氧化碳结合力等临床指标差异无统计学意义(P0.05)。随访显示,PD组肾功能恢复及存活与IHD组差异无统计学意义(P0.05)。PD组患者透析相关并发症发生率为11.4%,与IHD组(14.0%)相比差异无统计学意义(P0.05)。结论 PD治疗慢性肾脏病基础上的急性肾损伤效果与IHD基本相同,有利于患者肾脏功能的恢复,并且透析相关并发症发生率较低。     

腹膜纤维化机制与治疗新进展

腹膜透析作为一种有效的肾脏替代治疗,在终末期肾病中运用日渐广泛,甚至成为肾脏替代治疗的首选方案。但长期的腹膜透析会导致腹膜功能下降、腹膜结构改变,最终演变成腹膜纤维化,甚至包裹性腹膜硬化症,使超滤失败,严重时使患者退出腹膜透析。目前国内外研究主要包括:上皮细胞一间充质转化、腹膜透析液的生物不相容性、血管紧张素一醛固酮系统、氧化应激、腹膜炎症、全身微炎症状态、基因调控、生长及转化因子等,针对上述发病机制,提出了相应的治疗方法。      

Diagnostic and interventional nephrology

The fragmented care of nephrology patients that results from referral to a radiologist for renal ultrasound (US) and biopsy, a surgeon for dialysis access placement, and an interventional radiologist for dialysis catheter placement and vascular access procedures often leads to delays in the treatment of these patients. Many specialists perform and interpret sonograms particular to their specialty rather than relying on technicians for performance and radiologists for interpretation, and nephrologists recently have begun to embrace this technology as an aid in the diagnosis and treatment of their patients. By combining an understanding of the pathophysiology of renal disease with the ability to perform clinical correlation and apply the laboratory data, the nephrologist is ideally suited to perform and interpret renal US and US guidance for percutaneous renal biopsies. Additionally, patients requiring peritoneal dialysis (PD) access have traditionally been referred to a general surgeon for catheter placement, which incurs additional delay in therapy and loss of decision-making control by the referring nephrologist. Recent data has emphasized that the peritoneal dialysis access procedure can be performed safely and effectively by a nephrologist trained in PD access procedures. Nephrologists also successfully perform tunneled hemodialysis catheter placement and vascular access procedures on an outpatient basis. The medical needs of patients with renal disease can be safely and efficiently delivered by a nephrologist trained in interventional nephrology (IN). This growing area of expertise will minimize delays, reduce cost, and allow physicians with training in the management of end-stage renal disease (ESRD) patients to be involved in the procedural aspects of their patients' care. An aggressive approach to the development of IN training programs at academic centers is warranted.     

ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part I – Assessment and Management of Various Cardiovascular Risk Factors

Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.     

Caring for a Rehabilitation Patient with Chronic Renal Failure and End-Stage Renal Disease

Patients with chronic renal failure and end-stage renal disease frequently suffer medical setbacks that necessitate a course of rehabilitation. Planning care for these patients requires special consideration if they are to attain a level of function close to what they enjoyed prior to the event that required them to be hospitalized. In this article, the author describes chronic renal failure, end-stage renal disease, types of dialysis and types of access, assessment upon admission to rehabilitation, and nursing care for patients with chronic renal failure and end-stage renal disease in a rehabilitation facility. This information can help nurses learn about what to look for and what questions to ask, common medications and laboratory values, dietary management, and the creation of a successful rehabilitation experience.     

腹膜透析患者心血管病变的临床特点与护理

目的了解采用腹膜透析（PD）治疗终末期肾脏疾病患者透析前心血管疾病的临床特点,为判断预后和掌握护理观察重点提供依据。方法回顾性分析接受PD治疗的165例终末期肾病患者的资料,根据是否患有糖尿病分为糖尿病肾病组（DN组）和非糖尿病肾病组（非DN组）;根据左心室是否增大分为左室增大组（LVH组）和无左室增大组（无LVH组）。于治疗前1周行心脏超声检查及相关实验室指标检查。结果本组透析前均有明显的心脏病变,主要表现为左房左室增大、室间隔增厚;其中DN组的心脏受损更明显,心胸比和左房内径明显增大;DN组合并高血压的比例明显高于非DN组,且血色素及血白蛋白水平均明显低于非DN组。结论应监测PD患者心血管系统的指标变化,尤其是原发病为DN的老年患者,早期采取护理干预措施,以便及时防治心血管并发症发生。     

Biomarkers for the prediction of mortality and morbidity in patients with renal replacement therapy

The mortality of end-stage renal disease (ESRD) patients on dialysis remains high despite great improvement of dialysis technologies in the past decades. These patients die due to infectious diseases (mainly sepsis), cardiovascular diseases such as myocardial infarction, heart failure, stroke, and, in particular, sudden cardiac death. End stage renal disease is a complex condition, where the failure of kidney function is accompanied by numerous metabolic changes affecting almost all organ systems of the human body. Many of the biomarker characteristics of the individually affected organ systems have been associated with adverse outcomes. These biomarkers are different in patients with ESRD compared to the general population in the prediction of morbidity and mortality. Biomarker research in this field should aim to identify patients at risk for the different disease entities. Traditional biomarkers such as CRP, BNP, and troponins as well as new biomarkers such as fetuin, CD154, and relaxin were analyzed in patients on dialysis. We will include observational as well as prospective clinical trials in this review. Furthermore, we will also discuss proteomics biomarker studies. The article assess the potential diagnostic value of different biomarkers in daily clinical practice as well as their usefulness for clinical drug development in end stage renal disease patients.